The association between platelet dysfunction and adverse outcomes in cardiac surgical patients

Abstract

Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypassassociated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

“…This systematic review and meta-analysis showed that thrombocytopenia has a considerable prevalence (up to 21%) in ECMO patients. Thrombocytopenia has been demonstrated in patients undergoing different mechanical circulatory support (cardiopulmonary bypass, intra-aortic balloon pump, left ventricular assist device (LVAD)) [41][42][43][44][45][46] (Figure 4 in Supplemental material). The origin of thrombocytopenia is likely multifactorial (contact with foreign surfaces, platelet activation, inflammatory and coagulative cascade activation), with sepsis, medications, surgery, bleeding, intravascular devices, and blood transfusions as contributing factors [41][42][43] (Figure 3 and Figure 4 in Supplemental material).…”

Clinical utility of the Quantra® point‐of‐care haemostasis analyser during urgent cardiac surgery

“…Coagulopathic bleeding during cardiac surgery, especially in patients undergoing urgent or emergency procedures, is associated with increased blood component transfusion and prolonged hospital stay, which results in higher healthcare costs and a poorer outcome for patients [14,15]. We studied patients undergoing urgent surgery for unstable cardiac disease, who were nearly all taking antiplatelet medication; 68% of patients were transfused Viscoelastic testing devices can be used before, during and after bypass to assess the coagulation system, but not all parameters during the three time-points are equally valid at predicting bleeding and guiding the use of blood products [2,7,9].…”

“…Coagulopathic bleeding during cardiac surgery, especially in patients undergoing urgent or emergency procedures, is associated with increased blood component transfusion and prolonged hospital stay, which results in higher healthcare costs and a poorer outcome for patients . We studied patients undergoing urgent surgery for unstable cardiac disease, who were nearly all taking antiplatelet medication; 68% of patients were transfused blood products in our study; this compares with approximately 40% of patients undergoing elective surgery in our institution (based on continuous local audit data).…”

Strategies to eradicate resternotomy after cardiac surgery from clinical practice

“…This varied between 0.7% and 7.6% among centres. Of these 849 patients, 127 died inhospital or within 30 days, which gives a mortality rate of Anaesthesia 2021, 76, 3-5 doi:10.1111/anae.15182 listed for 'in-house' urgent procedures receiving antiplatelet medication and thromboprophylaxis [5]. Second, the routine use of aprotinin has now fallen out of favour for the prevention of bleeding, but the effects of this change are unclear at present [6].…”