Abstract
Background
Re-explorations after open-heart surgery is a necessity in this Cardiac Center when a patient is obviously bleeding or shows features of cardiovascular instability. Timely intervention may reduce morbidity and mortality
Objectives
This study aims to correlate the indications with the operative findings for re-explorations after open-heart surgeries as a way of justifying early surgical intervention.
Method
Between May2005 and April2011, 10,083 open-heart surgeries were performed in the Adult Cardiac Surgical Unit of the department of cardiac surgery, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India. The demographic data, the initial diagnoses, the types of surgery, the indications for re-exploration, the intraoperative findings, the timing, the estimated blood loss and treatment for the 362 patients who had reexploration were analysed using the Predictive Analysis Soft -ware(PASW)18.
Result
Out of the 10,083 patients who had cardiac operation within the period of study, three hundred and sixty two (3.6%) patients had re-exploration shortly after the operation. Males were 311(85.9%) while 51(14.1%) were female patients with mean age of 56.7+12.5years .The mean time interval between the primary surgery and the re-exploratory operation was 2.31+1.47hours and the mean chest tube drainage before re-exploration was 770.9+28.8ml. Coronary Artery Diseases (CAD) was the initial diagnosis 258 (71.3%) patients and Coronary Artery Bypass(CABG) operation was the initial surgery in 254(70.2%)patients, CABG and valve in 12(3.3%)patients, Valve surgery alone in 70(19.3%) patients, Bentall procedure(homograft aortic root replacement)in 13(3.6%) patients, others such as off-pump coronary artery bypass, Dor procedure(patch restoration of left ventricle by incising the aneurysm without excising it), pericardiectomy and thromboembelectomy in 13(3.6%). The indications for re-exploration were post operative haemorrhage in 283(78.2%) patients, Cardiac tamponade in 41(11.3%)patients, reactionary haemorrhage and cardiac tamponade in 12(3.3%)patients, clots In 20(5.5%) patients, open sternum 5(1.4%) and forgotten foreign body in 1(0.3%)patients. The intraoperative findings in 351(97.2%) patients revealed mediastinal clots and bleeding points, while no active bleeding was seen at re-operation in 11(2.8%) patients. Pearsons Chi-square test between the indications for re-exploration and the intraoperative findings was significant (p value<0.001).
Conclusion
There is strong evidence supporting early re-exploration in patients after open-heart surgeries, complicated by reactionary haemorrhage, cardiac tamponade and intra-thoracic clots; early re-exploration reduced morbidity and mortality.
Keywords: Re-operation after open-heart surgery, Indications, Early re-exploration, Good outcome , India
Introduction
The indications for re-exploration soon after cardiac surgeries are diverse and to decide on time for the re-exploration is challenging. The incidence of reexploration as reported worldwide is about 2-5%.1,2,3. This is a significant decrease from the earlier reported incidence of 15%, before improved surgical techniques were adopted.4. The commonest causes of chest reexploration are macrovascular or microvascular bleeding which can be massive or associated with haemodynamic instability leading to hypotension or cardiogenic shock. In addition, it could be due to clots in the mediastinum as detected by the compressive effect leading to cardiac tamponade or detected by transthoracic or transoesophageal echocardiography 5, and in some case when the chest was left open at the end of surgery 6.Reactionary hemorrhage is the most frequent indication for reexploration 6 and may occur because of surgical or systemic diseases.7 Studies have indicated that in 70 - 80 % of the cases bleeding is surgical 8
Intraoperative findings such as bleeding vessels or oozing from the sternal edge or bed of vessel graft or cannulation sites, the presence of clots or forgotten gauze. It is important to note that cardiac tamponade might not have the obvious clinical features of ‘tamponade’5 and early exploration prevents the continual loss of blood with subsequent reduction of the transfusion of blood and blood products as a result of anaemia and coagulopathy. The effect of blood loss on end organs like the kidneys are equally curtailed by early re-exploration and importantly, anxiety on part of the health workers in monitoring such unstable patients is therefore minimised.
On the other hand it has been noted that chest re-exploration after cardiac surgery may lead to increased transfusion of blood and blood products, prolonged ICU and Hospital stay 9, increased chest wound infection, slower recovery, and increased mortality.10
This study aims to determine the correlation between the indications and the operative findings at re-exploration after open heart surgery and to justify the need for early surgical intervention.
Reports
Patient and methods
Between May 2005 and April 2011, a total of 10,083 open-heart surgeries were performed in the Adult Cardiac Surgical Unit of the Hospital. Three hundred and sixty two of these patients (3.6% of the total open heart operations) were reexplored in the theatre for obvious bleeding or due to hemodynamic instability, clots in the mediatinum as detected by echocardiography or due to compressive effect leading to cardiac tamponade, forgotten Gauze and to close the chest which was left open at the primary surgery. They included only first-time re-exploration and excluded patients explored for sternal wound infections. The medical records of these patients were retrospectively reviewed. The demographic data, indication for reexploration, duration of surgery, estimated blood loss and intraoperative findings during the reexploration were analyzed using the Predictive Analysis Soft- ware (PASW) 18.
Surgical Technique
Initial management consisted of adequate drainage by the use of mediastinal tube drainage and pleural tube drainage to prevent cardiac tamponade, along with correction of any detectable haemostatic abnormalities.
The team consisted of one or more cardiac surgeon, surgeons’ assistant and a theatre nurse and a perfusionist should cardiopulmonary bypass be required. After the administration of general anaesthesia the operating site was prepared with povidone-iodine solution and sterile drapes were used to isolate the operating field.
Under appropriate antibiotic cover, the skin sutures and sternal wires were removed; the soft tissues and the sternal edges, wire points and the bed of internal mammary artery were inspected for any bleeding points. Any clots within the mediatinum and cavities were evacuated and systematic inspection of all operative sites was undertaken-cannulation sites (aortotomy and caval sites), vessels (Internal mammary artery, anterior jugular vein, thymic, intercostals), anastomotic sites (proximal and distal) and other areas such as the pericardial, pleural edges and lung tissue. Bleeding sites were controlled by applying stainless-steel clips, re-enforcing sutures, irrigation of the wound and application of bone wax on the sternal edges depending on the findings. After haemostasis was achieved the wound was thereafter irrigated with saline and closed in the standard manner after inserting appropriate drainage tubes. Sternal wire was used to close the sternum while the subcutaneous tissues and skin were closed with absorbable suture material. In cases of continuous and diffuse bleeding that could not be controlled surgically, the oozing area was packed with gauze and, the sternum left open, and only the skin was closed or cut edge of Saline Pack sutured round the wound edges. Coagulation studies were further done and derangement corrected as indicated. The packing was removed once the patient was stable by further re-exploration. The Hospital protocol is for early reexploration (within 12hrs after the primary surgery).
Result
Three hundred and sixty two patients had re-exploration between May 2005 and April 2011-comprising 3.6% of the total open-heart operations performed during this period of study in this Cardiac Centre. Out of these, 311(85.9%) patients were males and 51 (14.1%) females, with a mean age of 56.7+ 12.5 and a range of 21 - 83.5 years. The mean interval between the initial surgery and the re-exploration was 2.31 +1.47 hours, with a range of 1-12hours.The mean chest tube drainage of blood before re-exploration was 770.9 + 28.8ml and a range of 30-2670ml. The Diagnoses for the initial surgery were: Coronary Artery Diseases (CAD) in 258 (71.3%) patients, CAD and Valve Diseases in 13(3.6%) patients, Valve Diseases alone in 70(19.3%) patients, Aortic Root Aneurysm in 13(3.6%) patients, others (constrictive pericarditis, right atrial myxoma and pulmonary embolism) 8(2.2%) patients as shown in Table 1. The initial operation were : Coronary Artery Bypass(CABG) surgery in 254(70.2%)patients, CABG and valve in 12(3.3%)patients, Valve surgery in 70(19.3%) patients, Bentall procedure in 13(3.6%) patients, others such as Off-pump-coronary artery bypass, Dor procedure, pericardiectomy and thromboembelectomy in 13(3.6%) patients as shown in Table 2. The indications for re-exploration were as follows: reactionary haemorrhage in 283(78.2%)patients, cardiac tamponade in 41(11.3%) patients, both reactionary haemorrhage and cardiac tamponade in 12(3.3%)patients, clots in 20(5.5%) patients, open sternum in 5(1.4%),forgotten foreign body in 1(0.3%)patients as shown in Table 3.The intraoperative findings In 351(97.2%)patients revealed clots and actively bleeding points during the re-exploration while in11(2.8%)patients no active bleeding was seen as shown in Table 4. The cross tabulation between the indications for re-operation and the Intraoperative findings are shown in Table 5.The treatment offered re-operation is shown in Table 6.
Statistical analysis
The significance in the relationship between the indications for reexploration and the intraoperative findings was significant using Pearsons Chi-square which was significant (p value<0.001).
Conclusions
There is strong evidence supporting early re-exploration in patients after open-heart surgeries, complicated by reactionary haemorrhage, cardiac tamponade, and intra-thoracic clots formation; early re-exploration when indicated may help reduced morbidity and mortality.
Discussion
The main finding from the study was that early intervention prevents morbidity and mortality in patients with immediate complication after open heart surgery. The indications for the re-exploration are usually obvious and would not require complicated investigations and time is of immense essence.
The incidence of re-exploration 3.6% following open heart surgery from our study correlates well with other studies despite the fact that we adopted early surgical intervention 1,2,3. This study has shown that re-exploring the patients early when indicated instead of watchful waiting did not unusually increase the re-exploration rate. The study, also, demonstrated the correlation between the indications for re-exploration and the intraoperative findings as 97.2% of patients had the same intraoperative findings as the indications for surgery. The statistical relationship between the indications for re-exploration and the intraoperative findings using Pearson chi-square was significant (p value<0.001).
Mataraca and coworkers observed that delayed re-exploration was associated with a higher infection rate, which was responsible for high mortality 11. Delaying re-exploration with the attendant need for excessive use of allogeneic blood products or in the presence of clinical signs of cardiac tamponade represents a risk factor for increased morbidity and mortality as shown by Ranucci et al 12
The Indications for re-exploration from our study includes reactionary haemorrhage ,cardiac tamponade ,open sternum ,forgotten gauze and when juxtaposed with intraoperative findings of bleeding from cannulation and anastomotic sites, sternal edges, pericardial edges, heart surface, vessels(macrovascular and microvascular) and clots in the chest cavity gave even more credence as to the justification for the reexploration.
Choong and coworkers observed that patients requiring re-exploration for reactionary haemorrhage were at increased risk if time for re-exploration was prolonged for 12 h or more. On that basis, they strongly recommended a policy of early re-exploration for bleeding, as early re-exploration did not increase the risk of mortality and an identifiable cause was usually found 13. Also, Karthik et al concluded that patients who needed re-exploration were at higher risk of complications if the time to re-explore was prolonged and recommended that policies promoting early re-exploration should be encouraged 14 just as Choong and coworkers had also determined 13
The significance of a negative re-exploration for excessive postoperative hemorrhage after cardiac operation is not only advantageous in excluding surgical bleeding, a cause that can be readily controlled by ligation and suturing or application of clips. Various haematologic abnormalities could cause continued bleeding or oozing, could coexist and the pooled blood or clot removed during re-exploration. Thus even in situations of negative intraoperative findings, Pelletier and colleagues had shown that the removal of clots and consequent reduction in fibrinolytic activity in the mediatinum is therapeutic on its own.15 Evacuating the clots, a rich culture medium for proliferation of bacteria is known to help in reduction in infection rate.
Over dependence on investigative parameters like transoesophageal echocardiography ,which is widely considered the gold standard for the diagnosis of tamponade, may not really be so. The haemodynamically significant pericardial collections occurring early after cardiac surgery rarely cause the classical clinical or echocardiographic findings of tamponade. The recognition of this fact is necessary to ensure that appropriate surgical intervention was not delayed as observed by Price et al5. Thus from the moment such clinical suspicion is harboured an earlier intervention is advised as delay may be attended by dire consequences instead of waiting for the ‘’classical signs’’
Delayed re-exploration required continuous monitoring and the attendant continuous bleeding with blood loss which, from our study could be as high as 2670ml. This could have adverse effect on end organs and high morbidity and mortality .Early re-exploration shortly after cardiac surgery, when indicated did not lead to worse outcome but improved the clinical condition of the patient and good outcome.
The findings from our study showed that indications for re-exploration correlated well the intraoperative findings. Thus early re-exploration, when indicated reduced the incidence of morbidity and mortality as well as minimised the duration of anxiety among the managing team.
Table 1 -The Diagnosis for Initial Surgery
| Diagnosis | number | Percent (%) | |
| Coronary Artery Disease | 258 | 71.3 | |
| Coronoary Artery Disease + Valve Disease | 13 | 3.6 | |
| Valve Disease | 70 | 19.3 | |
| Aortic Root Aneurysm | 13 | 3.6 | |
| Others | 8 | 2.2 | |
| Total | 362 | 100.0 |
Table 2- The Initial Surgery
| Surgery | Number | Percent (%) | |
| 1 | CABG | 254 | 70.2 |
| 2 | CABG+Valve Surgery | 12 | 3.3 |
| 3 | Valve Surgery | 70 | 19.3 |
| 4 | Bentall’s procedure | 13 | 3.6 |
| 6 | Others | 13 | 3.6 |
| Total | 362 | 100 |
Table 3- Indications For Reexploration
| Indication | Number | Percent (%) | ||
|---|---|---|---|---|
| 1 2 3 4 5 6 | Reactionary Haemorrhage | 283 | 78.2 | |
| Cardiac Tamponade | 41 | 11.3 | ||
| Haemorrhage+Cardiac Tamponade | 12 | 3.3 | ||
| Clots | 20 | 5.5 | ||
| Open Sternum | 5 | 1.4 | ||
| Forgotten Gauze | 1 | .3 | ||
| Total | 362 | 100.0 | ||
Table 4 The Intraoperative Findings
| Findings | Number | Percent (%) | ||
|---|---|---|---|---|
| 12345678910 | No Bleeding | 10 | 2.8 | |
| Generalised Oozing | 66 | 18.2 | ||
| Clots | 97 | 26.8 | ||
| Bleeding Sternum | 69 | 19.1 | ||
| Bleeding Vessels | 64 | 17.7 | ||
| Bleeding Anastomotic Site | 9 | 2.5 | ||
| Bleedig Cannulation site | 16 | 4.4 | ||
| Clots+ bleeding Vessel | 8 | 2.2 | ||
| Bleeding Sternum+Vessel | 7 | 1.9 | ||
| Bleeding from Heart Surface | 10 | 2.8 | ||
| Bleeding from Others sites | 6 | 1.7 | ||
| Total | 362 | 100.0 | ||
| Note: 351(97.2%) patients had clots and bleeding areas in the chest at reexploration while 10(2.8%) showed no bleeding areas | ||||
Table 5-Cross tabulation between the indications and the Intra-operative Findings following Re-exploration
| Indications For Reexploration | Total | |||||||
|---|---|---|---|---|---|---|---|---|
| Reactionary Haemorrhage | Cardiac Tamponade | Reactionary haemorrhage+ Cardiac Tamponade | Clot | Open Sternum | Forgotten Gauze | |||
| Intraoperative Findings | No Bleeding | 2 | 7 | 0 | 0 | 0 | 0 | 9 |
| Generalised Oozing | 61 | 0 | 1 | 0 | 0 | 1 | 63 | |
| Clots | 70 | 13 | 5 | 7 | 1 | 0 | 96 | |
| Sternum | 44 | 6 | 2 | 11 | 3 | 0 | 66 | |
| Vessels | 49 | 10 | 2 | 1 | 0 | 0 | 62 | |
| Anastomotic Site | 3 | 3 | 0 | 0 | 1 | 0 | 7 | |
| Cannulation site | 12 | 1 | 0 | 0 | 0 | 0 | 13 | |
| Clot+Vessel | 5 | 0 | 0 | 1 | 0 | 0 | 6 | |
| Sternum+Vessel | 4 | 0 | 2 | 0 | 0 | 0 | 6 | |
| Heart Surface | 8 | 1 | 0 | 0 | 0 | 0 | 9 | |
| Others | 6 | 0 | 0 | 0 | 0 | 0 | 6 | |
| Total | 264 | 41 | 12 | 20 | 5 | 1 | 343 | |
| Testing using Pearsons Chi-square which was significant (p value<0.001), that is, x2=120.864(0.000). | ||||||||
Table 6 -Treatment at Re-exploration
| Treatment | Number | Percent(%) | ||
|---|---|---|---|---|
| 123456 | Irrigation | 209 | 57.7 | |
| Clipping of Vessels | 91 | 25.1 | ||
| Bone Waxing | 31 | 8.6 | ||
| Re-enforcing Sutures | 19 | 5.2 | ||
| Packing with Gauze | 6 | 1.7 | ||
| Others | 6 | 1.7 | ||
| Total | 362 | 100.0 | ||
Acknowledgment
Mr. Manoharan Theodore of Medical Records and Nursing staff of Intensive Care Unit of the Madras Medical Mission, Chennai, India for data collection and Mr. Raphael Y. Adebayo of the Department of Statistics University of Ibadan, Nigeria for statistical analysis.`
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
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