Original Article
Nonsurgical Strategies to Reduce Mortality in Patients Undergoing Cardiac Surgery: An Updated Consensus Process

https://doi.org/10.1053/j.jvca.2017.06.017Get rights and content

Objective

A careful choice of perioperative care strategies is pivotal to improve survival in cardiac surgery. However, there is no general agreement or particular attention to which nonsurgical interventions can reduce mortality in this setting. The authors sought to address this issue with a consensus-based approach.

Design

A systematic review of the literature followed by a consensus-based voting process.

Setting

A web-based international consensus conference.

Participants

More than 400 physicians from 52 countries participated in this web-based consensus conference.

Interventions

The authors identified all studies published in peer-reviewed journals that reported on interventions with a statistically significant effect on mortality in the setting of cardiac surgery through a systematic Medline/PubMed search and contacts with experts. These studies were discussed during a consensus meeting and those considered eligible for inclusion in this study were voted on by clinicians worldwide.

Measurements and Main Results

Eleven interventions finally were selected: 10 were shown to reduce mortality (aspirin, glycemic control, high-volume surgeons, prophylactic intra-aortic balloon pump, levosimendan, leuko-depleted red blood cells transfusion, noninvasive ventilation, tranexamic acid, vacuum-assisted closure, and volatile agents), whereas 1 (aprotinin) increased mortality. A significant difference in the percentages of agreement among different countries and a variable gap between agreement and clinical practice were found for most of the interventions.

Conclusions

This updated consensus process identified 11 nonsurgical interventions with possible survival implications for patients undergoing cardiac surgery. This list of interventions may help cardiac anesthesiologists and intensivists worldwide in their daily clinical practice and can contribute to direct future research in the field.

Section snippets

Methods

Cardiac anesthesiologists, cardiac surgeons, intensivists, and cardiologists participated in this updated consensus conference in cardiac surgery mortality. They participated in person, through e-mail, or through the congress website (Fig 1).

Medline/PubMed, Scopus, and Embase were searched by 4 investigators (GL, SS, EF, MBR, CS) with no publication time limits, and the results were updated on November 27, 2015, to identify all randomized controlled trials (RCTs) and non-RCTs of any nonsurgical

Results

The consensus process flowchart is shown in Figure 1. The web survey identified the following 10 interventions that decreased unadjusted landmark mortality: aspirin,18, 19 high-volume surgeon,20, 21, 22 glycemic control,23, 24, 25, 26 prophylactic intra-aortic balloon pump (IABP),27, 28, 29, 30, 31, 32 leuko-depleted red blood cell transfusion (RBC),33, 34 levosimendan,35, 36, 37, 38, 39, 40, 41 noninvasive ventilation (NIV),42, 43 tranexamic acid,44 vacuum-assisted closure (VAC),45 volatile

Key Findings

All nonsurgical interventions, including drugs, techniques, and strategies, which have been shown in at least 1 study published in a peer-reviewed journal to significantly affect mortality in patients undergoing cardiac surgery, were identified. In particular, the authors found that aspirin, glycemic control, high-volume surgery, prophylactic IABP, levosimendan, leuko-depleted RBC transfusion, NIV, tranexamic acid, VAC, and volatile agents might reduce mortality, whereas aprotinin likely

Conclusions

This updated, international, web-based consensus conference process identified 11 interventions supported by widely agreed-on evidence suggesting an effect on mortality among patients undergoing cardiac surgery. The analysis of web voting confirmed that there was a gap between evidence and clinical practice and that both the perception of literature evidence and the clinical attitude of cardiac anesthesiologists and intensivists were significantly different among different countries for many of

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  • Cited by (0)

    M. Baiocchi, V. Lomivorotov, G. Monti, G. Paternoster, and H. Riha have received speaker fees from Orion Pharma, and G. Landoni has received speaker fees from AbbVie, Orion Pharma, Pall, and Tenax.

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