Eur J Cardiothorac Surg 2007;32:820. doi:10.1016/j.ejcts.2007.08.004
Copyright © 2007, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Reply to Yavuz et al.
Cliff K. Choonga,b,*,
Caroline Gerrarda,
Kimberley A. Goldsmitha,
Alain Vuylstekea
a Papworth Hospital NHS Trust, Cambridge, United Kingdom
b University of Cambridge, Cambridge, United Kingdom
Received 31 July 2007;
accepted 6 August 2007.
* Corresponding author. Address: University of Cambridge, Papworth Hospital, Papworth Everard, Cambridge CB23 8RE, United Kingdom. Tel.: +44 1480 830541; fax: +44 1954 710475. (Email: cliffchoong{at}hotmail.com).
Key Words: Coronary • Cardiac • Surgery • Re-exploration • Bleeding
We thank Yavuz et al. [1] for their interest and useful comments regarding our study. Yavuz et al. has stated that the current re-exploration rate for bleeding is 3.1% [1]. They have, however, not provided a reference for this figure of 3.1% and have not clarified whether this was following CABG alone or inclusive of all cardiac surgery. Our figure of 5.9% from a study population of 3220 consecutive patients over a 3-year period is inclusive of patients who had concomitant valve surgery (16.9%) and redo-CABG (2.4%) as stated in the manuscript [2]. Most authors would publish only good results and it is uncommon for authors to be willing to publish bad results. In our study, we have reported an honest appraisal of our current experience. This is within the 2–7% re-exploration rate as stated by Yavuz et al. [1]. The intention of the study was to learn from it so as to improve future patient outcomes. The study has demonstrated that earlier re-exploration is better and should be encouraged, while delayed re-exploration is associated with adverse outcomes. The study however did not analyse if there was any significant difference between re-exploration within the first 2, 4, 6 or 12 h. The study has found that the majority of the causes for excessive postoperative bleeding are from surgical sources and this is similar to other published reports. It is our belief that no surgeon would intentionally ignore the presence of any intraoperative bleeding and that chest closure would only occur when the surgeon is satisfied with haemostasis. Bleeding following chest closure can however still occur in a number of scenarios. Examples include vasospasm of a branch of a conduit or intercostal vessel perforated by a sternal wire that may not be bleeding at the time of closure. At a later stage, with vasodilation, the vessel would bleed. It is therefore very difficult in cardiac surgery, for a variety of reasons, to completely eliminate all surgical sources of bleeding. In the study [2], as stated in the results section of the manuscript, 82% of the patients underwent re-exploration because of persistent bleeding while the remaining patients were re-explored for cardiac tamponade. Of the 34 patients who were re-explored 
12 h, 15 (44%) were re-explored because of clinical evidence of cardiac tamponade. We have reported in the manuscript the results of the cardiac tamponade subgroup analysis. We have found that those who were re-explored <12 h had a lower mortality (0%) in comparison to those who were re-explored 12 h (mortality 46.7%; p
= 0.01). We would like to thank Yavuz et al. for their interest in the study, the questions they have raised and the useful comments made regarding this important area in cardiac surgery.
References
- Yavuz S, Eris C, Türk T. Re-exploration for excessive bleeding after coronary artery bypass surgery: how early is better?. Eur J Cardiothorac Surg 2007;32:819-820.[Free Full Text]
- Choong CK, Gerrard C, Goldsmith KA, Dunningham H, Vuylsteke A. Delayed re-exploration for bleeding after coronary artery bypass surgery results in adverse outcomes. Eur J Cardiothorac Surg 2007;31:835-839.
