Incidence Of Postoperative Renal Failure Research Articles

Clinical relevance of transcranial Doppler in a cardiac surgery setting: embolic load predicts difficult separation from cardiopulmonary bypass

BackgroundDuring cardiac surgery, transcranial Doppler (TCD) represents a non-invasive modality that allows measurement of red blood cell flow velocities in the cerebral arteries. TCD can also be used to detect and monitor embolic material in the cerebral circulation. Detection of microemboli is reported as a high intensity transient signal (HITS). The importance of cerebral microemboli during cardiac surgery has been linked to the increased incidence of postoperative renal failure, right ventricular dysfunction, and hemodynamic instability. The objective of this study is to determine whether the embolic load is associated with hemodynamic instability during cardiopulmonary bypass (CPB) separation and postoperative complications.MethodsA retrospective single-centre cohort study of 354 patients undergoing cardiac surgery between December 2015 and March 2020 was conducted. Patients were divided in tertiles, where 117 patients had a low quantity of embolic material (LEM), 119 patients have a medium quantity of microemboli (MEM) and 118 patients who have a high quantity of embolic material (HEM). The primary endpoint was a difficult CPB separation. Multivariate logistic regression was used to determine the potential association between a difficult CPB separation and the number of embolic materials.ResultsPatients who had a difficult CPB separation had more HITS compared to patients who had a successful CPB separation (p < 0.001). In the multivariate analysis, patients with MEM decreased their odds of having a difficult CPB weaning compared to patients in the HEM group (OR = 0.253, CI 0.111–0.593; p = 0.001). In the postoperative period patients in the HEM group have a higher Time of Persistent Organ Dysfunction (TPOD), a longer stay in the ICU, a longer duration under vasopressor drugs and a higher mortality rate compared to those in the MEM and LEM groups.ConclusionThe result of this study suggests that a high quantity of cerebral embolic material increases the odds of having a difficult CPB separation. Also, it seems to be associated to more complex surgery, a longer CPB time, a higher TPOD and a longer stay in the ICU. Six out of eight patients who died in this cohort were in the HEM group.

Prognostic value of TCBI for short-term outcomes in ATAD patients undergoing surgery.

Nutritional status has been reported to be associated with the prognosis of cardiovascular diseases. The study aimed to investigate the prognostic value of Triglycerides-total Cholesterol-Body weight-Index (TCBI) for short-term mortality in acute type A aortic dissection (ATAD) patients undergoing surgery. Totally, the data of 290 ATAD patients undergone surgery were, retrospectively, analyzed. After logistic regression analysis, TCBI was identified as an independent predictor of short-term mortality in ATAD surgery. The development of receive operating characteristic (ROC) curve demonstrated that TCBI (AUC = 0.745, P < 0.001) could provide well prognostic value for short-term mortality. Accordingly, the optimal cut-off value was identified as 883.5 and patients were divided into high TCBI (> 883.5) and low TCBI (≤ 883.5) groups. Furthermore, Kaplan-Meier analysis illustrated that short-term mortality increased significantly in the low TCBI group than in the high TCBI group (P < 0.0001). In addition, the incidence of postoperative renal failure was also elevated in the low TCBI group (P = 0.0011). Malnutrition by preoperative TCBI presented strong prognostic value for patients following ATAD surgery. And TCBI could be applied for risk stratification and therapeutic strategy-making in ATAD.

Effect of thoracic epidural anesthesia on postoperative outcome in major liver surgery: a retrospective cohort study

PurposePostoperative complications after major liver surgery are common. Thoracic epidural anesthesia may provide beneficial effects on postoperative outcome. We strove to compare postoperative outcomes in major liver surgery patients with and without thoracic epidural anesthesia.MethodsThis was a retrospective cohort study in a single university medical center. Patients undergoing elective major liver surgery between April 2012 and December 2016 were eligible for inclusion. We divided patients into two groups according to whether or not they had thoracic epidural anesthesia for major liver surgery. The primary outcome was postoperative hospital length of stay, i.e., from day of surgery until hospital discharge. Secondary outcomes included 30-day postoperative mortality and major postoperative complications. Additionally, we investigated the effect of thoracic epidural anesthesia on perioperative analgesia doses and the safety of thoracic epidural anesthesia.ResultsOf 328 patients included in this study, 177 (54.3%) received thoracic epidural anesthesia. There were no clinically important differences in postoperative hospital length of stay (11.0 [7.00–17.0] vs. 9.00 [7.00–14.0] days, p = 0.316, primary outcome), death (0.0 vs. 2.7%, p = 0.995), or the incidence of postoperative renal failure (0.6 vs. 0.0%, p = 0.99), sepsis (0.0 vs. 1.3%, p = 0.21), or pulmonary embolism (0.6 vs. 1.4%, p = 0.59) between patients with or without thoracic epidural anesthesia. Perioperative analgesia doses — including the intraoperative sufentanil dose (0.228 [0.170–0.332] vs. 0.405 [0.315–0.565] μg·kg−1·h−1, p < 0.0001) — were lower in patients with thoracic epidural anesthesia. No major thoracic epidural anesthesia-associated infections or bleedings occurred.ConclusionThis retrospective analysis suggests that thoracic epidural anesthesia does not reduce postoperative hospital length of stay in patients undergoing major liver surgery — but it may reduce perioperative analgesia doses. Thoracic epidural anesthesia was safe in this cohort of patients undergoing major liver surgery. These findings need to be confirmed in robust clinical trials.

A Multimodal Cardioprotection Strategy During Cardiac Surgery: The ProCCard Study

The ProCCard study tested whether combining several cardioprotective interventions would reduce the myocardial and other biological and clinical damage in patients undergoing cardiac surgery. Prospective, randomized, controlled trial. Multicenter tertiary care hospitals. 210 patients scheduled to undergo aortic valve surgery. A control group (standard of care) was compared to a treated group combining five perioperative cardioprotective techniques: anesthesia with sevoflurane, remote ischemic preconditioning, close intraoperative blood glucose control, moderate respiratory acidosis (pH 7.30) just before aortic unclamping (concept of the "pH paradox"), and gentle reperfusion just after aortic unclamping. The primary outcome was the postoperative 72-h area under the curve (AUC) for high-sensitivity cardiac troponin I (hsTnI). Secondary endpoints were biological markers and clinical events occurring during the 30 postoperative days and the prespecified subgroup analyses. The linear relationship between the 72-h AUC for hsTnI and aortic clamping time, significant in both groups (p < 0.0001), was not modified by the treatment (p = 0.57). The rate of adverse events at 30 days was identical. A non-significant reduction of the 72-h AUC for hsTnI (-24%, p = 0.15) was observed when sevoflurane was administered during cardiopulmonary bypass (46% of patients in the treated group). The incidence of postoperative renal failure was not reduced (p = 0.104). This multimodal cardioprotection has not demonstrated any biological or clinical benefit during cardiac surgery. The cardio- and reno-protective effects of sevoflurane and remote ischemic preconditioning therefore remain to be demonstrated in this context.

Tranexamic Acid in Hip Hemiarthroplasty Surgery: A Retrospective Analysis of Perioperative Outcome.

Introduction: Implantation of a dual-head hip prosthesis to treat medial femoral neck fractures is often associated with significant blood loss. In elective endoprosthetics procedures, it has already been demonstrated that administration of tranexamic acid (TXA) reduces blood loss and need for postoperative transfusions, as well as reducing the frequency of postoperative complications. The aim of this study is to show whether the administration of TXA also leads to a reduction in perioperative blood loss and haemorrhage-associated complications when applied as part of treatment of femoral neck fractures using a dual-head prosthesis. Methods: In a single-centre retrospective cohort study, 1g TXA i.v. was administered preoperatively to 93 patients who had suffered from femoral neck fractures. This group was compared to a comparison group of 65 patients who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, frequency of transfusion, and frequency of specific complications occurring. Results: The transfusion rate in the TXA group was 6% lower, whereby the volume of blood transfused was 26.7% lower than in the nonTXA group. However, neither result was significant. The calculated perioperative blood loss remained the same. Similarly, the incidence of postoperative renal failure was not significantly lower in the TXA group, at 6.5%, as compared to the nonTXA group (7.7%). A higher rate of complications or deaths as a result of TXA administration was not observed. The tranexamic acid effect seems to be related to the dose. Conclusion: Preoperative administration of TXA during implantation of a dual-head prosthesis for treatment of a femoral neck fracture does not lead to an increased complication rate. The study revealed a trend towards fewer transfusions required, but a significant reduction in blood loss could not be demonstrated. There should be further investigation of other factors influencing blood loss, in particular the dosing regimen followed for perioperative administration of TXA. Level of Evidence: Level 4: retrospective case-control study.

Early and midterm results of valve-sparing aortic root reconstruction with a bovine pericardium patch for patients with acute type a aortic dissection.

We evaluated the feasibility, effectiveness, and safety of valve-sparing aortic root reconstruction with a bovine pericardium patch for patients with acute type A aortic dissection (ATAAD). From January 2016 to January 2021, 895 consecutive patients with ATAAD received surgical treatment at our hospital. After applying our exclusion criteria, 508 patients were included in this research. Based on the attending surgeon's judgment and preference, 192 patients underwent our novel surgical novel surgical technique of valve-sparing aortic root reconstruction (repair group [RG]) and 316 patients underwent the Bentall procedure (Bentall group [BG]). In the RG, the early mortality rate was 4.2% (8/192). In the BG, the early mortality rate was 5.1% (16/316). There were no significant differences between groups. The incidence of postoperative renal failure in the BG was significantly higher than that in the RG. The mean follow-up time was 2.93 years (standard deviation, ±1.38 years). There were no significant differences between groups regarding ATAAD-related mortality and reoperation. In the RG, the rate of freedom from aortic root reoperation at 5 years was 98.2%, and the grade of aortic regurgitation 6 months later was significant less than that before surgery, and it did not worsen during later follow-up. Valve-sparing aortic root reconstruction with a bovine pericardium patch can be successfully performed for selected patients with ATAAD and is associated with low in-hospital and late mortality rates and low root reoperation rates during early and midterm follow-up.

Incidence and predictors of sternal surgical wound infection in cardiac surgery: A prospective study.

Sternal surgical wound infection (SSWI) in cardiac surgery is associated with increased morbidity. We investigated the incidence of SSWI, the main germs implicated and predictors of SSWI. Prospective study including patients undergoing full median sternotomy between January 2017 and December 2019. Patients were followed-up for 3 months after hospital discharge. All sternal wound infections up to 90 days after discharge were considered SSWI. 1004 patients were included. During follow-up, 68 (6.8%) patients presented SSWI. Patients with SSWI had a higher incidence of postoperative renal failure (29.4% vs 17.1%, P=.007), a higher incidence of early postoperative reoperation for non-infectious causes (42.6% vs 9.1%, P < .001), longer ICU stay (3 [2-9] days vs 2 [2-4] days, P=.006), and longer hospital stay (24.5 [14.8-38.3] days vs 10 [7-18] days, P < .001). Gram-positive germs were presented in 49% of the cultures, and gram-negative bacteria in 35%. Early reoperation for non-infectious causes (OR 4.90, 95% CI 1.03-23.7), and a longer ICU stay (OR 1.37 95% CI 1.10-1.72) were independent predictors of SSWI. SSWI is rare but leads to more postoperative complications. The need for early reoperation because of non-infectious cause and a longer ICU stay were independently associated with SSWI.

MO358: Analysis of Acute Kidney Injury Incidence in Patients After Left Ventricle Assist Device Implantation

Abstract BACKGROUND AND AIMS Chronic heart failure (CHF) in the terminal stage is a crucial issue of medicine. Heart transplantation is still the best treatment option. Lack of donors, long waiting time make heart transplantation almost impossible. Implantation of left ventricular assist device—LVAD) in patients with CHF is a bridge to transplantation. Nevertheless, the LVAD implantation procedure is time-consuming, requires significant material costs, and leads to numerous complications in the postoperative period. Acute kidney injury (AKI) is one of the most common and dangerous complications. Issues of AKI in patients with LVAD should be carefully taught. The aim of the study is to examine the incidence of postoperative renal failure after the implantation of LVAD and its relationship to outcomes. In addition, we want to share with our experience of AKI management in patients with LVAD. METHOD A retrospective analysis of 265 medical records of patients after surgical implantation of LVAD who were hospitalized to the National Research Cardiac Surgery Center, Nur-Sultan city, Kazakhstan. Period of hospitalization from 01.2015 to 10.2021 year. The Kidney Disease Improving Global Outcome (KDIGO) criteria were used to define AKI. RESULTS Total number of patients 265 after LVAD implantation. Male—85.66% and female—14.34%. Mean ICU stay of patient without severe AKI—7.17±5.47 days. Mean ICU stay of patient with severe AKI—11.82±7.47 days. Patients with severe AKI and blood purification—59 patients (24.9%), male—61–92.4%, femal—-5–7.6%. Total number of LVAD patients—265. ICU Mortality rate of patients after LVAD implantation—11 patients (4.15%). Severe AKI—59 patients (22.3%). Recovery of AKI—47 patients (79.66%). Transformation to terminal stage of chronic renal disease (CRD) with chronic dialysis—1 patient (1.69%). ICU Mortality rate of patients with severe AKI—11 (18.64%). CONCLUSION AKI is a common complication in the immediate postoperative period after LVAD implantation. AKI negatively affects the outcome of the disease. The mortality rate of LVAD patients with renal insufficiency exceeds by 14% the mortality of patients with renal insufficiency. Blood purification is the effective method of severe AKI therapy.

Risk of Postoperative Renal Failure in Radical Nephrectomy and Nephroureterectomy: A Validated Risk Prediction Model

Introduction: The study aimed to construct and validate a risk prediction model for incidence of postoperative renal failure (PORF) following radical nephrectomy and nephroureterectomy. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2005–2014 were used for the derivation cohort. A stepwise multivariate logistic regression analysis was conducted, and the final model was validated with an independent cohort from the ACS-NSQIP database years 2015–2017. Results: In cohort of 14,519 patients, 296 (2.0%) developed PORF. The final 9-factor model included age, gender, diabetes, hypertension, BMI, preoperative creatinine, hematocrit, platelet count, and surgical approach. Model receiver-operator curve analysis provided a C-statistic of 0.79 (0.77, 0.82; p < 0.001), and overall calibration testing R² was 0.99. Model performance in the validation cohort provided a C-statistic of 0.79 (0.76, 0.81; p < 0.001). Conclusion: PORF is a known risk factor for chronic kidney disease and cardiovascular morbidity, and is a common occurrence after unilateral kidney removal. The authors propose a robust and validated risk prediction model to aid in identification of high-risk patients and optimization of perioperative care.

Impact of Early, Low-Dose Factor VIIa on Subsequent Transfusions and Length of Stay in Cardiac Surgery

Recombinant factor VII (rFVIIa) is used to treat cardiac surgical bleeding in an off-label manner. However, optimal dosing and timing of administration to provide efficacious yet safe outcomes remain unknown. Retrospective, observational study. Tertiary care academic center. Cardiac surgical patients (N = 214) who received low-dose rFVIIa for cardiac surgical bleeding. Patients were allocated into one of three groups based on timing of rFVIIa administration during the course of bleeding resuscitation based on the number of hemostatic products given before rFVIIa administration: group one = ≤one products (n = 82); group two = two-to-four products (n = 73); and group three= ≥five products (n = 59). Patients who received low-dose rFVIIa later in the course of bleeding resuscitation (group three) had longer intensive care unit stays (p = 0.014) and increased incidence of postoperative renal failure when compared with group one (p = 0.039). Total transfusions were lowest in patients who received rFVIIa early in the course of resuscitation (group one) (median, two [interquartile range (IQR), 1-4.75]) and highest in group three (median, 11 [IQR, 8-14]; p < 0.001). Subsequent blood product transfusions after rFVIIa administration were highest in group two (p = 0.003); however, the median for all three groups was two products. There were no differences in thrombosis, reexplorations, or mortality in any of the groups. This study identified no differences in adverse outcomes based on timing of administration of low-dose rFVIIa for cardiac surgical bleeding defined by stage of resuscitation, but the benefits of early administration remain unclear.

Levosimendan for Treatment of Primary Graft Dysfunction After Heart Transplantation: Optimal Timing of Application.

Primary graft dysfunction remains a serious problem after heart transplant. Pharmacological treatment with the calcium sensitizer levosimendan may be an additive treatment for primary graft dysfunction. Patients undergoing heart transplant between 2010 and 2020 were retrospectively reviewed and divided depending on postoperative treatment with (n = 41) or without (n = 109) levosimendan. Recipients who received levosi mendan were further divided with regard to timing of levosimendan application (early group: started ≤48 hours posttransplant [n = 23]; late group: started >48 hours posttransplant [n = 18]). Patients who received levosimendan treatment displayed a remarkable incidence (87.8%) of postoperative primary graft dysfunction with need for venoarterial extracorporeal membrane oxygenation and therefore often presented with perioperative morbidity. Patient with early application of levosimendan showed significantly decreased duration of venoarterial extracorporeal membrane oxygenation support (5.1 ± 3.5 days vs 12.6 ± 9.3 days in those with late application; P < .01) and decreased mortality during venoarterial extracorporeal membrane oxygenation support (0.0% vs 33.3% in early vs late group; P < .01). In addition, compared with patients with late levosimendan application, patients with early application needed fewer blood transfusions (P < .05), had shorter ventilation times (279 ± 235 vs 428 ± 293 h; P = .03), and showed a trend of reduced incidence of postoperative renal failure (69.6% vs 94.4%; P = .06). Moreover, survival analyses indicated an increased survival for patients with early start of levosimendan therapy within the first 48 hours after heart transplant (P = .09). Pharmacotherapy with levosimendan may be a promising additive in the treatment of primary graft dysfunction after heart transplant. With administration of levosimendan within the first 48 hours posttransplant, rates of successful weaning from venoarterial extracorporeal membrane oxygenation and outcomes after heart transplant were shown to increase.

Experience of heart transplantation with an extended cold ischemic time of donor heart

Aim. A retrospective analysis of the outcomes of heart transplantation (HT) with extended cold ischemic time of donor heart (more than 4 hours) versus heart transplantation with short cold ischemia time (less than 4 hours).Material and methods. The retrospective analysis included 52 recipients who underwent HT in the period from July 20, 2012 to October 23, 2019 in Meshalkin National Medical Research Center. The patients were divided into two groups: group 1 (n=26) — orthotopic HT with extended cold ischemic time (more than 240 minutes), group 2 (n=26) — short cold ischemia time (less than 240 minutes). The effect of cold ischemia duration on hospital survival, the function of donor heart, and the postoperative course was assessed.Results. A retrospective analysis revealed a higher rate of hospital survival in the group of recipients with extended cold ischemic time (more than 240 minutes) 88,5% compared to 80,7% in the second group. There was no difference between the groups in the acute rejection rate, the need for inotropic agents, mechanical circulatory support, and cardiac pacing, as well as the incidence of postoperative renal failure and infectious complications.Conclusion. Due to the small number of patients, our experience in HT with extended cold ischemic time does not allow us to draw global conclusions, but a preliminary comparison of HT with extended and short cold ischemic time did not reveal significant advantages in one group or another. This provides a basis for further accumulation of experience and research.

Evaluation of Increase in Intraoperative Lactate Level as a Predictor of Outcome in Adults After Cardiac Surgery

Early onset hyperlactatemia develops intraoperatively or within the first 6 hours of admission to the intensive care unit (ICU) and is associated with a poor prognosis. The aim of the present study was to determine the utility of an increase in the intraoperative lactate level, independent of the absolute lactate value at baseline after induction, as a dynamic parameter for morbidity (ICU length of stay, postoperative renal failure, and inotrope use) and mortality in adults post-cardiac surgery. Retrospective observational study. Single-center study in an academic hospital. The study comprised 779 patients who underwent elective cardiac surgery. None. Patients were classified into the following 5 groups based on the increase in the intraoperative lactate level: (1) group 1-negative, (2) group 2-1- to 1.59-fold increase, (3) group 3-1.6- to 1.99-fold increase, (4) group 4-2- to 3-fold increase, and (5) group 5->3-fold increase. Logistic regression analyses were performed. Group 5 had a 4 times greater mortality (7.7%), the longest ICU length of stay (89.02 ± 78.73 h), and the greatest incidence of postoperative renal failure (n = 5 [19.2%]) compared with group 1. The increase in the intraoperative lactate level was a statistically significant predictor of mortality (p = 0.001) and ICU length of hospital stay (p = 0.0006) and was highly predictive for postoperative renal failure requiring renal replacement therapy (p = 0.001). An increase in intraoperative lactate, independent of the level on induction, is a useful dynamic parameter to identify patients at risk of postoperative morbidity and mortality and might provide an early trigger for introducing measures to avoid poor outcomes.

Current status of cardiovascular surgery in Japan, 2015 and 2016: analysis of data from Japan Cardiovascular Surgery Database. 4-Thoracic aortic surgery.

Thoracic and thoracoabdominal aortic diseases are treated using operative procedures like open aortic repair (OAR), thoracic endovascular aortic repair (TEVAR), or hybrid aortic repair (HAR), or a combination of OAR and TEVAR. The surgical approach to aortic repair has evolved over the decades. The purpose of this study was to examine the current trends in treatment. We extracted nationwide data of aortic repair procedures performed in 2015 and 2016 from the Japan Cardiovascular Surgery Database (JCVSD). In addition to estimating the number of cases, we also reviewed the respective operative mortalities and associated major morbidities (e.g., stroke, spinal cord insufficiency, and renal failure) according to disease pathology (e.g., acute dissection, chronic dissection, ruptured aneurysm, and unruptured aneurysm), site of operative repair (i.e., aortic root, ascending aorta, aortic root to arch, aortic arch, descending aorta, and thoracoabdominal aorta), and the preferred surgical approach (i.e., OAR, HAR, or TEVAR). The total number of cases studied was 35,427, with an overall operative mortality rate of 7.3%. Among the 3 procedures, 64% of patients were treated with OAR. Compared to the data from our previous report (also derived from the JCVSD in 2013 and 2014), the total number of cases and number of OAR, HAR, and TEVAR procedures have increased by 17.0%, 2.4%, 126.1%, and 34.9%, respectively. While the overall stroke rates following aortic arch surgical repair with HAR, OAR, and TEVAR were 10.1%, 8.4%, and 7.3%, respectively, OAR was found to have the lowest stroke rate when limited to cases presenting with a non-dissected/unruptured aorta. The incidence rates of paraplegia following descending/thoracoabdominal aortic surgical repair using HAR, OAR, and TEVAR were 6.3%/10.4%, 4.3%/8.9%, and 3.4%/4.6%, respectively. TEVAR was found to be associated with the lowest incidence of postoperative renal failure. The number of operations for thoracic and thoracoabdominal aortic diseases has increased, though the rate of operations using an OAR approach has decreased. While TEVAR showed the lowest mortality and morbidity rates, OAR demonstrated the lowest postoperative stroke rate for non-dissecting aortic arch aneurysms.

Does epidural anesthesia affect the outcomes of hepatic resections? Analysis of the ACS NSQIP database

Background: The aim of this study is to examine the effect of adjunct epidural anesthesia (ED) on post-hepatectomy outcomes from a national database. Methods: Patients undergoing hepatectomy in the NSQIP targeted file (2014–2016) were identified. Those with INR>1.5, Platelets< 100, bleeding disorders, and adjunct anesthesia (other than epidural) were excluded. Patients with and without EA were matched (1:1) using propensity scores to adjust for baseline differences. Results: Among 9,812 cases, 1,568 (16%) had EA. Of whom 1,434 were matched (1:1) to those without EA. The matched cohort is well-balanced on preoperative characteristics and type of operation (including concomitant resections, ablations and biliary reconstruction). In the case-matched cohort, patients with EA had higher incidence of postoperative renal failure (2.1% vs. 0.98%, p = 0.015), overall morbidity (41.9% vs. 36.5%, p = 0.003) and serious morbidity (24.1% vs. 20.4%, p=0.02) as well as longer hospital stay (median, 6 d vs. 5 d, p < 0.001) and operative time (mean, 257 min vs. 244 min). Postoperative Blood transfusions (17.7% vs. 23.2%, p < 0.001) and pneumonia (2.9% vs. 4.7%, p = 0.015) were less likely with EA. Conclusion: EA is associated with higher overall morbidity and longer hospital stay, but similar hepatectomy-specific complications. The use of EA is also associated with lower incidence of pneumonia and blood transfusions. These findings do not support the routine use of EA for hepatectomy.

Open repair of ruptured abdominal aortic aneurysm with associated horseshoe kidney.

Ruptured abdominal aortic aneurysms (RAAA) with concomitant horseshoe kidney (HK) present a unique challenge at the time of repair. The aim of this article was to propose the most rationale strategy during open repair (OR) of RAAA in the presence of HK. We identified and analyzed all patients treated at the clinic due to RAAA and HK. An extensive search was performed on all articles published up to August of 2017 describing open and endovascular repair of RAAA with concomitant horseshoe kidney. The following data were extracted and analyzed: patient number, number of renal arteries, Crawford classification of horseshoe kidney vascularization, type of aortic reconstruction, management with renal arteries, 30-day kidney failure and outcome. Transperitoneal approach followed by supraceliac aortic cross clamping without the division of the renal isthmus occurred in all our six cases. Four of them required additional procedures with accessory renal arteries after aortic replacement. Three of patients (50%) died during the first 30 postoperative days, while one developed transitory renal insufficiency. The renal isthmus was preserved in 43.90% and divided in 46.34% of cases. Crawford type I of HK vascularization was presented in 21.95% of cases, type II also in 39.02%, while the type III in 19.51% of cases. In 46.33% of cases a procedure with renal arteries was necessary. In 26.82% accessory renal arteries were ligated, while in 19.51% preserved (reattachment or aorto-renal bypass). Thirty-day mortality was 21.95%, while the incidence of postoperative renal failure was also 21.95%. There was not significant correlation between the renal artery ligation and the postoperative renal failure (r=-0.81, P=0.59). Transperitoneal approach should be preferred during urgent OR of RAAA with concomitant HK. A supraceliac aortic cross clamping and the placement of occlusive Fogarty catheters into both iliac arteries are recommended for proximal and distal bleeding control. Preservation of accessory renal arteries that are larger than 3 mm in diameter or supply more than 30% of renal parenchima is recommended. The division of the renal isthmus should be avoided if vascularized. It seems that renal arteries could be covered in emergency EVAR without any implications on postoperative kidney function, allowing broader aplication of endovascular treatment for thesse patients.

Sutureless Perceval Aortic Valve Versus Conventional Stented Bioprostheses: Meta-Analysis of Postoperative and Midterm Results in Isolated Aortic Valve Replacement.

BackgroundAortic stenosis is the most common valvular disease and has a dismal prognosis without surgical treatment. The aim of this meta‐analysis was to quantitatively assess the comparative effectiveness of the Perceval (LivaNova) valve versus conventional aortic bioprostheses.Methods and ResultsA total of 6 comparative studies were identified, including 639 and 760 patients who underwent, respectively, aortic valve replacement with the Perceval sutureless valve (P group) and with a conventional bioprosthesis (C group). Aortic cross‐clamping and cardiopulmonary bypass duration were significantly lower in the P group. No difference in postoperative mortality was shown for the P and C groups (2.8% versus 2.7%, respectively; odds ratio [OR]: 0.99 [95% confidence interval (CI), 0.52–1.88]; P=0.98). Incidence of postoperative renal failure was lower in the P group compared with the C group (2.7% versus 5.5%; OR: 0.45 [95% CI, 0.25–0.80]; P=0.007). Incidence of stroke (2.3% versus 1.7%; OR: 1.34 [95% CI, 0.56–3.21]; P=0.51) and paravalvular leak (3.1% versus 1.6%; OR: 2.52 [95% CI, 0.60–1.06]; P=0.21) was similar, whereas P group patients received fewer blood transfusions than C group patients (1.16±1.2 versus 2.13±2.2; mean difference: 0.99 [95% CI, −1.22 to −0.75]; P=0.001). The incidence of pacemaker implantation was higher in the P than the C group (7.9% versus 3.1%; OR: 2.45 [95% CI, 1.44–4.17]; P=0.001), whereas hemodynamic Perceval performance was better (transvalvular gradient 23.42±1.73 versus 22.8±1.86; mean difference: 0.90 [95% CI, 0.62–1.18]; P=0.001), even during follow‐up (10.98±5.7 versus 13.06±6.2; mean difference: −2.08 [95% CI, −3.96 to −0.21]; P=0.030). We found no difference in 1‐year mortality.ConclusionsThe Perceval bioprosthesis improves the postoperative course compared with conventional bioprostheses and is an option for high‐risk patients.

The Effects of Preoperative Volume Replacement in Diabetic Patients Undergoing Coronary Artery Bypass Grafting Surgery: Protocol for a Randomized Controlled Trial (VeRDiCT Trial).

BackgroundDiabetes mellitus is a major risk factor for prolonged hospital stays, renal failure, and mortality in patients having coronary artery bypass grafting (CABG). Complications pose a serious threat to patients and prolong intensive care and hospital stays. Low glomerular filtration rate (GFR) due to existing renal impairment or volume depletion may exacerbate acute renal impairment/failure in these patients. Preoperative volume replacement therapy (VRT) is reported to increase the GFR and we hypothesize that VRT will reduce renal impairment and related complications in diabetic patients.ObjectiveThe objective of this study is to establish the efficacy of preoperative VRT in reducing postoperative complications in diabetic patients undergoing CABG surgery. Time to “fit for discharge”, incidence of postoperative renal failure, cardiac injury, inflammation, and other health outcomes will be investigated.MethodsIn this open parallel group randomized controlled trial, 170 diabetic patients undergoing elective or urgent CABG surgery received 1 mL/kg/hour of Hartmann’s solution for 12 consecutive hours prior to surgery, versus routine care. The primary outcome was time until participants were “fit for discharge”, which is defined as presence of: normal temperature, pulse, and respiration; normal oxygen saturation on air; normal bowel function; and physical mobility. Secondary outcomes included: incidence of renal failure; markers of renal function, inflammation, and cardiac damage; operative morbidity; intensive care stay; patient-assessed outcome, including the Coronary Revascularization Outcome Questionnaire; and use of hospital resources.ResultsRecruitment started in July 2010. Enrolment for the study was completed in July 2014. Data analysis commenced in December 2016. Study results will be submitted for publication in the summer of 2017.ConclusionsVRT is a relatively easy treatment to administer in patients undergoing surgical procedures who are at risk of renal failure. This experimental protocol will increase scientific and clinical knowledge of VRT in diabetic patients undergoing elective or urgent CABG surgery. Findings supporting the efficacy of this intervention could easily be implemented in the health care system.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 02159606; http://www.controlled-trials.com/ISRCTN02159606 (Archived by WebCite at http://www.webcitation.org/6rDkSSkkK)

The impact of a multidisciplinary blood conservation protocol on patient outcomes and cost after cardiac surgery

ObjectiveAlthough associations between transfusion and inferior outcomes have been documented, there is a lack of blood transfusion standardization in cardiac surgery. At the Inova Heart and Vascular Institute, a multidisciplinary, criterion-driven algorithm for transfusion management was implemented. We examined the effect of our blood conservation protocol on transfusion rates and outcomes after cardiac surgery and on stability of transfusion over time. MethodsPatients undergoing first-time cardiac surgery from 2006 (full year before protocol) were compared with those in 2009 (after protocol) and propensity score matched to improve balance. Data were prospectively collected. Stability of transfusion incidence also was compared (2005-2006 vs 2008-2014). ResultsAfter matching, 890 patients from each year were included. Use of blood products decreased from 54% in 2006 to 25% in 2009 (P < .001). Patients in 2009 had a lower incidence of postoperative renal failure (2.6% vs 4%, P = .04), reoperations for bleeding (2% vs 4%, P = .004), and readmissions at less than 30 days (6% vs 12%, P < .001). No differences were found for operative mortality, deep sternal wound infection, or permanent strokes. Patients in 2009 had greater improvement in physical (P = .001) and mental (P = .02) quality of life than patients in 2006. Reduction of blood products led to significant cost savings for packed erythrocytes (P < .001) and platelets (P < .001). After protocol implementation, transfusion incidence remained 30% or less, with less than 28% in most years. ConclusionsA multidisciplinary blood conservation program can significantly control blood transfusion rates, improve outcomes, and be sustained over time. Efforts are needed to implement evidence-based protocols to standardize and decrease blood use in cardiac surgery to improve outcomes and reduce cost.

Relationship between transfusion volume and outcomes in children undergoing noncardiac surgery.

The objective of this study was to assess the relationship between the volume of red blood cells (RBCs) transfused and outcomes in children undergoing noncardiac surgery. Children undergoing noncardiac surgery recorded in the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) pediatric databases were included. Outcomes included 30-day mortality and the incidence of major postoperative complications. Children who received RBC transfusions were further classified into four subgroups based on the volume transfused. We used multivariable logistic regression analysis and propensity-matched analysis to match each child who received a transfusion with a nontransfused control and to compare the incidences of 30-day mortality and adverse postoperative outcomes. After propensity-matched analysis, there were 4496 children in the group that received transfusion volumes from 1 to 19 mL/kg, 1557 in the group that received volumes from 20 to 39 mL/kg, 506 in the group that received from 40 to 59 mL/kg, and 412 in the group that received ≥60 mL/kg. Children who received RBC transfusion volumes from 40 to 59 mL/kg and ≥60 mL/kg had an increased risk for 30-day mortality of 7.3% versus 1.4% (p < 0.001) and 11.2% versus 2.9% (p = 0.005), respectively, compared with their matched controls. No statistical difference was reported for children who were exposed to transfusion volumes from 20 to 39 mL/kg (3.3% vs 1.3%; p = 0.021), or from 1 to 19 mL/kg (1.4% vs. 1.2%; p = 0.691). Although no effect was observed on the incidence of postoperative renal failure or wound complications, RBC transfusions were associated with an increased incidence of postoperative infection when the volume transfused exceeded 20 mL/kg. RBC transfusion is associated with an increased incidence of 30-day mortality and postoperative infections in children undergoing noncardiac surgery, and there is a correlation between the volume of red blood cells transfused and the incidences of adverse outcomes. Potential associations related to the reason to transfuse, the cause of the bleeding, or the actual blood products themselves need to be studied in further prospective trials.