a Heart Center, Turku University Hospital, University of Turku , Turku , Finland.
b Department of Molecular Medicine and Surgery, Department of Cardiac Surgery , Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden.
Platelets. 2019;30(4):480-486. doi: 10.1080/09537104.2018.1466389. Epub 2018 Apr 20.
The impact of thrombocytopenia on postoperative bleeding and other major adverse events after cardiac surgery is unclear. This issue was investigated in a series of patients who underwent isolated coronary artery bypass grafting (CABG) from the prospective, multicenter E-CABG registry. Preoperative thrombocytopenia was defined as preoperative platelet count <150 × 10/L and it was considered moderate-severe when preoperative platelet count was <100 × 10/L. Multilevel mixed-effects regression analysis was performed to adjust the effect of thrombocytopenia on outcomes for baseline and operative covariates as well as for interinstitutional differences in patient-blood management. Among 7189 patients included in this analysis, 599 (8.3%) had preoperative thrombocytopenia. Patient with preoperative thrombocytopenia had an increased chest drainage output at 12 h (mean, 519 vs. 456 mL, adjusted coeff. 39, 95%CI 18-60) and rates of severe-massive bleeding (Universal Definition of Perioperative Bleeding (UDPB) severity grades 3-4: 12.7% vs. 8.1%, adjusted OR 1.47, 95%CI 1.11-1.93; E-CABG bleeding severity grades 2-3: 10.4% vs. 6.1%, adjusted OR 1.78, 95%CI 1.30-2.43). Thrombocytopenia was associated with an increased risk of hospital/30-day death (3.2% vs. 1.9%, adjusted OR 2.02, 95%CI 1.20-3.42), 1-year death (5.7% vs. 3.4%, adjusted HR 1.68, 95%CI 1.16-2.44), deep sternal wound infection (3.5% vs. 2.4%, adjusted OR 1.65, 95%CI 1.02-2.66), acute kidney injury (28.1% vs. 22.2%, OR 1.45, 1.18-1.78), and prolonged stay in the intensive care unit (mean, 3.6 vs 2.8 days, adjusted coeff. 0.74, 95%CI 0.40-1.09). Similar results were observed in a subset of patients with moderate-severe thrombocytopenia (51 patients, 0.7%). In particular, these patients had a markedly higher rate of acute kidney injury (40%, adjusted OR, 1.94, 95%CI 1.05-3.57), resternotomy for bleeding (7.8%, adjusted OR 3.49, 95%CI 1.20-10.21), and severe-massive bleeding (UDPB severity grades 3-4: 23.5%, adjusted OR 3.08, 95%CI 1.52-6.22; E-CABG bleeding severity grades 2-3: 23.5%, adjusted OR 4.43, 95%CI 2.15-9.15) compared to patients with normal preoperative platelet count. Mild preoperative thrombocytopenia is associated with increased risk of severe-massive bleeding, mortality, and other major adverse events after CABG. Such risks are markedly increased in patients with moderate-severe preoperative thrombocytopenia.
血小板减少症对心脏手术后出血和其他主要不良事件的影响尚不清楚。本研究通过前瞻性多中心 E-CABG 注册研究对一系列接受单纯冠状动脉旁路移植术（CABG）的患者进行了研究。术前血小板减少症定义为术前血小板计数<150×10/L，当术前血小板计数<100×10/L 时则认为是中重度血小板减少症。采用多水平混合效应回归分析调整血小板减少症对基线和手术相关变量以及患者血液管理方面机构间差异对结果的影响。在本分析纳入的 7189 例患者中，599 例（8.3%）存在术前血小板减少症。与术前无血小板减少症的患者相比，前者在术后 12 小时的胸腔引流量更多（平均 519 vs. 456 mL，调整后的系数 39，95%CI 18-60），且严重/大量出血的发生率更高（根据通用围术期出血定义（UDPB）严重程度分级 3-4 级：12.7% vs. 8.1%，调整后的比值比 1.47，95%CI 1.11-1.93；E-CABG 出血严重程度分级 2-3 级：10.4% vs. 6.1%，调整后的比值比 1.78，95%CI 1.30-2.43）。血小板减少症与住院/30 天死亡风险增加相关（3.2% vs. 1.9%，调整后的比值比 2.02，95%CI 1.20-3.42）、1 年死亡风险增加（5.7% vs. 3.4%，调整后的 HR 1.68，95%CI 1.16-2.44）、深部胸骨伤口感染（3.5% vs. 2.4%，调整后的比值比 1.65，95%CI 1.02-2.66）、急性肾损伤（28.1% vs. 22.2%，OR 1.45，95%CI 1.18-1.78）和 ICU 住院时间延长（平均 3.6 vs. 2.8 天，调整后的系数 0.74，95%CI 0.40-1.09）。在中重度血小板减少症（51 例，0.7%）患者亚组中也观察到了类似的结果。特别是这些患者的急性肾损伤发生率明显更高（40%，调整后的比值比 1.94，95%CI 1.05-3.57）、因出血行再次开胸（7.8%，调整后的比值比 3.49，95%CI 1.20-10.21）和严重/大量出血（UDPB 严重程度分级 3-4 级：23.5%，调整后的比值比 3.08，95%CI 1.52-6.22；E-CABG 出血严重程度分级 2-3 级：23.5%，调整后的比值比 4.43，95%CI 2.15-9.15）的发生率明显高于术前血小板计数正常的患者。轻度术前血小板减少症与 CABG 后严重/大量出血、死亡和其他主要不良事件的风险增加相关。在中重度术前血小板减少症患者中，这些风险明显增加。
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