Reoperative Valve Surgery Research Articles

Risk of mortality in patients requiring reoperative open-heart surgery

BackgroundImprovements in surgical techniques and perioperative care as well as increased patient life expectancies have led cardiothoracic surgeons to perform more complex operations, including reoperative open-heart surgeries. However, there is debate as to which patients are appropriate operative candidates for reoperative procedures. MethodsThis is a retrospective, single-center study of patients who underwent reoperative open-heart surgery via median sternotomy or thoracotomy over a 10-year period. Patients with previous ventricular assist device or heart transplant were excluded. Patients were stratified by age <65 years compared with age ≥65 years for analysis. Survival was assessed using Kaplan-Meier curves and log-rank tests. Multivariate analysis was performed with Cox proportional hazards regression. ResultsA total of 250 patients underwent reoperative open-heart surgery at our center from 2012 to 2022. In total, 176 patients underwent valve surgery, 53 underwent coronary artery bypass grafting, 31 underwent aortic surgery, and 29 underwent other operations. The overall mortality rate was 13.6% at 30 days and 21.2% at 1-year postoperatively. Patients ≥65 years old had a greater average survival compared with patients <65 years old (5.0 vs 4.1 years, P = .046). However, there were no differences in survival by age when patients were stratified by procedure, either coronary artery bypass grafting (P = .29) or valve surgery (P = .16). On multivariate analysis, reoperative valve surgery, intraoperative use of extracorporeal membrane oxygenation, and a greater number of reoperative surgeries were associated with lower survival. ConclusionPatients undergoing reoperative open-heart surgery are clinically complex and had lower survival with each subsequent reoperation.

Risk of reoperative valve surgery for endocarditis associated with drug use

BackgroundWe aimed to quantify incidence and operative risks associated with reoperative valve surgeries (RVS) in patients with drug-associated infective endocarditis in a multi-center setting. MethodsWe formed a registry of patients with drug-associated infective endocarditis who underwent valve surgeries at 8 US centers between 2011 and 2017. Outcomes of first-time valve surgery (FVS) and RVS were compared. Multivariable logistic regression models related RVS to 30-day mortality. Poisson regression models were fitted to evaluate temporal trends in overall case volume and proportions of patients undergoing RVS. ResultsThe cohort consisted of 925 patients with drug-associated infective endocarditis who underwent a valve surgery, of which 652 were FVS and 273 were RVS. Patients undergoing FVS had fewer comorbidities than those undergoing RVS. Overall case volume increased from 108 in 2012 to 229 cases in 2017 (P < .001). The proportion of redo valve cases increased from 19% in 2012 to 28% in 2017 (P < .001). The 30-day mortality in RVS was higher compared with FVS (8.1% vs 4.8%; P = .049). An increase in unadjusted mortality rates were observed as the number of prior cardiac surgeries increased, from 4.8% in FVS to 11.8% in ≥3 RVS. Multivariable model demonstrated that RVS was associated with an increased risk of 30-day mortality (odds ratio, 2.22; 95% confidence interval, 1.22-4.06; P = .010). ConclusionsAn increasing proportion of valve surgery for drug-associated infective endocarditis is for RVS. Despite being young and harboring few comorbidities, the RVS cohort is still susceptible to increased risk of 30-day mortality compared with those undergoing FVS.

Hybrid approach of percutaneous coronary intervention followed by minimally invasive mitral valve surgery: a 5-year single-center experience.

The current study evaluated the safety and feasibility of staged ("hybrid") percutaneous coronary intervention (PCI) followed by isolated minimally invasive mitral valve (MV) surgery [PCI + minimally invasive mitral valve surgery (MIMVS)], for patients with concomitant coronary artery and MV disease. A total of 93 patients who underwent PCI + MIMVS for coronary artery and MV disease between February 2009 and April 2014 were retrospectively analyzed. There were 54 (58.1%) men and 39 (41.9%) women. The mean age was 73±8 years, and all patients had severe mitral regurgitation. PCI was performed for single-vessel coronary artery disease in 40 (43%) patients, two-vessel in 49 (52.7%), and three-vessel in 4 (4.3%). Within a median of 48 days (IQR, 18-71) after PCI, 78 (83.9%) patients underwent primary valve surgery, and 15 (16.1%) underwent re-operative valve surgery, with 56 (60.2%) having MV replacement, and 37 (39.8%) having MV repair. Sixty-five (69.9%) patients were being treated with dual anti-platelet therapy at the time of surgery. The median number of transfused intra-operative red blood cell units was 1 (IQR, 0-2), and the intensive care unit and hospital lengths of stay were 46 hours (IQR, 27-76) and 8 days (IQR, 5-11), respectively. Post-operatively, there was 1 (1.1%) cerebrovascular accident, 2 (2.2%) patients developed acute kidney injury, and 4 (4.3%) required a re-operation for bleeding. Thirty-day mortality occurred in 4 (4.3%) patients. At a mean follow-up of 15.3±13.2 months, 3 (3.4%) patients required target-vessel revascularization. The survival rate was 89% and 85% at 1 and 3 years, respectively. In patients with concomitant coronary artery and MV disease, PCI + MIMVS can be safely performed and is associated with good short-term and follow-up outcomes.

A Contemporary Approach to Reoperative Aortic Valve Surgery: When is Less, More?

Although the benefits of minimally invasive valvular surgery are well established, the applicability of extending these techniques to reoperative aortic valve surgery is unknown. We evaluated our experience with a minimally invasive approach to this patient population. From January 2010 to September 2015, 21 patients underwent reoperative isolated aortic valve replacement via a minimally invasive approach by a single surgeon. All patients had preoperative evaluation with computerized tomography and coronary catheterization. Surgical approaches were right anterior thoracotomy (6/21) or upper hemisternotomy (15/21). Central aortic cannulation was preferred with femoral artery cannulation used in four patients (19%). In patients with left internal mammary artery (LIMA) grafts, no attempt to dissect or occlude the graft was made. Cold blood cardioplegia was administered antegrade (12/21) or retrograde (9/21); systemic cooling with a mean low temperature of 27.5 °C was employed. Mean age was 75.1 years with a range from 33 to 92 years, and 67% (14/21) were male. All procedures were completed with a minimally invasive approach. Mean ± SD cross-clamp time was 51.5 ± 9.2 minutes. Fourteen patients had patent LIMA grafts. No aortic, LIMA, or cardiac injuries occurred. There were no hospital deaths nor occurrences of perioperative myocardial infarction, stroke, wound infection, renal failure, or endocarditis/sepsis. One patient required a reoperation for bleeding. Sixty-two percent of patients were discharged to home; mean ± SD length of stay was 6 ± 3 days. With appropriate preoperative evaluation and careful surgical planning, a minimally invasive approach to reoperative aortic valve surgery can be performed in a safe and effective manner.

Abstract 11654: Surgical Versus Medical Therapy for Prosthetic Valve Endocarditis: A Systematic Review and Meta-Analysis of 32 Studies

Background: Prosthetic valve endocarditis (PVE) after valve replacement surgery is associated with significant morbidity and mortality. Whether a surgical or medical treatment strategy is preferable has not been clearly defined. Methods: A systematic review was performed to identify studies that compared re-operative valve surgery versus medical therapy for PVE. A meta-analysis was conducted on the outcomes of 30-day mortality, and follow-up survival and recurrent PVE. Risk ratios (RR) and 95% confidence intervals (CI) were calculated utilizing the Mantel-Haenszel method under a fixed or random effects model, as appropriate. Continuous and categorical variables were compared utilizing an independent t-test and a chi-square or Fisher’s exact test, respectively. Results: A total of 32 studies were identified, which included 2636 patients (Surgery=1320, Medical=1316), with a mean follow-up of 22 months (range 3-120). Patients undergoing valve reoperation were younger (58 ± 20 years versus 63 ± 22 years, p&lt;0.0001), with a higher incidence of heart failure (38% versus 28%, p=0.0001) and paravalvular complications (paravalvular leak, prosthetic valve dehiscence, and/or paravavular abscess; 43% versus 19%, p&lt;0.0001), while patients treated with medical therapy alone experienced more Staphylcoccus aureus PVE (32% versus 24%, p=0.0003). When compared with medical therapy, a valve reoperation was associated with a lower risk of 30-day mortality (25% versus 34%; RR 0.73, 95% CI 0.64-0.82, p&lt;0.00001), and a greater survival at follow-up (69% versus 58%; RR 1.27, 95% CI 1.05-1.53, p=0.01), which was driven by the 15 studies published in the year 2000 or later. In patients with left-sided PVE, valve reoperation was also associated with a lower risk of 30-day mortality (25% versus 33%; RR 0.74, 95% CI 0.64-0.86, p&lt;0.0001), and a greater survival at follow-up (71% versus 58%; RR 1.35, 95% CI 1.05-1.73, p=0.02), as compared with medical therapy. There was no difference in the incidence of recurrent PVE with regard to surgical versus medical therapy. Conclusions: Compared with medical therapy, reoperative valve surgery results in lower 30-day mortality and a greater survival at follow-up, and may be preferable for patients with PVE.

Redo valve surgery--current status and future perspectives.

Surgeons are now facing the challenge of redo valve surgery because of the increasing number of elderly individuals in Japan. The incidence of bioprosthesis dysfunction has increased among the various surgical indications of redo valve surgery due to the preference of patients and a paradigm shift in prostheses from mechanical valves to bioprostheses. Previous studies reported that the clinical outcomes of reoperative valvular surgery have markedly improved due to the maneuver of myocardial protection, cardiopulmonary bypass strategies, and appropriate safer surgical approach. The general surgical outcomes of redo valve surgery have been reported as being similar to those of primary valve surgery; however, this is still controversial and has not yet been confirmed in some developed countries. Although the unique surgical technique of transcatheter valve-in-valve implantation for bioprosthetic dysfunction is promising, redo valve surgery may become more prevalent in the future. We here reviewed the current status of reoperative valve surgery and future perspectives including catheter-based surgical interventions.

Aortic valve replacement after previous heart surgery in high-risk patients: Transapical aortic valve implantation versus conventional aortic valve replacement—a risk-adjusted and propensity score-based analysis

Cardiac reoperations have been associated with increased morbidity and mortality compared with first-time surgery. We analyzed our experience with reoperative aortic valve replacement (redo-AVR) and compared these results with those from patients who had undergone transapical aortic valve implantation (TA-AVI) as a second heart operation. In the present retrospective observational comparative study, we analyzed the outcome of 136 patients with previous cardiac surgery who had undergone conventional redo-AVR (n=59; since 2006) or TA-AVI (n=77; since 2008) with respect to the 30-day outcomes (Valve Academic Research Consortium criteria), 1- and 3-year survival, and the risk factors for both approaches after previous heart surgery. Neither group differed significantly in their risk profile, leading to similar Society of Thoracic Surgeon score and EuroSCORE. The 30-day mortality was 3.39% (n=2) in the redo-AVR group and 7.8% (n=6) in the redo TA-AVI group (P=.465). The overall combined safety endpoint at 30 days was significantly lower for the TA-AVI patients (18.1% vs 33.9% in redo-AVR; P=.036). The unadjusted and adjusted 1-year survival showed no difference between the 2 groups. The unadjusted 3-year survival revealed a 2.1-fold greater mortality risk after TA-AVI (P=.055). Adjustment by multivariate Cox regression analysis (hazard ratio, 1.427; 95% confidence interval, 0.635-3.209; P=.389) and propensity score (hazard ratio, 1.571; 95% confidence interval, 0.575-4.291; P=.378) led to a >50% risk reduction, resulting in similar 3-year survival in the 2 groups. Redo-AVR can be performed with acceptable results in high-risk patients and still serves as the reference standard. Reoperative valve surgery by TA-AVI is feasible and results in comparable short- and mid-term survival.

Presence of tricuspid regurgitation after left-heart valve surgery independently predicts mortality

Background: Significant tricuspid regurgitation (TR) occurring late after left-heart valve surgery is frequent and associated with decreased exercise tolerance and quality of life. Re-operative tricuspid valve (TV) surgery has been reported to result in early mortality rates as high as 10% to 25%. The aim of the study was to evaluate whether significant TR late after left-heart valve surgery impacts on prognosis. Methods: 602 consecutive patients after successful surgery of the aortic or/and the mitral valve (49±29 months post-surgery) were prospectively followed for 5 years. The severity of TR was assessed by echocardiography. Significant TR was defined as TR ≥ moderate. The primary endpoint was defined as cardiovascular death. Cox-Regression was used to determine the impact of TR on survival. Results: Significant TR was present in 122 (20.3%) patients, who were predominantly female (66% vs. 49%, p<0.001), had a higher EuroSCORE (9.8±2.5 vs. 8.9±2.3, p<0.001) and had more previous cardiac surgeries (1.2±0.5 vs. 1.1±0.3, p=0.010). They more often had atrial fibrillation (48% vs. 19%, p<0.001) and were more symptomatic (NYHA≥II 55% vs. 31% p<0.001). Patients with significant TR had larger right ventricles (36.9±7.9mm vs. 32.7±5.0mm, p<0.001), more dilated left and right atria (66.7±13.0mm vs. 57.9±8.3mm and 65.0±13.1mm vs. 55.3±7.5mm; both p<0.001) and presented with worse left ventricular function (LVEF<50%: 19% vs. 11%; p=0.020). In total, 132 (21.9%) patients died during follow up (36.1% with significant TR vs. 18.3% without; p<0.001). 76 (12.6%) patients died of cardiovascular causes (26.2% vs. 9.2%, p<0.001). By Kaplan-Meier analysis, overall survival was significantly worse in patients with significant TR (1-,3- and 5-year survival 91.8%, 81.2% and 63.9% vs. 96.0%, 89.0% and 81.7%; log rank p<0.001). By multivariable Cox regression analysis, age (p<0.001), left atrial enlargement (p<0.001), coronary artery disease (p=0.001) and significant TR (p=0.008) were found to independently predict cardiovascular mortality. Conclusion: Significant TR late after left-sided valve surgery is frequent and independently predicts mortality.

Invited Commentary

Invited Commentary

Does Prior Coronary Bypass Surgery Present a Unique Risk for Reoperative Valve Surgery?

Prior coronary surgery has been associated with a higher incidence of adverse outcomes after reoperative cardiac surgery compared with previous valve surgery. It is unclear whether this association is primarily due to greater patient comorbidity or the technical challenges posed by mediastinal reentry and operation in the setting of previous bypass grafts. This study was therefore designed to examine whether previous coronary artery bypass grafting (CABG) is a significant risk factor for adverse outcomes after reoperative cardiac surgery. From a prospective database of 1,093 consecutive adults who underwent reoperative cardiac surgery between 2000 and 2010, 363 patients undergoing isolated reoperative valve surgery were divided according to whether or not the previous surgery included CABG (group I, n= 133) or not (group II, n= 230). Propensity-adjusted multivariate analysis was performed in order to determine independent predictors of any morbidity or mortality, or decreased survival. Patients in group I were more likely to be elderly (p < 0.001), and have greater body mass indexes (p= 0.04), low ejection fractions (p= 0.001), and comorbidities of cerebrovascular disease (p= 0.04), peripheral vascular disease (p= 0.003), and diabetes (p < 0.001) compared with group II. Patent grafts were present in 94% (n= 111). Although group I patients were significantly more likely to experience major postoperative complications and had worse survival, after propensity adjustment no significant difference was observed in either any morbidity or mortality (p= 0.4) or in survival (p= 0.4). A history of CABG does not appear to present a unique risk in reoperative valve surgery. The major determinant of adverse outcomes is morbidity, not prior bypass grafts.

The Role of the Minimally Invasive Beating Heart Technique in Reoperative Valve Surgery

We reviewed our experience to assess potential advantages of minimally invasive surgery without aortic clamping over conventional median sternotomy and cardioplegic arrest during reoperative valve surgery. From August 2008 to August 2010, 22 reoperative valve procedures were performed through a minimally invasive approach without aortic cross-clamping [no-clamp group (NCG)]. Postoperative results were compared to a matched population in terms of sex, age, and type of surgery, and operated through median sternotomy with aortic cross-clamping and cardioplegic arrest [clamp group (CG)]. We performed 17 mitral valve replacements (MVRs), one mitral valve repair, one MVR associated to a tricuspid plasty (TVP), and three isolated TVP in both groups. Cardiopulmonary bypass (CPB) time was 166 and 163 minutes in NCG and CG, respectively. Intra-aortic balloon pump was necessary in two (NCG) and three (CG) patients. Two patients died in both groups from multiorgan failure. Biochemical analysis showed no significant differences in perioperative lactate or creatine kinase-MB values. Redo valve surgery with an unclamped aorta is feasible, effective, and at least as safe as surgery using cardioplegic arrest. There was, however, no difference in biochemical or clinical outcomes from conventional surgery using aortic clamping and cardioplegic techniques.

Reoperative valve surgery after open-heart valve surgery: a report of 155 cases

To summarize the characteristics of reoperative valve surgery after previous open-heart valve surgery. From 1996 to 2010, 155 patients who underwent reoperative valve surgery, either valve replacement or tricuspid annuloplasty or the repair of perivalvular leakage were included in the study. The reoperative interval was 1-266 (94.82 ± 85.37) months. All surgeries were carried out with extracorporeal circulation under moderated hypothermia. The cardioplegic solution in cold crystal or blood was used if heart beating was stopped during the surgery. The total in-hospital mortality was 5.81%, while it was 2.75% from 2005 to 2010. The end-diastolic dimension, size of atrium and ventricles were reduced after the reoperation. Ventricular arrhythmia and low cardiac output were the most frequent complications. The success rate of reoperative valve surgery can be improved by the distinctive therapeutic strategies based on the clinical characteristics and therapy principles obtained from practice experiences.

Reoperative Valve Surgery in the Elderly: Predictors of Risk and Long-Term Survival

Elderly patients requiring reoperative cardiac surgery for valve disease are considered high risk for immediate outcomes, but little is known about their long-term survival. It is often conjectured that medical therapy provides equivalent late survival in this population, which may dissuade both patient and surgeon from considering reoperation. We analyzed a cohort of such patients undergoing reoperative valve surgery to determine their long-term survival. From 1992 through 2007, 363 patients aged 75 years or more underwent reoperative isolated valve surgery; 211 (58%) had aortic valve replacement and 152 (42%) had mitral valve surgery. Mean age was 80.5 years. Hospital outcomes were prospectively recorded. Survival from all-cause death was determined from the Social Security Death Index. Hospital mortality was 13.8% (12.8% for aortic and 15.1% for mitral valve operations; p = 0.52). Multivariable predictors of hospital death were New York Heart Association functional class III or IV heart failure (odds ratio = 3.19, p = 0.012), dialysis (odds ratio = 15.63, p = 0.003), and more than one reoperation (odds ratio = 2.59, p = 0.058). At 5 years, overall survival was 62% ± 3% for all patients (66% ± 4% for aortic and 56% ± 4% for mitral valve patients). For aortic valve patients aged 80 years or more, 5-year survival was 60% ± 0.6%. Life expectancy table analysis predicted a 5-year survival of 57% for an age-matched and sex-matched comparison group. Reoperative surgery for elderly patients with isolated aortic or mitral valve pathology is associated with excellent long-term survival, particularly when treating aortic valve disease. While in-hospital mortality is higher among the elderly than among younger patients, specific predictors of poor outcome can be identified preoperatively to risk stratify these patients.

Effect of Prior Valve Type on Mortality in Reoperative Valve Surgery

Effect of Prior Valve Type on Mortality in Reoperative Valve Surgery

Effect of Prior Valve Type on Mortality in Reoperative Valve Surgery

The purpose of this study is to examine the effect of previously implanted valve type on hospital mortality in reoperative valve surgery. From 1990 to 2005, 743 patients underwent redo valve surgery at our institution. Patients were divided into those who received a mechanical valve during their prior operation (n = 236) and those who received a biological (porcine or pericardial) valve (n = 507). Perioperative data were analyzed retrospectively. Patients with failing mechanical valves were younger, more likely to be female, and had a higher prevalence of preoperative stroke and atrial arrhythmias, whereas patients with failing biological valves had more hypertension, diabetes mellitus, hyperlipidemia, and chronic obstructive pulmonary disease (all p < 0.05). Mechanical valve explant patients had fewer prior coronary bypass and aortic valve operations, but more mitral surgeries (all p < 0.05). Mechanical patients also had a higher prevalence of endocarditis (p = 0.001) and urgent or emergent surgery (p < 0.001). Hospital mortality was higher among patients undergoing mechanical valve explant by univariate analysis (13% versus 8%, p = 0.04), but not by multivariate analysis (odds ratio 1.6, 95% confidence interval 0.9 to 2.7, p = 0.1). Logistic regression revealed chronic obstructive pulmonary disease, peripheral vascular disease, endocarditis, and urgency of reoperation as independent predictors of hospital mortality. Explanting mechanical valves are associated with higher perioperative mortality than are tissue valves, likely because of different modes of failure and presentation. A lower risk of mortality for tissue valve reoperation may be an additional factor to consider when patients and surgeons choose a valve prosthesis type.

Minimally Invasive Reoperative Isolated Valve Surgery: Early and Mid-Term Results

Minimally invasive, nonsternotomy approaches for valve procedures may reduce the risks associated with cardiac surgery after prior sternotomy and may improve outcomes. We analyzed our institutional experience to test this hypothesis. Between 1995 and 2002, 498 patients with previous cardiac operations via sternotomy underwent isolated valve surgery: 337 via median sternotomy (aortic = 160; mitral = 177) and 161 via mini-thoracotomy (aortic = 61; mitral = 100). Data were collected prospectively using the New York State Cardiac Surgery Report Form. Preoperative incidences of congestive heart failure, renal disease, and nonelective procedures were higher in the sternotomy group. Hospital mortality was significantly lower with the minimally invasive approach, 5.6% (9/161) versus 11.3% (38/337) (univariate, p = 0.04). However, multivariate analysis (odds ratio: 95% confidence intervals, p value) revealed that chronic obstructive pulmonary disease (6.6: 1.4 to 3.1, p = 0.001), renal disease (4.1: 1.52 to 11.2, p = 0.01), cerebrovascular disease (2.2: 1.03 to 4.78, p = 0.04), and ejection faction <30% (1.5: 0.96 to 5.5, p = 0.06) were associated with increased mortality. While mean bypass time, cross-clamp times, and stroke rates were comparable between groups, patients undergoing minimally invasive valve surgery had no deep wound infections (0% vs 2.4%, p = 0.05), less need for blood products (p = 0.02), and shorter hospital stays (p = 0.009). Five-year survival was higher with minimally invasive techniques as compared to a sternotomy approach (92.4 +/- 2% and 86.0 +/- 2%, respectively, p = 0.08). Reoperative valve surgery can be safely performed using a nonsternotomy, minimally invasive approach, with at least equal mortality, less hospital morbidity, decreased hospital length of stay, and slightly favorable mid-term survival as compared to sternotomy.

Staged initial percutaneous coronary intervention followed by valve surgery (“hybrid approach”) for patients with complex coronary and valve disease

The goal of this study was to determine if a "hybrid" approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons' (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients. With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery. We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCI and compared it with the observed mortality. There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively. Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.

Operative strategies in patients with patent IMA grafts undergoing reoperative valve surgery

Objectives: Dissection and temporary occlusion of patent IMA grafts in patients undergoing reoperative procedures can be problematic. Especially in reoperative valve surgery, IMA grafts may alternatively be left untouched using moderate hypothermia for myocardial protection. We present our experience with both such operative strategies.

Minimally invasive reoperative valve surgery

Minimally invasive reoperative valve surgery

Abdominal complications following cardiac surgery

Between 1978 and 1991, 116 of 19,246 patients (0.6%) undergoing cardiac surgery developed abdominal complications (renal/hepatic failure excluded) within 30 days of their cardiac operation. Comparison with a randomly selected control group of 217 patients operated upon over the same period of time was also undertaken. Compared to the control group, the study patients were older (mean age, 63.3 ± 12.5 years vs 57.5 ± 21.5 years; P = 0.03), more likely to have a history of alcohol abuse (10% vs 4%; P = 0.03), and more likely to have a previous history of gastrointestinal problems (43% vs 17%; P = 0.0001). There was also a trend towards a greater number of patients having valvular surgery, particularly reoperative surgery, in the study group. Postoperatively, patients with marked low cardiac output, requiring the intra-aortic balloon pump, were more likely to develop abdominal complications. These complications included complicated peptic ulcer disease in 54 (47%), intestinal obstruction and/or perforation in 19 (16%), biliary tract disease in 13 (11%), mesenteric ischemia in 13 (11%), acute pancreatitis in 3 (3%), and miscellaneous complications in the remaining 14 (12%). Forty-three patients were treated medically and 73 patients required operative intervention. The surgical procedures performed were truncal vagotomy and drainage (12), oversewing of a perforation or a bleeding vessel (6), gastrectomy (2), intestinal resection (14), laparotomy only (14), cholecystectomy (14), and other (11). Mortality was 26% ( 30 116 ) with the mortality for medical and surgical treatment being 16% vs 32%, respectively ( P = 0.112). Intestinal ischemia had the highest mortality, with a rate of 85% ( 11 13 ). Despite intensive monitoring and care of cardiac surgical patients, abdominal complications do occur, although rarely. Risk factors include older age, a positive history of gastrointestinal disease, reoperative valve surgery, and severe postoperative low cardiac output.