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Letters to the Editor |
Department of Cardiovascular Surgery, Bursa Yüksek Ihtisas Education and Research Hospital, Bursa, Turkey
Received 6 June 2007; accepted 6 August 2007.
* Corresponding author. Address: Bursa Yüksek Ihtisas Education and Research Hospital, Department of Cardiovascular Surgery, Duacinari, 16330 Bursa, Turkey. Tel.: +90 224 360 5050; fax: +90 224 360 5055. (Email: syavuz{at}ttnet.net.tr).
Key Words: Re-exploration • Coronary artery bypass • Surgery • Bleeding • Risk factors
We read with great interest the article by Choong and associates [1]. We would like to congratulate the authors on their well-designed study with the important message that cardiac surgeons should be aggressive in early re-exploration, but we would also like to add some comments.
Excessive bleeding after coronary artery bypass surgery continues to be a concern for cardiac surgeons [2–5]. Re-exploration for bleeding is required in 2–7% of patients, being associated with increased rates of mortality (
10%) and morbidity. In addition, it utilizes hospital resources as a result of increased operative time, blood product use, and prolonged lengths of stay. However, with changes in surgical practice, new blood conservation techniques, and the introduction of antifibrinolytics for bleeding prophylaxis, there has been a substantial decline in the rate of re-exploration for bleeding; currently reported to be approximately 3.1%.
Many studies have attempted to identify patient-specific and procedure-related risk factors of re-exploration for excessive bleeding after coronary artery bypass surgery. The authors’ study re-emphasizes the known risk factors by multivariate analyses. These findings are similar to the reports in previous publications, but the rate of re-exploration is little higher (5.9% vs 3.1%). May the likely reason be valve surgery included in the study?
We think that the group requiring early re-exploration for bleeding is different in several respects from the later (longer than 12 h) group. We are not sure whether the groups compared (as being re-explored early or late) were homogenous. Because of the heterogeneity of these groups and the additional risk factors, these groups may yield inappropriate associations and invalid information despite extensive multivariate modeling. What are authors’ criteria for reoperating while they have compared the outcomes of patients who are reoperated on relatively early versus later or who are in a hemodynamically stable versus unstable condition?
The authors’ major finding is the direct link between adverse outcomes and the time delay to re-exploration. They found that the outcomes are significantly better and the mortality rate is lower (7% vs 29.4%) if there is a delay of less than 12 h to re-exploration. We agree with the authors’ point of view regarding earlier re-exploration. In this respect, my question is: how early is better? i.e.; the first 2 h, the first 4 h, the first 6 h or the first 12 h?
The authors have demonstrated that excessive postoperative bleeding is from surgical sources in the majority of patients (78%). We would like to know why so many incidences of surgical bleeding occurred in their surgical practice. We also would like to ask the authors: what precautions to prevent surgical bleeding from the graft were performed and have they changed any surgical methods in order to decrease the rate of postoperative bleeding? If bleeding from the surgical sites was adequately controlled, could the findings of adverse outcome be decreased?
Meticulous attention to surgical hemostasis and a compulsively thorough search for bleeding, or possibly application of recently developed modalities to facilitate perioperative correction of coagulopathy is important to improve outcomes.
Finally we comment that in a patient with excessive postoperative bleeding, the decision for re-exploration should be made with the knowledge that the outcome will not be worsened by the decision and may be improved.
References
This article has been cited by other articles:
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  C. K. Choong, C. Gerrard, K. A. Goldsmith, and A. Vuylsteke Reply to Yavuz et al. Eur. J. Cardiothorac. Surg., November 1, 2007; 32(5): 820 - 820. [Full Text] [PDF]
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