Incidence of Massive Transfusion and Overall Transfusion Requirements During Lung Transplantation Over a 25-Year Period.

OBJECTIVE: To establish the incidence of massive transfusion and overall transfusion requirements during lung transplantation, changes over time, and association with outcome in relation to patient complexity. DESIGN: Retrospective cohort study. SETTING: University hospital. PARTICIPANTS: All 514 adult patients who underwent transplantation from 1990 until 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient records and transfusion data, divided into 5-year intervals, were analyzed. The incidence of massive transfusion (>10 units of red blood cells [RBCs] in 24 h) was 27% and did not change over time, whereas the median (interquartile range) transfusion requirement in the whole cohort decreased from 8 (5-12) to 3 (0-10) RBCs (p < 0.001). In patients transplanted from the intensive care unit, the incidence of massive transfusion increased over time from 25% to 54% (p = 0.04) and median transfusion requirements from 4.5 (3-8.5) units to 14.5 (5-26) units of RBCs (p = 0.03). Multivariable analysis showed that circulatory support, pulmonary hypertension, re-transplantation, cystic fibrosis, Eisenmenger syndrome, bilateral transplantation, and low body mass index were associated with massive transfusion. Patients with massive transfusion had more primary graft dysfunction grade III at 0, 24, 48, and 72 hours (p < 0.001), higher 30-day mortality (13% v 4%; p < 0.001), and lower 5-year survival (hazard ratio 3.67 [95% confidence interval 1.72-7.85]; p < 0.001). CONCLUSION: The incidence of massive transfusion did not change over time, whereas transfusion requirements in the whole cohort decreased. In patients transplanted from the intensive care unit, massive transfusion and transfusion requirements increased. Massive transfusion was associated with poor outcome.

Hospital Costs Of Extracorporeal Life Support Therapy.

OBJECTIVES: To conduct an exploration of the hospital costs of extracorporeal life support therapy. Extracorporeal life support seems an efficient therapy for acute, potentially reversible cardiac or respiratory failure, when conventional therapy has been inadequate, or as bridge to transplant, but unfortunately, no evidence in randomized controlled trials is delivered yet. DESIGN: Single-center retrospective exploratory cohort cost study. The study is performed from a hospital perspective with a time horizon of patients' complete hospital admission in which they received extracorporeal life support. SETTING: ICU of a university teaching hospital in The Netherlands. PATIENTS: All 67 consecutive adult patients who were admitted to the ICU of the University Medical Center Groningen in the period 2010-2013 and received extracorporeal life support treatment. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The bottom-up microcosting method was used except when stated otherwise. Medical costs were estimated by multiplying every registered healthcare consumption with unit prices. Unit prices were largely based on Dutch reference prices. For each patient, the personnel costs and material costs were assessed in detail. The costs of extracorporeal life support were differentiated in costs of procedures and costs of daily surcharge of therapy. Procedure-related costs were subdivided in costs of devices and disposables, costs of additional human resources, and surgery hours. The mean total hospital costs were € 106.263 (€ 83.841 to € 126.266) per patient ($145,580). On average, 52% of the total costs arose from hospital nursing days and 11% of direct procedure-related extracorporeal life support costs. Surgery and diagnostics represented a vast amount of the remaining costs. CONCLUSIONS: This large and detailed economic evaluation of hospital costs of extracorporeal life support therapy in the Netherlands showed that mean total hospital cost of extracorporeal life support treatment is € 106.263 per patient. The majority of the costs are composed of nursing days.

Emergency transcatheter aortic valve implantation in patients with severe aortic regurgitation and a left ventricle assist device: A case report and systematic review.

BACKGROUND: Cardiogenic shock due to severe aortic regurgitation in patients with left ventricle assist devices is a life threatening condition. Here, we consider transcatheter aortic valve implantation as a treatment option. METHODS AND RESULTS: A patient with a left ventricle assist device was presented to us with cardiogenic shock due to severe aortic regurgitation. We successfully implanted a transcatheter aortic valve in emergency setting. The patient recovered and underwent cardiac transplantation three months afterwards. We performed a systematic literature review and identified 10 cases of patients with a left ventricle assist device undergoing transcatheter aortic valve implantation. In these cases, there was no procedural related mortality reported. In four (40%) patients, transcatheter aortic valve implantation resulted in significant paravalvular aortic regurgitation. In two of these cases it was due to migration of the valve towards the left ventricle. CONCLUSIONS: Our case report and review of literature suggests that transcatheter aortic valve implantation is a feasible and lifesaving treatment option for left ventricle assist device patients presenting with severe aortic regurgitation.

Platelet function in stored heparinised autologous blood is not superior to in patient platelet function during routine cardiopulmonary bypass.

BACKGROUND: In cardiac surgery, cardiopulmonary bypass (CPB) and unfractionated heparin have negative effects on blood platelet function. In acute normovolemic haemodilution autologous unfractionated heparinised blood is stored ex-vivo and retransfused at the end of the procedure to reduce (allogeneic) transfusion requirements. In this observational study we assessed whether platelet function is better preserved in ex vivo stored autologous blood compared to platelet function in the patient during CPB. METHODOLOGY/PRINCIPAL FINDING: We measured platelet aggregation responses pre-CPB, 5 min after the start of CPB, at the end of CPB, and after unfractionated heparin reversal, using multiple electrode aggregometry (Multiplate®) with adenosine diphosphate (ADP), thrombin receptor activating peptide (TRAP) and ristocetin activated test cells. We compared blood samples taken from the patient with samples taken from 100 ml ex-vivo stored blood, which we took to mimick blood storage during normovolemic haemodilution. Platelet function declined both in ex-vivo stored blood as well as in blood taken from the patient. At the end of CPB there were no differences in platelet aggregation responses between samples from the ex vivo stored blood and the patient. CONCLUSION/SIGNIFICANCE: Ex vivo preservation of autologous blood in unfractionated heparin does not seem to be profitable to preserve platelet function.

Bivalirudin is inferior to heparin in preservation of intraoperative autologous blood.

INTRODUCTION: Bivalirudin is used as an alternative to heparin in cardiac surgery, and may be superior to heparin with regard to platelet function. Bivalirudin however, is prone to cleavage by thrombin resulting in coagulation in areas of stasis. MATERIAL AND METHODS: We compared the preservation of platelet function and the quality of anticoagulation in autologous blood of 26 cardiac surgical patients collected intraoperatively and anticoagulated ex vivo with either bivalirudin or heparin, with supplementation of bivalirudin over time and prevention of stasis. RESULTS: We found in both preservatives a reduction in ADP-induced platelet aggregation response over a period of 105 minutes (median, IQR: 73-141) as measured by Multiplate®. Supplementation of additional bivalirudin (23 ± 1.1 µg/ml/hr) and prevention of stasis was not able to prevent thrombin generation. We found a 5-fold increase in levels of prothrombin fragment 1+2 in bivalirudin preserved autologous blood as compared to heparin preserved blood (F(1+2) levels median 8.9 nM [quartile percentiles 4.2-12.4] vs 1.3 nM [0.6-2.1], P=0.001 Mann-Whitney, n=10). CONCLUSIONS: Our study suggests that preservation of platelet function in autologous blood anticoagulated with bivalirudin is not a suitable alternative to heparin.