Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Ann Thorac Surg. 2011 Jun;91(6):1780-90. doi: 10.1016/j.athoracsur.2011.03.105.
Etiology for increased morbidity in patients (2% to 8%) undergoing reoperation for bleeding after cardiac surgery is unclear. Recent work suggests that it may be related to red-cell transfusion, but what role does reoperation itself play? We sought to determine prevalence of and risk factors for reoperation for bleeding, separate the effect of reoperation from that of transfusion on hospital mortality and major morbidity, and identify the source of bleeding.
From January 1, 2000 to January 1, 2010, 18,891 primary and repeat coronary artery bypass grafting, valve, or combined operations were performed. Risk factors for reoperation were identified by multivariable logistic regression. Hospital mortality and major morbidity were compared in propensity-matched patients requiring reoperation and not. Medical records from 2005 to 2010 were reviewed to determine bleeding source.
A total of 566 patients (3.0%) underwent reoperation for bleeding, with considerable variability over time. Risk factors included older age, higher acuity, greater comorbidity, aortic valve surgery, longer myocardial ischemic and cardiopulmonary bypass durations, and surgeon. Mortality was higher for propensity-matched patients requiring reoperation; 8.5% (68% confidence interval [CI] 7.3% to 9.9%) versus 1.8% (CI 1.2% to 2.5%). Both greater transfusion and reoperation were independently associated with increased risk of mortality and major morbidity. At reoperation, technical factors (74%), coagulopathy (13%), both (10%), or other (3.3%) causes were responsible for bleeding.
Transfusion and reoperation for bleeding both contribute to postoperative mortality and morbidity. Technical reasons are at the root of most bleeding, emphasizing a major focus for process improvement to minimize need for reoperation and blood use.
心脏手术后出血再次手术患者（2%-8%）发病率增加的病因尚不清楚。最近的研究表明，这可能与红细胞输注有关，但再次手术本身起什么作用呢？我们试图确定出血再次手术的发生率和危险因素，将再次手术的作用与输血的作用分开，以确定住院死亡率和主要发病率的关系，并确定出血的来源。
2000 年 1 月 1 日至 2010 年 1 月 1 日，共进行了 18891 例初次和再次冠状动脉旁路移植术、瓣膜或联合手术。多变量逻辑回归确定了再次手术的危险因素。对需要再次手术和不需要再次手术的患者进行倾向性匹配，比较住院死亡率和主要发病率。回顾 2005 年至 2010 年的病历以确定出血来源。
共有 566 例（3.0%）患者因出血而行再次手术，且随时间变化差异较大。危险因素包括年龄较大、病情较重、合并症较多、主动脉瓣手术、心肌缺血和体外循环时间较长以及外科医生。需要再次手术的患者死亡率更高；匹配患者的死亡率为 8.5%（置信区间 [CI]：7.3%至 9.9%），而不需要再次手术的患者死亡率为 1.8%（CI：1.2%至 2.5%）。输血和再次手术均与死亡率和主要发病率增加独立相关。再次手术时，技术因素（74%）、凝血障碍（13%）、两者均有（10%）或其他原因（3.3%）是出血的原因。
输血和再次手术导致术后死亡率和发病率增加。大多数出血是由技术原因引起的，这强调了主要的流程改进重点，以尽量减少再次手术和血液使用的需求。
