HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Vijayanagar, R. Articles by Weinstein, S. Search for Related Content PubMed PubMed Citation Articles by Vijayanagar, R. Articles by Weinstein, S.

J Thorac Cardiovasc Surg 1994;108:1149-1150
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Effect of previous nontransplant cardiac operations on the outcome of heart transplantation

Heart Transplant Service
Tampa General Hospital
Tampa, FL 33606

To the Editor:

In the January issue of the JOURNAL (1994;107:203-9), Ott and associates reported their experience with heart transplantation in patients with prior heart operations The authors are to be congratulated for their excellent results in these patients. Cardiac retransplantation is a known risk factor of poor patient outcome, and the low 1-year survival observed by the authors accords with those of other centers. More notably, the authors observed that patients with and without previous nontransplant cardiac operations had equivalent operative mortality, 1-year and 5-year survival, and postoperative morbidity. We find their observations intriguing, because redo sternotomies are generally associated with increased risks of mortality and other complications in patients who undergo nontransplant cardiac operations. ^{1, 2}

We recently performed a retrospective analysis to evaluate the effect of prior sternotomies on the outcome of heart transplantation. One hundred sixty-five patients who received primary heart transplantation were divided into three groups: no prior sternotomy (group 1, n = 102); one prior sternotomy (group 2, n = 47); and more than one prior sternotomy (group 3, n = 16). Operative mortality was significantly different among these groups (group 1, 7.8%; group 2, 8.5%; group 3, 31%; p = 0.0148). As a result, the 1-year actuarial survival was also significantly lower in group 3 (group 1, 83%; group 2, 81%; group 3, 52%; p = 0.0311). The association between more than one prior sternotomy and early posttransplantation death was further confirmed with multivariate analysis. Moreover, reexploration for excessive bleeding was more common in patients with prior sternotomies (group 1, 5%; group 2, 11%; group 3, 25%; p = 0.0225). Similarly, more patients with prior sternotomies required transfusion of platelets (group 1, 72%; group 2, 96%; group 3, 100%; p = 0.0003) or more than 2 units of packed red blood cells (group 1, 51%, group 2, 77%, group 3, 94%; p = 0.0003). A trend of more frequent requirement of dialysis for renal failure in patients with previous sternotomies was also observed (group 1, 6%; group 2, 11%; group 3, 19%), although the difference was not statistically significant. Our data thus suggest that previous nontransplant cardiac operations may be associated with more complications after heart transplantation. In particular, patients with more than one prior sternotomy may be at increased risk of early death.

The explanation for the discrepancy between our findings and those of Ott and associates is probably multifactorial. For example, 25% of our patients with more than one prior sternotomy required mechanical circulatory support before transplantation, which might have contributed to their increased operative mortality rate. A major difference between these studies was that we evaluated patients with one prior sternotomy and those with more than one previous sternotomy as two separate groups. It would be interesting to know whether higher operative mortality was observed by Ott's group in their patients with more than one previous cardiac operation. Another stark difference lies in the much lower incidence of postoperative bleeding observed by Ott and coworkers. In fact, only one patient in their series required reexploration for hemorrhage. On the contrary, our experience concurred with that of Lammermeier and colleagues, ³ who also reported a higher incidence of reexploration for posttransplantation bleeding in patients with prior sternotomies than in control patients (25% versus 8.2%, p < 0.01). This discrepancy is likely due to the precautions adopted by Ott and colleagues to prevent postoperative hemorrhage, such as routine use of the Cell Saver (Haemonetics Corp., Braintree, Mass.) and priming with fresh frozen plasma in the bypass circuit for patients with previous cardiac operations.

It is important to recognize the potential adverse impact of prior sternotomies on the outcome of patients undergoing heart transplantation. Meticulous attention to hemostasis during the transplant operation may help curtail postoperative transfusion requirement and the need for reexploration. However, whether such precautions suffice to reduce the operative mortality associated with more than one prior sternotomy must await further evaluation.

References

1. Salomon NW, Page US, Bigelow JC, Krause AH, Okies JE, Metzdorff MT. Reoperative coronary surgery: comparative analysis of 6591 patients undergoing primary bypass and 508 patients undergoing reoperative coronary artery bypass. J THORAC CARDIOVASC SURG 1990;100:250-9.[Abstract]
   
2. Dobell ARC, Jain AR. Catastrophic hemorrhage during redo sternotomy. Ann Thorac Surg 1984;37:273-8.[Abstract]
   
3. Lammermeier DE, Nakatani T, Sweeney MS, et al. Effect of prior cardiac surgery on survival after heart transplantation. Ann Thorac Surg 1989;48:168-72.[Abstract]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Vijayanagar, R. Articles by Weinstein, S. Search for Related Content PubMed PubMed Citation Articles by Vijayanagar, R. Articles by Weinstein, S.