Biancari Fausto, Kinnunen Eeva-Maija, Kiviniemi Tuomas, Tauriainen Tuomas, Anttila Vesa, Airaksinen Juhani K E, Brascia Debora, Vasques Francesco
Department of Surgery, University of Turku, Turku, Finland; Department of Surgery, University of Oulu, Oulu, Finland; Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
Department of Surgery, University of Oulu, Oulu, Finland.
J Cardiothorac Vasc Anesth. 2018 Aug;32(4):1618-1624. doi: 10.1053/j.jvca.2017.12.024. Epub 2017 Dec 13.
The aim of this study was to pool data on the proportion and prognostic impact of sources of bleeding in patients requiring re-exploration after adult cardiac surgery.
Systematic review of the literature and meta-analysis.
Multistitutional study.
A literature review was performed to identify studies published since 1990 evaluating the outcome after reoperation for bleeding or tamponade after adult cardiac surgery. Eighteen studies including 5,1497 patients fulfilled the selection criteria. Reoperation for bleeding/tamponade was performed in 2,455 patients (4.6%; 95% confidence interval [CI] 3.9%-5.2%, I 92%). These had a significantly higher risk of in-hospital/30-day mortality compared with patients not reoperated for bleeding (pooled rates: 9.3% v 2.3%; risk ratio 3.30; 95% CI 2.52-4.32; I 47%; 8 studies; 25,463 patients). Surgical sites of bleeding were identified in 65.7% of cases (95% CI 58.3%-73.2%; I 94%), cardiac site bleeding in 40.9% of cases (95% CI 29.7%-52.0%; I 94%), and mediastinal/sternum site bleeding in 27.0% of cases (95% CI 16.8%-37.3%; I 94%). The main sites of bleeding were the body of the graft (20.2%), the sternum (17.0%), vascular sutures (12.5%), the internal mammary artery harvest site (13.0%), and anastomoses (9.9%). In metaregression, surgical site bleeding was associated with a lower risk of in-hospital/30-day mortality compared with diffuse bleeding (p = 0.003).
Surgical site bleeding is identified in two-thirds of patients undergoing re-exploration after adult cardiac surgery. Meticulous surgical technique and systematic intraoperative checking of potential surgical sites of bleeding at the time of the original cardiac surgery may reduce the risk of such a severe complication.
本研究旨在汇总成年心脏手术后需要再次手术探查的患者出血来源比例及其预后影响的数据。
文献系统综述和荟萃分析。
多机构研究。
进行文献综述以确定1990年以来发表的评估成年心脏手术后因出血或心脏压塞再次手术结局的研究。18项研究共纳入51497例患者，符合纳入标准。2455例患者（4.6%；95%置信区间[CI]3.9%-5.2%，I²92%）因出血/心脏压塞接受再次手术。与未因出血接受再次手术的患者相比，这些患者院内/30天死亡率风险显著更高（合并率：9.3%对2.3%；风险比3.30；95%CI2.52-4.32；I²47%；8项研究；25463例患者）。65.7%的病例（95%CI58.3%-73.2%；I²94%）确定了手术部位出血，40.9%的病例（95%CI29.7%-52.0%；I²94%）为心脏部位出血，27.0%的病例（95%CI16.8%-37.3%；I²94%）为纵隔/胸骨部位出血。主要出血部位为移植物主体（20.2%）、胸骨（17.0%）、血管缝线（12.5%）、胸廓内动脉获取部位（13.0%）和吻合口（9.9%）。在meta回归分析中，与弥漫性出血相比，手术部位出血与较低的院内/30天死亡率风险相关（p=0.003）。
成年心脏手术后接受再次手术探查的患者中，三分之二被确定为手术部位出血。精细的手术技术以及在初次心脏手术时系统地术中检查潜在的手术部位出血，可能会降低这种严重并发症的风险。
