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Kidane B, Jacob N, Bruinooge A, Shen YC, Keshavjee S, dePerrot ME, Pierre AF, Yasufuku K, Cypel M, Waddell TK, Darling GE. Postoperative but not intraoperative transfusions are associated with respiratory failure after pneumonectomy. Eur J Cardiothorac Surg 2020; 58:1004-1009. [DOI: 10.1093/ejcts/ezaa107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 02/14/2020] [Accepted: 03/03/2020] [Indexed: 01/17/2023] Open
Abstract
Abstract
OBJECTIVES
Transfusion of blood products has been associated with increased risk of post-pneumonectomy respiratory failure. It is unclear whether intraoperative or postoperative transfusions confer a higher risk of respiratory failure. Our objective was to assess the role of transfusions in developing post-pneumonectomy respiratory failure.
METHODS
We performed a retrospective cohort study using prospectively collected data on consecutive pneumonectomies between 2005 and 2015. Patient records were reviewed for intraoperative/postoperative exposures. Univariable and multivariable analyses were performed.
RESULTS
Of the 251 pneumonectomies performed during the study period, 24 (9.6%) patients suffered respiratory failure. Ninety-day mortality was 5.6% (n = 14) and was more likely in patients with respiratory failure (7/24 vs 7/227, P < 0.001). Intraoperative and postoperative transfusions occurred in 42.2% (n = 106) and 44.6% (n = 112) of patients, respectively and were predominantly red blood cells. On univariable analysis, both intraoperative (P = 0.03) and postoperative transfusion (P = 0.004) were associated with a higher risk of respiratory failure. The multivariable model significantly predicted respiratory failure with an area under curve (AUC) = 0.88 (P = 0.001). On multivariable analysis, the only independent predictors of respiratory failure were postoperative transfusions [adjusted odds ratio (aOR) 6.54, 95% confidence interval (CI) 1.74–24.59; P = 0.005] and lower preoperative forced expiratory volume (adjusted OR 0.96, 95% CI 0.93–0.99; P = 0.03). Estimated blood loss was not significantly different (P = 0.91) between those with (median 800 ml, interquartile range 300–2000 ml) and without respiratory failure (median 800 ml, interquartile range 300–2000 ml).
CONCLUSIONS
Respiratory failure occurred in 9.6% of patients post-pneumonectomy and confers a higher risk of 90-day mortality. Postoperative (but not intraoperative) transfusion was the strongest independent predictor associated with respiratory failure. Intraoperative transfusion may be in reaction to active/unpredictable blood loss and may not be easily modifiable. However, postoperative transfusion may be modifiable and potentially avoidable. Transfusion thresholds should be assessed in light of potential cost-benefit trade-offs.
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Affiliation(s)
- Biniam Kidane
- Department of Surgery, Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Nithin Jacob
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Allan Bruinooge
- Department of Surgery, Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Yu Cindy Shen
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Shaf Keshavjee
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Marc E dePerrot
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Andrew F Pierre
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Kazuhiro Yasufuku
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Marcelo Cypel
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Thomas K Waddell
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Gail E Darling
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
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Haunschild J, Scharnowski S, Mende M, von Aspern K, Misfeld M, Mohr FW, Borger MA, Etz CD. Aortic root enlargement to mitigate patient-prosthesis mismatch: do early adverse events justify reluctance?†. Eur J Cardiothorac Surg 2019; 56:ezz016. [PMID: 30789225 DOI: 10.1093/ejcts/ezz016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/09/2019] [Accepted: 01/09/2019] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVES: Concomitant aortic root enlargement (ARE) at the time of surgical aortic valve replacement can be performed to avoid patient-prosthesis mismatch, an important predictor of adverse long-term outcome. METHODS: We performed a single-centre, retrospective analysis of 4120 patients receiving isolated aortic valve replacement, of whom 171 (4%) had concomitant ARE between January 2005 and December 2015. The analysis of postoperative outcome and early mortality was performed. Owing to inequality of the groups, patients were matched 1:1. RESULTS: The mean age of all 4120 patients was 68.8 ± 10.5 years, and comorbidities were equally balanced after matching. The mean aortic cross-clamp time, cardiopulmonary bypass time and total operative time were prolonged by 19, 20 and 27 min in the ARE group, respectively. Early mortality was not statistically significantly different with 1.4% in the surgical aortic valve replacement and 1.8% in the ARE group. Postoperative complications were <5% in all matched 338 patients: bleeding (3% vs 3%), pericardial effusion (3.0% vs 4.2%), sternal instability (1.8% vs 0%) and sternal wound infection (3.0% vs 1.2%). A significant higher number of patients had respiratory failure after ARE (unmatched: 17.1% vs 9.9%, P < 0.001; matched: 18.3% vs 9.5%, P = 0.028). Factors independently associated with overall mortality were age [hazard ratio (HR) 1.71], chronic obstructive pulmonary disease (HR 1.47), diabetes (HR 1.82), atrial fibrillation (HR 2.14) and postoperative respiratory failure (HR 2.84). CONCLUSIONS: ARE can be performed safely in experienced centres with no significant increase in the risk of early postoperative surgical complications and early mortality. However, the surgeon and the intensive care unit team should be aware of an increased risk for postoperative respiratory failure in ARE patients.
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Affiliation(s)
- Josephina Haunschild
- Department of Cardiac Surgery, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Sven Scharnowski
- Department of Cardiac Surgery, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Meinhard Mende
- Centre for Clinical Trials, University of Leipzig, Leipzig, Germany
| | - Konstantin von Aspern
- Department of Cardiac Surgery, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Christian D Etz
- Department of Cardiac Surgery, Heart Center Leipzig, University Leipzig, Leipzig, Germany
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