Incidence Of Re-exploration For Bleeding Research Articles

A modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement.

One of the crucial aspects of ascending aorta replacement is to achieve hemostasis of the proximal anastomosis. This study aimed to describe a modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement and compare its operative outcomes with the conventional prosthesis eversion technique. We conducted a retrospective analysis of all consecutive patients who had ascending aortic aneurysm and underwent ascending aorta replacement with the modified or conventional prosthesis eversion technique between January 2019 and December 2022 in our center. A total of 108 patients were included: 55 in the modified group and 53 in the conventional group. The durations of cardiopulmonary bypass, aortic cross-clamping and total operation in the conventional group were longer than those in the modified group. Furthermore, perioperative blood loss and the incidence of re-exploration for bleeding were significantly lower in the modified group. Accordingly, patients in the conventional group accepted more blood transfusion. The modified group had a shorter duration in intensive care unit (ICU) and hospital, and lower total hospitalization costs than those in the conventional group. The modified prosthesis eversion technique is an effective alternative for proximal anastomosis in ascending aorta replacement, with less blood loss, shorter operation time, and lower rate of postoperative complications compared with the conventional technique.

Sutureless valves versus aortic root enlargement for aortic valve replacement in small aortic annulus: A systematic review and pooled analysis.

Very few studies provide direct comparisons between aortic root enlargement and sutureless valve implantation in patients with a small aortic annulus who underwent aortic valve replacement. This study aims to provide comparative outcomes between the two in such a subset of patients, through a systematic review and pool analysis. The PubMed, Scopus and Embase databases were searched using the appropriate terms. The data from original articles mentioning aortic root enlargement and sutureless valves in a single or comparative study with another group of patients with a small aortic annulus were pooled and analyzed using descriptive statistics. Both cardiopulmonary bypass (68.4 vs. 125.03 min, p < 0.001) and aortic cross-clamp times were significantly shorter in the sutureless valve group, along with a concomitantly higher number of minimally invasive surgeries. The incidence of permanent pacemaker implantation (9.76% vs. 3.16%, p < 0.00001), patient prosthesis mis-match and paravalvular leak was significantly higher in the sutureless valve group. In comparison, the incidence of re-exploration for bleeding was higher in the aortic root enlargement group (5.27% vs. 3.16%, p < 0.02). The two groups had no differences in the duration of hospital stays or mortality. Sutureless valves demonstrated a comparable hemodynamic outcome with aortic root enlargement in patients with a small aortic annulus. In addition to this, it greatly facilitated minimally invasive surgery. However, the high incidence of pacemaker implantation is still a concern for the widespread recommendation of sutureless valves, especially in young patients with a small aortic annulus.

Aplicación de un programa de ahorro de sangre en cirugía cardiaca: análisis y resultados

Introduction and objectivePreoperative anemia, reexploration for bleeding and need for transfusion are common problems in patients undergoing mayor cardiac surgery and are associated with an increase morbidity and mortality. The objective of the present report is to evaluate our surgical results focusing on hematological parameters after the implementation of a Patient Blood Management (PBM) program. MethodsBetween March 2021 and May 2022, we have consecutively operated on 104 mayor cardiac surgery patients with the PBM program. The mean patient age was 65±11 years, 66% of the patients were male, 21% had a EuroScore II>5, 24% had preoperative anemia, and 2,8% were Jehovah's Witnesses who refused transfusions. The 19,2% of the procedures were off-pump coronary artery bypass grafting, 8,7% endocarditis, 10,6% redo operations, 2,9% acute aortic syndromes, and 34% urgent or emergent cases. ResultsThe incidence of reexploration for bleeding was 1,9% and the perioperative transfusion rate was 25%; 87,5% of the patients operated on electively and 90,5% of the isolated coronary patients did not receive blood components. The mean number of red blood cell concentrates (total transfusion index), fresh frozen plasma, and pooled platelets transfused per patient was 0.47, 0.16, and 0.07, respectively. ConclusionsThe PBM has allowed us to achieve our quality objectives in terms of reintervention for bleeding and perioperative transfusion rate.

Association between frailty and long-term outcomes among patients undergoing thoracic aortic surgery via median sternotomy.

Preoperative assessment of frailty is important for predicting postoperative outcomes. This study investigated the association between frailty and late outcomes among patients who underwent thoracic aortic surgery via median sternotomy. A total of 1010 patients underwent thoracic aortic surgery via median sternotomy between April 2008 and December 2016. Patients < 65years of age, those who underwent urgent or emergent surgery, and those with incomplete data were excluded; as such, 374 patients were ultimately included in the present study. Frailty was evaluated using an index comprising history of dementia, body mass index < 18.5kg/m2, and hypoalbuminemia. A frailty score from 0 to 3 was determined by assigning 1 point for each criterion met. Frailty was defined as a score ≥ 1. Patients were categorized into of 2 groups: frail (n = 52) and non-frail (n = 322). The mean follow-up was 6.1 ± 3.1years. Overall in-hospital mortality did not differ between the frail and non-frail groups. However, the incidence of re-exploration for bleeding and discharge to a health care facility was higher in the frail group than in the non-frail group. Multivariable analysis revealed that preoperative frailty was an independent predictor of late mortality during follow-up [hazard ratio 3.71 (95% confidence interval 2.16-6.37); P < 0.001]. Preoperative frailty was associated with late mortality after thoracic aortic surgery. Assessment of preoperative frailty using a simple frailty index may be useful in the decision-making process for elderly patients.

Mechanical Circulatory Support During Lung Transplantation: Choices, Outcomes and Impact of Duration

<h3>Purpose</h3> Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) has recently replaced cardiopulmonary bypass (CPB) as the method of choice for mechanical circulatory support during lung transplantation (LTx). The aim of this study was to compare the outcomes of using ECMO versus CPB and examine the impact of its duration in a contemporary LTx cohort. <h3>Methods</h3> Between January 2017, and January 2020, 379 LTx were performed at our center. CPB was utilized in 111 and VA ECMO in 33 cases (unmatched cohort). After exclusion of patients who underwent concomitant cardiac procedures or retransplantation (all were in CPB group), the 33 VA ECMO patients were matched to CPB patients with a 1:2 ratio based on primary diagnosis, LTx type (bilateral or single), age, lung allocation score, body mass index, donor type (brain death or cardiac death), and duration of mechanical circulatory support. <h3>Results</h3> In the unmatched cohort, CPB group had a significantly higher incidence of re-exploration for bleeding and hospital mortality compared to ECMO group (15.3% vs 3.0%, <b>p = .047</b>; 10.8% vs 0%, <b>p = .038</b>, respectively). There were no statistically significant differences between CPB and ECMO groups in ICU stay, hospital stay, incidence of primary graft dysfunction (PGD) at 72 hours, postoperative tracheostomy, post-transplant ECMO use, re-admission, or 1-year survival. In the matched cohort, the differences between CPB and ECMO groups in both incidence of re-exploration for bleeding or hospital mortality were found to be statistically insignificant (13.6% vs 3.0%, <i>p</i> = .092; 7.6% vs 0%, <i>p</i> = .125, respectively). The differences between both groups in the other outcome endpoints remained insignificant. In the CPB group, patients with higher grades of PGD at 72 hours had significantly longer duration of CPB (PGD 0, 1, 2, 3 median 217, 209, 250, 289 minutes, <b>p = .014</b>, respectively). In the ECMO group, there were no differences in duration of ECMO between patients with different PGD grades. <h3>Conclusion</h3> Despite having a significantly higher incidence of re-exploration for bleeding and hospital mortality in CPB group in the unmatched cohort, there were no statistically significant differences between the two groups in the studied outcomes in the matched cohort, although there were strong trends. Notably, longer CPB time was associated with higher PGD grades whereas time on ECMO was not associated with PGD grades.

Impact of Non-Valvular Non-Coronary Concomitant Procedures on Outcomes of Surgical Aortic Valve Replacement in Intermediate Risk Patients.

Introduction: advanced age and concomitant procedures could increase the risk of perioperative complications during surgical aortic valve replacement (SAVR). We aimed to evaluate results of elderly patients undergoing SAVR and evaluate the impact of concomitant non-valvular, non-coronary procedures on the outcomes. Methods: A retrospective single-centre study, evaluating 464 elderly patients (mean age = 75.6 ± 4 years) undergoing either isolated-SAVR (I-SAVR = 211) or combined-SAVR (C-SAVR = 253) between 01/2007 and 12/2017. Combined-SAVR involved non-valvular, non-coronary procedures. Study endpoints are postoperative results concerning the VARC-II criteria, valve dysfunction, long-term freedom from redo-AVR and survival. Results: males were 52.8%. Patients had an intermediate risk profile (mean EuroSCORE-II (%) 5.2 ± 5). Postoperative results reported no significant differences in incidence of re-exploration for bleeding (6.6% vs. 6.7%, p = 1.0), stroke (0.9% vs. 0.4%, p = 0.59), dialysis (6.2% vs. 9.5%, p = 0.23) and pacemaker implantation (3.3% vs. 2.8%, p = 0.79) between I-SAVR and C-SAVR groups. Thirty-day (2.4% vs. 7.1% p = 0.03), one-year (5.7% vs. 13.8%, p = 0.003) and overall mortality (24.6% vs. 37.5%, p = 0.002) were lower in the isolated-SAVR group. Re-AVR was indicated in 1.7% of patients due to endocarditis. Conclusions: SAVR in elderly patients offers good outcomes with increased life quality and rare re-operation for structural valvular deterioration. Mortality rates were significantly higher when SAVR was combined with another “non-valvular, non-coronary” procedure.

Thrombotic microangiopathy following aortic surgery with hypothermic circulatory arrest: a single-centre experience of an underestimated cause of acute renal failure.

Acute kidney injury (AKI) following surgery involving the heart-lung-machine is associated with high mortality and morbidity. In addition to the known mechanisms, thrombotic microangiopathy (TMA) triggered by the dysregulation of complement activation was recently described as another pathophysiological pathway for AKI following aortic surgery. The aim of this retrospective study was to analyse incidence, predictors and outcome in these patients. Between January 2018 and September 2019, consecutive patients undergoing aortic surgery requiring hypothermic circulatory arrest were retrospectively reviewed. If suspected, diagnostic algorithm was initiated to identify a TMA and its risk factors, and postoperative outcome parameters were comparably investigated. The incidence of TMA in the analysed cohort (n = 247) was 4.5%. Multivariable logistic regression indicated female gender {odds ratio (OR) 4.905 [95% confidence interval (CI) 1.234-19.495], P = 0.024} and aortic valve replacement [OR 8.886 (95% CI 1.030-76.660), P = 0.047] as independent predictors of TMA, while cardiopulmonary bypass, X-clamp and hypothermic circulatory arrest times showed no statistically significance. TMA resulted in postoperative AKI (82%), neurological disorders (73%) and thrombocytopaenia [31 (interquartile range 25-42) G/l], corresponding to the diagnostic criteria. Operative mortality and morbidity were equal to patients without postoperative TMA, despite a higher incidence of re-exploration for bleeding (27 vs 6%; P = 0.027). After 6 months, survival, laboratory parameters and need for dialysis were comparable between the groups. TMA is a potential differential diagnosis for the cause of AKI following aortic surgery regardless of the hypothermic circulatory arrest time. Timely diagnosis and appropriate treatment resulted in a comparable outcome concerning mortality and renal function.

Inpatient Lung Transplant Evaluation Is Associated With Increased Risk of Morbidity, Mortality, and Cost of Care After Transplant.

How does the setting of lung transplant evaluation relate to perioperative outcomes, short-term postoperative outcomes, and healthcare costs accrued after transplant? We reviewed the records of patients who underwent primary, bilateral lung transplantation at our center between January 1, 2014 and May 31, 2016. Patient evaluation setting was categorized as inpatient, outpatient, or combined. Demographics, clinical characteristics, and cost of care were assessed. The study included 207 patients: 40 (19.3%) evaluated as inpatients, 146 (70.5%) as outpatients, and 21 (10.1%) as combined. Inpatients had the highest mean lung allocation scores (71.2 vs 49.7 [combined] and 40.8 [outpatient]; P < 0.001), lowest functional status at listing (P < 0.001), highest number of blood products used during surgery (P < 0.001), highest incidence of re-exploration for bleeding (P = 0.006), and longest posttransplant hospital stays (median, 35 vs 15 days [combined] and 12 days [outpatient]; P < 0.001). One-year survival trended lower for inpatients (log-rank, P = 0.056). Inpatient evaluations had the highest total, variable, and fixed costs of posttransplant care (P < 0.001). Inpatient lung transplant evaluation was associated with longer hospital stays, higher perioperative morbidity, and lower 1-year survival. Partial or complete inpatient evaluation was associated with a higher cost of care posttransplant.

Bleeding complications after dual antiplatelet therapy with ticagrelor versus dual antiplatelet therapy with clopidogrel-a propensity-matched comparative study of two antiplatelet regimes in off-pump coronary artery bypass grafting.

Ticagrelor combined with aspirin had shown better saphenous vein graft patency than aspirin with clopidogrel after off-pump coronary artery bypass grafting. However, the safety of this drug in regard to bleeding complications remains unknown. The aim of our study was to assess the bleeding complications of dual antiplatelet therapy with aspirin and ticagrelor compared with aspirin and clopidogrel within the first 3months after off-pump surgery. Three hundred eighty-two consecutive patients who were prescribed aspirin with ticagrelor (ticagrelor group) were compared with 660 patients who received aspirin and clopidogrel (clopidogrel group). After propensity matching, 144 patients in each group were compared for bleeding events and major adverse cardiac and cerebral events. Major bleeding was defined as composite outcome of re-exploration for bleeding, any fatal bleeding, intracranial bleeding, and any bleeding requiring hospitalization. Patients in the ticagrelor group had more incidence of re-exploration for bleeding (p=0.042), pericardial effusion requiring drainage (p=0.007), readmissions (p < 0.01), gastrointestinal bleeding (p=0.01), and major bleeding (5.8% vs. 2.1%, p< 0.01, OR 2.8 (1.43-5.58)). After propensity analysis, gastrointestinal bleed (p=0.024), major bleeding (7.6% vs.1.4%, p < 0.001, OR 5.8 (1.28-26.97)), length of ICU stay (p=0.039), and readmissions (p=0.003, OR 11.83 (1.51-92.86)) were more in the ticagrelor group. Major adverse cardiac and cerebral events were similar between the groups. Dual antiplatelet therapy with aspirin and ticagrelor increased gastrointestinal bleeding events, major bleeding events, and readmission rates compared with aspirin and clopidogrel after off-pump coronary artery bypass grafting.

EP14 FLUID MANAGEMENT PROTOCOL APPLICATION WITH COLLOIDS ABOLITION REDUCES RE-EXPLORATION FOR BLEEDING AND BLOOD PRODUCTS USE IN CARDIAC SURGERY PATIENTS

Abstract Background and aim: Colloids administration has been associated with post-operative acute kidney injury and bleeding. Aim of the study is to evaluate if the incidence of re-exploration for bleeding was modified by application of perioperative fluid management protocol with careful balanced crystalloids infusion and colloids administration abolition. Methods: We retrospectively analysed data collected in the Institutional database. 784 patients were considered in the analysis. 459 patients (Group A) underwent cardiac operations before perioperative fluid management protocol was strictly applied and 325 patients (Group B) underwent cardiac operations after protocol application. Results: No differences were found for pre-operative characteristics except for hypertension and NYHA class (higher in A Group). Intraoperative variables were similar in both groups. No differences were found between groups for post operative complications, except for the incidence of re-exploration for bleeding (4.3% vs 1.5%; p:0.02), time on mechanical ventilation (31.3 vs 13.4 hours; p:0.006), sternal wound infection (3.9 vs 0.3%; p:0.02), post-operative pneumonia incidence (2.9 vs 0%; p:0.01), mean RBC units transfused (3.8 vs 2.6 Units; p:0.03) and numbers of patients receiving fresh frozen plasma transfusions (13.7% vs 3.7%; p:0.02), which were higher in Group A. Conclusions: Fluid management protocol application and colloids avoidance significantly reduce re-exploration for bleeding and post-operative blood products use after cardiac surgery.

Re-exploration for bleeding associated with increased incidence of the need for reintervention after coronary artery bypass graft surgery.

Re-exploration for bleeding after cardiac surgery increases the risk of other severe postoperative complications and early mortality. Patients re-explored for bleeding after coronary artery bypass grafting are potentially subject to threats to graft patency. Our goal was to assess the effects of re-exploration for bleeding regarding the incidence of coronary angiographies, the need for coronary reintervention and mortality during long-term follow-up. Within the SWEDEHEART registry, all isolated coronary artery bypass operations with a single internal mammary artery and saphenous vein graft in patients aged 40-80 between the years 2005 and 2015 were identified. Incidences of coronary angiography and the subsequent need for coronary reintervention were recorded, and multivariable adjusted hazard ratios (HRs) were calculated. The study cohort consisted of 27957 patients, and the mean follow-up time was 6.5 ± 3.1 years. The incidence of re-exploration for bleeding was 3.8% (n = 1071). The cumulative incidence [95% confidence interval (CI)] of a clinically occurring coronary angiography within 1 year after surgery was 7.8% (6.3-9.7) in re-explored and 4.8% (4.6-5.1) in non-re-explored patients, and the adjusted HR was 1.64 (1.31-2.06), (P < 0.001). The cumulative incidence of the need for coronary reintervention within 1 year (95% CI) was 4.9% (3.7-6.4) in re-explored and 2.6% (2.4-2.8) in non-re-explored patients, and the adjusted HR was 1.91 (1.43-2.56). No difference in incidence or hazard ratio was observed beyond the first year. Mortality rate was increased within but not beyond 90 days after surgery. Re-exploration for bleeding is associated with an increased risk for the need of repeat coronary reintervention during the first year after coronary artery bypass surgery.

Hybrid Coronary Revascularization Versus On-Pump Coronary Artery Bypass Grafting

Hybrid coronary revascularization (HCR) is an evolving coronary revascularization strategy for the treatment of multivessel coronary artery disease. We provide a comparative analysis to conventional on-pump coronary artery bypass graft surgery (CABG) with long-term follow-up. We included all double on-pump CABG (n= 682) and HCR (147 robotic-assisted minimally invasive bypass grafts of the left internal thoracic artery to the left anterior descending coronary artery and percutaneous coronary intervention to one of the non-left anterior descending coronary artery vessels) performed in our institution between March 2004 and November 2015. We performed an adjusted analysis using inverse-probability weighting based on the propensity score of receiving either on-pump CABG or HCR. In the adjusted analysis, there was no statistically significant difference in the incidence of reexploration for bleeding, perioperative myocardial infarction, stroke, need for hemodialysis, blood transfusion rate, prolonged mechanical ventilation, and intensive care unit length of stay. Hybrid coronary revascularization was associated with lower inhospital mortality (CABG 1.3%, HCR 0%, p= 0.008), and shorter mean (± SD) hospital length of stay (CABG 6.7 ± 4.7 days, HCR 4.5 ± 2.1 days, p < 0.001). After a median follow-up period of 70 months (range, 37 to 106) for the CABG group and 96 months (range, 53 to 114) for the HCR group, there was no significant difference in survival (CABG 92%, HCR 97%, p= 0.13) or freedom from any form of revascularization (CABG 93%, HCR 91%, p= 0.27). Hybrid coronary revascularization was superior in freedom from angina (CABG 70%, HCR 91%, p < 0.001). For selected patients, HCR is associated with a faster postoperative recovery as well as similar short-term and long-term outcomes when compared with standard on-pump CABG.

Use of an intraoperative checklist to decrease the incidence of re-exploration for postoperative bleeding after cardiac surgery.

We have implemented an intraoperative checklist aiming to reduce the incidence of re-exploration for bleeding after cardiac surgery. The present report addresses the results of adopting such a checklist regarding the incidence of postoperative bleeding. The checklist was implemented by presenting it in several staff meetings of the Catharina Heart Center. Copies of the checklist were presented in every operating room. Data were collected by the Catharina Heart Center, aligned with the 'Meetbaar Beter' data manual and validated by 'Meetbaar Beter' through their data quality system. The incidence of re-exploration for bleeding was analysed in a variable life-adjusted display curve. The patient population operated after the implementation of the checklist was compared with a recent historical population before its implementation. From January 2013 through April 2016, 4817 cardiac surgical procedures were performed in our institution. Before May 2015, 3210 procedures were performed (Group 1), complicated by 112 re-exploration for bleeding (3.5%). The 'reoperation for bleeding checklist' was implemented on 1 May 2015. After this date, the number of re-explorations for bleeding decreased to 29 (1.8%) of the 1607 cardiac surgical procedures (Group 2) (P < 0.05). An intraoperative checklist is feasible to implement, low cost, quick and simple to measure with a significant reduction in the incidence of re-exploration for bleeding. This report shows an example of the positive effects of transparency in publishing outcomes' data in cardiac surgery.

A comparison of high-dose and low-dose tranexamic acid antifibrinolytic protocols for primary coronary artery bypass surgery.

Background and Aims:Tranexamic acid (TA) is used for prophylactic antifibrinolysis in coronary artery bypass surgeries to reduce bleeding. We evaluated the efficacy of two different doses of TA for prophylactic antifibrinolysis in patients undergoing primary coronary artery bypass grafting (CABG) surgery in this retrospective cohort study at a tertiary care referral centre.Methods:One-hundred eighty-four patients who underwent primary CABG with cardiopulmonary bypass (CPB) via sternotomy between January 2009 and June 2011 were evaluated. Pre-operative patient characteristics, intraoperative data, post-operative bleeding, transfusions, organ dysfunction and 30-day mortality were compared between high-dose TA (30 mg/kg loading dose followed by infusion of 15 mg/kg/h until the end of surgery along with 2 mg/kg priming dose in the bypass circuit) and low-dose TA (15 mg/kg loading dose followed by infusion of 6 mg/kg/h until the end of surgery along with 1 mg/kg priming dose in the bypass circuit) groups. Univariate comparative analysis of all categorical and continuous variables was performed between the two groups by appropriate statistical tests. Linear and logistic regression analyses were performed to control for the effect of confounding on the outcome variables.Results:Chest tube output, perioperative transfusion of blood products and incidence of re-exploration for bleeding did not differ significantly (P> 0.05) between groups. Post-operative complications and 30-day mortality were comparable between the groups. The presence of cardiogenic shock and increased pre-operative creatinine were found to be associated with increased chest tube output on the post-operative day 2 by multivariable linear regression model.Conclusions:Low-dose TA protocol is as effective as high-dose protocol for antifibrinolysis in patients undergoing primary CABG with CPB.

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Introduction: Cardiac-Intensive Care Unit (CICU) readmission is a marker of the quality of care provided by the ICU. CICU re-admission has been reported between 4-14% following all cardiac surgery with mortality rate among these patients being as high as 17%. Patients who deteriorate on the ward are transferred-back early to the CICU in our institution. Methods: Prospectively collected data from all patients who underwent cardiac surgery between 2005 and 2012 (n=7160) was retrieved from our validated database. Patients who required CICU re-admission (Study group, n=152) was matched at a 1:3 ratio to those who did not require CICU readmission (control group, 456) using the 17-factored logistic Euroscore and next neighbour matching. Preoperative characteristics, early postoperative outcome and survival were compared between patients groups. Results: CICU readmission rate was 2.1%. There were no significant differences between the two groups in terms of the pre-op characteristics namely age, pre-op haemoglobin, BMI, gender, ethnic race, history of lung disease, urgency of operation and Logistic Euroscore. The types of operative procedures were similar in both groups. The study group did have more diabetic patients (14.4% v/s 8.8%, p=0.04) and a tendency to more (a) females (28.3 v/s 22.1, p=0.08) and (b) patients with peripheral vascular disease (33.6% v/s 25.7%, p=0.06). Patients who required CICU readmission had higher incidence of re-exploration for bleeding (p<0.01) overall blood transfusion (p=0.01), any infections (including chest infections) (p<0.01), need for renal replacement therapy (p=0.03), atrial fibrillation (p=0.01) and gastro-intestinal complications (<0.01). The most common reasons for CICU readmissions were cardiac (24%) and respiratory problems (36%). The median initial ICU stay was shorter in the study group (2 days v/s 4 days, p<0.01) and the median overall stay was longer in that group (21 days v/s 8 days, p<0.01). Hospital survival, however was not significantly different (89% v/s 93%, p=0.09). Multivariate analysis (age, gender, DM, smoking history, history of lung disease, PVD, ejection fraction, operative urgency, type of cardiac procedure, CPB time, re-exploration for bleeding, day of CICU discharge, duration of first ICU stay, log Euroscore, blood transfusion) showed that the factors associated with CICU re-admission were re-exploration for bleeding (odds ratio 3.8, p<0.01) and a history of peripheral vascular disease (odds ratio 1.5, p=0.05) Conclusions: CICU readmission rate was low in our institution. Predictive factors for re-admission included history of PVD and the need for re-exploration. In this matched cohort, survival of the re-admitted group was similar to the non-re-admitted group possibly reflecting the fact that patients are transferred back to CICU early.

Deep sternal wound infection after cardiac surgery

BackgroundDeep sternal wound infection (DSWI) is a serious postoperative complication of cardiac surgery. In this study we investigated the incidence of DSWI and effect of re-exploration for bleeding on DSWI mortality.MethodsWe reviewed 73,700 cases registered in the Japan Adult Cardiovascular Surgery Database (JACVSD) during the period from 2004 to 2009 and divided them into five groups: 26,597 of isolated coronary artery bypass graft (CABG) cases, 23,136 valvular surgery cases, 17,441 thoracic aortic surgery cases, 4,726 valvular surgery plus CABG cases, and 1,800 thoracic aortic surgery plus CABG cases. We calculated the overall incidence of postoperative DSWI, incidence of postoperative DSWI according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI cases according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI according to whether re-exploration for bleeding, and the intervals between the operation and deaths according to whether re-exploration for bleeding were investigated. Operative mortality is defined as in-hospital or 30-day mortality. Risk factors for DSWI were also examined.ResultsThe overall incidence of postoperative DSWI was 1.8%. The incidence of postoperative DSWI was 1.8% after isolated CABG, 1.3% after valve surgery, 2.8% after valve surgery plus CABG, 1.9% after thoracic aortic surgery, and 3.4% after thoracic aortic surgery plus CABG. The 30-day and operative mortality in patients with DSWI was higher after more complicated operative procedures. The incidence of re-exploration for bleeding in DSWI cases was 11.1%. The overall 30-day/operative mortality after DSWI with re-exploration for bleeding was 23.0%/48.0%, and it was significantly higher than in the absence of re-exploration for bleeding (8.1%/22.0%). The difference between the intervals between the operation and death according to whether re-exploration for bleeding had been performed was not significant. Age and cardiogenic shock were significant risk factors related to re-exploration for bleeding, and diabetes control was a significant risk factor related to DSWI for all surgical groups. Previous CABG was a significant risk factor related to both re-exploration for bleeding and DSWI for all surgical groups.ConclusionsThe incidence of DSWI after cardiac surgery according to the data entered in the JACVSD registry during the period from 2004 to 2009 was 1.8%, and more complicated procedures were followed by higher incidence and mortality. When re-exploration for bleeding was performed, mortality was significantly higher than when it was not performed. Prevention of DSWI and establishment of an effective appropriate treatment for DSWI may improve the outcome of cardiac surgery.

EComment. Postoperative bleeding in cardiac surgery: the issue is not resolved yet

I read with great interest the article by Kristensen et al. [1]. They showed an incidence of reexploration for bleeding after cardiac surgery of 7%. Also, it was found that low ejection fraction, high EuroSCORE, procedures other than isolated coronary artery bypass graft surgery (CABG), prolonged time on extracorporeal circulation, low body mass, and others were significant risk factors for reoperation for bleeding. Indeed, operative mortality (15.8%) increased by three times for reexplored patients.

In-Hospital Outcomes of Off-Pump Multivessel Total Arterial and Conventional Coronary Artery Bypass Grafting: Single Surgeon, Single Center Experience

Despite increasing recognition that off-pump coronary artery bypass surgery and total arterial revascularization individually are associated with improved outcomes, concerns persist regarding the safety of combining these two techniques. We compared in-hospital outcomes for off-pump multivessel total arterial and conventional coronary artery bypass grafting. From September 1998 to September 2008, 580 consecutive patients receiving off-pump multivessel arterial grafts only were compared with a control group of patients (n = 806) undergoing off-pump coronary artery bypass grafting with internal thoracic artery and saphenous veins operated on by the same surgeon. Two different statistical approaches were used to compare groups in this retrospective analysis. First, propensity score analysis was used to match patients from each group. Second, a multivariate analysis was performed looking at a combined patient outcome of death, intraaortic balloon counterpulsation utilization, myocardial infarction, stroke, prolonged ventilation, and reoperation for any cause on all patients in both groups. After matching by propensity score, the major clinical outcomes in total arterial (n = 346) and control (n = 346) groups were found to be similar. The in-hospital mortality in the total arterial group was 1.2% as compared with 2.0% in matched patients (p = 0.8). However, patients in the total arterial group were found to have a significantly increased incidence of reexploration for bleeding (p < 0.0001) and blood product usage (p < 0.0001). There was a higher incidence of combined morbidity outcome (18.8% versus 12.1%; p = 0.001) for the control group compared with the total arterial group. Multivariate analysis failed to show that total arterial grafting was an independent predictor of the combined morbidity outcome. Off-pump multivessel total arterial grafting can be performed safely with superior in-hospital outcomes compared with off-pump conventional coronary artery bypass grafting.

Video-Assisted Thoracic Surgery in Lung Cancer Resection

: This meta-analysis sought to determine whether video-assisted thoracic surgery (VATS) improves clinical and resource outcomes compared with thoracotomy (OPEN) in adults undergoing lobectomy for nonsmall cell lung cancer. : A comprehensive search was undertaken to identify all randomized (RCT) and nonrandomized (non-RCT) controlled trials comparing VATS with OPEN thoracotomy available up to April 2007. The primary outcome was survival. Secondary outcomes included any other reported clinical outcome and resource utilization. Odds ratios (OR), weighted mean differences (WMD), or standardized mean differences (SMD), and their 95% confidence intervals (95% CI) were analyzed as appropriate. : Baseline prognosis was more favorable for VATS (more females, smaller tumor size, less advanced stage, histology associated with peripheral location and with more indolent disease) than for OPEN in non-RCTs, but not RCT. Postoperative complications were significantly reduced in the VATS group compared with OPEN surgery when both RCT and non-RCT were considered in aggregate (OR 0.48, 95% CI 0.32-0.70). Although overall blood loss was significantly reduced with VATS compared with OPEN (-80 mL, 95% CI -110 to -50 mL), the incidence of excessive blood loss (generally defined as >500 mL) and incidence of re-exploration for bleeding was not significantly reduced. Pain measured via visual analog scales (10-point VAS) was significantly reduced by <1 point on day 1, by >2 points at 1 week, and by <1 point at week 2 to 4. Similarly, analgesia requirements were significantly reduced in the VATS group. Postoperative vital capacity was significantly improved (WMD 20, 95% CI 15-25), and at 1 year was significantly greater for VATS versus OPEN surgery (WMD 7, 95% CI 2-12). The incidence of patients reporting limited activity at 3 months was reduced (OR 0.04, 95% CI 0.00-0.82), and time to full activity was significantly reduced in the VATS versus OPEN surgery (WMD -1.5, 95% CI -2.1 to -0.9). Overall patient-reported physical function scores did not differ between groups at 3 years follow-up. Hospital length of stay was significantly reduced by 2.6 days despite increased 16 minutes of operating time for VATS versus OPEN. The incidence of cancer recurrence (local or distal) was not significantly different, but chemotherapy delays were significantly reduced for VATS versus OPEN (OR 0.15, 95% CI 0.06-0.38). The need for chemotherapy reduction was also decreased (OR 0.37, 95% CI 0.16-0.87), and the number of patients who did not receive at least 75% of their planned chemotherapy without delays were reduced (OR 0.41, 95% CI 0.18-0.93). The risk of death was not significantly reduced when RCTs were considered alone; however, when non-RCTs (n = 18) were included, the risk of death at 1 to 5 years was significantly reduced (OR 0.72, 95% CI 0.55-0.94; P = 0.02) for VATS versus OPEN. Stage-specific survival to 5 years was not significantly different between groups. : This meta-analysis suggests that there may be some short term, and possibly even long-term, advantages to performing lung resections with VATS techniques rather than through conventional thoracotomy. Overall, VATS for lobectomy may reduce acute and chronic pain, perioperative morbidity, and improve delivery of adjuvant therapies, without a decrease in stage specific long-term survival. However, the results are largely dependent on non-RCTs, and future adequately powered randomized trials with long-term follow-up are encouraged.

INVITED COMMENTARY

More than 5,000 pediatric heart transplants have been performed worldwide. Advances in perioperative care, surgical techniques, and immunosuppressive and surveillance protocols have contributed to improved early survival of children transplanted in the recent era. In this report on pediatric transplantation the population is heterogeneous, the volume is small, and the mean follow-up is only 5.2 ± 3.6 years; nevertheless, the authors should be commended for their remarkable overall results. Survival in the Loma Linda pediatric transplant experience with more than 400 recipients (75% with complex congenital heart disease and 24% with cardiomyopathy) at 1-, 5-, and 10-year is 85%, 75%, and 66%, respectively. However, the 100 children transplanted as neonates have a significantly better 10-year survival compared with the other pediatric groups: 75% versus 64%.Primary graft failure is a disappointing development after transplantation, and its etiology is certainly multifactorial. Although this complication is part of every transplant center experience, the high incidence (12.7%) of severe right ventricular failure in this report is somewhat puzzling. To their credit, the transplant team changed their protocol after 1995, resulting in better early perioperative results. They avoided grafts with prolonged ischemic time (≥4 hours), rejected donor-recipient body surface mismatches, and used nitric oxide in 44% of their transplant procedures. In the absence of fixed pulmonary hypertension or high pulmonary vascular resistance index, acute graft dysfunction may be a function of graft preservation and procurement methods, intraoperative protection, implantation techniques, and management of graft reperfusion. In our series, neither prolonged graft ischemic time (range, 49 to 608 minutes) nor donor-recipient size mismatch (range, 0.59 to 4.65) had any adverse effect on early or long-term outcome of recipients with congential heart disease. Excessive transfusion of blood products is known to contribute to graft right ventricular dysfunction. Modification of surgical technique and the selective use of certain pharmacologic hemostatic agents can keep the incidence of postoperative bleeding to less than 8%, as compared with the 44% incidence of reexploration for bleeding reported in this series.The intermediate-term results of pediatric heart transplantation have improved considerably, but the durability of such therapy is threatened by the development of posttransplant graft vasculopathy, hypertension, renal insufficiency, malignancies, delayed rejection, and infection. These morbidities, along with compliance and psychosocial issues during adolescence, continue to challenge the commitment of transplant teams keen on enhancing the quality of life and achieving long-term survival for pediatric heart transplant recipients. More than 5,000 pediatric heart transplants have been performed worldwide. Advances in perioperative care, surgical techniques, and immunosuppressive and surveillance protocols have contributed to improved early survival of children transplanted in the recent era. In this report on pediatric transplantation the population is heterogeneous, the volume is small, and the mean follow-up is only 5.2 ± 3.6 years; nevertheless, the authors should be commended for their remarkable overall results. Survival in the Loma Linda pediatric transplant experience with more than 400 recipients (75% with complex congenital heart disease and 24% with cardiomyopathy) at 1-, 5-, and 10-year is 85%, 75%, and 66%, respectively. However, the 100 children transplanted as neonates have a significantly better 10-year survival compared with the other pediatric groups: 75% versus 64%. Primary graft failure is a disappointing development after transplantation, and its etiology is certainly multifactorial. Although this complication is part of every transplant center experience, the high incidence (12.7%) of severe right ventricular failure in this report is somewhat puzzling. To their credit, the transplant team changed their protocol after 1995, resulting in better early perioperative results. They avoided grafts with prolonged ischemic time (≥4 hours), rejected donor-recipient body surface mismatches, and used nitric oxide in 44% of their transplant procedures. In the absence of fixed pulmonary hypertension or high pulmonary vascular resistance index, acute graft dysfunction may be a function of graft preservation and procurement methods, intraoperative protection, implantation techniques, and management of graft reperfusion. In our series, neither prolonged graft ischemic time (range, 49 to 608 minutes) nor donor-recipient size mismatch (range, 0.59 to 4.65) had any adverse effect on early or long-term outcome of recipients with congential heart disease. Excessive transfusion of blood products is known to contribute to graft right ventricular dysfunction. Modification of surgical technique and the selective use of certain pharmacologic hemostatic agents can keep the incidence of postoperative bleeding to less than 8%, as compared with the 44% incidence of reexploration for bleeding reported in this series. The intermediate-term results of pediatric heart transplantation have improved considerably, but the durability of such therapy is threatened by the development of posttransplant graft vasculopathy, hypertension, renal insufficiency, malignancies, delayed rejection, and infection. These morbidities, along with compliance and psychosocial issues during adolescence, continue to challenge the commitment of transplant teams keen on enhancing the quality of life and achieving long-term survival for pediatric heart transplant recipients.