- Split View
-
Views
-
Cite
Cite
Fleur Plumereau, Frédéric Pinaud, Alexandra Roch, Christophe Baufreton, Do patients with haematological malignancy who need cardiopulmonary bypass have a short-term higher mortality or a higher chance of disease progression?, Interactive CardioVascular and Thoracic Surgery, Volume 19, Issue 3, September 2014, Pages 474–478, https://doi.org/10.1093/icvts/ivu190
- Share Icon Share
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with haematological malignancy (HM) who need cardiopulmonary bypass (CPB) have a higher short-term mortality or a higher chance of disease progression secondary to CPB. Altogether, 107 papers were found using the reported search terms, but ultimately only eight were relevant to our subject. We found four case series and four case–control series. Most of the found papers were only short series. The largest series included 56 patients with HM and requiring CPB, suggesting that HM patients rarely require CPB surgery and/or are not operated on. Most of these studies showed that the overall postoperative morbidity rate was increased, reaching 50–60% of the patients. These comorbidities were mainly related to postoperative infections, bleeding and blood transfusions, which were highly significant. However, in most papers, the postoperative hospital stay was not different and the in-hospital mortality rate of HM patients was similar to that of healthy patients. One paper demonstrated that the time taken before initiating chemotherapy was longer in patients who underwent CPB surgery. No paper reported an acute change in blood disorders. Long-term mortality rates were not mentioned in some papers, but when it was stated, the HM patients’ long-term mortality seemed not increased by using CPB surgery, with more than 80% survival at 3 years and 20–25% progression of the disease at 3 years. Although these study limitations are linked to the low-evidence levels in some of the papers used, haematological malignancies should not be considered a contraindication for cardiac CPB surgery.
INTRODUCTION
A best evidence topic was constructed according to a structured protocol, which was described in detail in ICVTS [1].
THREE-PART QUESTION
In [patients with haematological malignancy], is the use of [cardiopulmonary bypass] associated with [an increase in short-term survival or disease progression]?
CLINICAL SCENARIO
You are performing an aortic valve replacement in a 60-year old patient. During the preoperative consultation, you learn that the patient suffers from chronic lymphocytic leukaemia (CLL). The preoperative evaluation shows 80 000 lymphocytes per ml. You are reluctant to perform this open-heart procedure. The patient undergoes leukapheresis so as to reduce lymphocyte rates by half, and then has an aortic valve replacement with cardiopulmonary bypass (CPB). There are no postoperative complications, and the patient is still alive. You wonder whether heart surgery might affect the patient’s postoperative haematological outcome.
SEARCH STRATEGY
The Medline, Cochrane and Ovid databases were searched from the date of inception to August 2013. The search terms (((((‘Cardiopulmonary Bypass’[MeSH]) OR (‘Thoracic Surgery’[MeSH] OR ‘Cardiac Surgical Procedures’[MeSH]))) OR CABG)) AND ((‘Hematologic Neoplasms’[MeSH]) OR ‘Leukemia’[MeSH]) were used to narrow down the list of articles related to our question.
SEARCH OUTCOME
In total, 107 abstracts were identified, of which eight were deemed relevant. Each abstract was read, and only studies with CPB were used. We were able to review four case–control studies and four case series, which we used to address the question. The results are summarized in Table 1.
Author, date, journal and country Study type (level of evidence) . | Patient group . | Outcomes . | Key results . | Study weakness . |
---|---|---|---|---|
Chan et al. (2012), Heart Lung Circ, Australia [2] Retrospective, single-centre case–control study (level 3b) | 83 patients with malignancy (68.7% had a solid organ tumour, and 31.3% had a HM) underwent open heart surgery compared with a control group of 216 patients without a history of cancer 2002–2009 | Hospital mortality Length of stay in the ICU Median hospital length Rate of hospital readmission Blood transfusion Infective complications | No statistically significant difference in mortality (6 in the cancer group and 8 in the non-cancer group). No mortality in the cancer group could be attributable to their malignancy Not significantly different Same in both groups (8 days) Not significantly different Higher in the cancer group, but the subgroup with HM had a very high blood transfusion rate A significantly increased rate of both pneumonia and septicaemia in the group with cancer, but in the subgroup with HM, 11.5% of patients had septicaemia, compared with 7% with solid organ malignancies (P = 0.79) | Small study Selection bias: HM and solid malignancies are 2 different pathologies Data on preoperative chemotherapy for the cancer patient were not collected No long-term data |
Guler et al. (2012), Cardiovasc J Afr, Turkey [3] Retrospective, single-centre case series study | 15 patients with HM (8 CLL, 6 NHL and 1 chronic myelocytic leukaemia) who underwent cardiac surgery | Morbidity 3-year survival rate | 4 postoperative complications with 3 reinterventions for bleeding 80% Cause of death: 3 intracranial bleeding and 2 undetermined | Small study Selection bias: all patients in remission |
Sommer et al. (2011), Eur J Cardiothorac Surg, Germany [4] Retrospective, single-centre case–control study (level 3b) | 56 patients with a history of a haematological malignancies (NHL: n = 29, HD: n = 5, ALL: n = 1, MPS: n = 12 and MGUS: n = 9) underwent open heart surgery compared with the control group containing 142 patients. 3 patients were considered cured of the malignancies, and 3 were in the complete remission 1995–2008 | In-hospital mortality Length of in-hospital time Length of ICU stay Complications Long-term survival Need for transfusion | Elevated in HM patients, without reaching statistical significance (P = 0.7) Not significantly different Not significantly different Trend towards elevated rates of vascular, pulmonary and infectious complications in HM patients, but no significant difference Significant difference, but in the HM subgroup, NHL patients and MPS patients demonstrated an impaired survival when compared with those with MGUS and Hodgkin’s disease Intraoperatively, increased need observed in HM patients (P <0.001) During hospital stay, more units of platelets or erythrocyte concentrates were transfused (non-significant difference) | Selection bias: 3 patients were considered cured 15 received treatment for their haematological disorder at the time of surgery On matching criteria, significant difference in preoperative serum creatinine levels |
Fecher et al. (2004), Eur J Cardiothorac Surg, USA [5] Retrospective, single-centre, case series study (level 4) | 24 HM patients underwent open heart surgery. 2 had off-pump surgery 1996–2002 | Postoperative stay in the ICU and hospital Morbidity, postoperative complications Mortality | Average stay in the ICU 1.6 ± 1.1 days Mean stay 8.2 ± 5.8 days (postoperative stay was significantly longer in patients who had complications: 11 ± 7.1 vs 5.3 ± 1.7 days, P = 0.01) 12 patients (50%) had complications (bleeding, reoperation, stroke, infection and atrial fibrillation) Occurred in older patients (P = 0.06) 4.1% during hospital stay (1 patient died from gastrointestinal bleeding) 83% alive at 3 years. 3 deaths, including 2 due to progression of malignancy | Small study Selection bias: Other HM patients were not offered surgery due to high-operative risk, or advanced-stage disease 2 patients had no CPB (off-pump surgery) |
Potapov et al. (2002), Ann Thorac Surg, Germany [6] Retrospective, single-centre case–control study (level 3b) | 28 patients with CLL who underwent heart surgery with CPB were compared with the control group containing 25 patients with CLL but not requiring heart surgery 1992–2000 | Perioperative and long-term mortality Need for chemotherapy Chemotherapy-free survival time Development of severe infections Number of transfusions required | 4 of 28 patients died during postoperative days Long-term survival rates similar in both groups Patients of the control group required more chemotherapy (P = 0.049) No significant differences between groups More units of red blood cells were transfused in CLL patients (P = 0.041). No difference for FFP or PC | Small study One lost to follow-up Interpretation bias: Emergency surgery (4 cases) and increased postoperative mortality |
Ghosh et al. (1999), J Thorac Cardiovasc Surg, Australia [7] Retrospective, single-centre case series study (level 4) | 13 patients (8 CLL and 5 NHL) underwent heart surgery with CPB 1997–1998 | Stay in the ICU Postoperative infection Mortality during hospital stay Mean postoperative hospital stay Course of HMs in the long term Long-term morbidity | 43.4 ± 8.6 h 4 patients developed an infection during hospital stay None 10 ± 1.7 days 3 patients had chemotherapy during follow-up, others had non-HM 2 patients died (1 from disease progression) | Small study Selection bias: 9 of 13 patients were at low risk |
Samuels et al. (1999), Leuk Res, USA [8] Retrospective, single-centre case–control study (level 3b) | 12 patients with CLL who underwent heart surgery with CPB were compared with a control group containing 469 patients without CLL but requiring heart surgery | In-hospital and long-term mortality and morbidity Mean hospital stay Number of transfusions required | 2 patients died in the hospital (17%) 4 patients died of non-cardiac and non-CLL-related causes after a mean period of 7 months 7 patients (58%) with complications, of which 5 with infectious complications (42%) Average 15 days [7;50 days] 10 units of blood cells [1;28] 19 units of platelets [4;65] 6 units of fresh frozen plasma [2;9] | Poor comparability between both groups due to different sizes of groups 5 patients of the study group had another malignancy (bias confusion) No description of the control group |
Finck et al. (1993), Ann Thorac Surg, USA [9] Retrospective case series study (level 4) | 26 patients with CLL underwent heart surgery with CPB | Mean hospital stay Number of transfusion requirements Postoperative complication Comparison of preoperative blood count compared with postoperative infection In-hospital mortality rate Long-term mortality Course of CLL | 10.6 ± 7.7 days 4.7 ± 4.2 per patients [0;17] (2 patients did not require transfusion) 6 of 26 patients developed postoperative infection Only predictive variable: preoperative neutrophil count (P <0.05) 7.7% (2 patients died during hospital stay) 23 patients were followed up, 2 (8.7%) patients died, and 1 patient had progressive leukaemia (5.5 years of follow-up) 23.8% had progression of CLL at 3.4 ± 1.8 years of follow-up | Small-group study Selection bias: more CLL stage 0 |
Author, date, journal and country Study type (level of evidence) . | Patient group . | Outcomes . | Key results . | Study weakness . |
---|---|---|---|---|
Chan et al. (2012), Heart Lung Circ, Australia [2] Retrospective, single-centre case–control study (level 3b) | 83 patients with malignancy (68.7% had a solid organ tumour, and 31.3% had a HM) underwent open heart surgery compared with a control group of 216 patients without a history of cancer 2002–2009 | Hospital mortality Length of stay in the ICU Median hospital length Rate of hospital readmission Blood transfusion Infective complications | No statistically significant difference in mortality (6 in the cancer group and 8 in the non-cancer group). No mortality in the cancer group could be attributable to their malignancy Not significantly different Same in both groups (8 days) Not significantly different Higher in the cancer group, but the subgroup with HM had a very high blood transfusion rate A significantly increased rate of both pneumonia and septicaemia in the group with cancer, but in the subgroup with HM, 11.5% of patients had septicaemia, compared with 7% with solid organ malignancies (P = 0.79) | Small study Selection bias: HM and solid malignancies are 2 different pathologies Data on preoperative chemotherapy for the cancer patient were not collected No long-term data |
Guler et al. (2012), Cardiovasc J Afr, Turkey [3] Retrospective, single-centre case series study | 15 patients with HM (8 CLL, 6 NHL and 1 chronic myelocytic leukaemia) who underwent cardiac surgery | Morbidity 3-year survival rate | 4 postoperative complications with 3 reinterventions for bleeding 80% Cause of death: 3 intracranial bleeding and 2 undetermined | Small study Selection bias: all patients in remission |
Sommer et al. (2011), Eur J Cardiothorac Surg, Germany [4] Retrospective, single-centre case–control study (level 3b) | 56 patients with a history of a haematological malignancies (NHL: n = 29, HD: n = 5, ALL: n = 1, MPS: n = 12 and MGUS: n = 9) underwent open heart surgery compared with the control group containing 142 patients. 3 patients were considered cured of the malignancies, and 3 were in the complete remission 1995–2008 | In-hospital mortality Length of in-hospital time Length of ICU stay Complications Long-term survival Need for transfusion | Elevated in HM patients, without reaching statistical significance (P = 0.7) Not significantly different Not significantly different Trend towards elevated rates of vascular, pulmonary and infectious complications in HM patients, but no significant difference Significant difference, but in the HM subgroup, NHL patients and MPS patients demonstrated an impaired survival when compared with those with MGUS and Hodgkin’s disease Intraoperatively, increased need observed in HM patients (P <0.001) During hospital stay, more units of platelets or erythrocyte concentrates were transfused (non-significant difference) | Selection bias: 3 patients were considered cured 15 received treatment for their haematological disorder at the time of surgery On matching criteria, significant difference in preoperative serum creatinine levels |
Fecher et al. (2004), Eur J Cardiothorac Surg, USA [5] Retrospective, single-centre, case series study (level 4) | 24 HM patients underwent open heart surgery. 2 had off-pump surgery 1996–2002 | Postoperative stay in the ICU and hospital Morbidity, postoperative complications Mortality | Average stay in the ICU 1.6 ± 1.1 days Mean stay 8.2 ± 5.8 days (postoperative stay was significantly longer in patients who had complications: 11 ± 7.1 vs 5.3 ± 1.7 days, P = 0.01) 12 patients (50%) had complications (bleeding, reoperation, stroke, infection and atrial fibrillation) Occurred in older patients (P = 0.06) 4.1% during hospital stay (1 patient died from gastrointestinal bleeding) 83% alive at 3 years. 3 deaths, including 2 due to progression of malignancy | Small study Selection bias: Other HM patients were not offered surgery due to high-operative risk, or advanced-stage disease 2 patients had no CPB (off-pump surgery) |
Potapov et al. (2002), Ann Thorac Surg, Germany [6] Retrospective, single-centre case–control study (level 3b) | 28 patients with CLL who underwent heart surgery with CPB were compared with the control group containing 25 patients with CLL but not requiring heart surgery 1992–2000 | Perioperative and long-term mortality Need for chemotherapy Chemotherapy-free survival time Development of severe infections Number of transfusions required | 4 of 28 patients died during postoperative days Long-term survival rates similar in both groups Patients of the control group required more chemotherapy (P = 0.049) No significant differences between groups More units of red blood cells were transfused in CLL patients (P = 0.041). No difference for FFP or PC | Small study One lost to follow-up Interpretation bias: Emergency surgery (4 cases) and increased postoperative mortality |
Ghosh et al. (1999), J Thorac Cardiovasc Surg, Australia [7] Retrospective, single-centre case series study (level 4) | 13 patients (8 CLL and 5 NHL) underwent heart surgery with CPB 1997–1998 | Stay in the ICU Postoperative infection Mortality during hospital stay Mean postoperative hospital stay Course of HMs in the long term Long-term morbidity | 43.4 ± 8.6 h 4 patients developed an infection during hospital stay None 10 ± 1.7 days 3 patients had chemotherapy during follow-up, others had non-HM 2 patients died (1 from disease progression) | Small study Selection bias: 9 of 13 patients were at low risk |
Samuels et al. (1999), Leuk Res, USA [8] Retrospective, single-centre case–control study (level 3b) | 12 patients with CLL who underwent heart surgery with CPB were compared with a control group containing 469 patients without CLL but requiring heart surgery | In-hospital and long-term mortality and morbidity Mean hospital stay Number of transfusions required | 2 patients died in the hospital (17%) 4 patients died of non-cardiac and non-CLL-related causes after a mean period of 7 months 7 patients (58%) with complications, of which 5 with infectious complications (42%) Average 15 days [7;50 days] 10 units of blood cells [1;28] 19 units of platelets [4;65] 6 units of fresh frozen plasma [2;9] | Poor comparability between both groups due to different sizes of groups 5 patients of the study group had another malignancy (bias confusion) No description of the control group |
Finck et al. (1993), Ann Thorac Surg, USA [9] Retrospective case series study (level 4) | 26 patients with CLL underwent heart surgery with CPB | Mean hospital stay Number of transfusion requirements Postoperative complication Comparison of preoperative blood count compared with postoperative infection In-hospital mortality rate Long-term mortality Course of CLL | 10.6 ± 7.7 days 4.7 ± 4.2 per patients [0;17] (2 patients did not require transfusion) 6 of 26 patients developed postoperative infection Only predictive variable: preoperative neutrophil count (P <0.05) 7.7% (2 patients died during hospital stay) 23 patients were followed up, 2 (8.7%) patients died, and 1 patient had progressive leukaemia (5.5 years of follow-up) 23.8% had progression of CLL at 3.4 ± 1.8 years of follow-up | Small-group study Selection bias: more CLL stage 0 |
CLL: chronic lymphatic leukaemia; NHL: non-Hodgkin’s lymphoma; ICU: intensive care unit; HM: haematological malignancy; CPB: cardiopulmonary bypass; HD: Hodgkin’s disease; ALL: acute lymphatic leukaemia; MGUS: monoclonal gammopathy of undetermined significance; MPS: myeloproliferative syndrome; FFP: fresh frozen plasma; PC: platelets concentrates.
Author, date, journal and country Study type (level of evidence) . | Patient group . | Outcomes . | Key results . | Study weakness . |
---|---|---|---|---|
Chan et al. (2012), Heart Lung Circ, Australia [2] Retrospective, single-centre case–control study (level 3b) | 83 patients with malignancy (68.7% had a solid organ tumour, and 31.3% had a HM) underwent open heart surgery compared with a control group of 216 patients without a history of cancer 2002–2009 | Hospital mortality Length of stay in the ICU Median hospital length Rate of hospital readmission Blood transfusion Infective complications | No statistically significant difference in mortality (6 in the cancer group and 8 in the non-cancer group). No mortality in the cancer group could be attributable to their malignancy Not significantly different Same in both groups (8 days) Not significantly different Higher in the cancer group, but the subgroup with HM had a very high blood transfusion rate A significantly increased rate of both pneumonia and septicaemia in the group with cancer, but in the subgroup with HM, 11.5% of patients had septicaemia, compared with 7% with solid organ malignancies (P = 0.79) | Small study Selection bias: HM and solid malignancies are 2 different pathologies Data on preoperative chemotherapy for the cancer patient were not collected No long-term data |
Guler et al. (2012), Cardiovasc J Afr, Turkey [3] Retrospective, single-centre case series study | 15 patients with HM (8 CLL, 6 NHL and 1 chronic myelocytic leukaemia) who underwent cardiac surgery | Morbidity 3-year survival rate | 4 postoperative complications with 3 reinterventions for bleeding 80% Cause of death: 3 intracranial bleeding and 2 undetermined | Small study Selection bias: all patients in remission |
Sommer et al. (2011), Eur J Cardiothorac Surg, Germany [4] Retrospective, single-centre case–control study (level 3b) | 56 patients with a history of a haematological malignancies (NHL: n = 29, HD: n = 5, ALL: n = 1, MPS: n = 12 and MGUS: n = 9) underwent open heart surgery compared with the control group containing 142 patients. 3 patients were considered cured of the malignancies, and 3 were in the complete remission 1995–2008 | In-hospital mortality Length of in-hospital time Length of ICU stay Complications Long-term survival Need for transfusion | Elevated in HM patients, without reaching statistical significance (P = 0.7) Not significantly different Not significantly different Trend towards elevated rates of vascular, pulmonary and infectious complications in HM patients, but no significant difference Significant difference, but in the HM subgroup, NHL patients and MPS patients demonstrated an impaired survival when compared with those with MGUS and Hodgkin’s disease Intraoperatively, increased need observed in HM patients (P <0.001) During hospital stay, more units of platelets or erythrocyte concentrates were transfused (non-significant difference) | Selection bias: 3 patients were considered cured 15 received treatment for their haematological disorder at the time of surgery On matching criteria, significant difference in preoperative serum creatinine levels |
Fecher et al. (2004), Eur J Cardiothorac Surg, USA [5] Retrospective, single-centre, case series study (level 4) | 24 HM patients underwent open heart surgery. 2 had off-pump surgery 1996–2002 | Postoperative stay in the ICU and hospital Morbidity, postoperative complications Mortality | Average stay in the ICU 1.6 ± 1.1 days Mean stay 8.2 ± 5.8 days (postoperative stay was significantly longer in patients who had complications: 11 ± 7.1 vs 5.3 ± 1.7 days, P = 0.01) 12 patients (50%) had complications (bleeding, reoperation, stroke, infection and atrial fibrillation) Occurred in older patients (P = 0.06) 4.1% during hospital stay (1 patient died from gastrointestinal bleeding) 83% alive at 3 years. 3 deaths, including 2 due to progression of malignancy | Small study Selection bias: Other HM patients were not offered surgery due to high-operative risk, or advanced-stage disease 2 patients had no CPB (off-pump surgery) |
Potapov et al. (2002), Ann Thorac Surg, Germany [6] Retrospective, single-centre case–control study (level 3b) | 28 patients with CLL who underwent heart surgery with CPB were compared with the control group containing 25 patients with CLL but not requiring heart surgery 1992–2000 | Perioperative and long-term mortality Need for chemotherapy Chemotherapy-free survival time Development of severe infections Number of transfusions required | 4 of 28 patients died during postoperative days Long-term survival rates similar in both groups Patients of the control group required more chemotherapy (P = 0.049) No significant differences between groups More units of red blood cells were transfused in CLL patients (P = 0.041). No difference for FFP or PC | Small study One lost to follow-up Interpretation bias: Emergency surgery (4 cases) and increased postoperative mortality |
Ghosh et al. (1999), J Thorac Cardiovasc Surg, Australia [7] Retrospective, single-centre case series study (level 4) | 13 patients (8 CLL and 5 NHL) underwent heart surgery with CPB 1997–1998 | Stay in the ICU Postoperative infection Mortality during hospital stay Mean postoperative hospital stay Course of HMs in the long term Long-term morbidity | 43.4 ± 8.6 h 4 patients developed an infection during hospital stay None 10 ± 1.7 days 3 patients had chemotherapy during follow-up, others had non-HM 2 patients died (1 from disease progression) | Small study Selection bias: 9 of 13 patients were at low risk |
Samuels et al. (1999), Leuk Res, USA [8] Retrospective, single-centre case–control study (level 3b) | 12 patients with CLL who underwent heart surgery with CPB were compared with a control group containing 469 patients without CLL but requiring heart surgery | In-hospital and long-term mortality and morbidity Mean hospital stay Number of transfusions required | 2 patients died in the hospital (17%) 4 patients died of non-cardiac and non-CLL-related causes after a mean period of 7 months 7 patients (58%) with complications, of which 5 with infectious complications (42%) Average 15 days [7;50 days] 10 units of blood cells [1;28] 19 units of platelets [4;65] 6 units of fresh frozen plasma [2;9] | Poor comparability between both groups due to different sizes of groups 5 patients of the study group had another malignancy (bias confusion) No description of the control group |
Finck et al. (1993), Ann Thorac Surg, USA [9] Retrospective case series study (level 4) | 26 patients with CLL underwent heart surgery with CPB | Mean hospital stay Number of transfusion requirements Postoperative complication Comparison of preoperative blood count compared with postoperative infection In-hospital mortality rate Long-term mortality Course of CLL | 10.6 ± 7.7 days 4.7 ± 4.2 per patients [0;17] (2 patients did not require transfusion) 6 of 26 patients developed postoperative infection Only predictive variable: preoperative neutrophil count (P <0.05) 7.7% (2 patients died during hospital stay) 23 patients were followed up, 2 (8.7%) patients died, and 1 patient had progressive leukaemia (5.5 years of follow-up) 23.8% had progression of CLL at 3.4 ± 1.8 years of follow-up | Small-group study Selection bias: more CLL stage 0 |
Author, date, journal and country Study type (level of evidence) . | Patient group . | Outcomes . | Key results . | Study weakness . |
---|---|---|---|---|
Chan et al. (2012), Heart Lung Circ, Australia [2] Retrospective, single-centre case–control study (level 3b) | 83 patients with malignancy (68.7% had a solid organ tumour, and 31.3% had a HM) underwent open heart surgery compared with a control group of 216 patients without a history of cancer 2002–2009 | Hospital mortality Length of stay in the ICU Median hospital length Rate of hospital readmission Blood transfusion Infective complications | No statistically significant difference in mortality (6 in the cancer group and 8 in the non-cancer group). No mortality in the cancer group could be attributable to their malignancy Not significantly different Same in both groups (8 days) Not significantly different Higher in the cancer group, but the subgroup with HM had a very high blood transfusion rate A significantly increased rate of both pneumonia and septicaemia in the group with cancer, but in the subgroup with HM, 11.5% of patients had septicaemia, compared with 7% with solid organ malignancies (P = 0.79) | Small study Selection bias: HM and solid malignancies are 2 different pathologies Data on preoperative chemotherapy for the cancer patient were not collected No long-term data |
Guler et al. (2012), Cardiovasc J Afr, Turkey [3] Retrospective, single-centre case series study | 15 patients with HM (8 CLL, 6 NHL and 1 chronic myelocytic leukaemia) who underwent cardiac surgery | Morbidity 3-year survival rate | 4 postoperative complications with 3 reinterventions for bleeding 80% Cause of death: 3 intracranial bleeding and 2 undetermined | Small study Selection bias: all patients in remission |
Sommer et al. (2011), Eur J Cardiothorac Surg, Germany [4] Retrospective, single-centre case–control study (level 3b) | 56 patients with a history of a haematological malignancies (NHL: n = 29, HD: n = 5, ALL: n = 1, MPS: n = 12 and MGUS: n = 9) underwent open heart surgery compared with the control group containing 142 patients. 3 patients were considered cured of the malignancies, and 3 were in the complete remission 1995–2008 | In-hospital mortality Length of in-hospital time Length of ICU stay Complications Long-term survival Need for transfusion | Elevated in HM patients, without reaching statistical significance (P = 0.7) Not significantly different Not significantly different Trend towards elevated rates of vascular, pulmonary and infectious complications in HM patients, but no significant difference Significant difference, but in the HM subgroup, NHL patients and MPS patients demonstrated an impaired survival when compared with those with MGUS and Hodgkin’s disease Intraoperatively, increased need observed in HM patients (P <0.001) During hospital stay, more units of platelets or erythrocyte concentrates were transfused (non-significant difference) | Selection bias: 3 patients were considered cured 15 received treatment for their haematological disorder at the time of surgery On matching criteria, significant difference in preoperative serum creatinine levels |
Fecher et al. (2004), Eur J Cardiothorac Surg, USA [5] Retrospective, single-centre, case series study (level 4) | 24 HM patients underwent open heart surgery. 2 had off-pump surgery 1996–2002 | Postoperative stay in the ICU and hospital Morbidity, postoperative complications Mortality | Average stay in the ICU 1.6 ± 1.1 days Mean stay 8.2 ± 5.8 days (postoperative stay was significantly longer in patients who had complications: 11 ± 7.1 vs 5.3 ± 1.7 days, P = 0.01) 12 patients (50%) had complications (bleeding, reoperation, stroke, infection and atrial fibrillation) Occurred in older patients (P = 0.06) 4.1% during hospital stay (1 patient died from gastrointestinal bleeding) 83% alive at 3 years. 3 deaths, including 2 due to progression of malignancy | Small study Selection bias: Other HM patients were not offered surgery due to high-operative risk, or advanced-stage disease 2 patients had no CPB (off-pump surgery) |
Potapov et al. (2002), Ann Thorac Surg, Germany [6] Retrospective, single-centre case–control study (level 3b) | 28 patients with CLL who underwent heart surgery with CPB were compared with the control group containing 25 patients with CLL but not requiring heart surgery 1992–2000 | Perioperative and long-term mortality Need for chemotherapy Chemotherapy-free survival time Development of severe infections Number of transfusions required | 4 of 28 patients died during postoperative days Long-term survival rates similar in both groups Patients of the control group required more chemotherapy (P = 0.049) No significant differences between groups More units of red blood cells were transfused in CLL patients (P = 0.041). No difference for FFP or PC | Small study One lost to follow-up Interpretation bias: Emergency surgery (4 cases) and increased postoperative mortality |
Ghosh et al. (1999), J Thorac Cardiovasc Surg, Australia [7] Retrospective, single-centre case series study (level 4) | 13 patients (8 CLL and 5 NHL) underwent heart surgery with CPB 1997–1998 | Stay in the ICU Postoperative infection Mortality during hospital stay Mean postoperative hospital stay Course of HMs in the long term Long-term morbidity | 43.4 ± 8.6 h 4 patients developed an infection during hospital stay None 10 ± 1.7 days 3 patients had chemotherapy during follow-up, others had non-HM 2 patients died (1 from disease progression) | Small study Selection bias: 9 of 13 patients were at low risk |
Samuels et al. (1999), Leuk Res, USA [8] Retrospective, single-centre case–control study (level 3b) | 12 patients with CLL who underwent heart surgery with CPB were compared with a control group containing 469 patients without CLL but requiring heart surgery | In-hospital and long-term mortality and morbidity Mean hospital stay Number of transfusions required | 2 patients died in the hospital (17%) 4 patients died of non-cardiac and non-CLL-related causes after a mean period of 7 months 7 patients (58%) with complications, of which 5 with infectious complications (42%) Average 15 days [7;50 days] 10 units of blood cells [1;28] 19 units of platelets [4;65] 6 units of fresh frozen plasma [2;9] | Poor comparability between both groups due to different sizes of groups 5 patients of the study group had another malignancy (bias confusion) No description of the control group |
Finck et al. (1993), Ann Thorac Surg, USA [9] Retrospective case series study (level 4) | 26 patients with CLL underwent heart surgery with CPB | Mean hospital stay Number of transfusion requirements Postoperative complication Comparison of preoperative blood count compared with postoperative infection In-hospital mortality rate Long-term mortality Course of CLL | 10.6 ± 7.7 days 4.7 ± 4.2 per patients [0;17] (2 patients did not require transfusion) 6 of 26 patients developed postoperative infection Only predictive variable: preoperative neutrophil count (P <0.05) 7.7% (2 patients died during hospital stay) 23 patients were followed up, 2 (8.7%) patients died, and 1 patient had progressive leukaemia (5.5 years of follow-up) 23.8% had progression of CLL at 3.4 ± 1.8 years of follow-up | Small-group study Selection bias: more CLL stage 0 |
CLL: chronic lymphatic leukaemia; NHL: non-Hodgkin’s lymphoma; ICU: intensive care unit; HM: haematological malignancy; CPB: cardiopulmonary bypass; HD: Hodgkin’s disease; ALL: acute lymphatic leukaemia; MGUS: monoclonal gammopathy of undetermined significance; MPS: myeloproliferative syndrome; FFP: fresh frozen plasma; PC: platelets concentrates.
RESULTS
Chan et al. [2] compared 83 patients with malignancy. Of those, 68.7% had a solid organ tumour, whereas 31.3% had an haematological malignancy (HM) and had undergone cardiac surgery with CPB. The study also featured a control group of 216 patients without cancer who had undergone cardiac surgery with CPB. There was no statistically significant difference in hospital mortality. The rates of infective complications and blood transfusion were significantly increased in the cancer group, but the HM patient subgroup had more infective complications and blood transfusions compared with the solid malignancy subgroup.
Guler et al. [3] evaluated 15 HM patients who underwent cardiac surgery. All were in remission. The 3-year survival rate was 80%. All deaths had a non-HM cause.
Sommer et al. [4] studied 142 patients identified as suitable controls for 56 cardiac surgery patients with HMs, of which three were considered cured, three were in complete remission and 15 received treatments for their haematological disorder at the time of surgery. In-hospital mortality was elevated in HM patients, but not to a statistically significant degree. One death was related to fatal cytopenia. Patients with a history of irradiation exhibited elevated rates of respiratory and renal failure; here again, the difference was not statistically significant.
The Fecher et al. study [5] observed a cohort of 24 HM patients who had undergone cardiac surgery. The authors found no significant difference between patients experiencing complications and those without. The survival rate at 3 years was 83%, with two deaths related to the progression of malignancy.
Potapov et al. [6] compared 28 CLL patients who had undergone cardiac surgery with CPB with a control group of 25 CLL patients who had not received surgery. The study concluded that there were no significant differences between the two groups with regard to long-term infection rates. Chemotherapy indications were similar between the two groups during follow-up. There were also no significant differences regarding the need to initiate chemotherapy (and, thus, no difference in the evolution of CLL). Overall survival was similar in both groups.
Ghosh et al. [7] studied a small cohort of 13 HM patients who had undergone cardiac surgery. During the follow-up, three experienced the evolution of malignancy, requiring treatment by chemotherapy. Given that the study sample was very small, no firm conclusions could be drawn.
Samuels et al. [8] investigated 12 CLL patients who had had cardiac surgery with CPB. The authors compared them with a group of non-CLL patients who had had cardiac surgery with CPB during the same period. Two patients died from sepsis during hospitalization, and morbidity during the postoperative stay was linked to infectious complications. Comparison of the two groups was not possible, because the difference in sample sizes was too large. This study was also biased by associated comorbidities, because five patients displayed another neoplasia.
Finck et al. [9] observed 26 CLL patients who had undergone cardiac surgery with CPB. Two patients died during their hospital stay, and two others died later, including one death because of progressive leukaemia. Long-term follow-up of the 23 living patients revealed that five presented with leukaemia progression. Of the 26 patients, six succumbed to postoperative infections. Comparing these six patients with the 20 others, the preoperative absolute neutrophil count (P <0.05) was the only predictive variable.
CLINICAL BOTTOM LINE
Although the evidence is somewhat scarce, we conclude that using CPB surgery does not increase long-term mortality in HM patients. Furthermore, there does not seem to be any risk of malignancy progression to a more aggressive form following cardiac CPB surgery. The routine use of leucocyte depletion filters and cell-saver technique during CPB surgery known to decrease the risk of haematogenous tumour dissemination [10, 11] might explain these results. These studies also show that the overall postoperative morbidity rate was increased, mainly related to postoperative infections and blood transfusions, and already known to increase morbidity and mortality by itself [12–14].
Although the limitations of this study are linked to the low-evidence levels of the papers from which it draws, the authors of this best evidence topic think that haematological malignancies should not be considered a contraindication for cardiac CPB surgery. However, preoperatively, the stage of the malignancy should be evaluated to assess postoperative risk properly.
Conflict of interest: none declared.