Adverse outcomes from reoperation after cardiac surgery: There's more to it than blood

Abstract

Despite antifibrinolytic drugs and improved medical management of coagulopathy, bleeding sufficient to require reexploration after cardiac surgery continues to occur. But, which leads to adverse outcomes: bleeding or reexploration? Ruel and colleagues 1 provide valuable insights regarding the consequences of reexploration in their single-institution observational study of approximately 17,000 patients. A key finding from their study was that in-hospital mortality increased from 2.8% to 12% among patients requiring reexploration, greater than would be expected using standard risk adjustment. Reexploration also was associated with an increased likelihood of surgical site infection, intensive care unit (ICU) readmission, postoperative atrial fibrillation, and renal insufficiency, and with increased ICU and hospital lengths of stay. Ruel and colleagues 1 provide several interesting insights. Many of us would assume that worse outcomes associated with reexploration arise from its association with blood loss and blood transfusion. Of note, the authors found that reexploration was independently associated (odds ratio [OR], 3.4) with mortality, even with adjustment for blood product administration (OR, 1.02 per unit) in a multivariable model. This is robust evidence that the negative impact of reexploration on mortality and morbidity cannot be blamed on the ill effects of blood transfusions alone. The authors 1 confirmed previous findings that urgent or emergency surgery increases the likelihood of reexploration 2-4 and that delayed reexploration worsens outcomes. 4 Of the 4.2% individuals requiring reexploration, 54.2% underwent reexploration on the day of surgery. These patients had an OR of 2.0 (P < .001) for mortality, compared with 6.4 (P<.001) for those undergoing later reexplorations. We were intrigued by the authors' findings 1 that tricuspid valve repair was associated with both reexploration (OR, 2.6; P <.

Safety and efficacy of ketorolac in improving the prognosis of acute type A aortic dissection patients: a protocol of a randomized, double-blinded, and placebo-controlled study

“…The primary endpoint of efficacy was used to calculate the sample size. In the literature, the total death rate of hospitalization after surgery was 25% [ 7 ], the incidence of organ malperfusion syndrome was 15–33% [ 19 , 20 ], permanent dialysis was 2.6% [ 21 ], tracheotomy was 8% [ 22 ], neurological impairment was 6.9% [ 22 ], postoperative mechanical circulatory support was 20% [ 23 ], unplanned cardiac reoperation was 4.2% [ 24 ], and postoperative cardiac arrest was 0.7–5.2% [ 25 ]. Therefore, we assumed that the incidence of composite endpoint events in the control group is 70%, and the incidence of composite endpoint events in the ketorolac group is reduced to 40%.…”