CC BY
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II. ХИРУРГИЯ
UDC 616-006.66
THE POSITIVE INFLUENCE OF RESTERNOTOMY ON COURSE OF POSTOPERATIONAL PERIOD IN CARDIOSURGICAL PATIENTS
ABOUT THE AUTHORS
Sagatov Inkar Yergaliyevich - dr. med., a surgeon of cardiac surgery department of the NSCS named after A.N. Syzganov.
Sagatov I.Ye., Ongarbayev K.O., Imammyrzaev U.Ye.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Kazakh Medical University of Continuous Education, Almaty
Key words
resternotomy, operational risk, cardiac surgery, postoperational period.
Abstract
In this article there were analyzed the reasons that led to repeated sternotomy in early postoperational period in patients with ischemic heart disease, acquired heart disease and congenital heart malformations. There was relatively shown an operational risk in this category of patients in relation to those who were not in need of the resternotomy in early post operational period.
Кардиохирургияльщ aypyëapfa операциядан кешнп мерз1мшде ем алу курсына рестернотомияньщ д±рыс эсер1
Cafaтов И.Е., Oнfapбaев К.О., Имаммырзаев У.Е.
А.Н. Cbi3f3H0B атындаш Улттык, шлыми хирургиялык, орталыш, Алматы, К,азак, медициналык, Y3äiKCi3 б1л1м беру университет!, Алматы
Туйш сездер
рестернотомия, ота кауп, журек хирургиясы, отадан KeéiHri
кезен-
Ацдатпа
Макалада журект'щ ишемиялык ауруы, журек какпакшаларыныц журе пайда болган акаулары жэне журект'щ туа пайда болган акауларына шалдыккан наукастарда, отадан кeйiнгi ерте кезецде кайта стернотомияга алып келген себептер сарапталды. Осы санатташ наукастармен, отадан кейнп ерте кезецдеп рестернотомиясыз вткен наукастардыц катынасы ота кeзiндeгi ^iп кврсeткiшi ретнде са-лыстырылды.
ОБ АВТОРАХ
Сагатов Инкар Ергалиевич - д.м.н., врач-хирург отделения кардиохирургии ННЦХ им.А.Н. Сызганова inkar_sagatov@rambler.ru
Положительное влияние рестернотомии на курс послеоперационного периода у кардиохирургических больных
Сагатов И.Е., Онгарбаев К.О., Имаммырзаев У.Е.
Национальный научный центр хирургии им. Сызганова, Алматы, Казахский медицинский университет непрерывного образования, Алматы
Ключевые слова
рестернотомия, операционный риск, кардиохирургия, послео-
Аннотация
В статье проанализированы причины, приведшие к повторной стернотомии в раннем послеоперационном периоде у пациентов с ишемической болезнью сердца, приобретенными пороками клапанов сердца и врожденными пороками сердца. Сравнительно показан операционный риск у этой категории по отношению к тем пациентам, у которых ранний послеоперационный период протекал без необхо-
перационный период. димости в рестернотомии.
Unfortunately, in heart operations carried out through longitudinal sternotomic incision, in a number of cases, as a rule, the repeated surgeries are required because of developed bleeding in early postoperational period. In majority of cases resternotomy is a justified surgery in those cases, when we manage to prevent serious complications and possible fatal outcome in minimum risks. Therefore, it is obvious that timely and effectively performed resternotomy positively influences the frequency of postoperational complications and lethality [1, 2, 3, 4].
The aim of research is to carry out an analysis of reasons of the resternotomy in patients operated concerning ischemic heart disease, acquired heart defects and congenital heart malformations.
Materials and methods
There have been examined 19 patients whom 20 resternotomies were performed in early postoperational period. All patients were treated in inpatient cardisurgical department of the National Scientific Center of Surgery named after A.N. Syzganov (clinical base of KazMUCE) in 2013: 6 patients, included into group 1, were operated concerning ischemic heart disease, 9 patients (group 2) - concerning acquired heart defects, and 4 patients (group 3) - concerning congenital heart malformations. The patients' age varied in the range from 19 till 69 years. The average age made 46,9±17,9 years. Among patients females predominated insignificantly (52,6%).
Results
In group 1 there were performed 4 resternotomies in 4 patients. In all 4 patients the bleeding was a reason of resternotomy. In 3 cases the bleeding source was not detected. In 1 case the bleeding appeared from aortotomic section in patient, whom the CABG was performed in combination with aortic valve by mechanical prosthesis.
In group 2 there were performed 11 resternotomies in 11 patients. Resternotomy was performed concerning bleeding, originated from the branch of transverse vein (1 patient), edge of aortotomic section (1 patient), lower edge of left atrium section (1 patient), periosteum and places of stakes of the sternum (1 patient), but also from right atrium, distal and proximal ends of anastomosis, places of the reimplantation of coronary arteries in patient after Bentall de Bono procedure (1 patient). 1 resternotomy was performed on the 8th day after operation in patient who underwent operation prosthetic repair of the mitral valve and annuloplastic repair of the tricuspid valve by de Vega concerning
the again arisen «fresh» thrombus of left atrium. 2 sternotomies were performed concerning tricuspid valve insufficiency of the 3rd degree in 1 case and tricuspid valve stenosis - in another case. In both cases the prosthetic repair was performed: in the first case the mechanical valve was implanted, in the second case - biological valve. In 3 cases the source of bleeding was not detected.
In group 3 there were performed 5 sternotomies in 4 patients. Analysis of reasons of resternotomy showed that in 2 patients the bleeding was caused due to insufficient coagulation of sternum periosteum in 1 case, and the transverse break of sternum in the region of manubrium - in another case. It should be noted that the patient with break of sternum underwent resternotomy twice. In rest 2 cases resternotomy with revision and accurate hemostasis allowed to avoid the further progressing of bleeding, however it did not allow to detect the basic source of bleeding with big reliability.
Operational risk according to EuroSCORE in patients with ischemic heart disease and acquired heart disease, undergone resternotomy in early postoperational period, made (17,4±14,3)% versus (5,0±0,6)% in patients with the same pathologic conditions, but without repeated sternotomy (p=0,000).
Discussion
According to data of some authors, bleeding after operations CABG is found in 8,04% of patients and in 3,95% cases, it leads to resternotomy with bleeding control and sanitation of a pericardial cavity [1].
The quantity and intensity of the hemorrhagic discharge by draining lines are the basic criteria of an estimation of the character of post operational bleeding. Despite a great quantity of researches on this topic, nowadays there is no consensus about when we should pass from conservative therapy to surgical treatment. Thus a number of researches was directed to detection of the reasons of "increased bleeding" and it was not specified what it means [1, 2, 5].
Bleeding rate by draining lines 8% from due volume of the circulating blood and more in the first hours of operation or 2.5% from due volume of the circulating blood per hour during the first 3 hours of CABG is an indication for carrying out of surgical treatment [1].
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
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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 [3].
Conclusions
Thus, according to our data in the structure of all reasons of resternotomies in early postoperational
period in cardiosurgical patients the most frequent reason was bleeding appeared with a frequency of 84,2%.
In absolutely majority cases resternotomy with revision and sanitation of bleeding control was a justified procedure that allowed to avoid the further progressing of a bleeding and to improve significantly the patient's condition and even to prevent the lethal outcome.
References
1. Krivosheya A.V. Influence of times of resternotomy on the results of treatment of postoperative bleeding in cardiac surgery patients. Dis... can. med. - M.2008 - 87p. (in Russ.).
2. Sagatov I.Ye. Resternotomy in cardiac surgery: the frequency and causes of occurrence. AGIUV Bulletin, the Republican conference «Continuing medical education - a guarantee of safety and quality of care,» mat-s, Almaty. 2014. № 3. p.143-145. (in Russ.).
3. LaPar DJ, Ailawadi G, Harris DA, Hajzus VA, Lau CL, Kern JA, Kron IL. A protocol-driven approach to car-
diac reoperation reduces mortality and cardiac injury at the time of resternotomy. Ann Thorac Surg. 2013 Sep; 96(3): p.865-870.
4. Morales D, Williams E, John R. Is resternotomy in cardiac surgery still a problem? Interact Cardiovasc Thorac Surg. 2010 Sep; 11(3): p.277-286.
5. Sagatov I.Ye. Modeling of operational risk in patients of cardiosurgical profile // 22nd Annual Meeting of the ASCVTS, Abstractbook. Istanbul, Turkey. 2014. P.789. (in Russ.).
