1	Complications After Adult Cardiac Surgery Alexander Kogan MD Department of Cardiothoracic Surgery Rabin Medical Center, Campus Beilinson
2	Complications Bleeding LV and RV dysfunction Respiratory problems Acute renal failure Neurological problems Infection
3	Bleeding Surgical Non-surgical 2-3.5% of patients require chest reopening
4	Surgical bleeding First hour > 300 ml Two hours > 500 ml Three hours > 1000 ml Reopening as early as possible! Risk factor for mortality and morbidity not chest reopening itself, but amount of blood products
5	Nonsurgical bleeding (causes) Drugs - aspirin, plavix, clexan, warfarin Hypothermia (especially after OPCAB) Bypass-induced platelets dysfunction Bypass-induced fibrinolysis Heparin rebound
6	Nonsurgical bleeding (treatment) Maintain of normothermia Replacement of clotting factors by blood products Platelets infusion Aprotinin against fibrinolysis Repeated doses of protamin Desmopressin? Aminocaproic acid? Recombinant factor VII?
7	LV and RV dysfunction (I) Arrhythmia's Preload Cardiac tamponade Afterload Contractility
8	LV and RV dysfunction (II) (Arrhythmia's I) Maintain NSR, aggressive treatment of arrhythmia's In the case of bradicardia - temporary epicardial pacemaker ( HR around 85-90) VT or VF in the early postoperative period may be connected to reperfusion or if persisted - early graft closure Coronary angiography or/and reoperation
9	LV and RV dysfunction (III) (Arrhythmia's II) Most frequent arrhythmia - AF 30-35% of all patients after cardiac surgery Usually 2nd or 3rd postoperative day Treatment of choice - amiodaron Usually AF refractory to electrical cardioversion
10	LV and RV dysfunction (IV) (Preload I) Usually patient return from operative room hypovolemic Surgical bleeding Extravasation Excessive diuresis Reduced fluid intake Vasodilatation at end of CPB
11	LV and RV dysfunction (V) (Preload II) Assessment of preload by TEE, PA catheter,CVP Treatment - volume Hypervolemia in early postoperative period - very rare condition
12	LV and RV dysfunction (VI) (Tamponade) 0.6 - 1.2% of all patients after cardiac surgery Early presentation - unstable patient High CVP and PCWP and low BP and CO Decreasing urine output High blood lactate Confirmation - TEE or TTE Treatment - immediate chest opening
13	LV and RV dysfunction (VII) (Afterload I) Causes Pain Surgical stress Hypoxia Acidosis Hypertensive disorders Obstructive cardiomiopathy
14	LV and RV dysfunction (VIII) (Afterload II) Treatment Anesthetics and analgesics Nitrovasodilators Alfa- and Beta-blockers Correction of acidosis and hypoxia
15	LV and RV dysfunction (IX) (Contractility - Low cardiac output syndrome) Myocardial stunning - defined as transient regional myocardial dysfunction due to mismatch between myocardial perfusion and function Well-recognized phenomenon following CPB Linked to myocardial preservation during aortic cross-clamp and preexisting ventricular dysfunction Disappear during 8-16 hours
16	LV and RV dysfunction (X) (Contractility - Low cardiac output syndrome) Hibernating Myocardium - chronic reversible segmental dysfunction arising from prolonged hypoperfusion Usually reversible during 8-16 hours after successful revascularization
17	LV and RV dysfunction (XI) (Contractility - Low cardiac output syndrome) Treatment Rhythm control Preload optimization Afterload optimization Inotropic support Intra-aortic ballon pump
18	LV and RV dysfunction (XII) (Pharmacological treatment of ventricular dysfunction) Nitroglycerine Nitroprusside Labetalol Adrenaline Noradrenaline Dobutamine Milrinone NO Thyroid Hormone Prostaglandin's
19	Respiratory problems Hypoxia Atelectasis - 90% of patients Decreasing of FRC COPD
20	Acute renal failure I Non - oliguric ARF - 5-10% Oliguric ARF - 0.5-1%
21	Acute renal failure II Risk factors Preexisting RF Valve surgery Hemodinamic instability Short time interval between surgery and angiography
22	Acute renal failure III Treatment Optimal volume state Adequate cardiac output Diuretics (fusid) Renal dose dopamine ??? Haemodialysis or CVVHD
23	Neurological problems I CVA - 1.5-2% Cognitive disorders - 5-15% “Subtle” neurological dysfunction - 30%!!
24	Neurological problems II Risk factors Valvular Vs.CABG surgery Aortic atherosclerosis Carotid disease Intracardiac thrombus Age
25	Neurological problems III Prevention Carefully patient selection (OPCAB) Detection patient with aortic atherosclerosis by using TEE or epiaortic US Doppler study of carotid arteries or angiography Intraoperative de-airng Combined surgery - Carotid endarterectomy + heart surgery
26	Infection Pneumonia Wound infection, especially sternal wound infection - 2.5-3% Blood stream infection