Mortality In Cardiac Surgery Patients Research Articles

Can Serum Cystatin C predict long-term survival in cardiac surgery patients?

Renal dysfunction is a risk factor for morbidity and mortality in cardiac surgery patients. Serum Cystatin C (sCysC) is a well-recognized marker of early renal dysfunction but few reports evaluate its prognostic cardio-vascular role. The aim of the study is to consider the prognostic value of sCysC for cardiovascular mortality. Four hundred twenty-four cardiac-surgery patients (264 men and 160 women) were enrolled. At admission, all patients were tested for renal function and inflammatory status. Patients were subdivided in subgroups according to the values of the following variables: sCysC, serum Creatinine (sCrea), age, high sensitivity-C Reactive Protein, fibrinogen, surgical procedures and Kaplan-Meier cumulative survival curves were plotted. The primary end-point was cardiovascular mortality. In order to evaluate the simultaneous independent impact of all measured variables on survival we fitted a multivariate Cox-Proportional Hazard Model (CPHM). In Kaplan-Meier analysis 124 patients (29.4%) reached the end-point. In multivariate CPHM, the only significant predictors of mortality were sCysC (p<0.00001, risk ratio: 1.529, CI: 1.29-1.80) and age (p=0.039, risk ratio: 1.019, CI: 1.001-1.037). When replacing sCysC with sCrea, the only significant predictor of mortality was sCrea (p=0.0026; risk ratio 1.20; CI: 1.06-1.36). Increased levels of sCysC can be considered a useful biomarker of cardiovascular mortality in cardiac-surgery patients.

Perioperative body weight change is associated with in-hospital mortality in cardiac surgical patients with postoperative acute kidney injury.

BackgroundPostoperative acute kidney injury (AKI) is common following cardiac surgery (CS). Body weight (BW) may be an amenable variable by representing the summation of the nutritional and the fluid status. However, the predictive role of perioperative BW changes in CS patients with severe postoperative AKI is never explored. This study aimed to evaluate this association.MethodsThis study was conducted using a prospectively collected multicenter cohort, NSARF (National Taiwan University Hospital Study Group on Acute Renal Failure) database. The adult CS patients with postoperative AKI requiring renal replacement therapy (RRT), who had clear initial consciousness, received CS within 14 days of hospitalization, and underwent RRT within seven days after CS in intensive care units from January 2001 to January 2014 were enrolled. With the endpoint of 30-day postoperative mortality, we evaluated the association between the clinical factors denoting fluid status and patients outcomes.ResultsA total of 188 patients (70 female, mean age 63.7 ± 15.2 years) were enrolled. Comparing with the survivors (n = 124), the non-survivors (n = 64) had a significantly higher perioperative BW change [3.6 ± 6.1% versus 0.1 ± 8.3%, p = 0.003] but not the postoperative and pre-RRT BW changes. By using multivariate Cox proportional hazards model, the independent indicators of 30-day postoperative mortality included perioperative BW change (p = 0.026) and packed red blood cells transfusion (p = 0.007), postoperative intra-aortic balloon pump (p = 0.001) and central venous pressure level (p = 0.005), as well as heart rate (p = 0.022), sequential organ failure assessment score (p < 0.001), logistic organ dysfunction score (p = 0.001), and blood total bilirubin level (p = 0.044) at RRT initiation. The generalized additive models further demonstrated, in a multivariate manner, that the mortality risk rose significantly during a perioperative BW change of 2% to 15%.ConclusionsPerioperative BW change was independently associated with an increased risk for 30-day postoperative mortality in CS patients with RRT-requiring AKI.

THE FACTORS INFLUENCING RENAL RECOVERY IN CARDIAC SURGERY ASSOCIATED ACUTE KIDNEY INJURY

Background. In-hospital mortality of cardiac surgery patients with AKI is 3-7 times higher than those without AKI. This prospective observational study was dedicated to evaluate a differential approach of applying continuous and intermittent modalities in CS-AKIpatients on the rate and grade of renalfunction recovery.&#x0D; Methods. One hundred and six adult cardiac surgery patients admitted hospital in 2008-2011 years, who had AKI and met inclusion criteria were allocated in CRRTorIRRTgroup.&#x0D; Results. Sixty eight cardiac surgery with AKI patients who needed RRT were discharged from hospital. Among them, recovery of renalfunction was observed in 54 patients (79,4%) and 14 patients (20,6%) remained RRT-depen- dant. Complete recovery of renalfunction was reached in 33 patients (48,5%), while partial was observed in 21 patients (30,9%). Univariate analysis showed that complete recovery of renalfunction in CS-AKI significantly associated with reducing of dopamine dose during thefirst day of RRT (p=0,01) and long-term use of dobutamine (p=0,009). Partial recovery was associated with early dobutamine withdrawal (p=0,005) and absence of MOT (p=0,016), while RRT- dependence at discharge was associated with absence of MOT (p=0,006) and escalation of dopamine dose on thefirst day of RRT (p=0,025). The rate of renal recovery was statistically significantly higher in patients with CS-AKI with MOFthan inpatients with CS-AKI without MOF. In univariate analysis RRT-dependance at discharge of patients with CS-AKI with MOF was statistically significantly associated with arising of dopamine dose during thefirst day of RRT (p=0,006) and no-use of dobutamine at RRT start (p=0,006). Partial recovery was associated with early withdrawal of dobutamine (p=0,038).&#x0D; Discussion. Frequency of renal recovery inpresented study was higher than in VA/NIHAcute Renal Failure Trial Network study because of differences inpatients'population and corresponds to otherstudies of CS-AKIpatients.&#x0D; Conclusions. Recovery of renalfunction in CS-AKI patients associated with decreasing dose of dopamine, prolonged use ofdobutamine, illness severity and does not associated with specific RRT modality.

Impact of Milrinone Administration in Adult Cardiac Surgery Patients: Updated Meta-Analysis.

To determine the effects of milrinone on short-term mortality in cardiac surgery patients with focus on the presence or absence of heterogeneity of the effect. A systematic review and meta-analysis. Five hundred thirty-seven adult cardiac surgery patients from 12 RCTs. Milrinone administration. The authors conducted a systematic Medline and Pubmed search to assess the effect of milrinone on short-term mortality in adult cardiac surgery patients. Subanalysis was performed according to the timing for commencement of milrinone administration and the type of comparators. The primary outcome was any short-term mortality. Overall analysis showed no difference in mortality rates in patients who received milrinone and patients who received comparators (odds ratio = 1.25, 95% CI 0.45-3.51, p = 0.67). In subanalysis for the timing to commence milrinone administration and the type of comparators, odds ratio for mortality varied from 0.19 (placebo as control drug, start of administration after cardiopulmonary bypass) to 2.58 (levosimendan as control drug, start of administration after cardiopulmonary bypass). Among RCTs to assess the effect of milrinone administration in adult cardiac surgery patients, there are wide variations of the odds ratios of administration of milrinone for short-term mortality according to the comparators and the timing of administration. This fact may suggest that a simple pooling meta-analysis is not applicable for assessing the risk and benefit of milrinone administration in an adult cardiac surgery cohort.

Does the severity of preoperative anemia or blood transfusion have a stronger impact on long-term survival after cardiac surgery?

BackgroundPreoperative anemia and transfusion are associated with increased morbidity and mortality in cardiac surgery patients. It is unclear which of these factors plays the leading role in poor outcomes after cardiac surgery. The goal of this study was to analyze the influence of anemias of varying severity and intraoperative transfusion on long-term survival, and to characterize their interaction in cardiac surgery patients. MethodsThis was an observational cohort study conducted at a German university hospital. All patients undergoing cardiac surgery between 2006 and 2011 were screened for eligibility; duration of follow-up was 3 years. A total of 4494 patients were suitable for analysis; data on long-term survival were available for 3131 of these patients. The main outcome measure was survival at the 3-year follow-up. Length of stay and in-hospital mortality were assessed as secondary outcomes. ResultsMultivariate Cox regression analyses indicated that both the severity of preoperative anemia (mild anemia: hazard ratio [HR], 1.441; 95% confidence interval [CI], 1.201-1.728; severe anemia: HR, 1.805; 95% CI, 1.336-2.440) and intraoperative transfusion (HR, 1.340; 95% CI, 1.109-1.620) were associated with decreased long-term survival. Long-term survival was worse in anemic patients who received an intraoperative transfusion compared with those who did not receive an intraoperative transfusion. ConclusionsBoth preoperative anemia and transfusion are by themselves and in combination associated with decreased long-term survival. When anemic patients require transfusion, our results provide evidence that the risk of death after cardiac surgery may depend to a considerable extent on the severity of preoperative anemia.

A randomized controlled trial of levosimendan to reduce mortality in high-risk cardiac surgery patients (CHEETAH): Rationale and design

Patients undergoing cardiac surgery are at risk of perioperative low cardiac output syndrome due to postoperative myocardial dysfunction. Myocardial dysfunction in patients undergoing cardiac surgery is a potential indication for the use of levosimendan, a calcium sensitizer with 3 beneficial cardiovascular effects (inotropic, vasodilatory, and anti-inflammatory), which appears effective in improving clinically relevant outcomes. Double-blind, placebo-controlled, multicenter randomized trial. Tertiary care hospitals. Cardiac surgery patients (n = 1,000) with postoperative myocardial dysfunction (defined as patients with intraaortic balloon pump and/or high-dose standard inotropic support) will be randomized to receive a continuous infusion of either levosimendan (0.05-0.2 μg/[kg min]) or placebo for 24-48 hours. The primary end point will be 30-day mortality. Secondary end points will be mortality at 1 year, time on mechanical ventilation, acute kidney injury, decision to stop the study drug due to adverse events or to start open-label levosimendan, and length of intensive care unit and hospital stay. We will test the hypothesis that levosimendan reduces 30-day mortality in cardiac surgery patients with postoperative myocardial dysfunction. This trial is planned to determine whether levosimendan could improve survival in patients with postoperative low cardiac output syndrome. The results of this double-blind, placebo-controlled randomized trial may provide important insights into the management of low cardiac output in cardiac surgery.

DIFFERENTIAL APPROACH OF CONTINUOUS AND INTERMITTENT RENAL REPLACEMENT THERAPY APPLYING IN CARDIAC SURGERY ACUTE KIDNEY INJURY

Background: In-hospital mortality of cardiac surgery patients with AKI is 3-7 times higher than those without AKI. This prospective observational study was dedicated to evaluate a differential approach ofapplying continuous and intermittent modalities of RRT in cardiac surgery patients.&#x0D; Methods. One hundred and six adult cardiac surgery patients admitted hospital in 2008-2011 years, who had AKI and met inclusion criteria were allocated in CRRTor IRRTgroup.&#x0D; Results. Observed in-hospital mortality of CRRT patients was significantly lower than predicted by APACHE II (р=0,01), in contrast with IRRT group. The in-hospital mortality of cardiac surgery patients with AKI and multiorgan dysfunction treated with CRRT was significantly lower than in patients treated with IRRT (32,5% vs 67,6%, р=0,012) and lower than predicted by APACHE II (32,5% vs 50%, р=0,025), while in IRRT group observed in-hospital mortality was significantly higher (67,6% vs 46%, р=0,012) than predicted.&#x0D; Discussion. The complexity of the treatment of cardiac surgery patients with AKI and, especially, the subset with critical illness, could explain the lack of association between RRT modality and renal recovery and the in-hospital mortality of whole cohort, as well. This is a basis for differential and complementary applying ofdifferent RRT modalities according to the specific clinical situation.&#x0D; Conclusions. Differential applying of continuous RRT modalities for the treatment of cardiac surgery patients with&#x0D; AKI, as a component of MOF, and intermittent RRT for the patients, who have not multiorgan dysfunction, could contribute to reducing in-hospital mortality in this cohort.

Phase of Care Mortality Analysis: A Unique Method for Comparing Mortality Differences Among Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Patients

The objective of this study is based on the phase of care mortality analysis (POCMA), an effective tool to evaluate the root cause of in-hospital mortality in cardiac surgery patients. POCMA has not been used to compare operative mortalities among transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) populations, and may provide insight that could affect patient safety initiatives and improve outcomes in aortic valve surgery. We included patients who underwent TAVR or isolated SAVR between 2011 and March 31, 2015 and did not survive the index hospitalization. A multidisciplinary heart team made POCMA assignments as part of the weekly morbidity and mortality conference, pinpointing the phase of care and subcategory that directly caused or had the greatest effect on each mortality. During the study period, 240 patients underwent TAVR and 530 underwent SAVR. Unadjusted mortality rates were significantly higher in the TAVR group, 5.0% (n = 12) compared with SAVR, 1.9% (n = 10) (P = 0.016). TAVR deaths by phase of care are as follows: 0 for preoperative, 9 (72.8%) for intraoperative, 2 (18.2%) for postoperative intensive care unit, and 1 (9.1%) for postoperative floor. By comparison, 4 (40%) SAVR deaths had a root cause in the preoperative phase, 1 (10%) in the intraoperative phase, and 5 (50%) in the postoperative intensive care unit phase. POCMA is a novel method of categorizing in-hospital mortalities. Our single institution review revealed that patients who underwent TAVR more often expired because of intraoperative technical issues, whereas SAVR deaths were typically the result of patient selection or postoperative complications.

In-Hospital Mortality in Cardiac Surgery Patients After Readmission to the Intensive Care Unit: A Single-Center Experience with 10,992 Patients

Determine if readmission to the intensive care unit (ICU) after cardiac surgery procedures is associated with increased mortality. This was a retrospective non-randomized study to evaluate the cause of readmission and mortality rate in patients readmitted to the ICU after cardiac surgery and to compare the clinical variables of patients readmitted to the ICU who died and those who survived. The study was performed in a single university hospital. This was an analysis of 10,992 consecutive adult patients. Readmission rate to the ICU, mortality rate, the reason for readmission to the ICU, type of surgery, length of stay, cause of mortality, and day of the week of ICU readmission were analyzed. All patients underwent cardiac surgery at a single center and were discharged after primary stay from the ICU. A total of 197 (1,8%) of 10,992 patients were readmitted to the ICU. In-hospital mortality rate for patients readmitted and not readmitted to the ICU was 23.9% and 4.7%, respectively. The main causes of ICU readmission were cardiac (40%) and respiratory (37%) complications. The mortality rate in readmitted patients who underwent coronary artery bypass graft (CABG) or valve surgery was 26% and 19%, respectively. Patient readmission to the ICU following cardiac surgery was associated with a 5-fold increase in hospital mortality rate compared to non-readmitted patients. The highest mortality rate was observed among readmitted patients who underwent CABG. Older age, previous myocardial infarction, and initial long length of stay in the post-operative ward were independent risk factors for death after readmission to the ICU.

One Year Survival and Predictors of Mortality in Cardiac Surgery Patients With Prolonged Intensive Care Unit Stay

Scant information exists in the literature on the outcomes of cardiac surgery patients with significantly prolonged intensive care unit (ICU) stay. Most published data is outdated and does not reflect current practice. This study aims to help physicians and families understand the outcome of cardiac surgery and make informed decisions for these high risk patients.

Fresh‐frozen plasma transfusion did not reduce 30‐day mortality in patients undergoing cardiopulmonary bypass cardiac surgery with excessive bleeding: the PLASMACARD multicenter cohort study

During on-pump cardiac surgery, hemorrhagic complications occur frequently. Fresh-frozen plasma (FFP) is widely transfused to provide coagulation factors. Yet, no randomized clinical trial has demonstrated its benefits on mortality. We assessed the relationship between therapeutic transfusion of FFP and 30-day mortality in cardiac surgery patients suffering from excessive bleeding in a prospective cohort study. Adult patients who underwent on-pump cardiac surgery and experienced excessive bleeding during the 48-hour perioperative period were recruited from 15 French centers between February 2004 and January 2006. Patients who received a preventive FFP transfusion were excluded. The association between FFP transfusion and all cause 30-day mortality was estimated using a Cox proportional hazards model, adjusted for confounding. A propensity score (PS) sensitivity analysis was also performed. Among 967 patients included in this study, 58.1% received FFP. The median dose was 11.3 mL/kg (interquartile range, 7.6-19.5). The cumulative 30-day mortality rate was 11.3% (95% confidence interval [CI], 9.5-13.5). FFP transfusion was associated with a higher 30-day mortality (hazard ratio [HR], 3.2; 95% CI, 1.7-6.1) in univariate analysis; however, after adjusting for prognostic factors, there was no longer any association (HR, 1.5; 95% CI, 0.8-3.0, p = 0.20). The results of the PS analysis were consistent with the adjusted analysis. Among on-pump cardiac surgery patients experiencing excessive perioperative bleeding, there is no evidence of a beneficial impact of FFP transfusion on mortality.

017 * INCREASED PERIOPERATIVE MORTALITY FOLLOWING APROTININ WITHDRAWAL: A REAL-WORLD ANALYSIS OF BLOOD MANAGEMENT STRATEGIES IN ADULT CARDIAC SURGERY

Objectives: Coagulopathic haemorrhage remains a major cause of perioperative morbidity in cardiac surgery. The serine protease inhibitor aprotinin prevents coagulopathic haemorrhage but was withdrawn in 2008 after clinical studies raised significant safety concerns. After careful re-analysis, aprotinin has been re-licensed for the prevention of coagulopathic haemorrhage. To better understand the risks and benefits of re-introducing aprotinin into practice, we aimed to determine the effect of the withdrawal of aprotinin on transfusion, bleeding, acute kidney injury (AKI) and mortality. Methods: Adult patients having cardiac surgery between 1 January 2005 and 31 December 2010 at a single tertiary cardiac centre, and for whom clinical, haematology and blood bank data were available, were included. Outcomes were compared between patients (n = 3587) operated on before aprotinin's withdrawal and propensity-matched patients (n = 3030) operated on after its withdrawal. Outcomes are presented as adjusted odds ratios (OR) or hazard ratios (HR) (95% confidence interval). Sensitivity analyses established the likely influence of regression, selection and time series bias on our results. Results: Aprotinin withdrawal was associated with significant increases in exposure to allogenic red blood cells: OR 1.24 (1.09-1.42), platelets 2.16 (1.81-2.58), fresh frozen plasma 1.81 (1.45-2.26) and cryoprecipitate 3.90 (1.69-8.98). Re-sternotomy for bleeding increased post-suspension, 2.10 (1.37-3.23), although blood loss on ITU was not significantly increased. Aprotinin withdrawal was associated with a significant increase in AKI incidence, 1.71 (1.51-1.93), and higher 30-day mortality rates, HR 2.10 (1.11-3.98). The results of sensitivity analyses did not alter our conclusions. Conclusions: The withdrawal of aprotinin resulted in increased allogenic blood component exposure, post-procedural AKI and mortality in cardiac surgery patients.

U-Shape Association Between Hemoglobin A1c and Late Mortality in Patients With Heart Failure After Cardiac Surgery

Hemoglobin A1c (HbA1c) levels are used as a measure of glycemic control, with greater levels indicating poorer control and a greater risk of death. However, recent studies have found a U-shaped association between the HbA1c levels and mortality in patients with heart failure, with the lowest risk of death associated with elevated HbA1c levels, usually >7%. Cardiac surgery is frequently used to mitigate the signs and symptoms of heart failure. The purpose of the present study was to determine the association between HbA1c levels and late mortality in cardiac surgery patients with and without heart failure. Patients with and without New York Heart Association class III or IV heart failure were divided into quartiles according to the preoperative HbA1c level. Mortality was determined for each group and compared using chi-square tests and Cox modeling. Of the 311 patients with heart failure, 65 (21%) were dead at follow-up compared to 57 of 669 patients (9%) without heart failure (p <0.001). After adjusting for confounders, the patients without heart failure and with HbA1c ≤5.7% had the lowest risk of death. In patients with preoperative heart failure, we found a U-shaped association between HbA1c levels and late mortality, with those patients with HbA1c levels of 5.8% to 6.2% having the lowest risk of death. HbA1c levels ≤5.7% and ≥7.2% were associated with statistically significant greater risks of death. In conclusion, we found in patients with heart failure that the lowest risk of death was associated with HbA1c levels of 5.8% to 6.2%.

Predictors of operative mortality in cardiac surgery patients with prolonged intensive care unit duration

Predictors of operative mortality in cardiac surgery patients with prolonged intensive care unit duration

Editorial Comment: Acute kidney injury on normally functioning kidneys and long-term mortality after coronary bypass surgery

Editorial Comment: Acute kidney injury on normally functioning kidneys and long-term mortality after coronary bypass surgery

Effect of preoperative renal function on long-term survival after cardiac surgery

The study objective was to investigate the effect of renal failure on intermediate-term survival in cardiac surgery patients. All patients aged 18 years or older undergoing coronary artery bypass grafting, valvular surgery, thoracic aortic surgery, or a combination of these from January 1, 2002 to December 1, 2005 were included. Data were obtained from the cardiac surgery and intensive care databases. Using a matching algorithm, the date of death was obtained from the National Death Index. The simplified Medical Diet for Renal Disease formula was used to calculate the estimated glomerular filtration rate, and the patients were stratified accordingly. An estimation of the effect of the preoperative renal function on the interval to death was determined using Cox regression analysis with and without cubic splines and polynomial regression. The long-term survival was described using the Kaplan-Meier product limit method. A total of 5297 patients were included in the present study. The vital status of all patients was obtained at a mean of 2.9 years (range, 1-5) postoperatively. The actuarial 1-year survival rate was 96% ± 1%, and the 3-year survival rate was 92% ± 1%. The greatest early mortality occurred in the severe renal dysfunction group; however, the dialysis-dependent renal failure group showed increased mortality over time compared with the other groups. The lowest risk of death (longest interval to death) occurred with an estimated glomerular filtration rate of approximately 90 mL/min/1.73 m(2). The results of our study have shown that preoperative renal dysfunction is an independent predictor of long-term mortality in cardiac surgery patients.

The correlation between peri-operative hyperglycemia and mortality in cardiac surgery patients: a systematic review

Hyperglycemia occurs frequently in patients undergoing cardiac surgery. It has been identified as a risk factor for increased peri-operative morbidity and mortality. To review the evidence of the correlation of peri-operative hyperglycemia with mortality in cardiac surgery patients and to discuss the main results in order to provide evidence-based knowledge for the appropriate glycemic control. We searched the electronic databases MEDLINE, CINAHL and EMBASE in June 2010. The material of our study was articles published between 1 January 1990 and 31 May 2010, which investigated the correlation between peri-operative hyperglycemia and in-hospital and/or 30-day cardiac surgery mortality. Out of the 16 reviewed articles in our study, 12 (75%) significantly associated hyperglycemia and inadequate blood glucose control with increased mortality. In addition, four of the reviewed articles were controlled randomized trials and among them only one demonstrated strong correlation between poor glycemic control and mortality. No study was multi-centre and the reviewed articles were characterized by different definitions of peri-operative hyperglycemia, different intensity and duration of the applied therapy and heterogeneity of the population. It is clear that peri-operative hyperglycemia is harmful for cardiac surgery patients. The significant shortage of randomized controlled trials, the absence of multicentre studies, the different definitions of peri-operative hyperglycemia, the different intensity and duration of the applied insulin therapy protocol and the heterogeneity of the studied population (diabetics and non-diabetics) are significant limitations, which could explain the inconsistent findings of the literature. These limitations indicate the need for further research.

Descending aortic calcification increases renal dysfunction and in-hospital mortality in cardiac surgery patients with intraaortic balloon pump counterpulsation placed perioperatively: a case control study

IntroductionAcute kidney injury (AKI) after cardiac surgery increases length of hospital stay and in-hospital mortality. A significant number of patients undergoing cardiac surgical procedures require perioperative intra-aortic balloon pump (IABP) support. Use of an IABP has been linked to an increased incidence of perioperative renal dysfunction and death. This might be due to dislodgement of atherosclerotic material in the descending thoracic aorta (DTA). Therefore, we retrospectively studied the correlation between DTA atheroma, AKI and in-hospital mortality.MethodsA total of 454 patients were retrospectively matched to one of four groups: -IABP/-DTA atheroma, +IABP/-DTA atheroma, -IABP/+DTA atheroma, +IABP/+DTA atheroma. Patients were then matched according to presence/absence of DTA atheroma, presence/absence of IABP, performed surgical procedure, age, gender and left ventricular ejection fraction (LVEF). DTA atheroma was assessed through standard transesophageal echocardiography (TEE) imaging studies of the descending thoracic aorta.ResultsBasic patient characteristics, except for age and gender, did not differ between groups. Perioperative AKI in patients with -DTA atheroma/+IABP was 5.1% versus 1.7% in patients with -DTA atheroma/-IABP. In patients with +DTA atheroma/+IABP the incidence of AKI was 12.6% versus 5.1% in patients with +DTA atheroma/-IABP. In-hospital mortality in patients with +DTA atheroma/-IABP was 3.4% versus 8.4% with +DTA atheroma/+IABP. In patients with +DTA atheroma/+IABP in hospital mortality was 20.2% versus 6.4% with +DTA atheroma/-IABP. Multivariate logistic regression identified DTA atheroma > 1 mm (P = *0.002, odds ratio (OR) = 4.13, confidence interval (CI) = 1.66 to 10.30), as well as IABP support (P = *0.015, OR = 3.04, CI = 1.24 to 7.45) as independent predictors of perioperative AKI and increased in-hospital mortality. DTA atheroma in conjunction with IABP significantly increased the risk of developing acute kidney injury (P = 0.0016) and in-hospital mortality (P = 0.0001) when compared to control subjects without IABP and without DTA atheroma.ConclusionsPerioperative IABP and DTA atheroma are independent predictors of perioperative AKI and in-hospital mortality. Whether adding an IABP in patients with severe DTA calcification increases their risk of developing AKI and mortality postoperatively cannot be clearly answered in this study. Nevertheless, when IABP and DTA are combined, patients are more likely to develop AKI and to die postoperatively in comparison to patients without IABP and DTA atheroma.

Preoperative Arterial Pulse Pressure Has No Apparent Association with Perioperative Mortality After Lower Extremity Arterial Bypass

Arterial pulse pressure hypertension is associated with perioperative morbidity and mortality in cardiac surgery patients. However, its association with perioperative mortality in other high-risk surgical populations has not been determined. In this study, we tested the hypothesis that increased preoperative arterial pulse pressure is associated with 30-day and 1-year all-cause mortality after lower extremity arterial bypass surgery. A retrospective review of patients who had infrainguinal arterial bypass surgery at a single center over a 6-year period (January 2002 to January 2008) was performed (n = 556). Mean, systolic, and diastolic arterial blood pressure were determined from a single noninvasive oscillometric blood pressure cuff reading in the operating room before the administration of anesthetic drugs. Pulse pressure was calculated from this measurement in a retrospective manner by subtracting diastolic pressure from systolic pressure. Mortality for all subjects was determined using the social security death index. Comorbid conditions, preoperative medications, and anesthetic techniques were recorded. Univariate and multivariate analyses were performed to evaluate the association between arterial pulse pressure and the primary outcome variables, and all-cause 30-day and 1-year mortality. Of the 556 patients, a large percentage had elevated pulse pressure (44.9% had pulse pressure ≥80). Thirty-day mortality was 5.1% and 1-year mortality was 17.8%. There was no apparent association between preoperative pulse pressure and 30-day (P = 0.35) or 1-year (P = 0.14) all-cause mortality. Independent predictors of 30-day mortality were age ≥80 years (P = 0.02), ASA physical status ≥IV (P = 0.04), baseline creatinine >2.0 mg/dL (P < 0.0001), and emergency surgery (P = 0.009). The same variables were associated with 1-year mortality, as were the Lee's Revised Cardiac Risk Index score, female gender, and gangrene or ulcer as an indication for surgery. Our results suggest that increased preoperative arterial pulse pressure might not be associated with all-cause mortality after lower extremity arterial bypass surgery.

Blood transfusion during cardiac surgery dose-dependently stimulates inflammation and coagulopathy in the lung: a case-control study

Blood transfusion is associated with increased morbidity and mortality in cardiac surgery patients, but the cause and effect relation remains unknown. We hypothesized that blood transfusion is associated with changes in pulmonary and systemic inflammation and coagulopathy, occurring in patients who do not meet the clinical diagnosis of transfusion-related acute lung injury (TRALI).