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

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Presentation on theme: "Should Asymptomatic Patients Discharged with Lower Hemoglobin Expect Worse Outcomes After Valve Surgery? Niv Ad, MD Sari D. Holmes, PhD Alan M. Speir,"— Presentation transcript:

1 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

2 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

3 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

4 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

5 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)

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

7 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)

8 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?

9 Patient Characteristics Before PSM Characteristic Hgb >8 g/dL (n = 891) Hgb ≤8 g/dL (n = 153) P Age 62.0 ± 13.862.2 ± 15.10.924 Female 319 (36)68 (44)0.041 Ejection fraction (%) 57.7 ± 10.458.3 ± 9.60.507 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 ± 4.96.0 ± 9.3<0.001 Preop Hgb (g/dL) 13.1 ± 1.911.3 ± 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 ± 44135 ± 530.010

10 Results – Entire Sample Sample included: Mean age- 62.1 ± 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

11 Distribution of Discharge Hgb

12

13 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%)

14 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)

15 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?

16 Distribution of Propensity Scores

17

18 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 ± 13.862.1 ± 14.262.1 ± 15.1 Female *^ 249 (34)70 (46)68 (45) Ejection fraction (%) 57.6 ± 10.658.2 ± 9.658.2 ± 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 ± 4.64.3 ± 6.06.0 ± 9.3 Preop Hgb (g/dL) *^ 13.4 ± 1.711.4 ± 2.011.3 ± 1.8 Elective status *^ 675 (91)118 (78) Single valve procedure *^ 682 (92)120 (79)116 (76) CPB time (mins) *^ 121 ± 41131 ± 53134 ± 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)

19 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 ± 13.862.1 ± 14.262.1 ± 15.1 Female *^ 249 (34)70 (46)68 (45) Ejection fraction (%) 57.6 ± 10.658.2 ± 9.658.2 ± 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 ± 4.64.3 ± 6.06.0 ± 9.3 Preop Hgb (g/dL) *^ 13.4 ± 1.711.4 ± 2.011.3 ± 1.8 Elective status *^ 675 (91)118 (78) Single valve procedure *^ 682 (92)120 (79)116 (76) CPB time (mins) *^ 121 ± 41131 ± 53134 ± 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)

20 Patient Characteristics After PSM Characteristic Hgb >8 g/dL (n = 152) Hgb ≤8 g/dL (n = 152) P Age 62.1 ± 14.262.1 ± 15.10.994 Female 70 (46)68 (45)0.818 Ejection fraction (%) 58.2 ± 9.658.2 ± 9.70.994 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 ± 6.06.0 ± 9.30.063 Preop Hgb (g/dL) 11.4 ± 2.011.3 ± 1.80.651 Elective status 118 (78) >0.999 Single valve procedure 120 (79)116 (76)0.582 CPB time (mins) 131 ± 53134 ± 520.680

21 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)

22 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)

23 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)

24 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?

25 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)

26 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)

27 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

28 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.

29 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!

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