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Ann Thorac Surg 1998;66:306-307
© 1998 The Society of Thoracic Surgeons

Correspondence

Prevention of gastrointestinal bleeding after a cardiac operation

Olivier A. Stchepinsky, MDa, Yves V. Theodose, MDa, Jean-Paul D. Huisman, MDa, Yvon M. Gaultier, MDa, Hans C. Maas, MDa

a William Harvey Rehabilitation Center, Le Haut Boscq, 50190 Saint-Martin D’Aubigny, France

To the Editor

Of all patients undergoing cardiac operations with extracorporeal circulation, 0.6% to 2% will have gastrointestinal hemorrhage during their immediate follow-up [1], with a high mortality (25% to 27%) [2]. The bad prognosis of these complications is explained by the difficulties of their diagnosis, the severity of the ulcers (great number, big size, distant localization) and by associated complications (chronic respiratory failure, chronic cardiac failure, arrhythmias, renal failure, anemia before cardiac operation, septic status) [3, 4]. The factors that predispose to these complications are the following: bypass time, associated valvular operation, prolonged hypotension episodes, need for reoperation for bleeding, need for inotrope support, and age 70 years or greater [3].

In the William Harvey Center for cardiac rehabilitation, St Martin d’Aubigny, France, 2,285 patients consecutively entered a study from January 1992 to August 1996. The aim of this study was to compare 1,151 patients (population 1) who underwent a cardiac operation from January 1992 to April 1994 (27 months) without any systematic drug protection for gastric bleeding and 1,134 patients (population 2) from May 1994 to August 1996 (28 months) who received an acid pump inhibitor systematically.

In population 1 we noted 8 bleeding duodenal ulcers (0.69%) in patients hospitalized in an intensive care unit, with confirmation by endoscopy: 2 patients died and 5 were treated before bleeding by histamine H2-receptor antagonist or antiacid drug, none by acid pump inhibitor. The average age was 68 years; duration of the stay before bleeding, 20.3 days; and number of coronary bypass grafts, 2.3. Three patients underwent a valvular operation: 1 aortic, 1 mitral, and 1 associated valvular aortic operation and bypass. Two patients were treated with a single anticoagulant therapy (1 with oral vitamin K inhibitor [fluindione] and 1 with heparin) and 6 patients with a therapy associating anticoagulant and antiinflammatory agents (4 with acetyl salicylic acid). We noted two overdoses of Fluindione (international normalized ratio = 8) and one death.

In population 2 there was only one hemorrhage (0.09%). There were no differences (on average) between the two populations (Table 1) in regard to their sizes, their age, the beginning of their rehabilitation, the time of their operation, the number of coronary bypass grafts for each patient, and the number of valvular prostheses for each patient.


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  		Table 1. Patient Data

 
We compared the risk of gastroduodenal bleeding between the two populations with the {chi}2 test with Yates’ correction and we found a low risk in population 2 with a p value of less than 0.05. Consequently, there is a beneficial effect of acid pump inhibitor for the patients seen after a recent cardiac operation during their cardiac rehabilitation.

References

  1. Ohri S.K., Somasundaram S., Koak Y., et al. The effect of intestinal hypoperfusion on intestinal absorption and permeability during cardiopulmonary bypass. Gastroenterology 1994;106:318-323.[Medline]
  2. Lazar H.L., Hudson H., McCann J., et al. Gastrointestinal complications following cardiac surgery. Cardiovasc Surg 1995;3:341-345.[Medline]
  3. Ohri S., Desai J.B., Gaer J., et al. Intraabdominal complications after cardiopulmonary bypass. Ann Thorac Surg 1991;52:826-831.[Abstract]
  4. Ott M.J., Buchman T.J., Baumgartner W.A. Postoperative abdominal complications in cardiopulmonary bypass patients: a case-controlled study. Ann Thorac Surg 1995;59:1210-1213.[Abstract/Free Full Text]




This Article
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