Days Alive and Out of the Hospital After Heart Transplantation: A Retrospective Cohort Study.

OBJECTIVE: Evaluate days alive and out of the hospital (DAOH) as an outcome measure after orthotopic heart transplantation in patients with mechanical circulatory support (MCS) as a bridge to transplant compared to those patients without prior MCS. DESIGN: A retrospective observational study of adult patients who underwent cardiac transplantation between January 1, 2015, and January 1, 2020. The primary outcome was DAOH at 365 days (DAOH365) after an orthotopic heart transplant. A Poisson regression model was fitted to detect the association between independent variables and DAOH365. SETTING: An academic tertiary referral center. PARTICIPANTS: A total of 235 heart transplant patients were included-103 MCS as a bridge to transplant patients, and 132 direct orthotopic heart transplants without prior MCS. MEASUREMENTS AND MAIN RESULTS: The median DAOH365 for the entire cohort was 348 days (IQR 335.0-354.0). There was no difference in DAOH365 between the MCS patients and patients without MCS (347.0 days [IQR 336.0-353.0] v 348.0 days [IQR 334.0-354.0], p = 0.43). Multivariate analysis identified patients who underwent a transplant after the 2018 heart transplant allocation change, pretransplant pulmonary hypertension, and increased total ischemic time as predictors of reduced DAOH365. CONCLUSIONS: In this analysis of patients undergoing orthotopic heart transplantation, there was no significant difference in DAOH365 in patients with prior MCS as a bridge to transplant compared to those without MCS. Incorporating days alive and out of the hospital into the pre-transplant evaluation may improve understanding and conceptualization of the post-transplantation patient experience and aid in shared decision-making with clinicians.

Routine Type and Screens Are Unnecessary in Primary Total Joint Arthroplasty: Follow-up After a Change in Practice.

Background: Routine type and screens (T&S) prior to total hip (THA) and total knee arthroplasty (TKA) are common despite low transfusion rates. Our institution implemented a practice change after previously demonstrating a transfusion rate of 1.06%. The purpose of this study is to present the follow-up data 1 year after the practice change of discontinuing routine T&S orders in primary total joint arthroplasty. Methods: A practice change was implemented discontinuing routine T&S orders prior to elective primary total joint arthroplasties. We retrospectively reviewed prospectively collected data on preoperative T&S, hemoglobin values, transfusion rates, bleeding disorders, and anticoagulation status. Results: A total of 663 patients were included in the study (273 THAs and 390 TKAs). The cumulative transfusion rate was 0.75. No patients received an intraoperative transfusion. Three patients (1.1%) received a postoperative transfusion after THA, and 3 patients (0.5%) received a transfusion after TKA. The mean preoperative hemoglobin in the transfused patients was 12.1 g/dL. Thirteen patients underwent a preoperative T&S (2.0%), and only 2 required transfusion (15.4%). Only 1 patient who required transfusion was on preoperative anticoagulation, and no patients with bleeding disorders required transfusions. Discontinuing routine T&S resulted in an estimated cost savings of $124,325.50. Conclusions: Discontinuation of routine T&S did not result in any adverse consequences. If required, T&S can safely be performed intraoperatively or postoperatively. Surgeons may consider obtaining a T&S if their preoperative hemoglobin is less than 11-12 g/dL or if significant blood loss is expected in a complex primary total joint arthroplasty.

Routine Type and Screens Are Unnecessary for Primary Total Hip and Knee Arthroplasties at an Academic Hospital.

BACKGROUND: Despite decreasing transfusion rates, routine type and screens are frequently used before primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The aims of this study were to characterize transfusion rates and identify any factors that affect the likelihood of transfusion to determine if it is safe to discontinue routine preoperative type and screens at an academic hospital. METHODS: A retrospective chart review was performed for all patients who underwent primary THA or TKA in 2019 at an academic institution by a fellowship-trained arthroplasty surgeon. Data on preoperative type and screens, transfusion rates, bleeding disorders, and anticoagulation status were obtained. Patients were considered to have a preoperative type and screen if it was performed within 30 days before surgery. RESULTS: Overall, 379 patients were included in the study. Of these, 210 underwent primary THA and 169 underwent primary TKA. Four patients received transfusions during their hospitalization for a cumulative transfusion rate of 1.06%. No patients received an intraoperative transfusion. One (0.59%) patient received a postoperative transfusion after TKA, and 3 (1.43%) patients received a postoperative transfusion after THA. The mean preoperative hemoglobin of the 4 transfused patients was 10.8 g/dL. CONCLUSIONS: In summary, performing a preoperative routine type and screen is likely unnecessary at academic medical centers. Consideration for obtaining a type and screen may include complex primary surgeries or when patients have preoperative hemoglobin of less than 11 g/dL. Ultimately, preoperative type and screen should be considered on a case-by-case basis using clinical judgment.