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The independent effect of a platelet transfusion on bleeding and adverse outcomes in cardiac surgery
ABSTRACT PRESENTATIONS: FRIDAY, MAY 13, 2016 Oral Abstract Presentations 303 Friday, May 13, 2016 08:30 - 09:00, Auditorium 3 OP-47 The independent effect of a platelet transfusion on bleeding and adverse outcomes in cardiac surgery Fabienne van Hout1, EK Hogervorst1, PMJ Rosseel2, JG van der Bom1, M. Bentala2, A. Brand1, NJM van der Meer,2 LMG van de Watering1 1 Sanquin / Leiden University Medical Center, Leiden, The Netherlands, 2Amphia Hospital, Breda, The Netherlands
Introduction. The aim of this study was to assess the independent effect of a single pre-emptive intraoperative platelet transfusion on bleeding and adverse outcomes, in patients undergoing cardiac surgery, in the absence of concomitant intraoperative transfusion of other blood products. Methods. The cohort used for this observational study comprised 23,860 patients who underwent cardiac surgery between 1997 and 2013. Patients who received 1 pre-emptive intraoperative platelet transfusion and no other blood products were defined as the intervention group. The intervention group was matched 1:3 by closest propensity score to identify the reference group consisting of patients who received no intraoperative transfusion and who were most comparable to the intervention group. Results. The intervention group comprised 169 patients and the reference group comprised 507 patients. There was no difference between the groups with regard to bleeding, thromboembolic and infectious complications, organ failure, in-hospital mortality and composite endpoints. However patients in the intervention group more often showed indicators of worse clinical condition postoperatively: prolonged mechanical ventilation, odds ratio 1.49 (95% confidence interval 1.05, 2.11), prolonged intensive care 1.43 (1.01, 2.03), vasoactive medication 1.72, (1.10, 2.67), red blood cell 1.99 (1.39, 2.85), plasma 4.36 (2.44, 7.78), and platelet transfusion 14.31 (8.64, 23.70) than patients in the reference group. Discussion. In our study, intraoperative pre-emptive platelet transfusion was not associated with bleeding complications or with the risk of adverse events in cardiac surgery. However, patients transfused with one unit of platelets showed more indicators of worse clinical condition.
therapy (DAPT). Patients with acute aortic dissection type A (AAD) often present with similar symptoms and may be prescribed DAPT before the diagnosis of AAD is established. Treatment with DAPT prior to AAD surgery has been associated with an increased 30-day mortality and intraoperative bleeding. European Society of Cardiology’s (ESC) guidelines for ACS incorporated ticagrelor in 2011 and currently recommend DAPT with ticagrelor and aspirin as first line treatment. Method. We performed a retrospective single-centre observational study with inclusion of 171 patients operated for AAD type A from January 1, 2010 - December 31, 2014 at, Rigshospitalet, Copenhagen, Denmark. Patients were identified through a surgical database and data collected from patient records and the intensive care patient data management system. Primary endpoint was 30-day mortality. Secondary endpoints were intraoperative bleeding and perioperative transfusions requirements. Statistical analyses were performed using SPSS Statistics version 22. Results. Patients receiving any kind of antiplatelet therapy (APT) (n¼73) did not show an increased 30-day mortality (29% vs. 20%, p¼0.18). APT prior to surgery was associated with an increased intraoperative bleeding (4.8 ⫾ 3.9 L vs. 3.3 ⫾ 4.9 L, po0.001) and transfusion requirements of red blood cells (3.8 ⫾ 3.5 L vs. 2.3 ⫾ 2.4 L, po0.001), fresh frozen plasma (3.8 ⫾ 3.4 L vs. 2.5 ⫾ 2.0, p¼0.004) and platelets (2.4 ⫾ 2.2 L vs. 1.6 ⫾ 1.7 L, p¼0.01), respectively. Echocardiography was less often performed among patients receiving APT compared to no APT (19% vs. 45%, po0.001). There was no difference in 30-day mortality among patients receiving DAPT compared to APT and no APT (24% vs 24%, p¼0.95). DAPT including ticagrelor (n¼15) showed a significantly increased intraoperative bleeding compared to clopidogrel (n¼29) (7.6 ⫾ 3.1 L vs. 4.7 ⫾ 4.1 L, p¼0.004). Among patients receiving DAPT, 30% fulfilled ESC criteria for APT. Discussion. In agreement with previous studies, the use of APT was associated with increased intraoperative bleeding and transfusion requirement. However, no significant association was found between patients treated with platelet inhibitors and mortality. Pre-surgery DAPT with ticagrelor further increased intraoperative bleeding compared to clopidogrel. Only a minor proportion of patients fulfilled ESC criteria for DAPT. In the future, immediate echocardiography may contribute in establishing the diagnosis of AAD, although we cannot make any conclusions in this respect due to the observational design in the present study. OP-49 Platelet microvesicle production during cardiac surgery
OP-48
David Smith1, J. Schofield2, J. Holloway2 N. Englyst2
Outcome in patients operated for acute aortic dissection: Influence of preoperative antiplatelet therapy on mortality and bleeding complications Raphaelle Chemtob1, H. Møller Sørensen1, L. Holmvang2, P. Skov Olsen3, H. Berg Ravn1 1 Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 2 Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 3Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
Introduction. Outcome in patients with acute coronary syndrome (ACS) is improved when treated with dual antiplatelet
S36
1
Southampton General Hospital, Department of Anaesthesia, UK, University of Southampton, UK
2
Introduction. Platelet microvesicles (PMV - formerly named microparticles) are sub-micron blebs shed from the cell membrane of activated platelets. Their numbers are low in the normal population but may increase in vascular disease states (1). An inability to generate PMV causes a bleeding diathesis (2). The role of PMV in cardiac surgery has not been defined. Methods. 49 patients having elective cardiac surgery donated paired arterial and venous blood samples at eight points during the perioperative period and a further venous sample on day 5. Samples were centrifuged twice at 2000g and the resultant platelet-poor plasma was stored at -80oC. Thawed samples
Journal of Cardiothoracic and Vascular Anesthesia, Vol 30, No S1 (May), 2016: pp S36–S46
Introduction. The aim of this study was to assess the independent effect of a single pre-emptive intraoperative platelet transfusion on bleeding and adverse outcomes, in patients undergoing cardiac surgery, in the absence of concomitant intraoperative transfusion of other blood products. Methods. The cohort used for this observational study comprised 23,860 patients who underwent cardiac surgery between 1997 and 2013. Patients who received 1 pre-emptive intraoperative platelet transfusion and no other blood products were defined as the intervention group. The intervention group was matched 1:3 by closest propensity score to identify the reference group consisting of patients who received no intraoperative transfusion and who were most comparable to the intervention group. Results. The intervention group comprised 169 patients and the reference group comprised 507 patients. There was no difference between the groups with regard to bleeding, thromboembolic and infectious complications, organ failure, in-hospital mortality and composite endpoints. However patients in the intervention group more often showed indicators of worse clinical condition postoperatively: prolonged mechanical ventilation, odds ratio 1.49 (95% confidence interval 1.05, 2.11), prolonged intensive care 1.43 (1.01, 2.03), vasoactive medication 1.72, (1.10, 2.67), red blood cell 1.99 (1.39, 2.85), plasma 4.36 (2.44, 7.78), and platelet transfusion 14.31 (8.64, 23.70) than patients in the reference group. Discussion. In our study, intraoperative pre-emptive platelet transfusion was not associated with bleeding complications or with the risk of adverse events in cardiac surgery. However, patients transfused with one unit of platelets showed more indicators of worse clinical condition.
therapy (DAPT). Patients with acute aortic dissection type A (AAD) often present with similar symptoms and may be prescribed DAPT before the diagnosis of AAD is established. Treatment with DAPT prior to AAD surgery has been associated with an increased 30-day mortality and intraoperative bleeding. European Society of Cardiology’s (ESC) guidelines for ACS incorporated ticagrelor in 2011 and currently recommend DAPT with ticagrelor and aspirin as first line treatment. Method. We performed a retrospective single-centre observational study with inclusion of 171 patients operated for AAD type A from January 1, 2010 - December 31, 2014 at, Rigshospitalet, Copenhagen, Denmark. Patients were identified through a surgical database and data collected from patient records and the intensive care patient data management system. Primary endpoint was 30-day mortality. Secondary endpoints were intraoperative bleeding and perioperative transfusions requirements. Statistical analyses were performed using SPSS Statistics version 22. Results. Patients receiving any kind of antiplatelet therapy (APT) (n¼73) did not show an increased 30-day mortality (29% vs. 20%, p¼0.18). APT prior to surgery was associated with an increased intraoperative bleeding (4.8 ⫾ 3.9 L vs. 3.3 ⫾ 4.9 L, po0.001) and transfusion requirements of red blood cells (3.8 ⫾ 3.5 L vs. 2.3 ⫾ 2.4 L, po0.001), fresh frozen plasma (3.8 ⫾ 3.4 L vs. 2.5 ⫾ 2.0, p¼0.004) and platelets (2.4 ⫾ 2.2 L vs. 1.6 ⫾ 1.7 L, p¼0.01), respectively. Echocardiography was less often performed among patients receiving APT compared to no APT (19% vs. 45%, po0.001). There was no difference in 30-day mortality among patients receiving DAPT compared to APT and no APT (24% vs 24%, p¼0.95). DAPT including ticagrelor (n¼15) showed a significantly increased intraoperative bleeding compared to clopidogrel (n¼29) (7.6 ⫾ 3.1 L vs. 4.7 ⫾ 4.1 L, p¼0.004). Among patients receiving DAPT, 30% fulfilled ESC criteria for APT. Discussion. In agreement with previous studies, the use of APT was associated with increased intraoperative bleeding and transfusion requirement. However, no significant association was found between patients treated with platelet inhibitors and mortality. Pre-surgery DAPT with ticagrelor further increased intraoperative bleeding compared to clopidogrel. Only a minor proportion of patients fulfilled ESC criteria for DAPT. In the future, immediate echocardiography may contribute in establishing the diagnosis of AAD, although we cannot make any conclusions in this respect due to the observational design in the present study. OP-49 Platelet microvesicle production during cardiac surgery
OP-48
David Smith1, J. Schofield2, J. Holloway2 N. Englyst2
Outcome in patients operated for acute aortic dissection: Influence of preoperative antiplatelet therapy on mortality and bleeding complications Raphaelle Chemtob1, H. Møller Sørensen1, L. Holmvang2, P. Skov Olsen3, H. Berg Ravn1 1 Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 2 Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 3Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
Introduction. Outcome in patients with acute coronary syndrome (ACS) is improved when treated with dual antiplatelet
S36
1
Southampton General Hospital, Department of Anaesthesia, UK, University of Southampton, UK
2
Introduction. Platelet microvesicles (PMV - formerly named microparticles) are sub-micron blebs shed from the cell membrane of activated platelets. Their numbers are low in the normal population but may increase in vascular disease states (1). An inability to generate PMV causes a bleeding diathesis (2). The role of PMV in cardiac surgery has not been defined. Methods. 49 patients having elective cardiac surgery donated paired arterial and venous blood samples at eight points during the perioperative period and a further venous sample on day 5. Samples were centrifuged twice at 2000g and the resultant platelet-poor plasma was stored at -80oC. Thawed samples
Journal of Cardiothoracic and Vascular Anesthesia, Vol 30, No S1 (May), 2016: pp S36–S46