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J Thorac Cardiovasc Surg 1996;111:1037-1046
© 1996 Mosby, Inc.
SURGERY FOR ACQUIRED HEART DISEASE |
From the Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Mo.
Received for publication June 21, 1995 Revisions requested Oct. 24, 1995; revisions received Dec. 28, 1995 Accepted for publication Jan. 3, 1996 Address for reprints: Michael Rosenbloom, MD, Division of Cardiothoracic Surgery, 3108 Queeny Tower, One Barnes Hospital Plaza, St. Louis, MO 63110.
Abstract
Objective: Although previous studies have included early reexploration for bleeding as a risk factor in analyzing adverse outcomes after cardiac operations, reexploration for bleeding has not been systematically examined as a multivariate risk factor for increased morbidity and mortality after cardiac surgery. Furthermore, multivariate predictors of the need for reexploration have not been identified. Accordingly, we performed a retrospective analysis of 6100 patients requiring cardiopulmonary bypass from January 1, 1986, to December 31, 1993.
Methods: Eighty-five patients who had ventricular assist devices were excluded from further analysis because of the prevalence of bleeding and the significant morbidity and mortality associated with placement of a ventricular assist device, unrelated to reexploration. In the remaining 6015 patients, potential adverse outcomes analyzed included operative mortality, mediastinitis, stroke, renal failure, adult respiratory distress syndrome, prolonged mechanical ventilation, sepsis, atrial arrhythmias, and ventricular arrhythmias. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, race, history of reoperation, urgency of the operation, congestive heart failure, prior myocardial infarction, renal failure, diabetes, hypertension, chronic obstructive pulmonary disease or stroke, and the bypass and crossclamp time.
Results: The overall incidence of reexploration was 4.2% (253/6015). Four independent risk factors—increased patient age (p < 0.001), preoperative renal insufficiency (p = 0.02), operation other than coronary bypass (p < 0.001), and prolonged bypass time (p = 0.03)—were identified as predictors of the need for reexploration. The preoperative use of aspirin, heparin, or thrombolytic agents and the bleeding time were not identified as predictors. Reexploration for bleeding was identified as a strong independent risk factor for operative mortality (p = 0.005), renal failure (p < 0.0001), prolonged mechanical ventilation (p < 0.0001), adult respiratory distress syndrome (p = 0.03), sepsis (p< 0.0001), and atrial arrhythmias (p = 0.006).
Conclusion: These data indicate that meticulous attention to surgical hemostasis and possibly application of recently developed modalities designed to facilitate perioperative correction of coagulopathy could improve outcomes after cardiac operations. (J THORAC CARDIOVASC SURG 1996;111:1037-46)
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