Introduction
Patients and methods
Definitions
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Emergent: done immediately or within 24 h of diagnosis
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urgent: operations done during the same hospital admission
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Group 1: patients explored for massive bleeding (blood loss within 12 h > 2000 ml).
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Group 2: patients with severe and massive bleeding managed conservatively
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Group 3: patients with insignificant, mild or moderate bleeding managed conservatively.
Workup
Management of bleeding
Follow up
Statistical analysis
Results
Prevalence and trends
Perioperative characteristics
Variables | Group 1 (n = 13) | Group 2 (n = 285) | Group 3 (n = 267) | P |
---|---|---|---|---|
Age, median (IQR), y | 51.0 (40.0–57.5) | 55.0 (47.0–62.0) | 54.0 (44.0–61.0) | 0.6 |
Sex, n (%) | ||||
Male | 10 (76.9%) | 228 (80.0%) | 194 (72.7%) | 0.3 |
Female | 3 (23.1%) | 57 (20.0%) | 73 (27.3%) | |
BSA, median (IQR), m2 | 1.8 (1.7–2.0) | 1.8 (1.7–1.9) | 1.8 (1.6–1.9) | 0.5 |
BMI, n (%) | ||||
Under weight | 1 (7.7%) | 93 (32.6%) | 76 (28.5%) | <0.001 |
Average | 6 (46.2%) | 189 (66.3%) | 189 (70.8%) | |
Obese | 6 (46.2%) | 3 (1.1%) | 2 (0.7%) | |
NYHA functional class, n (%) | ||||
I | 0 (0.0%) | 24 (8.4%) | 73 (27.3%) | <0.001 |
II | 7 (53.8%) | 216 (75.8%) | 138 (51.7%) | |
III | 5 (38.5%) | 44 (15.4%) | 49 (18.4%) | |
IV | 1 (7.7%) | 1 (0.4%) | 7 (2.6%) | |
Canadian score, n (%) | ||||
0 | 0 (0.0%) | 67 (23.5%) | 40 (15.0%) | 0.003 |
1 | 4 (30.8%) | 111 (38.9%) | 99 (37.2%) | |
2 | 8 (61.5%) | 55 (19.3%) | 70 (26.3%) | |
3 | 1 (7.7%) | 51 (17.9%) | 52 (19.5%) | |
4 | 0 (0.0%) | 1 (0.4%) | 5 (1.9%) | |
EuroSCORE, median (IQR) | 1.3 1.25–1.6 | 0.97 0.9–1.3 | 1.0 0.9–1.3 | <0.001 |
Ejection fraction, n (%) | ||||
> 50% | 5 (38.5%) | 130 (45.6%) | 140 (52.4%) | 0.2 |
30–50% | 8 (61.5%) | 144 (50.5%) | 122 (45.7%) | |
< 30% | 0 (0.0%) | 11 (3.9%) | 5 (1.9%) | |
Preoperative shock, n (%) | 1 (7.7%) | 8 (2.7%) | 8 (2.9%) | 0.6 |
Atrial fibrillation, n (%) | 1 (7.7%) | 37 (12.3%) | 39 (14.0%) | 0.7 |
Operative priority, n (%) | ||||
Elective | 9 (69.2%) | 268 (94.0%) | 237 (88.8%) | <0.001 |
Urgent | 2 (15.4%) | 14 (4.9%) | 23 (8.6%) | |
Emergent | 2 (15.4%) | 3 (1.1%) | 7 (2.6%) | |
Hypertension, n (%) | 9 (69.2%) | 139 (48.8%) | 132 (49.4%) | 0.3 |
Diabetes mellitus, n (%) | 8 (61.5%) | 141 (49.5%) | 144 (53.9%) | 0.4 |
Smoking, n (%) | 5 (38.5%) | 107 (37.6%) | 94 (35.2%) | 0.9 |
Chronic lung disease, n (%) | 5 (38.5%) | 37 (13.0%) | 16 (6.0%) | <0.001 |
Stroke, n (%) | 0 (0.0%) | 2 (0.7%) | 5 (1.9%) | 0.4 |
PVD, n (%) | 2 (15.4%) | 10 (3.5%) | 8 (3.0%) | 0.06 |
Anemia, n (%) | 3 (23.1%) | 122 (43.1%) | 102 (38.2%) | 0.2 |
Preoperative medications, n (%) | ||||
Aspirin, | 7 (53.8%) | 168 (58.9%) | 134 (50.2%) | 0.1 |
Plavix | 5 (38.5%) | 69 (24.2%) | 67 (25.1%) | |
Warfarin | 1 (7.7%) | 47 (16.9%) | 66 (24.7%) | |
Platelets count, median (IQR), ×109/L | 215.5 (179.5–238.5) | 245.3 (225.0–338.8) | 235.7 (214.5–301.5) | <0.001 |
Serum creatinine, median (IQR), μmol/L | 114.9 (86.0–156.0) | 88.0 (74.0–99.0) | 89.9 (75.0–104.0) | 0.02 |
Based ACT, median (IQR), sec | 121.6 (112.0–132.5) | 128.2 (118.3–139.0) | 127.8 (116.0–137.0) | 0.2 |
Variables | Group 1 (n = 13) | Group 2 (n = 285) | Group 3 (n = 267) | P |
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Type of surgery, n (%): | ||||
CABG | 9 (69.2%) | 224 (78.6%) | 187 (70.0%) | 0.2 |
mitral valve replacement | 2 (15.4%) | 39 (13.7%) | 42 (15.8%) | |
combined operation | 0 (0.0%) | 2 (0.7%) | 6 (2.2%) | |
Others | 2 (15.4%) | 20 (7.0%) | 32 (12.0%) | |
CBP time, median (IQR), min | 105.5 (78.5–140.8) | 108.5 (84.8–139.0) | 109.5 (84.0–150.8) | 0.3 |
Clamping time, median (IQR), min | 61.5 (45.5–99.0) | 65.0 (49.8–84.3) | 64.0 (50.0–89.0) | 0.4 |
Mechanical assist devices (ECMO, IAB), n (%): | 2 (15.4%) | 9 (3.2%) | 5 (1.9%) | 0.01 |
Lowest HCT, Mean ± SD | 17.8 ± 3.4 | 17.5 ± 3.0 | 17.6 ± 3.2 | 0.8 |
ACT after protamine, Mean ± SD, sec | 131.5 ± 12.6 | 132.3 ± 29.2 | 130.7 ± 30.6 | 0.8 |
Lowest temperature during CPB, Mean ± SD | 28.0 ± 3.2 | 29.2 ± 2.4 | 29.2 ± 2.6 | 0.2 |
Drainage, median (IQR), ml | 1735.0 (1352.5–2201.3) | 800.0 (650.0–1000.0) | 690.0 (460.0–860.0) | <0.001 |
Intraoperative transfusion of Packed RBCs, median (IQR), units | 2.0 (2.0–3.0) | 2.0 (1.0–3.0) | 2.0 (1.0–2.0) | <0.001 |
Cause of reexploration | Tamponade | 5 |
Cardiac arrest | 2 | |
Massive bleeding | 6 | |
Time from primary operation to reexploration, Median (IQR), hours | 23 (9–192) | |
Site of bleeding | Proximal anastomosis | 2 |
Distal anastomosis | 2 | |
Atriotomy | 2 | |
LIMA | 1 | |
Chest wall (mammary bed) | 2 | |
RV | 1 | |
IVC | 1 | |
Unidentified (diffuse bleeding) | 2 | |
Outcome | Survived | 11 |
Died | 2 |
Predictors of reexploration
Variable | SE | Wald | Odds Ratio (95% Confidence interval) | P |
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BMI | 0.14 | 29.7 | 2.1 (1.6–2.8) | 0.003 |
NYHA functional class | 0.5 | 3.2 | 2.3 (0.9–5.7) | 0.07 |
EuroSCORE | 0.7 | 6.4 | 5.5 (1.5–20.6) | 0.006 |
Operative priority (urgent/emergent) | 0.8 | 11.6 | 2.9 (1.6–14.8) | 0.02 |
Chronic lung diseases | 0.9 | 1.9 | 3.5 (0.6–20.8) | 0.1 |
Platelets count | 0.01 | 5.6 | 0.98 (0.96–0.99) | 0.01 |
Serum creatinine | 0.14 | 29.7 | 2.1 (1.6–2.8) | 0.003 |
Impact of reexploration on outcome
Variables | Group 1 (n = 13) | Group 2 (n = 285) | Group 3 (n = 267) | P |
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Postoperative transfusion of Packed RBCs, median (IQR), unit | 11.0 (5.0–13.0) | 2.0 (2.0–4.0) | 1.0 (0.0–2.0) | <0.001 |
Fresh frozen plasma, median (IQR), unit | 12.0 (9.5–15.0) | 4.0 (4.0–6.0) | 3.0 (2.0–4.0) | <0.001 |
Platelets, median (IQR), unit | 9.1 (6.0–12.0) | 6.2 (4.0–6.0) | 3.3 (0.0–2.0) | <0.001 |
Serum lactate, median (IQR), unit mmol/L | 3.0 (2.0–3.0) | 2.0 (1.0–2.0) | 2.0 (1.0–2.0) | <0.001 |
ACT, median (IQR), sec | 120.0 (117.3–143.8) | 117.0 (110.0–122.3) | 112.0 (101.5–120.0) | <0.001 |
PT, median (IQR), sec | 12.0 (10.3–14.3) | 12.0 (11.0–12.2) | 12.0 (11.0–18.0) | <0.001 |
Postoperative EF | 37.5 (31.3–45.0) | 40.0 (35.0–50.0) | 45.0 (40.0–55.0) | <0.001 |
Serum creatinine, median (IQR), μmol/L | 116.0 (83.5–191.0) | 99.0 (85.0–120.0) | 91.0 (84.0–117.0) | 0.09 |
Ventilator hours, median (IQR), hrs | 35.5 (24.5–197.3) | 14.0 (8.0–20.0) | 14.0 (8.0–24.0) | <0.001 |
ICU stay, median (IQR), days | 3.5 (2.3–6.8) | 2.0 (2.0–3.3) | 3.0(2.0–24.0) | <0.001 |
Hospital stay, median (IQR), days | 13.0 (11.5–17.5) | 7.0 (7.0–8.0) | 7.0 (6.0–8.0) | <0.001 |
Deep sternal wound infection, n (%) | 2 (15.4%) | 12 (4.2%) | 6 (2.2%) | 0.03 |
Mortality, n (%) | 2 (15.4%) | 13 (4.6%) | 1 (0.4%) | <0.001 |
Risk factors of adverse outcome
Variable | SE | Wald | Odds Ratio (95% Confidence interval) | P |
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Requirement for Packed RBCs transfusion | 0.3 | 10.7 | 2.3 (1.4–3.8) | 0.001 |
Requirement for Fresh frozen plasma | 0.3 | 8.2 | 0.4 (0.2–0.7) | 0.004 |
Serum lactate | 0.3 | 11.1 | 2.9 (1.5–5.4) | 0.001 |
Platelets | 0.3 | 3.5 | 1.6 (1.0–2.7) | 0.06 |
Serum creatinine | 0.03 | 0.004 | 1.0 (0.9–1.0) | 0.9 |
Ventilator hours | 0.001 | 5.3 | 1.1 (1.1–1.1) | 0.01 |
ICU stay | 0.04 | 5.5 | 1.1 (1.0–1.2) | 0.01 |
Hospital stay | 0.01 | 3.8 | 0.98 (0.96–0.99) | 0.004 |