Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay.
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.
Karthik
Shishir
S
Department of Cardiothoracic Surgery, The Cardiothoracic Centre-Liverpool, Liverpool, United Kingdom. suchkats@yahoo.com
Grayson
Antony D
AD
McCarron
Emer E
EE
Pullan
D Mark
DM
Desmond
Michael J
MJ
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D015992:Body Mass Index; D002316:Cardiotonic Agents / Q000627:therapeutic use; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D005260:Female; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010027:Osteotomy / Q000706:statistics & numerical data; D019106:Postoperative Hemorrhage / Q000139:chemically induced / Q000601:surgery*; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D013249:Sternum / Q000601:surgery; D016896:Treatment Outcome
D000925:Anticoagulants; D002316:Cardiotonic Agents; D006493:Heparin; D001241:Aspirin