Is there a correlation between late re-exploration after cardiac surgery and removal of epicardial pacemaker wires?

Abstract

BackgroundRe-exploration for bleeding accounts for increased morbidity and mortality after major cardiac operations. The use of temporary epicardial pacemaker wires is a common procedure at many departments. The removal of these wires postoperatively can potentially lead to a serious bleeding necessitating intervention.MethodsFrom Jan 2011 till Dec 2015 a total of 4244 major cardiac procedures were carried out at our department. We used temporary epicardial pacemaker wires in all cases. We collected all re-explorations for bleeding and pericardial tamponade from our surgical database and then we focused on the late re-explorations, meaning on the 4th postoperative day and thereafter, trying to identify the removal of the temporary pacemaker wires as the definite cause of bleeding. Patients’ records and medication were examined.ResultsThirty-nine late re-explorations for bleeding, consisting of repeat sternotomies, thoracotomies and subxiphoid pericardial drainages, were gathered. Eight patients had an acute bleeding incidence after removal of the temporary wires (0.18%). In four of these patients, a pericardial drainage was inserted, whereas the remaining patients were re-explorated through a repeat sternotomy. Two patients died of the acute pericardial tamponade, three had a blood transfusion and one had a wound infection. Seven out of eight patients were either on dual antiplatelet therapy or on combination of aspirin and vitamin K antagonist.ConclusionsA need for re-exploration due to removal of the temporary pacemaker wires is a very rare complication, which however increases morbidity and mortality. Adjustment of the postoperative anticoagulation therapy at the time of removal of the wires could further minimize or even prevent this serious complication.

Incidence of tamponade following temporary epicardial pacing wire removal

“…While the use of antiplatelet agents and anticoagulation is hypothesized to play a role in this complication, larger numbers would be needed to develop definitive results. Despite these limitations, our findings are in keeping with prior studies that report a very low risk of tamponade following TEPW removal 2,3 …”

“…This is a contemporary study examining the rates of bleeding and tamponade following TEPW removal at a single institution. Our center's rate of 9.4 cases per 10 000 is very similar to the Cleveland Clinic experience of 9.7/10 000, 2 and half of that experienced by Bougioukas et al 3 (18/10 000).…”

“…However, there does appear to be an increase in incidence over time, with all of the events being in the second half of the study period. This is in the same era as Bourgioukas et al 3 who found a higher incidence. The increase incidence over time may reflect evolving recommendations for dual antiplatelet therapy in ACS 5‐7 and anticoagulation guidelines 7,8 as well as a trend toward increasing DVT prophylaxis.…”

“…It is most commonly used as a precautionary measure to ensure a stable cardiac rhythm in the early postoperative period, particularly in cases of bradyarrhythmias 1 . Although it is standard practice in most centers to pull and remove the TEPW before discharge, there are reports of tamponade following removal 2,3 . Alternatively, cutting pacing wires and allowing them to retract internally can have long term morbidity, often related to pacing wire migration 4 …”

Meta-analysis of the Sources of Bleeding after Adult Cardiac Surgery

“…Sites of insertion of temporary pace-maker wires and of chest tubes may account for less frequent causes of excessive bleeding. 5,10,28 These findings suggest that most of severe bleeding events can be prevented by a meticulous surgical technique and systematic checking of potential sites of bleeding. After having observed that severe bleeding originated mostly from surgical sites, 16 Loor et al 7 introduced a checklist for a systematic intraoperative evaluation of potential surgical sources of bleeding.…”