blood transfusion – ABC CARDIOL

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Original Article

Restrictive versus Liberal Transfusion Strategies in Acute Myocardial Infarction and Anemia: A Meta-Analysis and Trial Sequential Analysis

Ronaldo C. Fabiano et al. Lara Melo Alleh Nogueira Douglas M. Gewehr … Giuliano Generoso Rhanderson Cardoso Marcio S. Bittencourt

Abstract

Background:

The optimal transfusion strategy in acute myocardial infarction (AMI)-associated anemia remains uncertain.

Objectives:

To compare all-cause mortality between liberal versus restrictive transfusion strategies in patients with AMI-associated anemia, using a meta-analytic approach.

Methods:

Pubmed, Embase, and ClinicalTrials.gov were systematically searched for randomized controlled trials (RCTs) comparing liberal and restrictive transfusion strategies in AMI-associated anemia. Random-effects meta-analysis and trial sequential analysis (TSA) were conducted to compare blood use, efficacy, and safety endpoints. The p-values were 2-sided with an α of 0.05.

Results:

In a pooled analysis involving 4,217 participants from three RCTs followed-up for 30 days, no statistically significant differences emerged between restrictive and liberal strategies in all-cause mortality (RR 1.03; 95% CI 0.67–1.57; p=0.90) and other efficacy endpoints (recurrent AMI, unscheduled revascularization, acute heart failure, stroke, and acute kidney injury), as well as in safety endpoints including allergic reactions, infection, and acute lung injury. TSA did not reach futility boundaries. In patients assigned to restrictive strategy, substantial differences in transfusion use were observed across RCTs, correlating with mortality rates, and likely accounting for between-study heterogeneity in treatment effects.

Conclusions:

In patients with AMI-associated anemia, there is no clear superiority between liberal and restrictive transfusion strategies in all-cause mortality or other major outcomes in 30 days. However, the heterogeneity observed in blood use between the restrictive groups likely explains variable findings across RCTs.

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Editorial

Could Less Be Worth More?

Luiz Maurino Abreu

The use of biologically active products, such as stored blood, in the therapeutic arsenal generates controversy. With the development of hemotherapy, related complications, such as transfusion-transmitted infections, transfusion-related acute lung injury (TRALI), and severe hemolytic reactions, have become rare.^, However, possible volume overload, with consequent pulmonary edema (transfusion-associated circulatory overload, TACO) and its clinical implications, is associated with a major cause of post-transfusion morbidity and mortality. Predisposing factors for the condition include ischemic cardiomyopathy and chronic kidney disease, often present in the context of acute myocardial infarction (AMI).^,

Anemia can worsen myocardial ischemia in AMI, with an impact on mortality. Two main strategies are present in clinical trials in the management of this condition: restrictive transfusion and liberal transfusion. The choice between these approaches remains a controversial topic, with critical implications for clinical practice and patient outcomes.

[…]

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IJCS

Editorial

Lower Rate of Blood Transfusion after Heart Surgery in a Tertiary Hospital

Leonardo Secchin Canale

Special interest in surgical bleeding and methods to limit its occurrence is growing after the possibility that transfusion of blood products might be causally related to complications and negative outcomes has been raised. In the same vein, studies have been conducted to evaluate whether limiting blood product transfusions (ie, being more conservative in the indication for it) would increase the safety of transfusion or even reduce some patterns of complications. The current study is a contribution to this larger discussion.

Moraes et al. report the experience of a large tertiary center in bleeding patterns after heart operations. Four hundred and twenty-three patients (51% coronary artery bypass surgery and 33% valve operations) were evaluated for total bleeding and for the use of blood products. Perioperative bleeding was measured by weighing sponges, a validated method for a difficult enterprise. Postoperative bleeding was determined by the total chest tube output in the first 24 h after the end of the operation.

[…]

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IJCS

Original Article

Adverse Events and Risk Factors of Blood Transfusion in Cardiovascular Surgery: A Prospective Cohort Study

Ana Paula Tagliari et al. Lucas Molinari Veloso da Silveira Adriano Nunes Kochi Anderson Castro de Souza … Marcelo Curcio Gib Tanara Martins de Freitas Cristiano Blaya Martins Leandro Totti Cavazzola Orlando Carlos Belmonte Wender

Abstract

Background:

Hemodilution, transoperative bleeding and cardiopulmonary bypass (CPB) are some of the factors associated with high transfusion rates in cardiac surgery.

Objective:

To analyze the incidence of blood transfusion and early postoperative outcomes in cardiac surgery patients.

Methods:

Cohort study of patients undergoing cardiac surgery in a university hospital, consecutively enrolled from May 2015 to February 2017. Data were prospectively collected and comparisons were made between two patients’ groups: transfused and not transfused. Student’s t-test, chi-square test, and logistic regression were used, and a p-value < 0.05 was considered significant.

Results:

Among the 271 patients evaluated, 100 (37%) required transfusion in the transoperative (32.1%) and/or postoperative periods (19.5%). The following predictors of transfusion were identified by multivariate analysis: EuroScore II (OR 1.2); chronic kidney disease (CKD) (OR 3.2); transoperative bleeding ≥ 500 mL (OR 6.7); baseline hemoglobin (Hb) ≤ 10 g/dL (OR 11.5); activated partial thromboplastin time (aPTT) (OR 1.1) and CPB duration (OR 1.03). Transfusion was associated with prolonged mechanical ventilation (≥ 24h) (2.4% vs. 23%), delirium (5.9% vs. 18%), bronchopneumonia (1.2% vs. 16%), acute renal failure (3.5% vs. 25%), acute on CKD (0.6% vs. 8%), stroke or transient ischemic attack (1.8% vs. 8%), intensive care unit stay ≥ 72 h (36% vs. 57%), longer hospital stay (8 ± 4 days vs. 16 ± 15 days), as well as increased early mortality (1.75% vs. 15%).

Conclusion:

EuroScore II, CKD, major transoperative bleeding, preoperative Hb and aPTT values and CPB time were independent predictors of transfusion, which was associated with a higher rate of adverse outcomes, including early mortality.

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Original Article

Echocardiography in thalassemic patients on blood transfusions and chelation without heart failure

Alexandre Rodrigues et al. Fábio Villaça Guimarães-Filho João Carlos Ferreira Braga Cássia Spínola Custódio Rodrigues … Paulo Waib Antonio Fabron-Junior Doralice Marvulle Tan Ana Cristina C. V. França Marina Politi Okoshi Katashi Okoshi

BACKGROUND: Patients with thalassemia major present chronic hemolysis and require regular blood transfusions which may cause iron overload cardiomyopathy and chronic heart failure. Hemochromatosis is characterized by excessive iron accumulation in tissues, and heart involvement is the main cause of death in patients with thalassemia. OBJECTIVE: The aim of this study was to evaluate cardiac structure and function by conventional Doppler echocardiography and tissue Doppler imaging in patients with TM and no clinical evidence of heart failure. METHODS: This is a prospective observational study including 18 patients with thalassemia major (TM) receiving regular blood transfusion. To separately evaluate anemia and blood transfusion effects, two gender, age, weight, and height-matched control groups were included: one with healthy individuals (Healthy, n=18) and one with iron deficient anemia patients (Anemia, n=18). Statistical analysis was performed using ANOVA followed by Tukey’s test or Kruskal-Wallis’s and Dunn’s test. RESULTS: The following echocardiographic variables presented significantly higher values in TM than the Anemia and Healthy groups: left atrium volume index (Healthy: 16.4±6.08; Anemia: 17.9±7.02; TM: 24.1±8.30 cm³/m²); mitral septal E/Em ratio (Healthy: 6.55±1.60; Anemia: 6.74±0.74; TM: 8.10±1.31); and duration of reverse pulmonary vein flow [Healthy: 74.0 (59.0-74.0); Anemia: 70.5 (67.0-74.0); TM: 111 (87.0-120) ms]. The mitral E/A ratio was higher in TM than Anemia (Healthy: 1.80±0.40; Anemia: 1.80±0.24; TM: 2.03±0.34). No differences were found in left ventricular structures and systolic function indexes. CONCLUSION: Conventional Doppler echocardiography and tissue Doppler allow changes in left ventricular diastolic function to be identified in asymptomatic patients with thalassemia major.

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Artigo Original

Myocardial revascularization surgery without extracorporeal circulation minimizes postoperative bleeding and the need for transfusion

Fernando Antibas Atik et al. Leonardo Augusto Miana Fábio B. Jatene José Otávio C. Auler Júnior Sérgio Almeida de Oliveira

OBJECTIVE: To compare myocardial revascularization (MR) with and without extracorporeal circulation (ECC) in regard to postoperative bleeding and the need for blood and hemoderivate transfusion. METHODS: From November 2001 to February 2002, 186 patients undergoing myocardial revascularization were assessed, excluding those who underwent associated procedures. The patients were divided into 2 groups as follows: group A – comprising 116 patients undergoing MR with ECC; and group B – comprising 69 patients undergoing MR without ECC. Both groups were comparable in regard to pre- and intraoperative characteristics, except for the greater number of distal anastomoses (P=0.0004) in group A, and greater prothrombin activity (P=0.04) and INR (P=0.03) in group B. To avoid discrepancies between the groups, 140 patients with statistically similar characteristics were selected. RESULTS: Studying the paired groups, both the total bleeding volume in 24 hours (P=0.001) and the bleeding volume indexed for body surface (P=0.004) were greater in group A (609.6 ± 395.8 mL; 331.8 ± 225.8 mL/m², respectively) than in group B (437.2 ± 315 mL; 241 ± 173.9 mL/m², respectively). Although the need for transfusion was not significantly different between the groups (P=0.1), the amount of erythrocyte concentrate transfused was greater in group A (P=0.01). No statistical difference was observed in regard to transfusion of other hemocomponents and the need for surgical review of hemostasis. CONCLUSION: Myocardial revascularization without ECC was more advantageous than MR with ECC in regard to smaller postoperative blood loss and a lesser need for transfusion of erythrocyte concentrate. The repercussions of this finding may be innumerable, particularly in regard to minimization of morbid factors and hospital costs.

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