Anemia as a Risk Factor for Organ Dysfunctions in Patients Operated on Heart Valves

Aim      To study the effects of pre- and postoperative anemia on the risk and the structure of internal organ dysfunction in patients undergoing surgery for acquired heart diseases (AHD).

Material and methods  This was a retrospective cohort study including 610 primarily operated patients with AHD. A comparative analysis of the incidence and the structure of internal organ dysfunction was performed, and the likelihood of intraoperative hemotransfusion was determined for patients with preoperative anemia (Hb <130 g/l) and without it. The incidence and the nature of internal organ damage were compared in patients with postoperative Hb < 90 g/l and 90–130 g/l.

Results The presence of postoperative anemia detected in 45 % of patients at two days after the surgery 6-fold increased the risk of acute heart failure (odds ratio [OR], 5.75; 95 % confidence interval [CI], 1.23–26.84; р=0.016), 4-fold increased the risk of multiorgan failure (MOF) (OR, 4.2; 95 % CI, 1.16–15.64; р=0.03), and 5-fold increased the likelihood of hemotransfusion (OR, 4.74; 95 % CI, 3.12–7.19; р<0.0001). Severe and moderate anemia (Hb <90 g/l) was observed in 11.2 % of patients, which presence 6-fold increased the risk of brain dysfunction (OR, 5.72; 95 % CI, 2.17–15.06; р=0.001) and MOF (OR, 5.97; 95 % CI, 1.94–18.35; р=0.004) compared to patients with Hb 90–130 g/l.

Conclusion      In patients with AHD, postoperative anemia increases the risk of circulatory decompensation at two days after the surgery and of MOF and also increases the likelihood of intraoperative hemotransfusion; postoperative anemia with Hb <90 g/l increases the risk of brain damage and MOF.

1. Meybohm P, Westphal S, Ravn HB, Ranucci M, Agarwal S, Choorapoikayil S et al. Perioperative Anemia Management as Part of PBM in Cardiac Surgery – A Narrative Updated Review. Journal of Cardiothoracic and Vascular Anesthesia. 2020;34(4):1060–73. DOI: 10.1053/j.jvca.2019.06.047

2. Beutler E, Waalen J. The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration? Blood. 2006;107(5):1747–50. DOI: 10.1182/blood-2005-07-3046

3. Padmanabhan H, Siau K, Curtis J, Ng A, Menon S, Luckraz H et al. Preoperative Anemia and Outcomes in Cardiovascular Surgery: Systematic Review and Meta-Analysis. The Annals of Thoracic Surgery. 2019;108(6):1840–8. DOI: 10.1016/j.athoracsur.2019.04.108

4. Karski JM, Mathieu M, Cheng D, Carroll J, Scott GJ. Etiology of preoperative anemia in patients undergoing scheduled cardiac surgery. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 1999;46(10):979–82. DOI: 10.1007/BF03013135

5. Fowler AJ, Ahmad T, Phull MK, Allard S, Gillies MA, Pearse RM. Meta-analysis of the association between preoperative anaemia and mortality after surgery. British Journal of Surgery. 2015;102(11):1314–24. DOI: 10.1002/bjs.9861

6. Hart S, Cserti-Gazdewich CM, McCluskey SA. Red cell transfusion and the immune system. Anaesthesia. 2015;70(Suppl 1):38–45. DOI: 10.1111/anae.12892

7. Wang J. Restrictive vs liberal transfusion for upper gastrointestinal bleeding: A meta-analysis of randomized controlled trials. World Journal of Gastroenterology. 2013;19(40):6919–27. DOI: 10.3748/wjg.v19.i40.6919

8. Hayes MM, Uhl L. To transfuse or not transfuse: an intensive appraisal of red blood cell transfusions in the ICU. Current Opinion in Hematology. 2018;25(6):468–72. DOI: 10.1097/MOH.0000000000000460

9. Shehata N, Mistry N, da Costa BR, Pereira TV, Whitlock R, Curley GF et al. Restrictive compared with liberal red cell transfusion strategies in cardiac surgery: a meta-analysis. European Heart Journal. 2019;40(13):1081–8. DOI: 10.1093/eurheartj/ehy435

10. Nakamura RE, Vincent J-L, Fukushima JT, Almeida JP de, Franco RA, Lee Park C et al. A liberal strategy of red blood cell transfusion reduces cardiogenic shock in elderly patients undergoing cardiac surgery. The Journal of Thoracic and Cardiovascular Surgery. 2015;150(5):1314–20. DOI: 10.1016/j.jtcvs.2015.07.051

11. Garg AX, Badner N, Bagshaw SM, Cuerden MS, Fergusson DA, Gregory AJ et al. Safety of a Restrictive versus Liberal Approach to Red Blood Cell Transfusion on the Outcome of AKI in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial. Journal of the American Society of Nephrology. 2019;30(7):1294–304. DOI: 10.1681/ASN.2019010004

12. Hajjar LA, Vincent J-L, Galas FRBG, Nakamura RE, Silva CMP, Santos MH et al. Transfusion Requirements After Cardiac Surgery: The TRACS Randomized Controlled Trial. JAMA. 2010;304(14):1559–67. DOI: 10.1001/jama.2010.1446

13. Cortés-Puch I, Wiley BM, Sun J, Klein HG, Welsh J, Danner RL et al. Risks of restrictive red blood cell transfusion strategies in patients with cardiovascular disease (CVD): a meta-analysis: Restrictive RBC transfusion triggers with CVD. Transfusion Medicine. 2018;28(5):335–45. DOI: 10.1111/tme.12535

14. Lim HS. Cardiogenic Shock: Failure of Oxygen Delivery and Oxygen Utilization: Oxygen delivery in cardiogenic shock. Clinical Cardiology. 2016;39(8):477–83. DOI: 10.1002/clc.22564

15. Maganti MD, Rao V, Borger MA, Ivanov J, David TE. Predictors of low cardiac output syndrome after isolated aortic valve surgery. Circulation. 2005;112(9 Suppl):I448-452. DOI: 10.1161/CIRCULATIONAHA.104.526087

16. Maganti M, Badiwala M, Sheikh A, Scully H, Feindel C, David TE et al. Predictors of low cardiac output syndrome after isolated mitral valve surgery. The Journal of Thoracic and Cardiovascular Surgery. 2010;140(4):790–6. DOI: 10.1016/j.jtcvs.2009.11.022

17. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E et al. Acute Respiratory Distress Syndrome: The Berlin Definition. JAMA. 2012;307(23):2526–33. DOI: 10.1001/jama.2012.5669

18. Thomas ME, Blaine C, Dawnay A, Devonald MAJ, Ftouh S, Laing C et al. The definition of acute kidney injury and its use in practice. Kidney International. 2015;87(1):62–73. DOI: 10.1038/ki.2014.328

19. Kim C, Connell H, McGeorge A, Hu R. Prevalence of preoperative anaemia in patients having first-time cardiac surgery and its impact on clinical outcome. A retrospective observational study. Perfusion. 2015;30(4):277–83. DOI: 10.1177/0267659114542457

20. Tuinman PR, Vlaar AP, Cornet AD, Hofstra JJ, Levi M, Meijers JC et al. Blood transfusion during cardiac surgery is associated with inflammation and coagulation in the lung: a case control study. Critical Care. 2011;15(1):R59. DOI: 10.1186/cc10032

21. Müller MCA, Tuinman PR. Contribution of damage-associated molecular patterns to transfusion-related acute lung injury in cardiac surgery. Blood Transfusion. 2014;12(3):368–75. DOI: 10.2450/2014.0184-13