Need For Postoperative Dialysis Research Articles

Initial Experience of Anesthetic Management in Combined Liver-Kidney Transplantation: A Case Report

In this case report, we present a successful combined liver-kidney transplantation (CLKT) performed on a 41-year-old female with end-stage liver and renal disease. The patient, previously undergoing liver transplantation and regular hemodialysis, underwent CLKT with a focus on specific anesthesia management strategies. Key aspects included the use of desflurane for anesthesia, balanced crystalloid solutions for fluid management, and careful monitoring of hemodynamics without intraoperative renal replacement therapy. Despite substantial intraoperative fluid and blood product administration, careful management ensured stable vital signs and acid-base balance. The patient's postoperative recovery was notable for significant improvements in liver and renal functions, demonstrated by decreased creatinine and bilirubin levels, and improved estimated glomerular filtration rate, without the need for postoperative dialysis. This case underscores the effectiveness of CLKT in patients with concurrent liver and renal dysfunction, highlighting the importance of tailored anesthesia and fluid management strategies. The report contributes to the limited literature on anesthesia in CLKT, providing insights for better outcomes in such complex surgical procedures.

Early results of total arterial off-pump coronary artery bypass grafting using bilateral internal mammary arteries

Background: The optimal coronary artery bypass grafting (CABG) technique is still evolving. This study aimed to evaluate the early results of the total arterial off-pump technique using bilateral internal mammary arteries.
 Methods: This study was performed from May 2018 to May 2019 at a cardiac surgery center in India. It included 200 patients with coronary artery disease who had off-pump CABG using bilateral internal mammary arteries. The patients had follow-ups for three months. There were 50 females, and the mean age was 50±10 years.
 Results: Conversion to on-pump was required in one case (0.5%). The use of complete vein grafts was needed in three cases (1.5%), and vein graft extension was done for two cases (1%). Intra-aortic balloon pump was used in one case (0.5%). Postoperative re-exploration for bleeding was done in two cases (1%), and sternal dehiscence or deep infection occurred in two cases (1%). A pacemaker was used in one case (0.5%), and postoperative need for dialysis occurred in three patients (1.5%). No operative mortality or postoperative stroke was reported. Redo surgery was required in one patient (0.5%).
 Conclusions: Off-pump total arterial revascularization technique using bilateral internal mammary arteries could have an acceptable early outcome.

Intermediate outcomes following arch reconstruction with frozen elephant trunk, a single centre study

BackgroundSurgery on the aortic arch and proximal descending thoracic aorta can be lifesaving but is also associated with significant morbidity, ranging from minor infections to severe neurological impairments as well as a substantial risk of mortality. The aim of this study is to clinically assess outcomes, with special regards to neurologic injury, as well as to seek to identify predictors of in-hospital mortality in two patient groups with different underlying aortic pathology, aneurysms and dissections, undergoing arch/descending aortic repair.Methods34 patients (17 aneurysms, 17 dissections) underwent surgery involving the arch and/or descending aorta, using the Thoraflex or E-Vita frozen elephant trunk graft. 40% were female. Subgroup analysis of aneurysms compared to dissections were performed. Mean follow-up time was 53.9 months and mean age 63.5 years.ResultsIn-hospital mortality was 18%. Survival was comparable between aneurysms and dissections. Incidence of spinal cord injury was 9% and stroke 9%. 67% suffered any form of neurological affection, when also cognitive afflictions were included. Perioperative reoperation rate was 29% (bleeding 21%, visceral ischemia 6%, infection 2%), the need for postoperative dialysis was 11% and a series of other minor complications such as atrial fibrillation and pleurocentesis were common.ConclusionPostoperative dialysis was found to be a predictor of in-hospital mortality, while both dialysis as well as reoperation due to bleeding and/or visceral ischemia increased the risk for overall mortality, irrespective of preoperative diagnosis. Previous or current smoking appeared to be associated with negative outcomes regarding both in-hospital and overall mortality during follow-up.Trial registration Retrospectively enrolled.

Impact of Preoperative Atrial Fibrillation on In-Hospital Outcomes of Coronary Artery Bypass Grafting

Perioperative atrial fibrillation (AF) is associated with increased mortality, morbidity, and excess healthcare costs. The objective of our study was to assess if preoperative AF in patients undergoing coronary artery bypass grafting is a predictor of operative mortality, postoperative stroke, and need for postoperative dialysis by interrogating a large registry database. We included all isolated procedures performed between February 1996 and March 2019. We used a generalized linear mixed model to assess the effect of preoperative AF on mortality stroke and the need for postoperative dialysis after adjusting for the relevant confounders derived from EuroSCORE 2. Confounders considered included age, gender, neurological dysfunction, renal dysfunction, recent myocardial infarction, pulmonary disease, unstable angina, NYHA class, pulmonary hypertension, diabetes on insulin and peripheral vascular disease, and urgency of the operation. We treated the hospital and operating consultant as random effect variables. We also performed LV function subgroup analyses to assess the effect of preoperative AF on the outcomes of interest. The incidence of pre-existent AF in the cohort of patients we analyzed (N=356,040 patients) was 3.5% (N=12,664). In the unadjusted baseline characteristics, preoperative AF patients had more associated comorbidities. After adjustment, preoperative AF remained a significant predictor of increased mortality (odds ratio [OR]: 1.63, confidence interval [CI] 1.48-1.79, p < 0.001), stroke (OR: 1.33, CI 1.16-1.54, p = 0.001), and need for renal dialysis (OR:1.61, CI 1.46-1.78, p < 0.001). Preoperative AF was a significant predictor of adverse outcomes in patients with moderate and good LV function but not in patients with poor LV function (EF <30%). Our study suggests that preoperative AF is associated with an increased risk for perioperative mortality and stroke in patients undergoing coronary artery bypass grafting.

The preservation of accessory renal arteries should be considered the treatment of choice in complex endovascular aortic repair

ObjectiveThe objective of this study was to evaluate renal function and renal parenchymal length changes secondary to the coverage or preservation of accessory renal arteries (ARAs) in complex aortic repair. MethodsThis was a single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f-b EVAR) who presented with ARAs. Two groups were created, a preserved ARA group, with incorporation of the vessel as a dedicated fenestration or branch in the endograft plan, and a non-preserved ARA group, without incorporation of them. Early >30% decline of glomerular filtration rate (GFR), kidney infarcts, and endoleaks were evaluated. Mid-term results with freedom from kidney shrinkage (defined as length decrease >10%) at follow-up, freedom from GFR decrease >30%, or need for postoperative dialysis at follow-up were also analyzed. Primary assisted patency of incorporated ARAs was calculated. ResultsFrom 2011 through 2020, 145 patients undergoing complex aortic repair presented with an ARA. After excluding ruptured aneurysms, 33 patients had the ARA preserved with their incorporation into the stent graft (preserved ARA group), and 99 did not have preservation of them (not-preserved ARA group). There were no statistical differences in demographics or type of aneurysm. Patients in the ARA-preserved group had more ARAs (median of two per patient vs one in the non-preserved ARA group; P = .01) and bigger ARAs (median 4 vs 3 mm in the non-preserved ARA group; P = .001). Early postoperative worsening >30% of GFR (23% vs 6%; P = .03) as well as postoperative renal infarction (57% vs 6%; P = .001) and ARA-related endoleaks (20% vs 0%; P = .01) were statistically higher for the not-preserved ARA group. Mid-term kidney length showed significant shrinkage in the not-preserved ARA group compared with the ARA preserved group (9.7% vs 0%; P = .001). Freedom from >30% GFR decline at 2 years was significantly higher for the preserved ARA group (83% vs 47%; P = .01).Two-year primary assisted patency of incorporated ARA was 94%. ConclusionsComplex aortic repair incorporation of ARA is feasible, with low complications and good primary assisted patency at 2 years. It leads to less postoperative early renal dysfunction as well as higher freedom for mid-term renal disfunction and kidney shrinkage.

Abstract 13263: Sex Differences in Outcomes After Cardiac Surgery: Insights From a National Database

Introduction: Female sex is considered an independent risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK national database to compare outcomes following surgical revascularisation and valvular cardiac procedures between females and males. Hypothesis: Females have worse outcomes following cardiac surgery than males. Methods: Using data from National Adult Cardiac Surgery Audit (NACSA), we identified all elective and urgent, isolated coronary artery by-pass grafting (CABG), aortic valve replacement (AVR) and mitral valve replacement/repair (MVR) procedures from 2010-2018. We compared baseline data, operative data and outcomes of mortality, stroke, renal failure, deep sternal wound infection, return to theatre for bleeding and length of hospital stay. Multivariable logistical/linear regression models were used to assess relationships between sex and our outcomes, adjusting for baseline characteristics. Results: Females, compared to males, had a greater odds of experiencing 30-day mortality in each procedure (CABG OR 1.76, CI 1.47-2.09, p&lt;0.001; AVR OR 1.59, CI 1.27-1.99, p&lt;0.001; MVR OR 1.37, CI 1.09-1.71, p=0.006). After CABG, females also experienced increased need for post-operative dialysis (OR 1.31, CI 1.12-1.52, p&lt;0.001), deep sternal wound infections (OR 1.43, CI 1.11-1.83, p=0.005) and length of stay (Beta 1.2, CI 1.0-1.4, p&lt;0.001) compared to males. Female sex was protective against returning to theatre for post-operative bleeding following CABG (OR 0.76, CI 0.65-0.87, p&lt;0.001) and AVR (OR 0.72, CI 0.61-0.84, p&lt;0.001). Conclusions: Despite advances in cardiac surgery, females in the UK have an increased risk of short-term mortality after cardiac surgery compared to males. This highlights the need to focus on the understanding of the causes behind these disparities and therefore implementation of strategies to improve this.

Predicting acute kidney injury following nonemergent cardiac surgery: A preoperative scorecard.

To determine the predictors of postoperative acute kidney injury (AKI) following nonemergent cardiac surgery among patients with variable preoperative estimated glomerular filtration rate (eGFR) levels. A retrospective study of patients who underwent elective or in-hospital cardiac surgical procedures was performed between January 2006 and November 2015. The procedures included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), or combined CABG and AVR. The primary outcome AKI (any stage) following nonemergent cardiac surgery utilizing the 2012 Kidney Disease-Improving Global Outcomes (KDIGO) criteria. Patients were categorized based on the following renal outcomes: mild AKI, severe AKI (KDIGO stage 2 or 3), and postoperative dialysis. Patients with G5 preoperative kidney function (including dialysis patients) were excluded. A total of 6675 patients were included in our study. The mean age was 66.8 years (SD ± 10.4), with 76.3% being males. A total of 4487 patients had normal or mildly decreased eGFR (G1 or G2) preoperatively (67.2%), while 1960 patients were in the G3 category (29.4%). Only 228 patients (3.4%) had G4 renal function. A total of 1453 (21.7%) patients experienced postoperative AKI. The need for postoperative dialysis occurred in 3.2% of the AKI subgroup. In-hospital mortality was higher among the AKI subgroup (7.2% vs. 0.5%; p < .0001). In an adjusted model, a lower preoperative eGFR category was the strongest predictor of AKI. A practical scorecard for the preoperative estimation of severe AKI for nonemergent cardiac procedures incorporating these parameters was developed. Preoperative eGFR is the strongest predictor of postoperative AKI in individuals undergoing nonemergent cardiac surgery. A practical scorecard incorporating preoperative predictors of AKI may allow informed decision-making and predict AKI following nonemergent cardiac surgery.

Risk of renal failure and death when renal arteries are involved in endovascular aortic aneurysm repair

ObjectiveEndovascular abdominal aortic repair can involve the incorporation of renal arteries. Revascularization after intentional or unintentional renal artery (RA) coverage is not always technically successful, and the loss of a single RA may result in the need for postoperative dialysis. Thus, we compared the outcomes after endovascular aneurysm repair (EVAR) stratified by RA involvement (RAI). MethodsPatient data from the Vascular Quality Initiative from 2009 to 2018 registry were analyzed. The exclusion criteria were preoperative dialysis, missing RAI data, and repair above the superior mesenteric artery. The repair type cohorts were defined as (1) no RAI (NRAI), (2) RAI with revascularization (RAI-R), and (3) RAI with no revascularization (RAI-NR). A sensitivity analysis was performed by excluding ruptured presentations. The primary outcome was the need for postoperative dialysis. The secondary outcomes were 30-day mortality, dialysis at follow-up, postoperative renal function, and 2-year survival. Multivariate analysis was used to determine the independent predictors for postoperative dialysis. The 2-year survival analysis was performed using Kaplan-Meier log-rank test. ResultsOf 54,020 patients in the EVAR and TEVAR (thoracic EVAR)/complex EVAR modules in the Vascular Quality Initiative, 25,724 met the criteria for inclusion (NRAI, n = 24,879; RAI-R, n = 733; RAI-NR, n = 112). The demographics and comorbidities were similar among the three groups. The RAI-NR group had more frequently had ruptured or symptomatic aneurysms. The postoperative dialysis requirement was higher in the RAI-NR group (NRAI, 0.7%; RAI-R, 2.2%; RAI-NR, 17%; P < .0001), as were the 30-day mortality and dialysis requirement at follow-up. On multivariate analysis, RAI-R (odds ratio [OR], 2.2; P = .03) and RAI-NR (OR, 5.9; P < .0001) were independent predictors of postoperative dialysis and remained so after excluding ruptured presentations (RAI-R: OR, 3; P = .003; RAI-NR: OR, 22.3; P < .0001). Other independent predictors of the need for postoperative dialysis were worse preoperative renal function, a symptomatic presentation, any preoperative or intraoperative blood transfusion, and larger blood loss (≥200 mL). Excluding those with rupture, the overall survival at 2 years on Kaplan-Meier analysis was lower for the RAI-NR group (NRAI, 92%; RAI-R, 89%; RAI-NR, 80%; P = .004). ConclusionsRAI is highly predictive of the need for postoperative and permanent dialysis after EVAR. RAI-NR was associated with lower overall survival. These risks should be considered when planning and performing EVAR and should be weighed against the risks of open repair when considering the treatment options.

Influence of Intraoperative Transesophageal Echocardiography and Pulmonary Artery Catheter Monitoring on Outcomes in Liver Transplantation

Background.Anesthetic management of orthotopic liver transplantation (OLT) can be challenging. Management involves responding to sudden hemodynamic shifts, addressing instability, and performing ongoing volume assessment. To best prepare for these perturbations, various monitors are used intraoperatively. We sought to explore the impact of transesophageal echocardiography (TEE) and pulmonary artery catheter (PAC) use on outcomes of patients undergoing OLT.Methods.We retrospectively reviewed records of patients who underwent OLT at a single institution and included all who were monitored intraoperatively with TEE alone, PAC alone, or both methods concurrently (TEE + PAC). We determined whether these groups had differences in length of hospitalization (primary outcome), 30-day mortality rate, and other outcomes.Results.Three hundred eighteen liver transplant operations were included in the study. Patients in the TEE + PAC group had the shortest median length of hospitalization (TEE + PAC, 8.6 days; TEE, 10.3; PAC, 9.1; P = 0.04). The TEE + PAC group also had the lowest 30-day mortality rate (TEE + PAC, n = 1 [1.3%]; TEE, n = 5 [12.8%]; PAC, n = 7 [3.5%]; P = 0.009). However, the TEE + PAC group also had the highest rate of a new postoperative need for dialysis (TEE + PAC, n = 8 [10.3%]; TEE, n = 2 [5.1%]; PAC, n = 1 [0.5%]; P < 0.001).Conclusions.Compared with either TEE alone or PAC alone, intraoperative monitoring with TEE + PAC during OLT was associated with the shortest length of hospitalization and lowest 30-day mortality rate. Transplant anesthesiologists should be aware of the potential benefit on patient mortality and hospital length of stay with concurrent intraoperative TEE + PAC monitoring and the increased need for new postoperative dialysis.

Comparative effects of human albumin versus modern hydroxyethyl starch in living-donor renal transplant

Background Living-donor renal transplantation is considered the best therapy for renal failure patients. The outcome and graft function are affected by various perioperative variables. Fluid management remains a controversy whether to use crystalloids or colloids with the effect of either type of solution on graft function and overall morbidity. Patients and methods We studied 120 patients with end-stage renal disease, who were on regular hemodialysis scheduled for living-related kidney transplantation. The patients were assigned to receive either 6% hydroxylethyl starch (HES) 130/0.4 (Voluven) (HES group: n=60) or albumin 5% (ALB group: n=60) for intraoperative use. In both groups, normal saline was administered at 10 ml/kg/h. In addition, patients received 250 ml boluses of either Voluven (HES group) with a maximum of 50 ml/kg/day or ALB 5% (ALB group) to maintain their central venous pressure between 12 and 15 mmHg. Blood transfusion was given based on the hemoglobin level ( Results There were no statistically significant differences between the two groups regarding hemodynamic variables, onset of diuresis, or need for postoperative dialysis. Perioperative laboratory workup (BUN, creatinine, creatinine clearance, and INR) were similar in both study groups. Conclusion There are no statistically significant differences between the use of HES solutions and ALB 5% on the outcome of living-donor renal transplant recipients. Using either solutions is comparable to the other with no special side effects.

Severe autosomal dominant polycystic kidney disease

A 61-year-old man with a known history of autosomal dominant polycystic kidney disease (ADPKD) and stage IV chronic kidney disease presented with a 6-month history of abdominal pain, nausea, vomiting...

Reoperation for mitral paravalvular leak: a single-centre experience with 200 patients.

Paravalvular leak (PVL) is a major cause of morbidity and mortality after mitral valve replacement. Risk factors and data on long-term surgical outcomes are lacking. Between January 1995 and December 2012, 206 [118 males (57%)] patients underwent reoperation due to mitral PVL. Mean age was 64 ± 11 years. Haemolytic anaemia was present in 85 (41%) patients, while 137 (67%) patients were in New York Heart Association Class III or IV. Baseline creatinine was above 1.5 in 91 (44%) patients, while chronic steroids were used in 14 (7%) patients. Active endocarditis was present in 8 (4%) patients. Device occlusion was attempted in 21 (10%) patients. PVL was most common at the aortomitral curtain (82 patients, 40%). Repair was possible in 105 (51%) patients. Early mortality occurred in 11 (5%) patients. Mean follow-up was 5 (maximum 19) years. Overall survival at 1, 5 and 15 years was 83%, 62% and 16%, respectively. Death due to heart failure or cardiogenic shock occurred in 39 patients. Recurrence occurred in 43 (21%) patients and reoperation was required in 19 patients. Multivariate analysis revealed advanced New York Heart Association class (P < 0.0001), active endocarditis (P = 0.013), chronic steroids (P = 0.022), previous coronary artery bypass grafting (P = 0.026), baseline creatinine above 1.5 (P = 0.001), postoperative need for dialysis (P = 0.036) and residual PVL (P < 0.0001) to be predictors of late mortality. Active endocarditis (P = 0.0004) and chronic steroids (P = 0.002) were significant predictors for PVL recurrence. Freedom from reoperation due to PVL recurrence was 89% and 84%, while freedom from late intervention was 94% and 61% at 5 and 15 years, respectively. PVL after mitral valve replacement is associated with increased morbidity and mortality. Re-repair is possible, but recurrent PVL is a risk factor for late mortality, and reoperation should be performed prior to the onset of advanced heart failure.

Abstract 14775: Current Results of Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms

Introduction: Open repair of thoracic and thoracoabdominal aortic aneurysms (DTA and TAAA respectively) constitutes a benchmark for comparison with endovascular techniques. Hypothesis. To evaluate the current results of the open repair of DTA and TAAA. Methods. Open DTA and TAAA repair was performed on 675 consecutive patients (210 TAA and 465 TAAA). Three surgical techniques were used based on the type of the aneurysm and the risk profile of the patient: clamp and saw, partial bypass or hypothermic circulatory arrest. Spinal drain was used in 82.7% of patients. Regression analysis was performed to identify independent determinants of in-hospital and late outcomes and individual major postoperative complications. Propensity matching (PPM) was used to compare results of the different surgical techniques Results. Operative mortality was 5.6% (38/675); incidence of postoperative spinal cord injury, stroke, need for tracheostomy, myocardial infarction and dialysis were 2.8%, 0.7%, 7.7%, 0.6% and 5.2% respectively. Kaplan Mayer survival at five-year was 57.8%. Female gender, urgent operation and preoperative dialysis were independent predictors of adverse in-hospital adverse events. Preoperative renal and respiratory failure were associated with follow-up death. Female gender and preoperative chronic pulmonary disease were associated with postoperative need for tracheostomy, whereas preoperative renal failure, urgent operation and peripheral vascular disease predicted the need for postoperative dialysis. Due to the low number of events, logistic regression analysis was not possible for predictors of spinal cord injury. In the PPM groups no difference was found in the early and late outcome between patients treated with different techniques (see table). Conclusion: In the current era open TAA and TAAA repair allows excellent outcomes.

Urine Biomarkers and Perioperative Acute Kidney Injury: The Impact of Preoperative Estimated GFR

The interaction between baseline kidney function and the performance of biomarkers of acute kidney injury (AKI) on the development of AKI is unclear. Post hoc analysis of prospective cohort study. The 1,219 TRIBE-AKI Consortium adult cardiac surgery cohort participants. Unadjusted postoperative urinary biomarkers of AKI measured within 6 hours of surgery. AKI was defined as AKI Network stage 1 (any AKI) or higher, as well as a doubling of serum creatinine level from the preoperative value or the need for post-operative dialysis (severe AKI). Stratified analyses by preoperative estimated glomerular filtration rate (eGFR)≤ 60 versus > 60mL/min/1.73m(2). 180 (42%) patients with preoperative eGFRs≤60mL/min/1.73m(2) developed clinical AKI compared with 246 (31%) of those with eGFRs>60mL/min/1.73m(2) (P<0.001). For log2-transformed biomarker concentrations, there was a significant interaction between any AKI and baseline eGFR for interleukin 18 (P=0.007) and borderline significance for liver-type fatty acid binding protein (P=0.06). For all biomarkers, the adjusted relative risk (RR) point estimates for the risk for any AKI were higher in those with elevated baseline eGFRs compared with those with eGFRs≤60mL/min/1.73m(2). However, the difference in magnitude of these risks was low (adjusted RRs were 1.04 [95% CI, 0.99-1.09] and 1.11 [95% CI, 1.07-1.15] for those with preoperative eGFRs≤60mL/min/1.73m(2) and those with higher eGFRs, respectively). Although no biomarker displayed an interaction for baseline eGFR and severe AKI, log2-transformed interleukin 18 and kidney injury molecule 1 had significant adjusted RRs for severe AKI in those with and without baseline eGFRs≤60mL/min/1.73m(2). Limited numbers of patients with severe AKI and post-operative dialysis. The association between early postoperative AKI urinary biomarkers and AKI is modified by preoperative eGFR. The degree of this modification and its impact on the biomarker-AKI association is small across biomarkers. Our findings suggest that distinct biomarker cutoffs for those with and without a preoperative eGFR≤60mL/min/1.73m(2) is not necessary.

Acute kidney injury following surgical aortic valve replacement.

Acute kidney injury (AKI) is a significant complication of surgical aortic valve replacement (SAVR). This study sought to describe AKI following SAVR, its risk factors, predictors and effect on long-term survival. We retrospectively reviewed 2169 patients who underwent isolated SAVR between 2000 and 2012. The main end-points were occurrence of AKI, postoperative complications, and short- and long-term survival rates following SAVR. Patients were divided into two groups: AKI+ (n = 181) and AKI- (n = 1945). AKI occurred in 8.5% of patients, of which 3.9% (n = 7) needed dialysis. Predictors of AKI after SAVR were body mass index (BMI) and intraoperative packed red blood cells (PRBC) transfusion. AKI+ patients had a more complicated postoperative course and higher cumulative mortality (25% vs. 17%, p = 0.012) with a median follow-up of 4.1 years. AKI was not found to be an independent predictor of mortality. Predictors of AKI after SAVR are increased BMI and intraoperative PRBC transfusion. AKI conferred an increase in hospital length of stay and cumulative mortality while the need for postoperative dialysis was associated with the most complicated hospital stays and the highest in-hospital and cumulative mortalities; therefore careful recognition of patients at risk of AKI is warranted for a better preoperative renal optimization. However, incidence of AKI was lower than what is reported after both on-CPB cardiac surgeries and transcatheter aortic valve replacement, moreover AKI was not found to be an independent predictor of mortality.

Excessive Postoperative Bleeding and Outcomes in Neonates Undergoing Cardiopulmonary Bypass

Neonates undergoing cardiac surgery are especially prone to the hemostatic alterations of cardiopulmonary bypass (CPB) and are at high risk for post-CPB bleeding. An immature coagulation system, significant hemodilution from the CPB prime, long CPB times at low temperatures, and extensive suture lines increase neonates' susceptibility to bleeding after CPB. In this study, we examined the relationship between excessive bleeding in neonates after CPB and major postoperative adverse events. We retrospectively reviewed the medical records of 169 neonates who underwent complex congenital heart surgery with CPB between January 1, 2010, and December 31, 2011. Perioperative data were collected and analyzed with specific focus on post-CPB bleeding as measured by 24-hour postoperative chest tube output (CTO), post-CPB transfusion requirements, and major postoperative adverse events, including renal dysfunction, dialysis, thrombosis, extracorporeal membrane oxygenation (ECMO), and in-hospital mortality. We used Spearman correlation to determine correlations between multiple perioperative variables and 24-hour CTO and postoperative blood product requirements. Also, we used logistic regression analysis to determine the association between excessive bleeding (defined as 24-hour CTO >75th percentile) and major postoperative adverse events. Significant correlations were found between 24-hour CTO and postoperative blood product transfusion with weight, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, CPB time, and lowest temperature. Logistic regression found that excessive bleeding after CPB was an independent predictor of postoperative dialysis (relative risk [RR] 12.0; confidence interval, 1.50-54.69; P = 0.02) and ECMO (RR 9.95; confidence interval, 3.07-28.47; P = 0.0008). RACHS-1 score was a significant predictor of in-hospital mortality (P = 0.03). Excessive postoperative bleeding in neonates after CPB is independently associated with increased adverse events, specifically the need for postoperative dialysis and ECMO support. Our findings in neonates are congruent with other recent research that also has found increasing transfusion requirements after pediatric CPB to be independently associated with an increase in major postoperative adverse events. Our results may aid clinicians in anticipating potential adverse events after neonatal bypass and in allocating the resources necessary to manage these events.

Perioperative renal protection strategies in liver transplantation.

Renal failure is one of the most common and major complications in liver transplant recipients. It has been reported to occur at an incidence of 17% to 95%. This complication is associated with prolonged hospital stay in the intensive care unit, the need for postoperative dialysis, infectious complications, acute rejection, and increased mortality. The causes of renal function deterioration differ in the preoperative and postoperative periods. By identifying patients at risk of developing chronic renal failure and by implementing strategies for renal protection at an early stage, it is possible to slow down the progression of renal failure and improve the long-term outcomes in liver transplant recipients.

A New Score to Predict Post Operative Complications after Endovascular Treatment of Thoraco Abdominal Aortic Aneurysms

Background: The endovascular treatment of thoraco abdominal aortic aneurysms (TAAA) is a minimally invasive solution. However, patient selection remains a major problem. We have analysed our experience to identify the risk factors for post-operative morbidity and mortality and to construct a scoring system to identify those patients likely to benefit from this treatment.Methods : We have analysed a consecutive cohort of patients treated electively for TAAA using endovascular techniques between 2006 and October 2012. All data were collected prospectively. The risk factors associated with spinal cord ischemia (SCI), the need for post-operative dialysis and 30 day mortality were determined using multivariate statistical techniques and a logistic regression model including all variables that were significant on univariate analysis (p < 0.05). A predictive score was calculated using a Received Operating Characteristic (ROC) curve, defining best specificity and sensibility.Results : We analysed the data from 113 patients (median age 70 years). The 30 day mortality rate was 8% (10 patients). The SCI rate was 6% (7 patients). One patient (1%) required long-term dialysis after the aortic procedure. The cumulative early mortality, SCI and permanent dialysis rate was 14% (17 patients). In multivariate analysis, adverse outcome was associated with advanced age (OR = 1.110; p = 0.011), and Crawford type I or II or III (OR = 9.191; p = 0.002) as compared with Crawford type IV. Pre-operative beta blocker (BB) treatment was a protective factor (OR = 0.099; p = 0.005). A predictive score was then constructed: Score = -10.060 + 0.104x(A) +2.229x(B) -1.315x(C)(A = patient age; B = 1 if TAAA Crawford type 1, 2 or 3, 0 if TAAA type 4; C = 1 if on-going BB treatment (30 days pre-surgery minimum), 0 if none). Its sensitivity and specificity were 88% and 89% respectively. Conclusion : We propose a simple predictive scoring system. This tool is useful in predicting the most feared complications after endovascular TAAA repair and has potential use in the identification and counselling of vulnerable patients being considered for surgery. More data are needed to refine the prediction of individual operative risks.

Preoperative INTERMACS Profiles Determine Postoperative Outcomes in Critically Ill Patients Undergoing Emergency Heart Transplantation

Background— Postoperative outcomes of patients with advanced heart failure undergoing ventricular assist device implantation are strongly influenced by their preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles. We sought to investigate whether a similar association exists in patients undergoing emergency heart transplantation. Methods and Results— By means of the Spanish National Heart Transplant Registry database, we identified 704 adult patients treated with emergency heart transplantation in 15 Spanish centers between 2000 and 2009. Post-transplant outcomes were analyzed pertaining to patient preoperative INTERMACS profiles, which were retrospectively assigned by 2 blinded cardiologists. Before transplantation, INTERMACS profile 1 (critical cardiogenic shock) was present in 207 patients, INTERMACS profile 2 (progressive decline) in 291, INTERMACS profile 3 (inotropic dependence) in 176, and INTERMACS profile 4 (resting symptoms) was present in 30 patients. In-hospital postoperative mortality rates were, respectively, 43%, 26.8%, and 18% in patients with profiles 1, 2, and 3 to 4 ( P &lt;0.001). INTERMACS 1 patients also presented the highest incidence of primary graft failure (1: 31.3%, 2: 22.3%, 3–4: 21.8%; P =0.03) and postoperative need for dialysis (1: 33.2%, 2: 18.9%, 3–4: 21.5%; P &lt;0.001). Adjusted odds-ratios for in-hospital postoperative mortality were 4.38 (95% confidence interval, 2.51–7.66) for profile 1 versus 3 to 4, 2.49 (95% confidence interval, 1.56–3.97) for profile 1 versus 2, and 1.76 (95% confidence interval, 1.02–3.03) for profile 2 versus 3 to 4. Long-term survival after hospital discharge was not influenced by preoperative INTERMACS profiles. Conclusions— Preoperative INTERMACS profiles determine outcomes after emergency heart transplantation. Results call for a change in policies related to the management of heart transplant candidates presenting with INTERMACS profiles 1 and 2.

Heart Transplantation in Patients Aged 70 Years and Older: A Two-Decade Experience

Objective Advanced age has been viewed as a contraindication to orthotopic heart transplantation (OHT). We analyzed the outcome of OHT in patients who were aged 70 years or older and compared the results with those in younger patients during a two-decade period. Methods A total of 519 patients underwent first-time single-organ OHT at our institution from 1988 to 2009. Patients were divided into three groups by age: ≥ 70-years old (group 1, n = 37), 60 to 69-years old (group 2, n = 206), and ≤60-years old (group 3, n = 276). Primary endpoints were 30-days, and 1-, 5-, and 10-years survival. Secondary outcomes included re-operation for bleeding, postoperative need for dialysis, and length of postoperative intubation. Results There was no significant difference in survival between the greater than or equal to 70-year-old group and the two younger age groups for the first 10 years after OHT. Survival rates at 30 days, and 1-, 5-, and 10-years, and median survival in group 1 recipients were 100%, 94.6%, 83.2%, 51.7%, and 10.9 years (CI 7.1–11.0), respectively; in group 2 those numbers were 97.6%, 92.7%, 73.8%, 47.7%, and 9.1 years (CI 6.7–10.9), respectively; and in group 3 those numbers were 96.4%, 92.0%, 74.7%, 57.1%, and 12.2 years (CI 10.7–15.4; P = NS), respectively. There was no significant difference in secondary outcomes of re-operation for bleeding, postoperative need for dialysis, and prolonged intubation among the three age groups. Conclusions Patients who are aged 70 years and older can undergo heart transplantation with similar morbidity and mortality when compared with younger recipients. Advanced heart failure patients who are aged 70 years and older should not be excluded from transplant consideration based solely on an age criterion. Stringent patient selection, however, is necessary.