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Ann Thorac Surg 2007;83:1558-1559
© 2007 The Society of Thoracic Surgeons

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How To Do It

Staged Reoperation: A Novel Strategy for High-Risk Patients

Department of Cardiothoracic Surgery, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas

Accepted for publication March 7, 2006.

^_* Address correspondence to Dr Cohn, Texas Heart Institute, 6770 Bertner, Suite 355, P.O. Box 20345, MC2-114A, Houston, TX 77225 (Email: wcohn{at}heart.thi.tmc.edu).

	Abstract

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A staged reoperative approach may be advantageous in improving surgical outcomes in patients who require multiple reoperations. Patients undergo redo sternotomy and mediastinal dissection only to the extent necessary to perform the indicated procedure. After chest tubes are placed and the sternum and soft tissues are temporarily closed, patients are taken to the postoperative intensive care unit until normothermia is achieved, clotting studies are within normal limits, and chest tube output is nominal. Patients are subsequently returned to the operating room for heparinization, cannulation, and initiation of cardiopulmonary bypass to perform the indicated procedure.

	Introduction

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During the past 30 years, cardiac surgical techniques have been continually refined, resulting in improved patient outcomes. Patients who otherwise would not have been considered for surgery 10 to 20 years ago are now deemed acceptable surgical candidates. Today, in large centers, patients may require multiple reoperations. However, such procedures are associated with an increased risk of postoperative hemorrhage due to the presence of dense adhesions and the need for extensive dissection. The resultant bleeding is accentuated by prolonged cardiopulmonary bypass (CPB) and coagulopathy, which are frequently encountered in complex cardiac operations. Therefore, a staged reoperative approach may be advantageous in improving surgical outcomes in patients who require challenging reoperations.

If a staged approach is indicated, patients undergo redo-sternotomy and mediastinal dissection only to the extent necessary for cannulation and for performing the indicated procedure. However, before systemic heparinization and cannulation, chest tubes are placed and the sternum and soft tissues are temporarily closed. Patients are then taken to the postoperative intensive care unit where hypothermia is corrected and the coagulopathy is addressed. Patients remain there until blood loss stops and blood volume is normalized. Red blood cells and clotting factors are transfused as needed. Patients are subsequently returned to the operating room (usually the following day) for heparinization, cannulation, and initiation of CPB. Herein we describe the successful implementation of this approach in a high-risk surgical patient.

	Technique

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A 55-year-old man went to another medical facility 3 years ago with signs and symptoms of Streptobacillus endocarditis. Despite aggressive antibiotic therapy, he had severe mitral regurgitation develop, which required mitral valve replacement with a 31-mm bileaflet mechanical prosthesis. He did well initially, but returned 5 months later with recurrent prosthetic endocarditis caused by the same organism. He underwent successful replacement of the mechanical valve with a new 31-mm bileaflet mechanical prosthesis. Again, he did well for several months, but he returned 18 months later with progressive congestive heart failure and dyspnea on exertion.

Transesophageal echocardiography revealed severe mitral regurgitation due to a large posterior-lateral periprosthetic leak. Hemodynamic compromise complicated by acute renal failure necessitated inotropic support and intraaortic balloon pump insertion before reoperation. Once stabilized, he was returned to the operating room for a third-time mitral valve replacement. During the operation, the mitral annulus was found to be very fragile; nevertheless, the repeat replacement was accomplished with a third mechanical prosthesis. Despite profound coagulopathy requiring massive transfusion, the patient was successfully weaned from CPB with inotropic support.

Immediately postoperatively, signs and symptoms of severe congestive failure remained, with markedly elevated pulmonary artery pressures and a low cardiac output. Transesophageal echocardiography performed on postoperative day 3 showed a large, persistent periprosthetic leak adjacent to the intraatrial septum and left ventricular outflow tract. The patient was returned to the operating room, where the valve was explanted, the annulus reinforced with strips of Teflon pledgets (Boston Scientific, Framingham, MA), and the valve reimplanted. Once again, he was weaned from CPB with inotropic support and returned to the cardiac intensive care unit. Transesophageal echocardiography showed a well-seated prosthesis with no significant mitral regurgitation.

After a prolonged intensive care unit stay, which was complicated by ventilator dependence and renal failure, the patient was transferred to a rehabilitation facility. Although his initial course was one of gradual but continued improvement, it was short-lived. Within 1 month of discharge, he began experiencing progressive congestive failure and exacerbation of his now chronic renal insufficiency. Repeat transesophageal echocardiography showed return of severe periprosthetic mitral regurgitation. Because the operative risk of a fifth-time mitral valve replacement was prohibitively high, he was transferred to our facility to be evaluated for cardiac transplantation. However, after evaluation for cardiac transplantation, it was our assessment that the staged reoperative approach described above would ameliorate some of the risks associated with the patient’s undergoing a fifth-time MVR. After extensive consultation with the patient and family, we elected to proceed with mitral valve replacement.

The patient was taken to the operating room, where we performed a fifth-time sternotomy using an oscillating saw. As anticipated, there was dense scar tissue throughout the mediastinum, especially in the area of the ascending aorta and superior vena cava. After 2 hours of difficult dissection, mediastinal structures were adequately freed to enable cannulation, institution of CPB, and exposure of the mitral valve. By this point, the patient’s body temperature had reached 34.5°C, and several areas in the mediastinum were continuously oozing blood, including several sites of abraded epicardial fat. Transfusion with platelets, fresh frozen plasma, and packed red blood cells had already commenced. The prospect of initiating systemic anticoagulation and CPB in an already coagulopathic, bleeding patient was unattractive and compounded by the suspicion that the patient would require a complete reconstruction of the mitral annulus, which would, in all likelihood, require prolonged CPB times.

The Argon Beam Coagulator (ConMed Corporation, Utica, NY) was used to control diffuse oozing, and the mediastinum was packed with GelFoam and thrombin. Two chest tubes were placed, and the skin was approximated with running nylon sutures. The patient was transferred to the cardiac surgical recovery unit, where he required 10 additional units of platelets, six additional units of fresh frozen plasma, and 4 units of packed red blood cells. Chest tube drainage was initially brisk (220 cc, 180 cc, and 160 cc for the first, second, and third postoperative hours, respectively). As clotting studies returned to within normal limits and the patient was rewarmed, chest tube output decreased. By morning, drainage was scant and serosanguineous.

The patient was returned to the operating room, where aprotinin was administered and his chest was reopened. After heparin administration, an incision was made in the left groin, and the common femoral artery and vein were dissected to permit cannulation. A second venous cannula was placed in the superior vena cava, which was dissected with difficulty. The ascending aorta was cross clamped, and both antegrade and retrograde blood cardioplegia were administered. The mitral valve prosthesis was readily visualized through a biatrial incision. The previously placed prosthesis was excised, and the annulus was reconstructed using strips of bovine pericardium. A mechanical bileaflet prosthesis (the patient’s fifth) was secured to the neo-annulus with interrupted pledgeted sutures, and the left atrium and right atrium were closed. The patient was weaned from CPB and epinephrine and vasopressin drips were administered. Transesophageal echocardiography showed preserved left ventricular function and a well-seated prosthesis with no perivalvular leak. Despite our staged approach, the patient was coagulopathic and required continued and aggressive factor replacement.

Once reasonable hemostasis was obtained, the patient was returned to the intensive care unit. Postoperative bleeding was moderate (140 cc, 110 cc, and 90 cc for the first, second, and third hours, respectively). By the following morning, bleeding had essentially stopped. He was extubated later that day. He had transient exacerbation of his renal insufficiency develop, but the remainder of his postoperative course was uneventful.

	Comment

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We believe this approach is attractive for a number of reasons. Although staged reoperation requires an additional procedure, patients who undergo complex, multiple reoperations, if subjected to mediastinal dissection and complete repair in a single operation, will often, despite our best efforts, require a subsequent second operation to control postoperative hemorrhage (generally at a time of night that is less convenient). Planning a two-stage operation may reduce the need for emergent reoperation. Moreover, it is probable that this staged approach will result in reduced transfusion requirements, which will favorably affect outcomes because length of intensive care unit and hospital stays and mortality and major morbidity are known to be affected by massive transfusion [1–4].

We have now used this approach in 4 additional patients and have found it to be a valuable adjunct in each case. Although bleeding was not prohibitive at the conclusion of the first stage, allowing mechanical bleeding to resolve before CPB contributed significantly to the final outcome. Staged reoperation is now our approach of choice in patients who require reoperation for left ventricular assist device exchange.

	References

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1. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care Ann Thorac Surg 1990;49:179-186.[Abstract]
2. Unsworth-White MJ, Herriot A, Valencia O, et al. Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality Ann Thorac Surg 1995;59:664-667.[Abstract/Free Full Text]
3. Moore FA, Moore EE, Sauaia A. Blood transfusion: an independent risk factor for postinjury multiple organ failure Arch Surg 1997;132:620-625.[Abstract/Free Full Text]
4. Karkouti K, Wijeysundera DN, Yau TM, et al. The independent association of massive blood loss with mortality in cardiac surgery Transfusion 2004;44:1453-1462.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): William Cohn Igor D. Gregoric Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cohn, W. Articles by Frazier, O.H. Search for Related Content PubMed PubMed Citation Articles by Cohn, W. Articles by Frazier, O.H. Related Collections Cardiac - other