Mitigating the Risk: Transfusion or Reoperation for Bleeding After Cardiac Surgery

Background. Several studies have establishedmorbidity associated with bleeding after cardiac surgery. Although reoperation has been implicated as the marker for this morbidity, there remains limited understanding regarding relative morbidities of reoperation and substantial transfusion. Methods. The Society of Thoracic Surgeons (STS) Maryland Adult Cardiac Surgery Database (July 2011September 2018) was reviewed (N = 23,240). Substantial transfusion was defined as requiring greater than the reoperation group median red blood cells (5 units) and non-red blood cells (4 units). Patients were stratified into 4 subgroups: group 1, no reoperation without substantial transfusion (n = 22,365); group 2, reoperation without substantial transfusion (n = 351); group 3, no reoperation with substantial transfusion (n = 350); and group 4, reoperation with substantial transfusion (n = 167). Operative morbidity and mortality were compared. Results. Reoperation patients were older with a higher STS predicted risk of mortality (1.8% vs 1.2%, P <.001). Multivariable analysis demonstrated that group 4 increased the odds of renal failure (odds ratio [OR] 7.36, P<.001), stroke (OR3.24, P=.002), andoperativemortality(OR8.68, P<.001) compared with group 1. Both group 2 and group 3 increased the odds of mortality and renal failure comparedwith group 1. However, group 3 had greater risk for renal failure (OR 3.48, P <.001) and mortality (OR 2.91, P <.001) than group 2. Conclusions. Although reoperation for bleeding is associated with morbidity after cardiac surgery, substantial transfusion without reoperation appears to increase morbidity compared with a limited-transfusion reoperative approach. Better timing for reoperation and guided transfusion approaches may mitigate morbidity compared with substantial transfusion alone. (C) 2020 by The Society of Thoracic Surgeons.