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J Thorac Cardiovasc Surg 2008;135:316-323
© 2008 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Adverse events during reoperative cardiac surgery: Frequency, characterization, and rescue

Eric E. Roselli, MD^a,_*, Gösta B. Pettersson, MD, PhD^a,_*, Eugene H. Blackstone, MD^a,b,, Mariano E. Brizzio, MD^a, Penny L. Houghtaling, MS^b, Regina Hauck, MBA^a, Jacob M. Burke^a, Bruce W. Lytle, MD^a

^a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
^b Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio

Received for publication May 4, 2007; revisions received August 13, 2007; accepted for publication August 23, 2007.

^_* Address for reprints: Eric E. Roselli, MD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave/Desk F24, Cleveland, OH 44195. (Email: roselle{at}ccf.org).

Objectives: To (1) determine frequency of occurrence and risk factors for intraoperative adverse events (IAE) during reoperative cardiac surgery, (2) characterize them with respect to structure injured, timing, and use of preventive strategies, and (3) identify the impact on outcome in terms of successful and unsuccessful rescue and cost.

Methods: Operative notes of 1847 patients undergoing reoperative cardiac surgery were reviewed to identify and characterize documented intraoperative adverse events. Logistic regression modeling was used to identify risk factors for intraoperative adverse events and outcomes. Expected versus observed poor outcomes (stroke, myocardial infarction, death) was used to measure rescue.

Results: Among 127 patients, 145 (7%) intraoperative adverse events occurred. These included injuries to bypass grafts (n = 47), heart (n = 38), and great vessels (n = 28) and ischemia without graft injury (n = 22). Most occurred on opening (n = 34, 23%) and during prebypass dissection (n = 57, 39%). Risk incremented as reoperations increased. Seventy-seven patients experienced 1 or more lapses in preventive strategies. Patients with intraoperative adverse events had a greater number of poor outcomes (n = 24 [19%] vs n = 107 [6.2%]; P < .0001) and incurred higher direct technical intraoperative and postoperative costs (ratio 1.3). Twelve patients with intraoperative adverse events were predicted to have poor outcomes versus 24 who did (P < .0001), indicating 12 "failures to rescue."

Conclusions: Adverse events still occur regularly during cardiac reoperation, are related to complexity of the procedure, and occur particularly during dissection and often when preventive strategies have not been used. Compensatory rescue measures are not always successful. Adverse events lead to poor patient outcome and higher cost.