Planned Versus Unplanned Reexplorations for Bleeding: A Comparison of Morbidity and Mortality

Abstract

Mediastinal reexplorations for bleeding are associated with significant morbidity and mortality. This study hypothesized that bleeding patients who undergo delayed chest closure after an initial operation experience similar outcomes in comparison with patients who have initial chest closure and later require an unplanned reexploration. This study included all patients in the Johns Hopkins University School of Medicine (Baltimore, MD) institutional Society of Thoracic Surgeons (STS) database who underwent cardiac surgical procedures or thoracic transplantation from 2011 to June 2014, had an intraoperative red blood cell transfusion requirement of 2units or more, and required mediastinal reexploration for bleeding. Reexplorations were classified as planned (temporary chest closure for a planned "second look") or unplanned (initial sternal closure and subsequent reexploration). The two groups were then propensity matched. The primary outcome was 30-day mortality. Secondary outcomes were major complication rates, hospital length of stay, duration of mechanical ventilation, and incidence of postoperative pneumonia and cardiac arrest. Among 3,293 patients, 110 (3.3%) met inclusion criteria and required mediastinal reexploration for bleeding. This group included 62 planned (56%) and 48 unplanned (44%) reexplorations. After propensity matching 30 pairs of patients across 16 variables, operative mortality rates were comparable (37% vs 37%; p=1.00) between unplanned and planned reexploration cohorts. There were no differences in rates of deep sternal wound infection, renal failure, postoperative hospital length of stay, pneumonia, or cardiac arrest, with the exception of a higher rate of prolonged intubation (93% vs 53%; p < 0.01) in the planned reexploration group. Delayed sternal closure is a safe alternative to initial definitive chest closure when concern exists for postoperative bleeding.