The thrombelastometry parameter CTEXTEM as an independent risk factor for mortality in bleeding patients

TL;DR

Prolonged clotting time (CTEXTEM) measured by rotational thromboelastometry is an independent predictor of 30-day mortality in bleeding patients.

Contribution

CTEXTEM is shown to be an independent risk factor for mortality in bleeding patients across multiple clinical groups.

Findings

CTEXTEM had predictive power for 30-day mortality in cardiothoracic surgery, trauma, and medical bleeding patients.

Prolonged CTEXTEM remained an independent risk predictor for 30-day mortality after adjusting for confounding factors.

Elevated CTEXTEM was associated with significantly higher 30-day mortality rates in all patient groups.

Abstract

Pathologic thromboelastometric results may indicate a coagulation disorder. During bleeding, the prolongation of CTEXTEM (Clotting Time) measured by rotational thromboelastometry (ROTEM) can detect alterations in the extrinsic pathway. However, the significance of a prolonged CTEXTEM for risk stratification in patients with bleeding remains unclear.

A total of 2035 consecutive patients were retrospectively examined between 2014 and 2020 from a bleeding database at Saarland University Hospital. The database includes patients tested with ROTEM during bleeding. The study population was split into three groups: Cardiothoracic surgery with cardiopulmonary bypass (CPB, n = 753), trauma (n = 206) and medical bleeding (n = 1076). The impact of CTEXTEM on 30-day mortality was assessed using C-statistic. Threshold values for CTEXTEM reaching a specificity > 90% for 30-day mortality were selected. Adjusted hazard ratios (adjHR [95% confidence interval]) were calculated with multivariable Cox models.

The C-statistic showed that CTEXTEM (C-statistic for groups 1–3: 0.62, threshold ≥ 110 s (CPB); 0.65, threshold ≥ 98 s (trauma); 0.63, threshold ≥ 99 s (medical bleeding)) had a predictive power for 30-day mortality in all groups. The determined threshold value of CTEXTEM reaching a specificity > 90% remained an independent risk predictor for 30-day mortality even after adjustment for confounding factors (CPB: adjHR 2.5 [1.5–4.2], p < 0.001; trauma: adjHR 3.9 [1.8–8.7], p = 0.001; medical bleeding: adjHR 1.8 [1.4–2.5], p < 0.001). The 30-day mortality rate was significantly increased (CPB: CTEXTEM ≥ 110 s, 26% versus 9%, p < 0.001; trauma: CTEXTEM ≥ 98 s, 41% versus 11%, p < 0.001; medical bleeding: CTEXTEM ≥ 99 s, 41% versus 22%, p < 0.001).

Our results indicate that CTEXTEM-detected alterations in the extrinsic pathway may be an independent predictor of 30-day mortality in patients with bleeding.

The online version contains supplementary material available at 10.1007/s00068-025-03079-z.

Question: Bleeding can result in coagulation disorders. Rotational thromboelastometry can detect alterations in the extrinsic pathway by measuring clotting time (CTEXTEM). The significance of a prolonged CTEXTEM for risk stratification remains unclear.

Findings: 2035 consecutive patients between 2014 and 2020 were retrospectively analysed and threshold value of CTEXTEM remained an independent risk predictor for 30-day mortality.

Meaning: Elevated CTEXTEM could be an independent predictor of 30-day mortality in patients with bleeding.

The online version contains supplementary material available at 10.1007/s00068-025-03079-z.

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