Prevalence and Causes of Mediastinal Reexploration for Excessive Bleeding after Cardiac Surgery Procedures

Document Type : Research Paper


1 Cardiac surgeon, Department of Cardiac Surgery, Faculty of Medical Science. Mashhad University of Medical Sciences, Iran

2 Resident of cardiac surgery, Department of Cardiac Surgery, Faculty of Medical Science. Mashhad University of Medical Sciences, Iran

3 Student Research Committee, Faculty of medicine, Mashhad University of Medical Sciences, Mashhad, Iran

4 Student Research Committee, Faculty of medicine, Mashhad University of Medical Sciences, Mashhad


Introduction: Postoperative bleeding in cardiac surgery is not an uncommon complication and can be evaluated with surgical and nonsurgical causes. Although any type of coagulopathy should be treated before, during, and after the surgical procedure, cardiac surgeons should have perfect surgical techniques for step by step hemostasis to minimize blood loss.
Materials and Method: This retrospective study was conducted on 85 patients out of 1075 (0.07%) ones required Reexploration of the Mediastinal to control the excessive bleeding after different cardiac procedures in Imam Reza Hospital in Mashhad of Iran from January 2018 to January 2019.
Results: Out of 85 patients who required Mediastinal Reexploration, 61 (71%) and 24(29%) patients underwent the off-pump procedure and cardiopulmonary bypass, respectively. The most common sites for surgical bleeding in the order were missed branches of left internal mammary artery / saphenous vein graft (65%), proximal or distal coronary anastomosis (18%), and aortic /atrial suture line (16%). The death in patients under study was 7 (8%), half of which were not related to Mediastinal Reexploration.
Conclusion: The possibility of postoperative bleeding can be minimized through correction of clotting factor deficiencies, improvement of surgical techniques in hemostasis.


  1. Ranucci M, Baryshnikova E, Crapelli GB, Rahe‐Meyer N, Menicanti L, Frigiola A, et al. Randomized, double‐blinded, placebo‐controlled trial of fibrinogen concentrate supplementation after complex cardiac surgery. J Am Heart Assoc. 2015; 4:e002066.
  2. Kozek-Langenecker SA, Afshari A, Albaladejo P, Santullano CA, De Robertis E, Filipescu DC, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013; 30:270-382.
  3. Karlsson M, Ternström L, Hyllner M, Baghaei F, Flinck A, Skrtic S, et al. Prophylactic fibrinogen infusion reduces bleeding after coronary artery bypass surgery. Thromb Haemost. 2009; 102:1137-44.
  4. Rahe-Meyer N, Pichlmaier M, Haverich A, Solomon C, Winterhalter M, Piepenbrock S, et al. Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study. Br J Anaesth. 2009; 102:785-92.
  5. Fenger-Eriksen C, Lindberg-Larsen M, Christensen AQ, Ingerslev J, Sørensen B. Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth. 2008; 101:769-73.
  6. Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, et al. Anti‐fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2011; 1:CD001886.  
  7. Vuylsteke A, Pagel C, Gerrard C, Reddy B, Nashef S, Aldam P, et al. The Papworth Bleeding Risk Score: a stratification scheme for identifying cardiac surgery patients at risk of excessive early postoperative bleeding. Eur J Cardio Thorac Surg. 2011; 39:924-30.
  8. Karkouti K, O’Farrell R, Yau TM, Beattie WS. Reducing Bleeding in Cardiac Surgery Research Group. Prediction of massive blood transfusion in cardiac surgery. Can J Anaesth. 2006; 53:781-94.
  9. Ravn HB, Lindskov C, Folkersen L, Hvas AM. Transfusion requirements in 811 patients during and after cardiac surgery: a prospective observational study. J Cardiothorac Vasc Anesth. 2011; 25:36-41.
  10. Heinze G, Schemper M. A solution to the problem of separation in logistic regression. Statist Med. 2002; 21:2409-19.
  11. Karkouti K, Levi M, Murphy GJ, Sellke FW, Shore-Lesserson L, Christian von Heymann MD, Ranucci M. Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg. 2013;1:6.
  12. Ranucci M, Aronson S, Dietrich W, Dyke CM, Hofmann A, Karkouti K, et al. Patient blood management during cardiac surgery: do we have enough evidence for clinical practice? J Thorac Cardiovasc Surg. 2011; 142:249-e1.
  13. Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011; 91:944-82.
  14. Sharif-Barfeh Z, Beigoli S, Marouzi S, Sharifi-Rad A, Asoodeh A, Chamani J. Multi-spectroscopic and HPLC studies of the interaction between estradiol and cyclophosphamide with human serum albumin: binary and ternary systems. J Solution Chem. 2017; 46:488-504.
  15. Ferraris VA, Ferraris SP, Saha SP, Hessel II EA, Haan CK, Royston BD, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg. 2007; 83:S27-86.
  16. Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation. 2007; 116:2544-52.
  17. Geissler RG, Rotering H, Buddendick H, Franz D, Bunzemeier H, Roeder N, et al. Utilisation of blood components in cardiac surgery: a single-Centre retrospective analysis with regard to diagnosis-related procedures. Transfus Med Hemother. 2015; 42:75-82.
  18. Herrett E, Gallagher AM, Bhaskaran K, Forbes H, Mathur R, van Staa T, et al. Data resource profile: clinical practice research datalink (CPRD). Int J Epidemiol. 2015; 44:827-36.
  19. Llewelyn CA, Wells AW, Amin M, Casbard A, Johnson AJ, Ballard S, et al. The EASTR study: a new approach to determine the reasons for transfusion in epidemiological studies. Transfus Med. 2009; 19:89-98.
  20. Sanei H, Asoodeh A, Hamedakbari-Tusi Sh, Chamani J. Multi-spectroscopic investigations of aspirin and colchicine interactions with human hemoglobin: binary and ternary systems. J Solution Chem. 2011; 40:1905-31.
  21. Rafter N, Hickey A, Condell S, Conroy R, O'Connor P, Vaughan D, et al. Adverse events in healthcare: learning from mistakes. QJM. 2015; 108:273-7.
  22. Dyke C, Aronson S, Dietrich W, Hofmann A, Karkouti K, Levi M, et al. Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg. 2014; 147:1458-63e1.
  23. Ranucci M, Baryshnikova E, Castelvecchio S, Pelissero G; Surgical and Clinical Outcome Research (SCORE) Group. Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery. Ann Thorac Surg. 2013; 96:478-85.