Nonemergent Cardiac Surgery Research Articles

THE IMPACT OF ROTATIONAL THROMBOELASTOMETRY (ROTEM) ON IN-HOSPITAL OUTCOMES AND BLOOD PRODUCT UTILIZATION FOLLOWING CARDIAC SURGERY

Point-of-care viscoelastic coagulation testing, including rotational thromboelastometry (ROTEM) and thromboelastography (TEG), was introduced in cardiac surgery to allow for the quick diagnosis of coagulopathies and for the targeted treatment of bleeding patients. Despite the purported benefits of these tests, studies evaluating their value have proven conflicting in their results. The purpose of this study was to determine the contemporary effect of ROTEM on in-hospital outcomes and blood product utilization in patients undergoing cardiac surgery. Patients undergoing first-time, non-emergent cardiac surgery at the New Brunswick Heart Centre were considered. ROTEM was implemented at the New Brunswick Heart Centre over the course of 2016. As such, pre-ROTEM patients included those operated on in 2015, while post-ROTEM patients included those operated on in 2017. Comparisons were made on the basis of baseline characteristics, intra-operative characteristics, in-hospital post-operative outcomes and rates of blood product utilization intra-operatively and/or within the first 24 hours following surgery. A total of 1,438 patients were included (pre-ROTEM: n=691; post-ROTEM: n=747). ROTEM was used in 0% of pre-ROTEM and 15.5% of post-ROTEM patients. No differences in baseline characteristics were noted, including age≥70 years (39.1% vs. 38.2%, p=0.76), female sex (22.6% vs. 21.7%, p=0.73), BMI≥30kg/m2 (40.4% vs. 39.2%, p=0.71), renal failure (3.9% vs. 3.6%, p=0.88), urgent status (55.3% vs. 57.3%, p=0.47) and mean baseline hematocrit (36.3% vs. 36.5%, p=0.56). Intra-operatively, pre-ROTEM patients were less likely to undergo isolated CABG and isolated valve procedures and more likely to undergo combined CABG/valve and other procedures (p < 0.0001). In-hospital mortality (2.5% vs. 1.5%, p=0.25), re-operation for bleeding (0.7% vs. 1.9%, p=0.09) and stroke (1.0% vs. 1.9%, p=0.25) did not differ between the two groups. While rates of coagulation product use, defined as ≥1 dose of FFP, platelets, cryoprecipitate, FEIBA and/or fibrinogen concentrate, were comparable between the pre- and post-ROTEM patients, rates of pRBC use were lower in the post-ROTEM population (Table 1). Following risk adjustment, ROTEM was significantly associated with reduced pRBC use (OR 0.53, 95% CI 0.39-0.73,p < 0.0001) but was not associated with coagulation product use (OR 0.88, 95% CI 0.64-1.21,p=0.43). The institution of ROTEM at our centre did not have an effect on in-hospital outcomes or coagulation product utilization. It was, however, associated with reduced pRBC use, although it is not clear as to whether or not this phenomenon was the result of ROTEM use or the result of overall changes in clinical practice patterns.

Relative value of cystatin C and creatinine-based estimates of glomerular filtration rate in predicting long-term mortality after cardiac surgery: a cohort study

ObjectiveRenal dysfunction predicts an increased risk of both early and long-term mortality after cardiac surgery. Cystatin C enables glomerular filtration rate (GFR) to be estimated accurately and may be superior...

Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients

Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04). The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed. ClinicalTrials.gov identifier: NCT00981474.

Outcomes of patients on dual antiplatelet therapy post-coronary stenting following emergency noncardiac surgery.

The outcomes of patients on dual antiplatelet therapy (DAPT) post-coronary stenting following emergency noncardiac surgery remain unclear. This retrospective cohort study included patients on DAPT post-coronary stenting who underwent emergency noncardiac surgery within 24hours of diagnosis from April 2007 to March 2018 where DAPT was discontinued within <5days for aspirin and 7days for P2Y12 inhibitors. Our primary outcome was 180-day mortality in these patients. We investigated factors associated with bleeding within 180days after surgery as our secondary outcome and exploratorily examined factors affecting 180-day mortality. Of 62,528 patients who underwent any surgery under general anaesthesia during the 11-year study period, 133 patients (0.22% of all and 1.41% of emergency surgical patients) were analysed. Among the eligible patients, 180-day mortality was 9.8% (13/133). Eighteen patients (13.5%) developed bleeding within 180days after surgery, which was the most common post-operative complication. Restarting antiplatelet agents <2days post-operatively (OR, 4.51; 95% CI, 1.56-13.0; P=0.005) and stent implantation at bifurcation lesions before surgery (OR, 3.28; 95% CI, 1.07-10.1; P=0.04) were associated with post-operative bleeding. Patients on haemodialysis had the worse prognosis (hazard ratio, 5.73; 95% CI, 1.87-17.5; P=0.002) in terms of 180-day mortality. The 180-day mortality following emergency noncardiac surgery was approximately 10% in patients on DAPT post-coronary stenting. Restarting antiplatelet agents earlier than 2days post-operatively and coronary stenting at bifurcation lesions were associated with bleeding within 180days after surgery.

Genome-wide association study of myocardial infarction, atrial fibrillation, acute stroke, acute kidney injury and delirium after cardiac surgery \u2013 a sub-analysis of the RIPHeart-Study

BackgroundThe aim of our study was the identification of genetic variants associated with postoperative complications after cardiac surgery.MethodsWe conducted a prospective, double-blind, multicenter, randomized trial (RIPHeart). We performed a genome-wide association study (GWAS) in 1170 patients of both genders (871 males, 299 females) from the RIPHeart-Study cohort. Patients undergoing non-emergent cardiac surgery were included. Primary endpoint comprises a binary composite complication rate covering atrial fibrillation, delirium, non-fatal myocardial infarction, acute renal failure and/or any new stroke until hospital discharge with a maximum of fourteen days after surgery.ResultsA total of 547,644 genotyped markers were available for analysis. Following quality control and adjustment for clinical covariate, one SNP reached genome-wide significance (PHLPP2, rs78064607, p = 3.77 × 10− 8) and 139 (adjusted for all other outcomes) SNPs showed promising association with p < 1 × 10− 5 from the GWAS.ConclusionsWe identified several potential loci, in particular PHLPP2, BBS9, RyR2, DUSP4 and HSPA8, associated with new-onset of atrial fibrillation, delirium, myocardial infarction, acute kidney injury and stroke after cardiac surgery.Trial registrationThe study was registered with ClinicalTrials.gov NCT01067703, prospectively registered on 11 Feb 2010.

Optimal Duration for Clopidogrel Suspension Prior to Coronary Artery Bypass Grafting.

BackgroundAmerican College of Cardiology (ACC) guidelines suggest clopidogrel (Plavix) suspension for 5 days before non-emergent cardiac surgery (class IIa, level B). It puts the patients with recent angioplasty and ongoing ischemia at a higher risk of stent thrombosis. We sought to determine the bleeding risk in patients who stopped clopidogrel at 3 and less than 3 days before coronary artery bypass grafting (CABG) as compared to the usual 5 days prior to CABG.MethodsA retrospective single center study was performed; and a total of 90 patients were included. Forty patients were not on clopidogrel but underwent CABG and hence were used as a control group (group 3). Fifty remaining patients were divided into three groups. Patients in whom clopidogrel was stopped 3 days or less before CABG were included in group 1 (n = 25); group 2 included patients who followed the standard ACC guidelines and clopidogrel was suspended 5 days before the CABG (n = 17); and finally patients who had stopped clopidogrel 4 days prior to surgery were included in group 4 (n = 8). This was compared to controls. Postoperative hemoglobin drop was analyzed between subgroups using IBM SPSS version 25.ResultsThe mean age of the included population was 69.9 years (46 - 88) with 65% of them being male and 35% female patients. The difference in the hemoglobin fall was compared amongst these groups using the one-way ANOVA. There were no outliers, as assessed by boxplot, the data were normally distributed for each group, as assessed by Shapiro-Wilk test (P > 0.05), and there was homogeneity of variances, as assessed by Levene’s test of homogeneity of variances (P > 0.05). The fall in hemoglobin for the four different groups was analyzed. The fall in hemoglobin in group 1 (stopped clopidogrel 3 days or less before CABG) was (n = 25, 2.36 ± 1.24), the fall in group 2 (stopped clopidogrel 5 days prior to CABG) was (n = 17, 2.89 ± 1.22), the fall in hemoglobin in group 3 (patients not on clopidogrel) was (n = 40, 2.54 ± 1.35), and the fall in hemoglobin in group 4 (patients stopped clopidogrel 4 days prior to CABG) was (n = 8, 2.02 ± 1.31). ANOVA was subsequently performed on the patient data, which showed no statistical difference between all the four groups regarding the fall in hemoglobin during surgery (P = 0.41).ConclusionsOur study concludes that there was no significant difference in the hemoglobin drop of the patients who had clopidogrel stopped 3 days prior to the major procedure like CABG in comparison to the patients who stopped clopidogrel 5 days before surgery. We advocate, that early cessation of clopidogrel is posing a threat of thrombosis in high risk patients with no additional benefit of decreased bleeding risks. However, large population studies are needed to validate the results.

Causes of Dyspnea after Cardiac Surgery.

Postoperative dyspnea is common after cardiac surgery, even in low-risk patients. Cardiac surgeons and anesthesiologists are familiar with patients suffering from dyspnea in the early postoperative period, but in some cases, conventional treatment strategies may be ineffective, and a consultation with a pulmonologist may be required. The aim of this study is to investigate the causes of dyspnea after cardiac surgery in this particular patient group. The hospital database was searched for non-emergency cardiac surgery for the period January 2014-October 2015. Individuals with an impaired spirometry result and a history of any pulmonic disease were excluded. Only patients for whom a pulmonary consultation was needed because of dyspnea in the postoperative course were enrolled in the study. Causes of dyspnea were analyzed according to consultation reports and computed tomography findings. One hundred and three patients were enrolled in the study. Of those, 67 (65%) were male, and the mean age was 61.50±9.43. The most common procedure was the coronary artery bypass grafting. Atelectasis (n=57, 42%) was the most common cause of dyspnea. The length of the intensive care unit (ICU) stay was significantly longer in the pneumonia group (p=0.012). Hospital mortality in the pneumonia group was significantly higher compared with other subgroups (p<0.001). After cardiac surgery, atelectasis was the most common cause of dyspnea, followed by pleural effusion and pneumonia. Patients who experienced dyspnea due to pneumonia had a longer ICU stay. Developing the treatment strategies with consideration of these causes may help reduce the length of stay, morbidity, and mortality in this patient group.

Correction to: A Novel Bridging Strategy for Patients Undergoing Emergent Non-Cardiac Surgery with a Recent Coronary Stent.

In the original publication, the abstract text, informed consent and disclosure text have been published incorrectly.

A Novel Bridging Strategy for Patients Undergoing Emergent Non-Cardiac Surgery with a Recent Coronary Stent.

IntroductionNot infrequently, patients undergoing dual antiplatelet therapy for a recent cardiac stent develop a need for a non-cardiac surgery. Most of these surgeries can be delayed while the antiplatelet treatment is stopped and normal platelet function returns in order to avoid potential surgical complications and excessive bleeding. However, there are a number of patients who require urgent surgery where the procedure cannot be postponed. To date, no agents have been proven to bridge the patient off dual-antiplatelet therapy.MethodsA 46-year-old man was admitted to the hospital with an acute anterior wall myocardial infarction. He was urgently taken to the catheterization lab where he was found to have a totally occluded proximal left anterior descending coronary artery (LAD). He was successfully stented with a drug-eluting stent of the LAD, but subsequently developed a sarcoma 2 months later that required urgent surgery. The novel direct-acting, reversible P2Y12 receptor inhibitor cangrelor was used to bridge this patient followed by ongoing antiplatelet treatment, allowing surgery for the removal of a soft tissue sarcoma.ResultsCangrelor was successfully used to bridge a patient with a recent stent placement and current antiplatelet treatment undergoing the removal of a soft tissue sarcoma.ConclusionThis case report demonstrates the use of a novel, now currently available, short-acting antiplatelet agent that can be used for bridging patients undergoing non-cardiac surgery who had a recent myocardial infarction and stent placement.

Post-traumatic stress disorder among patients waiting for cardiac surgery

Aim of the studyThe study aims at a preliminary assessment of the occurrence of PTSD among patients awaiting major heart surgery and the assessment off the reliability of the Impact of Event Scale – Revised (IES-R).Subject or material and methods100 consecutive patients scheduled to non-emergency cardiac surgery were screened using a brief list of PTSD symptoms. Those who responded affirmatively, were ask to fill in the IES-R and then underwent structured Mini International Neuropsychiatric Interview (MINI) and a clinical assessment according to the DSM-5 criteria.ResultsFourteen of fifteen patients who completed the IES-R obtained results indicating a possibility of PTSD. Five of them refused to undergo a psychiatric examination. Four of nine patients whose IES-R scores indicated PTSD, met its criteria according to MINI. and DSM-5. One PTSD case was related to cardiological problems.DiscussionThe results of the present study do not support the hypothesis that heart disease is a stressor causing PTSD in patients awaiting cardiac surgery. Moreover, the results impair the conclusions suggesting high rate of PTSD occurrence among some populations of cardiological patients, in research conducted with self-rating scales. The results of the presented study demonstrate that clinical psychiatric examination is necessary to properly confirm a PTSD diagnosis.ConclusionsThe prevalence of PTSD (4%) in the study group was higher than in the general population in Poland, but the heart related stressor was found only in one case (1%), that is equal with the rate of PTSD. The reliability of IES-R is low due to a large number of false-positives.

Prediction of Post Operative Complication in Patients with Valvular Heart Surgery Based on O2 Challenge Test and A-A Gradient.

Patients with valvular heart diseases may have more physiological lung derangements and therefore at current study we studied correlation of O2 challenge, A-AG tests and spirometry values of patients who underwent valve surgery on post op respiratory complications. Method: 180 adult patients undergoing non-emergency cardiac valvular surgery were studied. On operating room all patients had arterial blood gas profile (ABG) at room air, 20 minutes after putting on ventilator with 100% O2, and pump oxygenator. Pulmonary function tests, alveolar Oxygen Pressure, mean Arterial pressure of carbon dioxide and alveolar -arterial gradients measured. Results: FEV1, FVC and FEV1/FVC%, pressure of arterial Blood Gasses (O2 and CO2) with fraction of inspired oxygen of 100% and air (PO2-100 and PO2-air), were significantly different between patients with POPC and patients without POPC (p-value <0.05). Indeed PO2-100 and PO2-air were significantly lower in patients with POPC. A-AG100 (p-value: 0.02) and A -AG21 (p-value: 0.02) were significantly higher in patients with POPC in comparison with patients without POPC. The AUC of A-AG100 for predicting POPC was 0.59 (95% confidence interval (CI) 0.51-0.67). The optimal cut point of A-AG100 was 311 and showed evidence of high relatively sensitivity of 80% and a negative predictive value of 61%. Conclusion: Valvular heart surgery still has significant post op complication and mortality. There is significant correlation between A-AG100, A-AG21 percent, PaO2100, and FEV1/FVC with post op complications in these patients. We recommend measurement of these values in pre op evaluation of patient who need cardiac surgery.

Prophylaxis of postoperative nausea and vomiting after cardiac surgery in high-risk patients: A randomized controlled study.

Context:The role of prophylaxis for postoperative nausea and vomiting (PONV) in cardiac surgery is under debate.Aims:To study the risk factors for PONV after cardiac surgery and the role of betamethasone with or without droperidol for its prevention.Setting and Design:Randomized open-label controlled study comparing standard care with PONV prophylaxis from February to November 2016.Methods:Five hundred and two patients with planned nonemergent cardiac surgery were included. Interventions: In the intervention arm, PONV prophylaxis (4 mg betamethasone with/without 0.625 mg droperidol) was administered in high-risk patients (two or more risk factors). Patients in the control arm were treated as per routine hospital practices.Results:Female sex, past history of PONV, and migraines were associated with a significantly increased risk of PONV, while motion sickness, smoking status, and volatile anesthetics were not. Pain and treatment with nefopam or ketoprofen were associated with an increased risk of PONV. PONV was less frequent in the active arm compared to controls (45.5% vs. 54.0%, P = 0.063; visual analogic scale 10.9 vs. 15.3 mm, P = 0.043). Among the 180 patients (35.6%) with ≥2 risk factors, prophylaxis was associated with reduced PONV (intention-to-treat: 46.8% vs. 67.8%, P = 0.0061; per-protocol: 39.2% vs. 69%, P = 0.0002). In multivariate analysis, prophylaxis was independently associated with PONV (odds ratio [OR]: 0.324, 95% confidence interval: 0.167–0.629, P = 0.0009), as were female sex, past history of PONV, and migraines (OR: 3.027, 3.031, and 2.160 respectively). No drug-related side effects were reported.Conclusion:Betamethasone with/without droperidol was effective in decreasing PONV in high risk cardiac surgical patients without any side effect.

312 - Contribution of Heart Failure to Readmissions Following Non-Emergent Cardiac Surgery

312 - Contribution of Heart Failure to Readmissions Following Non-Emergent Cardiac Surgery

Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score-matched observational cohort study.

Delay of surgery for hip fracture is associated with increased risk of morbidity and mortality, but the effects of surgical delays on mortality and resource use in the context of other emergency surgeries is poorly described. Our objective was to measure the independent association between delay of emergency surgery and in-hospital mortality, length of stay and costs. We identified all adult patients who underwent emergency noncardiac surgery between January 2012 and October 2014 at a single tertiary care centre. Delay of surgery was defined as the time from surgical booking to operating room entry exceeding institutionally defined acceptable wait times, based on a standardized 5-level priority system that accounted for surgery type and indication. Patients with delayed surgery were matched to those without delay using propensity scores derived from variables that accounted for details of admission and the hospital stay, patient characteristics, physiologic instability, and surgical urgency and risk. Of 15 160 patients, 2820 (18.6%) experienced a delay. The mortality rates were 4.9% (138/2820) for those with delay and 3.2% (391/12 340) for those without delay (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.30-1.93). Within the propensity-matched cohort, delay was significantly associated with mortality (OR 1.56, 95% CI 1.18-2.06), increased length of stay (incident rate ratio 1.07, 95% CI 1.01-1.11) and higher total costs (incident rate ratio 1.06, 95% CI 1.01-1.11). Delayed operating room access for emergency surgery was associated with increased risk of inhospital mortality, longer length of stay and higher costs. System issues appeared to underlie most delays and must be addressed to improve the outcomes of emergency surgery.

CAN OLDER PATIENTS WITH SYMPTOMATIC SEVERE AORTIC STENOSIS UNDERGO EMERGENCY NON-CARDIAC SURGERY WITH AN ACCEPTABLE RISK?

Background: Risk stratification of elderly symptomatic severe aortic stenosis(AS) patients who need emergent non-cardiac surgery can be problematic. Our objective was to determine the outcome of patients with symptomatic severe AS who underwent emergent non-cardiac surgery without aortic valve

Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery

The efficacy of statins in reducing perioperative cardiovascular and other organ system complications in patients undergoing noncardiac surgery remains controversial. Owing to a paucity of randomized clinical trials, analyses of large databases may facilitate informed hypothesis generation and more efficient trial design. To evaluate associations of early perioperative statin use with outcomes in a national cohort of veterans undergoing noncardiac surgery. This retrospective, observational cohort analysis included 180 478 veterans undergoing elective or emergent noncardiac surgery (including vascular, general, neurosurgery, orthopedic, thoracic, urologic, and otolaryngologic) who were admitted within 7 days of surgery and sampled by the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients were admitted to Department of Veterans Affairs hospitals and underwent 30-day postoperative follow-up. Data were collected from October 1, 2005, to September 30, 2010, and analyzed from November 28, 2013, to October 31, 2016. Statin use on the day of or the day after surgery. All-cause 30-day mortality (primary outcome) and standardized 30-day cardiovascular and noncardiovascular outcomes captured by VASQIP. Use of statins and other perioperative cardiovascular medications was ascertained from the Veterans Affairs Pharmacy Benefits Management research database. A total of 180 478 eligible patients (95.6% men and 4.4% women; mean [SD] age, 63.8 [11.6] years) underwent analysis, and 96 486 were included in the propensity score-matched cohort (96.3% men; 3.7% women; mean [SD] age, 65.9 [10.6] years). At the time of hospital admission, 37.8% of patients had an active outpatient prescription for a statin, of whom 80.8% were prescribed simvastatin and 59.5% used moderate-intensity dosing. Exposure to a statin on the day of or the day after surgery based on an inpatient prescription was noted in 31.5% of the cohort. Among 48 243 propensity score-matched pairs of early perioperative statin-exposed and nonexposed patients, 30-day all-cause mortality was significantly reduced in exposed patients (relative risk, 0.82; 95% CI, 0.75-0.89; P < .001; number needed to treat, 244; 95% CI, 170-432). Of the secondary outcomes, a significant association with reduced risk of any complication was noted (relative risk, 0.82; 95% CI, 0.79-0.86; P < .001; number needed to treat, 67; 95% CI, 55-87); all were significant except for the central nervous system and thrombosis categories, with the greatest risk reduction (relative risk, 0.73; 95% CI, 0.64-0.83) for cardiac complications. Early perioperative exposure to a statin was associated with a significant reduction in all-cause perioperative mortality and several cardiovascular and noncardiovascular complications. However, the potential for selection biases in these results must be considered.

A multicentre randomised controlled trial of Transfusion Indication Threshold Reduction on transfusion rates, morbidity and health-care resource use following cardiac surgery (TITRe2).

Uncertainty about optimal red blood cell transfusion thresholds in cardiac surgery is reflected in widely varying transfusion rates between surgeons and cardiac centres. To test the hypothesis that a restrictive compared with a liberal threshold for red blood cell transfusion after cardiac surgery reduces post-operative morbidity and health-care costs. Multicentre, parallel randomised controlled trial and within-trial cost-utility analysis from a UK NHS and Personal Social Services perspective. We could not blind health-care staff but tried to blind participants. Random allocations were generated by computer and minimised by centre and operation. Seventeen specialist cardiac surgery centres in UK NHS hospitals. Patients aged > 16 years undergoing non-emergency cardiac surgery with post-operative haemoglobin < 9 g/dl. Exclusion criteria were: unwilling to have transfusion owing to beliefs; platelet, red blood cell or clotting disorder; ongoing or recurrent sepsis; and critical limb ischaemia. Participants in the liberal group were eligible for transfusion immediately after randomisation (post-operative haemoglobin < 9 g/dl); participants in the restrictive group were eligible for transfusion if their post-operative haemoglobin fell to < 7.5 g/dl during the index hospital stay. The primary outcome was a composite outcome of any serious infectious (sepsis or wound infection) or ischaemic event (permanent stroke, myocardial infarction, gut infarction or acute kidney injury) during the 3 months after randomisation. Events were verified or adjudicated by blinded personnel. Secondary outcomes included blood products transfused; infectious events; ischaemic events; quality of life (European Quality of Life-5 Dimensions); duration of intensive care or high-dependency unit stay; duration of hospital stay; significant pulmonary morbidity; all-cause mortality; resource use, costs and cost-effectiveness. We randomised 2007 participants between 15 July 2009 and 18 February 2013; four withdrew, leaving 1000 and 1003 in the restrictive and liberal groups, respectively. Transfusion rates after randomisation were 53.4% (534/1000) and 92.2% (925/1003). The primary outcome occurred in 35.1% (331/944) and 33.0% (317/962) of participants in the restrictive and liberal groups [odds ratio (OR) 1.11, 95% confidence interval (CI) 0.91 to 1.34; p = 0.30], respectively. There were no subgroup effects for the primary outcome, although some sensitivity analyses substantially altered the estimated OR. There were no differences for secondary clinical outcomes except for mortality, with more deaths in the restrictive group (4.2%, 42/1000 vs. 2.6%, 26/1003; hazard ratio 1.64, 95% CI 1.00 to 2.67; p = 0.045). Serious post-operative complications excluding primary outcome events occurred in 35.7% (354/991) and 34.2% (339/991) of participants in the restrictive and liberal groups, respectively. The total cost per participant from surgery to 3 months postoperatively differed little by group, just £182 less (standard error £488) in the restrictive group, largely owing to the difference in red blood cells cost. In the base-case cost-effectiveness results, the point estimate suggested that the restrictive threshold was cost-effective; however, this result was very uncertain partly owing to the negligible difference in quality-adjusted life-years gained. A restrictive transfusion threshold is not superior to a liberal threshold after cardiac surgery. This finding supports restrictive transfusion due to reduced consumption and costs of red blood cells. However, secondary findings create uncertainty about recommending restrictive transfusion and prompt a new hypothesis that liberal transfusion may be superior after cardiac surgery. Reanalyses of existing trial datasets, excluding all participants who did not breach the liberal threshold, followed by a meta-analysis of the reanalysed results are the most obvious research steps to address the new hypothesis about the possible harm of red blood cell transfusion. Current Controlled Trials ISRCTN70923932. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 60. See the NIHR Journals Library website for further project information.

Are lower levels of red blood cell transfusion more cost-effective than liberal levels after cardiac surgery? Findings from the TITRe2 randomised controlled trial

ObjectiveTo assess the incremental cost and cost-effectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery.DesignA within-trial cost-effectiveness analysis with a 3-month time horizon, based...

Development of the Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ).

Some variability in recovery and outcomes after cardiac surgery may be influenced by psychosocial aspects not routinely captured. Preliminary evidence suggests patient expectations impact health status, but there is no specific measure of expectations for cardiac surgery. The purpose of this study was to adapt an expectations scale to cardiac surgery and assess the psychometric properties of the scale. Before surgery, 93 patients awaiting non-emergent cardiac surgery completed questionnaires, including the adapted Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ). At 1year after surgery, 68 patients completed questionnaires. Mean C-SPEQ score was 39.4±9.02, and scores were normally distributed (Cronbach's alpha=0.86). Higher score indicated negative expectations. Higher presurgery C-SPEQ score was correlated with greater depression (r=0.32, p=0.01) and perceived stress (r=0.36, p=0.003), but not state anxiety (r=0.18, p=0.14), at one-year post-surgery. Higher C-SPEQ was associated with longer recovery time (B=0.14, p=0.006) and lower physical HRQL after surgery (B=-0.31, p=0.005). Higher C-SPEQ was not related to greater odds for perioperative complications (OR 1.01, p=0.68) or readmissions <30days (OR 1.05, p=0.31). C-SPEQ score was not related to survival. Adaptation of an expectations questionnaire to cardiac surgery patients was successful with acceptable reliability and validity. Negative expectations had a detrimental impact on recovery and HRQL following cardiac surgery but were not related to clinical outcomes. Although focus is mainly on improving clinical outcomes, there are opportunities to improve non-clinical aspects of the patient experience. Presurgical education might better prepare patients, reduce negative expectations, and improve psychosocial outcomes after cardiac surgery.

Routine operation theatre extubation after cardiac surgery in the elderly.

The aim was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate operation theatre (OT) extubation after on-pump or off-pump cardiac surgery. A retrospective analysis was performed of prospectively collected data over a 4-year period (2011-14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years were considered eligible for immediate OT or intensive care unit (ICU) early extubation after meeting specific criteria. All types of non-emergency cardiac surgery were included. Cardiac surgical risk stratification was assessed with EuroSCORE II and age, creatinine level and left ventricular ejection fraction (ACEF) score. Among the 415 patients operated on during the period, 275 (66.3%) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The rate of risk of reintubation within 24 h of surgery after OT extubation was 2.1%. The in-hospital mortality rate was 4.7%, and the complication rate was 11.6%, independently of extubation timing. Elderly patients extubated in the OT had a significantly lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time, less complications and shorter length of stay than ICU-extubated patients. In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74-228.8, P = 0.004), and had good discriminating power [receiver operating characteristics (ROC) area 0.713]. On the other hand, the EuroSCORE ROC area used to predict OT extubation was 0.694, and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation versus 37.3% when the risk value was over 2.11 (P = 0.0002). OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. A key point of this success was the use of a short-acting volatile agent to maintain anaesthesia throughout the procedure. Low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly.