Re-Exploration for Bleeding or Tamponade after Cardiac Surgery: Impact of Timing and Indication on Outcome

Abstract

Objectives Re-exploration after cardiac surgery remains a frequent complication with adverse outcomes. The aim of this study was to evaluate the impact of timing and indication of re-exploration on outcome.

Methods A retrospective, observational study on a cohort of 209 patients, who underwent re-exploration after cardiac surgery between January 2005 and December 2011, was performed. The cohort was matched for age, gender, and procedure with patients who were not re-explored during the same period.

Results The intraoperative and postoperative transfusion requirements were higher in the re-exploration group (p < 0.01). Patients in the re-exploration group had significantly higher incidences of postoperative acute renal injury (10.0 vs. 3.3%), sternal wound (9.1 vs. 2.4%) and pulmonary (13.4 vs. 4.3%) infections, longer ventilation time (22 [range, 14–52] vs. 12 [range, 9–16] hours) and intensive care unit stay (5 [range, 3–7] vs. 2 [range, 2–4] days), and higher mortality rate (9.6 vs. 3.3%). However, the multivariate logistic regression analysis demonstrated that not the re-exploration itself, but the deleterious effects of re-exploration (blood loss and transfusion requirement) were independent risk factors for mortality. Mortality was 5.3% for patients who were re-explored within the first 12 hours and 20.3% for patients who were re-explored after 12 hours (p = 0.003). Mortality was 3.6% for patients with bleeding and 31.4% for patients with cardiac tamponade for indication of re-exploration (p < 0.001).

Conclusions This study suggests that re-exploration after cardiac surgery is associated with increased mortality and morbidity. Patients with delayed re-exploration and suffering from cardiac tamponade have adverse outcome.

Keywords

re-exploration - bleeding - tamponade - cardiac surgery

• References

• 1 Moulton MJ, Creswell LL, Mackey ME, Cox JL, Rosenbloom M. Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg 1996; 111 (5) 1037-1046
• 2 Karthik S, Grayson AD, McCarron EE, Pullan DM, Desmond MJ. Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay. Ann Thorac Surg 2004; 78 (2) 527-534 , discussion 534
• 3 Biancari F, Mikkola R, Heikkinen J, Lahtinen J, Airaksinen KE, Juvonen T. Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2012; 41 (1) 50-55
• 4 Despotis GJ, Filos KS, Zoys TN, Hogue Jr CW, Spitznagel E, Lappas DG. Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients. Anesth Analg 1996; 82 (1) 13-21
• 5 Choong CK, Gerrard C, Goldsmith KA, Dunningham H, Vuylsteke A. Delayed re-exploration for bleeding after coronary artery bypass surgery results in adverse outcomes. Eur J Cardiothorac Surg 2007; 31 (5) 834-838
• 6 Čanádyová J, Zmeko D, Mokráček A. Re-exploration for bleeding or tamponade after cardiac operation. Interact Cardiovasc Thorac Surg 2012; 14 (6) 704-707
• 7 Haneya A, Kobuch R, Kolat P , et al. Impact of re-exploration for bleeding or tamponade on outcome after cardiac surgery. Thorac Cardiovasc Surg 2013; 61-0P99 : 10.1055/s-0032-1332338
• 8 Kirklin JW, Barratt-Boyes BG. Cardiac Surgery, 2nd ed. New York: Wiley; 1993: 224
• 9 Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE. Eur Heart J 2003; 24 (9) 881-882
• 10 Haneya A, Philipp A, Schmid C , et al. Minimised versus conventional cardiopulmonary bypass: outcome of high-risk patients. Eur J Cardiothorac Surg 2009; 36 (5) 844-848
• 11 Haneya A, Philipp A, Von Suesskind-Schwendi M , et al. Impact of minimized extracorporeal circulation on outcome in patients with preoperative anemia undergoing coronary artery bypass surgery. ASAIO J 2013; 59 (3) 269-274
• 12 Woodman RC, Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990; 76 (9) 1680-1697
• 13 Kristensen KL, Rauer LJ, Mortensen PE, Kjeldsen BJ. Reoperation for bleeding in cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 14 (6) 709-713
• 14 Hall TS, Brevetti GR, Skoultchi AJ, Sines JC, Gregory P, Spotnitz AJ. Re-exploration for hemorrhage following open heart surgery differentiation on the causes of bleeding and the impact on patient outcomes. Ann Thorac Cardiovasc Surg 2001; 7 (6) 352-357
• 15 Koch CG, Li L, Duncan AI , et al. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg 2006; 81 (5) 1650-1657
• 16 Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116 (22) 2544-2552
• 17 Scott BH, Seifert FC, Grimson R. Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery. Ann Card Anaesth 2008; 11 (1) 15-19
• 18 Ikäheimo MJ, Huikuri HV, Airaksinen KE , et al. Pericardial effusion after cardiac surgery: incidence, relation to the type of surgery, antithrombotic therapy, and early coronary bypass graft patency. Am Heart J 1988; 116 (1 Pt 1): 97-102
• 19 Pepi M, Muratori M, Barbier P , et al. Pericardial effusion after cardiac surgery: incidence, site, size, and haemodynamic consequences. Br Heart J 1994; 72 (4) 327-331
• 20 ten Tusscher BL, Groeneveld JA, Kamp O, Jansen EK, Beishuizen A, Girbes AR. Predicting outcome of rethoracotomy for suspected pericardial tamponade following cardio-thoracic surgery in the intensive care unit. J Cardiothorac Surg 2011; 6: 79
• 21 Kubota H, Miyata H, Motomura N , et al. Deep sternal wound infection after cardiac surgery. J Cardiothorac Surg 2013; 8: 132