- Email: [email protected]
Correspondence
1472
CORRESPONDENCE
ally, Ms Maureen O’Brien provided technical assistance to this project.
A. Laurie W. Shroyer, PhD Gary K. Grunwald, PhD Fred H. Edwards, MD Frederick L. Grover, MD
Ann Thorac Surg 1998;66:1466 –72
David B. Ross, MD Allan McIntyre, MD Carolyn MacDougall, RN Division of Cardiovascular Surgery and Cardiac Anaesthesia QEII Health Sciences Center 1796 Summer St, Halifax, NS Canada B3H 3A7
Reference
Division of Cardiac Research Veterans Affairs Medical Center 1055 Clermont St (151R) Denver, CO 80220
1. Pelletier MP, Solymoss S, Lee A, Chiu RC-J. Negative reexploration for cardiac postoperative bleeding: can it be therapeutic? Ann Thorac Surg 1998;65:999 –1002.
References
To the Editor:
1. Shroyer ALW, Grover FL, Edwards FH. 1995 Coronary artery bypass risk model: The Society of Thoracic Surgeons Adult Cardiac National Database. Ann Thorac Surg 1998;65:879– 84. 2. Hosmer DW, Lemeshow S. Applied logistic regression. New York: John Wiley and Sons, 1989:171–3. 3. Grover FL, Johnson RR, Shroyer ALW, Marshall G, Hammermeister KE. The Veterans Affairs Continuous Improvement in Cardiac Surgery Study. Ann Thorac Surg 1994;587:1845–51.
Reoperation for Cardiac Postoperative Bleeding To the Editor: We read with interest the article by Pelletier and associates [1] describing a novel theory explaining why negative exploration for bleeding after a cardiac operation sometimes seems therapeutic. We also have noted this effect on occasion. The reoperation rate for bleeding quoted in this article of 3% to 5% (7% for redo cases) seems high, at least in our experience. From March 1995 to March 1998, we performed 3,213 open cardiac operations of all types including routine cases as well as emergency thoracic aortic operations. As we are the only cardiac center for our region, this represents an unselected population. All patients received an antifibrinolytic agent, almost always «-aminocaproic acid (150 mg/kg loading dose and 15 mg z kg21 h21 infusion for the duration of the operation). A few patients received aprotinin. Forty-one patients underwent reoperation for bleeding (1.27%; 95% confidence interval, 0.89% to 1.66%). In the 373 patients (11.6%) who had had one or more previous cardiac operations the reoperation rate for bleeding was 2.41% (95% confidence interval, 0.86% to 3.97%). An aggressive approach to reoperation for bleeding was employed, and overall only 29.6% of all patients required transfusion of blood products. For those having had one or more previous cardiac operations the transfusion rate was 46%. With meticulous surgical technique and the routine use of antifibrinolytic agents the problem of postoperative bleeding can be reduced to a fraction of its former rate with obvious benefits for both the patients and the surgical staff.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Reply
We appreciate the comments of Dr Ross and colleagues. The reoperation rate for bleeding of 3% to 5% (7% for redo cases) quoted in our article, although seemingly high, is not only in concordance with published reports [1–3] but also in accord with available data from The Society of Thoracic Surgeons national cardiac surgery database. Reoperation rates for first-time coronary artery bypass, aortic valve replacement, and mitral valve replacement in 1995 to 1996 were 2.05%, 3.68%, and 4.23%, respectively. For redo cases, the incidence rose to 2.95%, 5.46%, and 4.34%. With the current practice of using autotransfusion systems for mediastinal blood, colleagues at one of our institutions also have reported a low reexploration rate of 1.5% after coronary artery bypass, with a transfusion-free rate of 51.9% [4]. With the increasingly popular use of agents such as «-aminocaproic acid and aprotinin, and with many studies demonstrating decreased postoperative bleeding as the result, a reduction in reexploration rate could be expected. Marc P. Pelletier, MD Ray C.-J. Chiu, MD, PhD Division of Cardiothoracic Surgery McGill University 1650 Cedar Ave, Rm C9.169 Montreal, PQ, Canada H3G 1A4
References 1. Moulton MJ, Creswell LL, Mackey ME, et al. Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg 1996;111:1037– 46. 2. Spiess BD, Gilies BS, Chandler W, Verrier E. Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiovasc Anesth 1995;9:168–73. 3. Unsworth-White MJ, Herriot A, Valencia O, et al. Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality. Ann Thorac Surg 1995;59: 664–7. 4. DeVarennes B, Nguyen D, Denis F, Ergina P, Latter D, Morin JE. Reinfusion of mediastinal blood in CABG patients: impact on homologous transfusions and rate of reexploration. J Card Surg 1996;11:387–95.
0003-4975/98/$19.00
CORRESPONDENCE
ally, Ms Maureen O’Brien provided technical assistance to this project.
A. Laurie W. Shroyer, PhD Gary K. Grunwald, PhD Fred H. Edwards, MD Frederick L. Grover, MD
Ann Thorac Surg 1998;66:1466 –72
David B. Ross, MD Allan McIntyre, MD Carolyn MacDougall, RN Division of Cardiovascular Surgery and Cardiac Anaesthesia QEII Health Sciences Center 1796 Summer St, Halifax, NS Canada B3H 3A7
Reference
Division of Cardiac Research Veterans Affairs Medical Center 1055 Clermont St (151R) Denver, CO 80220
1. Pelletier MP, Solymoss S, Lee A, Chiu RC-J. Negative reexploration for cardiac postoperative bleeding: can it be therapeutic? Ann Thorac Surg 1998;65:999 –1002.
References
To the Editor:
1. Shroyer ALW, Grover FL, Edwards FH. 1995 Coronary artery bypass risk model: The Society of Thoracic Surgeons Adult Cardiac National Database. Ann Thorac Surg 1998;65:879– 84. 2. Hosmer DW, Lemeshow S. Applied logistic regression. New York: John Wiley and Sons, 1989:171–3. 3. Grover FL, Johnson RR, Shroyer ALW, Marshall G, Hammermeister KE. The Veterans Affairs Continuous Improvement in Cardiac Surgery Study. Ann Thorac Surg 1994;587:1845–51.
Reoperation for Cardiac Postoperative Bleeding To the Editor: We read with interest the article by Pelletier and associates [1] describing a novel theory explaining why negative exploration for bleeding after a cardiac operation sometimes seems therapeutic. We also have noted this effect on occasion. The reoperation rate for bleeding quoted in this article of 3% to 5% (7% for redo cases) seems high, at least in our experience. From March 1995 to March 1998, we performed 3,213 open cardiac operations of all types including routine cases as well as emergency thoracic aortic operations. As we are the only cardiac center for our region, this represents an unselected population. All patients received an antifibrinolytic agent, almost always «-aminocaproic acid (150 mg/kg loading dose and 15 mg z kg21 h21 infusion for the duration of the operation). A few patients received aprotinin. Forty-one patients underwent reoperation for bleeding (1.27%; 95% confidence interval, 0.89% to 1.66%). In the 373 patients (11.6%) who had had one or more previous cardiac operations the reoperation rate for bleeding was 2.41% (95% confidence interval, 0.86% to 3.97%). An aggressive approach to reoperation for bleeding was employed, and overall only 29.6% of all patients required transfusion of blood products. For those having had one or more previous cardiac operations the transfusion rate was 46%. With meticulous surgical technique and the routine use of antifibrinolytic agents the problem of postoperative bleeding can be reduced to a fraction of its former rate with obvious benefits for both the patients and the surgical staff.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Reply
We appreciate the comments of Dr Ross and colleagues. The reoperation rate for bleeding of 3% to 5% (7% for redo cases) quoted in our article, although seemingly high, is not only in concordance with published reports [1–3] but also in accord with available data from The Society of Thoracic Surgeons national cardiac surgery database. Reoperation rates for first-time coronary artery bypass, aortic valve replacement, and mitral valve replacement in 1995 to 1996 were 2.05%, 3.68%, and 4.23%, respectively. For redo cases, the incidence rose to 2.95%, 5.46%, and 4.34%. With the current practice of using autotransfusion systems for mediastinal blood, colleagues at one of our institutions also have reported a low reexploration rate of 1.5% after coronary artery bypass, with a transfusion-free rate of 51.9% [4]. With the increasingly popular use of agents such as «-aminocaproic acid and aprotinin, and with many studies demonstrating decreased postoperative bleeding as the result, a reduction in reexploration rate could be expected. Marc P. Pelletier, MD Ray C.-J. Chiu, MD, PhD Division of Cardiothoracic Surgery McGill University 1650 Cedar Ave, Rm C9.169 Montreal, PQ, Canada H3G 1A4
References 1. Moulton MJ, Creswell LL, Mackey ME, et al. Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg 1996;111:1037– 46. 2. Spiess BD, Gilies BS, Chandler W, Verrier E. Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiovasc Anesth 1995;9:168–73. 3. Unsworth-White MJ, Herriot A, Valencia O, et al. Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality. Ann Thorac Surg 1995;59: 664–7. 4. DeVarennes B, Nguyen D, Denis F, Ergina P, Latter D, Morin JE. Reinfusion of mediastinal blood in CABG patients: impact on homologous transfusions and rate of reexploration. J Card Surg 1996;11:387–95.
0003-4975/98/$19.00