Invited Commentary

Abstract

Surgical reexploration to control blood loss is a serious complication of cardiac surgery and is, per se, a marker of severe postoperative bleeding. Patients who require this procedure invariably experience an increased morbidity and mortality rate. There are many possible explanations for this association. Severe bleeding is a determinant of bad outcomes, either directly (as a factor leading to hemodynamic instability and acute anemia) or indirectly (as a determinant of massive blood transfusions); additionally, surgical reexploration may increase the risk for infections. The study from Fröjd and Jeppsson [1Fröjd V. Jeppsson A. Reexploration for bleeding and its association with mortality after cardiac surgery.Ann Thorac Surg. 2016; 102: 109-117Google Scholar] is confirmative of previous findings, actually showing that surgical reexploration doubles the early and even the medium-long term mortality risk. Even if this information is not new, this study offers some interesting points of discussion. The first one is related to the decision-making process for the surgical reexploration and its timing. As the authors admit, their surgical reexploration rate is considerable (6.0%) as a consequence of their aggressive policy of early reexploration in actively bleeding patients. Certainly, delaying a necessary surgical reexploration means burdening the patient with the weight of ongoing hemodynamic instability, poor systemic oxygen delivery, and transfusions; conversely, an inappropriate surgical approach to patients affected by disorders of the hemostatic system adds risks to a risky clinical condition. This conundrum is still unsolved in the daily clinical practice, even if point-of-care coagulation tests may probably offer a useful piece of information. The second important point is the identification of 2 theoretically modifiable risk factors: preoperative low levels of fibrinogen and dual antiplatelet therapy <5 days before surgery. It is difficult to hypothesize that preoperative fibrinogen supplementation is a viable option (unless in presence of very low, presently not established, fibrinogen levels) as a recent study from the same group has demonstrated [2Jeppsson A. Waldén K. Roman-Emanuel C. Thimour-Bergström L. Karlsson M. Preoperative supplementation with fibrinogen concentrate in cardiac surgery: A randomized controlled study.Br J Anaesth. 2016; 116: 208-214Crossref Scopus (45) Google Scholar]. Conversely, the correct timing of surgery in patients under dual antiplatelet therapy is probably an issue that may benefit from a preoperative assessment of platelet function with one of the existing point-of-care tests [3Ferraris V.A. Saha S.P. Oestreich J.H. et al.2012 update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients having cardiac and noncardiac operations.Ann Thorac Surg. 2012; 94: 1761-1781Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar]. This last option will probably gain a wider popularity once the new generation of antiplatelet agents (acting on the powerful platelet thrombin receptor) will enter the clinical scenario. Reexploration for Bleeding and Its Association With Mortality After Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 102Issue 1PreviewExcessive bleeding after cardiac surgical procedures sometimes necessitates reexploration. This study described the associations between reexploration for bleeding and morbidity and mortality after cardiac surgical procedures. In addition, independent predictors of reexploration were identified. Full-Text PDF