In cardiac surgery, preoperative anemia concerns 20 to 30% of patients, leading to perioperative transfusion. Anemia and transfusion are recognized as independent factors of postoperative morbidity and mortality with severity and dose-dependent effects. Associated with postoperative bleeding, these three factors form a deadly triad. Patient Blood Management (PBM) programs have been developed and are based on three pillars: optimization of blood mass, minimization of blood loss and optimization of anemia tolerance including a blood transfusion strategy. The positive impacts on the quality of care provided to the patient (significant reduction of transfusion rates, of postoperative complications, of mortality, and length of hospital stays) but also its economic impact at the level of one institution, or even on national level, have been proven. In France, PBM programs, specifically in cardiac surgery, have not been as well developed, probably due to a lack of formation and information of medical community. The High Authority of Health has recently published national guidelines on PBM in cardiac surgery on the initiative of French national societies and PBM programs are now incorporated in enhanced recovery after surgery programs. This article provides a review of literature of PBM concept in cardiac surgery in France.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with cardiogenic shock. It results in cardiopulmonary shunting with reduced native cardiac output. Volume expansion is usually administered to increase native cardiac output, in order to improve peripheric perfusion or to avoid thromboembolic complications in cardiac cavities. End-tidal carbon dioxide (EtCO2) is known to be related to native cardiac output. Our hypothesis was that EtCO2 changes induced by passive leg raising predict fluid responsiveness in patients under VA-ECMO. In this prospective, interventional study, patients under VA-ECMO support were included, provided they required volume expansion. The protocol included three sequential steps: (1) Baseline in supine position (2) Passive leg raising (3) Volume expansion in basal position. Hemodynamic parameters were recorded at each step. Fluid responsiveness was defined as a velocity time integral at the left ventricle outflow tract increase of 15

L’anémie préopératoire en chirurgie cardiaque concerne 20 à 30 % des patients, les exposant fortement à la transfusion périopératoire. Anémie et transfusion en chirurgie cardiaque sont des facteurs indépendants de morbi-mortalité postopératoire avec des effets proportionnels à la sévérité de l’anémie et au volume de transfusion. Associés à des saignements périopératoires, l’ensemble constitue une véritable triade morbide. Des programmes de Patient Blood Management (PBM) ont ainsi été développés pour lutter contre l'anémie, en se basant sur trois piliers : optimisation de la masse sanguine, minimisation des pertes sanguines et optimisation de la tolérance à l’anémie intégrant une véritable stratégie transfusionnelle. Les impacts positifs du PBM sur la qualité des soins prodigués au patient (réduction significative du recours à la transfusion, des complications postopératoires, de la mortalité et des durées de séjours) mais également son impact économique à l’échelle d’un établissement voire à l’échelle nationale ne sont plus à démontrer. La France accusait un certain retard sur l’intégration du PBM, notamment en chirurgie cardiaque, mais les recommandations d’experts publiées par l’HAS en 2022 et son intégration dans des programmes de réhabilitation précoce tendent à combler ce retard du PBM. Cet article propose une revue de la littérature du programme PBM en chirurgie cardiaque en France.

Fibrinogen concentrate may reduce allogeneic blood product transfusion in cardiac surgery patients with bleeding associated with acquired hypofibrinogenemia. The European Society of Anaesthesiology and Intensive Care (ESAIC) has issued guidelines, but compliance to these guidelines has not been studied yet. This multicentre observational cohort study was aimed at evaluating the compliance of fibrinogen prescription with ESAIC. Adult patients undergoing cardiac surgery with cardiopulmonary bypass in 13 French cardiac surgery centres were recruited from March 2017 to April 2018. Compliance with ESAIC guidelines was considered whenever patients received fibrinogen in case of hypofibrinogenemia and clinically relevant bleeding, or when patients did not receive fibrinogen concentrate if there was no hypofibrinogenemia and/or no clinically relevant bleeding. The primary endpoint was the percentage of patients who complied those guidelines. Secondary endpoints were to assess the consequences of non-compliance on in-hospital deaths and hospital length-of-stay. Among 2,649 adult patients undergoing cardiac surgery with cardiopulmonary bypass, 374 (14.1

Background Red blood cell (RBC) transfusions are frequent in patients after cardiac surgery. This study assessed whether a bundle of care including pre-operative and post-operative administration of erythropoietin (EPO) with intravenous iron supplementation, and restrictive transfusion adjusted for ScvO(2) could result in reduced postoperative transfusions. Methods In this single-centre, randomised, open-label, parallel-group controlled pilot study, patients undergoing elective cardiac surgery with high risk of transfusion in a University Hospital were enrolled by the investigator and the randomisation procedure using a central internet-based system was made by the clinical research assistant. Since the trial was open-label, no masking was used. Patients were assigned (1:1) to either the STOP group (40,000 IU subcutaneous EPO combined with 20 mg/kg intravenous ferric carboxymaltose if Hb < 13 g/dL the day before surgery or at ICU admission, and RBC transfusion if Hb <= 8 g/dL and ScvO(2) <= 65%, or additional EPO dose if 8 < Hb < 13 g/dL) or to the control group (RBC transfusion if Hb <= 8 g/dL, or, if 8 < Hb < 13 g/dL, intravenous iron sucrose 200 mg or 300 mg according to weight). Primary outcome was the incidence of postoperative RBC transfusion up to hospital discharge or postoperative day 28. The trial is registered with ClinicalTrials.gov, NCT04141631. Findings Between Jan 20, 2020, and Sept 6, 2022, among 128 patients enrolled, 123 (male, 54.4%, 67/123) were included in the full analysis set: 62 in the STOP group and 61 in the control group. Nine patients (14.5%, 9/62) in the STOP group required RBC transfusion vs 19 (31.2%, 19/61) in the control group (odds ratio 0.37 [95% CI: 0.15-0.91], p = 0.03). The median length of follow up to transfusion was 2.6 days (1.5; 4.6) and 3.3 (1.6; 4.2) in control and STOP groups respectively (p = 0.61). Interpretation The bundle of care may reduce postoperative RBC transfusion. The findings should be taken with caution due to the unblinded and exploratory nature of the study.

BACKGROUND: Temporary mechanical circulatory support as well as multidisciplinary team approach in a regional care organization might improve survival of cardiogenic shock. No study has evaluated the relative effect of each temporary mechanical circulatory support on mortality in the context of a regional network. METHODS: Prospective observational data were retrieved from patients consecutively admitted with cardiogenic shock to the intensive care units in 3 centers organized into a regional cardiac assistance network. Temporary mechanical circulatory support indication was decided by a heart team, based on the initial shock severity or if shock was refractory to medical treatment within 24 hours of admission. A propensity score for circulatory support use was used as an adjustment co-variable to emulate a target trial. The primary endpoint was in-hospital mortality. RESULTS: Two hundred and forty-six patients were included in the study (median age: 59.5 years, 71.9% male): 121 received early mechanical assistance. The main etiologies were acute myocardial infraction (46.8%) and decompensated heart failure (27.2%). Patients who received early mechanical assistance had more severe conditions than other patients. Their crude in-hospital mortality was 38% and 22.4% in other patients but adjusted in-hospital mortality was not different (hazard ratio 0.91, 95% CI:0.65-1.26). Patients with mechanical assistance had a higher rate of complications than others

Objective Withdrawn in the early 2000s, aprotinin marketing authorization was reinstated by the European Medicine Agency with a restrictive indication (isolated coronary artery bypass grafting, iCABG) and pending a safety registry (NAPaR) intended to record the pattern of use of aprotinin and assess patient safety (1). Despite a ¾ off-label use, it was completed without any safety signal (2). Two different dose regimen were used: full-dose (FD) and half-dose (HD) aprotinin. The objective was to compare both efficacy and safety of each dose regimen in cardiac surgery with cardiopulmonary bypass. Design and method Between Feb. 2016 and Aug. 2022, 6,730 adult patients received aprotinin across nine European countries and were included in the registry. To reduce biases and to well balance the probability of receiving each aprotinin dose regimen, we built a propensity score (PS) based on preoperative patients’ characteristics: gender, age, BMI, redo surgery, severe renal impairment, active endocarditis, antiplatelet /anticoagulant agents, emergency surgery, and procedure type (on label/off-label). Then, we performed a regression on the PS-Inverse Probability of Treatment Weighting (IPTW) cohort to analyze the outcomes. The primary outcome was the rate of reoperation for bleeding or tamponade. Three safety outcomes were also investigated: in-hospital mortality, major adverse cardiovascular and cerebral events (MACCE) and renal injury. Results and conclusions Among the 6,730 patients, 5,359 had a full set of data allowing building the PS. Reoperation was significantly reduced in FD vs. HD aprotinin, whereas renal injury was slightly increased (Table 1). No difference was found on both mortality and MACCE.In cardiac surgery with cardiopulmonary bypass, the FD regimen of aprotinin was associated with a decrease in postoperative reoperation for bleeding at the expense of a slight increase in renal injury without any other safety risk. A large multicenter randomized trial is mandatory to consolidate these results.

Aims Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) restores circulation and tissue oxygenation in cardiogenic shock (CS) patients, but can also lead to complications. This study aimed to quantify VA-ECMO complications and analyse their association with overall survival as well as favourable neurological outcome (cerebral performance categories 1 + 2).Methods and results All-comer patients with CS treated with VA-ECMO were retrospectively enrolled from 16 centres in four countries (2005-2019). Neurological, bleeding, and ischaemic adverse events (AEs) were considered. From these, typical VA-ECMO complications were identified and analysed separately as device-related complications. n = 501. Overall, 118 were women (24%), median age was 56.0 years, median lactate was 8.1 mmol/L. Acute myocardial infarction caused CS in 289 patients (58%). Thirty-days mortality was 40% (198/501 patients). At least one device-related complication occurred in 252/486 (52%) patients, neurological AEs in 108/469 (23%), bleeding in 192/480 (40%), ischaemic AEs in 123/478 (26%). The 22% of patients with the most AEs accounted for 50% of all AEs. All types of AEs were associated with a worse prognosis. Aside from neurological ones, all AEs and device-related complications were more likely to occur in women; although prediction of AEs outside of neurological AEs was generally poor.Conclusion Therapy and device-related complications occur in half of all patients treated with VA-ECMO and are associated with a worse prognosis. They accumulate in some patients, especially in women. Aside from neurological events, identification of patients at risk is difficult, highlighting the need to establish additional quantitative markers of complication risk to guide VA-ECMO treatment in CS. Graphical abstract

Confronting oxytocin and vasopressin deficits in autism spectrum disorders and rare syndromes brought promises and disappointments for the treatment of social disabilities. We searched downstream of oxytocin and vasopressin for targets alleviating social deficits in a mouse model of Prader-Willi syndrome and Schaaf-Yang syndrome, both associated with high prevalence of autism. We found a population of neurons in the lateral septum—activated on termination of social contacts—which oxytocin and vasopressin inhibit as per degree of peer affiliation. These are somatostatin neurons expressing oxytocin receptors coupled to GABA-B signaling, which are inhibited via GABA-A channels by vasopressin-excited GABA neurons. Loss of oxytocin or vasopressin signaling recapitulated the disease phenotype. By contrast, deactivation of somatostatin neurons or receptor signaling alleviated social deficits of disease models by increasing the duration of contacts with mates and strangers. These findings provide new insights into the treatment framework of social disabilities in neuropsychiatric disorders.

Introduction: The European Medicines Agency restored aprotinin (APR) use for preventing blood loss in patients undergoing isolated coronary artery bypass graft (iCABG) in 2016 but requested the collection of patient and surgery data in a registry (NAPaR). The aim of this analysis was to evaluate the impact of APR reintroduction in France on the main hospital costs (operating room, transfusion and intensive unit stay) compared to the current use of tranexamic acid (TXA), which was the only antifibrinolytic available before APR reinstatement. Methods: A multicenter before-after post-hoc analysis to compare APR and TXA was carried out in four French university hospitals. APR use followed the ARCOTHOVA (French Association of Cardiothoracic and Vascular Anesthetists) protocol, which had framed three main indications in 2018. Data from 236 APR patients were retrieved from the NAPaR (N = 874); 223 TXA patients were retrospectively retrieved from each center database and matched to APR patients upon indication classes. Budget impact was evaluated using both direct costs associated with antifibrinolytics and transfusion products (within the first 48 h) and other costs such as surgery duration and ICU stay. Results: The 459 collected patients were distributed as: 17% on-label; 83% off-label. Mean cost per patient until ICU discharge tended to be lower in the APR group versus the TXA group, which resulted in an estimated gross saving of (sic)3136 per patient. These savings concerned operating room and transfusion costs but were mainly driven by reduced ICU stays. When extrapolated to the whole French NAPaR population, the total savings of the therapeutic switch was estimated at around (sic)3 million. Conclusion: The budget impact projected that using APR according to ARCOTHOVA protocol resulted in decreased requirement for transfusion and complications related to surgery. Both were associated with substantial cost savings from the hospital's perspective compared with exclusive use of TXA.

Objective: To assess the relationship between red blood cell (RBC) transfusion exposure and in-hospital mortality after isolated coronary artery bypass graft (CABG) surgery. Background: RBC transfusion was commonly used to treat anemia in isolated CABG surgery, but transfusion was found an independent risk factor of postoperative mortality; recent guidelines on patient blood management strategy issued in the last decade may have changed transfusion incidence and related mortality. Methods: A retrospective cohort study was conducted from the National database on patients’ hospital discharge reports. Consecutive adult patients who underwent isolated CABG surgery in France from January 1, 2016, to December 31, 2018, were included. The primary outcome was the in-hospital mortality rate. RBC transfusion during the hospital stay was identified by specific codes and ordered as categorical variables (no, moderate, or massive transfusion). Results: A total of 37,498 participants were studied [mean (SD) age, 66.5 (9.6) years, 31,587 (84.2%) were men]. In-hospital mortality rate was 1.45% (n=541) and RBC transfusion rate was 9.4% (n=3521). In-hospital deaths were more frequent among transfused patients [1.06% (361) if no transfusion up to 10.2% (n=113) if massive transfusion]. After adjustment for confounding variables, RBC transfusion remained a significant independent factor of in-hospital mortality: odds ratio=1.66 (95% confidence interval: 1.27–2.19, P<0.001) for moderate transfusion, 6.40 (95% confidence interval: 5.07–8.09, P<0.001) if massive. Conclusions and Relevance: Despite a modest patients’ exposure to transfusion, this study suggests that RBC administration is an independent factor of in-hospital mortality in isolated CABG surgery.

IntroductionPatient Blood Management (PBM) has been encouraged in cardiac surgery to prevent anemia- and transfusion-induced morbidity and mortality.(1) Preoperative anemia has an increasing prevalence due to an ageing population with more chronic diseases, and affects up to 20 to 40% of patients who are scheduled for cardiac surgery.(2) Preoperative anemia by its own is an independent factor of adverse outcome, but it is also an independent factor of allogenic red blood cell (RBC) transfusions, which are associated too with a higher mortality risk.(3) Therefore blood conservation strategy in cardiac surgery is aimed at reducing both risks.MethodsThis was a single-center, prospective, comparative, open label randomized trial. All patients signed a written informed consent. This trial protocol was approved by the local ethics committee (Sud Mediterrannée V 19.04.02.61948) and the French National Agency of Security of Drugs (ANSM) and was registered online at ClinicalTrails.gov (NCT04141631). An independent trial safety committee monitored trial benefit/risk ratio and safety for the entire duration of the study.In the control group, postoperative RBC transfusion was performed if hemoglobin (Hb) <= 8g/dL; if Hb >8g/dL two administrations of oxide ferric sucrose (Venofer®, Viforpharma) were performed. In the STOP group (Optimisation Transfusion Strategy), EPO and CMF were administered if Hb <13g/dL the day before or at ICU admission the day of surgery; postoperative RBC transfusion was performed in case of Hb <8g/dL associated with ScvO2 <65%. The primary endpoint was the proportion of patients transfused with RBC units after surgery, during the ICU stay up to hospital discharge or postoperative day 28, whatever came firstResultsFrom January 2020 to August 2022, 128 patients were randomized: 63 in the control group and 65 in the STOP group with no statistical difference in demographic, pre- and intraoperative characteristics. The mean preoperative Hb was 12.9 ±1.3 g/dL. Postoperative erythrocyte transfusion incidence was significantly lower in STOP group: 14.52% vs 31.15%, respectively (p < 0.03) with RR 0.466 ([95% CI: 0.2291-0.9479](Figure 1). In STOP group, all transfusions respected the ScVO2 threshold < 65% with a mean of 54.84 ±7.51%. Hb values were significantly higher in STOP group versus control Group from the first postoperative day to hospital discharge and one month after discharge, respectively (p<0.01) (Figure 2). There were no statistically significant differences between the 2 groups for the ICU or the hospital lengths of stay, or mortality. There were no significant difference between the 2 groups for any postoperative complications.DiscussionIn this study, an optimized and individualized PBM strategy with preoperative EPO and FCM the day associated with ScvO2 to guide postoperative erythrocyte transfusion reduced the incidence of transfusion by 50% and increased postoperative Hb concentrations at short and medium term.

Acute heart failure (AHF) due to acute myocardial infarction (AMI) is likely to involve cardiogenic shock (CS), with neuro-hormonal activation. A relationship between AHF, CS and vasopressin response is suspected. This study aimed to investigate the implication of vasopressin on hemodynamic parameters and tissue perfusion at the early phase of CS complicating AMI. Experiments were performed on male Wistar rats submitted or not to left coronary artery ligation (AMI and Sham). Six groups were studied Sham and AMI treated or not with either a vasopressin antagonist SR-49059 (Sham-SR, AMI-SR) or agonist terlipressin (Sham-TLP, AMI-TLP). Animals were sacrificed one day after surgery (D1) and after hemodynamic parameters determination. Vascular responses to vasopressin were evaluated, ex vivo, on aorta. AHF was defined by a left ventricular ejection fraction below 40%. CS was defined by AHF plus tissue hypoperfusion evidenced by elevated serum lactate level or low mesenteric oxygen saturation (SmO2) at D1. Mortality rates were 40% in AMI, 0% in AMI-SR and 33% in AMI-TLP. Immediately after surgery, a sharp decrease in SmO2 was observed in all groups. At D1, SmO2 recovered in Sham and in SR-treated animals while it remained low in AMI and further decreased in TLP-treated groups. The incidence of CS among AHF animals was 72% in AMI or AMI-TLP while it was reduced to 25% in AMI-SR. Plasma copeptin level was increased by AMI. Maximal contractile response to vasopressin was decreased in AMI (32%) as in TLP- and SR- treated groups regardless of ligation. Increased vasopressin secretion occurring in the early phase of AMI may be responsible of mesenteric hypoperfusion resulting in tissue hypoxia. Treatment with a vasopressin antagonist enhanced mesenteric perfusion and improve survival. This could be an interesting therapeutic strategy to prevent progression to cardiogenic shock.

BACKGROUND It is currently unclear if active left ventricular (LV) unloading should be used as a primary treatment strategy or as a bailout in patients with cardiogenic shock (CS) treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). OBJECTIVES This study sought to evaluate the association between timing of active LV unloading and implantation of VA-ECMO with outcomes of patients with CS.METHODS Data from 421 patients with CS treated with VA-ECMO and active LV unloading at 18 tertiary care centers in 4 countries were analyzed. Patients were stratified by timing of device implantation in early vs delayed active LV unloading (defined by implantation before up to 2 hours after VA-ECMO). Adjusted Cox and logistic regression models were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as successful weaning from ventilation.RESULTS Overall, 310 (73.6%) patients with CS were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (HR: 0.64; 95% CI: 0.46-0.88) and a higher likelihood of successful weaning from ventilation (OR: 2.17; 95% CI: 1.19-3.93) but not with more complications. Importantly, the relative mortality risk increased and the likelihood of successful weaning from ventilation decreased almost proportionally with the time interval between VA-ECMO implantation and (delayed) initiation of active LV unloading.CONCLUSIONS This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO, although the findings need to be validated in a randomized controlled trial.(J Am Coll Cardiol HF 2023;11:321-330) (c) 2023 by the American College of Cardiology Foundation.

Editor—Fischer and colleagues1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar recently published the results of an RCT addressing restrictive transfusion in the postoperative period of cardiac surgery. They reported that exposure to red blood cell (RBC) transfusion can be substantially reduced (by 21%) when central venous oxygen saturation (Scvo2) <70% was added to a restrictive haemoglobin trigger of 9 g dl−1. Use of Scvo2 could change the practice of RBC transfusion in cardiac surgery. However, several issues need to be clarified before considering whether Scvo2 should be implemented in a patient blood management strategy and eventually included in guidelines. First, which Scvo2 threshold do we choose as a trigger for transfusion? Our findings and those of Fisher and colleagues1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar showed that Scvo2 in addition to a low haemoglobin transfusion trigger reduced the incidence of transfusion by 32% in the ICU after cardiac surgery.1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,2Zeroual N. Blin C. Saour M. et al.Restrictive transfusion strategy after cardiac surgery: role of central venous oxygen saturation trigger: a randomized controlled trial.Anesthesiology. 2021; 134: 370-380Crossref PubMed Scopus (23) Google Scholar Both studies indicate that Scvo2 might improve individualisation of RBC transfusion. Indeed, Scvo2 provides an interesting link between haemoglobin concentration and tissue oxygen delivery, and thus can serve as an objective marker of anaemia tolerance. In the study by Fischer and colleagues,1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Scvo2 <70% was based on a study in noncardiac surgery, where Scvo2 threshold was founded on a physiological concept.1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In our study, Scvo2 threshold was set at ≤65% because it had shown a good positive predictive value (85%) to predict an Scvo2 increase of 5% after RBC transfusion in a previous observational study in cardiac and vascular surgery.3Zeroual N. Samarani G. Gallais J. et al.ScvO2 changes after red-blood-cell transfusion for anaemia in cardio-thoracic and vascular ICU patients: an observational study.Vox Sang. 2018; 113: 136-142Crossref PubMed Scopus (8) Google Scholar Choosing a higher Scvo2 threshold minimises the risk of anaemia-induced dysoxia with a comfortable safety margin but with a lower benefit on RBC transfusion reduction. A lower Scvo2 threshold, such as 65%, is therefore likely to reduce RBC transfusion when compared with a threshold of 70%.1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,2Zeroual N. Blin C. Saour M. et al.Restrictive transfusion strategy after cardiac surgery: role of central venous oxygen saturation trigger: a randomized controlled trial.Anesthesiology. 2021; 134: 370-380Crossref PubMed Scopus (23) Google Scholar Decreasing the Scvo2 threshold below 65% would decrease transfusion incidence even more, possibly at the expense of higher O2 extraction, to preserve tissue oxygen distribution. Further investigations are needed to establish whether Scvo2 threshold could be individualised to optimise RBC transfusion. Second, how do we treat anaemia in the absence of transfusion? In both studies, owing to the absence of Scvo2 measurement after ICU discharge, anaemia treatment in surgical wards was blinded to metabolic measures, and transfusion was guided by standard of care. This change in the transfusion strategy could have jeopardised the benefit on RBC transfusion reduction observed in the ICU. In the study of Fischer and colleagues,1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar the transfusion incidence after ICU discharge is unknown. In our study, 50% of patients not transfused in the ICU were transfused on the surgical ward. Importantly, almost 80% of these patients received only one or two RBC units.2Zeroual N. Blin C. Saour M. et al.Restrictive transfusion strategy after cardiac surgery: role of central venous oxygen saturation trigger: a randomized controlled trial.Anesthesiology. 2021; 134: 370-380Crossref PubMed Scopus (23) Google Scholar This modest transfusion requirement to treat postoperative anaemia may not be the best strategy. On the other hand, in larger studies on restrictive transfusion, anaemia of ∼9 g dl−1 persisted up to 4 weeks after inclusion in the study.4Mazer C.D. Whitlock R.P. Fergusson D.A. et al.Restrictive or liberal red-cell transfusion for cardiac surgery.N Engl J Med. 2017; 377: 2133-2144Crossref PubMed Scopus (458) Google Scholar,5Murphy G.J. Pike K. Rogers C.A. et al.Liberal or restrictive transfusion after cardiac surgery.N Engl J Med. 2015; 372: 997-1008Crossref PubMed Scopus (562) Google Scholar Therefore, to avoid anaemia without resorting to RBC transfusion, treatment with iron supplementation and erythropoietin could be an interesting alternative. Short-term treatment has shown encouraging results.6Spahn D.R. Schoenrath F. Spahn G.H. et al.Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial.Lancet. 2019; 393: 2201-2212Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar Fischer and colleagues1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar did not report that they anticipated anaemia treatment with iron supplementation and erythropoietin was not mentioned. In our study, i.v. iron and erythropoietin administration was allowed, and haemoglobin concentration reached around 10 g dl−1 2 weeks after surgery.2Zeroual N. Blin C. Saour M. et al.Restrictive transfusion strategy after cardiac surgery: role of central venous oxygen saturation trigger: a randomized controlled trial.Anesthesiology. 2021; 134: 370-380Crossref PubMed Scopus (23) Google Scholar Studies are needed to confirm this encouraging trend and to assess whether these treatments can be used even more intensively after cardiac surgery. Third, what is the added value of restrictive transfusion guided by Scvo2? Several large-scale studies have shown higher mortality risk associated with RBC transfusion in cardiac surgery.7Murphy G.J. Reeves B.C. Rogers C.A. Rizvi S.I.A. Culliford L. Angelini G.D. Increased mortality, post-operative morbidity and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552Crossref PubMed Scopus (1040) Google Scholar, 8Koch C.G. Li L. Duncan A.I. et al.Transfusion in coronary artery bypass grafting is associated with reduced long-term survival.Ann Thorac Surg. 2006; 81: 1650-1657Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar, 9Paone G. Likosky D.S. Brewer R. et al.Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality.Ann Thorac Surg. 2014; 97: 87-93Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar Therefore, restrictive transfusion has been promoted, but no benefit on postoperative outcome has been shown yet.7Murphy G.J. Reeves B.C. Rogers C.A. Rizvi S.I.A. Culliford L. Angelini G.D. Increased mortality, post-operative morbidity and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552Crossref PubMed Scopus (1040) Google Scholar, 8Koch C.G. Li L. Duncan A.I. et al.Transfusion in coronary artery bypass grafting is associated with reduced long-term survival.Ann Thorac Surg. 2006; 81: 1650-1657Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar, 9Paone G. Likosky D.S. Brewer R. et al.Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality.Ann Thorac Surg. 2014; 97: 87-93Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar Conversely, liberal transfusion has not shown better outcome.7Murphy G.J. Reeves B.C. Rogers C.A. Rizvi S.I.A. Culliford L. Angelini G.D. Increased mortality, post-operative morbidity and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552Crossref PubMed Scopus (1040) Google Scholar, 8Koch C.G. Li L. Duncan A.I. et al.Transfusion in coronary artery bypass grafting is associated with reduced long-term survival.Ann Thorac Surg. 2006; 81: 1650-1657Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar, 9Paone G. Likosky D.S. Brewer R. et al.Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality.Ann Thorac Surg. 2014; 97: 87-93Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar, 10Mazer C.D. Whitlock R.P. Fergusson D.A. et al.Six-month outcomes after restrictive or liberal transfusion for cardiac surgery.N Engl J Med. 2018; 379: 1224-1233Crossref PubMed Scopus (152) Google Scholar The absence of benefit of restrictive transfusion over liberal transfusion, despite evidence of adverse effects of RBC transfusion, suggests that avoiding RBC transfusion may be sufficient to improve outcomes. Indeed, a restrictive transfusion strategy helps reduce transfusion but delays anaemia correction. We may suspect that the lack of difference in outcome between liberal and restrictive transfusion strategies may result from a switch of the transfusion risks to the deleterious effects of prolonged anaemia.7Murphy G.J. Reeves B.C. Rogers C.A. Rizvi S.I.A. Culliford L. Angelini G.D. Increased mortality, post-operative morbidity and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552Crossref PubMed Scopus (1040) Google Scholar,8Koch C.G. Li L. Duncan A.I. et al.Transfusion in coronary artery bypass grafting is associated with reduced long-term survival.Ann Thorac Surg. 2006; 81: 1650-1657Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar The studies by Fischer and colleagues1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar and us were not designed to assess outcomes, and RBC transfusion guidance by Scvo2 was limited to ICU stay. Further studies are needed to assess whether individualisation of RBC transfusion by Scvo2 whenever it is possible, plus aggressive treatment of anaemia by iron supplementation and erythropoietin administration, improves outcomes. In conclusion, Fischer and colleagues1Fischer M.O. Guinot P.G. Debroczi S. et al.Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.Br J Anaesth. 2022; 128: 37-44Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar provide evidence that individualisation of transfusion according to a metabolic marker beyond haemoglobin concentration may reduce RBC transfusion. However, restrictive transfusion can contribute to prolonged anaemia, which has been shown to increase mortality after noncardiac surgery11Turan A. Rivas E. Devereaux P.J. et al.Association between postoperative haemoglobin concentrations and composite of non-fatal myocardial infarction and all-cause mortality in noncardiac surgical patients: post hoc analysis of the POISE-2 trial.Br J Anaesth. 2020; 126: 87-93Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar and would require supplementary treatment to correct without transfusion. The authors declare no conflicts of interest. Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trialBritish Journal of AnaesthesiaVol. 128Issue 1PreviewCurrent practice guidelines for red blood cell (RBC) transfusion in ICUs are based on haemoglobin threshold, without consideration of oxygen delivery or consumption. We aimed to evaluate an individual physiological threshold-guided by central venous oxygen saturation S c vO 2 . Full-Text PDF Open Archive

Abstract Background: Encouraging results in several series of patients on refractory cardiogenic shock (CS) led to the consideration of including temporary mechanical circulatory support (TMCS) in the guidelines for CS management. Benefit on survival might be improved when TMCS devices are initiated early. This study assessed early TMCS for CS in the real-world condition of a cardiac assistance regional network. Methods: We examined the clinical features and outcomes of patients treated with TMCS, using data from a prospective cohort of patients admitted for CS in a cardiac assistance regional network. Patients were eligible when CS included systolic blood pressure (SBP) <90 mmHg despite adequate filling pressure or need of catecholamine to maintain SPB>90 mmHg, signs of congestion or tissue hypo-perfusion or blood lactate >2mmol/L. TMCS indication, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or percutaneous left ventricle assistance (Impella) was based on the initial severity of CS or if shock was refractory to medical treatment. To estimate the effect of early TMCS on mortality, we emulated a target trial of TMCS implantation versus no TMCS within 24 hours of ICU admission. Patients were followed until hospital discharge, death, or 180 days. Inverse probability of treatment weighting with propensity score was used to adjust for confounders. Results: Among 372 patients, 246 were included in the study: 121 treated by early TMCS (TMCS group) and 125 not treated by early TMCS (controls). Median age was 59.5 years, 71.9% were male, and the main etiologies were acute myocardial infraction (MI) (46.8%) and decompensated heart failure (27.2%). Crude in-hospital mortality was 38% (46/121) in the TMCS group and 22.4% (28/125) in the control group. After emulation, in-hospital mortality was not different between the TMCS group and the control group (HR=0.91, 95%CI:0.65-1.26). In sub-group analyses, in-hospital mortality was not different among patients with MI (HR=0.82, 95%CI:0.52-1.32), with other etiology than MI (HR=1.19, 95%CI:0.70-2.04), and with VA-ECMO only (HR=0.87, 95%CI:0.62-1.22). TMCS patients had two-fold longer hospital stays, and a higher rate of complications than controls. Conclusion: In this emulated target trial from real-world data, patients with CS treated with early TMCS had no improvement in survival compared to controls. Trial registration number: NCT03528291, registered trials May 18, 2017

BACKGROUND: “Macintosh”-videolaryngoscopes (VLs) are VLs that allow both direct and indirect laryngoscopy for intubation. We describe the decision-making and implementation-processes that our hospital used regarding the choice of device. We compared the performances of 4 Macintosh-VLs both in direct and indirect laryngoscopy. METHODS: A quality-improvement-project for airway management aiming at implementing Macintosh-VL for all intubation procedures performed in the operating room, involving 4 Macintosh-VLs (McGrath-Mac, C-MAC-S, C-MAC-S-Pocket-Monitor [PM], and APA). Three consecutive steps were described: (1) direct laryngoscopy with Macintosh-VL, (2) indirect laryngoscopy with Macintosh-VL (intubation attempt with Macintosh-style blade in case of Cormack I or II), (3) intubation attempt with hyperangulated blade in case of Cormack III/IV or failure of Macintosh-style blade. The main end point was the need to move to step III and use a hyperangulated blade. A mixed-effects multivariable logistic regression analysis was performed to compare devices on the main end point while considering site as a random effect. Comparison of means was performed using analysis of variance and Tukey’s test for multiple comparisons (number of laryngoscopy attempts, numeric rate scale [NRS] difficulty of intubation and NRS user-friendliness). Comparison of percentages was performed using a χ 2 test for the need to move to step III and a Kruskal-Wallis test for the quality of image (bad, passable, good, very good, excellent). A P value ≤.008 was considered statistically significant. RESULTS: From May to September 2017, 589 patients were included. Using the McGrath-Mac (22/180 [12%]) was associated with less use of hyperangulated blade than using the C-MAC-S (39/132 [30%], odds ratio [OR] [99.2% confidence interval {CI}] 0.34 [0.16–0.77], P = .0005), the APA (35/138 [25%], OR [99.2% CI] 0.42 [0.19–0.93]; P = .004), but not the C-MAC-S-PM (29/139 [21%], OR [99.2% CI] 0.53 [0.23–1.2]; P = .04). Overall, the number of intubation attempts was significantly lower using the McGrath Mac than the C-MAC-S or the C-MAC-S-PMVLs. Subjective appreciation of intubation difficulty and user-friendliness of the devices showed respectively lower and higher NRS scores for the McGrath-Mac compared to the other devices, whereas subjective assessment of image quality showed higher quality for the C-MAC-S and C-MAC-S-PM compared to the APA or McGrath-Mac. CONCLUSIONS: Among 4 single-use Macintosh-VLs, glottic visualization in direct and indirect laryngoscopy with the Macintosh-style blade was significantly improved with the McGrath-Mac compared to other Macintosh-VLs, leading to a less frequent need to resort to the hyperangulated blade and reduced overall number of intubation attempts.

Background: Recent guidelines on transfusion in cardiac surgery suggest that hemoglobin might not be the only criterion to trigger transfusion. Central venous oxygen saturation (Svo 2 ), which is related to the balance between tissue oxygen delivery and consumption, may help the decision process of transfusion. We designed a randomized study to test whether central Svo 2 –guided transfusion could reduce transfusion incidence after cardiac surgery.

Background Recent guidelines on transfusion in cardiac surgery suggest that hemoglobin might not be the only criterion to trigger transfusion. Central venous oxygen saturation (Svo 2), which is related to the balance between tissue oxygen delivery and consumption, may help the decision process of transfusion. We designed a randomized study to test whether central Svo 2–guided transfusion could reduce transfusion incidence after cardiac surgery. Methods This single center, single-blinded, randomized controlled trial was conducted on adult patients after cardiac surgery in the intensive care unit (ICU) of a tertiary university hospital. Patients were screened preoperatively and were assigned randomly to two study groups (control or Svo 2) if they developed anemia (hemoglobin less than 9 g/dl), without active bleeding, during their ICU stay. Patients were transfused at each anemia episode during their ICU stay except the Svo 2 patients who were transfused only if the pretransfusion central Svo 2 was less than or equal to 65%. The primary outcome was the proportion of patients transfused in the ICU. The main secondary endpoints were (1) number of erythrocyte units transfused in the ICU and at study discharge, and (2) the proportion of patients transfused at study discharge. Results Among 484 screened patients, 100 were randomized, with 50 in each group. All control patients were transfused in the ICU with a total of 94 transfused erythrocyte units. In the Svo 2 group, 34 (68%) patients were transfused (odds ratio, 0.031 [95% CI, 0 to 0.153]; P < 0.001 vs. controls), with a total of 65 erythrocyte units. At study discharge, eight patients of the Svo 2 group remained nontransfused and the cumulative count of erythrocyte units was 96 in the Svo 2 group and 126 in the control group. Conclusions A restrictive transfusion strategy adjusted with central Svo 2 may allow a significant reduction in the incidence of transfusion. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background: Novel oral anticoagulants are used in atrial fibrillation. Idarucizumab has been approved for reversal of dabigatran in situations of life-threatening hemorrhage or emergency surgery. Objectives: We report a single center experience of ten patients on dabigatran therapy who were given idarucizumab prior to heart transplantation. Methods & results: The mean plasma concentration of dabigatran prior to reversal was 139 ± 89 ng/ml. Hemoglobin, hematocrit and platelet levels were decreased after surgery. Surgical procedures were successfully performed with no increased risk, especially regarding bleeding complications. All patients were alive after 90 days. Conclusion: Dabigatran reversal with idarucizumab in contexts of emergency surgery/urgent procedures is an attractive and safe option to be taken into consideration for patients with end stage heart disease awaiting transplantation and indication of anticoagulant therapy.