Postoperative Acute Renal Failure Research Articles

Impact of a kidney-adjusted ERAS® protocol on postoperative outcomes in patients undergoing partial nephrectomy

PurposeEvaluation of a kidney-adjusted enhanced recovery after surgery (ERAS®) protocol (kERAS) in patients undergoing nephron-sparing surgery (PN).MethodsThe kERAS protocol is a multidimensional protocol focusing on optimized perioperative fluid and nutrition management as well as strict intraoperative and postoperative blood pressure limits. It was applied in a prospective cohort (n = 147) of patients undergoing open or robotic PN. Patients were analyzed for the development of acute postoperative renal failure (AKI), achievement of TRIFECTA criteria, upstaging or new onset of chronic kidney disease (CKD) and length of hospital stay (LOS) and compared to a retrospective cohort (n = 162) without application of the protocol.ResultsCox regression analyses could not confirm a protective effect of kERAS on the development of AKI post-surgery. A positive effect was observed on TRIFECTA achievement (OR 2.2, 95% CI 1.0-4.5, p = 0.0374). Patients treated with the kERAS protocol showed less long-term CKD upstaging compared to those treated with the standard protocol (p = 0.0033). There was no significant effect on LOS and new onset of CKD.ConclusionThe implementation of a kERAS protocol can have a positive influence on long-term renal function in patients undergoing PN. It can be used safely without promoting AKI. Furthermore, it can be realized with a manageable amount of additional effort.

Postoperative Acute Renal Failure: Etiologies and Prognostic Factors

Postoperative acute renal failure is a rare complication in the surgical context. It is the consequence of a significant and prolonged decrease in the glomerular filtration rate, leading to a failure to eliminate nitrogen catabolism products and a hydroelectrolytic disorder. Early recognition of risk factors and prevention of spinal cord ischemia are the two fundamental elements in the management of postoperative renal failure.

Long-term outcomes of minimally invasive concomitant mitral and tricuspid valve surgery with surgical ablation.

We compared the outcomes of a right mini-thoracotomy (RMT) versus those of a sternotomy for concomitant mitral and tricuspid valve surgery and surgical ablation. We analysed patients who underwent concomitant mitral and tricuspid valve surgery and surgical ablation at a single institution (mean follow-up: 7 years) after propensity score matching. The primary and secondary outcomes were all-cause death, composite major adverse events (including stroke, reoperation, readmission, permanent pacemaker insertion) and recurrence of atrial fibrillation (A-fib). A subgroup analysis was performed. A total of 797 procedures (mean age: 61.6 years; RMT: 45.2%; female: 66.5%; mitral valve repair: 33.6%) were done; 267 pairs were matched. The 5- and 10-year overall survival in the matched cohort was 92.7% and 86.9% for the RMT group and 92.1% and 83.1% for the sternotomy group (P = 0.879). Significant differences were not observed in major adverse events (P = 0.273; hazard ratio: 0.76) and A-fib recurrence (P = 0.080; hazard ratio: 0.72). The RMT group had lower rates of postoperative low cardiac output syndrome (P = 0.019) and acute renal failure (P = 0.003). Atrial fibrillation high-risk factors (including long-standing A-fib, enlarged left atrium, old age) exhibited significant interactions (P for interaction = 0.002) with the approach regarding A-fib recurrence. In this study, an RMT exhibited no significant differences in long-term outcomes compared to a sternotomy, but it could remain a clinically reasonable option. Patients with a high risk of A-fib may have favourable ablation outcomes with a sternotomy.

Hematocrit and Renal Failure in Aortic Arch Surgery: A Society of Thoracic Surgeons Database Study

BackgroundThis study examined the association between cardiopulmonary bypass (CPB) hematocrit and postoperative acute renal failure (ARF) in patients undergoing aortic arch surgery with hypothermic circulatory arrest. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from 2011 to 2019 for patients undergoing aortic arch surgery with hypothermic circulatory arrest. A multivariable logistic regression model estimated the adjusted odds of postoperative ARF on the basis of CPB hematocrit. Effects were stratified by preoperative kidney function and the duration of hypothermic circulatory arrest by using interaction terms. The study also investigated the association between postoperative ARF and major postoperative outcomes by using multivariable regression models. ResultsOn adjusted analysis, higher CPB hematocrit (>20%-25%, >25%-30%, >30%) was associated with lower odds of ARF as compared with lower CPB hematocrit (≤20%) (>20-25%, aOR, 0.78; 95% CI, 0.65-0.93; P = .006; >25%-30%, aOR, 0.65; 95% CI, 0.50-0.84; P = .0007; >30%, aOR, 0.45; 95% CI, 0.28-0.72; P = .0008). The predicted probability of postoperative ARF by CPB hematocrit was higher in patients with lower preoperative renal function (estimated glomerular filtration rate, <60 mL/min/1.73 m2) (interaction P = .03). The association between hematocrit and postoperative ARF was not significantly modified by hypothermic circulatory arrest time (interaction P = .74). All postoperative outcomes were significantly worse in patients with postoperative ARF (all P < .0001). ConclusionsAmong patients undergoing aortic arch surgery, a higher CPB hematocrit level is associated with reduced likelihood of postoperative ARF. Preoperative renal function, but not hypothermic circulatory arrest duration, significantly modified this association. The maintenance of higher CPB hematocrit may reduce the incidence of postoperative ARF, especially for patients with poor preoperative renal function.

Evaluating the relationship between lactate levels during coronary artery bypass graft surgery and postoperative renal dysfunction.

Postoperative Acute renal failure related to cardiac surgery is a common complication due to cardiac surgery and is estimated to influence up to 30% of patients. Serum lactate is a famous biomarker of tissue ischemia and is regularly checked during surgery. In this retrospective observational research, the records of 395 patients undergoing CABG were examined. Patients were classified into 4 groups based on the difference between the maximum lactate level measured during surgery and its baseline level. Also creatinine and urea levels, blood sugar, hemoglobin, and hematocrit pre, postoperative were recorded. The intraoperative and postoperative use of inotropes and the durations of surgery, cardiopulmonary bypass pump, and aortic cross-clamping were also recorded. According to the results, pre, post and 24-hour postoperative blood urea nitrogen were not significantly related to intraoperative lactate changes. Also, pre and 24-hour postoperative creatinine had no significant relationship with intraoperative lactate changes, while postoperative creatinine was significantly associated with intraoperative lactate changes (P value=0.05). The duration of cardiopulmonary bypass (P value=0.02), intraoperative inotrope infusion (P value=0.03), inotrope infusion during the first six hours in ICU (P value=0.049), and receiving packed cell (P value=0.006) and receiving platelets during surgery (P value=0.04) were significantly related to intraoperative lactate changes. Furthermore, no significant relationship was observed between the duration of hospitalization in the ICU and the hospital and intraoperative lactate changes. According to the results, blood lactate level is an unreliable marker for predicting renal dysfunction postoperative.

Perioperative complications of minor and major reinterventions for peripheral arterial disease.

Patients with peripheral arterial disease (PAD) frequently require reinterventions after lower-extremity revascularization (LER) to maintain perfusion. Current Society for Vascular Surgery guidelines define reinterventions as major or minor based on the magnitude of the procedure. While prior studies have compared primary LER procedures of different magnitudes, similar studies for reinterventions have not been performed. The objective of this study is to compare perioperative outcomes associated with major and minor reinterventions. Patients undergoing LER for PAD at a tertiary care center from 2013 to 2017 were included. A retrospective review of electronic medical records was performed, and reinterventions were categorized as major or minor based on the procedure magnitude. Minor reinterventions included endovascular procedures and open revision with patch angioplasty, while major reinterventions were characterized by open surgical or endovascular LER with catheter-directed thrombolysis (CDT). Perioperative outcomes following LER were captured and compared for major and minor reinterventions. An additional subgroup analysis was performed comparing outcomes associated with major reinterventions stratified into open major surgical reinterventions and CDT. This study included 713 patients over a mean follow-up of 2.5years. A total of 291 patients underwent 696 ipsilateral reinterventions (range = 1-12 reinterventions). Most reinterventions were minor (72.1%, N = 502) and 27.9% (N = 194) were major. Patients receiving reinterventions had an average age of 67.2 ± 11.5 and most were white (73.5%) males (60.1%) initially treated for claudication (58.2%) and CLTI (41.8%). There was significantly higher post-operative bleeding (9.8% vs 3.4%, p = .001), arterial thrombosis (3.1% vs 1.0%, p = .047), and acute renal failure (6.2% vs 2.4%, p = .014) after major reinterventions than minor. Additionally, major reinterventions had significantly higher return to the OR (17.0% vs 11.3%, p = .046) and longer hospital stays (7.5 vs 4.3days, p = <.0001). Overall, major reinterventions were associated with significantly increased perioperative morbidity (37.6% vs 19.7%, p ≤ .001) with no difference in perioperative mortality. In the subgroup analysis, open reinterventions resulted in significantly longer hospital stays (8.6days vs 5.5days, p ≤ .001) and more wound infections than CDT (11.0% vs 0%, p = .017). However, there was no other significant difference in morbidity or mortality following treatment with open surgical reinterventions or CDT. In this study, major reinterventions after LER were associated with greater perioperative morbidity than minor reinterventions, with no difference in mortality. Major reinterventions performed via open surgery and CDT had similar morbidity and mortality.

Morbi-Mortality of Coronary Surgery in Elderly Patients in Algeria

Nearly 10% of the Algerian population (estimated at 44 millions) is aged over 70, and many of them have coronary heart disease. At the same time, life expectancy at the age of 70 still appears to be high. Objective: To evaluate the results of coronary surgery in these patients. Methodology: We compared 88 consecutive patients in their 70s who underwent isolated coronary artery bypass grafting between 2016 and 2019 with 165 patients aged 50 to 60. The two groups were matched for major risk factors. Patients were contacted by telephone and sent a quality of life questionnaire. Results: Operative mortality was 2.3% in septuagenarians, compared with 1.2% in 50-60 year olds (P not significant). There was a higher incidence of low flow, postoperative acute renal failure and transfusion in patients in their seventies. Long-term survival (mean follow-up of 2.8 years) was higher in the 50- to 60-year-olds: 89.7% compared with 77.9% (P=0.025). We found four independent risk factors for increased long-term mortality: age, diabetes, history of stroke and postoperative blood transfusion. Conclusion: For selected septuagenarians, isolated coronary surgery can be proposed, and the short- and medium-term results will be comparable to those in a younger population.

Outcomes of bariatric surgery in the setting of compensated advanced chronic liver disease associated with clinically significant portal hypertension: a multicenter, retrospective, cohort study on feasibility and safety.

The obesity epidemic has led to an increase in the proportion of patients with chronic liver disease due to metabolic associated steatosic liver disease and in the prevalence of obesity in patients with cirrhosis. Metabolic and bariatric surgery (MBS) has been proven to determine weight loss, obesity-related medical problems remission, and liver steatosis, inflammation, and fibrosis improvement. However, cirrhosis and portal hypertension are well-known risk factors for increased morbidity and mortality after surgery. The aim of this study is to evaluate the safety of MBS in patients with compensated advanced chronic liver disease (cALCD) and clinically significant portal hypertension (CSPH). This is an international, multicentric, retrospective study on 63 individuals affected by obesity with cALCD and CSPH who underwent MBS in tertiary referral centers with experts hepatobiliary surgeons between January 2010 and October 2022. The primary endpoint was postoperative mortality at 90 days. The secondary endpoints included postoperative weight loss at last follow-up and postoperative complication rate. In addition, the authors performed subgroup analyses of Child-Pugh (A vs. B) score, MELD (≤9 vs. >9) score, and type of surgery. One patient (1.6%) experienced gastric leakage and mortality. There were three (5%) reported cases of portal vein thrombosis, two (3%) postoperative acute renal failure, and one (1.6%) postoperative encephalopathy. Child-Pugh score A resulted to be a protective factor for intraoperative bleeding requiring transfusion at univariate analysis (OR: 0.73, 95% CI: 0.55-0.97, P =0.046) but not at multivariate analysis. MELD>9 score and the type of surgery did not result to be a risk factor for any postoperative complication. MBS is safe in patients with cALCD and CSPH performed in tertiary bariatric referral centers with hepatobiliary expert surgeons. Larger, prospective studies with longer follow-up periods are needed to confirm these results.

The 5-factor modified frailty index (mFI-5) predicts adverse outcomes after elective anterior cervical discectomy and fusion (ACDF)

BackgroundAnterior cervical discectomy and fusion (ACDF) is a reliable procedure commonly performed in older patients with degenerative diseases of the cervical spine. Over 130,000 procedures are performed every year with an annual increase of 5%, and overall morbidity rates can reach as high as 19.3%, indicating a need for surgeons to gauge their patients’ risk for adverse outcomes. Frailty is an age-associated decline in functioning of multiple organ systems and has been shown to predict adverse outcomes following various spine procedures. There have been several proposed frailty indices of various factors including the 11-factor modified frailty index (mFI-11), which has been shown to be an effective tool for predicting complications in patients undergoing ACDF. However, there is a paucity of literature assessing the utility of the 5-factor modified frailty index (mFI-5) as a risk stratification tool for patients undergoing ACDF. The purpose of this study was to analyze the predictive capability of the mFI-5 score for 30-day postoperative adverse events following elective ACDF. MethodsA retrospective review was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2019. Patients older than 50 years of age who underwent elective ACDF were identified using Current Procedural Terminology ([CPT] codes 22554, 22551, 22552, and 63075). Exclusion criteria removed patients under the age of 51, as well as those with fractures, sepsis, disseminated cancer, a prior operation in the last 30 days, ascites, wound infection, or an emergency surgery. Patients were grouped using mFI scores of 1, 2, and 3+. Univariate analysis, using chi-squared and one-way analysis of variance (ANOVA) tests, was conducted to compare demographics, comorbidities, and postoperative complications across the varying cohorts based on mFI-5 scores. Multivariate logistic regression, including patient demographics and preoperative comorbidities as covariates, was performed to evaluate if mFI-5 scores were independent predictors of 30-day postoperative adverse events. Covariates including race, BMI, sex, ASA, and comorbidities were included in regression models. ResultsThe 45,991 patients were identified and allocated in cohorts based on mFI-5 score. Rates for superficial surgical site infection (SSI), organ/deep space SSI, pneumonia, progressive renal insufficiency, acute renal failure (ARF), urinary tract infection (UTI), stroke/cardiovascular accident (CVA), cardiac arrest requiring cardiopulmonary resuscitation (CPR), myocardial infarction, bleeding requiring transfusions, deep vein thrombosis/thrombophlebitis, sepsis, septic shock, readmissions, reoperation, and mortality incrementally increased with mFI-5 scores from 0 to 3+. Multivariate regression analysis revealed that mFI-5 scores 1 to 3+ increased the odds, in a stepwise manner, of total complications, cardiac arrest requiring CPR, pneumonia and mortality. MFI-5 scores of 2 and 3+ were independent predictors of readmission (2: OR=1.5, p<.001; 3+: OR=2.0, p<.001) and myocardial infarction (2: OR=3.4, p=.001; 3+: OR=6.9, p<.001). A score of 3+ increased the odds of ARF (OR=9.7, p=.022), septic shock (OR=3.6, p=.036), UTI (OR=2.1, p=.007), bleeding requiring transfusions (OR=2.1, p=.016), and reoperations (OR=1.7, p=.004). ConclusionmFI-5 score is a quick and viable option for surgeons to use as an assessment tool to stratify high risk patients undergoing elective ACDF, as increasing mFI-5 scores showed significantly higher rates of all adverse outcomes accounted for in this study, except for deep incisional SSI, wound disruption, and PE. Additionally, moderate to severe mFI-5 scores of 2 or 3+ were independent predictors for 30-day postoperative ARF, UTI, MI, bleeding requiring transfusions, septic shock, reoperation, and readmissions following elective ACDF surgery in adults over 50 years old.

Nutritional Risk Assessment and Adverse Events in Patients Undergoing Left Ventricular Assist Device Implantation-A Retrospective Cohort Study Using Hospital Information System.

Clinical or subclinical malnutrition occurs in 30% to 70% of patients with advanced heart failure and increases the risk of postoperative adverse events. The main objective of this study was to assess the nutritional status of patients prior to left ventricular assist device (LVAD) implantation using different methods of malnutrition assessment and to evaluate the relationship between nutritional status and postoperative adverse events. A retrospective cohort study included 120 patients aged 26-74 years referred for LVAD surgery. Preoperative nutritional status (NRS-2002-Nutritional Risk Score 2002, NRI-Nutritional Risk Index, PNI-Prognostic Nutritional Index; TLC-total lymphocyte count) and postoperative adverse events were assessed. Moderate to severe malnutrition was found in 55.8%, 43.3%, 40.0%, and 20% of all patients, respectively, according to the PNI, NRI, TLC, and NRS-2002 scores. Patients with a TLC < 1200 cells/m3 had a higher risk of postoperative acute renal failure [hazard ratio (HR): 2.5; 95% confidence interval (95% CI): 1.01-6.3] and death during the observation period [HR = 2.1; 95% CI: 1.2-3.5]. Moderate to severe malnutrition was also associated with a significantly increased risk of in-hospital death [for the NRI score, HR = 4.9 (95% CI: 1.1-22.0); for the PNI score, HR = 5.0 (95% CI: 1.1-22.3)]. In conclusion, moderate to severe malnutrition prior to LVAD implantation has been identified as a risk factor for postoperative acute renal failure and mortality. Assessment of nutritional risk may improve patient selection and early initiation of nutritional support.

Abstract 15183: Diabetes is Associated With Worse Postoperative Mortality and Morbidity in Bariatric Surgery, Regardless of the Procedure

Introduction: Bariatric surgery is an efficient treatment for obesity. Objectives: We aimed to assess the impact of diabetes on postoperative outcomes of bariatric surgery. Further, we compared the outcomes of different techniques in patients with diabetes. Methods: We used data from the National Inpatient Sample (2015-2019) to identify patients who underwent either sleeve gastrectomy, Roux-en-Y, or gastric banding. Outcomes included postoperative mortality (primary outcome), major bleeding, atrial fibrillation, and acute renal failure. Results: Patients with diabetes had an overall increased risk of perioperative complications when compared to non-diabetic ones for all three types of bariatric surgery. Among patients who underwent sleeve gastrectomy, diabetes was associated with a higher adjusted risk of mortality [aOR 2.07 (1.36-3.16)], atrial fibrillation [aOR 1.07 (1.02-1.11)], and acute renal failure [aOR 1.51 (1.39-1.64)] but a similar risk of major bleeding. Among patients who underwent Roux-en-Y, diabetes did not increase the risk of mortality and bleeding. Still, it was associated with a higher risk of atrial fibrillation [aOR 2.24 (1.25-4.02)] and acute renal failure [aOR 1.36 (1.21-1.62)]. Among patients who underwent gastric banding, diabetes was only associated with a higher risk of major bleeding [aOR 2.94 (1.42-5.88)]. When comparing the 3 techniques in diabetes patients, Roux-en-Y was significantly associated with a higher mortality rate (1.05%, 0.06%, 0%), atrial fibrillation (7.04%, 3.35%,3.48%), and acute renal failure (6.32%, 1.29%, 3.48%) (Roux-en-Y, sleeve, gastric banding; respectively). Major bleedings were more common in Roux-en-Y (1.05%) than in Sleeve (0.5%) (p&lt;0.001). Conclusions: Diabetes is associated with worse postoperative outcomes regardless of the type of bariatric surgery performed. Among diabetes patients, Roux-En-Y was associated with higher mortality and morbidity.

CARC1: Impella 5.5 Percutaneous Left Ventricular Assist Device (LVAD) Bridge to Orthotopic Heart Transplant (OHT): A Case Series

Background: Limited donor organ availability necessitates the use of mechanical circulatory support (MCS) as a bridge to transplant for patients in medically refractory end-stage heart failure. The increasing availability, flow capability and durability of the Impella 5.5 percutaneous LVAD has benefitted patients with its minimally invasive nature. We present a single-center case series of patients supported with Impella 5.5 to OHT, demonstrating the safety and feasibility of this approach in what is, to our knowledge, the largest reported series to date. Methods: From January 2021 to present, 31 consecutive patients supported by Impella 5.5 underwent OHT at our institution. Demographic data, etiology of illness, details of procedures, duration of support, postoperative complications, and outcomes were analyzed. We additionally report two different methods of complete device removal during OHT – via device transection in the field versus removal from the axillary insertion site. Results: Of 31 patients, 80.7% (25/31) were male and the average age was 49.5 (21-70) years. The etiology of cardiomyopathy was predominantly nonischemic in 77.4% (24/31) of patients. Average length of stay was 78.2 days (27-229) with an average 53.1 days (19-133) in the intensive care unit. 27 patients (87.1%) had device placed in the right axillary artery, with 3 being on the left. Average Impella 5.5 duration was 29.6 days (2-97). During OHT, 67.7% (21/31) had device transected in the aorta and sent off the field, while the remaining 32.3% had device removal via axillary site. 8 patients (25.8%) underwent multiple organ transplant (7 kidney, 1 liver). Two patients (6.5%) suffered neurological insult. Notably, in both cases, the device was removed via the second method. There was 1 vascular complication, requiring axillary artery repair. Three patients (9.7%) had postoperative acute kidney injury or renal failure. Average days from OHT to discharge were 26.0 (7-80). There was 1 death in a patient who developed mixed septic and cardiogenic shock, and another death in a patient who developed a mediastinal infection several months postoperatively. The 30-day survival rate was 96.8% (30/31). 6.5% (2/31) patients had concern for rejection. Eleven patients (35.5%) were alive at 1 year, while another 18 (58.0%) were alive but had not yet reached 1 year post-transplant. Conclusion: Based on our institutional experience, Impella 5.5 is safe and reliable for prolonged bridge to OHT, as demonstrated in the high 30-day and 1-year survival rates. Complication rates were relatively low while offering a minimally invasive approach and avoiding resternotomy at time of OHT. We speculate that device removal via transection in the ascending aorta poses a lower stroke risk than the more established alternative, but further work will need to demonstrate superiority of either technique. Finally, further studies are needed urgently to determine the optimal MCS approach in patients awaiting OHT. Table 1. Prolonged Impella 5.5 Support as Bridge to Transplant

What enhances the in-hospital mortality following total hip arthroplasty? A national inpatient sample-based study.

With prolonged life expectancy and advancements in prosthetic designs, the proportion of patients belonging to diverse age groups undergoing total hip arthroplasty (THA) has progressively increased. In this context, the details regarding risk factors associated with mortality after THA, and its prevalence need to be clearly understood. This study sought to identify the possible co-morbidities associated with post-THA mortality. Based on Nationwide Inpatient Sample (NIS) database, patients undergoing THA from 2016 to 2019 (using ICD-10CMP) were identified. The included cohort was stratified into two groups: "early mortality" and "no mortality" groups. The data regarding patients' demographics, co-morbidities, and associated complications were compared between the groups. Overall, 337,249 patients underwent THA, among whom, 332 (0.1%) died during their hospital admission ("early mortality" group). The remaining patients were included under "no mortality" group (336,917 patients). There was significantly higher mortality in the patients, who underwent emergent THA (as compared with elective THA: odd's ratio 0.075; p < 0.001). Based on multivariate analysis, presence of liver cirrhosis, chronic kidney disease (CKD) and previous history of organ transplant increased the odds of mortality {odds ratio [Exp (B)]} after THA by 4.66- (p < 0.001), 2.37-fold (p < 0.001) and 1.91-fold (p = 0.04), respectively. Among post-THA complications, acute renal failure (ARF), pulmonary embolism (PE), pneumonia, myocardial infarction (MI), and prosthetic dislocation increased the odds of post-THA mortality by 20.64-fold (p < 0.001), 19.35-fold (p < 0.001), 8.21-fold (p < 0.001), 2.71-fold (p = 0.05) and 2.54-fold (p < 0.001), respectively. THA is a safe surgery with low mortality rate during early post-operative period. Cirrhosis, CKD, and previous history of organ transplant were the most common co-morbidities associated with post-THA mortality. Among post-operative complications, ARF, PE, pneumonia, MI, and prosthetic dislocation substantially enhanced the odds of post-THA mortality.

Outcomes of Emergent Isolated Coronary Bypass Grafting in Heart Failure Patients.

Patients with previously diagnosed HF are at greater risk for subsequent morbidity and mortality when hospitalized for an Acute Myocardial Infarction (AMI). The purpose of our study was to describe the time trend of the incidence of emergent CABG in patients with and without HF, the clinical characteristics, outcomes, and the risk factors for mortality of surgical revascularization in the short and medium term. This was a single-center retrospective observational study of patients who underwent isolated emergency CABG from January 2009 to January 2020. A propensity-score matching analysis yielded two comparable groups (n = 430) of patients without (n = 215) and with (n = 215) heart failure. In-hospital mortality did not differ in the two groups (2.8%; p &gt; 0.9); the patients with heart failure presented more frequently with cardiogenic shock, and there was an association with mortality and mechanical circulatory support (OR 16.7-95% CI 3.31-140; p = 0.002) and postoperative acute renal failure (OR 15.9-95% CI 0.66-203; p = 0.036). In the early- and mid-term, heart failure and NSTEMI were associated with mortality (HR 3.47-95% CI 1.15-10.5; p = 0.028), along with age (HR 1.28-95% CI 1.21-1.36; p &lt; 0.001). Surgical revascularization offers an excellent solution for patients with acute coronary syndrome, leading to a good immediate prognosis even in those with chronic heart failure.

Comparison of open and robotic-assisted partial nephrectomy approaches using multicentric data (UroCCR-47 study)

We compared the outcomes of robotic-assisted partial nephrectomy (RPN) and open partial nephrectomy (OPN) using contemporary data to respond to unmet clinical needs. Data from patients included in the registry who underwent partial nephrectomy between January 01, 2014 and June 30, 2017 within 20 centres of the French Network for Research on Kidney Cancer UroCCR were collected (NCT03293563). Statistical methods included adjusted multivariable analyses. Rates of peri- and post-operative transfusion, and of surgical revision, were lower in the RPN (n = 1434) than the OPN (n = 571) group (2.9% vs. 6.0%, p = 0.0012; 3.8% vs. 11.5%, p < 0.0001; 2.4% vs. 6.7%, p < 0.0001, respectively). In multivariable analyses, RPN was independently associated with fewer early post-operative complications than OPN (overall: odds-ratio [95% confidence interval, CI] = 0.48 [0.35–0.66]; severe: 0.29 [0.16–0.54], p < 0.0001 for both) and shorter hospital stays (34% [30%; 37%], p < 0.0001). RPN was also a significantly associated with a decresedrisk of post-operative acute renal failure, and new-onset chronic kidney disease at 3 and 12 months post-surgery. There were no between-group differences in oncological outcomes. In comparison with OPN, RPN was associated with improved peri- and post-operative morbidity, better functional outcomes, and shorter hospital stays. Our results support the use of RPN, even for large and complex tumours.

Risk Factors and Clinical Outcomes of Unplanned Reintubation after Planned Extubation in Adult Patients admitted to the Intensive Care Unit after Cardiac Surgery

Purpose : This study aimed to identify risk factors for unplanned reintubation after planned extubation and to analyze the clinical outcomes in patients admitted to the intensive care unit after cardiac surgery.Methods : The study examined patients who underwent intubation and planned extubation admitted to the intensive care unit after cardiac surgery between January 1, 2017, and December 31, 2021. The reintubation group comprised 58 patients underwent unplanned reintubation within 7 days of planned extubation. The maintenance group comprised 116 patients who did not undergo reintubation and were matched with the reintubation group using the rational for matching criteria. Data were collected retrospectively from electronic medical records. We used the independent t-test, Mann-Whitney U test, &lt;i&gt;χ&lt;/i&gt;&lt;sup&gt;2&lt;/sup&gt;-test, Fisher’s exact test, and logistic regression analysis with SPSS/WIN 27.0.Results : The multivariate logistic regression analysis demonstrated that albumin (odds ratio [OR]=0.38, 95% confidence interval [CI]=0.20-0.72), surgery time (OR=1.54, 95% CI=1.20-1.97), PaO&lt;sub&gt;2&lt;/sub&gt; before extubation (OR=0.85 per 10 mmHg, 95% CI=0.75-0.97), postoperative arrhythmia (OR=2.82, 95% CI=1.22-6.51), reoperation due to bleeding (OR=4.65, 95% CI=1.27-17.07), and postoperative acute renal failure (OR=2.97, 95% CI=1.09-8.04) were risk factors for unplanned reintubation. The reintubation group had a higher in-hospital mortality rate (&lt;i&gt;χ&lt;/i&gt;&lt;sup&gt;2&lt;/sup&gt;=33.74, &lt;i&gt;p&lt;/i&gt;＜.001), longer intensive care unit stay (Z=-7.81, &lt;i&gt;p&lt;/i&gt;＜.001), and longer hospital stay than the maintenance group (Z=-8.29, &lt;i&gt;p&lt;/i&gt;＜.001).Conclusion : These results identified risk factors and clinical outcomes of unplanned reintubation after planned extubation after cardiac surgery. These findings should be considered when developing and managing an intervention program to prevent and reduce the incidence of unplanned reintubation.

A comparison of thoracoabdominal aortic aneurysms open repair in patients with or without “shaggy aorta”

ObjectiveIn the field of thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR), some preoperative characteristics are established risk factors for adverse outcomes, whereas others are supposed to be relevant, but their role still need to be defined; among them, the presence of “shaggy aorta” (SA), an extensive and irregular atheroma within the aorta. The aim of this study is to report the results of a single-center large cohort of patients treated with OSR for TAAA with SA, comparing the outcomes with patients affected by TAAA without SA, and analyzing the impact of the scores for SA on the outcomes. MethodsAll consecutive patients receiving OSR for TAAA between 2012 and 2021 were retrospectively analyzed. Clinical data from patients with degenerative TAAA were included and analyzed for preoperative characteristics and postoperative outcomes; patients with ruptured TAAA, and patients with aortic dissection were excluded from the analysis. Patients with degenerative aortic aneurysm, thrombus measurement in non-aneurysmal aortic segments (≤40 mm), atheroma thickness ≥5 mm, and finger-like thrombus projection were included in the SA group, whereas the others were included in the non-shaggy aorta group (NSA group). The SA group and NSA group were compared using a propensity-matched comparison. Preoperative computed tomography scans of patients in the SA group were also stratified according to SA grading scores. ResultsA total of 58 patients with SA were identified (male, n = 43 [74.1%], mean age 70.1 ± 7.8 years) among 497 patients with TAAA treated with open surgical repair. After propensity matching, there were 57 patients in the SA group and 57 in the NSA group with correction of all differences in baseline characteristics. Patients in the SA group presented significantly higher in-hospital mortality (SA group, 14.0% vs NSA group, 3.5%; P = .047), postoperative acute renal failure (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease [RIFLE], 3-5) (SA group, 21.1% vs NSA group, 5.3%; P = .013), and postoperative embolization (SA group, 28.1% vs NSA group, 8.8%; P = .008). Spinal cord ischemia and stroke rate were not significantly influenced by the presence of SA. In the SA group, 16 patients (27.6%) with end-organ embolization were compared with 42 patients (72.4%) without a documented embolization considering the grade of aortic “shagginess” and no significant difference was identified (P = .546). ConclusionsDespite a better knowledge of the SA disease, new classifications, and intraoperative adjuncts, TAAA patients with SA treated with OSR have worse postoperative outcomes if compared with patients without SA. The presence of SA is a risk factor itself, whereas the grade of “shagginess” seems not to impact on postoperative outcomes.

Canaries, Coal Mines, and Kidneys

Higher Rates of Dialysis and Subsequent Mortality in the New Allocation Era for Heart TransplantsThe Annals of Thoracic SurgeryPreviewIn 2018, a United Network for Organ Sharing (UNOS) policy change increased prioritization of patients bridged with temporary mechanical circulatory support devices, such as venoarterial ECMO, for cardiac transplantation. Considering increased waitlist acuity, we sought to characterize whether this was associated with an increased risk for development of postoperative acute renal failure requiring dialysis (AKI-D) and risk of death after transplantation. Full-Text PDF

Effects of norepinephrine infusion during cardiopulmonary bypass on perioperative changes in lactic acid level (Norcal).

Hyperlactatemia, a problem reported in up to 30% of cardiac surgery patients, results from excessive production of or decreased clearance of lactate. It is typically a symptom of tissue hypoperfusion and may be associated with the prevalence of postoperative acute mesenteric ischemia and renal failure, or prolonged intensive care unit (ICU) and hospital stay, and increased 30-day mortality. Eighty cardiac surgery patients using cardiopulmonary bypass (CPB) were randomly assigned into either a placebo (n = 39) or norepinephrine 0.05-0.2 µg/kg/min (n = 41) as well as norepinephrine boluses during CPB to maintain mean arterial blood pressure (MAP) at 65 to 80 mm Hg. Patient assignments were done after receiving ethical approval to proceed. The primary result was the perioperative changes in lactic acid level. Secondary findings were also recorded, including hemodynamic variables, the incidence of vasoplegia, intraoperative hypotension, myocardial ischemia, the need for vasopressor support, postoperative complications, and mortality. The peak levels and perioperative changes in blood lactate during the first 24 postoperative hours, the number of patients who experienced early hyperlactatemia on admission to the ICU (Placebo: 46.2%, Norepinephrine: 51.2%, p = .650), vasoplegia, hemodynamic changes, incidences of intraoperative hypotension, myocardial ischemia, postoperative complications, and mortality rates were similar in the two groups. Patients in the norepinephrine group received lower intraoperative rescue norepinephrine boluses to maintain the target MAP (p = .039) and had higher MAP values during the CPB and intraoperative blood loss [mean difference [95% confidence interval]; 177 [20.9-334.3] ml, p = .027]. norepinephrine and placebo infusions during the CPB with the maintenance of MAP from 65 to 80 mmHg had comparative effects on the changes in blood lactate and incidence of vasoplegia after cardiac surgery. Norepinephrine infusion maintained higher MAP values during the CPB.

Higher Rates of Dialysis and Subsequent Mortality in the New Allocation Era for Heart Transplants

BackgroundIn 2018, a United Network for Organ Sharing (UNOS) policy change increased prioritization of patients bridged with temporary mechanical circulatory support devices, such as venoarterial ECMO, for cardiac transplantation. Considering increased waitlist acuity, we sought to characterize whether this was associated with an increased risk for development of postoperative acute renal failure requiring dialysis (AKI-D) and risk of death after transplantation. MethodsDialysis-naive adults receiving single-organ heart transplant between November 2009 and February 2020 were stratified by receipt of AKI-D. Era 1 and era 2 were defined by the periods of UNOS allocation before and after policy change, respectively. Multivariable logistic regression was performed to determine risk factors for AKI-D. Rates of AKI-D were compared by propensity score–matched cohorts. Survival was compared by Kaplan-Meier analysis. ResultsA total of 20 698 patients were included. Venoarterial ECMO use significantly increased in era 2 (5.6% vs 0.58%; P < .01). Overall prevalence of AKI-D was greater in era 2 (13.5% vs 10.2%; P < .01). Use of preoperative ECMO, intra-aortic balloon pump, and ventilators and longer ischemia times were identified as independent risk factors for development of AKI-D. Five- and 10-year survival rates were significantly decreased for patients with AKI-D. There was no short-term survival difference of patients with AKI-D between era 2 and the more contemporary era 1. ConclusionsPatients in whom AKI-D develops after transplantation have significantly worse short- and long-term outcomes. Preoperative use of ECMO, preoperative ventilator support, and longer ischemia times are risk factors for development of AKI-D, and their prevalence has increased since the allocation policy change.