Postoperative Acute Kidney Failure Research Articles

Restrictive intraoperative fluid intake in liver surgery and postoperative renal function: A propensity score matched study

BackgroundPostoperative acute kidney injury (AKI) is a common complication in hepatic surgery. In hepatic surgery, relative hypovolemia may help to limit blood loss, but the consequences of restrictive fluid intake are unknown. The goal of this study was to determine the influence of intraoperative fluid intake on the incidence of AKI and its consequences. MethodsData from 397 consecutive patients who underwent liver resection were prospectively recorded and retrospectively analyszed. We compared the incidence of postoperative acute kidney failure in patients given restrictive (≤ 5 mL/kg/h) versus liberal (> 5 mL/kg/h) fluid therapy. We calculated a 1:1 match propensity score using logistic regression to estimate the likelihood of patients receiving restrictive or liberal intraoperative fluid intakes. The association between the intraoperative fluid intake strategy and occurrence of postoperative AKI were tested using a Cox frailty model on the database of matched patients. ResultsPostoperative AKI was diagnosed in 133 of the 397 patients. Fluid intake strategy was restrictive for 121 patients and liberal for 276 patients. After propensity score matching to balance confounding factors, the liberal strategy was associated with a significantly lower risk for postoperative AKI compared to the restrictive strategy (Hazard Ratio 0.40 [0.29; 0.56], P<0.001). Patients with postoperative AKI had longer hospital stays and higher mortality. There were no cases of further blood loss in the liberal fluid intake group. ConclusionsA restrictive fluid intake strategy is a risk factor for developing postoperative AKI, with serious consequences, without reducing blood loss in liver surgery.

Reproducibility of Hospital Rankings Based on Centers for Medicare & Medicaid Services Hospital Compare Measures as a Function of Measure Reliability

Unreliable performance measures can mask poor-quality care and distort financial incentives in value-based purchasing. To examine the association between test-retest reliability and the reproducibility of hospital rankings. In a cross-sectional design, Centers for Medicare & Medicaid Services Hospital Compare data were analyzed for the 2017 (based on 2014-2017 data) and 2018 (based on 2015-2018 data) reporting periods. The study was conducted from December 13, 2020, to September 30, 2021. This analysis was based on 28 measures, including mortality (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), readmissions (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), and surgical complications (postoperative acute kidney failure, postoperative respiratory failure, postoperative sepsis, and failure to rescue). Measure reliability based on test-retest reliability testing. The reproducibility of hospital rankings was quantified by calculating the reclassification rate across the 2017 and 2018 reporting periods after categorizing the hospitals into terciles, quartiles, deciles, and statistical outliers. Linear regression analysis was used to examine the association between the reclassification rate and the intraclass correlation coefficient for each of the classification systems. The analytic cohort consisted of 28 measures from 4452 hospitals with a median of 2927 (IQR, 2378-3160) hospitals contributing data for each measure. The hospitals participating in the Inpatient Prospective Payment System (n = 3195) had a median bed size of 141 (IQR, 69-261), average daily census of 70 (IQR, 24-155) patients, and a median disproportionate share hospital percentage of 38.2% (IQR, 18.7%-36.6%). The median intraclass correlation coefficient was 0.78 (IQR, 0.72-0.81), ranging between 0.50 and 0.85. The median reclassification rate was 70% (IQR, 62%-71%) when hospitals were ranked by deciles, 43% (IQR, 39%-45%) when ranked by quartiles, 34% (IQR, 31%-36%) when ranked by terciles, and 3.8% (IQR, 2.0%-6.2%) when ranked by outlier status. Increases in measure reliability were not associated with decreases in the reclassification rate. Each 0.1-point increase in the intraclass correlation coefficient was associated with a 6.80 (95% CI, 2.28-11.30; P = .005) percentage-point increase in the reclassification rate when hospitals were ranked into performance deciles, 4.15 (95% CI, 1.16-7.14; P = .008) when ranked into performance quartiles, 1.47 (95% CI, 1.84, 4.77; P = .37) when ranked into performance terciles, and 3.70 (95% CI, 1.30-6.09; P = .004) when ranked by outlier status. In this study, more reliable measures were not associated with lower rates of reclassifying hospitals using test-retest reliability testing. These findings suggest that measure reliability should not be assessed with test-retest reliability testing.

Technical success and short-term results from mechanical thrombectomy for lower extremity iliofemoral deep vein thrombosis using a computer aided mechanical aspiration thrombectomy device

BackgroundThe symptoms of deep vein thrombosis (DVT) include severe pain and swelling, and the complications can include post-thrombotic syndrome and recurrent venous thromboembolism. Aspiration thrombectomy (AT) treats arterial and venous disease by removing acute thrombus without reliance on thrombolytic agents but also has the potential to remove fresh blood. Intelligent aspiration is designed to minimize blood loss during AT by aspirating continuously in the thrombus but only intermittently when in a patent vascular segment with active flow. The Indigo System with Lightning 12 intelligent aspiration (Penumbra, Inc, Alameda, Calif) uses an automatic valve controlled by a proprietary computer algorithm to optimize thrombus removal and minimize blood loss. This computer-aided mechanical AT (CMAT) system was used for 16 consecutive patients. MethodsThe present retrospective review included 16 patients who had undergone CMAT for iliofemoral acute DVT from July 2020 to June 2021. The primary outcome was >70% thrombus removal as determined by multiplanar venography. The secondary outcomes included single-session therapy, blood loss during aspiration, the need for postprocedure blood transfusion, thrombolytic use, symptom resolution before discharge, and periprocedural complications. ResultsSixteen patients (mean age, 58.6 years; range, 31-80 years; 75.0% women) had undergone CMAT with the Lightning 12 system. All the patients had presented with pain and swelling of 2 to 16 days in duration. No patient had presented with phlegmasia. Access was obtained via the popliteal (n = 11), posterior tibial (n = 3), small saphenous (n = 1), or soleal (n = 1) vein. Thrombus reduction of ≥70% was achieved for all 16 patients (100%). Single-session therapy was successful for 15 patients (93.8%). Eight patients (50%) had received stents. All patients had experienced symptom resolution before discharge. The median blood loss was 155.0 mL (interquartile range, 95.0-187.5), and no patient had required a postprocedure transfusion. One patient had undergone angioplasty after thrombectomy, and one patient (6.2%) had received adjunctive tissue plasminogen activator therapy. No patient had developed postoperative acute kidney failure. No periprocedural complications occurred. At 1 to 8 months of follow-up, 15 of the 16 patients (93.8%) had patency of the treated iliofemoral area, and 14 (87.5%) had no recurrent symptoms. ConclusionsThese results suggest that CMAT using the Lightning 12 system is safe for clot removal for patients with acute iliofemoral DVT with a high rate of single-session technical success and symptom resolution. In the present case series, the Lightning 12 system was also associated with low blood loss, and no patient had required a blood transfusion.

Mitral surgical redo versus transapical transcatheter mitral valve implantation.

Transcatheter methods have been rapidly evolving to provide an alternative less invasive therapeutic option, mainly because redo patients often present with multiple comorbidities and high operative risk. We sought to evaluate and compare our experience with transapical transcatheter mitral valve replacement (TA-TMVR) to conventional redo mitral valve replacement in patients presenting with degenerated biological mitral valve prostheses or failed valve annuloplasty. Between March 2012 and November 2020, 74 consecutive high-risk patients underwent surgical redo mitral valve replacement (n = 33) or TA-TMVR (n = 41) at our institution. All patients presented with a history of a surgical mitral valve procedure. All transcatheter procedures were performed using the SAPIEN XT/3™ prostheses. Data collection was prospectively according to MVARC criteria. The mean logistic EuroSCORE-II of the whole cohort was 19.9±16.7%, and the median STS-score was 11.1±12.5%. The mean age in the SMVR group was 63.7±12.8 years and in the TMVR group 73.6±9.7 years. Patients undergoing TA-TMVR presented with significantly higher risk scores. Echocardiography at follow up showed no obstruction of the left ventricular outflow tract, no paravalvular leakage and excellent transvalvular gradients in both groups (3.9±1.2 mmHg and 4.2±0.8 mmHg in the surgical and transcatheter arm respectively). There was no difference in postoperative major adverse events between the groups with no strokes in the whole cohort. Both methods showed similar survival rates at one year and a 30-day mortality of 15.2% and 9.8% in SAVR and TMVR group, respectively. Despite using contrast dye in the transcatheter group, the rate of postoperative acute kidney failure was similar between the groups. Despite several contraindications for surgery, we showed the non-inferiority of TA-TMVR compared to conventional surgical redo procedures in high-risk patients. With its excellent hemodynamic and similar survival rate, TA-TMVR offers a feasible alternative to the conventional surgical redo procedure in selected patients.

P859Infective endocarditis requiring surgical intervention: safety and therapeutic impact of preoperative coronary angiography

Abstract Introduction Preoperative coronary angiography (CA) cannot be performed systematically in patients with infective endocarditis requiring surgical treatment due to a high risk of embolization, in cases of aortic endocarditis, or when abscesses or vegetations are present. Purpose The aim of this study is to assess the safety and the therapeutic impact of preoperative coronary angiography in infective endocarditis requiring surgery. Methods This monocentric, observational study included patients with infective endocarditis requiring surgical treatment who were hospitalized between March 2013 and December 2016 in our Hospital. The outcome were i) the occurence of post-CA complications, such as neurological embolization, acute kidney failure requiring post-operative dialysis, or ii) necessity for surgical myocardial revascularization, and the mortality at 28 days and one year. Results 193 patients were included among which 178 were effectively operated on. 119 patients had an aortic endocarditis with an aortic vegetation for 74 patients. Invasive coronary angiography was performed in 142 patients (91.6% by radial approach), and 14 patients were evaluated by coronary tomodensitometry (one patient had exploration with both techniques). CA was carried out regardless of the location of the endocarditis, whether it was aortic or not (p=0,39), and regardless of the existence of abscesses and/ or adenoids (p=0,09), even in case of emergency surgery (p=0,79). Among the 178 patients operated on, 35 had significant coronary lesion(s) and 25 underwent an associated artery bypass graft. Neurological embolization occurred after angiography in only 2 patients with mitral endocarditis, and none was observed in patients with aortic endocarditis. Acute renal failure after CA was observed in 15 (10.6%) Surgery was performed in 173 patients, and 25 of them had a myocardial revascularization. No increase in post-operative dialysis rate was observed (p=0,43) and there were no differences in the mortality rates, neither at 28 days (p=0,77) nor at 12 months following surgery (p=0,59). Conclusion Preoperative CA was not associated with a higher occurence of complications, such as embolizaton or post-operative acute kidney failure, and did not decrease post-operative mortality in infective endocarditis (aortic or not) requiring surgery.

Impact of postoperative acute kidney failure in long-term survival after heart valve surgery.

We investigated the impact of acute kidney failure after a heart valve procedure among patients with or without chronic kidney disease (CKD). All patients who had undergone a surgical valve procedure between 2005 and 2017 at our institution were divided into 2 groups depending on whether they had previous history of CKD (estimated glomerular filtration rate <60 ml/min/1.73 m2) or not. Homogeneous groups were obtained by propensity score matching. Long-term mortality was compared between the 2 groups and according to the occurrence of postoperative acute kidney failure. Level of significance was set at P-value <0.008 for multiple comparison tests. From the 3907 patients included to this study, 1476 (37.78%) had previous history of CKD. After adjusting for propensity score 1:1, patients with preoperative impaired renal function were at a higher risk of acute kidney failure (26.83% vs 10.16%, P < 0.001) and postoperative mortality (8.48% vs 5.17%, P = 0.001). In the follow-up, they had a poorer survival at 1, 5 and 10 years as compared to patients with normal renal function (88% vs 91.95%, 78.29% vs 81.11% and 56.13% vs 66.29%, respectively; P < 0.001). Patients without postoperative kidney failure had similar survival whether they had preoperative CKD or not [hazard ratio (HR) 1.16, 99.2% confidence interval (CI) 0.87-2.52; P = 0.142]. As compared to patients with postoperative preserved renal function, those with postoperative kidney failure had a higher long-term mortality either if they had previous kidney disease or not [(HR 2.18, 99.2% CI 1.75-2.72; P < 0.001) and (HR 1.48, 99.2% CI 1.33-1.65; P < 0.001), respectively]. Preoperative CKD was the strongest predictor of acute kidney failure (odds ratio 4.45; 95% CI 3.59-5.53; P < 0.001). Patients with CKD are at higher risk of postoperative adverse events and have poorer long-term outcomes. Postoperative acute kidney failure increases long-term mortality.

Infective endocarditis requiring surgical intervention: Safety and therapeutic impact of preoperative coronary angiography

Preoperative coronary angiography (CA) cannot be performed systematically in patients with infective endocarditis requiring surgical treatment due to a high risk of embolization, in cases of aortic endocarditis, or when abscesses or vegetations are present. The aim of this study is to assess the safety and the therapeutic impact of preoperative coronary angiography in infective endocarditis requiring surgery. This monocentric, observational study included patients with infective endocarditis requiring surgical treatment who were hospitalized between March 2013 and December 2016 in Rangueil Hospital. The outcome were i) the occurrence of post-CA complications, such as neurological embolization, acute kidney failure requiring postoperative dialysis, or ii) necessity for surgical myocardial revascularization, and the mortality at 28 days and one year. Hundred and ninety-three patients were included in this study, among which 119 had aortic endocarditis. Hundred and fifty-five patients had theoretical indication of CA and 142 interventions were performed. The procedure was carried out regardless of the location of the endocarditis, whether it was aortic or not ( P = 0.39), and regardless of the existence of abscesses and/or adenoids ( P = 0.09), even in case of emergency surgery ( P = 0.79). Neurological embolization occurred after angiography in only 2 patients with mitral endocarditis, and none was observed in patients with aortic endocarditis. Surgery was performed in 173 patients, and 25 of them had a myocardial revascularization. No increase in postoperative dialysis rate was observed ( P = 0.43) and there were no differences in the mortality rates, neither at 28 days ( P = 0.77) nor at 12 months following surgery ( P = 0.59). Preoperative CA was not associated with a higher occurrence of complications, such as embolizaton or postoperative acute kidney failure, and did not decrease postoperative mortality in infective endocarditis (aortic or not) requiring surgery.

Long-term Survival and Evolution of the Kidney Function for Liver Transplant Patients Who Required Postoperative Dialysis

Patients who underwent orthotopic liver transplantation (OLT) frequently develop chronic kidney disease, with those who present postoperative acute kidney failure and require renal replacement therapy (RRT) at higher risk. The objective of the study was to assess the kidney function and long-term survival of patients who underwent OLT and required RRT during or in the immediate postoperative period. Medical records of OLT and postoperative RRT patients with over 6-month survival were reviewed between January 1, 2005, and December 31, 2015. A variance analysis was carried out for repeated measurements to compare the estimate glomerular filtration rate (eGFR) baseline with the different periods (statistical significance level P < .05). Kaplan-Meier estimator was used to estimate the survival rate. Of 539 patients, 20 (3.7%) met the selection criteria. The basal eGFR at 6 months and 1, 3, 5, and 7 years was 93.41 ± 25, 78.28 ± 33, 73.06 ± 29, 65.96 ± 19, 79.81 ± 28, and 59.06 ± 24 mL/min/1.73 m2, respectively. The comparison of the eGFR baseline within the different periods was statistically significant at 1 year and at 3 years. Four patients died, 3 of them due to sepsis and 1 due to recurrence of hepatitis C virus infection. The average survival was 28 months. The probability of surviving at 1 year was 100%, at 3 years was 84.21% (95% confidence interval: 58.65–94.62), and at 5 and 10 years was 78.6% (95% confidence interval: 52.49–91.39). In conclusion, we have found a progressive worsening of the kidney function in the long term in patients who required postoperative dialysis. However, actuarial survival of these patients was very successful.

The impact of continuous non-invasive arterial blood pressure monitoring on blood pressure stability during general anaesthesia in orthopaedic patients: A randomised trial.

In patients undergoing general anaesthesia, intraoperative hypotension occurs frequently and is associated with adverse outcomes such as postoperative acute kidney failure, myocardial infarction or stroke. A history of chronic hypertension renders patients more susceptible to a decrease in blood pressure (BP) after induction of general anaesthesia. As a patient's BP is generally monitored intermittently via an upper arm cuff, there may be a delay in the detection of hypotension by the anaesthetist. The current study investigates whether the presence of continuous BP monitoring leads to improved BP stability. Randomised, controlled and single-centre study. A total of 160 orthopaedic patients undergoing general anaesthesia with a history of chronic hypertension. The patients were randomised to either a study group (n = 77) that received continuous non-invasive BP monitoring in addition to oscillometric intermittent monitoring, or a control group (n = 83) whose BP was monitored intermittently only. The interval for oscillometric measurements in both groups was set to 3 min. After induction of general anaesthesia, oscillometric BP values of the two groups were compared for the first hour of the procedure. Anaesthetists were blinded to the purpose of the study. BP stability and hypotensive events. There was no difference in baseline BP between the groups. After adjustment for multiple testing, mean arterial BP in the study group was significantly higher than in the control group at 12 and 15 min. Mean ± SD for study and control group, respectively were: 12 min, 102 ± 24 vs. 90 ± 26 mmHg (P = 0.039) and 15 min, 102 ± 21 vs. 90 ± 23 mmHg (P = 0.023). Hypotensive readings below a mean pressure of 55 mmHg occurred more often in the control group (25 vs. 7, P = 0.047). Continuous monitoring contributes to BP stability in the studied population. NCT02519101.

Cystatin C and NGAL as Biomarkers for Early Detection of Acute Kidney Injury in Geriatrics

Acute kidney injury (AKI) is associated with cardiovascular mortality and morbidity especially in high-risk patients undergoing cardiac surgery. It ranges from 7.7% to 28.1% in different studies. The aim of this study was to compare cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) with Creatinine as an early marker for acute kidney injury in geriatrics. From 2013 through 2015, 307 consecutive high-risk elderly patients older than 70 years undergoing emergency coronary artery bypass grafting using extracorporeal circulation were studied. All patients underwent diagnostic coronary angiography and the surgical procedure within 1 week in single hospital stay and were randomized according to timing of interval between coronary angiographyand cardiac procedure as follows: group I, less than 2 days; group II, between 2 and 4 days; and group III, higher than 4 days. Renal function was analyzed by serum cystatin C, NGAL, and creatinine. Blood samples were obtained from each patient at five time points: basal value before operation, in the four hours after operation, and on the first, third, and fifth postoperative days. Glomerular filtration rate (GFR) was calculated by Cockcroft-Gault (CG). A total of 56 patients developed postoperative acute kidney failure according to the risk, injury, and failure; and loss; and end-stage kidney disease classification. Perioperative fluid requirements, urine output, and vasopressor need during and after cardiopulmonary bypass were similar. 30-day mortality in groups was higher in group I than group II and group III (P = 0.025). AKI was least prominent in group III compared to group I and group II (P = 0.001) and expectedly, postoperative dialysis requirement was least common in group III (15, 16.66%). Patients in group III had the most favorable clinical outcome with regards to the length of ICU and hospital stay. Overall serum creatinine, cystatin C, and urine NGAL levels changed significantly throughout the entire length of following-up period in group I and group II, but not in group III. Changes in serum levels of cystatin, creatinine, and creatinine clearance were prominent in later than 24 hours. Urinary NGAL was the first variable to rise in the immediate postoperative period. Cystatin GFR was a more rapid marker than serum creatinine GFR to show acute kidney injury in three groups was a significant marker.

Cardiac Catheterization and Postoperative Acute Kidney Failure in Congenital Heart Pediatric Patients

Cardiac Catheterization and Postoperative Acute Kidney Failure in Congenital Heart Pediatric Patients

Update: Advances in Pediatric Cardiac Intensive Care

Update: Advances in Pediatric Cardiac Intensive Care

Cardiac Catheterization and Postoperative Acute Kidney Failure in Congenital Heart Pediatric Patients

Acute renal failure (ARF) is a severe complication of cardiac operations in pediatric patients. Angiography with the exposure to contrast media is a risk factor for ARF. In the present study, we explored the association between timing of angiography, dose of contrast media, and the incidence of ARF after cardiac operations in pediatric patients. We performed a retrospective analysis of prospectively collected data. Angiographic data and other covariates were collected in 277 patients aged ≤12 years receiving angiography and cardiac operations during the same hospital stay. Renal outcome was assessed according to the pediatric Risk, Injury, Failure, Loss of function, End stage score (pRIFLE). One hundred seventy-seven (64%) patients suffered some degree of postoperative renal dysfunction, and 55 (20%) had ARF (pRIFLE stage Failure). Patients with ARF received a significantly (P < 0.001) larger dose of iodine contrast media (4.6 ± 2.6 g/kg) with respect to the other patients (2.8 ± 2.2 g/kg), with a relative risk increase for ARF of 31% per each incremental iodine dose of 1 g/kg at the univariate analysis. A multivariable risk model demonstrated that the risk for ARF is 20 times higher in patients aged younger than 2 years and 3 times higher in case of postoperative low cardiac output. Within this model, the iodine dose on angiography is confirmed as an independent risk factor for ARF, with a relative risk increase for ARF of 16% per each incremental iodine dose of 1 g/kg. Angiography before cardiac surgery is an important risk factor for ARF in pediatric patients. Being a modifiable risk factor, the contrast media dose should be limited to the lowest possible value, avoiding large doses of iodine which, together with other factors (age and postoperative low cardiac output), concur in the determinism of postoperative ARF.

Dissecting aortic aneurysm in a 23 year-old hypertensive woman

A 23 year-old woman was admitted to our hospital after loss of consciousness with chest pain in a stress situation (the woman’s wedding ceremony). The patient had been irregularly treated for mild hypertension from the age of eight. Secondary causes of hypertension were never diagnosed. There were no morphological features of Marfan syndrome in the patient. She had been operated upon for vesicoureteral reflux in childhood. The patient was admitted in a stable condition. Her physical examination revealed diastolic aortic murmur and tachycardia, blood pressure was normal. Transthoracic echocardiography showed expansion of ascending aorta to 43 mm and thoracic aorta dissection (Fig. 1). Chest computed tomography demonstrated thoracic aorta dissection, which began 15 mm above the aortic valve, expansion of ascending aorta to 44 mm, expansion of arch of aorta to 28 mm and pseudocanal of the descending aorta to 6.5 mm (Fig. 2). The dissection included brachiocephalic trunk, both common carotid arteries, left subclavian artery and abdominal aorta to the celiac trunk (Fig. 3). The patient was operated upon immediately. A dissecting aneurysm DeBakey I type was diagnosed intraoperatively. The Bentall de Bono procedure was done with implantation CompositGraft St. Jude Medical 25. The early postoperative period was complicated by bleeding, requiring rethoracotomy and low output syndrome. Because of this, the patient was treated with pressor amines. In the following days, postoperative acute kidney failure occurred and patient was subjected to dialysis. Tamponade occurred and a puncture was performed with evacuation of liquid. The antihypertensive treatment was modified and vitamin K antagonist therapy was initiated. The patient was discharged from hospital on the 26th day of treatment. Aortal dissection is one of the most life-threatening complications of hypertension. The commonest causes of aortal dissection are arterial wall abnormalities, which had not been demonstrated in histopathology in our patient. Long term, inadequately treated hypertension was the only aetiology factor of aortic dissection in this young woman.

Aspirin before heart surgery reduces the risk of postoperative acute kidney failure

Aspirin before heart surgery reduces the risk of postoperative acute kidney failure

Italian multicenter study on complications of laparoscopic myomectomy

Study objective To study intraoperative and postoperative complications of laparoscopic myomectomy and patients’ characteristics influencing this risk. Design Prospective study, with a review of the patient records by the first author (Canadian Task Force classification II-2). Setting Four Italian referral centers. Patients The incidence and type of complications occurring in 2050 laparoscopic myomectomies undertaken from January 1998 through December 2004 were recorded. Interventions The surgical technique, as well as the expertise of the operators, was the same for the 4 centers. Injection of vasoconstrictive agents was used in 37%. The serosa was always incised in a vertical fashion; mechanical enucleation of the myoma was completed whenever possible; suture was performed in 1 or 2 layers with deep and large stitches swaged to 1 or 0 polyglactin sutures that were tied intracorporeally or extracorporeally. Measurements and main results Single or multiple myomectomies (n = 2050) for symptomatic myomas measuring at least 4 cm in diameter were performed. Most patients (48%) had more than 1 myoma, with a maximum of 15 per patient (myomas removed for patients: 2.26 ± 1.8, mean ± SD). Myoma size ranged from 1 to 20 cm (mean 6.40 ± 2.6 SD). Myomas smaller than 4 cm were removed during myomectomy for larger ones. Total complication rate was 11.1% (225/2050 cases). Minor complications accounted for 9.1% (187/2050 cases) and major complications for 2.02% (38/2050 cases). The most serious events were hemorrhages (14 cases, 0.68%) requiring blood transfusions in 3 cases (0.14%); 10 postoperative hematomas (0.48%, one in the broad ligament and 9 in the myomectomy scar); 1 bowel injury (0.04%); 1 postoperative acute kidney failure (0.04%); and 2 unexpected sarcomas (0.09%). Failure to complete planned surgery occurred in 7 cases (0.34%). Two patients were readmitted for surgery (0.09%): 1 had a laparoscopic hysterectomy because of a severe blood loss, and the other had drainage of a hematoma in the broad ligament. After a follow-up period of 41.70 ± 23.03 months (mean ± SD), 386 (22.9%) patients conceived, with a pregnancy rate in patients wishing pregnancy of 69.8%; among them, 1 (0.26%) recorded spontaneous uterine rupture at 33 weeks gestation. Odds ratio computed to estimate the risk of complications in relation to the patient characteristics showed that the probability of complications significantly rises with an increase in the number (more than 3 myomas OR: 4.46, p <.001) and with the intramural (OR: 1.48, p <.05) or the intraligamentous location of myomas (OR: 2.36, p <.01) whereas the myoma size seems to influence particularly the risk of major complications (OR: 6.88, p <.001). Conclusions This is one of the largest series reported of laparoscopic myomectomy and the first focused on complications. The complication rate appears to be better than acceptable in comparison with complication rates reported after laparotomic myomectomies. Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique with an extremely low failure rate and good results in terms of pregnancy outcome.

Pre- and early postoperative risk factors for death after cardiac transplantation: a single center analysis.

Due to the limited number of donor organs, death on the waiting list and waiting time for cardiac transplantation have markedly increased. A pressing need of appropriate selection criteria for patients who would benefit most from transplantation is apparent. The purpose of this study is to identify pre- and early postoperative risk factors that influence long term survival after cardiac transplantation. 702 consecutive patients who underwent cardiac transplantation between 3/1984 and 12/1997 were analyzed retrospectively for the influence of different pre- and early postoperative risk factors on early (30 days) and late death (5 years). Univariate and multivariate regression analysis revealed risk factors for early as well as late death. Predictors of early death were higher preoperative PVR, retransplantation, longer ischemic time, postoperative acute kidney failure and longer intubation time. Risk factors for late death were early transplant era, previous cardiac surgery, patients awaiting transplantation in a hospital, prolonged stay in an intensive care unit, and any rejection during the first month after transplantation. These results demonstrate that pre- and early postoperative risk factors have significant influence on early and long term survival.

Pre- and early postoperative risk factors for death after cardiac transplantation: A single center analysis

Abstract Due to the limited number of donor organs, death on the waiting list and waiting time for cardiac transplantation have markedly increased. A pressing need of appropiate selection criteria for patients who would benefit most from transplantation is apparent. The purpose of this study is to identify pre- and early postoperative risk factors that influence long term survival after cardiac transplantation. 702 consecutive patients who underwent cardiac transplantation between 3/1984 and 12/1997 were analyzed retrospectively for the influence of different pre- and early postoperative risk factors on early (30 days) and late death (5 years). Univariate and multivariate regression analysis revealed risk factors for early as well as late death. Predictors of early death were higher preoperative PVR, retransplantation, longer ischemic time, postoperative acute kidney failure and longer intubation time. Risk factors for late death were early transplant era, previous cardiac surgery, patients awaiting transplantation in a hospital, prolonged stay in an intensive care unit, and any rejection during the first month after transplantation. These results demonstrate that pre- and early postoperative risk factors have significant inluence on early and long term survival.