The Effect of Blood Transfusion on Outcomes in Aortic Surgery

Abstract

The use of blood transfusion in cardiac surgery varies widely. The beneficial effects of blood products are offset by an increase in morbidity and mortality. Despite multiple studies showing an association between blood product exposure and adverse short- and long-term events, it is difficult to determine causality. Nevertheless, the implication is sufficient to warrant the search for alternative strategies to reduce the use of blood products while providing a standard of care that optimizes postoperative outcomes. Aortic surgery, in particular, is associated with an increased risk of bleeding requiring a blood transfusion. There is a paucity of evidence within aortic surgery regarding the deleterious effects of blood products. Here, we review the current evidence regarding patient outcomes after blood transfusion in cardiac surgery, with special emphasis on aortic surgery.

Keywords

cardiac surgical procedures - thoracic surgery - thoracic aorta - blood transfusion - morbidity - mortality - thoracic aortic aneurysm - dissection

• References

• 1 Goodnough LT. Transfusion medicine. In: Goldman L, Schafer AI. , eds. Goldman's Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2015: 1191-1198
• 2 Ferraris VA, Ferraris SP, Saha SP. , et al; Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion. 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 2007; 83 (5, Suppl): S27-S86
• 3 McQuilten ZK, Andrianopoulos N, Wood EM. , et al. Transfusion practice varies widely in cardiac surgery: Results from a national registry. J Thorac Cardiovasc Surg 2014; 147 (05) 1684-1690.e1
• 4 Yaffee DW, DeAnda A, Ngai JY. , et al. Blood conservation strategies can be applied safely to high-risk complex aortic surgery. J Cardiothorac Vasc Anesth 2015; 29 (03) 703-709
• 5 Smith D, Grossi EA, Balsam LB. , et al. The Impact of a Blood Conservation Program in Complex Aortic Surgery. Aorta (Stamford) 2013; 1 (04) 219-226
• 6 Chu MW, Losenno KL, Moore K, Berta D, Hewitt J, Ralley F. Blood conservation strategies reduce the need for transfusions in ascending and aortic arch surgery. Perfusion 2013; 28 (04) 315-321
• 7 Miller RD. Patient blood management: transfusion therapy. In: Miller RD. , ed. Miller's Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015: 1830-1867
• 8 Liu H, Yan H, Christian S. , et al. Physiological derangement of trauma patient. In: Scher CS. , ed. Anesthesia for Trauma. 1st ed. New York, NY: Springer; 2014: 45-65
• 9 Bunn HF. Approach to the anemias. In: Goldman L, Schafer AI. , eds. Goldman's Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016: 1059-1068
• 10 Koch CG, Li L, Sessler DI. , et al. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med 2008; 358 (12) 1229-1239
• 11 Argalious MY, Dalton JE, Mascha EJ, Cywinski JB, Clair DG. Association of red blood cell transfusion and postoperative outcomes after endovascular aortic repair. Semin Cardiothorac Vasc Anesth 2011; 15 (1-2): 49-55
• 12 Nussmeier N, Sarwar M, Searles B. , et al. Anesthesia for cardiac surgical procedures. In: Miller RD. , ed. Miller's Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015: 2007-2095
• 13 Ferraris VA, Brown JR, Despotis GJ. , et al; Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion; International Consortium for Evidence Based Perfusion. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91 (03) 944-982
• 14 Koch CG, Li L, Duncan AI. , et al. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg 2006; 81 (05) 1650-1657
• 15 Yu PJ, Cassiere HA, Dellis SL. , et al. Dose-dependent effects of intraoperative low volume red blood cell transfusions on postoperative outcomes in cardiac surgery patients. J Cardiothorac Vasc Anesth 2014; 28 (06) 1545-1549
• 16 Surgenor SD, DeFoe GR, Fillinger MP. , et al. Intraoperative red blood cell transfusion during coronary artery bypass graft surgery increases the risk of postoperative low-output heart failure. Circulation 2006; 114 (1, Suppl): I43-I48
• 17 Koch CG, Li L, Duncan AI. , et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med 2006; 34 (06) 1608-1616
• 18 Paone G, Likosky DS, Brewer R. , et al; Membership of the Michigan Society of Thoracic and Cardiovascular Surgeons. Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality. Ann Thorac Surg 2014; 97 (01) 87-93 , discussion 93–94
• 19 Koster A, Zittermann A, Börgermann J. , et al. Transfusion of 1 and 2 units of red blood cells does not increase mortality and organ failure in patients undergoing isolated coronary artery bypass grafting. Eur J Cardiothorac Surg 2016; 49 (03) 931-936
• 20 Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116 (22) 2544-2552
• 21 Isil CT, Yazici P, Bakir I. Risk factors and outcome of increased red blood cell transfusion in cardiac surgical patients aged 65 years and older. Thorac Cardiovasc Surg 2015; 63 (01) 39-44
• 22 Yun JJ, Helm RE, Kramer RS. , et al; Northern New England Cardiovascular Disease Study Group. Limited blood transfusion does not impact survival in octogenarians undergoing cardiac operations. Ann Thorac Surg 2012; 94 (06) 2038-2045
• 23 Carrascal Y, Maroto L, Rey J. , et al. Impact of preoperative anemia on cardiac surgery in octogenarians. Interact Cardiovasc Thorac Surg 2010; 10 (02) 249-255
• 24 Wu WC, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001; 345 (17) 1230-1236
• 25 Dardashti A, Ederoth P, Algotsson L, Brondén B, Lührs C, Bjursten H. Blood transfusion after cardiac surgery: is it the patient or the transfusion that carries the risk?. Acta Anaesthesiol Scand 2011; 55 (08) 952-961
• 26 Warwick R, Mediratta N, Chalmers J. , et al. Is single-unit blood transfusion bad post-coronary artery bypass surgery?. Interact Cardiovasc Thorac Surg 2013; 16 (06) 765-771
• 27 Cambria RP, Clouse WD, Davison JK, Dunn PF, Corey M, Dorer D. Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year interval. Ann Surg 2002; 236 (04) 471-479 , discussion 479
• 28 Muñoz M, Ariza D, Gomez-Ramirez S, Hernandez P, García-Erce J, Leal-Noval S. Preoperative anemia in elective cardiac surgery: prevalence, risk factors, and influence on postoperative outcome. Transfus Altern Transfus Med 2010; 11 (02) 47-56
• 29 Hogervorst EK, Rosseel PM, van de Watering LM. , et al. Intraoperative anemia and single red blood cell transfusion during cardiac surgery: an assessment of postoperative outcome including patients refusing blood transfusion. J Cardiothorac Vasc Anesth 2016; 30 (02) 363-372
• 30 Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, van Rensburg A, Beattie WS. The influence of baseline hemoglobin concentration on tolerance of anemia in cardiac surgery. Transfusion 2008; 48 (04) 666-672
• 31 Carson JL, Stanworth SJ, Roubinian N. , et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2016; 10: CD002042
• 32 Carson JL, Brooks MM, Abbott JD. , et al. Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. Am Heart J 2013; 165 (06) 964-971.e1
• 33 Murphy GJ, Pike K, Rogers CA. , et al; TITRe2 Investigators. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 2015; 372 (11) 997-1008
• 34 Avgerinos DV, DeBois W, Salemi A. Blood conservation strategies in cardiac surgery: more is better. Eur J Cardiothorac Surg 2014; 46 (05) 865-870
• 35 Ad N, Holmes SD, Patel J. , et al. The impact of a multidisciplinary blood conservation protocol on patient outcomes and cost after cardiac surgery. J Thorac Cardiovasc Surg 2017; 153 (03) 597-605.e1
• 36 Razavi SA, Carter AB, Puskas JD, Gregg SR, Aziz IF, Buchman TG. Reduced red blood cell transfusion in cardiothoracic surgery after implementation of a novel clinical decision support tool. J Am Coll Surg 2014; 219 (05) 1028-1036
• 37 Elmi M, Mahar A, Kagedan D. , et al. The impact of blood transfusion on perioperative outcomes following gastric cancer resection: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Can J Surg 2016; 59 (05) 322-329
• 38 Martin AN, Kerwin MJ, Turrentine FE. , et al. Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy. J Surg Res 2016; 206 (01) 106-112
• 39 Stone TJ, Riesenman PJ, Charles AG. Red blood cell transfusion within the first 24 hours of admission is associated with increased mortality in the pediatric trauma population: a retrospective cohort study. J Trauma Manag Outcomes 2008; 2 (01) 9
• 40 Demaret P, Tucci M, Karam O, Trottier H, Ducruet T, Lacroix J. Clinical outcomes associated with RBC transfusions in critically ill children: a 1-year prospective study. Pediatr Crit Care Med 2015; 16 (06) 505-514
• 41 Zheng Y, Lu C, Wei S, Li Y, Long L, Yin P. Association of red blood cell transfusion and in-hospital mortality in patients admitted to the intensive care unit: a systematic review and meta-analysis. Crit Care 2014; 18 (06) 515
• 42 DeAnda Jr A, Elefteriades JA, Hasaniya NW, Lattouf OM, Lazzara RR. Improving outcomes through the use of surgical sealants for anastomotic sealing during cardiovascular surgery. J Card Surg 2009; 24 (03) 325-333
• 43 Jakobsen CJ, Ryhammer PK, Tang M, Andreasen JJ, Mortensen PE. Transfusion of blood during cardiac surgery is associated with higher long-term mortality in low-risk patients. Eur J Cardiothorac Surg 2012; 42 (01) 114-120
• 44 Kleczynski P, Dziewierz A, Bagienski M. , et al. Association between blood transfusions and 12-month mortality after transcatheter aortic valve implantation. Int Heart J 2017; 58 (01) 50-55
• 45 Surgenor SD, Kramer RS, Olmstead EM. , et al; Northern New England Cardiovascular Disease Study Group. The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery. Anesth Analg 2009; 108 (06) 1741-1746
• 46 Engoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg 2002; 74 (04) 1180-1186
• 47 Santos AA, Sousa AG, Thomé HO, Machado RL, Piotto RF. Impact on early and late mortality after blood transfusion in coronary artery bypass graft surgery. Rev Bras Cir Cardiovasc 2013; 28 (01) 1-9
• 48 Engoren M, Schwann TA, Jewell E. , et al. Is transfusion associated with graft occlusion after cardiac operations?. Ann Thorac Surg 2015; 99 (02) 502-508