Negative reexploration for cardiac postoperative bleeding: can it be therapeutic?

Abstract

Reexploration of the mediastinum for bleeding is required in 3% to 7% of patients after cardiac operation, with many proving to have no surgically correctable cause. In spite of a "negative exploration," the bleeding often ceases. We propose the hypothesis that such a negative exploration can be therapeutic by reducing marked fibrinolytic activity in the mediastinal cavity. Fibrinolytic activity in shed mediastinal blood was compared with that in the system blood in 5 patients after cardiac operation by measuring fibrinogen, fibrin degradation product, plasminogen activator inhibitor-1, and alpha2-antiplasmin levels. Fibrinolytic activity in mediastinal blood was markedly increased when compared with paired systemic venous blood. This was indicated by the mediastinal blood's lower fibrinogen levels (0.47 versus 1.91 U/mL; p < 0.001), very high levels of fibrin degradation products (1,350 versus 200 ng/mL; p < 0.05), and higher levels of plasminogen activator inhibitor-1 (55.5 versus 28.1 ng/mL; p < 0.005). Decreased levels of alpha2-antiplasmin were also observed in the mediastinum (0.50 versus 0.61 U/mL; p < 0.05). Our data confirm that fibrinolytic activity can be extremely high in the mediastinum in response to clot formation. This may explain the hemostatic effects of a negative reexploration, where irrigation and the removal of clots may reduce the fibrinolytic process; this may allow the bleeding ends of capillaries and small vessels to thrombose. Decreased levels of alpha2-antiplasmin observed suggest that lysine analogs, such as epsilon-aminocaproic acid, may have a beneficial role when locally delivered into the mediastinum.