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Predictors of packed red cell transfusion after isolated primary coronary artery bypass grafting – The experience of a single cardiac center: A prospective observational study
Elsayed M Elmistekawy, Lee Errett, Hosam F Fawzy
Journal of Cardiothoracic Surgery , 2009, DOI: 10.1186/1749-8090-4-20
Abstract: 105 patients undergoing isolated, first-time CABG were reviewed for their preoperative variables and followed for intraoperative and postoperative data. Patients were 97 males and 8 females, with mean age 58.28 ± 10.97 years. Regression logistic analysis was used for identifying the strongest perioperative predictors of PRBC transfusion.PRBC transfusion was used in 71 patients (67.6%); 35 patients (33.3%) needed > 2 units and 14 (13.3%) of these needed > 4 units. Univariate analysis identified female gender, age > 65 years, body weight ≤ 70 Kg, BSA ≤ 1.75 m2, BMI ≤ 25, preoperative hemoglobin ≤ 13 gm/dL, preoperative hematocrit ≤ 40%, serum creatinine > 100 μmol/L, Euro SCORE (standard/logistic) > 2, use of CPB, radial artery use, higher number of distal anastomoses, and postoperative chest tube drainage > 1000 mL as significant predictors. The strongest predictors using multivariate analysis were CPB use, hematocrit, body weight, and serum creatinine.The predictors of PRBC transfusion after primary isolated CABG are use of CPB, hematocrit ≤ 40%, weight ≤ 70 Kg, and serum creatinine > 100 μmol/L. This leads to better utilization of blood bank resources and cost-efficient targeted use of expensive blood conservation modalities.Blood component transfusion has been an important part of coronary artery bypass graft surgery (CABG) since its inception [1]. Transfusion rates in cardiac surgery remain high despite major advances in perioperative blood conservation and institutions continue to vary significantly in their transfusion practices for CABG surgery [2-7]. The mean number of packed red blood cells (PRBCs) transfused in CABG ranges from 0 to 6.3 units per patient, and the frequency of transfusion ranges from 16% to 100% [1]. The National Blood Service for England issues approximately 2.2 million units of blood a year, of which 10% are used in cardiac surgical units [8,9]. Nearly 20% of all blood transfusions in the United States are associated with cardiac surgery [
Transfusion associated graft versus host disease in an immunocompetent individual following coronary artery bypass grafting
Nagendra Girish,Ramakrishna M,Hegde Devi,Damodar Sharad
Indian Journal of Critical Care Medicine , 2008,
Abstract: Transfusion associated graft versus host disease (TA-GVHD) is a rare but commonly fatal complication of transfusion of cellular blood products, which usually occurs in immunosuppressed individuals following transfusion and subsequent engraftment of viable T lymphocytes. Very rarely it may arise in apparently immunocompetent individuals. The clinical syndrome consists of fever, skin rash, diarrhoea, hepatic dysfunction, and bone marrow aplasia. The outcome is nearly always fatal. We present here a case report of fatal TA-GVHD in a "presumed" immunocompetent patient, post coronary artery bypass grafting surgery after transfusion of blood products. The patient died 24 days after transfusion. There is a perceived increased risk of TA-GVHD following bypass grafting and other surgical procedures where cardiopulmonary bypass is required. TA-GVHD is probably underreported and the incidence is felt to be too low to warrant routine irradiation of cellular products for this group of patients. Clinicians, pathologists, and transfusion centers should be aware of this rare but devastating complication of blood transfusion after cardiac surgery.
Predictors of Atrial Fibrillation Following Coronary Artery Bypass Grafting
Feridoun Sabzi, Abdol Hamid Zokaei and Abdol Rasoul Moloudi
Clinical Medicine Insights: Cardiology , 2012, DOI: 10.4137/CMC.S7170
Abstract: Background: Atrial fibrillation (AF) is a frequent and serious complication of coronary artery bypass graft (CABG) surgery. Methods: We undertook a retrospective review of the records of patients undergoing CABG at Imam Ali Hospital between February 1, 2003 and February 1, 2006. The patients were divided in two groups, ie, Group A (AF) and Group B (no AF). The association between the occurrence of AF following CABG and other variables was compared with respect to continuous or categorical variables by t-test and c2-test. Results: Multivariate logistic regression analysis of potentially predictive factors in univariate analysis showed that opium use, type of operation, and crossclamp time were predictors of AF following CABG. Conclusion: This study identifies some new predictors of postoperative AF, control of which could lead to a lower incidence of AF and reduced morbidity, mortality, and resource utilization for patients undergoing cardiac surgery.
Comparison of Bleeding and Transfusion in Patients who Undergo Coronary Artery Bypass Grafting with and without Cardiopulmonary Bypass
M Abbaszadeh,F Mehrani,A Boloorian,E Jazayeri Gharehbagh
Payavard Salamat , 2011,
Abstract: Background and Aim: Excessive Bleeding continues to play a key role and an important cause of morbidity and mortality after cardiopulmonary bypass (CPB). The goal of this study was to determine the differences in bleeding and transfusion between OPCAB and on -pump CABG patients.Materials and Methods: In a randomized, double blinded prospective study 300 patient's undergoing coronary revascularization surgery were enrolled, 150 CABG patients were compared with 150 OPCAB patients. The patients were assessed during the first 72 hours to determine the postoperative side effects. The 2 groups were compared using the chi-square test or fisher's exact test and the rank sum test.Results: CABG patients received more intraoperative red blood cells (P<0.0001), more albumin and more fresh- frozen plasma (P<0.0001). Postoperatively, CABG patients were more likely to receive more platelets (29.3% ν 70.7 %, P<0.007). During the operative and the initial 4-hour postoperative period OPCAB patients exhibited greater blood loss (P<0.0001); however, at 12,24and 72 hours postoperatively, CABG patients exhibited greater blood loss. There were4 death in CABG patients (P<0.05)Conclusion: Despite not reversing the heparin at the end of the OPCAB surgery, OPCAB surgery was associated with an overall reduction in platelets, fresh- frozen plasma, Albumin and transfusion requirements.
Hybrid Coronary Revascularization as a Safe, Feasible, and Viable Alternative to Conventional Coronary Artery Bypass Grafting: What Is the Current Evidence?  [PDF]
Arjan J. F. P. Verhaegh,Ryan E. Accord,Leen van Garsse,Jos G. Maessen
Minimally Invasive Surgery , 2013, DOI: 10.1155/2013/142616
Abstract: The “hybrid” approach to multivessel coronary artery disease combines surgical left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass grafting and percutaneous coronary intervention of the remaining lesions. Ideally, the LITA to LAD bypass graft is performed in a minimally invasive fashion. This review aims to clarify the place of hybrid coronary revascularization (HCR) in the current therapeutic armamentarium against multivessel coronary artery disease. Eighteen studies including 970 patients were included for analysis. The postoperative LITA patency varied between 93.0% and 100.0%. The mean overall survival rate in hybrid treated patients was 98.1%. Hybrid treated patients showed statistically significant shorter hospital length of stay (LOS), intensive care unit (ICU) LOS, and intubation time, less packed red blood cell (PRBC) transfusion requirements, and lower in-hospital major adverse cardiac and cerebrovascular event (MACCE) rates compared with patients treated by on-pump and off-pump coronary artery bypass grafting (CABG). This resulted in a significant reduction in costs for hybrid treated patients in the postoperative period. In studies completed to date, HCR appears to be a promising and cost-effective alternative for CABG in the treatment of multivessel coronary artery disease in a selected patient population. 1. Introduction Coronary artery bypass grafting (CABG) is considered to be the “gold standard” in patients with multivessel disease and remains the treatment of choice for patients with severe coronary artery disease, including three-vessel or left main coronary artery disease [1]. The use of CABG, as compared with both percutaneous coronary intervention (PCI) and medical therapy, is superior with regard to long-term symptom relief, major adverse cardiac or cerebrovascular events and survival benefit [1–4]. However, because of the use of cardiopulmonary bypass and median sternotomy, CABG is associated with significant surgical trauma leading to a long rehabilitation period and delayed postoperative improvement of quality of life [5]. An alternative “hybrid” approach to multivessel coronary artery disease combines surgical left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass grafting and percutaneous coronary intervention of the remaining lesions [3, 6–8]. Ideally, the LITA to LAD bypass graft is performed in a minimally invasive fashion through minimally invasive direct coronary artery bypass grafting (MIDCAB) [9]. This hybrid approach takes advantage of
Does Plavix Have Any Influences on Postoperative Bleeding and Blood Transfusion after Urgent and Emergent Coronary Artery Bypass Grafting  [PDF]
Shervin Ziabakhsh Tabary
Journal of Medical Sciences , 2008,
Abstract: The aim of this study was to evaluate the effects of Plavix on blood loss and blood and blood products usage following CABG. Three hundred and ninety two patients underwent urgent or emergent CABG, 364 of those met with inclusion criteria, 56 patients had Plavix exposure (group 1), 98 patients had both ASA and Plavix exposure (group 2) and 136 patients had ASA exposure (group 3) within a week of operation. The remaining 74 patients were on no antiaggregant therapy (group 4). Total chest tube drainage during the first 24 h, the incidence of reoperation for bleeding, blood and blood products usage and the early outcome (duration of mechanical ventilation, the intensive care unit stay and total hospital stay), were assessed. Total chest tube drainage was significantly higher in the patients with Plavix exposure and increased amount of transfusions with blood products were also observed in those patients. The patients with Plavix exposure required significantly more reoperation for bleeding. The duration of controlled ventilation and intensive care unit stay were also significantly longer in the patients with Plavix exposure. Present results support the recent history of Plavix treatment associated with increased blood loss, transfusion and reoperation requirement after CABG.
Anesthesia for coronary artery bypass grafting with hypothermic cardiopulmonary bypass in a patient with a A2B negative Blood Group
M Toufan,F Sepasi,A Alizadeh,R Azarfarin
Iranian Cardiovascular Research Journal , 2008,
Abstract: A2B negative is one of rare subgroups of ABO blood group system. Herein, we report a 59-year-old male patientwho was candidate for coronary artery bypass grafting surgery (CABG) due to coronary artery stenosis. The patient`s blood group was reported as AB negative in routine laboratory, and because of doubtful result, a complementary test confirmed his blood group as A2B negative. The consultant hematologist recommended reserving either negative A2B packed red blood cell (PRBC) or if unavailable O- blood group. After induction of anesthesia three units of patient’s own blood were collected and replaced by colloid solution. The patient underwentCABG with hypothermic cardiopulmonary bypass. The collected autologous blood units were transfused at the end of operation. The patient received one unit of A2B- homologous PRBC in the postoperative period, and was discharged without any reaction to transfusion.
Can local application of Tranexamic acid reduce post-coronary bypass surgery blood loss? A randomized controlled trial
Hosam Fawzy, Elsayed Elmistekawy, Daniel Bonneau, David Latter, Lee Errett
Journal of Cardiothoracic Surgery , 2009, DOI: 10.1186/1749-8090-4-25
Abstract: Systemic use of antifibrinolytic reduces the postoperative blood loss.The purpose of this study was to examine the effectiveness of local application of tranexamic acid to reduce blood loss after coronary artery bypass grafting (CABG).Thirty eight patients scheduled for primary isolated coronary artery bypass grafting were included in this double blind, prospective, randomized, placebo controlled study.Tranexamic acid (TA) group (19 patients) received 1 gram of TA diluted in 100 ml normal saline. Placebo group (19 patients) received 100 ml of normal saline only. The solution was purred in the pericardial and mediastinal cavities.Both groups were comparable in their baseline demographic and surgical characteristics. During the first 24 hours post-operatively, cumulative blood loss was significantly less in TA group (median of 626 ml) compared to Placebo group (median of 1040 ml) (P = 0.04). There was no significant difference in the post-op Packed RBCs transfusion between both groups (median of one unit in each) (P = 0.82). Significant less platelets transfusion required in TA group (median zero unit) than in placebo group (median 2 units) (P = 0.03). Apart from re-exploration for excessive surgical bleeding in one patient in TA group, no difference was found in morbidity or mortality between both groups.Topical application of tranexamic acid in patients undergoing primary coronary artery bypass grafting led to a significant reduction in postoperative blood loss without adding extra risk to the patient.Coagulopathy remains a common problem after coronary artery bypass Grafting (CABG) using cardiopulmonary bypass (CPB). It results from many factors like thrombocytopenia, acquired platelet dysfunction, clotting factors loss, free heparin, and increased fibrinolysis [1-3]. Lemmer and Colleagues [4] found that extracorporeal circulation results in significant fibrinolysis, as reflected by increased concentrations of plasmin and fibrin degradation products (FDP), both of
Axillobifemoral bypass grafting  [PDF]
Davidovi? Lazar B.,Mitri? Milan S.,Kosti? Du?an M.,Maksimovi? ?ivan V.
Srpski Arhiv za Celokupno Lekarstvo , 2004, DOI: 10.2298/sarh0406157d
Abstract: INTRODUCTION Axillo-femoral bypass (AxF) means connecting the axillar and femoral artery with the graft that is placed subcutaneously [1]. Usually, this graft is connected with contralateral femoral artery via one accessory subcutaneous graft, and this connection is known as axillobifemoral bypass (AxFF). This extra-anatomic procedure is an alternative method to the standard reconstruction of aortoiliac region when there are contraindications for general or local reasons. OBJECTIVE The objective of this paper is to show early and late results of AxFF bypass grafting as well as to show the indications for AxFF bypass. METHODS The sample consisted of 37 patients. The procedure was performed in 28 patients who suffered from aortoiliac occlusive disease and who were at high risk due to the comorbidity- in one patient with the rupture of juxtarenal aneurysm of abdominal aorta; in five patients with aortoenteric fistula, in two patients with iatrogenic lesion of abdominal aorta and in one female patient with anus preternaturalis definitivus who was treated for rectovaginal fistula. Donor's right axillary artery was used in 26 cases (70.3%), and donor's left axillary artery was used in 9 cases (29.7%). Dacron graft was used in 34 patients and Polytetrafluo-roethlylene graft was used in three patients. Simultaneously, profundo-plastic was done in four patients and femoro-popliteal bypass was performed in three patients. In five patients who suffered from aortoenteric fistula, simultaneous intervention of gastrointerstinal system has been done, x2 test was used for statistical evaluation and life table method was used for verification of late graft patency. RESULTS The rate of early postoperative mortality was 13.5%. The causes of death were: sepsis -1, MOFS - 3, and infarct myocardium -1. The mean follow up period was 40.1 months, ranging from six months to 17 years. During the follow up period, an early graft thrombosis was identified in two and late graft occlusion was reported in four patients. As the cause of occlusion, the progression of occlusive disease of receptive artery was identified in three patients, while anastomotic neointimae hyperplasia of recipient artery was identified in one patient. Three patients died during the follow up period. As the cause of death, CVI was reported in two patients and malignancy of the urinary tract was fpund in one patient. The other complications were - artery angulation on the level of proximal anastomosis in one patient (Figure 1), false aneurysm in one patient, perigraft seroma in one patient and graft infection in
Pre-operative high sensitive C-reactive protein predicts cardiovascular events after coronary artery bypass grafting surgery: A prospective observational study  [cached]
Balciunas Mindaugas,Bagdonaite Loreta,Samalavicius Robertas,Griskevicius Laimonas
Annals of Cardiac Anaesthesia , 2009,
Abstract: C-reactive protein is a powerful independent predictor of cardiovascular events in patients with coronary artery disease. The relation between C-reactive protein (CRP) concentration and in-hospital outcome, after coronary artery bypass grafting (CABG), has not yet been established. The study aims to evaluate the predictive value of pre-operative CRP for in-hospital cardiovascular events after CABG surgery. High-sensitivity CRP (hs-CRP) levels were measured pre-operatively on the day of surgery in 66 patients scheduled for elective on pump CABG surgery. Post-operative cardiovascular events such as death from cardiovascular causes, ischemic stroke, myocardial damage, myocardial infarction and low output heart failure were recorded. During the first 30 days after surgery, 54 patients were free from observed events and 14 developed the following cardiovascular events: 10 (15%) had myocardial damage, four (6%) had low output heart failure and two (3%) suffered stroke. No patients died during the follow-up period. Serum concentration of hs-CRP ≥ 3.3 mg/l (cut-off point obtained by ROC analysis) was related to higher risk of post-operative cardiovascular events (36% vs 6%, P = 0.01), myocardial damage (24% vs 6%, P = 0.04) and low output heart failure (12% vs 0%, P = 0.04). Multivariate logistic regression analysis showed that hs-CRP ≥ 3.3 mg/l ( P = 0.002, O.R.: 19.3 (95% confidence interval (CI) 2.9-128.0)), intra-operative transfusion of red blood cells ( P = 0.04, O.R.: 9.9 (95% C.I. 1.1-85.5)) and absence of diuretics in daily antihypertensive treatment ( P = 0.02, O.R.: 15.1 (95% C.I. 1.4-160.6) were independent predictors of combined cardiovascular event. Patients having hs-CRP value greater or equal to 3.3 mg/l pre-operatively have an increased risk of post-operative cardiovascular events after on pump coronary artery bypass grafting surgery.
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