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Ann Thorac Surg 2004;78:527-534
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

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

Shishir Karthik, FRCSa*, Antony D. Grayson, BSb, Emer E. McCarron, FRCSa, D. Mark Pullan, FRCS(C-Th)a, Michael J. Desmond, FRCAc

a Department of Cardiothoracic Surgery, the Cardiothoracic Centre–Liverpool, Liverpool, United Kingdom
b Department of Research and Development, the Cardiothoracic Centre–Liverpool, Liverpool, United Kingdom
c Department of Cardiothoracic Anesthesia, the Cardiothoracic Centre–Liverpool, Liverpool, United Kingdom

Accepted for publication February 20, 2004.

* Address reprint requests to Dr Karthik, Leeds General Infirmary, Great George St, Leeds LS17 8AP, UK
e-mail: suchkats{at}yahoo.com

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.




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