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The incidence and risk factors of hypofibrinogenemia in cardiovascular surgery

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Abstract

Objective

Cardiovascular surgery often causes massive bleeding due to coagulopathy, with hypofibrinogenemia being a major causative factor. We assessed the intraoperative incidence of hypofibrinogenemia and explored predictors of hypofibrinogenemia.

Methods

The intraoperative serum fibrinogen level (SFL) was routinely measured in 872 consecutive patients [mean age: 66.9 ± 13.3 years; 598 men (68.6%)] undergoing cardiovascular surgery from July 2013 to November 2016 at Nagoya University Hospital. There were 275 aortic surgeries, 200 cases of coronary artery bypass grafting (CABG), 334 valvular surgeries and 63 other surgeries. We estimated hypofibrinogenemia incidence (intraoperative lowest SFL ≤ 150 mg/dL) and identified its predictors by a logistic regression analysis.

Results

The average intraoperative lowest SFL of all cases, aortic surgery, CABG and valvular surgery was 185 ± 71, 156 ± 65, 198 ± 69 and 198 ± 68 mg/dL, respectively. Aortic surgery had a significantly lower intraoperative lowest SFL than CABG (p < 0.001) and valvular surgery (p < 0.001). The incidence of hypofibrinogenemia was 32.8%, 50.2%, 26.5% and 22.8% in all cases, aortic surgery, CABG and valvular surgery, respectively. The predictors of hypofibrinogenemia were the preoperative SFL, re-do surgery and perfusion time. A receiver operating characteristics curve analysis showed that the best preoperative SFL cutoff value for predicting hypofibrinogenemia was 308.5 mg/dL. Assuming preoperative SFL 300 mg/dL as the cutoff, the odds ratio for hypofibrinogenemia was 7.22 (95% confidence interval 5.26–9.92, p < 0.001).

Conclusions

The incidence of hypofibrinogenemia in aortic surgery was high. The preoperative SFL, re-do surgery and perfusion time were identified as predictors for hypofibrinogenemia. Intraoperative measurement of SFL is important for detecting hypofibrinogenemia and applying appropriate and prompt transfusion treatment.

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Authors and Affiliations

  1. Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8650, Aichi, Japan

    Toshihiko Nishi, Masato Mutsuga, Toshiaki Akita, Yuji Narita, Kazuro Fujimoto, Yoshiyuki Tokuda, Sachie Terazawa, Hideki Ito & Akihiko Usui

  2. Department of Anesthesiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8650, Aichi, Japan

    Kimitoshi Nishiwaki

Authors
  1. Toshihiko Nishi
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  2. Masato Mutsuga
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  3. Toshiaki Akita
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  4. Yuji Narita
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  5. Kazuro Fujimoto
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  6. Yoshiyuki Tokuda
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  9. Kimitoshi Nishiwaki
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  10. Akihiko Usui
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Correspondence to Toshihiko Nishi.

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Supplementary file1 (DOCX 15 kb)

Supplementary file2 (DOCX 14 kb)

Supplementary file3 (DOCX 15 kb)

11748_2019_1201_MOESM4_ESM.pdf

Supplement Figure 1 Blood transfusion protocol in our hospital. RBCs are administered when the hemoglobin value is < 7.0–8.0 g/dL at the end of CPB. Fibrinogen concentrate is administered targeting an SFL 200 mg/dL when the SFL at the end of CPB is <150 mg/dL. FFP is administered at the discretion of the surgeon and the anesthesiologist. PC is administered when the platelet count is <5–10×104/μL. After hemostasis is roughly achieved, PC is administered. CPB cardiopulmonary bypass, SFL serum fibrinogen level, RBC red blood cell, FFP fresh frozen plasma, PC platelet concentrate (PDF 81 kb)

11748_2019_1201_MOESM5_ESM.pdf

Supplement Figure 2-5 Intraoperative lowest SFL in, a all cases, b aortic surgery, c CABG and d valvular surgery. Hypofibrinogenemia was defined that intraoperative lowest SFL was under 150 mg/dL. SFL serum fibrinogen level, CABG coronary artery bypass grafting. (PDF 44 kb)

Supplementary file6 (PDF 43 kb)

Supplementary file7 (PDF 43 kb)

Supplementary file8 (PDF 43 kb)

11748_2019_1201_MOESM9_ESM.pdf

Supplement Figure 6 The comparison of the intraoperative lowest SFL of aortic surgery, CABG and valvular surgery. Aortic surgery showed a significantly lower intraoperative SFL than CABG and valvular surgery. SFL serum fibrinogen level, CABG coronary artery bypass grafting. (PDF 60 kb)

11748_2019_1201_MOESM10_ESM.pdf

Supplement Figure 7 Preoperative SFL and intraoperative lowest SFL in elective degenerative aneurysm, acute dissection and chronic dissection. A one-way ANOVA was used to analyze the significance, and the p values were >0.05 for both preoperative SFL and intraoperative lowest SFL. SFL serum fibrinogen level. (PDF 9 kb)

11748_2019_1201_MOESM11_ESM.pdf

Supplement Figure 8 Preoperative SFL and intraoperative lowest SFL in elective degenerative aneurysm, elective valvular surgery and elective CABG. A one-way ANOVA was used to analyze the significance, and the p values were 0.008 for preoperative SFL and <0.001 for intraoperative lowest SFL. The post hoc test (Bonferroni) results are reported in the graph. SFL serum fibrinogen level, CABG coronary artery bypass grafting (PDF 10 kb)

11748_2019_1201_MOESM12_ESM.pdf

Supplement Figure 9 Receiver operating characteristic curve for preoperative SFL as a predictor of hypofibrinogenemia. The area under the curve for the preoperative SFL was 0.81 (95% confidence interval, 0.78–0.84). We found that the best preoperative SFL cutoff value for predicting hypofibrinogenemia was 308.5 mg/dL (arrow). SFL serum fibrinogen level. (PDF 23 kb)

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Nishi, T., Mutsuga, M., Akita, T. et al. The incidence and risk factors of hypofibrinogenemia in cardiovascular surgery. Gen Thorac Cardiovasc Surg 68, 335–341 (2020). https://doi.org/10.1007/s11748-019-01201-8

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  • DOI: https://doi.org/10.1007/s11748-019-01201-8

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