Cardiothoracic Surgery

Cryopreserved platelets fail noninferiority and increase bleeding in high-risk cardiac surgery

In CLIP-II, 202 high-risk cardiac surgery patients requiring platelets were randomized to cryopreserved versus liquid-stored products. Twenty-four–hour chest tube loss was numerically higher with cryopreserved platelets, and noninferiority for bleeding was not established. Cryopreserved platelets were associated with greater intraoperative and total perioperative blood loss and higher use of red cells, plasma, and cryoprecipitate. Patients receiving cryopreserved platelets also had longer times to extubation and ICU or hospital stay, without excess prespecified adverse events. These findings argue against routine replacement of liquid-stored platelets with dimethyl sulfoxide–cryopreserved platelets for surgical bleeding control. 1

Prophylactic norepinephrine during induction does not reduce severe hypotension in cardiac surgery

The EPITUBE randomized trial assigned 210 cardiac surgery patients to prophylactic norepinephrine infusion or on-demand ephedrine at induction. Prophylactic norepinephrine did not reduce severe hypotension, defined as MAP <55 mm Hg, with nearly identical incidences between groups. It did reduce episodes of MAP <65 mm Hg, but this did not translate into fewer intubation complications or better postoperative outcomes. Rates of acute kidney injury, ventilation time, ICU length of stay, and mortality were similar with both vasopressor strategies. 2

Pre-operative anaemia increases 120-day mortality, largely mediated by red cell transfusion

This nationwide Netherlands cohort included 71,053 adult cardiac surgery patients, of whom 20.3% had pre-operative anaemia by WHO criteria. Anaemic patients had substantially higher red blood cell transfusion rates and higher 120-day mortality than non-anaemic patients. After multivariable adjustment, pre-operative anaemia remained independently associated with mortality (adjusted OR 1.66, 95% CI 1.47–1.87). Mediation analysis showed that red blood cell transfusion accounted for about 59% of the anaemia–mortality association, especially in patients aged 70 years or older. These data support systematic pre-operative anaemia optimization and cautious, individualized transfusion strategies, particularly in older patients. 3

Myval TAVR valve matches contemporary SAPIEN/Evolut platforms at 1 year in severe aortic stenosis

The LANDMARK trial randomized 768 patients with symptomatic severe native aortic stenosis to Myval versus contemporary SAPIEN or Evolut transcatheter valves. At 1 year, freedom from the composite of all-cause mortality, stroke, and valve- or procedure-related hospitalization was virtually identical (87.0% vs 86.9%). Noninferiority of Myval for the composite endpoint was demonstrated, and extended outcomes including quality of life were also comparable. Clinical and hemodynamic performance remained similar through 1 year in this predominantly elderly, low-risk cohort, supporting Myval as a viable alternative platform. 4