Bleeding Requiring Blood Transfusion Research Articles

Predictors of Morbidity and Mortality After Colorectal Surgery in Patients With Cirrhotic Liver Disease-A Retrospective Analysis of 54 Cases at a Tertiary Care Center.

BackgroundDespite various existing scores that predict morbidity and mortality of patients with cirrhotic liver disease (CLD), data on specific risk stratification of patients with CLD undergoing colorectal surgery (CRS) are rare. The aim of this study was to assess in-hospital morbidity and mortality of patients with liver cirrhosis scheduled for CRS, with specific focus on possible pitfalls of surgery in this special cohort.MethodsBetween 1996 and 2018, 54 patients with CLD undergoing CRS were identified and included in this study cohort. Postoperative morbidity and mortality were assessed using the Clavien/Dindo (C/D) classification as well as by type of complication. Univariate and multivariate analyses were performed to analyze the predictive factors for increased postoperative morbidity.ResultsOf the patients, 37% patients died during the procedure or postoperatively. Major complications were seen in 23.1% of patients (>C/D IIIb). Patients with Child B or C cirrhosis as well as patients undergoing emergency surgery experienced significantly more major complications (p = 0.04 and p = 0.023, respectively). The most common complications were bleeding requiring blood transfusion (51.1%) and cardiocirculatory instability due to bleeding or sepsis (44.4%). In 53.7% of patients, an anastomosis was created without a protective ostomy. Anastomotic leakage occurred in 20.7% of these patients. Multivariate analysis showed that a primary anastomosis without a protective ostomy was the strongest risk factor for major complications (p = 0.042).DiscussionMorbidity and mortality after CRS in patients with CLD remains high and is not only influenced by liver function but also by surgical variables. Considering the high rate of anastomotic leakage, creating a protective or definitive ostomy must be considered with regard to the underlying pathology, the extent of CLD, and the patient's condition. Moreover, our data suggest that surgery in these most fragile patients should be performed only in experienced centers with immediate contact to hepatologists and experts in hemostasis.

National Yearly Trend of Utilization and Procedural Complication of the Watchman Device in the United States.

BackgroundComplication from the Watchman device (Boston Scientific Corp, Marlborough, Massachusetts) is operator-dependent, with the latest EWOLUTION trial showing low complication rates (1.8%) thought to be due to maturing physician experience.ObjectivesThe objective of this study is to understand the yearly trend of utilization and complication rates of the Watchman device in hospitalized patients.MethodsThe national inpatient sample (NIS) was queried for all hospitalization with primary atrial fibrillation or flutter from 2016 to 2019 with percutaneous left atrial appendage occlusion (LAAO). The frequency of peri-procedural complications, including death, stroke, major bleeding requiring blood transfusion, pericardial effusion, post-op hypotension, cardiac arrest, postprocedural CHF, implant displacement/leak, systemic embolism, and requiring repeat procedures, were assessed.ResultsFrom 2016 to 2019, an estimated 60,350 LAAO procedures were performed. The majority of the procedure was done in white (84.88%), males (58.40%), with a mean age of 76, at teaching hospitals (88.27%). Complication rates were around 5.72%, with no change from 2016 to 2019 (annual percentage change, APC: 6.23; p-value: 0.170) despite rapid increase in yearly utilization of Watchman from 1.12% in 2016 to 5.45% in 2019 (APC: 62.30; p-value of 0.013). Pericardial effusion (3.41%) was the most common complication, followed by bleeding requiring transfusion (1.40%) that had no significant change over time.ConclusionOur study demonstrates that trend of complications with the Watchman device implantation in the real-world practice didn’t improve over time, possibly due to characteristics inherent to the device and patient population. Hence, we expect a further drop in nationwide complication rates with the improved design of Watchman-FLX and increased placement experience.

Veno-Arterial Extracorporeal Membrane Oxygenation in Elective High-Risk Percutaneous Coronary Interventions.

BackgroundThe safety and feasibility of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as mechanical circulatory support in high-risk percutaneous coronary intervention (HR-PCI) remain unclear.MethodsThis retrospective study included patients with complex and high-risk coronary artery disease who underwent elective PCI with VA-ECMO support pre-operatively during March 2019–December 2020. Rates of VA-ECMO-related complications, complications during PCI, death, myocardial infarction, and stroke during hospitalisation and 1-year post-operatively were analysed.ResultsOverall, 36 patients (average age: 63.6 ± 8.9 years) underwent PCI. The average duration of VA-ECMO support was 12.5 (range, 3.0–26.3) h. Intra-aortic balloon pump counterpulsation was used in 44.4% of patients. The SYNTAX score was 34.6 ± 8.4 pre-operatively and 10.8 ± 8.8 post-operatively (P < 0.001). Intraoperative complications included pericardial tamponade (N = 2, 5.6%), acute left-sided heart failure (N = 1, 2.8%), malignant arrhythmia requiring electrocardioversion (N = 2, 5.6%), and no deaths. Blood haemoglobin levels before PCI and 24 h after VA-ECMO withdrawal were 145.4 ± 20.2 g/L and 105.7 ± 21.7 g/L, respectively (P < 0.001). Outcomes during hospitalisation included death (N = 1, 2.8%), stroke (N = 1, 2.8%), lower limb ischaemia (N = 2, 5.6%), lower limb deep venous thrombosis (N = 1, 2.8%), cannulation site haematoma (N = 2, 5.6%), acute renal injury (N = 2, 5.6%), bacteraemia (N = 2, 5.6%), bleeding requiring blood transfusion (N = 5, 13.9%), and no recurrent myocardial infarctions. Within 1 year post-operatively, two patients (5.6%) were hospitalised for heart failure.ConclusionsVeno-arterial extracorporeal membrane oxygenation mechanical circulation support during HR-PCI is a safe and feasible strategy for achieving revascularisation in complex and high-risk coronary artery lesions. VA-ECMO-related complications require special attention.

Safety and efficacy of immediate heparin reversal with protamine after complex percutaneous coronary intervention

BackgroundCompared to simple percutaneous coronary intervention (PCI), complex PCI is associated with higher bleeding and thrombotic risk. No previous study has evaluated the use of protamine after PCI with contemporary technologies. This study aimed to evaluate the safety and efficacy of manual compression with and without protamine after transfemoral complex PCI.MethodsWe retrospectively analyzed 160 patients (protamine group, n = 92; non-protamine group, n = 68) who underwent complex PCI via the femoral artery. The primary outcome was a composite of in-hospital death, myocardial infarction, stent thrombosis, stroke/systemic embolism, bleeding requiring blood transfusion, and vascular access complications.ResultsThe primary outcome was significantly lower in the protamine group than in the non-protamine group (4.3% vs. 17.6%; p = 0.006). This was driven mainly by the lower incidences of hematoma in the protamine group (3.3% vs. 13.2%, p = 0.020). Furthermore, the protamine group had a significantly shorter hospital stay than the non-protamine group (4.8 ± 3.7 days vs. 8.4 ± 8.3 days, p = 0.001). While > 90% of the patients had acute coronary syndrome, there were no incidences of myocardial infarction or stent thrombosis in either group.ConclusionsAmong patients who underwent complex PCI via transfemoral access, immediate protamine administration was associated with a significantly lower rate of vascular access complications, especially hematoma, and shorter hospital stay than no protamine administration.

Trans-radial approach versus trans-femoral approach in patients with acute coronary syndrome undergoing percutaneous coronary intervention: An updated meta-analysis of randomized controlled trials.

IntroductionTrans-radial approach (TRA) is recommended over trans-femoral approach (TFA) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We intended to study the effect of access on all-cause mortality.Methods and resultsWe searched PubMed and EMBASE for randomized studies on patients with ACS undergoing PCI. The primary outcome was all-cause mortality at 30-days. The secondary outcomes included in-hospital mortality, major adverse cardiac or cerebrovascular event (MACE) as defined by the study, net adverse clinical event (NACE), non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, study-defined major bleeding, and minor bleeding, vascular complications, hematoma, pseudoaneurysm, non-access site bleeding, need for transfusion, access site cross-over, contrast volume, procedure duration, and hospital stay duration. We studied 20,122 ACS patients, including 10,037 and 10,085 patients undergoing trans-radial and trans-femoral approaches, respectively. We found mortality benefit in patients with ACS for the trans-radial approach [(1.7% vs. 2.3%; RR: 0.75; 95% CI: 0.62–0.91; P = 0.004; I2 = 0%). Out of 10,465 patients with STEMI, 5,189 patients had TRA and 5,276 had TFA procedures. A similar benefit was observed in patients with STEMI alone [(2.3% vs. 3.3%; RR: 0.71; 95% CI: 0.56–0.90; P = 0.004; I2 = 0%). We observed reduced MACE, NACE, major bleeding, vascular complications, and pseudoaneurysms. No difference in re-infarction, stroke, and serious bleeding requiring blood transfusions were noted. We noticed a small decrease in contrast volume(ml) {mean difference (95% CI): −4.6 [−8.5 to −0.7]}, small but significantly increase in procedural time {mean difference (95% CI) 1.2 [0.1 to 2.3]}and fluoroscopy time {mean difference (95% CI) 0.8 [0.3 to1.4] min} in the trans-radial group.ConclusionTRA has significantly reduced 30-day all-cause mortality among patients undergoing PCI for ACS. TRA should be the preferred vascular access in patients with ACS.

Perioperative Bleeding Requiring Blood Transfusions is Associated With Increased Risk of Stroke After Transcatheter and Surgical Aortic Valve Replacement

The authors aimed to investigate the impact of severe bleeding and use of red blood cell (RBC) transfusion on the development of postoperative stroke after surgical (SAVR) and transcatheter aortic valve replacement (TAVR), taken from the FinnValve registry. Nationwide, retrospective observational study. Five Finnish university hospitals participated in the registry. A total of 6,463 patients who underwent SAVR (n=4,333) or TAVR (n=2,130). Patients who underwent TAVR or SAVR with a bioprosthesis with or without coronary revascularization. The incidence of postoperative stroke after SAVR was 3.8%. In multivariate analysis, the number of transfused RBC units (odds ratio [OR], 1.098; 95% confidence interval [CI], 1.064-1.133) was one of the independent predictors of postoperative stroke. The incidence of stroke increased, along with the severity of perioperative bleeding, according to the European Coronary Artery Bypass Grafting (E-CABG) bleeding grades were as follows: grade 0, 2.2% (reference group); grade 1, 3.4% (adjusted OR, 1.841; 95% CI, 1.105-3.066); grade 2, 5.5% (adjusted OR, 3.282; 95% CI, 1.948-5.529); and grade 3, 14.8% (adjusted OR, 7.103; 95% CI, 3.612-13.966). The incidence of postoperative stroke after TAVR was 2.5%. The number of transfused RBC units was an independent predictor of stroke after TAVR (adjusted OR, 1.155; 95% CI, 1.058-1.261). The incidence of postoperative stroke increased, along with the severity of perioperative bleeding, as stratified by the E-CABG bleeding grades: E-CABG grade 0, 1.7%; grade 1, 5.3% (adjusted OR, 1.270; 95% CI, 0.532-3.035); grade 2, 10.0% (adjusted OR, 2.898; 95% CI, 1.101-7.627); and grade 3, 30.0% (adjusted OR, 10.706; 95% CI, 2.389-47.987). Perioperative bleeding requiring RBC transfusion and/or reoperation for intrathoracic bleeding is associated with an increased risk of postoperative stroke after SAVR and TAVR. Patient blood management and meticulous preprocedural planning and operative technique aiming to avoid significant perioperative bleeding may reduce the risk of cerebrovascular complications.

Non-descent vaginal hysterectomy surgery associated with less complications and good prognosis

Background: Removal of the uterus through vagina when performed in a case without uterine descent or prolapse is known as “non-descent vaginal hysterectomy” or NDVH. Vaginal route is preferred as compared to laparoscopic and abdominal methods. The advantages of vaginal hysterectomy being fewer complications, less post-operative stay, cost effective, and useful in bulky uterus. Aims and Objectives: The aims of the study were as follows: (1) To study the intraoperative and post-operative complications encountered during NDVH and their management. (2) To assess the intraoperative blood loss, the operative time, and post-operative hospital stay. (3) To study and check the feasibility of vaginal route as the primary route for all hysterectomies in the absence of uterine prolapse. Materials and Methods: A total of 50 patients were included in the study. Detailed history was taken including obstetric history and menstrual history and clinical examination was performed. After taking written, informed consent and doing proper pre-operative preparation, the patient was posted for NDVH. Post-operative complications were noted. Patients were asked to come for follow-up after 15 days. Results: In 92% of cases operated, no intraoperative complications were found suggesting low morbidity associated with the procedure. Hemorrhage requiring blood transfusion was found in 4% of cases. Average operative time was 61.2 ± 27.89 min, average blood loss was 170 ± 81.44 ml, and average hospital stay was 5.94 ± 4.95 days. On histopathological examination, 40% were having leiomyoma and dysfunctional uterine bleeding was seen in 22% of cases. Pain was the most common complication seen in 30% of cases while vaginal discharge was seen in just 4% of cases. About 80% of patients were discharged on post-operative day 5. Conclusion: In 92% of NDVH cases, no intraoperative complications were found suggesting low morbidity associated with the procedure. The post-operative hospital stay was restricted to 5 days in 80% of cases which indicates early discharge of the patient. Post-operative complications such as vaginal discharge and fever were seen only in 4% of cases. NDVH should, therefore, be considered as the primary route for all hysterectomies unless contraindicated in the absence of prolapse.

Evaluation of the safety profile of endoscopic pyloromyotomy by G-POEM: a French multicenter study.

Background:Gastric per oral endoscopic esophageal myotomy (G-POEM) is a promising procedure to treat refractory gastroparesis. The safety profile of G-POEM is an important topic because gastroparesis is a functional pathology, with a procedure whose effectiveness is between 50 and 65% depending on the studies.Objectives:We present this retrospective multicenter study, with the aim of establishing a safety profile, focusing on serious adverse events (AEs).Design:This was a multicenter observational cohort study conducted in five French expert centers.Methods:All patients who underwent G-POEM for refractory gastroparesis between 2015 and 2021 were included for analysis. AEs were classified into per endoscopic, early postoperative, and late postoperative, up to 1 month. Their severity was assessed using Dindo–Clavien and American Society for Gastrointestinal Endoscopy classification. The primary objective was to evaluate the rate of G-POEM severe AEs. Secondary objectives were to document other postoperative AEs, and to identify predictive factors.Results:In all, 217 patients were included: 81 men and 136 women, mean age 52 ± 17 years. The average procedural time was 44 ± 14 min (12–78). The average hospital stay was 3.7 ± 2.3 days. The AEs rate classified as Clavien–Dindo ⩾3 was 0.4% (one delayed bleeding requiring blood transfusion and endoscopic management). There were no deaths or patients admitted to intensive care unit. The rates of mucosotomy and capnoperitoneum were 3.7 and 1.8%, respectively, without clinical consequences. Most patients (81.5%) did not experience any AE. Three cases of dumping syndrome occurred, quickly managed by dietary measures.Conclusion:Our study confirms the safety of G-POEM with less than 0.5% of serious AEs, medically managed. This outcome makes this a procedure to have a good benefit–risk ratio.

P-OGC68 Prophylactic Endoluminal Vacuum Therapy (EVT) following oesophagectomy

Abstract Background Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for the management of anastomotic leaks following oesophagectomy. However, patients are often critically unwell with mediastinitis and established sepsis by the time the leak is diagnosed. This results in a protracted recovery period regardless of the effectiveness of EVT in treating the leak. Prophylactic EVT to protect the anastomosis following oesophagectomy may reduce the incidence of anastomotic leak, and/or mediastinitis and sepsis if the anastomosis does fail. We report the outcomes of two patients considered high risk for anastomotic leak who were managed with prophylactic EVT following esophagectomy for cancer. Methods Two patients received prophylactic EVT following oesophagectomy between May and July 2021. The patients were considered high risk for anastomotic leak due to technical concerns with, or complications during, the operation. In both cases the oesophagogastric anastomosis (OGA) was fashioned with a circular stapler. The endoluminal vacuum device (EVD) was constructed using an 18F nasogastric tube and a piece of open cell foam, and placed intraluminally across the anastomosis under endoscopic guidance at the time of surgery. Continuous negative pressure (125mmHg) was applied. Information relating to treatment and outcome was recorded prospectively. Results Patient-1, a 72-year-old female, ASA 2, underwent minimally invasive oesophgectomy for an adenocarcinoma at the gastro-oesophageal junction. After creating the stapled OGA, inspection revealed the proximal (oesophageal) tissue doughnut was complete but attenuated. Patient 2, a 67-year-old male, ASA 3, underwent a hybrid Ivor Lewis oesophgectomy for a lower 1/3 oesophageal adenocarcinoma. Surgery was complicated by significant intra-abdominal bleeding requiring blood transfusion and pressor support. In both cases, endoscopic assessment of the anastomosis following removal of the prophylactic EVD was performed day seven post-operatively. The anastomoses were healthy with no evidence of a leak, dehiscence, or early stricture formation. Conclusions In this limited case series, prophylactic EVT of the OGA following oesophagectomy was delivered safely with no complications related to insertion of the EVD or delivery of EVT. This intervention should be considered in cases where the risk of anastomotic leak is high. An intraluminal EVD situated across the OGA may minimise the extent of extraluminal contamination, and the systemic consequences of sepsis associated with this, should an anastomotic breakdown occur. Further studies are required to determine the safety of prophylactic EVT following oesophagectomy, and whether this improves surgical outcomes by reducing the incidence and impact of anastomotic leaks.

Extracorporeal membrane oxygenation support for SARS-CoV-2: a multi-centered, prospective, observational study in critically ill 92 patients in Saudi Arabia

BackgroundExtracorporeal membrane oxygenation (ECMO) has been used as a rescue strategy in patients with severe with acute respiratory distress syndrome (ARDS) due to SARS-CoV-2 infection, but there has been little evidence of its efficacy.ObjectivesTo describe the effect of ECMO rescue therapy on patient-important outcomes in patients with severe SARS-CoV-2.MethodsA case series study was conducted for the laboratory-confirmed SARS-CoV-2 patients who were admitted to the ICUs of 22 Saudi hospitals, between March 1, 2020, and October 30, 2020, by reviewing patient’s medical records prospectively.ResultsECMO use was associated with higher in-hospital mortality (40.2% vs. 48.9%; p = 0.000); lower COVID-19 virological cure (41.3% vs 14.1%, p = 0.000); and longer hospitalization (20.2 days vs 29.1 days; p = 0.000), ICU stay (12.6 vs 26 days; p = 0.000) and mechanical ventilation use (14.2 days vs 22.4 days; p = 0.000) compared to non-ECMO group. Also, there was a high number of patients with septic shock (19.6%) and multiple organ failure (10.9%); and more complications occurred at any time during hospitalization [pneumothorax (5% vs 29.3%, p = 0.000), bleeding requiring blood transfusion (7.1% vs 38%, p = 0.000), pulmonary embolism (6.4% vs 15.2%, p = 0.016), and gastrointestinal bleeding (3.3% vs 8.7%, p = 0.017)] in the ECMO group. However, PaO2 was significantly higher in the 72-h post-ECMO initiation group and PCO2 was significantly lower in the 72-h post-ECMO start group than those in the 12-h pre-ECMO group (62.9 vs. 70 mmHg, p = 0.002 and 61.8 vs. 51 mmHg, p = 0.042, respectively).ConclusionFollowing the use of ECMO, the mortality rate of patients and length of ICU and hospital stay were not improved. However, these findings need to be carefully interpreted, as most of our cohort patients were relatively old and had multiple severe comorbidities. Future randomized trials, although challenging to conduct, are highly needed to confirm or dispute reported observations.

Ketorolac use and risk of bleeding after appendectomy in children with perforated appendicitis

BackgroundKetorolac is an opioid sparing agent commonly used in children. However, ketorolac may be avoided in children with peritonitis owing to a possible increased risk of bleeding. MethodsA retrospective cohort study of healthy children 2–18 years who underwent appendectomy for perforated appendicitis was performed using the Pediatric Health Information System (2009–2019). Multivariable logistic regression was used to evaluate the association between perioperative ketorolac use and postoperative blood transfusions within 30 days of surgery, adjusting for patient and hospital level factors. An interaction between ketorolac and ibuprofen was evaluated to identify synergistic effects. ResultsOverall, 55,603 children with perforated appendicitis underwent appendectomy and 82.3% (N = 45,769) received ketorolac. Of those, 32% (N = 14,864) also received ibuprofen. Receipt of a blood transfusion was infrequent (N = 189, 0.3%). On multivariable logistic regression analysis, perioperative ketorolac administration was associated with decreased odds of a blood transfusion (OR 0.53, 95% CI: 0.35–0.79). However, children receiving ketorolac and ibuprofen were more likely to require a blood transfusion (OR 1.99, 95% CI: 1.42–2.79). In a subset of children receiving ketorolac, each additional day of ketorolac was associated with an increase odds of blood transfusion (OR 1.39, 95% CI: 1.30–1.49). ConclusionPerioperative ketorolac alone is not associated with an increased risk of significant bleeding in children undergoing appendectomy for perforated appendicitis. However, use of both ketorolac and ibuprofen during hospitalization was associated with increased risk of bleeding, although precise timing of administration of these medications was unable to be determined. Extended ketorolac use was also associated with increased risk of bleeding requiring blood transfusion. Level of evidenceLevel III.

Treatment Options After a Diagnosis of Early Miscarriage: Expectant, Medical, and Surgical.

Approximately 12% of pregnancies end in an early miscarriage (up to week 12 + 0 of pregnancy). Over the past 10 to 15 years, two alternatives to curettage have appeared in the pertinent international treatment guidelines: expectant treatment and medical (drug) treatment. In this review, we discuss the advantages and disadvantages of each of these therapeutic options. This review is based on pertinent publications (January 2000 to February 2021) retrieved by a selective search in PubMed, as well as on the guidelines of the American College of Obstetrics and Gynecologists, the Association of the Scientific Medical Societies in Germany, the National Institute for Health and Care Excellence/Royal College of Obstetricians and Gynaecologists, and the International Federation of Gynaecology and Obstetrics. Three effective and safe treatment options are available after a diagnosis of early miscarriage. Expectant treatment yields success rates of 66-91%, depending on the type of miscarriage. Its complications include hemorrhage requiring blood transfusion in 1-2% of cases. If expectant therapy fails, subsequent treatment with misoprostol or curettage is indicated. Drug therapy with misoprostol yields a complete termination in 81-95% of cases and is thus a valid alternative to expectant therapy, with the advantage of better planning capability. The vaginal application of misoprostol is the most effective means of administration, with the fewest side effects. Curettage is needed in 5-20% of cases. Suctional curettage has a success rate of 97-98%, with an associated anesthesia-related risk of 0.2%, a 0.1% risk of perforation, and a 2-3% rate of repeat curettage. If there is no acute indication for the surgical treatment of an early miscarriage, the patient can choose among three treatment options. Expectant and medical treatment can be provided on an outpatient basis. Curettage is the treatment of choice in the presence of infection, marked and persistent bleeding, hemodynamic instability, or a pre-existing coagulopathy.

Abstract 13609: Impact of Frailty on Hospital-Related Outcomes of Elective Left Atrial Appendage Closure

Introduction: Atrial fibrillation as the most common arrhythmia worldwide results in a significantly elevated risk of cardioembolic stroke. Left atrial appendage (LAA) closure has been advocated and supported by randomized clinical trials as an alternative treatment in patients with atrial fibrillation who have contraindications for anticoagulation. The safety of this procedure in patients who are considered frail remains unknown since they have been underrepresented in most clinical studies. Our study aims to investigate the impact of frailty on hospital-related outcomes in patients undergoing elective LAA closure. Methods: We reviewed the National Inpatient Sample database from January 2016 to December 2017 to identify patients that underwent elective percutaneous LAA closure using the ICD-10 code 02L73DK for the procedure. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. An individual is considered frail if they present &gt;=1 diagnosis within the indicator. The outcomes include in-hospital mortality, hemorrhage requiring blood transfusion, respiratory failure, sepsis, length of stay, and total hospitalization cost. Multivariate logistic or linear regression was adopted to determine the impact of frailty on the outcomes while reducing the effect of possible confounding baseline characteristics. Results: From the period of January 2016 to December 2017, a total of 14795 patients underwent elective LAA closure. Of those patients, 830 were determined to meet the criteria for frailty, while 13965 were considered non-frail. The frail group is older than the non-frail group with a mean age of 78.77 years old than 75.53 years old. Frailty was associated with an increased risk of hemorrhage requiring transfusion (odds ratio 2.82, p=0.030) and a longer length of stay (2.10 vs 1.30 days, p=0.003). The frail group appears to have higher hospitalization costs, but the result was not statistically significant ($122668.2 vs $114295.3, p=0.091). Conclusions: The presence of frailty was associated with an increased risk of hemorrhage requiring transfusion and a longer length of hospital stay after elective left atrial appendage closure.

Abstract 12504: The Gender-Based Outcome in the Patients Undergoing Percutaneous Left Atrial Appendage Occlusion With the Watchman Device: A Longitudinal Nationwide Inpatient Sample Analysis

Introduction: Compared to men, women have an increased risk of having a stroke, cardiovascular disease, and death. It requires continuous anticoagulation use based on CHA 2 DS 2 -VASc scores for stroke prevention. The Watchman device is indicated for patients with non-valvular AF at high risk of stroke who have contraindications to long-term anticoagulation use. We sought to determine the periprocedural outcome difference based on gender in the patients undergoing watchman device implantation. Methods: National Inpatient Sample databases from 2016 to 2018 were utilized using Stata 16.0. NIS databases are the ICD-10-CM code-based largest publicly available all-payer inpatient database. Patients with atrial fibrillation who underwent the watchman procedure were identified; later divided and compared based on gender. Multivariate logistic regression, linear regression, and student t-t-tests were used for analysis. Data were further analyzed after greedy propensity matching for accuracy. Results: Out of 33,825 patients who had the procedure, 14,105 (41.8%) were female, and 19,690 (58.2%) were male. The mean age for women and men were 76.5±7.5 and 75.6±8.1 respectively. Co-morbidities such as DM, CAD, CKD, PVD, and history of CABG were more in men, whereas anemia and pulmonary hypertension were more in women. Mortalities in women were 30 whereas it was 26 in men. There was no difference in mortality on multivariate logistic regression analysis. Complications such as pericardial drain and major bleeding requiring blood transfusion were higher in women. There was no difference in pericardial complications, ischemic stroke, hemorrhagic stroke, and AKI. The overall mean LOS and cost per hospitalization were higher in women. Conclusions: Patients undergoing watchman procedure showed no difference in periprocedural mortality between men and women; however, women had high events of pericardial drainage and major bleeding requiring blood transfusion.

Impact of atrial fibrillation in patients with colorectal cancer: a national inpatient sample database analysis

Abstract Background Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting approximately 1–2% overall population (1). Its causal relationship with colorectal cancer (CRC) is much for debate. According to one hypothesis, the presence of autoantibodies directed against ionic channels or acetylcholine receptors can predispose to the development of atrial fibrillation (2–3). Thus, AF may be regarded as an inflammatory complication in patients with colon cancer. Our study objective was to determine if AF impacts the outcome of patients with CRC. Method We analyzed the National Inpatient Sample (NIS) database from Oct-2015 to Dec 2018 using Stata 16.0. The NIS databases are released under the Healthcare Cost and Utilization Project, which includes inpatient admissions from the United States' participating hospitals. Total population with CRC were identified using their respective ICD-10 diagnostic codes then divided based on AF. To determine atrial fibrillation association with mortality and complications, we used multivariate logistic regression analysis using weights to generate nationally representative results. Later, a propensity-matched population analysis was done for the accuracy of the results. Result We found 245,305 patients admitted with CRC between Oct 2015 to Dec-2018 in the USA, out of which 28,170 (11.5%) were having AF. The mean age for the patients with AF was 77±10 compare to 65±14 years in those without AF. Patients with AF were associated with higher comorbidities and had a high population percentage with Carlson category three or above. There were 1,456 (5.2%) mortalities in the AF group compared to 5,689 (2.6%) in the other. The higher odds of mortality in patients with AF was present in multivariate logistic regression analysis in both non-propensity matched [1.71 (1.45–2.02), P-value: &amp;lt;0.000] and propensity-matched [1.44 (1.18–1.75), P-value: &amp;lt;0.001] cohorts. Patients with AF were hospitalized longer (9.20±7.8 vs. 6.85±7.0 days), leading to a high admission costs (US$ 25,875±22,875 vs. 20,087±19,314). Odds of complications such as need for blood transfusions [1.61 (1.05–1.29), P-value: 0.005], hemorrhage requiring blood transfusion [1.17 (1.05–1.29), P-value: 0.003], lower-GI bleed [1.31 (1.21–1.43), P-value: &amp;lt;0.001], sepsis [1.45 (1.30–1.62), P-value: &amp;lt;0.001], respiratory failure [1.39 (1.15–1.67), P-value: 0.001] etc. were also higher in group of patients with CRC and AF. Conclusion In our retrospective, propensity-matched national inpatient sample analyses of patients admitted with colorectal cancer, atrial fibrillation is associated with higher morbidity and mortality. AF was associated with a high burden of complications with prolonged hospital stay leading to increased health care expenditures. Funding Acknowledgement Type of funding sources: None.

Sex-differences in outcomes after percutaneous coronary intervention of chronic total occlusions: insights from a large single-center registry

Abstract Introduction Patients undergoing PCI of chronic total occlusions (CTO) are at high risk of both periprocedural and post-procedural adverse events. Whether sex-differences in outcomes exist after PCI of CTO remains unclear. Purpose We sought to investigate sex-differences in outcomes after CTO-PCI among an unselected real-world cohort of patients. Methods In our single-center retrospective study, patients who underwent elective CTO intervention from January 2000 to December 2019 were included. The primary endpoint of interest was major adverse cardiac events (MACE) defined as the composite of death, myocardial infarction (MI), and target vessel revascularization (TVR) at 1 year of follow-up. Results A total 1897 patients were included of which 368 were women (19.4%). Women were older (67±11.3 years vs. 62.6±10.9 years) and had a higher prevalence of comorbidities including diabetes and chronic kidney disease. Women had higher rates of procedure-related complications including increased risk of post-procedural bleeding requiring blood transfusion (3.0% vs 1.1%; p=0.007), and acute vessel closure (1.36% vs 0.2%; p=0.009). In multivariable-adjusted models for baseline confounders, female sex was associated with higher risk of MACE and TVR (Table 1). Conclusion Gender differences in CTO management are observed, with fewer females going for CTO revascularization in contemporary practice. Female sex is associated with procedural-related complications, higher MACE, and TVR even after successful CTO intervention. Funding Acknowledgement Type of funding sources: None.

Effect of thrombocytopenia in patients with infective endocarditis: an insight from the National Inpatient Sample database

Abstract Introduction Infective endocarditis (IE) is one of the feared diseases in septic patients, and incidences are rising due to the intravenous drug abuse epidemic. Sepsis causes an escalation of the platelet destructions leading to thrombocytopenia (1). Few independent hospital-based studies have proposed increase mortality with thrombocytopenia in patients with IE (2–5). We aim to evaluate the significance of thrombocytopenia in IE subjects from the national inpatient sample (NIS) database. Method We analyzed the NIS database from Jan-2016 to Dec-2018 using Stata 16.0. NIS is the largest publicly available all-payer inpatient care database in the United States, containing data on more than seven million hospital stays per year. We identified patients with IE with or without thrombocytopenia using ICD-10 codes. The primary outcome of interest was in-hospital mortality comparison. We adjusted potential confounders (age, sex, diabetes, hypertension, etc.) with multivariate logistic regression analysis. Further analysis was done after balancing the population co-morbidity using a Greedy propensity match for accuracy. Results A total of 174,495 subjects were included in this study with a diagnosis of IE. Among these individuals, 33,285 patients had a concurrent diagnosis of thrombocytopenia. The mean ages were 53±19.5 years for the thrombocytopenia group and 55±19.8 years for others. Females were equally represented in both cohorts. There were 4,945 (14.86%) vs 2,835 (2.01%) mortalities reported in with and without thrombocytopenia group respectively. After propensity matching, there was a pronounced increase in mortality [Odds ratio (OR): 1.93 (1.72 – 2.15), p-value: &amp;lt;0.001] in the group with thrombocytopenia comparing to others. Complications such as Major bleeding requiring blood transfusion [OR: 1.45 (1.35–1.57)], acute myocardial infarction [OR: 1.56 (1.35–1.70)], complete heart block [OR: 1.44 (1.16–1.53)], cardiac arrest [OR: 1.44 (1.25–1.72)], acute respiratory failure [OR: 1.51 (1.39–1.73)] and pressor support requirement [(OR: 1.73 (1.57–2.01)] were notably higher in the cohort of thrombocytopenia with statistically significant p-value (&amp;lt;0.001). The difference in length of stay between both cohorts after propensity match wasn't statistically significant. Conclusion In conclusion, IE patients with thrombocytopenia have higher incidences of in-patient mortality and poor outcomes than cohort without thrombocytopenia. Some of the adverse consequences could be temporally explained by complications related to underlying thrombocytopenia. Further investigations are needed to delineate the outcome in this group of subjects. Funding Acknowledgement Type of funding sources: None.

58 Should Single Group and Save (G&amp;S) Sampling be Implemented in Spinal Cord Stimulation Surgery (SCSS)?

Abstract Aim SCSS is offered to patients who have persistent chronic neuropathic pain after trials of conservative management. Although severe bleeding complications are rare, it is common practice to take two G&amp;S samples from patients pre-operatively. Unnecessary testing can induce patient anxiety and is a financial burden to the NHS. We aim to determine if a single G&amp;S sample before SCSS would be beneficial, and to assess the association between number of risk factors for bleeding and blood loss in SCSS. Method Retrospective analysis of 100 patients in one centre who had SCSS over a 3-year period. Bleeding risk factors, haemoglobin levels and complications were recorded for each patient. A review of current literature along with a cost analysis was subsequently performed. Results An average drop in haemoglobin levels of 9g/L post-operatively was seen. No patients required blood transfusions. There was no statistically significant difference (P = 0.364) between number of risk factors and blood loss. Conclusions The results obtained suggest that SCSS carries a low risk of adverse bleeding requiring blood transfusions. With the lack of guidelines for preoperative G&amp;S samples it is difficult to make decisions on the amount of samples needed before SCSS. Single G&amp;S sampling in patients without bleeding risk factors can reduce patient burden, save costs, and reduce environmental footprints left by laboratory tests. Those with risk factors may still benefit from two pre-operative G&amp;S samples to ensure patient safety.

1600 Assessing Necessity and Cost-Effectiveness of Routine Pre-Thyroidectomy Group and Save Tests

Abstract Aim To determine the necessity and cost effectiveness of routine blood group and save tests (G&amp;S) before thyroidectomy Background Sub-total or total thyroidectomy is the mainstay of treatment for several thyroid disorders. The incidence of post-thyroidectomy haemorrhage has been reported between 0.36% and 4.3% in the literature. Many patients undergo routine G&amp;S testing in anticipation of a peri-operative haemorrhage requiring blood transfusion. Method Retrospective review identified 276 patients undergoing an elective total or sub-total thyroidectomy at a London University Teaching Hospital between February 2018 and August 2020. Electronic medical and transfusion department records were audited to identify patients who had pre-operative G&amp;S tests, pre-operatively reserved blood products and peri-operative transfusions. Results 261 (94.6%) patients had a valid pre-operative group and save test. 17 (6.16%) patients had a total of 61 units of blood products ordered pre-operatively. Only 2 patients required transfusion. Conclusions The blood transfusion rate for elective thyroidectomies at this centre was 0.72%. Routine G&amp;S tests cost the trust thousands of pounds and create unnecessary burden on healthcare providers’ time and hospital resources. We propose that routine pre-operative G&amp;S tests are unnecessary for elective thyroidectomies.

Comparison between OPEN STONE SURGERY vs PERCUTENOUS NEPHROLITHOTOMY in Management of Renal Stones By Using S.T.O.N.E Nephrolithometry Scoring System

Abstract Background In spite of Percutaneous nephrolithotomy (PCNL) became the first-line treatment option for patients with large and complex renal stones, there still remains a need of using open stone surgery (OSS) for removal of stones as a second or third line of treatment option. To date, 3 scoring systems have been proposed utilizing different metrics including the Guy’s Stone Score, S.T.O.N.E. nephrolithometry and the Clinical Research Office of the Endourological Society (CROES) nomogram, and that used to assess and estimate the treatment success rate. Aim of the Work To evaluate and compare between OSS and PCNL in the management of renal stones by using the S.T.O.N.E. nephrolithometry scoring system to predict and assess the stone free rate and the correlation with peri-operative complications in that two procedures. Patients and Methods A total 100 patients who need surgical intervention for renal stones were treated with OSS (35 pa ents) and PCNL (65 pa ents) from January 2019 ll the end of October 2019, were invited to participate in the present study. This was a multicenter, comparative, prospective cohort controlled study. This study was controlled by the standard results recorded in the previous literatures. Only adult(&amp;gt;18 ys. Old) patients with renal stone size ≥ 20mm were involved in the study. Peri-operative and follow-up data included stone free rate and complications were collected for all patients and were compared between both procedures. S.T.O.N.E nephrolithometry scoring systems was applied to preoperative non-contrast computed tomography(CTUT) for all cases and compared the results of both procedures. Stone-free rate was diagnosed using early postoperative kidney, ureter, bladder X-rays(KUB) and another CTUT on the postoperative day30. Results There was a significant difference between the PCNL group and the OSS group in the primary stone free rate (90% and 97.5% respec vely, p-value=0.021), peri-operative major complications (3% and 14.3% respectively, p-value=0.033), opera ve me (123.46 ± 34.61 and 175.71 ± 55.10 respec vely, p-value=0.000) and postopera ve hospital stay (3.52 ± 0.84 and 5.23 ± 1.00 respec vely, p-value=0.000), while there was no significant difference in the intra-opera ve bleeding requiring blood transfusion (10.8% and 14.3% respec vely, pvalue=0.124). S.T.O.N.E score showed a significant difference between PCNL and OSS groups ( 7 (6-11) and 10 (7-12) respectively, p-value=0.000) and it also had a significant rela on with the outcome SFR (p-value=0.000) a er both PCNL and OSS(r= -0.581 and r= -0.567 respec vely), the higher the score, the lower the SFR and the higher the possibility of OSS choice. While this score had on relation with the peri-operative complications. Conclusion The S.T.O.N.E. nephrolithometry score was predictive of the stone-free status in both surgical procedures (PCNL and OSS) and can be used as an formal guidance for surgical planning and patient counseling. This score would be classified into two categories “low” score range from 5 to 8 recommend PCNL procedure with expec ng SFR of 88% to 97% and “high” score range from 9 to 12 recommend Open Stone Surgery with expec ng SFR of 90% to 96%, to reach the most acceptable results for each procedures to sa sfy the patient and the doctor. The S.T.O.N.E score was not associated with the peri-operative complications in both procedures.