Should Asymptomatic Patients Discharged with Lower Hemoglobin Expect Worse Outcomes After Valve Surgery? Niv Ad, MD Sari D. Holmes, PhD Alan M. Speir,

Slides:

Advertisements

Similar presentations

© 2010, American Heart Association. All rights reserved. A Validated Risk Score for In-hospital Mortality in Patients with Heart Failure from the American.

Advertisements

1 Outcomes for Patients with ST-Elevation Myocardial Infarction in Hospitals With and Without Onsite Coronary Artery Bypass Graft Surgery: The New York.

A Randomized Trial of Protocol-Based Care for Early Septic Shock Andrea Caballero, MD January 15, 2015 LSU Journal Club The ProCESS Investigators. N Engl.

Does Preoperative Hemoglobin Value Predict Postoperative Cardiovascular Complications after Total Joint Arthroplasty? Kishor Gandhi MD, MPH, Eugene Viscusi.

I MPACT OF P REOPERATIVE A NEMIA O N E ARLY AND L ATE O UTCOMES A FTER S URGICAL A ORTIC V ALVE R EPLACEMENT Rohan S. Menon BS, Wilson Szeto MD, Kanika.

Steroids In caRdiac Surgery (SIRS) Trial

Widimsky P, Tousek P, Rokyta R, et al. Charles University Prague, CZ PRAGUE-7 Study (Hot Lines presenter)

STS 2015 John V. Conte, MD Professor of Surgery Johns Hopkins University School of Medicine On Behalf of the CoreValve US Investigators Transcatheter Aortic.

The Influence of Radial vs. Femoral Access on Acute Blood Loss in Patients Undergoing Percutaneous Coronary Intervention Amit Nanda 1, Eric Novak MS 2,

Use of Psoas Muscle Size as a Frailty Assessment Tool for Open and Transcatheter Aortic Valve Replacement Raghavendra Paknikar BS Jeffrey Friedman BS David.

Valvular heart surgery in Rajavithi hospital Dr.WITTAWAT PIBUL Rajavithi Hospital.

5 Years Results of Off-Pump VS On-Pump CABG 5 Years Results of Off-Pump VS On-Pump CABG Prospective Non-randomized Comparative Study Piya Cherntanomwong*,

TRANSCEND: Telmisartan Randomized AssesmeNt Study in aCE iNtolerant Subjects with Cardiovascular Disease ONTARGET / TRANSCEND Investigators Koon K. Teo,

CHARM-Alternative: Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity - Alternative Purpose To determine whether the angiotensin.

CHARM-Preserved: Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity - Preserved Purpose To determine whether the angiotensin.

Validation of Mayo Clinic Risk Adjustment Model for In-Hospital Mortality following Percutaneous Coronary Interventions using the National Cardiovascular.

Predicting Patients at Risk for Poor Global Outcomes after DT- MCS Therapy Suzanne V. Arnold, MD, MHA Saint Luke’s Mid America Heart Institute/UMKC May.

Blood Pressure Lability During Cardiac Surgery Is Associated With Adverse Outcomes Solomon Aronson, Edwin G. Avery, Cornelius Dyke, Joseph Varon, Jerrold.

Patterns of red blood cell transfusion use and outcomes in patients undergoing percutaneous coronary intervention in contemporary clinical practice: Insights.

The New Priority: Decreasing Readmissions after Cardiothoracic Surgery: How Do We Get There? Michael Zhen-Yu Tong, MD, MBA Department of Cardiothoracic.

Specialized Atrial Fibrillation Clinic reduces cardiovascular morbidity and mortality in patients with atrial fibrillation Jeroen ML Hendriks, MSc Robert.

CPORT- E Trial Randomized trial comparing outcomes of non-primary PCI at hospitals with and without on-site cardiac surgery.

A 20-year Experience with Isolated Pericardiectomy An Analysis of Indications and Outcomes Gillaspie EA, Stulak JM, Daly RC, Greason KL, Joyce LD, Oh J,

Monthly Journal article review: Vimmi Kang PGY 2

Gregg W. Stone, Tim Clayton, Roxana Mehran, Efthymios N. Deliargyris, Jayne Prats, Stuart J. Pocock TCT 2012; JACC 2012;60(17SupplB):B16 The HORIZONS-AMI.

Randomized Trial of Ea rly S urgery Versus Conventional Treatment for Infective E ndocarditis (EASE) Duk-Hyun Kang, MD, PhD on behalf of The EASE Trial.

Long Term Clinical Outcomes Following Drug-Eluting and Bare Metal Stenting in Massachusetts Laura Mauri, MD, MSc; Treacy Silverstein, B.Sc.; Ann Lovett,

Use of Arteriotomy Closure Devices and the Risk of Vascular Complications: An Analysis of 227,879 Patients in the NCDR Sameer K. Mehta MD, Andrew D. Frutkin.

Michael A. Nelson, MD 1 Michele D. Voeltz, MD 1 Frederick Feit, MD 2 A. Michael Lincoff, MD 3 Steven V. Manoukian, MD 1 1 Emory University School of Medicine.

TRANSCEND: Telmisartan Randomized AssesmeNt Study in aCE iNtolerant Subjects with Cardiovascular Disease ONTARGET / TRANSCEND Investigators Koon K. Teo,

A Novel Score to Estimate the Risk of Pneumonia After Cardiac Surgery

A Contemporary Analysis of Pulmonary Hypertension in Patients Undergoing Mitral Valve Surgery: Is this a Risk Factor? Thank you to the society and panel.

Bleeding in Patients Undergoing Percutaneous Coronary Interventions: A Risk Model From 302,152 Patients in the NCDR. Sameer K. Mehta MD, Andrew D. Frutkin.

Deep Hypothermic Circulatory Arrest in the Elderly: Is it Safe? Adam D. Zimmet, Irving L. Kron, Alan M. Speir, Clifford E. Fonner, and Ivan K. Crosby University.

Does Moderate Hypothermia Really Carry Less Bleeding Risk than Deep Hypothermia For Circulatory Arrest? A Propensity-Matched Comparison in Hemiarch Replacement.

Heart rate in heart failure: Heart rate in heart failure: risk marker or risk factor? A subanalysis of the SHIFT trial on behalf of the Investigators M.

Presented by Renato D. Lopes, MD, PhD, Duke Clinical Research Institute, Duke University, USA for the ARISTOTLE investigators. Efficacy and Safety of Apixaban.

Alberto Repossini, Thierry A Folliguet

Preoperative Hemoglobin A1c and the Occurrence of Atrial Fibrillation Following On-pump Coronary Artery Bypass surgery in Type-2 Diabetic Patients Akbar.

Department of Cardiothoracic and Vascular Surgery 1 School of Public Health 2 The University of Texas Medical School at Houston Memorial Hermann Heart.

The Case for Rate Control: In the Management of Atrial Fibrillation Charles W. Clogston, M.D. Cardiologist CHI St. Vincent Heart Clinic Arkansas April.

Increasing Response Rates Among Open- Heart Surgery Patients on Health-Related Quality of Life Surveys Through an Intense Longitudinal Follow-Up Algorithm:

Prof. Dr. Sigmund Silber, FESC, FACC On behalf of the RESOLUTE

Angiotensin converting enzyme inhibitors / angiotensin receptor blockers and contrast induced nephropathy in patients receiving cardiac catheterization:

Update on the Watchman Device CRT 2010 Washington, DC

Lako S, Daka A, Nurka T, Dedej T, Memishaj S

Is There a Need to Address AF in patients Undergoing Valve Surgery?

Washington Hospital Center

Successful Cox Maze Procedure During Mitral Valve Surgery Restores Patient Survival Without Increasing Operative Risk Niv Ad, MD Chief, Cardiac Surgery.

Niv Ad, MD Chief, Cardiac Surgery Professor of Surgery, VCU

Niv Ad, MD, Linda Henry, PhD, RN, Deborah J. Shuman, BS, Sari D

Should asymptomatic patients discharged with lower hemoglobin expect worse outcomes after valve surgery? Niv Ad, MD, Sari D. Holmes, PhD, Deborah J.

Amiodarone after surgical ablation for atrial fibrillation: Is it really necessary? A prospective randomized controlled trial Niv Ad, MD, Sari D. Holmes,

Mild-to-moderate functional tricuspid regurgitation in patients undergoing mitral valve surgery Sun Kyun Ro, MD, Joon Bum Kim, MD, Sung Ho Jung, MD,

Comparison of EuroSCORE II, Original EuroSCORE, and The Society of Thoracic Surgeons Risk Score in Cardiac Surgery Patients Niv Ad, MD, Sari D. Holmes,

Less Is More: Results of a Statewide Analysis of the Impact of Blood Transfusion on Coronary Artery Bypass Grafting Outcomes Todd C. Crawford, MD, J.

Linda Henry, PhD, RN, Linda Halpin, MSN, RN, Sharon Hunt, MBA, Sari D

No Financial Disclosure or Conflict of Interest

Left-Sided Surgical Ablation for Patients With Atrial Fibrillation Who Are Undergoing Concomitant Cardiac Surgical Procedures Niv Ad, MD, Sari D. Holmes,

Minimally Invasive Fibrillating Heart Surgery: A Safe and Effective Approach for Mitral Valve and Surgical Ablation for Atrial Fibrillation Paul S. Massimiano,

Microplegia During Coronary Artery Bypass Grafting Was Associated With Less Low Cardiac Output Syndrome: A Propensity-Matched Comparison Khaled D. Algarni,

Do we increase the operative risk by adding the Cox Maze III procedure to aortic valve replacement and coronary artery bypass surgery? Niv Ad, MD, Linda.

A. Thomas Pezzella, MD, Sari D

Growing Evidence For Practice

Niv Ad, MD, Sari D. Holmes, PhD, Deborah J

The impact of a multidisciplinary blood conservation protocol on patient outcomes and cost after cardiac surgery Niv Ad, MD, Sari D. Holmes, PhD, Jay.

Larger Sheath Size for Infrainguinal Endovascular Intervention is Associated with Minor but Not Major Morbidity or Mortality Scott R. Levin MD, Alik.

Is TCAR best under LA or GA

Transcarotid Artery Revascularization versus Transfemoral Carotid Artery Stenting for Treatment of Carotid Artery Stenosis Patric Liang, MD; Marc L.

Transcatheter versus medical treatment of symptomatic severe tricuspid regurgitation: a propensity score matched analysis Maurizio Taramasso MD, PhD from.

Presentation transcript:

Should Asymptomatic Patients Discharged with Lower Hemoglobin Expect Worse Outcomes After Valve Surgery? Niv Ad, MD Sari D. Holmes, PhD Alan M. Speir, MD Graciela Pritchard, BS Linda Halpin, MSN, RN Inova Heart and Vascular Institute Falls Church, VA

Disclosure Information Niv Ad, MD AtriCure: consulting and speaker bureau Medtronic: consulting and speaker bureau Left Atrial Appendage Occlusion, LLC: co-owner Alan M. Speir, MD Medtronic: Advisory board

Background Blood transfusion has been associated with increased morbidity and cost in cardiac surgery patients The decision to transfuse following cardiac surgery is often subjective and based primarily on low Hgb levels, age even in asymptomatic patients

Purpose Study Purposes: To determine whether asymptomatic patients discharged with lower Hgb levels are at increased risk for: Perioperative complications Inferior quality of life Increased 1-year mortality

Methodology Data collected prospectively on 1,107 valve-only procedures performed between 2008 and mid-2014 Patients discharged alive with complete data (N =1,044) and divided into two groups: Discharge Hgb levels ≤8 g/dL (n=153) Discharge Hgb levels >8 g/dL (n=891)

Methodology Asymptomatic Patients: Clinically stable Ambulating well Normal BP & no orthostatic hypotension No dizziness, tachycardia, tachypnea, or shortness of breath

Methodology Multivariate analysis with Hgb as a continuous variable supplemented by a propensity score matching (PSM) conducted between Hgb groups (152 patient pairs after PSM)

Primary Research Questions Question 1: Does lower discharge Hgb level impact outcomes in the entire sample, adjusting for clinical factors with multivariate analyses? Question 2: After PSM based on discharge Hgb, do patients with discharge Hgb ≤8 g/dL have worse outcomes? Question 3: What is the role of blood product transfusion on outcomes?

Patient Characteristics Before PSM Characteristic Hgb >8 g/dL (n = 891) Hgb ≤8 g/dL (n = 153) P Age 62.0 ± ± Female 319 (36)68 (44)0.041 Ejection fraction (%) 57.7 ± ± CHF 260 (29)68 (44)<0.001 Diabetes 132 (15)43 (28)<0.001 Hypertension 527 (59)104 (68)0.039 PVD 51 (6)13 (9)0.187 Previous CVA 63 (7)20 (13)0.011 CPD 162 (18)45 (29)0.001 EuroSCORE II (%) 2.8 ± ± 9.3<0.001 Preop Hgb (g/dL) 13.1 ± ± 1.8<0.001 Elective status 793 (89)119 (78)<0.001 Single valve procedure 802 (90)116 (76)<0.001 CPB time (mins) 123 ± ±

Results – Entire Sample Sample included: Mean age ± 14.0 Y and 37% female pts 918 single-valve,114 double-valve,12 triple-valve MV (n =514), AV (n =593), TV (n =72), PV (n =3) Mean Hgb at discharge = 9.9 ± 1.7 g/dL

Distribution of Discharge Hgb

STS-Defined Outcomes Outcome Total Sample (N = 1,044) Prolonged ventilation (>24 hrs) 86 (8%) Pneumonia 25 (2%) Stroke/TIA 10 (1%) Reoperation for bleeding 17 (2%) Renal failure 12 (1%) Readmissions <30 days 97 (9%) Death <30 days 3 (0.3%)

Results – Entire Sample Multivariate analyses in entire sample, DC Hgb (continuous variable) not predictive of: Post discharge mortality <30 days (OR=1.04, P=0.916) Discharge to home (OR=1.07, P=0.435) Readmission <30 days (OR=0.92, P=0.307) One-year survival (HR=0.87, P=0.363)

Primary Research Questions Question 1: Does lower discharge Hgb level impact outcomes in the entire sample, adjusting for clinical factors with multivariate analyses? Question 2: After PSM based on discharge Hgb, do patients with discharge Hgb ≤8 g/dL have worse outcomes? Question 3: What is the role of blood product transfusion on outcomes?

Distribution of Propensity Scores

Patient Characteristics by Group Characteristic Unmatched Hgb >8 g/dL (n = 739) Matched Hgb >8 g/dL (n = 152) Matched Hgb ≤8 g/dL (n = 152) Age 62.0 ± ± ± 15.1 Female *^ 249 (34)70 (46)68 (45) Ejection fraction (%) 57.6 ± ± ± 9.7 CHF *^ 195 (26)65 (43)68 (45) Diabetes *^ 92 (12)40 (26)43 (28) Hypertension *^ 425 (58)102 (67)103 (68) PVD * 36 (5)15 (10)13 (9) Previous CVA *^ 46 (6)17 (11)19 (13) CPD *^ 120 (16)42 (28)44 (29) EuroSCORE II (%) *^ 2.5 ± ± ± 9.3 Preop Hgb (g/dL) *^ 13.4 ± ± ± 1.8 Elective status *^ 675 (91)118 (78) Single valve procedure *^ 682 (92)120 (79)116 (76) CPB time (mins) *^ 121 ± ± ± 52 * Unmatched vs. Matched Hgb >8 g/dL groups (P < 0.05) ^ Unmatched Hgb > 8 g/dL vs. Matched Hgb ≤8 g/dL groups (P <0.05)

Patient Characteristics by Group Characteristic Unmatched Hgb >8 g/dL (n = 739) Matched Hgb >8 g/dL (n = 152) Matched Hgb ≤8 g/dL (n = 152) Age 62.0 ± ± ± 15.1 Female *^ 249 (34)70 (46)68 (45) Ejection fraction (%) 57.6 ± ± ± 9.7 CHF *^ 195 (26)65 (43)68 (45) Diabetes *^ 92 (12)40 (26)43 (28) Hypertension *^ 425 (58)102 (67)103 (68) PVD * 36 (5)15 (10)13 (9) Previous CVA *^ 46 (6)17 (11)19 (13) CPD *^ 120 (16)42 (28)44 (29) EuroSCORE II (%) *^ 2.5 ± ± ± 9.3 Preop Hgb (g/dL) *^ 13.4 ± ± ± 1.8 Elective status *^ 675 (91)118 (78) Single valve procedure *^ 682 (92)120 (79)116 (76) CPB time (mins) *^ 121 ± ± ± 52 * Unmatched vs. Matched Hgb >8 g/dL groups (P < 0.05) ^ Unmatched Hgb > 8 g/dL vs. Matched Hgb ≤8 g/dL groups (P <0.05)

Patient Characteristics After PSM Characteristic Hgb >8 g/dL (n = 152) Hgb ≤8 g/dL (n = 152) P Age 62.1 ± ± Female 70 (46)68 (45)0.818 Ejection fraction (%) 58.2 ± ± CHF 65 (43)68 (45)0.729 Diabetes 40 (26)43 (28)0.699 Hypertension 102 (67)103 (68)0.903 PVD 15 (10)13 (9)0.692 Previous CVA 17 (11)19 (13)0.723 CPD 42 (28)44 (29)0.799 EuroSCORE II (%) 4.3 ± ± Preop Hgb (g/dL) 11.4 ± ± Elective status 118 (78) >0.999 Single valve procedure 120 (79)116 (76)0.582 CPB time (mins) 131 ± ±

Results – PSM Groups Matched Hgb ≤ 8 grp similar to Hgb > 8 grp on: Post-DC mortality 0.999) Discharge to home (81% vs. 80%, P=0.667) Readmission <30 days (14% vs. 16%, P=0.522) One-year survival (89% vs. 91%, P=0.67)

Cumulative One-Year Survival Months Patients at Risk (95% CI) Hgb ≤8 g/dLHgb >8 g/dL 6118 (0.91–0.98)108 (0.90–0.98) 9106 (0.88–0.97)100 (0.89–0.98) 1296 (0.84–0.95)89 (0.86–0.97)

HRQL Improvement at 6 Months Hgb > 8 g/dL Hgb ≤ 8 g/dL PHYSICAL COMPOSITE HRQL SCORE PRESURGERY 6 MONTHS Physical (28% vs. 18% increase; P=0.268) Mental (7% vs. 6% increase; P=0.943)

Primary Research Questions Question 1: Does lower discharge Hgb level impact outcomes in the entire sample, adjusting for clinical factors with multivariate analyses? Question 2: After PSM based on discharge Hgb, do patients with discharge Hgb ≤8 g/dL have worse outcomes? Question 3: What is the role of blood product transfusion on outcomes?

Results – Blood Transfusion Multivariate analyses in entire sample found blood product transfusion (22%): Poorer 1-year survival (HR=2.27, P=0.036) Not related to readmissions (OR=1.51, P=0.244)

Results – Blood Transfusion In matched sample, pts with transfusions were (46%): Similar in 30-day mortality (0.7% vs. 0%, P=0.461) Similar on readmissions (17% vs. 13%, P=0.366) Less likely to be discharged to home (69% vs. 89%, P<0.001) Worse on 1-year cumulative survival (85.7% vs. 94.8%, P=0.012) even after adjusting for discharge Hgb level (HR=3.00, P=0.021)

Summary In both multivariate and PSM analyses lower discharge Hgb in asymptomatic patients was not associated with increased post discharge complications and inferior survival Blood transfusion was associated with increased mortality at one year, however this was not the primary focus of the study

Conclusions We found that symptomatic patients with lower Hgb levels can be safely discharged following valve surgery without being transfused just to correct anemia. Based on our consistent experience in a busy center, it is imperative to change the culture around transfusion. Implementation of blood conservation protocols has been associated with improved outcomes and cost savings.

Inova Heart & Vascular Institute Cardiac Surgery Research Research Team Members: Niv Ad, MD Rabia R. Ali, BS Katherine Armstrong, BS Jill C. Bennick Hester Dean, BS Linda Halpin, MSN, RN Sari D. Holmes, PhD Deborah Lamont, BSN, RN Lisa M. Martin, PhD Paul S. Massimiano, MD Casey E. Miller, BS, CCRP Graciela Pritchard, BS Deborah J. Shuman, BS Alan M. Speir, MD Thank you!