High-risk Cardiac Patients Research Articles

Cardiac Troponin I after Carotid Endarterectomy in Different Cardiac Risk Patients

We compared postoperative cardiac damage, defined as cardiac troponin I (cTnI) elevation, in low, medium, and high cardiac risk patients, after carotid endarterectomy (CEA). The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) criteria for stratifying patients considered for vascular surgery into low, medium, and high cardiac risk groups were used prospectively. For all patients (n = 324), cTnI value assessments were made before surgery and on postoperative days 1, 3, and 7. Postoperative cTnI values ranging from .05 to .5 ng/mL were classified as myocardial ischemia; values more than .5 ng/mL were classified as myocardial infarction. Cardiac damage was defined as either myocardial ischemia or infarction. Mortality was .003%, stroke rate was null, and symptomatic myocardial infarction was null as well. Low-risk patients (16 of 140) and medium-risk patients (28 of 160) increased their troponin levels on days 1 and 3 postoperatively. However, none of the high-risk patients (n = 24) showed any postoperative cardiac damage. Low and medium cardiac risk patients showed higher troponin values on each separate day, in comparison with high cardiac risk patients. CEA is followed by a high incidence of asymptomatic cTnI increase that is associated with late cardiac events. However, high cardiac risk patients as defined by the VSG-CRI criteria do not seem to suffer higher cardiac damage after CEA compared with low and medium cardiac risk patients.

Trics-III prospective randomised controlled trial of a restrictive or liberal blood transfusion protocol

S – Scientific Session 2 Outcomes following freestyle stentless aortic bioprosthesis implantation: The Australian experience up to 10 years Andrew Sherrah , Paul Bannon , Richmond Jeremy , Rajesh Puranik , Peter Brady , David Marshman , Manu Mathur , John Brereton , James Edwards , Robert Stuklis , Paul Hendel , Matthew Bayfield , Michael Wilson , Michael Vallely 1,2,3,7 Sydney Medical School, University of Sydney, Sydney, Australia The Baird Institute, Royal Prince Alfred Hospital, Sydney, Australia Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, Australia Darcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, Australia Australian School of Advanced Medicine, Macquarie University, Sydney, Australia Corresponding author. Introduction: The choice of valvular prosthesis in aortic valve replacement surgery must be tailored to the needs of the individual patient. We report our clinical and echocardiographic outcomes up to 10 years post-operatively following use of the Freestyle bioprosthesis for aortic valve and root surgery utilising several different surgical approaches. Methods: The retrospective collection of this data was approved by the local ethics committees. From January, 2004 until July, 2014, 237 patients underwent Freestyle bioprosthesis implantation at the aortic position at five Australian hospitals. Preand post-operative clinical data were collected, as well as post-operative echocardiographic data. Total clinical follow-up consisted of 560 patient-years and was 100% complete within 18 months of the date of study completion. Results: Mean age was 63 13 years and 81.4% of patients were male. The most commonly used prosthesis size was 27 mm (32.5%) and 41.4% of patients required concurrent replacement of their ascending aorta. 31.7% of patients required a concurrent cardiac procedure. Pre-operatively, 30.3% of patients were in NYHA Class III or IV; at last post-operative follow-up this was 2.9%. 30 day mortality from all causes was 4.3%. All cause survival at 5 and 10 years of follow-up was 82.6 3.9% and 56.4 10.5%, respectively. Freedom from valvular or coronary artery re-intervention at 5 and 10 years was 92.9 3.4% and 73.3 10.6%, respectively. The mean maximum aortic systolic gradient at 1, 5 and 10 years was 12.3 9.0 mmHg, 10.2 5.3 mmHg and 8.4 0.0 mmHg, respectively. At the completion of follow-up, 91.7% of patients had trivial or nil aortic regurgitation. Discussion: We demonstrate comparable long term outcomes to the large international series’ for implantation of the Freestyle porcine bioprosthesis in the aortic position. This is inclusive of multiple implantation techniques. The Freestyle is a suitable prosthesis choice in patients where there is associated aortic dilatation and long term anticoagulation is not desirable. Longer follow up data are required to assess the suitability of the prosthesis in younger patients. http://dx.doi.org/10.1016/j.hlc.2014.12.014 Trics-III prospective randomised controlled trial of a restrictive or liberal blood transfusion protocol Alistair Royse , Colin Royse , David Scott , Nadine Shehata , David Mazer , TRICS-III investigators University of Melbourne, Melbourne, Australia Royal Melbourne Hospital, Melbourne, Australia St Vincents Hospital, Melbourne, Australia Mt Sinai Hospital, Toronto, Canada St Michaels Hospital, Toronto, Canada Canadian Institutes of Health Research, Ottawa, Canada Introduction: Hypothesis: That a “restrictive” transfusion protocol is not inferior to a “liberal” transfusion protocol in high risk cardiac surgery patients as measured by a composite outcome of mortality and serious morbidity in high risk cardiac surgery patients. Methods: The primary endpoint is a composite endpoint of in-hospital mortality and major morbidity (myocardial infarction, new renal failure, new focal neurological deficit). The restrictive group will have a transfusion threshold of < 75 g/L throughout their hospital admission whereas the liberal group will have a transfusion threshold of < 95 g/L in the operating room (OR) and Intensive Care Unit (ICU) followed by a threshold of < 85 g/L in the ward. Secondary endpoints are to assess the impact of transfusion threshold on the incidence of adverse clinical events, blood utilisation and 6-month mortality. Adverse event outcomes include length of stay in the ICU and hospital, prolonged low cardiac output state, use of intra-aortic balloon pump ventricular assist device postoperatively, duration of mechanical ventilation, infection, acute kidney injury, and gut infarction. Results: This study is awaiting final ethics and governance clearance in Australia and will commence in 2014. Heart, Lung and Circulation (2015) 24S1, e5–e6 1443-9506/04/$36.00 ABSTRACTS

Urinary neutrophil gelatinase-associated lipocalin time course during cardiac surgery.

Background:NGAL is one of the most promising AKI biomarkers in cardiac surgery. However, the best timing to dose it and the reference values are still matter of discussion.Aim of the Study:We performed a uNGAL perioperative time course, to better understand its perioperative kinetics and its role in AKI diagnosis.Setting of the Study:San Raffaele University Hospital, cardiac surgery department.Material and Methods:We enrolled in this prospective observational study 19 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Based on preoperative characteristics, they were divided in low-risk and high-risk patients. uNGAL measurements were collected at pre-defined times before, during, and up to 24 hours after surgery.Statistical Analysis:Data were analysed by use of SAS 1999-2001 program or IBM SPSS Statistics.Results:In low-risk patients, uNGAL had the highest value immediately after general anesthesia induction (basal dosage: uNGAL: 12.20ng×ml-1, IQR 14.00). It later decreased significantly (3.40 ng×ml-1, IQR 4.80; P = 0.006) during CPB, and finally return to its original value 24 hours after surgery. In high-risk patients, uNGAL increased immediately after surgery; it had the highest value on ICU arrival (38,20 ng×ml-1; IQR 133,10) and remained high for several hours. A difference in uNGAL levels between the two groups was already observed at the end of surgery, but it became statistically significant on ICU arrival (P = 0.002).Conclusion:This study helps to better understand the different kinetics of this new biomarker in low-risk and high-risk cardiac patients.

Vascular protective effects of statin-related increase in serum 25-hydroxyvitamin D among high-risk cardiac patients.

To investigate the protective effects of statin-related increase in serum 25-hydroxyvitamin D [25(OH)D] on vascular function among high-risk cardiovascular patients. We studied 443 high-risk cardiovascular patients (coronary disease 83%, ischemic stroke 21%; mean age 68 ± 10 years; men 77%). Serum 25(OH)D was measured by ELISA assay. Carotid intima-media thickness (IMT) and brachial flow-mediated dilatation were measured by high-resolution vascular ultrasound. Circulating CD34KDR and CD133KDR endothelial progenitor cells (EPCs) were measured by flow cytometry. Three hundred and twenty-nine (74%) patients were statin users. Serum 25(OH)D was higher among statin users than nonusers (30.2 ± 12.8 versus 26.8 ± 8.5 ng/ml; P = 0.009), which remained significant after multivariable adjustment [B = +3.8, 95% confidence interval (CI) 0.6 to 6.9, P = 0.019). Serum 25(OH)D was associated with reduced carotid IMT (R = -0.11, P = 0.026), and increased circulating CD34KDR EPC (R = 0.13, P = 0.030) and CD133KDR EPC (R = 0.15, P = 0.012). Adjusted for potential confounders, serum 25(OH)D remained independently associated with reduced carotid IMT (B = -0.003, 95% CI -0.005 to 0.000, P = 0.017), and increased circulating CD34KDR EPC [B = 0.006, 95% CI 0.002 to 0.009, P = 0.001, log, unit (×10/ml)] and CD133KDR EPC [B = 0.004, 95% CI 0.001 to 0.008, P = 0.016, log, unit (×10/ml)]. Interaction test showed no multiplicative effect between statins and serum 25(OH)D on carotid IMT or EPCs. Serum 25(OH)D was negatively associated with HbA1c (B = -0.010, 95% CI -0.019 to -0.001, P = 0.035). There was no significant association between serum 25(OH)D and brachial flow-mediated dilatation (R = -0.045, P = 0.344). In patients with cardiovascular disease, statin use is associated with increased serum 25(OH)D, which is independently associated with reduced carotid atherosclerotic burden, increased circulating EPCs, and improved glycemic control. These may partially explain the pleotrophic effects of statins.

Do cardiac rehabilitation programs offer cardiopulmonary resuscitation training in Australia and New Zealand?

Background: Cardiac rehabilitation (CR) is an ideal environment to train high-risk cardiac patients and their families in basic life support, including cardiopulmonary resuscitation (CPR). However, whether this training is currently offered is unknown.

VLSI Technology for Real Time Monitoring System of High Risk Cardiac Patients

VLSI Technology for Real Time Monitoring System of High Risk Cardiac Patients

VLSI Technology for Real Time Monitoring System of High Risk Cardiac Patients

Recent developments in Cardiac surgery have led to increase in number of patients between the age group of 25 and 69 years of age who have survived Myocardial Infarction. Regular and continuous monitoring of these patients becomes essential as this age group of people is the real asset to a family. Hence this paper aims in design and development of low cost, light weight, portable real time monitoring system for cardiac patients. The proposed system employs a Field Programmable Gate Array (FPGA), a reconfigurable platform that performs online analysis of the acquired ECG signal continuously. FPGA based Arrhythmia detector, implemented on a DE0 Nano Altera Cyclone IV board is interfaced with GSM/GPS module to alert the physician or the caretaker on a mobile phone about the imminent fatal condition and location of the patient. If the portable system detects any arrhythmia, it automatically sends an alarm condition to the patient's care taker and doctor or ambulance centre. Through our proposed system the caretaker is immediately aware of the fatal condition of the patient, and hence immediate cardiopulmonary resuscitation (CPR) may be performed, because CPR can provide an efficient method for maintaining a flow of oxygen-rich blood to the body's vital organs before advanced emergency care is available for the patient.

ANTIBIOTIC PROPHYLAXIS FOR BACTERIAL ENDOCARDITIS: A STUDY OF KNOWLEDGE AND IMPLEMENTATION OF AMERICAN HEART ASSOCIATION GUIDELINES AMONG DENTISTS AND DENTAL HYGIENISTS

Knowledge and interpretation of the 2007 American Heart Association (AHA) guidelines regarding infective endocarditis (IE) prophylaxis among the dental community is not well established. Our aim was to determine how dentists and dental hygienists interpret the 2007 AHA guidelines and to assess the degree of heterogeneity in the dental community with respect to IE prophylaxis practice. A cross sectional survey was sent to a random sample of 450 dental hygienists and 450 dentists across Alberta. Contact information was obtained from professional organizations. Non responders were resent the survey at 2 weeks and 4 weeks. The survey asked whether the practitioner would recommend IE prophylaxis to (a) a high-risk cardiac patient undergoing a variety of dental procedures, and (b) in the setting of a variety of cardiac lesions for a patient requiring gingival manipulation. Pearson and chi-square tests were used for statistical analysis. Logistic regression was performed to identify demographic factors predictive of failure to follow the AHA guidelines for high-risk patients. P values < 0.05 were considered significant. The survey was completed by 149 hygienists (33%) and 194 dentists (43%). Use of prophylaxis for specific dental procedures was heterogeneous; for example, 46% of hygienists recommended prophylaxis for polishing, 43% did not, and 11% replied “sometimes”. Hygienists were more likely than dentists to inappropriately recommend IE prophylaxis for low-risk lesions including mitral valve prolapse (54% of hygienists, 42% of dentists recommending prophylaxis, p=0.009) and hypertrophic cardiomyopathy (23% vs 15%, p=0.036). Failure to recommend IE prophylaxis was also observed for high-risk lesions, including mechanical valve (only 81% of hygienists and 91% of dentists recommending prophylaxis, p=0.023). On logistic regression analysis, the only factor that was predictive of correctly recommending prophylaxis for high-risk lesions was subjects who responded affirmatively to the question” Did you refer to the 2007 AHA recommendations when completing this survey?” (OR 3.7, p=0.001). There is much heterogeneity within the dental community with respect to IE prophylaxis. Dental hygienists are more likely than dentists to recommend IE prophylaxis for low-risk cardiac lesions. Both dentists and hygienists did not consistently recommend prophylaxis for all high-risk cardiac lesions. Therefore, there is a need for continuing professional development among dentists and hygienists regarding IE prophylaxis. Dental practitioners may benefit from keeping the AHA guidelines in a readily accessible place in clinical settings so that they can readily refer to them when needed.

SodiUm SeleniTe Adminstration IN Cardiac Surgery (SUSTAIN CSX-trial): study design of an international multicenter randomized double-blinded controlled trial of high dose sodium-selenite administration in high-risk cardiac surgical patients.

BackgroundCardiac surgery has been shown to result in a significant decrease of the antioxidant selenium, which is associated with the development of multiorgan dysfunction and increased mortality. Thus, a large-scale study is needed to investigate the effect of perioperative selenium supplementation on the occurrence of postoperative organ dysfunction.Methods/DesignWe plan a prospective, randomized double-blind, multicenter controlled trial, which will be conducted in North and South America and in Europe. In this trial we will include 1,400 high-risk patients, who are most likely to benefit from selenium supplementation. This includes patients scheduled for non-emergent combined and/or complex procedures, or with a predicted operative mortality of ≥5% according to the EuroSCORE II. Eligible patients will be randomly assigned to either the treatment group (bolus infusion of 2,000 μg sodium selenite immediately prior to surgery, followed by an additional dosage of 2,000 μg at ICU admission, and a further daily supplementation of 1,000 μg up to 10 days or ICU discharge) or to the control group (placebo administration at the same time points).The primary endpoint of this study is a composite of 'persistent organ dysfunction’ (POD) and/or death within 30 days from surgery (POD + death). POD is defined as any need for life-sustaining therapies (mechanical ventilation, vasopressor therapy, mechanical circulatory support, continuous renal replacement therapy, or new intermittent hemodialysis) at any time within 30 days from surgery.DiscussionThe SUSTAIN-CSX™ study is a multicenter trial to investigate the effect of a perioperative high dosage sodium selenite supplementation in high-risk cardiac surgical patients.Trial registrationThis trial was registered at Clinicaltrials.gov (identifier: NCT02002247) on 28 November 2013.Electronic supplementary materialThe online version of this article (doi:10.1186/1745-6215-15-339) contains supplementary material, which is available to authorized users.

B-type natriuretic peptide-guided therapy for perioperative medicine?

The recent guideline from the European Society of Cardiology and European Society of Anesthesiology recommended the use of B-type natriuretic peptide (BNP) as preoperative testing for high-risk cardiac patients undergoing...

VLSI Implementation of Telemonitoring System for High Risk Cardiac Patients

VLSI Implementation of Telemonitoring System for High Risk Cardiac Patients

Methylprednisolone Not Beneficial in High-Risk Cardiac Surgery Patients (SIRS)

Methylprednisolone Not Beneficial in High-Risk Cardiac Surgery Patients (SIRS)

Prospective observational study on predicting adverse clinical outcomes in patients with implanted defibrillating devices – a study rationale, design and principal methods

The project “Predicting adverse clinical outcomes in patients with implanted defibrillating devices” is a prospective observational study in a group of high risk cardiac patients with already implanted either an implantable cardioverter-defibrillator (ICD) or a cardiac resynchronization therapy device with defibrillating mode (CRT-D). The primary project aim is to build predictive models for an appropriate ICD or CRT-D interventions and other adverse clinical outcomes based on clinical assessment of the cardiovascular system, general clinical status, advanced mathematical and statistical analysis of cardiovascular time series and biological signals, including pressure waveforms, ECG and cardiac impedance. Up to 600 ambulatory adult patients are scheduled to be enrolled and after the first visit they are expected to be followed-up every 6 months for a number of clinical outcomes, including antiarrhythmic therapy intervention, sudden and aborted cardiac death and total mortality. The project launched in March 2010 and is expected to end in February 2014.

Use of nitric oxide in thoracic surgery for a high risk cardiac patient

Nitric oxide (NO) is a selective pulmonary vasodilator especially in the presence of pulmonary artery hypertension. With right ventricle (RV) dysfunction, inhaled NO may increase RV ejection fraction and cardiac output. The main advantage of NO over intravenous therapy is its inability to decrease systemic pressure thereby maintaining the coronary perfusion pressure and the myocardial perfusion. In this case report, we discuss the use of NO in a routine thoracic surgery patient suffering with severe left ventricular dysfunction and a potential candidate for a very high cardiac risk.

Pilot Randomized Controlled Trial of Inhaled Milrinone in High-Risk Cardiac Surgical Patients

Background: Pulmonary hypertension is a major cause of mortality and morbidity in patients undergoing valvular and complex heart surgery. Inhaled milrinone has been used for the treatment of pulmonary hypertension, but its safety and effects compared with a placebo on hemodynamics and ventricular function have not been studied in patients undergoing high-risk valvular surgery. Methods: Twenty-one high-risk cardiac surgical patients with preoperative pulmonary hypertension were randomized in a double-blind study to receive inhaled milrinone or placebo. The inhalation occurred after the induction of anesthesia and before the surgical incision and cardiopulmonary bypass. The effects on ventricular function were evaluated by means of pulmonary artery catheterization and transesophageal echocardiography. The primary outcome variable was the systemic mean arterial pressure. Results: There were 8 men and 13 women (mean age 71 ± 6 years) with a mean Parsonnet score of 32 ± 9 who underwent a total of 17 complex procedures and 6 reoperations. There were no significant changes in mean arterial pressure throughout the study. A reduction in pulmonary vascular resistance (p = 0.0458) was observed in the inhaled milrinone group, but the change in mean pulmonary artery pressure was not significant (p = 0.1655). Right ventricular end-diastolic area (p = 0.0363) and right atrial transverse diameter (p < 0.0001) increased in the control group, but not with inhaled milrinone. No significant side effects occurred in the inhaled milrinone group. Conclusion: In this high-risk cardiac surgery cohort, the use of inhaled milrinone was not associated with systemic hypotension but with a reduced pulmonary vascular resistance and prevention of the increase in right-sided cavity dimensions.

Prevention of Late PJI

The definition of late PJI is variable in literature. Majority of the members of the consensus felt that any infection occurring after one year should be considered as late. Coventry defined stages of PJI, where Stage I is an acute infection that occurred within 3 months of the index procedure, Stage II is a delayed infection that occurred between 3 months and 2 years after the index procedure where there was no pain-free interval, and Stage III is a hematogenous infection where there is a pain-free stage [1]. Garvin and Hanssen defined a late chronic PJI as one that occurred 4 weeks after the index procedure with an insidious clinical onset [2]. McPherson et al defined a chronic infection as one that had symptoms for 4 weeks or longer [3]. In Sweden, a late PJI is defined as one that occurs 2 years after the index procedure. Due to the huge variation in time frames, we did not find consensus in defining a timeframe for a late PJI. However, we classified late PJI as late hematogenous PJI, where there was an asymptomatic period followed by clinical and/or radiographical signs of infection. The workgroup feels that late PJI arises as a result of bacteremia at a later stage [4] and should be distinguished with infections arising as a result of intraoperative contamination. Risk factors for late PJI are similar to those described for PJI in Workgroup 1 (Please see Question 1, Workgroup 1).

The Impact of a Microbial Sealant to Reduce Surgical Site Infections in High Risk Cardiac Surgery Patients

Introduction: Post-sternotomy infection is a serious cause for morbidity and mortality after cardiac surgery. The goal of this study was to evaluate the impact of a microbial sealant on post-sternotomy infections in high risk patients undergoing cardiac surgery. Methods: Between January 2006 and July 2008 a total of 291 consecutive patients underwent cardiac surgery with a Fowler score of at least 10, which indicates high risk patients to develop surgical site infection (SSI). Patients were divided into a control group (n=132) receiving standard institutional preoperative care and a microbial sealant group (n=159) received additionally a microbial skin sealant. Pre- and peri-operative characteristics were examined for both groups. The clinical end-point of this study was freedom of post-sternotomy infection. Results: Follow up was 100% completed. The preoperative risk score of the control and the microbial sealant group were similar, respectively 15.5 ± 4.0 and 15.2 ± 3.8 (p=0.513). Comparing pre- and peri-operative characteristics of both groups, significant higher rates of carotid artery disease (p=0.022) and diabetics (p=0.046) were found in the microbial sealant group. All other pre- and peri-operative characteristics were similar for both groups. The clinical end-point however, showed a significant decrease of SSI in the microbial sealant group 2.5% (n=4) versus the control group 7.6% (n=10), (p=0.045). Conclusions: This study showed that the additional use of a microbial sealant to standard institutional preoperative preparation reduces statistically significant the risk for surgical site infection in high risk patients undergoing cardiac surgery.

Amlodipine and cardiovascular outcomes in hypertensive patients: meta-analysis comparing amlodipine-based versus other antihypertensive therapy

Background/AimsThis meta-analysis compared the effects of amlodipine besylate, a charged dihydropyridine-type calcium channel blocker (CCB), with other non-CCB antihypertensive therapies regarding the cardiovascular outcome.MethodsData from seven long-term outcome trials comparing the cardiovascular outcomes of an amlodipine-based regimen with other active regimens were pooled and analyzed.ResultsThe risk of myocardial infarction was significantly decreased with an amlodipine-based regimen compared with a non-CCB-based regimen (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84 to 0.99; p = 0.03). The risk of stroke was also significantly decreased (OR, 0.84; 95% CI, 0.79 to 0.90; p < 0.00001). The risk of heart failure increased slightly with marginal significance for an amlodipine-based regimen compared with a non-CCB-based regimen (OR, 1.14; 95% CI, 0.98 to 1.31; p = 0.08). However, when compared overall with β-blockers and diuretics, amlodipine showed a comparable risk. Amlodipine-based regimens demonstrated a 10% risk reduction in overall cardiovascular events (OR, 0.90; 95% CI, 0.82 to 0.99; p = 0.02) and total mortality (OR, 0.95; 95% CI, 0.91 to 0.99; p = 0.01).ConclusionsAmlodipine reduced the risk of total cardiovascular events as well as all-cause mortality compared with non-CCB-based regimens, indicating its benefit for high-risk cardiac patients.

Preoperative Urinary Neutrophil Gelatinase-Associated Lipocalin and Outcome in High-Risk Heart Failure Patients Undergoing Cardiac Surgery

To investigate the ability of early urinary neutrophil gelatinase-associated lipocalin to predict postoperative complications in adult patients with ventricular dysfunction undergoing cardiac surgery. Prospective observational study. Single-center study, university hospital. Fifty-six adult high-risk cardiac surgical patients with preoperative cardiac failure. None. Demographic and clinical characteristics were obtained, and neutrophil gelatinase-associated lipocalin was measured at baseline and at several time points after surgery. Patient characteristics and neutrophil gelatinase-associated lipocalin levels were related to renal and patient outcome. On multivariate analyses, preoperative urinary neutrophil gelatinase-associated lipocalin was an independent predictor of length of intensive care stay (p = 0.004) and in-hospital stay (p = 0.04), but not of acute kidney injury or renal replacement therapy and was not associated with baseline renal function. In a cohort of high-risk cardiac surgery patients, preoperative urinary neutrophil gelatinase-associated lipocalin value provided prognostic information that was independent of the onset of acute kidney injury or of preoperative renal function.

Routine Intra-Aortic Balloon Pump Support in High-Risk Cardiac Surgery Patients

Routine Intra-Aortic Balloon Pump Support in High-Risk Cardiac Surgery Patients