Re-exploration for hemorrhage following open heart surgery differentiation on the causes of bleeding and the impact on patient outcomes

OBJECTIVES

To differentiate surgical bleeding requiring re-exploration from postoperative coagulopathy and determine the differences in patient outcomes.

METHODS

This was a retrospective chart review of 2,263 adult patients undergoing elective and emergency open heart procedures encompassing coronary artery bypass, valvular, and a combined procedure to determine the impact of source of bleeding leading to re-exploration.

RESULTS

Eighty-two patients (3.6%) required re-exploration. Sixty-six percent had surgical bleeding; the remaining 34% were coagulopathic. Postoperative coagulopathy was associated with preoperative heparin use (37% vs. 19.9% for controls p<0.05). Re-operative procedures combined bypass/ valve (p<0.001) and prolonged cardiopulmonary bypass and aortic cross-clamp times (p<0.05) were more prevalent in the coagulopathy group. Postoperative inotrope use was increased in patients who were re-explored (p<0.001), as were cardiac, pulmonary, renal and abdominal complications (p<0.001), and in all cases those patients with medically related bleeding had worse acute outcomes than the group with surgical causes for re-exploration. The hospital stay was prolonged for both patients with surgical bleeding (23.5 days) and patients with coagulopathy (27.1 days) compared to patients not undergoing re-exploration for bleeding (12.0 days, p<0.001). Survival was 91.3% for patients with surgical bleeding, 87.5% for patients with coagulopathy, and 98.0% for all others (p<0.01).

CONCLUSIONS

Severe postoperative hemorrhage is associated with significant morbidity and increased mortality. Postoperative hospital stay, morbidity, and mortality were significantly worse in patients suffering from coagulopathy when compared to those patients with hemorrhage from surgical causes.

Giant tumors of the chest: preoperative embolization and resection

Giant tumors of the chest are rare. These tumors comprise a spectrum of disease from benign lesions to highly aggressive malignant tumors with cells of origin in the pleura, pulmonary parenchyma, blood vessels, thymus, and connective tissues. We report four cases of giant tumors of the thorax treated with preoperative arterial embolization followed by complete surgical resection. Their diagnostic and treatment courses, imaging, and pathology are described.

Time course of cytokine release and complement activation after implantation of the HeartMate left ventricular assist device

Pro-inflammatory mediators, including interleukin-6 (IL-6), IL-8, and complement C3a, are released after cardiac surgery as part of the inflammatory response related to blood-biomaterial interaction in the cardiopulmonary bypass circuit. Post operative time course data for these mediators are not fully defined in patients receiving left ventricular assist device (LVAD) support. The authors performed enzyme linked immunosorbent assays for concentrations of IL-6, IL-8, and C3a in plasma in six HeartMate LVAD recipients at the following times: pre operatively; 4, 8, 16, 24, 36, and 48 hr post operatively; daily through the first week; and weekly thereafter for 6 weeks. All patients survived without major complications during the study. Pre operative concentrations of IL-6 and C3a in plasma were significantly increased compared with age matched controls. Post operatively, the concentrations of IL-6 and IL-8 in plasma took longer to return to baseline values after insertion of the LVAD than the trends reported in the literature after routine cardiopulmonary bypass alone. Concentrations of IL-6 and complement C3a continued to decrease to lower than baseline post operatively, reaching statistical significance after 6 weeks of LVAD support. The authors conclude that the presence of the HeartMate LVAD delays the return of pro-inflammatory mediator concentrations back to baseline values compared with routine cardiopulmonary bypass alone, but the device does not appear to be an ongoing source of cytokine release or complement activation.

U tubes and rare hepatobiliary complications

U tubes have been used for a wide variety of hepatobiliary problems. We report a patient with multiple complications possibly related to the use of a U tube. These include secondary biliary cirrhosis, intrahepatic bilomas, and enterocutaneous fistula. The relatively rare entities of intrahepatic biloma and enterocutaneous fistula are reviewed.

Pyocolpos: diagnosis and treatment

Pyocolpos is a rare complication of hydrocolpos. Hydrocolpos usually presents during adolescence and is associated with an imperforate hymen. The following is a case of a 3-month-old girl with pyocolpos. Her history was significant for a urinary tract infection (UTI) at 7 weeks of age. The authors believe that her UTI was caused by urinary retention secondary to hydrocolpos. A complete evaluation may have prevented the complication of pyocolpos.

Assessment of esophageal leak with oral fluorescein

Esophageal perforation may occur spontaneously or as a complication of esophageal operations. Treatment often mandates emergency operative intervention to close the leak or to provide adequate drainage. Recurrent or persistent leak can lead to prolonged drainage before final healing. We describe herein a minimally invasive and inexpensive technique using fluorescein dye that can confirm the persistence of esophageal leak drained by tube thoracostomy without requiring expensive and potentially morbid invasive or radiological techniques. Application of this technique assists in diagnosis when previously described minimally invasive techniques are impractical or yield inconclusive results.