Medical graphics to improve patient understanding and anxiety in elderly and cognitively impaired patients scheduled for transcatheter aortic valve implantation (TAVI)

BACKGROUND

Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI).

OBJECTIVES

We aimed to evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI.

METHODS

In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA).

RESULTS

Patient understanding was significantly higher in the Comic group [mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001]. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) [12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001]. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each).

CONCLUSIONS

Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020). Medical graphics entailed significant beneficial effects on the primary endpoints, patient understanding and periprocedural anxiety, compared to the usual patient informed consent (IC) procedure. Patient understanding of IC-related aspects was significantly higher in the Comic group, with a more pronounced benefit in patients with cognitive impairment (p for IC method and cognitive status < 0.001, respectively; p for IC method x MoCA category interaction = 0.017). There further was a significant decline of periprocedural anxiety in patients with and without cognitive impairment (p for IC method x measuring time point < 0.001; p for IC method x MoCA category x measuring time point interaction = 0.018).

Effects of doxorubicin and ibrutinib on atrial arrhythmogenity: ex-vivo assessment in human myocardium

Introduction

The cytostatic drugs doxorubicin (Dox) and ibrutinib (Ibr) are established in the treatment of various tumor diseases. In (pre-) clinical studies, both chemotherapeutic agents showed cardiotoxic side effects, including atrial fibrillation [1]. In this context, patients with limited cardiac performance or diabetes might be particularly vulnerable, as these pre-existing conditions represent independent risk factors for cardiac complications [2].

Objectives

The dose-dependency of acute pro-arrhythmogenic effects of Dox and Ibr on the contractile activity of human atrial muscle tissue was investigated.

Patients and methods

Atrial samples were taken intraoperatively during cardiac procedures. Functional muscle strips were prepared from the cardiac trabeculae, followed by incubation with different concentrations of Dox or Ibr for 30 minutes. Subsequently, functional measurements were performed. Isometric contraction force and arrhythmogenic occurrences were recorded. The samples were consecutively exposed to external stressors during measurement (Fig. 1).

We evaluated the overall occurrence of arrhythmogenic contractions and during which phase of the protocol they occurred. The latter was expressed as degree of arrhythmogenesis (Fig. 1).

Following the functional measurements, the muscle strips were conserved at −80°C.

Results

We isolated 127 muscle strips from 29 patients. Highest rates of overall arrhythmic contractions were observed at 10μM Dox and 0.5μM Ibr (77.8 & 100% vs. 58.4% (control)). Mean degree of arrhythmogenesis increased from 1.63 (control) to 2.17 (10μM Dox) and 3.11 (0.5μM Ibr).

Analyzing our data according to the included individuals, treatment with Dox and Ibr enhanced the degree of arrhythmogenesis in the majority of patients. (Fig. 2)

Conclusion

Our protocol is suitable for investigating drug related acute pro-arrhythmogenic effects on human atrial myocardium. Treatment of isolated atrial myocardium with Dox and Ibr enhanced its susceptibility to arrhythmogenic occurrences. Optimal pro-arrhythmogenic conditions were observed at 10μM Dox and 0.5μM Ibr. The treated samples showed higher overall rates of arrhythmogenic contractions and the arrhythmogenic activity occurred earlier within our protocol.

Outlook

We will correlate the experimentally obtained data with clinical patient data, such as LVEF, BMI and diabetic status. The conserved muscle strips will be analyzed using standardized assays comparing post-translational modification (e.g. phosphorylation and oxidation) of key regulators of excitation contraction coupling (e.g. PKA, CaMKII, Ca2+ channels).

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): DZHK (German Centre for Cardiovascular Research), partner site Berlin

The value of diastolic speckle-tracking parameters in predicting outcome after surgical ventricular restoration

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): DZHK (German Centre for Cardiovascular Research) BMBF (German Ministry of Education and Research)

Background. Parameters of speckle-tracking echocardiography (STE) are incorporated into the integrative assessment of left ventricular (LV) diastolic function 1. In this study we aimed to evaluate both established and novel STE parameters of LV diastolic function and their prognostic role in patients with LV anteroapical aneurysm planned for surgical ventricular restoration (SVR).

Methods. We retrospectively examined data of 137 patients (60 ± 11 years, 25% women) with anteroapical LV aneurysm who underwent SVR and for whom preoperative echocardiography was available and feasible for STE and for conventional assessment of LV diastolic function by transmitral flow. STE parameters evaluated were: left atrial reservoir strain (LAS), early and late global diastolic strain rate (GLSRe and GLSRa), ratio of early-to-late diastolic strain rate (GLSRe/GLSRa), and ratio of early diastolic transmitral flow velocity (E) to GLSRe and to GLSRa. In 24 patients we evaluated an association of diastolic echocardiographic parameters with mean pulmonary artery pressure (PAPm) and mean pulmonary capillary wedge pressure (PCWPm) obtained invasively within 6 days of echocardiography. Preoperative echocardiographic parameters were assessed in whole cohort of patients for the association with an outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation.

Results. During a median follow-up of 4.7 years (IQR: 1.4-8.1 years) events occurred in 59 patients. GLSRa, E/GLSRa and LAS demonstrated significant correlation with PAPm and PCWPm (Table 1). GLSRa with optimal cut-off value of ≤ 0.41 s-1 was able to detect PAPm &gt;30 mmHg with sensitivity of 0.8 and specificity of 0.8 (AUC 0.85; 95% CI 0.68-1.0; p = 0.008). E/GLSRa ≥1.24 m was able to detect PAPm &gt;30 mmHg with sensitivity of 1.0 and specificity of 0.8 (AUC 0.87; 95%CI 0.7-1.0; p = 0.005). There was significant difference in event-free survival between groups stratified by cut-offs for GLSRa (Fig. 1A) and E/GLSRa (Fig. 1B). After adjustment for important clinical (age, sex, plasma creatinine, atrial fibrillation) and echocardiographic parameters (fractional shortening and LV end-systolic volume index) GLSRa and E/GLSRa remained an independent predictors of events (HR 0.16; 95% CI: 0.03-0.86; p = 0.032 and HR 1.22; 95% CI: 1.03-1.43; p = 0.018) and demonstrated higher prognostic value compared to LAS, other STE parameters and conventional parameters of LV diastolic function.

Conclusion. Late diastolic longitudinal strain rate and ratio of early diastolic transmitral flow velocity to late diastolic longitudinal strain rate demonstrated association with hemodynamic parameters in patients with LV anteropaical aneurysm and might be used for the evaluation of LV diastolic function. These parameters showed prognostic value for patients underwent SVR and could be implemented for preoperative evaluation of these patients. Abstract Table 1. Correlation data  Abstract Figure 1. Survival curves

Effects of humidity and glidants on the flowability of pharmaceutical excipients. An experimental energetical approach during granular compaction

Granular materials are part of the design, production and final products of different industrial sectors. Powder flowability is a major topic in manufacturing and transport as it is closely related to process feasibility. Nonetheless, the flows of granular materials are not easy to describe or quantify, even in the simple case of dry monodisperse cohesionless particles. Flowability assessment is not a standard or normalized issue; still, no test is able predict powder flow behavior in all the different mechanical situations encountered during processing. This study aims (1) to evaluate flowability, as device-related, through the force or the energy supplied to the powder bed and (2) to study the effect of glidants and moisture content on flowability. To illustrate these aims, the flowability of two well-known pharmaceutical excipients, Avicel® PH-102 and Retalac® mixed with four different types of precipitated nano-silica (SIPERNAT® D10, D17, 50 S and 500 LS), was assessed using two granular compaction devices: Densitap® and FT4® compaction cell. Our results show that the hydrophilicity of colloidal silica affects surface coverage, ranging from 6% to over 80%. Binary mixtures with hydrophobic additives, D10 and D17, generated smaller silica aggregates with a wider spread on the surface of host particles. For Retalac® conditioned at 20% RH, HR values changed from 1.30 (acceptable flow) to 1.17 (good flow). For Avicel® PH-102, conditioned at 60% RH, HR values changed from 1.22 (fair flow) to less than 1.10 (excellent flow).

Circulatory efficiency in patients with severe aortic valve stenosis before and after aortic valve replacement

BACKGROUND

Circulatory efficiency reflects the ratio between total left ventricular work and the work required for maintaining cardiovascular circulation. The effect of severe aortic valve stenosis (AS) and aortic valve replacement (AVR) on left ventricular/circulatory mechanical power and efficiency is not yet fully understood. We aimed to quantify left ventricular (LV) efficiency in patients with severe AS before and after surgical AVR.

METHODS

Circulatory efficiency was computed from cardiovascular magnetic resonance (CMR) imaging derived volumetric data, echocardiographic and clinical data in patients with severe AS (n = 41) before and 4 months after AVR and in age and sex-matched healthy subjects (n = 10).

RESULTS

In patients with AS circulatory efficiency was significantly decreased compared to healthy subjects (9 ± 3% vs 12 ± 2%; p = 0.004). There were significant negative correlations between circulatory efficiency and LV myocardial mass (r = - 0.591, p < 0.001), myocardial fibrosis volume (r = - 0.427, p = 0.015), end systolic volume (r = - 0.609, p < 0.001) and NT-proBNP (r = - 0.444, p = 0.009) and significant positive correlation between circulatory efficiency and LV ejection fraction (r = 0.704, p < 0.001). After AVR, circulatory efficiency increased significantly in the total cohort (9 ± 3 vs 13 ± 5%; p < 0.001). However, in 10/41 (24%) patients, circulatory efficiency remained below 10% after AVR and, thus, did not restore to normal values. These patients also showed less reduction in myocardial fibrosis volume compared to patients with restored circulatory efficiency after AVR.

CONCLUSION

In our cohort, circulatory efficiency is reduced in patients with severe AS. In 76% of cases, AVR leads to normalization of circulatory efficiency. However, in 24% of patients, circulatory efficiency remained below normal values even after successful AVR. In these patients also less regression of myocardial fibrosis volume was seen. Trial Registration clinicaltrials.gov NCT03172338, June 1, 2017, retrospectively registered.

Cardiac computed tomography for therapy targeting in surgical repair of anteroapical left ventricular aneurysms: assessment of aneurysm volume and of anticipated residual left ventricular volume

Funding Acknowledgements

Type of funding sources: None.

Background

Surgical ventricular repair (SVR) is an established treatment option in patients with heart failure (HF) due to left ventricular (LV) aneurysms, whereby LV volume reduction is the principal therapeutic target. Precise planning therefore is essential for postoperative improvement of HF symptoms.

Purpose

In this study we evaluated the potential of cardiac computed tomography (CCT) to estimate the aneurysm volume and to predict the achievable residual LV volume.

Methods

 205 patients (11/2005-01/2016, m:w = 151:54, median 63.4 years; mean NYHA class 3.03) with anteroapical LV aneurysm underwent SVR combined with coronary artery bypass grafting (77%), mitral valve repair/replacement (19%), and LV thrombectomy (19%). CCT was performed before and 7 days after surgery. Volumetric assessment was made using dedicated software (syngo.via Cardiac Function, Siemens AG).  Preoperative CCT data of 48 consecutive patients were analyzed and then matched with effectively achieved postoperative volumes. To separate the aneurysm volume in the systole and diastole a plane determined by three landmarks on borders of scared to intact LV myocardium (antero-septal, lateral and inferior) was used. In this way ensued the retrospective estimation of the aneurysm volume (AnV/AnVI) and anticipated LV end diastolic and end systolic volume (LVEDVI, LVESVI).

Results

Mean diastolic and systolic estimated AnV were 92 ± 56.6 ml and 83.5 ± 61.6 ml respectively. Relation of AnV to LVEDV and to LVESV was 29.2% and 38.2%, correspondingly. There was significant correlation between anticipated and effectively achieved LVEDV and LVESV (r = 0.87 and r = 0.88, respectively, p &lt; 0.0001), and their indexed values (r = 0.83 and r = 0.83, respectively, p &lt; 0.0001). Anticipated LVEDVI was only 10.3 ± 22.5 ml/m2 greater than achieved LVEDVI (p = 0.003), and anticipated LVESVI was only 2.4 ± 20.3 ml/m2 greater than achieved LVESVI (p = 0.433).

Conclusions

Estimation of aneurysm volume and anticipated postoperative LV volume allows to predict if the therapeutic targets can be successfully achieved in individual patients. Based on the CCT assessment we propose an approach for surgical planning in anterior LV aneurysms.

Low-gradient aortic stenosis in patients with concomitant mitral regurgitation - a subgroup analysis from the German aortic valve registry (GARY)

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by German Cardiac Society, German Society for Thoracic and Cardiovascular Surgery, and German Heart Foundation. Statistical funding support by the German Center for Cardiovascular Research/Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK).

Background

Patients with severe aortic stenosis (AS) frequently present concomitant mitral regurgitation (MR), which may interfere with echocardiographic measurement of mean pressure gradient (MPG), maximal flow velocity and aortic valve area (AVA).

Purpose

We therefore, aimed to investigate the impact of different grades of MR on parameters of AS severity in a large cohort of all-comer patients with severe AS, prospectively included in the national German Aortic Registry (GARY).

Methods

 All patients undergoing transcatheter or surgical aortic valve replacement for severe AS enrolled in GARY between 2011 and 2017 were considered for this analysis. After excluding cases with mitral stenosis and unknown causes of MR, 119,641 patients were considered for the present study. Based on LVEF, the study population was divided into the following subgroups: group 1 (LVEF &lt; 30%, n = 7545), group 2 (LVEF 30-50%, n = 30,116), and group 3 (LVEF &gt; 50%, n = 81,980). Differences in the values of the mPG were explored in each group and in relation to the decremental values of aortic valve area (AVA).

Results

Overall, 37,489 (31.3%) patients had no MR, 77,890 (65.1%) had MR grade I-II, and 4262 (3.6%) had MR grade III-IV. 

In group 1, 2 and 3, no MR was reported in 1339 (17.7%), 7612 (25.3%) and 28,538 (34.8%) patients respectively. MR grade I-II was more frequently observed (group 1 5621 [74.5%] vs. group 2 20,972 [69.6%] vs. group 3 51,297 [62.6%]), whereas MR grade III-IV was observed less frequently and present only in 585 (7.7%), 1532 (5.1%) and 2145 (2.6%) patients in subgroups 1, 2 and 3, respectively.

The aortic mPG was significantly lower in subgroup 1 compared to 2 and 3 (33.74 ± 14.93 versus 41.4 ± 16.47 and 46 ± 16.19mmHg respectively, p &lt; 0.001). With increasing severity of MR, there was a significant reduction of the aortic mPG in each LVEF subgroup (Figure 1). This pattern was maintained irrespective of the AVA value.

Conclusions

 In patients with severe AS, concomitant MR may potentially affect diagnostic accuracy of echocardiographic AS evaluation. In this first GARY analysis of patients with severe AS and concomitant MR, we observed that increasing MR severity affects transvalvular aortic mPG and results in a low-gradient AS pattern. In contrast, AVA is a robust diagnostic parameter for the diagnosis of true severe AS that maintains its validity independently of LVEF and severity of concomitant MR.

Abstract Figure 1

Two-dimensional echocardiography compared to cardiac computed tomography for assessment of left ventricular volume and function in patients with anteroapical aneurysm

Funding Acknowledgements

Type of funding sources: None.

Background. Two-dimensional (2D) echocardiography is widely accepted method for the assessment of left ventricular (LV) morphology and function after myocardial infarction and for initial preoperative evaluation of patients planned for surgical ventricular repair (SVR). Magnetic resonance imaging and cardiac computer tomography (CT) provide more accurate measurements, but not always available.

Purpose. The aim of this study was to compare 2D-echocardiography and CT for preoperative assessment of patients with LV aneurysm in order to optimize the perioperative management in SVR.

Methods. Patients (n = 179, mean age 62.6 ± 11 years, 23.5% women) with LV anteroapical aneurysm due to myocardial infarction were examined by echocardiography and CT before SVR. LV end-diastolic and end-systolic volumes (LVEDV and LVESV) and ejection fraction (EF) obtained by two methods were compared pairwise. Prognostic role for the prediction of all-cause death was assessed for preoperative parameters in multivariate Cox regression model adjusted for patient age, sex, NYHA class, diabetes mellitus, renal failure, atrial fibrillation and arterial hypertension.

Results. There was a strong correlation for preoperative LVEDV and LVESV measured by echocardiography and CT (r = 0.85, r = 0.87, p &lt; 0.0001), however volumes obtained by echocardiography were smaller compared to those by CT (Table) with higher difference in patients with more dilated LV, as demonstrated by Bland-Altman analysis (Fig.). No significant difference in mean preoperative EF was observed with moderate correlation between two methods (r = 0.67, p &lt; 0.0001). In total 68 patients died during median follow up of 5.3 years (IQR: 1.7-8.7 years) after SVR. Comparable predictive value was demonstrated for LVEDV measured by CT and echocardiography (for 10 ml increase HR = 1.04, p = 0.004 and HR = 1.06, p = 0.0001), as well as for LVESV (for 10 ml increase HR = 1.04, p = 0.001 and HR = 1.07, p = 0.0001) and for EF (for 5% increase HR = 0.83, p = 0.004 and HR = 0.81, p = 0.004).

Conclusion. In patients with LV aneurysm 2D-echocardiography may be used for the assessment of LV volumes and function and have similar prognostic role compared to CT in patients evaluated for SVR. Underestimation of LV volumes by echocardiography must be considered, especially in patients with more dilated LV.

Comparison of CT and echocardiography Parameter CT Echo Mean difference p-value LVEDV, ml LVESV, ml EF, % 289 ± 104 198 ± 97 34 ± 12 222 ± 81 149 ± 67 35 ± 9 67 ± 56 49 ± 51 -0.9 ± 9.2 &lt;0.0001 &lt;0.0001 0.215 Abstract Figure. Bland-Altman plots for LVEDV and LVESV

Randomized clinical trial comparing a rivaroxaban-based with an antiplatelet-based strategy for cerebral embolization after TAVR (EARTH TAVR)-a magnetic resonance imaging substudy of the GALILEO trial

Background

Cerebral embolization in patients after Transcatheter Aortic Valve Replacement (TAVR) represents a serious complication, that was related to impaired bioprosthetic leaflet motion and new-onset atrial fibrillation (AFib).

Purpose

Hereafter we present the first randomized study comparing the effect of an anticoagulation plus antiplatelet with a dual antiplatelet antithrombotic treatment in patients after TAVR on cerebral embolizations as assessed by serial cerebral magnetic resonance imaging (MRI).

Methods

The Evaluation of Cerebral Thrombembolism After TAVR (EARTH - TAVR) study was conducted as an investigator initiated substudy of the multicenter, randomized, GALILEO study. After successful TAVR, patients without indication for chronic anticoagulation were randomly assigned to rivaroxaban 10mg plus acetylsalicylic acid 75–100mg once-daily or clopidogrel 75mg plus acetylsalicylic acid 75–100mg once-daily. Cerebral MRI scans were performed pre-TAVR as a baseline, post-TAVR (within 24–48 hours after TAVR) and 90 days after TAVR. The MRI protocol included diffusion-weighted (DWI) and fluid-attenuated inversion recovery (FLAIR) imaging. Cerebral embolic lesions were evaluated by an independent cerebral MRI core lab. The primary outcome measure of this study was the occurrence and extent of cerebral embolizations as measured by total volume of new ischaemic cerebral lesions.

Results

36 patients were enrolled in the EARTH and the GALILEO study. The DWI MRI scans revealed an increase of cerebral lesions and volume post-TAVR by a median of 4.75 (95% NBCI 2.1–8.9) and 0.26cm3 (95% NBCI 0.11–0.59). On FLAIR imaging, lesion number and volume increased by a median of 3 (95% NBCI 1.5–6) and 0.1 cm3 (95% NBCI 0.04–0.31). At the 90 days MRI scan, there was no statistically significant change in cerebral lesions, if compared to the post-TAVR scan, irrespective of the treatment arm.

Conclusion

Thromboembolic events occur largely in the periinterventional phase post TAVR. Thereafter, the risk for additional cerebral embolization is low. An additional rivaroxaban therapy beyond antiplatelet inhibition did not impact on cerebral thromboembolism.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bayer Pharmaceuticals

Prognostic role of left ventricular diastolic function assessed by speckle tracking echocardiography in patients after surgical ventricular repair

Background

Assessment of left ventricular (LV) diastolic function brings important prognostic information for patients with heart failure and could be evaluated by speckle tracking echocardiography (STE). Less known about its role in patients planned for surgical ventricular repair due to LV aneurysm.

Purpose

The aim of this study was to evaluate the prognostic role of STE parameters of LV diastolic function for prediction of all-cause mortality in patients after surgical ventricular repair.

Methods

We retrospectively evaluated data of 163 consecutive pts (mean age 62.3±11.5 years, 74.8% males) with anteroapical LV aneurysm who underwent surgical ventricular repair combined with coronary artery bypass surgery (71.8%) Prognostic role for prediction of all-cause mortality was assessed for various STE parameters, including left atrial strain (LAS) measured as peak reservoir strain and for the ratio of early to late global longitudinal strain rate (GLSRe/GLSRa).

Results

During a median follow-up of 4.7 years (IQR: 1.6–8.9 years) there were 65 deaths, 5 year survival rate was 73.8 (95% CI 67–79%). Baseline ejection fraction, end-diastolic and end-systolic volumes of LV did not differ between pts who died and survived at 5 year after the surgery, whereas LAS was significantly higher and GLSRe/GLSRa was significantly lower in survivors. Cox proportional hazard model adjusted to demographic and clinical variables demonstrated that LAS and GLSRe/GLSRa were independent predictors of all-cause death, with HR of 0.79 (95% CI 0.66–0.95, p=0.012) for each 5% increase of LAS and HR of 1.24 (95% CI 1.1–1.4, p=0.001) for each 0.5 increase of GLSRe/GLSRa. Moreover, GLSRe/GLSRa remained an independent predictor after additional adjustment for LV end-systolic volume, sphericity index and presence of mitral insufficiency of grade 2 and higher. A significant difference in median survival time was demonstrated according to the following cut-offs: LAS ≥16.7% (12.1 vs. 6.4 years, p=0.01), GLSRe/GLSRa ratio ≥2.3 (3.3 years vs. 10.2 years, p=0.0005) (Figure). The classification and regression tree analysis with the application of all two-dimensional, Doppler and various speckle-tracking echocardiographic parameters revealed that GLSRe/GLSRa and LAS were the most important echocardiographic variables for risk stratification for 5-year mortality.

Conclusion

This study demonstrates that STE parameters of LV diastolic function are important predictors of all-cause mortality after surgical ventricular repair due to anteroapical aneurysm of LV and could be used in the preoperative decision-making process.

Funding Acknowledgement

Type of funding source: None

Efficacy of quadruple treatment on different types of pre-operative anaemia: secondary analysis of a randomised controlled trial

In patients with pre-operative anaemia undergoing cardiac surgery, combination treatment with intravenous iron, subcutaneous erythropoietin alpha, vitamin B12 and oral folic acid reduces allogeneic blood product transfusions. It is unclear if certain types of anaemia particularly benefit from this treatment. We performed a post-hoc analysis of anaemic patients from a randomised trial on the 'Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery'. We used linear regression analyses to examine the efficacy of a combination anaemia treatment compared with placebo on the following deficiencies, each representing a part of the combination treatment: ferritin and transferrin saturation; endogenous erythropoietin; holotranscobalamine; and folic acid in erythrocytes. Efficacy was defined as change in reticulocyte count from baseline to the first, third and fifth postoperative days and represented erythropoietic activity in the immediate peri-operative recovery phase. In all 253 anaemic patients, iron deficiency was the most common cause of anaemia. Treatment significantly increased reticulocyte count in all regression analyses on postoperative days 1, 3 and 5 (all p < 0.001). Baseline ferritin and endogenous erythropoietin were negatively associated with change in reticulocyte count on postoperative day 5, with an unstandardised regression coefficient B of -0.08 (95%CI -0.14 to -0.02) and -0.14 (95%CI -0.23 to -0.06), respectively. Quadruple anaemia treatment was effective regardless of the cause of anaemia and its effect manifested early in the peri-operative recovery phase. The more pronounced a deficiency was, the stronger the subsequent boost to erythropoiesis may have been.