Postoperative Renal Failure Research Articles

Impact of socioeconomic deprivation on incidence and outcomes of acute type A aortic dissection repair in New Zealand.

Socioeconomic deprivation (SED) has been associated with increased 30-day mortality and reduced long-term survival after surgical repair of acute type A aortic dissection (ATAAD). The study aimedto determine the incidence rate ratio of ATAAD in New Zealand population with higher and lower SED indices and to evaluate any association between SED and outcomes after ATAAD repair. This was a retrospective cohort study. Patients who underwent ATAAD repair from March 2003 to May 2020 were identified. Overseas patients, those with chronic aortic dissection, and those who died in hospital before the operation were excluded. The total number of New Zealand residents was estimated based on the national 2018 Census. A total of 363 ATAAD patients met the eligibility criteria. The incidence of ATAAD was 70% greater in those who were more socioeconomically deprived (higher SED) compared with less socioeconomically deprived (lower SED) New Zealanders (odds ratio = 1.7; 95% confidence interval [CI] = 1.4-2.1; p < .0005). Postoperative cardiogenic shock, renal failure, pulmonary embolism, and respiratory failure were more common in the higher than in the lower SED group. Both groups had similar operative and in-hospital mortality and time intervals in the intensive care unit and hospital. Both groups had similar freedom from reoperation (hazards ratio [HR] = 1.1; 95% CI = 0.5-2.6; p = .746) and long-term survival (HR = 0.73; 95% CI = 0.5-1.1; p = .115). The incidence of ATAAD is greater in more socioeconomically deprived New Zealand residents. Following ATAAD repair, SED is not associated with worse short- or long-term outcomes in the universal health care system.

Can Peroperative Neutrophil To Lymphocyte Ratio Change (Deltanlr) Be Used as a Parameter in Predicting Acute Renal Failure Following Coronary Bypass Operations With Cardiopulmonary Bypass?

Inflammation plays a significant role in the pathogenesis of many diseases as well as postoperative acute renal failure (ARF). Preoperative neutrophil to lymphocyte ratio (NLR) values have a prognostic value for postoperative ARF after cardiovascular surgeries. Patients who underwent elective coronary artery bypass graft (CABG) with cardiopulmonary bypass in our clinic between December 15, 2015 and December 15, 2019, retrospectively were included in this study. Patients who did not develop ARF after the operation were categorized as Group 1, and patients who did were included in Group 2. NLR was calculated from the hemograms during three periods (Preoperative (Pre), Postcardiotomy (Pc), Postoperative Day 1 (Po1). DeltaNLR1 (PcNLR- PreNLR) and DeltaNLR2 (Po1NLR-PreNLR) values were obtained from these calculated values. The mean ages of patients in Group 1 (N = 274) and Group 2 (N = 61) were 60 ± 9.1 years and 67.7 ± 9.8 years, respectively (P < .001). In the multivariate analysis, being over 65 years of age (Odds ratio [OR]: 1.074, 95% confidence interval [CI]: 1.012-1.194, P = .030), postoperative inotropic need (OR: 0.678, CI 95%: 0.395-0.819, P = .021), increased blood product use (OR: 0.916, CI 95%: 0.779-0.986, P = .034), preoperative creatinine increase (OR: 1.974, CI 95%: 1.389-4.224, P = .007), PcNLR (OR : 1.988, CI 95%: 1.765-3.774, P <.001), Po1NLR (OR: 1.090, CI 95%: 1.007-2.116, P = .028), DeltaNLR1 (OR: 3.090, CI 95%: 1.698-6.430, P < .001) and DeltaNLR2 (OR: 1.676, CI 95%: 1.322-2.764, P = .003) were identified as independent predictors for predicting postoperative ARF. In this study, we have shown that peroperative NLR changes can be used as an effective parameter to predict ARF developing following CABG operations.

Predictors of renal replacement therapy in patients with continuous flow left ventricular assist devices.

Renal replacement therapy (RRT) after continuous flow left ventricular assist device (CF-LVAD) implantation significantly affects patients' quality of life and survival. To identify preoperative prognostic markers in patients requiring RRT after CF-LVAD implantation, we retrospectively reviewed data from patients who underwent implantation of a CF-LVAD at our institution during 2012-2017. Patients who required preoperative RRT were excluded. Preoperative and operative characteristics, as well as survival and adverse events, were compared between 74 (22.2%) patients requiring any duration of postoperative RRT and 259 (77.8%) not requiring RRT. Patients requiring RRT experienced more postoperative complications than patients who did not, including respiratory failure necessitating tracheostomy (35.7% vs 2.5%, p < 0.001), reoperation for bleeding (34.3% vs 11.7%, p < 0.001), and right heart failure necessitating perioperative mechanical circulatory support (32.4% vs 6.9%, p < 0.001). Patients requiring postoperative RRT also had poorer survival at 30days (74.7% vs 98.8%), 6months (48.2% vs 95.1%), and 12months (45.3% vs 90.2%) (p < 0.001). Significant predictors of RRT after CF-LVAD implantation included urine proteinuria (odds ratio [OR] 3.6, 95% confidence interval [CI] [1.7-7.6], p = 0.001), estimated glomerular filtration rate < 45mL/min/1.73m2 (OR 3.4, 95% CI [1.5-17.8], p = 0.004), and mean right atrial pressure to pulmonary capillary wedge pressure ratio ≥ 0.54 (OR 2.6, 95% CI [1.3-5.], p = 0.01). Of the 74 RRT patients, 11 (14.9%) recovered renal function before discharge, 36 (48.6%) still required RRT after discharge, and 27 (36.5%) died before discharge. We conclude that preoperative renal and right ventricular dysfunction significantly predict postoperative renal failure and mortality after CF-LVAD implantation.

Clinical Outcome of Reoperation for Mechanical Prosthesis at Aortic Position

Redo aortic valve surgery is usually associated with a high risk of mortality and complications. The aim of this study was to investigate the perioperative and long-term outcomes of reoperation after prior mechanical prosthesis implantation at the aortic position. The clinical data of 146 consecutive patients who underwent reoperation at the aortic position between 2003 and 2019 were analysed. Mean age was 51.5±12.7 years and 69 (47.3%) were female. The median interval from prior surgery to redo aortic valve surgery was 6 years. The aetiologies were pannus formation with prosthetic aortic stenosis in 62 cases (42.5%), prosthetic valve endocarditis (PVE) in five (3.4%), PVE with perivalvular leakage (PVL) in 16 (11.0%), PVL in 45 (30.8%), thrombosis in seven (4.8%), and aortic disease in 11 (7.5%). As for surgical procedure, aortic valve replacement was performed in 81 cases (55.5%), Bentall in 34 (23.3%), PVL repair in six (4.1%), and pannus debridement in 25 (17.1%). Fourteen (14) (9.6%) patients expired perioperatively. Prolonged ventilation time and postoperative renal failure were proved to be significant independent predictors of mortality according to multivariate analysis. Overall survival was 87.8%±7.4% and 76.4%±15.1% at 5 and 10 years, respectively. Survival was 87.7%±13.7% and 84.2%±15.6% in the pannus group, and 84.5%±12.6% and 74.6%±19.4% in the non-pannus group at 5 and 10 years, respectively (p=0.951). Survival was 87.5%±14.2% and 75.8%±22.7% in the PVL group and 84.7%±11.9% and 81.6%±13.5% in the non-PVL group at 5 and 10 years, respectively (p=0.365). Pannus formation and PVL are two major indications for reoperation of mechanical prosthesis at the aortic position. Redo aortic valve surgery has a satisfactory outcome but with a high risk of complications. Long-term survival of patients seems not to be related to the aetiology. Final decision-making of redo aortic valve surgery should be based on aetiology.

Hemoadsorption during Cardiopulmonary Bypass in Patients with Endocarditis Undergoing Valve Surgery: A Retrospective Single-Center Study.

Background: Aim of this study was to evaluate the outcomes of endocarditis patients undergoing valve surgery with the Cytosorb® hemoadsorption (HA) device during cardiopulmonary bypass. Methods: From 2009 until 2019, 241 patients had undergone valve surgery due to endocarditis at the Department of Cardiac Surgery, University Hospital of Basel. We compared patients who received HA during surgery (n = 41) versus patients without HA (n = 200), after applying inverse probability of treatment weighting. Results: In-hospital mortality, major adverse cardiac and cerebrovascular events and postoperative renal failure were similar in both groups. Demand for norepinephrine (88.4 vs. 52.8%; p = 0.001), milrinone (42.2 vs. 17.2%; p = 0.046), red blood cell concentrates (65.2 vs. 30.6%; p = 0.003), and platelets (HA vs. Control: 36.7 vs. 9.8%; p = 0.013) were higher in the HA group. In addition, a higher incidence of reoperation for bleeding (34.0 vs. 7.7 %; p = 0.011), and a prolonged length of in-hospital stay (15.2 (11.8 to 19.6) vs. 9.0 (7.1 to 11.3) days; p = 0.017) were observed in the HA group. Conclusions: No benefits of HA-therapy were observed in patients with infective endocarditis undergoing valve surgery.

Short-Term Outcomes of Transcatheter Versus Isolated Surgical Aortic Valve Replacement for Mediastinal Radiation-Associated Severe Aortic Stenosis.

Surgical aortic valve replacement (SAVR) is associated with adverse outcomes in patients with radiation-associated aortic stenosis. Transcatheter aortic valve replacement (TAVR) may improve outcomes in this population. We evaluated 1668 TAVR and 2611 patients with SAVR enrolled in the Society of Thoracic Surgeons' database between 2011 and 2018. Multiple logistic regression was used to compare 30- day outcomes between TAVR and SAVR. Propensity-matched analysis was performed to confirm results of the overall cohort. Additionally, the cohort was stratified into early (2011-2014) versus contemporary (2015-2018) TAVR eras, and 30-day outcomes for TAVR and SAVR were compared. Finally, outcomes with transfemoral TAVR versus SAVR were compared. In the overall cohort, TAVR was associated with significantly reduced 30-day mortality (odds ratio [OR]TAVR/SAVR=0.60 [0.40-0.91]). Postoperative atrial fibrillation, pneumonia, pleural effusion, renal failure, and bleeding also occurred less frequently with TAVR. Stroke/transient ischemic attack (TIA; ORTAVR/SAVR, 2.03 [1.09-3.77]) and pacemaker implantation (ORTAVR/SAVR, 1.62 [1.21-2.17]) were higher with TAVR. Propensity-matched analysis yielded similar results as the overall cohort. Following stratification by era, TAVR versus SAVR was associated with reduced 30-day mortality in the contemporary but not early era (OREarly, 0.78 [0.48-1.28]; ORContemporary, 0.31 [0.14-0.65]). Pacemaker implantation was higher with TAVR versus SAVR in both eras (OREarly, 1.60 [1.03-2.46]; ORContemporary, 1.64 [1.10-2.45]). There was also a nonsignificant trend towards increased stroke/TIA with TAVR during both eras (OREarly, 1.39 [0.58-3.36]; ORContemporary, 2.46 [0.99-6.10]). Finally, transfemoral TAVR (N=1369) versus SAVR revealed similar findings as the overall cohort; however, the association of TAVR with stroke/TIA was not statistically significant (ORStroke/TIA, 1.57 [0.79-3.09]). TAVR provides an effective and evolving alternative to SAVR for radiation-associated severe aortic stenosis and was associated with lower 30-day mortality and postoperative complications. TAVR was associated with increased pacemaker implantation and a trend towards increased stroke/TIA. In this unique population with extensive valvular and vascular calcifications, the risk of stroke/TIA with TAVR requires careful consideration and further investigation.

Drivers of Cost Associated With Minimally Invasive Esophagectomy

In this era of value-based healthcare, costs must be measured alongside patient outcomes to prioritize quality improvement and inform performance-based reimbursement strategies. We sought to identify drivers of costs for patients undergoing minimally invasive esophagectomy for esophageal cancer. Patients who underwent minimally invasive esophagectomy for esophageal cancer from December 2008 to March 2020 were included. Our institutional Society of Thoracic Surgeons database was merged with financial data to determine inpatient direct accounting costs in 2020 US dollars for total, operative (surgery and anesthesia), and postoperative (intensive care, floor, radiology, laboratory, etc) services. A supervised machine learning quantitative method, the lasso estimator with 10-fold cross-validation, was applied to identify predictors of costs. In the study cohort (n= 240) most had ≥cT2 pathology (82%), adenocarcinoma histology (90%), and received neoadjuvant therapy (78%). Mean length of stay was 8.00 days (SD, 4.13) with 45% inpatient morbidity rate and no deaths. The largest proportions of cost were from the operating room (30%), inpatient floor (30%), and postanesthesia care/intensive care units (20%). Preoperative predictors of operative costs were age (-5.18% per decade [95% confidence interval {CI}, -9.95 to -0.27], P= .039), body mass index ≥ 30 (+12.9% [95% CI, 0.00-27.5], P= .050), forced expiratory volume in 1 second (-3.24% per 10% forced expiratory volume in 1 second [95% CI, -5.80 to -0.61], P=.017), and year of surgery (+2.55% [95% CI, 0.97-4.15], P= .002). Predictors of postoperative costs were postoperative renal failure (+91.6% [95% CI, 9.93-233.8], P= .022), respiratory failure (+414.6% [95% CI, 158.7-923.6], P<.001), pneumonia (+136.1% [95% CI, 71.1-225.8], P < .001), and reoperation (+60.5% [95% CI, 21.5-111.9], P= .001). Costs associated with minimally invasive esophagectomy are driven by preoperative risk factors and postoperative outcomes. These data enable surgeons and policymakers to reduce cost variation, improve quality through standardization, and ultimately provide greater value to patients.

Outcomes After Vascular Surgery Procedures in Patients with COVID-19 Infection: A National Multicenter Cohort Study (COVID-VAS)

ObjectivesTo analyze the outcome of vascular procedures performed in patients with COVID-19 infection during the 2020 pandemic.MethodsThis is a multicenter, prospective observational cohort study. We analyzed data from 75 patients with COVID-19 infection undergoing vascular surgery procedures in 17 hospitals across Spain and Andorra between March and May 2020. The primary end point was 30-day mortality. Clinical Trials registry number NCT04333693.ResultsThe mean age was 70.9 (45–94) and 58 (77.0%) patients were male. Around 70.7% had postoperative complications, 36.0% of patients experienced respiratory failure, 22.7% acute renal failure, and 22.7% acute respiratory distress syndrome (ARDS). All-cause 30-days mortality rate was 37.3%. Multivariate analysis identified age >65 years (P = 0.009), American Society of Anesthesiologists (ASA) classification IV (P = 0.004), preoperative lymphocyte count <0.6 (×109/L) (P = 0.001) and lactate dehydrogenase (LDH) >500 (UI/L) (P = 0.004), need for invasive ventilation (P = 0.043), postoperative acute renal failure (P = 0.001), ARDS (P = 0.003) and major amputation (P = 0.009) as independent variables associated with mortality. Preoperative coma (P = 0.001), quick Sepsis Related Organ Failure Assessment (qSOFA) score ≥2 (P = 0.043), lymphocytes <0.6 (×109/L) (P = 0.019) leucocytes >11.5 (×109/L) (P = 0.007) and serum ferritin >1800 mg/dL (P = 0.004), bilateral lung infiltrates on thorax computed tomography (P = 0.025), and postoperative acute renal failure (P = 0.009) increased the risk of postoperative ARDS. qSOFA score ≥2 was the only risk factor associated with postoperative sepsis (P = 0.041).ConclusionsPatients with COVID-19 infection undergoing vascular surgery procedures showed poor 30-days survival. Age >65 years, preoperative lymphocytes <0.6 (x109/L) and LDH >500 (UI/L), and postoperative acute renal failure, ARDS and need for major amputation were identified as prognostic factors of 30-days mortality.

Predictors of death after receiving a modified Blalock-Taussig shunt in cyanotic heart children: A competing risk analysis.

ObjectiveTo determine risk factors affecting time-to-death ≤90 and >90 days in children who underwent a modified Blalock-Taussig shunt (MBTS).MethodsData from a retrospective cohort study were obtained from children aged 0–3 years who experienced MBTS between 2005 and 2016. Time-to-death (prior to Glenn/repair), time-to-alive up until December 2017 without repair, and time-to-progression to Glenn/repair following MBTS were presented using competing risks survival analysis. Demographic, surgical and anesthesia-related factors were recorded. Time-to-death ≤90 days and >90 days was analyzed using multivariate time-dependent Cox regression models to identify independent predictors and presented by adjusted hazard ratios (HR) and 95% confidence intervals (CI).ResultsOf 380 children, 119 died, 122 survived and 139 progressed to Glenn/repair. Time-to-death probability (95% CI) within 90 days was 0.18 (0.14–0.22). Predictors of time-to-death ≤90 days (n = 63) were low weight (<3 kg) (HR 7.6, 95% CI:2.8–20.4), preoperative ventilator support (HR 2.7, 95% CI:1.3–5.6), postoperative shunt thrombosis (HR 5.0, 95% CI:2.4–10.4), bleeding (HR 4.5, 95% CI:2.1–9.4) and renal failure (HR 4.1, 95% CI:1.5–10.9). Predictors of time-to-death >90 days (n = 56) were children diagnosed with pulmonary atresia with ventricular septal defect and single ventricle (compared to tetralogy of fallot) (HR 3.2, 95% CI:1.2–7.7 and HR 3.1, 95% CI:1.3–7.6, respectively), shunt size/weight ratio >1.1 vs <0.65 (HR 6.8, 95% CI:1.4–32.6) and longer duration of mechanical ventilator (HR 1.002, 95% CI:1.001–1.004). Shunt size/weight ratio ≥1.0 (vs <1.0) and ≥0.65 (vs <0.65) were predictors for overall time-to-death in neonates and toddlers, respectively (HR 13.1, 95% CI:2.8–61.4 and HR 7.8, 95% CI:1.7–34.8, respectively).ConclusionsPerioperative factors were associated with time-to-death ≤90 days, whereas particular cardiac defect, larger shunt size/weight ratio, and longer mechanical ventilation were associated with time-to-death >90 days after receiving MBTS. Larger shunt size/weight ratio should be reevaluated within 90 days to minimize the risk of shunt over flow.

Initial Clinical Experience With Mitral Valve Translocation for Secondary Mitral Regurgitation

BackgroundFunctional (secondary) mitral regurgitation (FMR) results from altered geometry of the mitral valve apparatus. Repair with restrictive mitral annuloplasty is associated with high rates of recurrent mitral regurgitation (MR). We developed a novel operative repair for FMR that translocates the intact mitral valve towards the apex. MethodsThe mitral valve was detached circumferentially and translocated into the ventricle with a frustum-shaped glutaraldehyde-treated autologous pericardial patch. Clinical and echocardiographic follow-up was performed. ResultsFifteen consecutive patients with FMR (mean age, 59 years; 67% female) had mitral valve translocation between 2018 and 2020. Preoperative mean ejection fraction, left ventricular end-diastolic dimension, and systolic pulmonary artery pressure were 40% ± 11%, 59 ± 8 mm, and 49 ± 21 mm Hg, respectively; 33% had atrial fibrillation. Cardiomyopathy was ischemic in 4 and nonischemic in 11. Concomitant procedures included tricuspid valve operation (n = 8), coronary artery bypass grafting (n = 4), and atrial fibrillation ablation (n = 5). Post bypass transesophageal echocardiogram demonstrated none/trace MR in all patients and mean gradient of 3 mm Hg (interquartile range, 2-4 mm Hg). Mean leaflet extent of coaptation was 14 ± 2 mm (range, 11-17 mm). There was no postoperative mortality, stroke, or renal failure. Predismissal echocardiography showed none/trace MR in 14 patients and mild MR in 1. One patient underwent successful late rerepair of a suture line leak. Twelve patients were alive at latest follow-up and MR at 1 and 6 months was mild or less in all patients with mean leaflet extent of coaptation of 14 ± 2 mm (range, 12-16 mm) at 6 months. ConclusionsMitral valve translocation creates a large surface of coaptation and effectively corrects FMR. Further study is needed to demonstrate the long-term durability and clinical utility of this operation.

Vascular Surgery Procedures in Patients with COVID-19 Infection

Most people infected with the COVID-19 virus will experience mild to moderate respiratory illness and recover without requiring special treatment. Older people and those with underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illness. Patients with COVID-19 infection undergoing vascular surgery procedures showed poor 30-days survival. Age >65 years, preoperative lymphocytes 500 (UI/L), and postoperative acute renal failure, ARDS and need for major amputation were identified as prognostic factors of 30-days mortality.

Outcomes of emergency endovascular versus open repair for abdominal aortic aneurysm rupture.

PurposeRuptured abdominal aortic aneurysm (rAAA) is one of the most common aortic emergencies in vascular surgery and is associated with high operative mortality and morbidity rates despite recent treatment advances. We evaluated operative mortality risks for the outcomes of emergency endovascular aneurysm repair (eEVAR) vs. open repair in rAAA.MethodsTwenty patients underwent eEVAR (n = 12) or open repair (n = 8) for rAAA between 2016 and 2020. We adopted the EVAR first strategy since 2018. Primary endpoints included in-hospital mortality and 1-year survival. The outcome variables were analyzed with Fisher exact, Mann-Whitney test, and linear by linear association. The Kaplan-Meier method was used to estimate survival.ResultsThere were 13 males (65.0%) and the median age of the study cohort was 78.0 years (range, 49–88 years). In-hospital mortality occurred in 7 patients (35.0%); 5 (50.0%) in the early period and 2 (20.0%) in the later period of this series. According to the procedure type, 4 (50.0%) and 3 (25.0%) in-hospital mortalities occurred in the open repair and eEVAR patients, respectively. In 6 patients (50.0%), eEVAR was performed on unfavorable anatomy. The 1-year survival of eEVAR vs. open repair group was 75% ± 12.5% and 50% ± 17.7%, respectively. On univariate analysis, preoperative high-risk indices, postoperative acute renal failure requiring dialysis, pulmonary complications, and prolonged mechanical ventilation were associated with higher operative mortality.ConclusionThe current data showed relatively superior outcomes with eEVAR vs. open repair for rAAA, even in some patients with unfavorable anatomy supporting the feasibility, efficacy, and safety of EVAR first strategy.

Outcomes of gasless laparoendoscopic single-port partial nephrectomy in 356 consecutive patients: Feasibility of a clampless and sutureless technique.

To investigate the outcomes and feasibilities of gasless laparoendoscopic single-port clampless sutureless partial nephrectomy. We reviewed 356 consecutive patients with primary unilateral non-metastatic renal masses who underwent gasless laparoendoscopic single-port partial nephrectomy (2011-2018), which was performed retroperitoneally using a three-dimensional flexible endoscope, without vascular clamping or renorrhaphy in principle. The median tumor size was 2.5cm, and 213 (60%), 105 (29%), and 38 (11%) patients had peripheral, central, and hilar tumors, respectively. Clampless and sutureless partial nephrectomy was accomplished in 337 patients (95%), while eight (2%) and 16 (4%) patients required vascular clamping and renorrhaphy, respectively. The median operative time and blood loss were 220min and 266mL, respectively; eight patients (2%) received blood transfusion. Clavien-Dindo grade 3a complications occurred in 27 patients (8%); all these patients had urinary leakage treated with ureteral stent placement, one of whom also developed a postoperative pseudoaneurysm. Among 324 patients diagnosed with renal cell carcinoma, six (2%) had positive surgical margins, and one (0.3%) and seven (2%) developed metastatic and local recurrences, respectively. During a median follow-up of 54months, no patient died from kidney cancer. The median percent decrease in estimated glomerular filtration rate at 3months after surgery was 5.7%. No patient experienced postoperative acute renal failure, while one patient with preexisting renal impairment started dialysis at 70months after surgery. Clampless and sutureless partial nephrectomy can be safely accomplished in most patients undergoing gasless laparoendoscopic single-port surgery, yielding favorable oncological and functional outcomes.

Prognostic value of the creatinine-albumin ratio in acute pancreatitis debridement

BackgroundIncreases in the levels of serum C-reactive protein (CRP) and creatinine (Cr) and decreases in those of albumin (Alb) are commonly observed in acute pancreatitis (AP). We aimed to evaluate the efficacy of the Cr/Alb and CRP/Alb ratios in the prediction of surgical treatment effect in AP patients.MethodsThis study retrospectively analyzed clinical data obtained from 140 AP patients who underwent debridement from January 2008 to November 2018 in Shanghai Ruijin Hospital. The Cr/Alb and CRP/Alb ratios at admission and before surgery were assessed in the analysis of clinical statistics, prediction of prognoses, and logistic regression analysis.ResultsThe admission Cr/Alb had the best predictive value of the four ratios. This value was significantly higher in patients with re-operation and those who died (P < 0.05) and was correlated with the Acute Physiology and Chronic Health Evaluation (APACHE II) score, admission CRP/Alb, preoperative Cr/Alb, and post-operative complications. The admission Cr/Alb could predict the risk of AP-related re-operation and mortality with sensitivities, specificities and areas under the curve of 86.3%, 61.7% and 0.824, and 73.4%, 81.3% and 0.794, respectively. At a cut-off value of 3.43, admission Cr/Alb values were indicative of a worse clinical state, including impaired laboratory test values, APACHE II scores, rates of post-operative complications and re-operation, and mortality (P < 0.05). In the logistic regression analysis, admission Cr/Alb values were independently related to the APACHE II score, post-operative renal failure, and mortality.ConclusionCr/Alb is a novel but promising, easy-to-measure, reproducible, non-invasive prognostic score for the prediction of the effect of debridement in AP patients.

Safety and Feasibility of Thoracoscopic Lung Resection for Non-Small-Cell Lung Cancer in Octogenarians.

Octogenarians comprise an increasing proportion of patients presenting with non-small-cell lung cancer (NSCLC). This study examines postoperative morbidity and mortality, and long-term survival in octogenarians undergoing thoracoscopic anatomic lung resection for NSCLC, compared with younger cohorts. We conducted a retrospective review of our institutional Society of Thoracic Surgeons General Thoracic Surgery Database of all patients ≥60 years old undergoing elective lobectomy or segmentectomy for pathologic stage I, II, and IIIA NSCLC between 2009 and 2018. Results were compared between octogenarians (n = 71) to 2 younger cohorts of 60- to 69-year-olds (n = 359) and 70- to 79-year-olds (n = 308). Long-term survival among octogenarians was graphically summarized using the Kaplan-Meier method. Cox regression analysis was used to identify preoperative risk factors for mortality. A greater proportion of octogenarians required intensive care unit admission and discharge to extended-care facilities; however, postoperative length of stay was similar between groups. Among postoperative complications, arrhythmia and renal failure were more likely in the older cohort. Compared to the youngest cohort, in-hospital and 30-day mortality were highest among octogenarians. Overall survival among octogenarians at 1, 3, and 5 years was 87.3%, 61.8%, and 50.5%, respectively. On multivariable Cox regression analysis of baseline demographic variables, presence of stroke (hazard ratio [HR] = 28.5, 95% confidence interval [CI]: 6.1 to 132.7, P < 0.001) and coronary artery disease (HR = 2.5, 95% CI: 1.2 to 5.3, P = 0.02) were significant predictors of overall mortality among octogenarians. Thoracoscopic resection can be performed with favorable early postoperative outcomes among octogenarians. Long-term survival, although comparable to their healthy peers, is worse than those of younger cohorts. Further study into preoperative risk stratification and alternative therapies among octogenarians is needed.

Congestive Heart Failure Predicts Major Complications and Increased Length of Stay in Lower Extremity Pedicled Flap Reconstruction.

Congestive heart failure affects 6.2 million people in the United States. Patients have a decreased cardiopulmonary reserve and often suffer from peripheral edema, important considerations in lower extremity reconstructive surgery. In this study, the authors sought to determine the impact of congestive heart failure on postoperative outcomes following lower extremity pedicled flap reconstruction using a national multi-institutional database. The authors isolated all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent lower extremity pedicled flap reconstruction from 2010 to 2016. Preoperative, intraoperative, and postoperative variables were compared between patients with and without congestive heart failure. Multivariable regressions were performed to determine the independent effect of congestive heart failure on postoperative outcomes. The authors identified 1895 patients who underwent lower extremity pedicled flap reconstruction, of whom 34 suffered from congestive heart failure. No significant difference was observed between patients with versus without congestive heart failure in postoperative wound complications (superficial wound infection, deep wound infection, and wound dehiscence), renal failure, or readmission. On multivariable analysis, congestive heart failure was independently associated with increased cardiopulmonary complications (i.e., myocardial infarction, cardiac arrest, pneumonia, reintubation, and failed ventilator weaning) (OR, 3.92; 95 percent CI, 1.53 to 9.12), septic events (OR, 4.65; 95 percent CI, 2.05 to 10.02), and length of hospital stay (β, 0.37; 95 percent CI, 0.01 to 0.72). In patients undergoing lower extremity pedicled flap reconstruction, congestive heart failure independently predicts a four-fold increase in postoperative sepsis and cardiopulmonary complications and a significantly increased length of hospital stay. The authors' findings highlight the need for heightened perioperative vigilance and medical optimization in this high-risk population. Risk, II.

Abstract 13533: Acute Post-operative Renal Failure and Mortality Risk Following Norwood Surgical Palliation: A Secondary Analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Use Database

Introduction: The Single Ventricle Reconstruction (SVR) trial randomized neonates with a single morphologic right ventricle undergoing Norwood to a modified Blalock-Taussig shunt (mBTS) or a right ventricle-to-pulmonary artery shunt at 15 centers. The trial demonstrated increased risk of death or heart transplant at one-year post-Norwood in subjects randomized to a mBTS. Using SVR public data, we evaluated incidence and risk factors for post-op renal failure after Norwood, and evaluated the relationship between renal failure, shunt type and one-year post-Norwood mortality. Methods: Post-op renal failure was defined a-priori as a 3-fold rise in creatinine from baseline, or dialysis use within 7 days of Norwood. We used multivariate logistic regression to evaluate risk factors for post-op renal failure and Cox hazard regression to determine the association between post-op renal failure and one-year post-Norwood mortality. Results: Overall 46/544 (8.4%) SVR trial subjects developed post-op renal failure, the majority (32/46, 69.6%) by post-op day 3. In multivariate analysis, risk factors for post-op renal failure included receipt of a mBTS (aOR 3.3, p=0.02), center volume &lt;15 cases/year (aOR 2.7, p=0.005), presence of ≥ 2 pre-op complications (aOR 4.0, p&lt;0.001), low birth weight (aOR 3.2, p=0.002), post-op heart block (aOR 8.5, p=0.001), and delayed sternal closure (aOR 5.3, p=0.026). Renal failure was an independent risk factor for one-year post-Norwood mortality (aHR 1.9, CI 1.1-3.2, p=0.019). When renal failure and shunt type were included as model covariates, there was interaction (p=0.049) with renal failure attenuating the mortality risk associated with receipt of a mBTS (p=0.24), Figure. Conclusions: In the SVR trial, post-op renal failure was relatively common but with modifiable risk factors including receipt of a mBTS. Our findings suggest that post-op renal failure accounts for some of the increased mortality risk associated with the mBTS.

Regurgitant Bicuspid Aortopathy: Is Valve-Sparing Root Replacement Equivalent to Bentall Procedure?

Repair of aortic root aneurysms with nonstenotic bicuspid valves (NS-BAVs) is achieved either with valve-sparing root replacement (VSRR) or conventional Bentall procedure (ROOT). Procedural and long-term outcomes comparing these 2 techniques are sparse and need investigation. From March 2004 to January 2019, 158 patients with an aortic root aneurysm and NS-BAV underwent VSRR (n= 78, 49.3%) or ROOT (n= 80, 50.6%). VSRR involved optional aortic valve repair (n= 47, 60%), and ROOT was performed with bioprosthetic (81.3%) or mechanical valve replacement (18.7%). Procedural and postoperative outcomes were obtained, and univariate and Kaplan-Meier analyses were performed. VSRR patients were younger (42.7 ± 12.0 years of age) than ROOT (54.8 ± 13.6 years of age) (P < .001). Cardiopulmonary bypass (CPB) and cross-clamp duration were longer in VSRR (CPB: 228.0 ± 39.1 minutes; cross-clamp: 200.1 ± 36.2 minutes) compared with ROOT (CPB: 199.5 ± 55 minutes; cross-clamp: 170.3 ± 39.5 minutes) (P < .001). Postoperative stroke, renal failure, pneumonia, and reoperation for bleeding were similar, but postoperative atrial and ventricular arrhythmias was lower in VSRR (15% vs 42%; P < .001). Length of stay and 30-day mortality were similar. At discharge, none had greater than trivial aortic insufficiency. Long-term 10-year survival and incidence of moderate-severe aortic insufficiency, aortic stenosis, and reoperation were equivalent between groups. Surgery for aortopathy associated with NS-BAV is safe and effective with either VSRR or ROOT. Despite its complexity, VSRR should be considered in the surgical treatment of this population.

Patients undergoing urgent trans-aortic valve implantation suffer from an increased mortality rate

Abstract Introduction Information on the outcome of urgent Transcatheter valve implantations (TAVI) is scarce, but available data suggest that it could be a reasonable option for the treatment of decompensated severe aortic valve stenosis. The prospects of an all-comer urgent population, however, are unknown. Here we report our experience with clinically indicated urgent TAVI implantation in an unselected patient population with severe aortic valve stenosis (AS). Purpose To compare the outcome of patients undergoing urgent or elective TAVI and to identify potential predictors of outcome. Methods A retrospective, single centre study of AS patients undergoing femoral or apical TAVI between 01. 01.2013 and 30.09.2018 was performed. Demographic information, medical history, clinical and procedural data were collected from the local electronic database. Urgent implantation was defined as accelerated, in-hospital patient preparation and urgent device placement following an acute admission. Survival was investigated with Kaplan-Meier survival analysis and log-rank test. Regression analysis was performed to identify possible predictors of mortality. Results During the study period TAVI was performed in 631 patients, of whom 53 (8.4%) underwent urgent TAVI. In the case of urgent procedures, the median admission-to-procedure time was 18 [10–29] days. Age, gender and the prevalence of diabetes mellitus, chronic obstructive lung disease (COPD) and a glomerular filtration rate of ≤30ml/min was comparable among the groups. Patients in the urgent group had a lower BMI (26 [23–28] vs. 27 [24–30]; p&amp;lt;0.05), had more frequently an ejection fraction &amp;lt;30% (30% vs 4%p&amp;lt;0.001) and a higher Euroscore II (5.3 [3.4–10.9]% vs 2.9 [1.7–4.5]%; p&amp;lt;0.001). The rate of apical implantation and post-operative stroke, pacemaker implantation and renal failure did not differ between the groups. Urgent patients, however, needed longer post-procedural hospitalization (6 [4–9] vs 4 [3–6] days; p&amp;lt;0.001) and had higher in-hospital (11.3% vs 3,1%; &amp;lt;0.001) and one-year mortality rates (28.3% vs 8.5%; p&amp;lt;0.001). Urgency was an independent predictor of overall one-year mortality (HR 3.0, p=0.001) and worsened the survival of the individuals who were discharged from the hospital (out-of-hospital mortality at one-year; HR 2.8, p=0.011), but had no effect on in-hospital mortality. In-hospital mortality was mainly determined by apical access (OR 3.1; p=0.016) and major post-operative stroke (OR 8.8.; p=0.006), with both worsening overall 1-year survival too (HR 1.8 for apical access and 4.8 for stroke; p&amp;lt;0.05). Mortality after a successful hospital discharge was increased not only by urgency (HR 2.8, p=0.011), but by COPD (HR 2.1; p=0.04) and prolonged post-operative hospitalization (HR 1.05/day; p=0.001) as well. Conclusion Stabilizing AS patients can mitigate the effect of urgency on peri-procedural survival. Urgency remains, however, an important determinant of one-year TAVI outcome. Funding Acknowledgement Type of funding source: None

Evaluation of Extracorporeal Membrane Oxygenation Therapy as a Bridging Method

With the implementation of the new heart allocation system, heart transplantation teams are prompted to reevaluate management of patients requiring mechanical circulatory support. The purpose of our study is to compare the outcomes of patients supported with extracorporeal membrane oxygenation (ECMO) before transplantation. The United Network for Organ Sharing database was queried for all adult patients (aged 18 years or more) who required support with ECMO before heart transplantation from 2001 to 2018. Patients were stratified into patients who did not require ECMO before transplantation, who were weaned off ECMO before transplantation, who were bridged immediately to transplantation from ECMO, and who were bridged to a left ventricular assist device (LVAD) before transplantation. Demographics and outcomes including 1-year survival, postoperative stroke, postoperative renal failure requiring dialysis, episodes of rejection, and graft failure were compared. Overall, 29,370 patients did not require ECMO before transplantation, 101 patients were weaned off ECMO before transplantation, 118 were bridged from ECMO directly to transplantation, and 55 patients were successfully bridged from ECMO to LVAD before transplantation. Kaplan-Meier survival estimates found a statistically significant decrease in 1-year survival for patients who were bridged from ECMO to transplantation compared with patients who were bridged to LVAD before subsequent transplantation (P < .001). Our study suggests bridging ECMO patients to an LVAD before transplantation will result in improved 1-year survival compared with patients bridged to immediate transplantation. With the new heart allocation system, continued evaluation of outcomes is required to inform management strategies.