Acute Mesenteric Ischemia After Open Heart Surgery

• Published in: Angiology 1998-04, Vol.49 (4), p.267-273
• Main Authors: Schütz, A., Eichinger, W., Breuer, M., Gansera, B., Kemkes, B.M.
• Format: Article
• Language: English
• Subjects: Acidosis - etiology; Acute Disease; Acute Kidney Injury - etiology; Age Factors; Aged; Angiography; Angioplasty, Balloon; Aortic Valve - surgery; Arteriosclerosis - surgery; Biological and medical sciences; Cardiopulmonary Bypass - adverse effects; Carotid Arteries - surgery; Coronary Artery Bypass - adverse effects; Female; Heart Defects, Congenital - surgery; Heart Neoplasms - surgery; Heart Valves - surgery; Hemodynamics; Humans; Incidence; Intestine, Small - blood supply; Intestines - blood supply; Ischemia - etiology; Ischemia - therapy; Lactates - blood; Laparotomy; Leukocytosis - etiology; Male; Medical sciences; Mesenteric Arteries - pathology; Mesenteric Vascular Occlusion - etiology; Mesenteric Vascular Occlusion - therapy; Mitral Valve - surgery; Necrosis; Osmolar Concentration; Prognosis; Reoperation; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Survival Rate
• ISSN: 0003-3197; 1940-1574
• DOI: 10.1177/000331979804900404

Acute mesenteric ischemia is a rare but severe complication after open heart surgery. Its incidence (0.2-0.4%) is quite low, but mortality rates are ranging between 70% and 100%. From October 1992 to December 1996, 4,640 patients underwent open heart surgery with cardiopulmonary bypass: 74.6% coronary artery bypass graft (CABG) operations, 23.2% valve replacement including aortic repairs, and 2.2% corrections of congenital heart diseases or tumors of the heart. The overall mortality rate (30 days) was 3.4%, and after CABG, 2.9%. Twelve patients (0.26%), following CABG (one combined with aortic valve replace ment, one with mitral reconstruction, and one with carotid disobliteration) developed signs of acute mesenteric ischemia in the early postoperative period (day 1 to 5). In all patients various abdominal symptoms, leukocytosis, acidosis, hyperlactatemia, hyperos molality, renal failure, and, finally, hemodynamic instability were observed. Eleven patients underwent emergency laparotomy. Mesenteric angiography was done if possible in still stable patients (n=7); it showed severe stenosis or occlusion prior to the operation in each case. Other diagnostic methods were not reliable. In six patients (55%) during the first look, extensive bowel necrosis was found and in five patients an ischemic intestine but no necrosis was detected. Of these, three patients were affected by extensive bowel gangrene at the second look. In the fourth patient a disseminated peripheral ischemia of the entire small intestine was found intraoperatively. After mechanical release and stim ulation normal bowel function could be reestablished. One patient underwent percuta neous transluminal angioplasty prior to the laparotomy. Bowel perfusion was still dete riorated but no necrosis was found intraoperatively. These patients were the only survivors in the investigated group; 10 of 12 patients (83.3%) died in the early postop erative period (day 1 to day 6). Predisposing factors for mesenteric ischemia are: arte riosclerotic patients after CABG (100%), age >70 years (91.7%), hyperosmotic dehy dration (100%), and cardiac ischemia in 25%. Mesenteric ischemia is a fatal complication with high mortality rates after open heart surgery, especially in older, dehydrated patients with generalized atherosclerotic vessel disease. As the acute mesenteric ischemia usually starts during anesthesia or in the early postoperative period, setting of immediate diagnosis is very difficult. With the occur r