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Analysis of prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery. J Cardiothorac Surg 2022; 17:82. [PMID: 35461233 PMCID: PMC9034579 DOI: 10.1186/s13019-022-01825-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 04/08/2022] [Indexed: 12/02/2022] Open
Abstract
Objective To explore the prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery. Methods We retrospectively analyzed the data of 100 patients who underwent unplanned re-exploration after cardiovascular surgery in our hospital between May 2010 and May 2020. There were 77 males and 23 females, aged (55.1 ± 15.2) years. Demographic characteristics, surgical information, perioperative complications were collected to establish a database. These patients were divided into surviving and non-surviving groups according to in-hospital mortality. Logistic regression was used for multivariable analysis to explore the prognostic factors of in-hospital mortality. These statistically significant indicators were selected for drawing the receiver operating characteristic curve of the evaluation model, calculating the area under the curve (AUC) and evaluating the effectiveness of the new model with Hosmer–Lemeshow C-statistic. Results In-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery was 26.0% (26/100). Multivariate logistics regression revealed that the operation time of unplanned re-exploration, the worst blood creatinine value within 48 h before the re-exploration, the worst lactate value within 24 h after the re-exploration, cardiac insufficiency, respiratory insufficiency, and acute kidney injury were independent prognostic factors (P < 0.05). The AUC of the new assessment model constituted by these prognostic factors was 0.910, and the Hosmer–Lemeshow C-statistic was 4.153 (P = 0.762). Conclusions Operation time of unplanned re-exploration, worst serum creatinine value within 48 h before re-exploration, worst lactate value within 24 h after re-exploration, cardiac insufficiency, respiratory insufficiency, and acute kidney injury are the main prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery. Identifying these prognostic factors can effectively facilitate preventive measures and improve patient outcomes.
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Senage T, Gerrard C, Moorjani N, Jenkins DP, Ali JM. Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting. J Thorac Dis 2021; 13:5670-5682. [PMID: 34795917 PMCID: PMC8575859 DOI: 10.21037/jtd-21-1241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
Background Significant bleeding following cardiac surgery is a recognised complication, associated with a requirement for re-exploration and blood transfusion, both associated with increased morbidity and early mortality. The aim of this study was to examine the impact of the volume of early postoperative bleeding on long-term survival for patients undergoing coronary artery bypass grafting (CABG). Methods A retrospective analysis was performed of patients undergoing first-time isolated CABG at a single centre between January 2003 and April 2013, conditional from 30-day survival. Results Six thousand two hundred and sixty-five patients were analysed, with a mean Logistic EuroSCORE of 4.9%. The mean age was 67.8 years. Median follow-up was 11.5 years. The overall 10- and 15-year survival was 70.6% and 51.9% respectively. Following surgery, 4.6% (n=291) required return to theatre for re-exploration, and 43.6% (n=2,733) received at least one red cell transfusion. In multivariable analysis, the strongest correlates of mortality were age, smoking history, BMI, COPD, renal impairment, preoperative left ventricular function and preoperative haemoglobin (Hb) level. Twelve-hour blood loss was an additional predictor of inferior long-term survival. Five-year survival was 89.6% for patients with <500 mL blood loss, 86.8% for 500–1,000 mL and 83.8% for >1,000 mL. Re-exploration and receiving blood transfusion were not associated with reduced long-term survival. Conclusions Significant 12-hour blood loss is associated with inferior long-term survival following CABG. This observation supports efforts aimed at improving intra-operative haemostasis and aggressive management of patients with early signs of bleeding.
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Affiliation(s)
- Thomas Senage
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK.,SPHERE (MethodS in Patient-Centred Outcomes and Health Research), University of Nantes, Nantes, France
| | - Caroline Gerrard
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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Patel K, Adalti S, Runwal S, Singh R, Ananthanarayanan C, Doshi C, Pandya H. Re‐exploration after off‐pump coronary artery bypass grafting: Incidence, risk factors, and impact of timing. J Card Surg 2020; 35:3062-3069. [DOI: 10.1111/jocs.14986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Kartik Patel
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Sudhir Adalti
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Shreyas Runwal
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Rahul Singh
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | | | - Chirag Doshi
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Himani Pandya
- Department of Research U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
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Barozzi L, Biagio LS, Meneguzzi M, Courvoisier DS, Walpoth BH, Faggian G. Novel, digital, chest drainage system in cardiac surgery. J Card Surg 2020; 35:1492-1497. [PMID: 32436655 PMCID: PMC7383877 DOI: 10.1111/jocs.14629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND A new, self-contained, digital, continuous pump-driven chest drainage system is compared in a randomized control trial to a traditional wall-suction system in cardiac surgery. METHODS One hundred and twenty adult elective cardiac patients undergoing coronary artery bypass graft and/or valve surgery were randomized to the study or control group. Both groups had similar pre/intra-operative demographics: age 67.8 vs 67.0 years, Euroscore 2.3 vs 2.2, and body surface area 1.92 vs 1.91 m2 . Additionally, a satisfaction assessment score (0-10) was performed by 52 staff members. RESULTS Given homogenous intra-operative variables, total chest-tube drainage was comparable among groups (566 vs 640 mL; ns), but the study group showed more efficient fluid collection during the early postoperative phase due to continuous suction (P = .01). Blood, cell saver transfusions and postoperative hemoglobin values were similar in both groups. The study group experienced drain removal after 29.8 vs 38.4 hours in the control group (ns). Seven crossovers from the Study to the Control group were registered but no patient had drain-related complications. The Personnel Satisfaction Assessment scored above 5 for all questions asked. CONCLUSIONS The new, digital, chest drainage system showed better early drainage of the chest cavity and was as reliable as conventional systems. Quicker drain removal might impact on intensive care unit (ICU) stay and reduce costs. Additional advantages are portable size, battery operation, patient mobility, noiseless function, digital indications and alarms. The satisfaction assessment of the new system by the staff revealed a higher score when compared to the traditional wall suction chest drainage system.
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Affiliation(s)
- Luca Barozzi
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | - Livio San Biagio
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | - Matteo Meneguzzi
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | | | - Beat H Walpoth
- Department of Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona, Verona, Italy
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Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC). TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:429-450. [PMID: 32082905 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/18/2023]
Abstract
Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.
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Ali JM, Wallwork K, Moorjani N. Do patients who require re-exploration for bleeding have inferior outcomes following cardiac surgery? Interact Cardiovasc Thorac Surg 2019; 28:613-618. [PMID: 30325417 DOI: 10.1093/icvts/ivy285] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/11/2018] [Accepted: 09/03/2018] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Do patients who require return to theatre (RTT) for bleeding have inferior outcomes following cardiac surgery? Altogether, 598 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In summary, patients who bleed following cardiac surgery and then RTT have increased mortality and experience greater morbidity, including neurological, respiratory and renal complications, which result in increased length of intensive care unit stay and hospital stay. It is not easy to dissect the relative contribution of the blood loss and consequent haemodynamic instability, the RTT and the increased blood product consumption to the inferior outcomes observed, as there is evidence that each is important. However, several studies have demonstrated RTT to be an independent predictor of morbidity and mortality, even when controlling for amount of transfusion. Patients who bleed and RTT beyond 12 h postoperatively appear to have the poorest outcomes, suggesting that the decision to RTT should not be delayed if there are concerns over significant bleeding, to ensure the best patient outcomes.
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Affiliation(s)
- Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Kate Wallwork
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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Kara H, Erden T. Feasibility and acceptability of continuous postoperative pericardial flushing for blood loss reduction in patients undergoing coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2019; 68:219-226. [PMID: 31325107 DOI: 10.1007/s11748-019-01174-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 07/07/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Postoperative bleeding requires blood transfusion and surgical re-exploration that can affect the short- and long-term postoperative outcomes. Interventions that can be used in the postoperative period to reduce blood loss should be developed. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. This study examined the feasibility and acceptability of CPPF for reducing bleeding after coronary artery bypass surgery. METHODS This pilot study adopted a prospective and group comparison design. Between January and April 2018, 42 patients who underwent isolated coronary artery bypass surgery received CPPF from sternal closure up to 8 h postoperative. The mean actual blood loss in the CPPF group was compared to the mean of retrospectively group (n = 58). In the CPPF group, an extra infusion catheter was inserted through one of the tube incision holes and an irrigation solution (0.9% NaCl at 38 °C) was delivered to the pericardial cavity by using a volumetric pump. Safety aspects, feasibility issues, and complications were documented. The primary outcome was blood loss, and it was assessed 18 h after the surgery. RESULTS CPPF was successfully completed in 40 patients (95.24%). Method-related complications were not observed. Feasibility was good in this experimental setting. Blood loss was lower in the CPPF group (257.24 mL) than non-CPPF group (p < 0.001). CONCLUSIONS CPPF after coronary artery bypass grafting surgery is safe, effective, feasible, and acceptable. However, standardized randomized clinical trials are necessary to draw definitive conclusions.
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Affiliation(s)
- Hakan Kara
- Department of Cardiovascular Surgery, Giresun Ada Hospital, Giresun, Turkey.
| | - Tuncay Erden
- Department of Cardiovascular Surgery, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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Saha S, Baraki H, Kutschka I, Hadem J. Predictive value of ScvO 2 monitoring for pericardial tamponade after cardiac surgery. Herz 2017; 44:76-81. [PMID: 29043406 DOI: 10.1007/s00059-017-4629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/10/2017] [Accepted: 09/11/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND We examined the predictive value of central venous oxygen saturation (ScvO2) changes regarding the occurrence of pericardial tamponade following cardiac surgery. METHODS We retrospectively identified 66 consecutive patients in whom ScvO2 and arterial lactate levels were analyzed during an 8‑h time interval preceding pericardiotomy due to pericardial tamponade (PT), and at equivalent time points in 30 control patients (C) who had an uncomplicated course. RESULTS The median age of the patients was 74 years (interquartile range, 63-78). Three percent of procedures were re-operations. There were no differences between the baseline values of PT and C patients. Pericardiotomy was performed on average 1 day (0-3.5) after cardiac surgery. PT patients displayed a significant decline (p < 0.001) to lower ScvO2 levels (p < 0.001) and a significant increase (p = 0.005) to higher arterial lactate levels (p = 0.019) during the 8 h preceding pericardiotomy, whereas C patients did not (p = 0.440 and p = 0.279, respectively). PT was associated with a longer hospital stay (p = 0.04) and a higher in-hospital mortality (p = 0.008). An ScvO2 decline below 60% (p = 0.018), a delta ScvO2 decline greater than 5% (p = 0.001), and a delta lactate increase greater than 0.18 mmol/l (p = 0.002) during the 8 h preceding pericardiotomy were independently associated with PT. None of these parameters predicted in-hospital mortality. CONCLUSION Deteriorations in ScvO2 might serve as an early marker of PT following cardiac surgery.
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Affiliation(s)
- S Saha
- Department of Cardiothoracic Surgery, University Clinic, Otto-von-Guericke-Universität, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - H Baraki
- Department of Cardiothoracic Surgery, University Clinic, Otto-von-Guericke-Universität, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - I Kutschka
- Department of Cardiothoracic Surgery, University Clinic, Otto-von-Guericke-Universität, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - J Hadem
- Department of Cardiothoracic Surgery, University Clinic, Otto-von-Guericke-Universität, Leipziger Straße 44, 39120, Magdeburg, Germany.
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Manshanden JS, Gielen CL, de Borgie CA, Klautz RJ, de Mol BA, Koolbergen DR. Continuous Postoperative Pericardial Flushing: A Pilot Study on Safety, Feasibility, and Effect on Blood Loss. EBioMedicine 2015; 2:1217-23. [PMID: 26501121 PMCID: PMC4587997 DOI: 10.1016/j.ebiom.2015.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Prolonged or excessive blood loss is a common complication after cardiac surgery. Blood remnants and clots, remaining in the pericardial space in spite of chest tube drainage, induce high fibrinolytic activity that may contribute to bleeding complications. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. In this pilot study, the safety and feasibility of CPPF were evaluated and the effect on blood loss and other related complications was investigated. METHODS Between November 2011 and April 2012 twenty-one adult patients undergoing surgery for congenital heart disease (CHD) received CPPF from sternal closure up to 12 h postoperative. With an inflow Redivac drain that was inserted through one of the chest tube incision holes, an irrigation solution (NaCl 0.9% at 38 °C) was delivered to the pericardial cavity using a volume controlled flushing system. Safety aspects, feasibility issues and complications were registered. The mean actual blood loss in the CPPF group was compared to the mean of a retrospective group (n = 126). RESULTS CPPF was successfully completed in 20 (95.2%) patients, and no method related complications were observed. Feasibility was good in this experimental setting. Patients receiving CPPF showed a 30% (P = 0.038) decrease in mean actual blood loss 12 h postoperatively. CONCLUSIONS CPPF after cardiac surgery was found to be safe and feasible in this experimental setting. The clinically relevant effect on blood loss needs to be confirmed in a randomized clinical trial.
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Affiliation(s)
- Johan S.J. Manshanden
- Department of Cardiothoracic Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Chantal L.I. Gielen
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | | | - Robert J.M. Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Bas A.J.M. de Mol
- Department of Cardiothoracic Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - David R. Koolbergen
- Department of Cardiothoracic Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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