Management of Perioperative Iron Deficiency in Cardiac Surgery: A Modified RAND Delphi Study.

BACKGROUND: Over the last decade, preoperative anemia has become recognized as a clinical condition in need of management. Although the etiology of preoperative anemia can be multifactorial, two thirds of anemic elective surgical patients have iron deficiency anemia. At the same time, one third of nonanemic elective surgical patients are also iron deficient. METHODS: Modified RAND Delphi methodology was used to identify areas of consensus among an expert panel regarding the management of iron deficiency in patients undergoing cardiac surgery. A list of statements was sent to panel members to respond to using a five-point Likert scale. All panel members subsequently attended a face-to-face meeting. The initial survey was presented and discussed, and panel members responded to each statement on the Likert scale again. Based on the second survey, the panel came to a consensus on recommendations. RESULTS: The panel recommended all patients undergoing cardiac surgery be evaluated for iron deficiency, whether or not anemia is present. Evaluation should include iron studies and reticulocyte hemoglobin content. If iron deficiency is present, with or without anemia, patients should receive parenteral iron. Erythropoietin-stimulating agents may be appropriate for some patients. CONCLUSIONS: Consensus of an expert panel resulted in a standardized approach to diagnosing and managing iron deficiency in patients undergoing cardiac surgery.

Early mortality and safety after transcatheter aortic valve replacement using the SAPIEN 3 in nonagenarians.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has been performed for many elderly patients with severe aortic stenosis (AS). The SAPIEN 3 is one of the latest balloon-expandable prosthesis. This study aimed to investigate the early clinical outcomes after TAVR using the SAPIEN 3 in nonagenarians. METHODS: A total of 97 consecutive patients underwent TAVR for severe AS between December 2015 and December 2016. Of these, 85 consecutive patients who underwent TAVR using the SAPIEN 3 were included. According to the age, patients were classified into age ≥ 90 years group (17 patients) or age < 90 years group (68 patients). The clinical outcomes including all-cause mortality and composite endpoint of early safety at 30 days were evaluated. RESULTS: The Society of Thoracic Surgeons score in age ≥ 90 years group was higher than age < 90 years group (12.3 ± 6.1% vs. 8.5 ± 5.1%, P < 0.01). There was no significant difference in 30-day mortality between the two groups. However, the life-threatening bleeding and major vascular complications in age ≥ 90 years group were greater than age < 90 years group (11.8% vs. 1.5%, P = 0.04 and 11.8% vs. 1.5%, P = 0.04, respectively). The composite endpoint of early safety at 30 days was similar between the two groups. Multivariate logistic regression analysis showed that prior myocardial infarction was an independent predictor of the composite endpoint of early safety (odds ratio: 4.76, 95% confidence interval: 1.02-22.21, P = 0.047). CONCLUSIONS: The early mortality and safety after TAVR using the SAPIEN 3 in nonagenarians were similar and acceptable despite of higher operative risk.

Transient Ischemic Dilatation during Stress Echocardiography: An Additional Marker of Significant Myocardial Ischemia.

AIM: Left ventricular (LV) transient ischemic dilatation (TID) is not clear how it relates to inducible myocardial ischemia during stress echocardiography (SE). METHODS AND RESULTS: Eighty-eight SEs were examined from the site certification phase of the ISCHEMIA Trial. LV end-diastolic volume (EDV) and end-systolic volume (ESV) were measured at rest and peak stages and the percent change calculated. Moderate or greater ischemia was defined as ≥3 segments with stress-induced severe hypokinesis or akinesis. Optimum cut points in stress-induced percent EDV and ESV change that identified moderate or greater myocardial ischemia were analyzed. Analysis from percentage distribution identified a > 13% LV volume increase in EDV or a > 9% LV volume increase in ESV as the optimum cutoff points for moderate or greater ischemia. Using these definitions for TID, there were 27 (31%) with TIDESV and 12 (14%) with TIDEDV . By logistic regression analysis and receiver operating characteristic curves, the percent change in ESV had a stronger association with moderate or greater myocardial ischemia than that of EDV change. Compared to those without TIDESV , cases with TIDESV had larger extent of inducible wall-motion abnormalities, lower peak stress LVEF, and higher likelihood of moderate or grater ischemia. For moderate or greater myocardial ischemia detection, TIDESV had a sensitivity of 46%, specificity of 83%, positive predictive value of 70%, and negative predictive value of 64%. CONCLUSION: Transient ischemic dilatation by SE is a marker of extensive myocardial ischemia and can be used as an additional marker of higher risk.

The impact of blood conservation on outcomes in cardiac surgery: is it safe and effective?

BACKGROUND: Increasing evidence shows that perioperative blood transfusion in cardiac surgery is associated with increased postoperative morbidity and mortality and decreased long-term survival. Tolerance of "permissive anemia" is an important element of perioperative blood conservation strategy. The safety of tolerating perioperative anemia has been a significant deterrent for widespread application of blood conservation. This study examines whether blood conservation is equally safe or superior to the common practice of transfusion in cardiac surgery. METHODS: The total study population consisted of 32,449 patients who underwent isolated coronary artery bypass surgery from June 2000 until December 2004 with complete data from 17 institutions in the State of New Jersey. Englewood Hospital and Medical Center (EH) has a well-established blood conservation program. Five hundred eighty-six EH patients (blood conservation cohort) were compared with a propensity score-matched cohort of 586 patients from the other New Jersey institutions (OH-M) representing the common practice of transfusion. Outcomes were classified as very serious complications, serious complications, or neither (no very serious complication or serious complication). Analysis consisted of McNemar tests and multiple logistic regression. RESULTS: Fewer patients were transfused at EH compared with OH-M (10.6% versus 42.5%; p < 0.0001). Englewood Hospital had 5 (0.8%) deaths versus 15 (2.5%) in the OH-M group (p = 0.02). Of the EH patients, 11.1% experienced a very serious complication or serious complication versus 18.7% in the OH-M cohort (p = 0.0002). Transfusion was associated with an increased risk of an adverse outcome in both cohorts (EH: odds ratio, 7.3; 95% confidence interval, 3.7 to 14.4 versus OH-M: odds ratio, 4.6; 95% confidence interval, 2.8 to 7.7). CONCLUSIONS: Blood conservation is safe and effective in reducing transfusions. Tolerance of perioperative anemia, which is one of the main components of blood conservation, does not increase the risk of complications or death in cardiac surgery. Avoidance of transfusion reduces the risk of complications. This study further solidifies the relationship between transfusion and adverse outcome in cardiac surgery.

Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center.

BACKGROUND: Previous studies defining perioperative risk factors for allogeneic transfusion requirements in cardiac surgery were limited to highly selected cardiac surgery populations or were associated with high transfusion rates. The purpose of this study was to determine perioperative risk factors and create a formula to predict transfusion requirements for major cardiac surgical procedures in a center that practices a multimodality approach to blood conservation. METHODS: We performed an observational study on 307 consecutive patients undergoing coronary artery bypass grafting, valve, and combined (coronary artery bypass grafting and valve) procedures. An equation was derived to estimate the risk of transfusion based on preoperative risk factors using multivariate analysis. In patients with a calculated probability of transfusion of at least 5%, intraoperative predictors of transfusion were identified by multivariate analysis. RESULTS: Thirty-five patients (11%) required intraoperative or postoperative allogeneic transfusions. Preoperative factors as independent predictors for transfusions included red blood cell mass, type of operation, urgency of operation, number of diseased vessels, serum creatinine of at least 1.3 mg/dL, and preoperative prothrombin time. Intraoperative factors included cardiopulmonary bypass time, three or fewer bypass grafts, lesser volume of acute normovolemic hemodilution removed, and total crystalloid infusion of at least 2,500 mL. The derived formula was applied to a validation cohort of 246 patients, and the observed transfusion rates conformed well to the predicted risks. CONCLUSIONS: A multimodality approach to blood conservation in cardiac surgery resulted in a low transfusion rate. Identifying patients' risks for transfusion should alter patient management perioperatively to decrease their transfusion rate and make more efficient use of blood resources.