Abstract
Background
Preoperative anemia is associated with increased morbidity and mortality after cardiac surgery. Since anemia is ultimately treated with red blood cell transfusions, we investigated the independent impact of anemia and transfusion on the outcome after coronary artery bypass grafting (CABG).
Methods
This study included 2761 consecutive patients who underwent isolated CABG. Anemia was defined as hemoglobin <12.0 g/dL in women and <13.0 g/dL in men. The main outcomes were 30-day and late mortality.
Results
Patients with preoperative anemia had an increased prevalence of significant comorbidities and were associated with higher unadjusted risk of early and late adverse events. Propensity score matching resulted in 560 pairs with similar baseline and operative characteristics. In these matched pairs, anemic patients had an increased risk of late all-cause death (P = 0.047) and acute kidney injury (P < 0.0001). However, when adjusted for the severity of perioperative bleeding, preoperative anemia was not associated with an increased mortality risk (HR 1.10, 95% CI 0.86–1.39). Instead, this regression model showed that the European CABG registry (E-CABG) bleeding classification was an independent predictor of late mortality (compared to grade 0: grade 1, HR 1.93, 95% CI 1.37–2.73, grade 2, HR 2.19, 95% CI 1.50–3.18, grade 3, HR 5.59, 95% CI 3.34–9.39, P < 0.0001).
Conclusions
When adjusted for important baseline characteristics and operative factors as well as for the severity of perioperative bleeding and the amount of transfused blood products, anemia was not associated with an increased risk of adverse events. Increased exposure to blood transfusion among anemic patients may be the determinant of their poorer late survival.
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References
Loor G, Rajeswaran J, Li L et al (2013) The least of 3 evils: exposure to red blood cell transfusion, anemia, or both? J Thorac Cardiovasc Surg 146:1480–1487
Ranucci M, Baryshnikova E, Castelvecchio S, Surgical and Clinical Outcome Research (SCORE) Group et al (2013) Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery. Ann Thorac Surg 96:478–485
von Heymann C, Kaufner L, Sander M, et al (2016) Does the severity of preoperative anemia or blood transfusion have a stronger impact on long-term survival after cardiac surgery? J Thorac Cardiovasc Surg 152:1412–1420
Karkouti K, Wijeysundera DN, Beattie WS, Reducing Bleeding in Cardiac Surgery (RBC) Investigators (2008) Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation 117:478–484
Kulier A, Levin J, Moser R, Investigators of the Multicenter Study of Perioperative Ischemia Research Group, Ischemia Research and Education Foundation et al (2007) Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 116:471–479
Spiegelstein D, Holmes SD, Pritchard G et al (2015) Preoperative hematocrit as a predictor of perioperative morbidities following nonemergent coronary artery bypass surgery. J Card Surg 30:20–26
Musallam KM, Tamim HM, Richards T et al (2011) Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 378:1396–1407
Oliver E, Carrio ML, Rodriguez-Castro D et al (2009) Relationships among haemoglobin level, packed red cell transfusion and clinical outcomes in patients after cardiac surgery. Intensive Care Med 35:1548–1555
Richards T, Musallam KM, Nassif J et al (2015) Impact of preoperative anaemia and blood transfusion on postoperative outcomes in gynaecological surgery. PLoS ONE 10:e0130861
Hung M, Besser M, Sharples LD et al (2011) The prevalence and association with transfusion, intensive care unit stay and mortality of pre-operative anaemia in a cohort of cardiac surgery patients. Anaesthesia 66:812–818
Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Ferraris SP, Saha SP et al (2007) Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 83:S27–S86
Ranucci M, Di Dedda U, Castelvecchio S, Surgical and Clinical Outcome Research (SCORE) Group et al (2012) Impact of preoperative anemia on outcome in adult cardiac surgery: a propensity-matched analysis. Ann Thorac Surg 94:1134–1141
Matsuda S, Fukui T, Shimizu J et al (2013) Associations between preoperative anemia and outcomes after off-pump coronary artery bypass grafting. Ann Thorac Surg 95:854–860
Kim CJ, Connell H, McGeorge AD et al (2015) Prevalence of preoperative anaemia in patients having first-time cardiac surgery and its impact on clinical outcome. A retrospective observational study. Perfusion 30:277–283
Patel KV (2008) Epidemiology of anemia in older adults. Semin Hematol 45:210–217
World Health Organization, Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. In: World Health Organization. Vitamin and Mineral Nutrition Information System (VMNIS). 2011, WHO/NMH/NHD/MNM/11.1. http://www.who.int/vmnis/indicators/haemoglobin.pdf. Accessed 21 July 2016
Nashef SA, Roques F, Sharples LD et al (2012) EuroSCORE II. Eur J Cardiothorac Surg 41:734–744
Biancari F, Ruggieri VG, Perrotti A et al (2015) European multicenter study on coronary artery bypass grafting (E-CABG registry): study protocol for a prospective clinical registry and proposal of classification of postoperative complications. J Cardiothorac Surg 10:90
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group (2013) KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Inter Suppl 3:1–150
Shaw RE, Johnson CK, Ferrari G et al (2013) Balancing the benefits and risks of blood transfusions in patients undergoing cardiac surgery: a propensity-matched analysis. Interact Cardiovasc Thorac Surg 17:96–102
Scott BH, Seifert FC, Grimson R (2008) Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery. Ann Card Anaesth 11:15–19
Miceli A, Romeo F, Glauber M et al (2014) Preoperative anemia increases mortality and postoperative morbidity after cardiac surgery. J Cardiothorac Surg 9:137
Klein AA, Collier TJ, Brar MS, Association of Cardiothoracic Anaesthetists (ACTA) et al (2016) The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK—the first association of cardiothoracic anaesthetists national audit. Anaesthesia 71:627–635
Fowler AJ, Ahmad T, Phull MK et al (2015) Meta-analysis of the association between preoperative anaemia and mortality after surgery. Br J Surg 102:1314–1324
Valeri CR, Cassidy G, Pivacek LE et al (2001) Anemia-induced increase in the bleeding time: implications for treatment of nonsurgical blood loss. Transfusion 41:977–983
Ho CH (1998) The hemostatic effect of packed red cell transfusion in patients with anemia. Transfusion 38:1011–1014
Tettamanti M, Lucca U, Gandini F et al (2010) Prevalence, incidence and types of mild anemia in the elderly: the “Health and Anemia” population-based study. Haematologica 95:1849–1856
Martinsson A, Andersson C, Andell P et al (2014) Anemia in the general population: prevalence, clinical correlates and prognostic impact. Eur J Epidemiol 29:489–498
World Health Organization, (2008) World wide prevalence of anaemia 1993-2005, WHO global database on anaemia. http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf?ua=1. Accessed 12 Sept 2016
Nijst P, Verbrugge FH, Bertrand PB et al (2016) Plasma volume is normal but heterogeneously distributed and true anemia is highly prevalent in patients with stable heart failure. J Card Fail 23:138–144
American society of anesthesiologists task force on perioperative blood management (2015) Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology 122:241–275
Society of thoracic surgeons blood conservation guideline task force, Ferraris VA, Brown JR et al (2011) 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines. Ann Thorac Surg 91:944–948
Cladellas M, Farre N, Comin-Colet J et al (2012) Effects of preoperative intravenous erythropoietin plus iron on outcome in anemic patients after cardiac valve replacement. Am J Cardiol 110:1021–1026
Sowade O, Warnke H, Scigalla P et al (1997) Avoidance of allogeneic blood transfusions by treatment with epoetin beta (recombinant human erythropoietin) in patients undergoing open-heart surgery. Blood 89:411–418
Litton E, Xiao J, Ho KM (2013) Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomized clinical trials. BMJ 347:f4822
Tanaka A, Ota T, Uriel N et al (2015) Cardiovascular surgery in Jehovah’s witness patients: the role of preoperative optimization. J Thorac Cardiovasc Surg 150:976–983
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This study was approved by the Institutional Review Board of the Oulu University Hospital.
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Tauriainen, T., Koski-Vähälä, J., Kinnunen, EM. et al. The Effect of Preoperative Anemia on the Outcome After Coronary Surgery. World J Surg 41, 1910–1918 (2017). https://doi.org/10.1007/s00268-017-3911-0
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DOI: https://doi.org/10.1007/s00268-017-3911-0