Blood Transfusion Requirements Research Articles

Impact of TTP on COVID-19 Patients Assessing Treatment Outcomes and Healthcare Expenditure

Background: Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy manifesting as hemolytic anemia, thrombocytopenia, fever, neurological symptoms, and renal failure triggered by the immune response leading to reduced levels of ADAMTS-13. We conducted a retrospective study on a national scale utilizing the National Inpatient Sample (NIS) database for year 2020 assessing the influence of COVID-19-induced thrombotic thrombocytopenic purpura (TTP) on morbidity and mortality. Our research focused on adults aged 18 and above who had contracted COVID-19, with the aim of investigating the effects of TTP on mortality rates, cardiovascular complications, and healthcare expenditures within our patient population. Results: Our study included 1,050,045 adult patients admitted with COVID-19. Of these, only 435 (0.0004%) patients developed TTP during the index hospitalization. Patients with TTP were relatively younger than those without (61.09 vs. 64.74, p = 0.03) (Table 1). Compared to patients without TTP, patients with TTP were more likely to have congestive heart failure (CHF) (26.44% vs. 16.81%, p = 0.03), ESRD (6.90% vs. 3.68%, p = 0.04), and were more often admitted to teaching hospitals (86.21% vs. 68.95%, p = 0.02) in the Midwest (51.27% vs. 23.28%, p = 0.01) and West (20.69% vs. 17.19%, p = 0.01) regions. Using multivariate regression analysis to adjust for confounders, including the severity of COVID infection (ARF, sepsis, and organ failure), we found that COVID patients with TTP had significantly higher mortality than patients without TTP (adjusted odds ratio (AOR) 3.39, 95% CI 1.85-6.22, p < 0.01) (Table 2). Additionally, COVID patients with TTP had higher odds of LE DVT/PE (AOR 3.89, 95% CI 1.52-9.93, p < 0.01), AKI (AOR 3.67, 95% CI 1.71-7.87, p < 0.01), AKI requiring dialysis (AOR 10.68, 95% CI 4.86-23.44, p < 0.01), GIB (AOR 3.66, 95% CI 1.70-7.87, p < 0.01), requiring blood transfusion (AOR 6.65, 95% CI 3.19-13.85, p < 0.01), and ICU admission (AOR 3.81, 95% CI 2.15-6.71, p < 0.01). In terms of resource utilization, patients with TTP had a longer adjusted LOS (9.45 days, 95% CI 6.49-12.42, p < 0.01) and higher adjusted total hospitalization charges ($179,916,95% CI −86,141-273,691, p < 0.01). Conclusion: COVID-19 has been associated with TMAs, including TTP. The underlying pathophysiology includes cytokine-mediated endothelial damage and increased levels of pro-coagulant factors, such as factor VIII, vWF, and fibrinogen. Our study found that COVID-19 with concomitant TTP had a threefold higher mortality rate compared to those without TTP. Additionally, patients with TTP had a three to fourfold increased risk of LE DVT/PE, AKI, GIB, and admission to the ICU compared to patients without TTP. The presence of TTP in COVID-19 patients was also associated with longer hospital stays and higher hospitalization charges. To summarize, our study revealed that the presence of TTP in patients with COVID-19 is linked to higher mortality and an increased occurrence of complications including DVT, PE, AKI and GIB. These complications are likely the result of thrombotic events associated with TTP. Further large scale studies are warranted.

Correction of Anemia with Intravenous Iron Mitigates Adverse Maternal Outcomes in Pregnancy

Background and Aim: Iron deficiency anemia (IDA) is common in pregnancy and associated with both maternal and fetal morbidity. Despite its high prevalence and associated complications, there is a lack of consensus regarding the treatment of iron deficiency (ID) in pregnant individuals. In spite of the higher efficacy and tolerance of intravenous (IV) iron compared to oral formulations, obstetric guidelines reserve its use for IDA refractory to oral treatment, even in late gestation. This study sought to determine maternal and neonatal outcomes in individuals receiving IV iron supplementation antepartum, stratified by severity of IDA. Methods: We performed a cohort study of pregnant individuals (age ≥18 years) who received at least one IV infusion of an iron formulation (iron sucrose (IS), low molecular weight iron dextran (LMWID), or ferric carboxymaltose (FCM)) during their pregnancy at a single center from 2011-2022. Our primary outcomes included both neonatal and maternal composite morbidity.Maternal composite morbidity was defined as postpartum hemorrhage, hysterectomy, puerperal infection, preeclampsia/gestational hypertension, maternal ICU admission, and/or requiring blood transfusion. Neonatal composite morbidity was defined as having either preterm birth, 5-minute Apgar less than seven, NICU admission, and/or low birth weight. Secondary outcomes included the incidence of pregnancy morbidity by anemia severity, defined by the World Health Organization Critiera as non-anemic (Hgb >11 g/dL, mild (Hgb 10 to 10.9 g/dL), moderate (Hgb 7 to 9.9 g/dL), or severe (Hgb < 7 g/dL), type of IV iron preparation used, and total iron dose received. Demographics, clinical characteristics, and perinatal outcomes were compared using chi-square or Fisher Exact test and two-sample t-tests. Results: A total of 312 pregnant individuals were included. The majority were 20-34 years (65.1%), multiparous (69.2%), and self-identified as being of White or Hispanic race (42.3% and 37.2%, respectively). Mean ferritin nadir during pregnancy was 12.9 ± 26.7 μg/L, which did not significantly differ between those with and without anemia. A total of 67.3% of individuals were anemic with Hgb < 11g/dL at some time during their pregnancy, with only 22.1% of individuals on admission to labor and delivery (L&D). In this cohort, most individuals (80.9%) received IV LMWID, 17.8% received IV IS, and only 1.0% received IV FCM. IV iron was well tolerated, with only 3 patients (0.96%) not completing their infusion due to reaction. More individuals with moderate anemia on admission received IV IS during pregnancy compared to those with mild and no anemia (50.0% vs 18.4% vs 15.0%, respectively, p<0.01). The mean number of infusions was 2.63±1.51 for IS compared to 1.20±0.40 for LMWID. Mean total iron dose received was 561±392 mg in those receiving IS compared to 979 ± 200 mg in those receiving LMWID. Only 23.4% of individuals received a total of 1,000mg or more of IS, compared to 91.3% of individuals who received LMWID. Anemia status was associated with the incidence of maternal composite morbidity, with more composite morbidity among anemic (25/69 (36.2%)) vs. non-anemic (59/243 (11.5%)) individuals (Table 1). In contrast, the incidence of neonatal composite morbidity did not significantly differ by anemia status. In those who were still anemic at the time of admission (N=69), the degree of anemia severity (mild vs moderate) was not significantly associated with maternal or neonatal composite morbidity (Table 2). Conclusions: Anemia status, regardless of severity, is associated with higher rates of maternal composite morbidity. Anemia on admission to L&D was less likely in those who received IV LMWID compared to those who received IV IS. The total dose of iron received was lower, on average, in those prescribed IS (despite the need for more infusion visits). IV iron therapy was safe and effective in this cohort of pregnant individuals and decreased the incidence of anemia on admission to L&D.

Self-Sustainability with Therapeutic Phlebotomy, a Solution to the National Blood Crisis?

CONCLUSION Hereditary hemochromatosis (HH) is a genetic condition associated with iron overload in the human body. The mainstay of treatment remains therapeutic phlebotomy. On August 1st, 2022, the American Red Cross approved using blood obtained from therapeutic phlebotomy for transfusion. While normal individuals can donate blood only as often as once in 56 days, individuals with HH can have phlebotomy as often as once weekly. Utilizing the blood collected from these patients could be a significant resource to mitigate the shortage of blood needed for transfusion. We aimed to quantify the number of units of blood removed by therapeutic phlebotomy from individuals with HH and assess its potential contribution to total units of blood required in a community hospital for two years (2021 and 2022). We retrospectively reviewed electronic medical records of adult individuals who underwent therapeutic phlebotomy at Saint Vincent Hospital between January 1, 2021, and December 31, 2022. Patients with hereditary hemochromatosis were identified based on a positive genetic test for HFE gene mutations. We collected data including gender, race, age at diagnosis, and the number of units of blood removed from patients during the study period. The total number of units transfused in the in-patient care services and operating room was obtained. A descriptive statistic was performed using R version 4.2.2 statistics software. A total of 112 patients received therapeutic phlebotomy over two years (2021 and 2022) of whom 65% (N=73) had a diagnosis of HH. A majority of the patients were males (60%, 44/73) and were non-Hispanic/Latino (85%, 62/73). The mean age at diagnosis of HH was 62 [standard deviation (SD): 17] years. The median number of units of blood removed by phlebotomy per patient with HH was 3 (2-5), the annual distribution is as displayed in Table 1. A total of 504 units of whole blood was removed through therapeutic phlebotomy from 73 patients during the study period. The total requirement for blood transfusion across all the departments in the hospital was 6065 units (2,733 units in 2021 and 3,332 units in 2022). The total number of units removed through therapeutic phlebotomy in HH patients represented 8.31% (504/6065 Units) and 82.49% (504/611 Units) of total units of blood requirement for the entire hospital and operating room respectively (Table 2). The units of blood removed through therapeutic phlebotomy of patients with HH, could potentially help sustain 8.31% of total blood requirement of the hospital. Primarily, over 82% of the demand from the operating room could be fulfilled if the entirety of the blood from therapeutic phlebotomy were to be transfused. Overcoming technical challenges in utilizing the blood from therapeutic phlebotomy for transfusion in routine clinical practice could help mitigate the national blood crisis and aid in self-sustainability of blood products at a community level. Our study highlights the need for broader efforts to create awareness and incentivizing re-utilization of blood obtained from therapeutic phlebotomy.

Gender Disparities in Outcomes of Autoimmune Hemolytic Anemia Admissions: An Analysis of the National Inpatient Sample

Introduction Autoimmune hemolytic anemia (AIHA) is a condition characterized by the immune destruction of red blood cells, which can necessitate hospitalization in severe cases. The purpose of this study is to compare outcomes of AIHA hospitalizations between genders. Methods We utilized the International Classification of Diseases (ICD) codes to identify all hospitalizations with the primary diagnosis of AIHA in the National Inpatient Sample (NIS) from 2002 to 2019. We excluded all pediatric (age < 18 years) and elective hospitalizations. We described the baseline characteristics of both groups including demographics and comorbidities. We fitted multivariable logistic regression models to compare outcomes between males and females while adjusting for age, race, and comorbidities. Results A total of 60,529 met the inclusion and exclusion criteria. The majority of these were females (59.1% vs 40.1%, p < 0.001). Males were older (median age 67 vs. 66 years, p < 0.001) and had more white race (73.4% vs. 67.9%, p < 0.001). The distribution of associated comorbidities also differed different between both groups ( (Table 1). On adjusted analysis, males had higher in-hospital mortality rates. They also had higher rates of most secondary outcomes; including rates of circulatory shock, need for mechanical ventilation, bacterial pneumonia, acute myocardial infarction, deep vein thrombosis, hemorrhagic stroke, acute kidney injury, and requiring new hemodialysis. Females had higher rates of urinary tract infections. No significant differences were found in the rates of requiring blood transfusions, sepsis, acute heart failure, pulmonary embolism, ischemic stroke, encephalopathy, and gastrointestinal bleeding (Figure 1). Furthermore, male hospitalizations were associated with higher costs (median [IQR] of $11,400 [6,700-20,500] vs. $10,000 [6,000- 17,200]) despite similar length of stay (median [IQR] of 4 days [3-7] vs. 4 days [3-7]). Conclusion Male patients hospitalized with AIHA experience poorer in-hospital compared to females. More research is essential to understand the underlying causes for these disparities and to tailor management to improve outcomes for both male and female AIHA patients.

High Response Rates Following Point-of-Care Anti-CD19 CAR T-Cell Therapy in Adults with Relapsed/Refractory Acute B Lymphoblastic Leukemia

Background Tisagenlecleucel and brexucabtagene autoleucel have demonstrated remarkable efficacy and safety results in adult patients with relapsed/ refractory acute B lymphoblastic leukemia (R/R B-ALL). Long term follow-up of the ZUMA-3 trial recently reported a median duration of response (DOR) of 14.6 months and an overall response rate of 71% (Hadjivassileva, EBMT 2023). Methods and patients We report results of a phase 1b/2 single center clinical trial (NCT02772198) involving point-of-care (POC) anti-CD19/CD28 costimulatory domain chimeric antigen receptor (CAR) T-cell therapy in adults with R/R B-ALL. Inclusion criteria were age ≥18 years, failure of at least 2 prior therapies, and a preserved organ function. Patients underwent a single leukapheresis procedure. Fresh CAR T products were delivered for immediate infusion. Lymphodepletion included fludarabine and cyclophosphamide. Cell dose was 1x10 6 CAR T cells/kg. Primary endpoints were 1-month disease response and safety. Secondary endpoints were the minimal residual disease (MRD) negativity rate, overall survival, progression-free survival (PFS), and production feasibility. Last follow-up was July 2023. Results Between 03/2017-05/2023, 28 patients enrolled. CAR T-cells were successfully produced in 27 patients (96%) who were included in the analysis. The median age was 33 years (range 19-77), and 7 (25%) patients had Karnofsky Performance Status <90%. Six patients (22%) had positive Philadelphia chromosome, and 14 patients (52%) had an extramedullary disease at leukapheresis. Nineteen patients (70%) had ≥3 prior lines of therapy, 18 patients (67%) underwent prior allogeneic hematopoietic stem-cell transplantation (allo-HCT), and 20 patients (74%) had prior exposure to inotuzumab-ozogamicin or blinatumomab. At leukapheresis, 16 patients (60%) had an active disease, while 11 patients (40%) were in complete morphological response (CR; MRD positive, n=7 [26%], MRD negative or not evaluated, n=4 [15%]). The median time between leukapheresis and cell infusion was 11 days (IQR 10-11). Only 3 patients (11%) received bridging chemotherapy. Grade 3-4 cytokine release syndrome and immune effector cell-associated neurotoxicity syndromes were observed in 30% of the patients, each. Six (22%) and 16 (59%) patients were treated with tocilizumab or corticosteroids, respectively. Severe neutropenia (<0.5k/μl) and thrombocytopenia (≤50 K/μl) occurred in 81% and 70% of the patients, respectively, and anemia requiring blood transfusion occurred in 71%. Three patients (11%) had grade 3 cardiovascular events, and 1 patient (4%) had grade 3 pleural effusion. Bloodstream bacterial infection occurred in 3 (11%) patients. Cellular therapy-related mortality was observed in 2 (7%) patients (both due to septic shock). The 1-month overall response rate was 88% (81% CR; MRD negative CR, 63%). MRD was evaluated by RT-PCR in most of the patients. The median follow-up was 19.7 months (IQR 4.7-43.2). Two-year overall survival and PFS were 62% (95% CI: 42-91), and 56% (95% CI: 38-84), respectively. The median DOR was not reached (95% CI: 6.1 months-not reached). PFS was not affected by prior exposure to inotuzumab-ozogamicin or blinatumomab (hazard ratio (HR) 0.7, 95% CI: 0.17-2.68, p=0.6). All eligible patients who achieved a response were offered consolidation with allo-HCT. Eight patients (30%) underwent allo-HCT (2 nd allo-HCT in 3 of them). The DOR was not affected by consolidation of CR with allo-HCT (HR 0.9, 95% CI: 0.2-4.1, p>0.9). Nevertheless, 2 patients (7%) died due to allo-HCT related complications while in CR. Conclusion Treatment with POC CAR T-cells, produced in an academic center, achieved high response and survival rates in adults with R/R B-ALL. These results are also comparable to the FDA approved CAR T-cells. The use of POC CAR T abrogates the need for cryopreservation and shipment of the cells, thus allowing a short vein-to-vein time without the need of bridging therapy in most patients.

Addressing Chronic Anemia in Sickle Cell Disease: Characterizing Erythropoiesis-Stimulating Agent (ESA) Utilization and Practice Patterns Among Providers

Background: Chronic anemia exerts profound impacts on the morbidity, mortality, and quality of life in individuals with sickle cell disease (SCD), but therapeutic options are limited. Erythropoietin-stimulating agents (ESAs) are the standard of care for managing anemia in chronic kidney disease (CKD). However, their utilization in SCD remains ad hoc, with limited literature and no guidelines supporting the use of ESAs in SCD. To address this knowledge gap, we present preliminary findings from a survey designed to evaluate provider practices and identify factors influencing the use of ESAs in SCD. Methods: We conducted a cross-sectional web-based survey from March-July 2023 among providers taking care of patients with SCD in the United States (US) and internationally. Survey items were developed to assess provider demographic characteristics, practice environments, and provider practices around ESA use in SCD. The data was collected and managed using REDCap electronic data capture tools hosted at the University of Pittsburgh. Descriptive statistics were used to report the data. Results: The survey has been completed by 33 providers as of a cut date of July 23, 2023. Most providers were hematologists who practiced in an academic setting (23/33, 69.7%), with an equal gender distribution (Table 1). The number of patients with SCD seen annually varied, with 101-300 patients being the most common cohort size (13/33, 39.4%). In the 12 months prior to survey completion, 15/33 (45.5%) providers treated at least 1 patient with SCD with ESAs, usually outpatient (Table 2). Commonly reported barriers to outpatient ESA therapy included lack of insurance approval/coverage or cost concerns, lack of provider experience, and patient tolerability/adherence or inability to perform self-injections. Fewer respondents reported no barriers to prescribing ESAs in the outpatient setting, compared to in the acute/inpatient setting (18.2% vs. 48.5%). The most commonly reported indications for starting ESAs in the outpatient setting were chronic anemia from end-stage renal disease or CKD, reduction of blood transfusion requirement, and chronic anemia in patients refractory to approved therapies. Less commonly reported indications include severe or symptomatic anemia alone and chronic anemia in the setting of cardiopulmonary disease. Respondents reported several contraindications to starting ESAs, including a history of venous thromboembolism (VTE), malignancy, stroke, coronary artery disease, hypertension, and frequent vaso-occlusive crises. Respondents also expressed concerns about the cost/insurance coverage, efficacy, safety, patient burden, and appropriate dosing of ESAs in patients with SCD. Only 18/33 (54.5%) respondents reported ever treating outpatients with SCD with ESAs; nearly all of them used 1 st generation ESAs, and a majority used 2 nd generation ESAs. For 1 st generation ESAs, the most common starting dose was 3500-7000 units (U) (50-100 U/kg; 22.2%) or 7001-14000 U (101-200 U/kg; 22.2 %). Once weekly was the most common dosing interval (50%), followed by three times a week (TIW; 27.8%) and twice a week (16.7%). The maximum dose used was 56001-70000 U (801-1000 U/kg) TIW. For 2 nd generation ESAs, the most common starting dose was 141-210 mcg (2.1-3.0 mcg/kg) (22.2%), and administration often occurred once every 2 weeks (44.4%) or weekly (27.8%). The maximum dose used was 211-315 mcg (3.1-4.5 mcg/kg) weekly. Outpatient ESAs were most often initiated for hemoglobin (Hb) < 6 g/dL (8/18, 44.4%), and Hb > 9 g/dL was the most common treatment target (6/18, 33.3%). ESAs were often combined with hydroxyurea, voxelotor, and simple transfusions (Table 2). Conclusion: These preliminary survey results show considerable variability in how ESAs are currently being used in people with SCD. These variations in clinical practice highlight both significant ambiguity about what works in this setting and the need for further research into the optimal use of ESAs for the management of chronic anemia in SCD (ongoing clinical trial: ACHiEvE-SCD, NCT05451940). Future directions include evaluating differences in practice patterns among adult vs. pediatric and US-based vs. non-US-based providers.

RED BLOOD CELL TRANSFUSION IN PATIENTS WITH PLACENTA ACCRETA SPECTRUM : A SYSTEMATIC REVIEW

Background: Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Methods: By comparing itself to the standards set by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. So, the experts were able to make sure that the study was as up-to-date as it was possible to be. For this search approach, publications that came out between 2013 and 2023 were taken into account. Several different online reference sources, like Pubmed and SagePub, were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: In the PubMed database, the results of our search brought up 32 articles, whereas the results of our search on SagePub brought up 25 articles. The results of the search conducted for the last year of 2013 yielded a total 32 articles for PubMed and 3 articles for SagePub. In the end, we compiled a total of 3 papers, 2 of which came from PubMed and 1 of which came from SagePub. We included five research that met the criteria. Conclusion: Based on the studies included in this review, we are unable to recommend the minimum of units of red blood cells that should be available before delivery for patients with placenta accreta spectrum. Future studies in the form of large clinical trials is required to study the minimum of RBCs units for PAS patients before delivery, to better inform future guidelines for predelivery blood ordering and transfusion support.

Urgent colonoscopy is not necessary in case of colonic diverticular bleeding without extravasation on contrast-enhanced computed tomography

Background and aimsAcute lower gastrointestinal bleeding (ALGIB) increase with age and the administration of antiplatelet drugs. Colonic diverticular bleeding (CDB) is the most common cause of ALGIB, and endoscopic hemostasis is an effective treatment for massive CDB. But in patients without extravasation on contrast-enhanced computed tomography (CECT), the efficacy of urgent colonoscopy (UCS) is controversial from the point of the clinical course, including rebleeding rate. We aimed to establish a potential strategy including UCS for CDB patients without extravasation on CECT. Patients and methodsPatients from two centers treated for CDB without extravasation on CECT between July 2014 and July 2019 were retrospectively identified (n = 282). Seventy-four underwent UCS, and 208 received conservative management. We conducted two analyses. The first analysis investigates the risk factors of rebleeding rate within 5 days after administration (very early rebleeding), and no UCS (NUCS) was not the independent factor of the very early rebleeding. The second analysis is whether UCS positively influenced the clinical course after hospitalization. ResultsThe prevalence of very early rebleeding and early rebleeding (6–30 days from admission), patients requiring blood transfusion within 0–5 days and 6–30 days post-admission, and duration of hospitalization were examined as clinical course factors between UCS and NUCS group. There was no significant difference between the UCS and non-UCS groups in the clinical course factors. UCS for the CDB patients without extravasation was not improved rebleeding rate and clinical course. ConclusionsUCS is not necessary in case ofCDB patient without extravasation on CECT.

Assessing the impact of different heparin dosing regimens for cardiopulmonary bypass on anticoagulation: the HepDOSE pilot study.

It has been suggested that a larger heparin dose during cardiopulmonary bypass (CPB) is associated with reduced perioperative coagulopathy and thromboembolic complications. We investigated the effect of different heparin doses during routine elective cardiac surgery. Our primary outcomes include blood loss and transfusion and secondary outcomes investigate the effects on coagulation biomarkers. In this prospective pilot trial, we allocated 60 patients undergoing cardiac surgery on CPB in a single tertiary cardiac centre into three groups to receive an initial dose of 300, 400, or 500 units (U) per kilogram of intravenous heparin prior to the commencement of CPB. Blood was sampled after induction of anesthesia, at 30 and 60min of CPB, and three minutes after heparin reversal with protamine. Samples were analyzed for fibrinopeptide A (FPA), fibrinopeptide B (FPB), D-dimer, and thrombin-antithrombin (TAT) complexes. Postoperative blood loss and transfusion was measured for the first 24-hr period after surgery. The total mean (95% CI) administered heparin dose in the 300U·kg-1, 400U·kg-1, and 500U·kg-1 groups were 39,975 (36,528 to 43,421) U, 43,195 (36,940 to 49,449) U and 47,900 (44,807 to 50,992) U, respectively. There were no statistically significant differences in FPA, FPB or D-dimer levels at the measured time intervals. There was a trend towards lower TAT levels while on CPB with greater heparin dosing, which was statistically significant after the administration of protamine. The clinical significance appears to be negligible, as there is no difference in overall blood loss and amount of packed red blood cell transfusion or other blood product transfusion. This pilot study indicates that, while larger heparin dosing for routine cardiac surgery results in subtle biochemical changes in coagulation, there is no demonstrable benefit in postoperative blood loss or transfusion requirements.

Bidirectional Glenn operation without cardiopulmonary bypass: Single center experience and results.

The bidirectional Glenn (BDG) shunt operation serves as temporary surgery for the treatment of single-ventricle physiology with the eventual Fontan procedure. In some cases, the procedure can be performed without the support of a cardiopulmonary bypass (CPB) machine. In this study, we present the surgical outcomes of off-pump BDG operation with the use of a temporary veno-atrial shunt to decompress the superior vena cava (SVC) during clamping time. A cohort of 23 patients underwent off-pump BDG operations at Cardiovascular Center, E Hospital. All patients were operated on using a veno-atrial shunt to decompress the SVC. Satisfactory results with mean oxygen saturation increased from 79.6 ± 11.2% to 87.2 ± 4.7%. The SVC clamping time was 14 ± 2.4 min (ranging from 12 to 21 min). Among 23 patients, only six patients required blood transfusion, 17 patients had BDG without blood transfusion. No neurological complications or deaths occurred after the surgery, and the post-operative period was uneventful. The use of veno-atrial shunts to decompress SVC during off-pump BDG operation is safe with good surgical outcomes and can avoid the deleterious effects caused by CPB. It is easily reproducible, at low cost and economically effective.

Predictors of intraoperative massive transfusion in orthotopic liver transplantation.

Although transfusion management has improved during the last decade, orthotopic liver transplantation (OLT) has been associated with considerable blood transfusion requirements which poses some challenges in securing blood bank inventories. Defining the predictors of massive blood transfusion before surgery will allow the blood bank to better manage patients' needs without delays. We evaluated the predictors of intraoperative massive transfusion in OLT. Data were collected on patients who underwent OLT between 2007 and 2017. Repeat OLTs were excluded. Analyzed variables included recipients' demographic and pretransplant laboratory variables, donors' data, and intraoperative variables. Massive transfusion was defined as intraoperative transfusion of ≥10 units of packed red blood cells (RBCs). Statistical analysis was performed using SPSS version 17.0. The study included 970 OLT patients. The median age of patients was 57 (range: 16-74) years; 609 (62.7%) were male. RBCs, thawed plasma, and platelets were transfused intraoperatively to 782 (80.6%) patients, 831 (85.7%) patients, and 422 (43.5%) patients, respectively. Massive transfusion was documented in 119 (12.3%) patients. In multivariate analysis, previous right abdominal surgery, the recipient's hemoglobin, Model for End Stage Liver Disease (MELD) score, cold ischemia time, warm ischemia time, and operation time were predictive of massive transfusion. There was a direct significant correlation between the number of RBC units transfused and plasma (Pearson correlation coefficient r = .794) and platelets (r = .65). Previous abdominal surgery, the recipient's hemoglobin, MELD score, cold ischemia time, warm ischemia time, and operation time were predictive of intraoperative massive transfusion in OLT.

Blood Transfusion Practices in Obstetrics: An Observational Study at a Tertiary Level Hospital in Bangladesh

One of the eight emergency obstetric components to reduce maternal mortality is blood transfusion. Region, facility, and clinician influence transfusion rates. Bangladesh lacks hospital-based data on obstetric blood transfusions. The study aims to review the incidence, indications, and hazards of blood transfusions among obstetric patients in a tertiary hospital. This descriptive cross-sectional study was undertaken at the Department of Obstetrics, Bangabandhu Sheikh Mujib Medical College Hospital, Faridpur, from June 2022 to December 2022. One hundred and fifty pregnant and postpartum mothers requiring blood transfusions were selected. We analyzed their demographics, clinical history, transfusion hazards, and hospital courses. The blood transfusion rate among obstetric patients was 28.36%. Among the 150 study participants, 71% were from rural areas. Only 8% of patients took ≥4 antenatal care (ANC) visits. Antepartum anemia (51%) and postpartum hemorrhage (40%) were major blood transfusion indications. The mean blood requirement was 1.83 ± 1.22 units (Range: 1 to 7). Forty eight percent of the transfused blood came from the patient’s friends and family, while 7% of the blood was bought. Seven percent of transfusions resulted in adverse reactions. High transfusion rates necessitate planned facility management. In addition to facility preparation, it is essential to strengthen ANC and educate pregnant women about the hazards of anemia during the pregnancy period. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(1): 49-54

INNV-37. BELZUTIFAN IMPACT ON VHL-ASSOCIATED CNS HEMANGIOBLASTOMAS

Abstract INTRODUCTION CNS hemangioblastomas are a leading cause of morbidity and mortality among patients with Von Hippel-Lindau (VHL) disease. Belzutifan, a selective hypoxia-inducible factor (HIF-2a) inhibitor, has been approved for the treatment of hemangioblastomas in VHL patients; however, long-term efficacy and safety data are lacking. METHODS The authors performed a retrospective chart review of all type Ia VHL with symptomatic CNS hemangioblastomas who were treated with Belzultifan at the Moffitt Cancer Center from August 2021 to June 2023. Patient demographics, clinical characteristics, tumor characteristics, and complications were assessed. Patients were re-evaluated with repeat CNS imaging every 3-6 months. RESULTS Eleven patients were identified. Median age is 35 years (IQR: 24-56) and 4/11 patients (36%) are female. Eight out of 11 patients had accessible genetic testing and 87.5% had a missense mutation in the VHL gene. Two patients (18%) had pathology-proven RCC and no patients had pheochromocytomas. One patient (9%) had complete response, eight (73%) had partial response, and two patients (18%) had stable disease at 6 months. Treatment was stopped on 8 patients once they reached stable response to treatment, with 1 patient at 6 months (12.5%), 5 patients at 1 year (62.5%), and 2 patients at 16 months (25%). Five out of 8 patients (62.5%) had sustained response (≥ 3 months) during the time Belzutifan was held. Treatment was restarted on the 3 patients who had progression of disease and all 3 had positive response to treatment at 3 months. All patients had anemia (CTCAE grade 1-2), but did not require blood transfusions, and 1 patient had visual disturbances after restarting Belzutifan. CONCLUSION All patients responded positively to Belzutifan based on surveillance CNS imaging, with no major side effects. The majority of patients had sustained response after having stopped the drug for 3 months.

Impact of transfusion on platelet aggregation and biomarkers in myocardial infarction patients with anemia: an ancillary study of the randomized REALITY trial

Abstract Importance Higher rates of thrombotic events have been reported in patients with myocardial infarction (MI) requiring blood transfusion. The impact of transfusion strategies on biomarkers of thrombosis and inflammation is still unknown. Objective Compare the impact of a liberal vs a restrictive transfusion strategy in anemic MI patients on P2Y12 mediated platelet reactivity and biomarkers of thrombosis and inflammation. Design and Setting: Prespecified ancillary study of the multicentric randomized REALITY trial, performed in 6 French centers between February 2018 and September 2019 (Figure). Patients randomized to a liberal (hemoglobin ≤10g/dL) or a restrictive (hemoglobin ≤8g/dL) transfusion strategy had platelet reactivity measured at baseline and after randomization. Participants: One hundred anemic acute MI patients from the REALITY trial (666 randomized patients). Measurements: Measurements of platelet reactivity included a centralized blinded VASP-PRI assay and PRU measured locally using encrypted VerifyNow assay. Biomarkers of thrombosis (P-selectin, PAI-1, vWF) and inflammation (TNF-α) were also measured. The primary endpoint was the change in the VASP-PRI (difference from baseline and post randomization) between the two randomized groups. Results Among 100 patients included (n=50 in each group), the most frequent P2Y12 inhibitors used was clopidogrel (48%) while 16% of the patients did not receive any P2Y12 inhibitors. Transfused patients received on average 2.4±1.6 units of packed red blood cells. We found no differences between groups in change in P2Y12-mediated platelet aggregation before and after randomization, measured either by the VASP PRI (difference 4.3%; 95% CI (-5.4% to 14.1%)) or by the PRU (difference 23.5; 95% CI (-20.8 to 67.8)). Similar results were found in transfused patients (n=71) regardless of the randomized group, VASP PRI (difference 1.6%; 95% CI (-6.7% to 10.0%)) or PRU (difference -17.6; 95% CI (-41.0 to 5.7)). We did not find an impact of transfusion strategy or transfusion itself in the levels of P-selectin, PAI-1, vWF and TNF-α. Conclusion and Relevance A liberal or a restrictive transfusion strategy does not impact platelet reactivity and biomarkers in MI patients with anemia, supporting the lack of clinically relevant difference in thrombotic risk between both strategies.

How vigilant were we in the diagnosis of peri-operative myocardial infarction before 2022 ESC guidelines?

Abstract Background The diagnosis of myocardial infarction (MI) after non-cardiac surgical intervention is complicated due to possible absence of symptoms as well as of objective ECG or echocardiography signs of ischemia. Aim This is a retrospective analysis of the prevalence of clinically diagnosed MI after non-cardiac surgery in two district hospitals with large-scale surgical services in the period of 2017 - 2022. Methods We retrospectively collected study data using electronic hospital records of all patients that underwent surgical operations for 6 years. Peri-operative MI was selected according to code I21 following any surgical procedure and verified by symptoms, elevated TnI, ECG and Echo changes. Results Total 103 028 patients underwent orthopedic, vascular, abdominal, neuro- surgery from 2017 to 2022. We found 45 patients diagnosed with MI, what makes the prevalence of 0,04%. Diagnostic criteria were: median TnI levels 4925 [1171; 13162] ng/L, symptoms [62% had typical anginal pain, 38% felt dyspnea, 22% had no symptoms], ECG changes {40% with ST elevation, 42% with ST depression, 16% bundle branch block}. Three patients (7%) were administered with troponin test before surgery. Patients with peri-operative MI were 81 [70; 86] years old, 49% females, with the history of CAD (42%), hypertension (71%), diabetes (33%), CKD (13%), anemia (38%), atrial fibrillation (33%), heart failure (47%). The duration of anesthesia was from 20 min to 3h 05 min and it was general in most cases. Bleeding requiring blood transfusion was observed in 27% of cases. It is known that 42% of patients used beta-blockers, 22% used statins before the operation, and 33% saw cardiologist in last 5 years. STEMI occurred in 44%, NSTEMI in 38% of patients, in 18% MI was unspecified, PCI was performed in 44%. Patients were transferred to ICU in 78% of cases and in 20% to cardiology ward. In-hospital deaths occurred in 49% of cases. Conclusions Little number of peri-operative myocardial infarctions are recognized in current practice, however, the mortality of these patients is very high. These findings highlights the importance of implementation of non-cardiac surgery guidelines, namely, routine troponin evaluation in high-risk patients.

Non-immunogenic staphylokinase in the treatment of high-risk massive pulmonary embolism in the early postoperative period due to femoral fragment wound

A case report of double thrombolytic therapy with non-immunogenic staphylokinase at a dose of 15 mg bolus over 15 s in a patient with a high-risk massive pulmonary embolism (PE) in the early postoperative period due to femoral wound is described. After the second thrombolysis, a decrease in the pulmonary arteries thrombotic lesions according to multislice computed tomography data, restoration of right ventricular function, and a decrease in pulmonary hypertension were observed. Reuse of the non-immunogenic staphylokinase did not lead to the major bleeding and hemorrhagic stroke, did not provoke a drop in hemoglobin and did not require blood transfusion. Upon discharge of the patient, normalization of the general blood test parameters was noted: the level of hemoglobin increased from 86 to 112 g/l, erythrocytes — from 2.8 to 3.5x1012/l, hematocrit — from 26 to 32%. Thus, non-immunogenic staphylokinase has demonstrated high efficacy and safety in the treatment of patient with a high-risk massive PE in the early postoperative period.

Abstract 17878: Clinical Profile, Procedure-Related Complications and Long-Term Outcomes in Men and Women With Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation: Insights From TAVI-NOR Study

Introduction: The incidence of aortic stenosis (AS) is increasing. If left untreated, AS progresses to clinical heart failure, reduced quality of life and functional capacity, and ultimately death. Hypothesis: Gender difference in survival benefits of transcatheter aortic valve implantation (TAVI) and frequencies of procedural complications. Methods: We included 600 consecutive, less selected, patients with symptomatic AS who underwent TAVI at our hospital. Clinical and echocardiographic data was analysed in SPSS. Data distribution was checked for normality. The inter-group comparison by Student’s t-test or chi square as appropriate. The association between gender and all-cause mortality assessed by Kaplan-Meier survival analysis with Log-rank test. Results: Mean age was 80.8±6.5 years of the study population. Women (49.3%) were older (82.2 ±5.3 years vs 79.5±7.3 years, p<0.001), had more severe AS and higher left ventricular ejection fraction and more often had basal septal hypertrophy. The prevalence of hypertension and use of antihypertensive medications were higher in women. The prevalence of diabetes mellitus, coronary artery disease, previous stroke, overall abnormal ECG, and atrial fibrillation was higher in men. The severity of symptoms, and prevalence of chronic kidney or lung diseases were comparable. The frequencies of procedure-related paravalvular leakage (PVL) ≥ grade II and endocarditis during follow-up were low, but significantly higher in men than women. No significant difference between genders in procedure-related access site dissection and pseudo-aneurysm, anaemia requiring blood transfusion, or new-onset renal failure. Need of permanent pacemaker implantation following TAVI was also comparable between genders. Mean event-free survival was 59±24 months for men and 66±25 months for women (p<0.001). Most apparent benefits was seen at 3-year follow-up where survival estimate for men was 84% and for women 92%. Conclusions: Results from TAVI-NOR study demonstrates that women with AS were older and had a higher burden of hypertensive heart disease, and showed a significantly better outcome. Men more frequently developed a significant PVL or endocarditis during follow-up.

Abstract 17742: Anterior Papillary Muscle Rupture After a Motor Vehicle Collision: A Rare Case of Torrential Tricuspid Regurgitation After Blunt Cardiac Injury

Introduction: Blunt cardiac injury is difficult to diagnose in the setting of polytrauma. Here we present a rare case of a torrential tricuspid regurgitation from a ruptured anterior papillary muscle after a motor vehicle collision (MVC). Case: A 55-year-old male presented to the ED after an MVC. He was hemodynamically unstable and hypoxic en route complaining of severe chest and left leg pain. Imaging demonstrated multiple rib fractures, a left acetabular fracture, and left open distal femur fracture. EKG identified atrial fibrillation with RVR and nonspecific ST changes. Labs were significant for leukocytosis and a troponin elevation to 11.98 concerning for blunt cardiac injury. A TTE demonstrated a mobile density in the RA and RV consistent with papillary muscle rupture and severe tricuspid regurgitation. An underfilled left ventricle compressed by the right heart and dilated RV were noted with septal flattening consistent with RV pressure and volume overload. Cardiothoracic surgery was consulted and recommended delayed tricuspid valve repair after other acute injuries were addressed considering the need for full anticoagulation. While in the ICU, his orthopedic injuries were addressed though his hemodynamics were complicated by frequent orthopedic interventions requiring blood transfusions. He later underwent TV replacement and it was found that the anterior papillary muscle was ruptured at its base without leaflet perforation. One week post-operatively the patient suffered a hypoxic PEA arrest. The shock team was consulted and he underwent bedside ECMO cannulation with impella placement for LV failure. After ten days on ECMO he was decannulated. Ultimately, the patient recovered well and was discharged to acute rehab. Discussion: MVCs are a leading cause of traumatic tricuspid insufficiency. However, this life-threatening condition may go undetected due polytrauma and the presence of coexisting distracting injuries. Guidelines are needed for the specific management of traumatic tricuspid regurgitation and associated right heart dysfunction. Additionally, the need for multiple surgical interventions can preclude anticoagulation which is a unique barrier to urgent valve replacement in these patients.

Comparison between conventional open-heart valve surgery and minimally invasive valve replacement surgery regarding the length of hospital stay and usage of blood derivates: insights from a single-centre, single-surgeon study conducted in Bosnia and Herzegovina

<p><strong>Aim<br /></strong> To analyse the correlation between different surgical methodologies employed in valve diseases treatment and their subsequent impact on the duration of hospitalization. <br /><strong>Methods<br /></strong> This retrospective study conducted at the Clinical Centre of the University of Sarajevo analysed medical records of 163 valve disease patients treated between January 2019 and November 2022. The patients were divided into two groups: 77 had openheart valve surgery and 86 underwent minimally invasive cardiac surgery (MICS). <br /><strong>Results<br /></strong> The mean duration of the surgical procedures was 3.9±1.3 hours, with conventional open-heart surgery requiring an average of 3.6±1.1 hours and minimally invasive cardiac surgery (MICS) procedure 4.2±1.5 hours. No substantial disparities were found in the total length of hospitalization between the two groups, as both conventional (8.2±4.5 days) and MICS (8.7±7.0 days) demonstrated similar duration. Similarly, the total duration of intensive care unit (ICU) stay displayed similarity, with conventional surgery patients staying an average of 3.9±2.8 days and MICS patients of 4.2±4.1 days. The pattern of blood transfusion and fresh-frozen plasma usage revealed higher rates in the conventional valve surgery group comparing to the MICS group. <br /><strong>Conclusion<br /></strong> Minimally invasive valve surgery, despite slightly longer operative times, resulted in lower blood transfusion requirements and comparable hospitalization and ICU stay.</p>

Low-Volume Acute Normovolemic Hemodilution Does Not Reduce Allogeneic Red Blood Cell Transfusion in Cardiac Surgery in the Modern Era of Patient Blood Management: A Propensity Score-Matched Cohort Study

Patients undergoing cardiac surgery often require blood transfusions, which are associated with increased morbidity and mortality. Patient blood management (PBM) strategies, including acute normovolemic hemodilution (ANH), have been implemented to minimize allogeneic transfusion requirements. Older studies suggested that ANH is associated with reduced transfusions; however, its effectiveness in the modern era of PBM remains unclear. This was a retrospective cohort study. The study was held at a single university hospital. 542 patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB) using low-priming-volume circuits between January 2017 and March 2022. Patients who received ANH were matched with those who did not receive ANH, using propensity scores. The primary outcome was the proportion of patients who received perioperative red blood cell (RBC) transfusion. Of the 542 eligible patients, 49 ANH cases were propensity-score matched to 97 controls. The median ANH volume was 450 mL (IQR, 400-800 mL). There was no significant difference in perioperative RBC transfusion rates between the 2 groups (24.5% in the ANH group vs 30.9% in the control group, p=0.42). The odds ratio for perioperative RBC transfusion in the ANH group versus the control group was 0.72 (95% CI, 0.32-1.55, p=0.42). Low-volume ANH was not associated with a significant reduction in perioperative allogeneic RBC transfusion during cardiac surgery with CPB using low-priming-volume circuits. The benefits of low-volume ANH in reducing the requirement for RBC transfusion in the modern era of PBM may be smaller than reported previously.