A protocol-driven approach to cardiac reoperation reduces mortality and cardiac injury at the time of resternotomy.

BACKGROUND

The purpose of this study was to determine whether an established protocol-driven approach to cardiac reoperations would improve patient outcomes and reduce resternotomy injuries.

METHODS

From 1995 to 2010, 946 patients undergoing cardiac reoperations were stratified into reoperative protocol (n=344, age=61±17 years) vs no-protocol (n=602, age=64±14 years) comparison groups.

RESULTS

Protocol patients underwent more complex reoperations (procedure type "other": 24% vs 15%, p<0.001). Initiation of CPB before sternotomy was similar between study groups (5% vs 3%, p=0.07). Resternotomy ventricular injuries were most common. Mortality was lower for protocol patients (6% vs 10%, p=0.04), and the use of a reoperative protocol was associated with a significantly reduced incidence of resternotomy injury (3% vs. 10%, p<0.001). On multivariate analysis, reoperative protocol was associated with a nearly 70% reduction in risk-adjusted odds of resternotomy injury (p=0.001).

CONCLUSIONS

A protocol-driven approach to cardiac reoperations is associated with reduced cardiac injury upon resternotomy and decreased mortality. The protocol-driven use of routine preoperative computed tomography angiography, alternative cannulation planning, avoidance of prior internal mammary artery grafts, and the early initiation of cardiopulmonary bypass before sternotomy for selected cases should be considered to improve operative results and efficiency.