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Incidence and Risk Factors

Lawrence J. Dacey, MD, MS; John J. Munoz, MD; Yvon R. Baribeau, MD; Edward R. Johnson, MD; Stephen J. Lahey, MD; Bruce J. Leavitt, MD; Reed D. Quinn, MD; William C. Nugent, MD; John D. Birkmeyer, MD; Gerald T. O'Connor, PhD, DSc; for the Northern New England Cardiovascular Disease Study Group

Arch Surg. 1998;133:442-447.

Objective  To assess mortality and risk factors associated with reexploration for hemorrhage in patients undergoing coronary artery bypass grafting (CABG).

Design  Regional cohort study. Patient characteristics, treatment variables, and outcome measures were collected prospectively.

Setting  All 5 centers performing cardiac surgery in Maine, New Hampshire, and Vermont.

Patients  A consecutive cohort of 8586 patients undergoing isolated CABG between 1992 and 1995.

Main Outcome Measures  Postoperative hemorrhage leading to reexploration, in-hospital mortality, and length of stay.

Results  A total of 305 patients (3.6%) underwent reexploration for bleeding. In these patients, in-hospital mortality was nearly 3 times higher (9.5% vs 3.3% for patients not requiring reoperation, P<.001) and average length of stay from surgery to discharge was significantly longer (14.5 days vs 8.6 days, P< .001). High rates of reexploration for hemorrhage were observed in patients with prolonged (>150 minutes) cardiopulmonary bypass (39 [11.1] of 351) and in those requiring an intra-aortic balloon pump intraoperatively (12 [8] of 139). In multivariate analysis, older age, smaller body surface area, prolonged cardiopulmonary bypass, and number of distal anastomoses were associated with increased bleeding risks. The use of thrombolytic therapy within 48 hours of surgery was weakly but not significantly associated with the need for reexploration. Factors not significantly associated with reexploration included patient sex, preoperative ejection fraction, surgical priority, history of liver disease, myocardial infarction, prior CABG, renal failure, and diabetes mellitus.

Conclusions  Hemorrhage requiring reexploration after CABG is associated with markedly increased mortality and length of stay. Patients predicted to have increased risks of bleeding may benefit from prophylactic use of aprotinin, aminocaproic acid, or other agents shown to reduce hemorrhage.

From the Departments of Surgery (Drs Dacey, Munoz, Nugent, and Birkmeyer), Medicine (Dr O'Connor), and Community & Family Medicine (Drs O'Connor and Birkmeyer), and the Center for the Evaluative Clinical Sciences (Drs O'Connor and Birkmeyer), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery (Dr Lahey), Beth Israel–Deaconess Medical Center, Boston, Mass; Department of Surgery (Dr Johnson), Eastern Maine Medical Center, Bangor, Me; Department of Surgery (Dr Leavitt), Fletcher-Allen Health Care, Burlington, Vt; Department of Surgery (Dr Quinn), Maine Medical Center, Portland, Me; and Department of Surgery (Dr Baribeau), Optima Health Catholic Medical Center, Manchester, NH.

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