Blood loss as the main cause of organ dysfunction after simultaneous ascending aorta and aortic arch replacement

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OBJECTIVE

To study the effect of intraoperative blood loss on postoperative outcomes in patients with aneurysm and/or dissection of ascending aorta and aortic arch.

MATERIAL AND METHODS

A retrospective analysis included 77 patients (mean age 52.8±11.4 years). All ones underwent ascending aorta and aortic arch replacement under cardiopulmonary bypass and antegrade cerebral perfusion with hypothermia (mean 23.9±3.2 °C) for aneurysm and/or dissection. To identify the relationship between blood loss and incidence of organ dysfunctions, we used the original parameter, i.e. blood loss index (intraoperative blood loss / weight / surgery time) (ml/kg/hour).

RESULTS

There was a significant correlation between blood loss index and postoperative organ dysfunctions (r=0.57, p<0.001). At the same time, we found no correlation between overall blood loss and postoperative organ dysfunctions (r=0.23, p=0.23). According to the ROC curve, the cut-off values were 2.9 ml/kg/hour for respiratory failure, 3.1 ml/kg/hour for cardiovascular failure and 6 ml/kg/hour for multiple organ failure. Sensitivity of each point was 72%, 81% and 84%, specificity 59%, 59% and 64%, respectively.

CONCLUSION

Blood loss index is valuable to predict organ dysfunctions after ascending aorta and aortic arch surgery. The conditionally «safe» blood loss index is less than 3 ml/kg/hour.

Keywords:

aortic aneurysm

aortic dissection

intraoperative blood loss

blood loss index

Authors:

Rizun L.I.

Petrovsky National Research Center of Surgery

ORCID: 0000-0002-9322-7858

Vinokurov I.A.

Sechenov First Moscow State Medical University

ORCID: 0000-0003-0433-2523

Akselrod B.A.

Petrovsky National Research Center of Surgery

ORCID: 0000-0002-4434-3123

Eremenko A.A.

Petrovsky National Research Center of Surgery;
Sechenov First Moscow State Medical University

ORCID: 0000-0001-5809-8563

Charchyan E.R.

Petrovsky National Research Center of Surgery

SPIN RSCI: 4641-0523
Scopus AuthorID: 14044681400
ORCID: 0000-0002-0488-2560

Belov Yu.V.

Petrovsky National Research Center of Surgery;
Sechenov First Moscow State Medical University

SPIN RSCI: 2740-1439
Scopus AuthorID: 7101862336
ResearcherID: 7101862336
ORCID: 0000-0002-9280-8845

Received:

11.08.2022

Accepted:

12.09.2022

List of references:

Bokeriya LA, Milievskaya EB, Kudzoeva ZF, Pryanishnikov VV, Skopin AI, Yurlov IA. Cardiovascular surgery — 2018. Diseases and congenital anomalies of cardiovascular system. M.: NMITsSSKh im. A.N. Bakuleva MZ RF; 2019. (In Russ.).
Belov YuV, Komarov RN. Handbook for thoracoabdominal aortic aneurysm surgery. M.: MIA; 2010. (In Russ.).
Semsroth S, Dumfarth J, Schachner T, et al. Das akute Aortensyndrom. Medizinische Klinik — Intensivmedizin und Notfallmedizin. 2014;109(5):371-384. https://doi.org/10.1007/s00063-014-0391-y
2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). European Heart Journal. 2014;35(41):2873-2926. https://doi.org/10.1093/eurheartj/ehu281
Keshavamurthy S, Mick SL, Damasiewicz H, Sabik JF. Bovine Pericardial Wrap for Intractable Bleeding After Graft Replacement of the Ascending Aorta. The Annals of Thoracic Surgery. 2015;100(2):735-737. https://doi.org/10.1016/j.athoracsur.2015.03.042
Natour E, Suedkamp M, Dapunt OE. Assessment of the effect on blood loss and transfusion requirements when adding a polyethylene glycol sealant to the anastomotic closure of aortic procedures: a case-control analysis of 102 patients undergoing Bentall procedures. Journal of Cardiothoracic Surgery. 2012;7:105. https://doi.org/10.1186/1749-8090-7-105
Boudart A, Yilmaz A, Kaya A. Minimal access compared to sternotomy for aortic root and arch surgery. Acta Chir Belg. 2022;122(2):144-149. https://doi.org/10.1080/00015458.2022.2050979
Tenorio ER, Oderich GS, Kölbel T, Dias NV, Sonesson B, Karelis A, Farber MA, Parodi FE, Timaran CH, Scott CK, Tsilimparis N, Fernandez C, Jakimowicz T, Jama K, Kratzberg J, Mougin J, Haulon S. Multicenter global early feasibility study to evaluate total endovascular arch repair using three-vessel inner branch stent-grafts for aneurysms and dissections. J Vasc Surg. 2021;74(4):1055-1065.e4. https://doi.org/10.1016/j.jvs.2021.03.029
Zhang L, Yu C, Chang Q, Sun X, Qian X, Luo X, Wei B. [Surgical outcomes of off-pump technique in extensive thoracoabdominal aorta replacement]. Zhonghua Wai Ke Za Zhi. 2016;54(2):119-124 Chinese. https://doi.org/10.3760/cma.j.issn.0529-5815.2016.02.009
Martens A, Koigeldiyev N, Beckmann E, Fleissner F, Kaufeld T, Krueger H, Stanelle D, Puntigam J, Haverich A, Shrestha M. Do not leave the heart arrested. Non-cardioplegic continuous myocardial perfusion during complex aortic arch repair improves cardiac outcome. Eur J Cardiothorac Surg. 2016;49(1):141-148. https://doi.org/10.1093/ejcts/ezv009
Tanaka Y, Mikamo A, Suzuki R, Kurazumi H, Kudo T, Takahashi M, Ikenaga S, Shirasawa B, Hamano K. Mortality and morbidity after total aortic arch replacement. Ann Thorac Surg. 2014;97(5):1569-1575. https://doi.org/10.1016/j.athoracsur.2014.01.014
Li J, Li L, Wang M, Li H, Sun L, Liu Y, Fan R, Zhang Z, Zou C, Zhang H, Gong M. Comparison of Prognosis Between Hybrid Debranching Surgery and Total Open Arch Replacement With Frozen Elephant Trunk for Type A Acute Aortic Syndrome Patients. Front Cardiovasc Med. 2021;8:689507. https://doi.org/10.3389/fcvm.2021.689507
Liu T, Fu Y, Liu J, Liu Y, Zhu J, Sun L, Gong M, Dong R, Zhang H. Body mass index is an independent predictor of acute kidney injury after urgent aortic arch surgery for acute DeBakey Type I aortic dissection. J Cardio thorac Surg. 2021;16(1):145. https://doi.org/10.1186/s13019-021-01533-8
Belov IuV, Charchian ÉR, Stepanenko AB, Gens AP, Khachatryan ZR. Surgical treatment of DeBakey type 1 aortic dissection. Pirogov Russian Journal of Surgery = Khirurgiya. Zurnal im. N.I. Pirogova. 2018;(7):8-17. (In Russ.). https://doi.org/10.17116/hirurgia201878
Boening A, Karck M, Conzelmann LO, Easo J, Krüger T, et al. German Registry for Acute Aortic Dissection Type A: Structure, Results, and Future Perspectives. The Thoracic and Cardiovascular Surgeon. 2017;65(2):77-84. https://doi.org/10.1055/s-0036-1572436
Nakamura T, Mikamo A, Matsuno Y, Fujita A, Kurazumi H, Suzuki R, Hamano K. Impact of acute kidney injury on prognosis of chronic kidney disease after aortic arch surgery. Interact Cardiovasc Thorac Surg. 2020;30(2):273-279. https://doi.org/10.1093/icvts/ivz247
Belov YuV, Charchyan ER, Vinokurov IA. Problem of cerebral protection during operations on aortic arch. Kardiologiya i serdechno-sosudistaya khirurgiya. 2013;6(1):40-42. (In Russ.).
Colli A, Carrozzini M, Francescato A, et al. Acute DeBakey Type I aortic dissection without intimal tear in the arch: is total arch replacement the right choice? Interactive CardioVascular and Thoracic Surgery. 2018;26(1):84-90. https://doi.org/10.1093/icvts/ivx229
Dumfarth J, Kofler M, Stastny L, Plaikner M, Krapf C, et al. Stroke after emergent surgery for acute type A aortic dissection: predictors, outcome and neurological recovery. European Journal of Cardio-Thoracic Surgery. 2018;53(5):1013-1020. https://doi.org/10.1093/ejcts/ezx465
Dyke C, Aronson S, Dietrich W, Hofmann A, Karkouti K, et al. Universal definition of perioperative bleeding in adult cardiac surgery. The Journal of Thoracic and Cardiovascular Surgery. 2014;147(5):1458-1463.e1. https://doi.org/10.1016/j.jtcvs.2013.10.070
Petrou A, Tzimas P, Siminelakis S. Massive bleeding in cardiac surgery. Definitions, predictors and challenges. Hippokratia. 2016;20(3):179-186.
Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg. 2018;53(1):79-111. https://doi.org/10.1093/ejcts/ezx325
Settepani F, Cappai A, Basciu A, Barbone A, Tarelli G. Outcome of open total arch replacement in the modern era. Journal of Vascular Surgery. 2016;63(2):537-545. https://doi.org/10.1016/j.jvs.2015.10.061
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(4):315-321. https://doi.org/10.1177/0267659113479816
Trekova NA, Charchyan ER, Akselrod BA, Seleznev MN, Guskov DA, Solovyeva IN. Modern technologies of blood sparing and reduction of donor blood transfusion in ascending aorta and aortic arch surgery. Anesteziol Reanimatol. 2015;60(5):20-26. (In Russ.).
St-Onge S, Lemoine É, Bouhout I, Rochon A, El-Hamamsy I, Lamarche Y, Demers P. Evaluation of the real-world impact of rotational thromboelastometry-guided transfusion protocol in patients undergoing proximal aortic surgery. J Thorac Cardiovasc Surg. 2019;157(3):1045-1054.e4. https://doi.org/10.1016/j.jtcvs.2018.07.043
JR, Steiner ME, Stowell CP, Sloan SR. Massive Transfusion in Cardiac Surgery: The Impact of Blood Component Ratios on Clinical Outcomes and Survival. Anesth Analg. 2017;124(6):1777-1782. https://doi.org/10.1213/ane.0000000000001926
Pupovac SS, Hemli JM, Scheinerman SJ, Hartman AR, Brinster DR. Transfusion in Elective Proximal Aortic Reconstruction: Where Do We Currently Stand? Int J Angiol. 2021;30(4):292-297. https://doi.org/10.1055/s-0041-1729860
Velasquez CA, Singh M, Bin Mahmood SU, Brownstein AJ, Zafar MA, Saeyeldin A, Ziganshin BA, Elefteriades JA. The Effect of Blood Transfusion on Outcomes in Aortic Surgery. Int J Angiol. 2017;26(3):135-142. https://doi.org/10.1055/s-0037-1604417
Bartoszko J, Wijeysundera DN, Karkouti K, Callum J, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC, Achen B, Brar S, Morrison D, Wong D, Bussières JS, de Waal T, Harle C, de Médicis É, McAdams C, Syed S, Tran D, Waters T; Transfusion Avoidance in Cardiac Surgery Study Investigators. Comparison of Two Major Perioperative Bleeding Scores for Cardiac Surgery Trials: Universal Definition of Perioperative Bleeding in Cardiac Surgery and European Coronary Artery Bypass Grafting Bleeding Severity Grade. Anesthesiology. 2018;129(6):1092-1100. https://doi.org/10.1097/ALN.0000000000002179

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