Sellman M, Intonti M A, Ivert T
Thoracic Surgical Clinic, Karolinska Hospital, Stockholm, Sweden.
Eur J Cardiothorac Surg. 1997 Mar;11(3):521-7. doi: 10.1016/s1010-7940(96)01111-6.
To study the incidence, causes and risk factors of reoperation for bleeding, 8563 coronary artery bypass procedures performed during 1970-1994 were reviewed.
Patients operated on during 1990-1994 were older, the internal mammary artery was used more frequently, more grafts were inserted, more combined and redo bypass procedures were performed than during 1970-1989. There were 402 early resternotomies but in 24 patients (6%) no bleeding was encountered and the compromised haemodynamics was caused by left ventricular failure. Postoperative bleeding caused reoperation in 378 patients (4.4%). There were 3.2% reoperations in 1994. The internal mammary artery or its bed was the main cause of the bleeding in 43%. The reoperations were performed earlier and emergent reoperations because of cardiac tamponade were less common during 1990-1994 than during 1970-1989. Reoperation for bleeding was required in 8.6% of patients 80 years of age and older. Combined coronary bypass surgery and intracardiac repair implied a 1.7 higher risk of reoperation for bleeding compared with patients undergoing primary isolated bypass surgery. Logistic regression analysis predicted old age, combined procedure, early year of surgery and use of the internal mammary artery as risk factors of reoperation for bleeding. The risk of reoperation was not significantly related to number of grafts inserted or if the patient had undergone previous cardiac surgery. Reoperation for bleeding increased the stay in intensive care by at least one day but did not increase the risk of wound infection.
Special precautions seem indicated to reduce the risk of reoperation for bleeding in particularly elderly patients undergoing combined coronary surgery and other intracardiac repair.
为研究出血后再次手术的发生率、原因及危险因素，我们回顾了1970年至1994年间进行的8563例冠状动脉搭桥手术。
与1970年至1989年期间相比，1990年至1994年期间接受手术的患者年龄更大，乳内动脉的使用更为频繁，植入的移植血管更多，进行的联合手术和再次搭桥手术更多。有402例早期再次开胸手术，但24例患者（6%）未发现出血，血流动力学受损是由左心室衰竭引起的。术后出血导致378例患者（4.4%）再次手术。1994年再次手术率为3.2%。43%的出血主要原因是乳内动脉或其床部。1990年至1994年期间再次手术时间更早，因心脏压塞进行的急诊再次手术比1970年至1989年期间更少。80岁及以上患者中8.6%需要因出血再次手术。与单纯初次冠状动脉搭桥手术患者相比，冠状动脉搭桥手术联合心内修复意味着再次手术出血风险高1.7倍。逻辑回归分析预测年龄大、联合手术、手术年份早和使用乳内动脉是出血后再次手术的危险因素。再次手术风险与植入的移植血管数量或患者是否曾接受过心脏手术无显著相关性。因出血再次手术使重症监护病房停留时间至少增加一天，但未增加伤口感染风险。
对于接受冠状动脉联合手术和其他心内修复的老年患者，似乎需要采取特殊预防措施以降低出血后再次手术的风险。
