Original article: cardiovascular
Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay

https://doi.org/10.1016/j.athoracsur.2004.02.088Get rights and content

Abstract

Background

We aimed to identify risk factors for reexploration for bleeding after surgical revascularization in our practice. We also looked at the impact of resternotomy and the effect of time delay on mortality and other in-hospital outcomes.

Methods

In all, 2,898 consecutive patients undergoing coronary artery bypass grafting between April 1999 and March 2002 were retrospectively analyzed from our cardiac surgery registry. Multivariate logistic regression analysis was used to identify risk factors for reexploration for bleeding. To assess the effect of preoperative aspirin and heparin, reexploration patients were propensity matched with unique patients not requiring reexploration. We carried out a casenote review to ascertain the timing and causes for bleeding in patients undergoing resternotomy.

Results

Eighty-nine patients (3.1%) underwent reexploration for bleeding. Multivariate analysis revealed smaller body mass index (p = 0.003), nonelective surgery (p = 0.022), 5 or more distal anastomoses (p = 0.035), and increased age (p = 0.041) to have increased risks. Propensity-matched analysis showed that preoperative use of aspirin (p = 0.004) and heparin (p = 0.001) were associated with increased risk in the on-pump coronary surgery group only. Patients requiring resternotomy had a significantly greater need for inotropic agents (p < 0.001), and longer intensive care unit stay (p < 0.001) and postoperative stay (p < 0.001) than their propensity-matched controls. However, there was no significant difference in the mortality rate. Adverse outcomes were significantly higher when patients waited more than 12 hours after return to the intensive care unit for resternotomy.

Conclusions

Risk factors for reexploration for bleeding after coronary artery bypass grafting include older age, smaller body mass index, nonelective cases, and 5 or more distal anastomoses. Preoperative aspirin and heparin were risk factors for the on-pump coronary artery surgery group. Patients needing reexploration are at higher risk of complications if the time to reexploration is prolonged. Policies that promote early return to the operating theater for reexploration should be encouraged.

Section snippets

Patient population and data

In all 2,898 consecutive patients undergoing CABG between April 1, 1999, and March 31, 2002, at the Cardiothoracic Center-Liverpool had data collected prospectively into our cardiac surgery registry. All patients undergoing CABG at our center, irrespective of the use of CPB, are fully heparinized, namely, they receive 300 U per kilogram body weight of heparin, irrespective of whether they are having off-pump or on-pump surgery. Patients undergoing CABG along with heart valve repair or

Incidence

Overall, of the 2,898 patients in the study, 89 (3.1%) patients required reexploration for bleeding after isolated CABG. The incidence of reexploration has increased from 2.9% in April 1999% to 4.3% in March 2002 (p < 0.001).

Of the 89 patients reexplored, the primary indication for reexploration was bleeding (n = 75). Other indications included 10 cases of tamponade, 2 cardiac arrests with bleeding, and 2 others. The major sites of bleeding were as follows: 42 graft/anastomoses, 23 sternal/left

Comment

Of 2,898 patients undergoing CABG in our study, 89 patients (3.1%) required resternotomy for bleeding. This figure compares quite well with incidence of 2% to 6% mentioned in the literature 1, 2, 3. We did notice an increase in the incidence of reexploration for bleeding from 2.9%, 1999 to 2000, to 4.3%, 2001 to 2002. This is different from the experience of Munoz and coworkers [14], who noted a decline in the rates of reexploration of 3.6% from 1992 to 1994, to 2.0% from 1995 to 1997.

An

Acknowledgements

We would like to acknowledge the cooperation given to us by all the Consultant Cardiac Surgeons at the Cardiothoracic Center-Liverpool: Mr John A. C. Chalmers, Mr Walid C. Dihmis, Mr Brian M. Fabri, Ms Elaine M. Griffiths, Mr Neeraj K. Mediratta, Mr D. Mark Pullan, and Mr Abbas Rashid. We would also like to thank Janet Deane, who maintains the quality and ensures completeness of data collected in our Cardiac Surgery Registry.

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Copyright © 2004 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.