Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
Ann Thorac Surg. 2011 Mar;91(3):740-7; discussion 747-9. doi: 10.1016/j.athoracsur.2010.11.007.
Bleeding complications are a major source of morbidity and reoperation after left ventricular assist device (LVAD) implantation, yet remain poorly characterized in patients receiving LVADs. We assessed bleeding complications in an institutional cohort of LVAD patients.
We reviewed patients who received continuous-flow (CF) LVADs at our institution (October 2004 to May 2009). Intraoperative and postoperative transfusion requirements (packed red blood cells, fresh frozen plasma, and platelets), chest tube output, and reoperation for bleeding complications were assessed. Univariate and multivariable Cox proportional hazard analysis assessed the impact of intraoperative bleeding on mortality. A subset of our patient population underwent delayed sternal closure as opposed to primary closure and an analysis of reoperation for bleeding was undertaken stratifying patients by approach to closure.
Eighty-six CF LVADs were implanted over our study period. Patients had poor preoperative cardiac function and high preoperative risk indices. Patients receiving LVADs had high intraoperative (11.6 ± 7.5 units) and postoperative (15.6 [±12.6] units in the first week) blood product requirements, as well as significant chest tube output (5,880 [±4,480] milliliters in the first week). On multivariable analysis, intraoperative packed red blood cell transfusions were a significant predictor of mortality. Eleven (28%) patients undergoing primary sternal closure required reoperation for bleeding, while delayed sternal closure patients generally had resolution of bleeding prior to sternal closure. The incidence of gastrointestinal bleeding was 28% at one year.
On multivariable analysis, intraoperative packed red blood cell transfusions were a significant predictor of 30-day and one-year mortality, while chest tube output during the first postoperative 48 hours predicted 30-day but not one-year mortality.
出血并发症是左心室辅助装置（LVAD）植入后发病率和再次手术的主要原因，但在接受 LVAD 治疗的患者中仍未得到充分描述。我们评估了我院 LVAD 患者的出血并发症。
我们回顾了我院 2004 年 10 月至 2009 年 5 月接受连续血流（CF）LVAD 的患者。评估了术中及术后输血需求（红细胞、新鲜冰冻血浆和血小板）、胸腔引流管引流量及因出血并发症而再次手术的情况。单变量和多变量 Cox 比例风险分析评估了术中出血对死亡率的影响。我们的一部分患者人群接受了延迟性胸骨闭合术，而不是直接闭合术，并对根据闭合术方法分层的患者进行了出血再手术分析。
在我们的研究期间，共植入了 86 个 CF LVAD。患者术前心功能较差，术前风险指数较高。LVAD 患者术中（11.6±7.5 单位）和术后（第一周内 15.6[±12.6]单位）输血需求较高，胸腔引流管引流量也较大（第一周内 5880[±4480]毫升）。多变量分析显示，术中输注红细胞是死亡的显著预测因素。11 名（28%）接受直接胸骨闭合术的患者因出血需要再次手术，而延迟性胸骨闭合术患者的胸骨闭合术一般在出血得到控制后进行。一年时的胃肠道出血发生率为 28%。
多变量分析显示，术中输注红细胞是 30 天和 1 年死亡率的显著预测因素，而术后 48 小时内胸腔引流管引流量预测 30 天死亡率，但不预测 1 年死亡率。
