Eric E. Roselli1, B. Gosta Pettersson1, Eugene H. Blackstone1, Mariano E. Brizzio1, Penny L. Houghtaling2, Regina Hauck2, Jacob M. Burke2, Bruce W. Lytle1; 1Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH
Objective: Reoperative cardiac surgery has become safer because of standardization of techniques to prevent and compensate for intraoperative adverse events (AE). Objectives were to characterize AEs, describe their impact on outcome and cost, and assess effectiveness of management strategies in terms of rescue from poor outcome.Methods: 1,853 consecutive reoperations performed from 7/2002 to 7/2004 in adults undergoing repeat sternotomy for cardiac disease were reviewed to identify AEs and management strategies. Using patients without AE, a logistic regression model for poor outcome (stroke, myocardial infarction [MI], death) was developed and applied to those who had events to calculate expected poor outcome.
Results: 145 AEs occurred in 127 patients (6.8%). Included were injuries to bypass grafts (n=47), heart (n=38), great vessels (n=28), and lungs (n=5). Other AEs were ischemia without graft injury (n=22) and ventricular fibrillation (n=5). Most occurred during dissection before cannulation (n=57), and less frequently during sternotomy (n=34), on CPB (n=34), during aortic clamping (n=8), or closing (n=12). Patients experiencing AE had more coronary (75% vs 64% multivessel), carotid (63% vs 51%), and peripheral vascular disease (68% vs 55%) and were more likely to have had chest radiation (6% vs 1.4%) than those who did not. They also had more poor outcomes (total 19% vs 6%, [P<.0001]; stroke 6.3% [n=8] vs 2.3% [n=40]; MI 3.9% [n=5] vs 0.41% [n=7]; death 12% [n=15] vs 4.0% [n=69]) and incurred higher direct technical costs (cost ratio 1.4; 95% CL 1.04-1.6). 12 patients with AE were predicted to have poor outcomes vs the 24 who experienced one (P=.03), indicating 12 "failures to rescue" (50%).
Conclusion: Adverse events during reoperative cardiac surgery occur with increased frequency in patients with a history of chest radiation and diffuse atherosclerosis. Occurrence of an adverse event is associated with 3 times the risk of death, 40% higher costs, and a doubling of expected risk of poor outcomes, although 81% of patients were rescued from an adverse event without sequelae. Further improvements in outcome are anticipated with refinement of prevention and rescue strategies.
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