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Perioperative transfusion and long-term mortality after cardiac surgery: a meta-analysis
Woldendorp K, Manuel L, Srivastava A, Doane M, Bassin L, Marshman D
General thoracic and cardiovascular surgery. 2023
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Abstract
OBJECTIVES Cardiac surgical procedures are associated with a high incidence of periprocedural blood loss and blood transfusion. Although both may be associated with a range of postoperative complications there is disagreement on the impact of blood transfusion on long-term mortality. This study aims to provide a comprehensive review of the published outcomes of perioperative blood transfusion, examined as a whole and by index procedure. METHODS A systematic review of perioperative blood transfusion cardiac surgical patients was conducted. Outcomes related to blood transfusion were analysed in a meta-analysis and aggregate survival data were derived to examine long-term survival. RESULTS Thirty-nine studies with 180,074 patients were identified, the majority (61.2%) undergoing coronary artery bypass surgery. Perioperative blood transfusions were noted in 42.2% of patients and was associated with significantly higher early mortality (OR 3.87, p < 0.001). After a median of 6.4 years (range 1-15), mortality remained significantly higher for those who received a perioperative transfusion (OR 2.01, p < 0.001). Pooled hazard ratio for long-term mortality similar for patients who underwent coronary surgery compared to isolated valve surgery. Differences in long-term mortality for all comers remained true when corrected for early mortality and when only including propensity matched studies. CONCLUSIONS Perioperative red blood transfusion appears to be associated with a significant reduction in long-term survival for patients after cardiac surgery. Strategies such as preoperative optimisation, intraoperative blood conservation, judicious use of postoperative transfusions, and professional development into minimally invasive techniques should be utilised where appropriate to minimise the need for perioperative transfusions.
PICO Summary
Population
Patients undergoing cardiac surgery (39 studies, n= 180,074).
Intervention
Red blood cell (RBC) transfusion.
Comparison
No RBC transfusion.
Outcome
The meta-analysis identified 180,074 patients with follow-up data ranging from 1 to 15 years. The majority (61.2%) of patients underwent coronary artery bypass surgery. Perioperative blood transfusions were noted in 42.2% of patients and was associated with significantly higher early mortality (OR= 3.87). After a median of 6.4 years (range 1, 15), mortality remained significantly higher for those who received a perioperative transfusion (OR= 2.01). Pooled hazard ratio for long-term mortality was similar for patients who underwent coronary surgery compared to isolated valve surgery. Differences in long-term mortality for all comers remained true when corrected for early mortality and when only including propensity matched studies.
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Reconstituted fresh whole blood improves clinical outcomes compared with stored component blood therapy for neonates undergoing cardiopulmonary bypass for cardiac surgery: a randomized controlled trial
Gruenwald CE, McCrindle BW, Crawford-Lean L, Holtby H, Parshuram C, Massicotte P, Van Arsdell G
The Journal of Thoracic and Cardiovascular Surgery. 2008;136((6):):1442-9.
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Abstract
OBJECTIVE This study compared the effects of reconstituted fresh whole blood against standard blood component therapy in neonates undergoing cardiac surgery. METHODS Patients less than 1 month of age were randomized to receive either reconstituted fresh whole blood (n = 31) or standard blood component therapy (n = 33) to prime the bypass circuit and for transfusion during the 24 hours after cardiopulmonary bypass. Primary outcome was chest tube drainage; secondary outcomes included transfusion needs, inotrope score, ventilation time, and hospital length of stay. RESULTS Patients who received reconstituted fresh whole blood had significantly less postoperative chest tube volume loss per kilogram of body weight (7. 7 mL/kg vs 11. 8 mL/kg; P = . 03). Standard blood component therapy was associated with higher inotropic score (6. 6 vs 3. 3; P = . 002), longer ventilation times (164 hours vs 119 hours; P = . 04), as well as longer hospital stays (18 days vs 12 days; P = . 006) than patients receiving reconstituted fresh whole blood. Of the different factors associated with the use of reconstituted fresh whole blood, lower platelet counts at 10 minutes and at the end of cardiopulmonary bypass, older age of cells used in the prime and throughout bypass, and exposures to higher number of allogeneic donors were found to be independent predictors of poor clinical outcomes. CONCLUSIONS Reconstituted fresh whole blood used for the prime, throughout cardiopulmonary bypass, and for all transfusion requirements within the first 24 hours postoperatively results in reduced chest tube volume loss and improved clinical outcomes in neonatal patients undergoing cardiac surgery.
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Fresh whole blood versus reconstituted blood for pump priming in heart surgery in infants
Mou SS, Giroir BP, Molitor-Kirsch EA, Leonard SR, Nikaidoh H, Nizzi F, Town DA, Roy LC, Scott W, Stromberg D
The New England Journal of Medicine. 2004;351((16):):1635-44.
Abstract
BACKGROUND In an attempt to reduce the coagulopathic and inflammatory responses seen after cardiopulmonary bypass, the use of fresh whole blood during heart operations has become the standard of care for neonates and infants at many institutions. We compared the use of fresh whole blood with the use of a combination of packed red cells and fresh-frozen plasma (reconstituted blood) for priming of the cardiopulmonary bypass circuit. METHODS We conducted a single-center, randomized, double-blind, controlled trial involving children less than one year of age who underwent open-heart surgery. Patients were assigned to receive either fresh whole blood that had been collected not more than 48 hours previously (96 patients) or reconstituted blood (104 patients) for bypass-circuit priming. Clinical outcomes and serologic measures of systemic inflammation and myocardial injury were compared between the groups. RESULTS The group that received reconstituted blood had a shorter stay in the intensive care unit than the group that received fresh whole blood (70. 5 hours vs. 97. 0 hours, P=0. 04). The group that received reconstituted blood also had a smaller cumulative fluid balance at 48 hours (-6. 9 ml per kilogram of body weight vs. 28. 8 ml per kilogram, P=0. 003). Early postoperative chest-tube output, blood-product transfusion requirements, and levels of serum mediators of inflammation and cardiac troponin I were similar in the two groups. CONCLUSIONS The use of fresh whole blood for cardiopulmonary bypass priming has no advantage over the use of a combination of packed red cells and fresh-frozen plasma during surgery for congenital heart disease. Moreover, circuit priming with fresh whole blood is associated with an increased length of stay in the intensive care unit and increased perioperative fluid overload.
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Irradiation of fresh whole blood for prevention of transfusion-associated graft-versus-host disease does not impair platelet function and clinical hemostasis after open heart surgery
Lavee J, Shinfeld A, Savion N, Thaler M, Mohr R, Goor DA
Vox Sanguinis. 1995;69((2):):104-9.
Abstract
Since our previous studies suggested that the transfusion of 1 unit fresh whole blood (FWB) after cardiopulmonary bypass (CPB) using a bubble oxygenator may provide hemostatic benefit equivalent to 8-10 units of platelet concentrates, we have routinely used FWB at the termination of CPB. Two patients who received FWB and developed transfusion-associated graft-versus-host disease (TA-GVHD) prompted us to investigate the effect of irradiation of FWB on platelet and clinical hemostasis. Twenty-four patients were randomized to receive either 1 unit FWB (12 patients), or 1 unit irradiated FWB (IrFWB, 1,500 cGy,12 patients) after CPB. Platelet aggregation on extracellular matrix, studied by a scanning electron microscope and graded from 1 to 4 (from poor to excellent aggregation), was similar in both groups preoperatively [3.3 +/- 0.9 (FWB) and 3.5 +/- 0.5 (Ir FWB)], and at the end of CPB [1.8 +/- 1.2 (FWB) and 1.9 +/- 0.9 (IrFWB)]. Platelet aggregation was similar after transfusion of FWB (3.0 +/- 1.0) and after IrFWB (3.2 +/- 0.8), as was the increase in platelet count. Twenty-four hours total postoperative bleeding was similar (560 +/- 420 and 523 +/- 236 ml for FWB and IrFWB, respectively). We conclude that irradiation of FWB for prevention of TA-GVHD does not impair platelet aggregating capacity, and can be used when blood is donated by the patient's next of kin.
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Fresh blood units contain large potent platelets that improve hemostasis after open heart operations
Mohr R, Goor DA, Yellin A, Moshkovitz Y, Shinfeld A, Martinowitz U
Annals of Thoracic Surgery. 1992;53((4):):650-4.
Abstract
Twenty units of fresh whole blood were separated into fresh packed red blood cells (PC) and platelet-rich plasma (PRP) and were transfused to 40 patients immediately after coronary bypass grafting. Patients were preoperatively randomized to receive either PRP (group A, 20 patients) or PC (group B, 20 patients). Platelet number in the PRP group was greater, but not significantly greater, than in the PC group (7.5 +/- 3 versus 5.9 +/- 2.2 x 10(10); p = not significant). However, mean platelet volume in the PC group was significantly greater (8.75 +/- 1.1 versus 6 +/- 0.7 fL). Postoperatively, group A patients bled more than group B (566 +/- 164 versus 327 +/- 41 mL; p less than 0.01) and received more red blood cell units (2.7 +/- 1.2 versus 1.6 +/- 0.7 U; p less than 0.05) and a larger number of blood products (5.9 +/- 3.7 versus 2.6 +/- 1.2 U; p less than 0.05). Transfusion of PRP to group A increased platelet count from 128 +/- 20 to 148 +/- 110 x 10(9)/L; however, platelet functions did not improve. Administration of PC to group B increased platelet count from 139 +/- 22 to 156 +/- 23 x 10(9)/L, improved platelet aggregation (with collagen from 33% +/- 20% to 53% +/- 23%, with epinephrine from 36% +/- 24% to 51% +/- 20%; p less than 0.05), and corrected the prolonged bleeding time. The results suggest that the improved hemostasis observed after fresh whole blood administration is related to the large, potent platelets that remained in the PC and were not separated to the PRP during standard platelet concentrate preparation.
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6.
Whole blood versus packed-cell transfusions: a physiologic comparison
Shackford SR, Virgilio RW, Peters RM
Annals of Surgery. 1981;193((3):):337-40.
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Abstract
Twenty-eight patients undergoing major aortic reconstructions were prospectively randomized into two groups to compare blood replacement with either whole blood (WB) or packed cells (PRBC). Cardiac index (CI), pulmonary capillary wedge pressure (PCWP), intrapulmonary shunt (Qs/Qt), serum colloid osmotic pressure (COP), platelets, prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen were measured before operation, during operation, and for three days after operation. The postoperative CI increased significantly in both groups from preoperative value, but was not significantly different between the groups. In the PRBC group, there was a significant decrease in postoperative COP and COP-PCWP gradient from preoperative value. This did not occur in the WB group. There was no significant difference between groups in postoperative Qs/Qt, nor was there any evidence of clinical or radiographic pulmonary dysfunction. Both groups manifested a prolongation of the PT and PTT immediately after operation, but these returned to normal without intervention by the first day after operation. It is felt that blood replacement with reconstituted packed red cells can provide effective volume replacement without producing coagulopathy. The decreases observed in COP and COP-PCWP gradient do not result in physiologic or clinical evidence of significant pulmonary dysfunction.
