Preoperative Renal Dysfunction Research Articles

SINGLE CENTER EXPERIENCE IN SURGICAL TREATMENT FOR ACTIVE ENDOCARDITIS BEFORE AND AFTER COVID–19 PANDEMIC

Abstract Background Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life–threatening condition. The impact of COVID–19 on diagnosis and outcome of surgical treatment of IE is uncertain. The aim of this study was to analyze the incidence, characteristics and outcomes of surgically treated IE before and after the COVID–19 pandemic. Methods This study retrospectively analyzed data of 536 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided in two groups depending on the date of operation: before (n=393) and after (n=142) COVID–19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied. Results We noticed a significant increase (p=0.006) in the prevalence of infective endocarditis admitted for surgery throughout the years, comparing it to overall hospitalizations in our cardiac surgery department (Figure 1). Patients from the post COVID cohort (after march 2020) had more comorbidities such as diabetes (29.6% vs 16.3% p=0.001), hypertension (71.1% vs 59.5% p=0.015), and preoperative kidney injury requiring dialysis (9.2% vs 2.5% p=0.002), but median additive and logistic Euroscore were not statistically different. In the post COVID group, we observed a greater prevalence of S. Aureus related endocarditis (24.5% vs 15.4% p=0.026), and a consequent reduction in S. non Aureus related endocarditis (12.2% vs 20.1% p=0.048) (Figure 2), a decrease of aortic valve replacement (43.0% vs 53.9%), while the number of mitral valve replacement ad repair resulted to be higher (21.1% vs 15.0% and 6.3% vs 4.3% respectively) (Figure 3). No differences in the two groups concerning early death but also death or relapse at one year after surgery. Data obtained by the multivariable analysis identify the preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality stratifying by time periods in analysis. Conclusions The incidence of surgical treated IE significant increase after COVID–19 pandemic with a higher incidence of mitral involvement instead of aortic valve. Despite the pandemic and the delay in surgical timing, results in terms of mortality and outcomes have improved and were largely unaffected by the COVID–19 pandemic.

Predictors of late outcomes after concomitant tricuspid valve repair with left-sided valve surgery.

Concomitant tricuspid valve (TV) repair is a safe and effective procedure to protect against late moderate or greater tricuspid regurgitation (TR) after left-sided valve surgery, but studies regarding its late outcomes and recurrent TR are limited. This study aimed to reveal the late outcomes and explore the predictors of mortality and recurrent TR among patients who underwent concomitant TV repair with left-sided valve surgery. This study included 645 patients (mean age, 69.7years; 44% male) who underwent concomitant TV repair with left-sided valve surgery (mitral valve surgery in 594 cases, aortic valve surgery in 172 cases) from 2006-2020. Preoperative TR was grade 4, 3, and less than 2 in 85, 235, and 325 patients, respectively. The median follow-up period was 4.6 (IQR 1.7-7.8) years. The in-hospital or 30-day mortality was 1.7% (n = 11). Regarding long-term outcomes after TV repair, 90.3% and 80.8% achieved 5- and 10-year survival, respectively, while 96.1% and 88.8% achieved 5- and 10-year freedom from recurrent TR, respectively. The following were independent predictors of overall mortality on multivariate analysis in patients with preoperative TR grade ≥ 3: prior pacemaker implantation, preoperative renal dysfunction, diabetes mellitus and NYHA class ≥ 3. Also, suture annuloplasty and ring type of ring annuloplasty were not independent risk factors for recurrent TR, classified as grade ≥ 3. Concomitant TV repair with left-sided valve surgery had acceptable outcomes in terms of survival and TR durability. In patients with preoperative TR grade ≥ 3, preoperative patient status had negative impacts on prognosis.

Oxidative Stress after on-Pump Cardiac Surgery in Patients with Preoperative Renal Dysfunction

Background: Renal dysfunction is a global health burden with a rising prevalence and increased morbidity and mortality. Since the complex and multifactorial pathophysiology of this disease and its consequences is not entirely understood, novel mechanisms are currently under investigation, one being oxidative stress. Malondialdehyde is a product of lipid peroxidation and has been widely utilised as an indirect biomarker of oxidative stress. The aim of this study was to investigate the perioperative oxidative stress in patients with preoperative renal dysfunction undergoing on-pump cardiac surgery. Methods: In 115 patients scheduled for on-pump cardiac surgery, serum concentrations of malondialdehyde were obtained pre-, intra- and postoperatively. The patients were enrolled into two study groups regarding their preoperative renal function, and the malondialdehyde concentrations were compared between the study groups. Results: Patients with preoperative renal dysfunction were older and had a higher mean EuroSCORE II score. On postoperative days 1, 2 and 3, the serum malondialdehyde levels were significantly higher in patients with preoperative renal dysfunction compared to those with normal kidney function. Using regression analysis, preoperative renal dysfunction was shown to be an independent predictor of higher postoperative malondialdehyde levels at all tested time points. Conclusions: In a pioneering study correlating cardiopulmonary bypass and oxidative stress biomarker malondialdehyde, patients with preoperative renal dysfunction were found to exhibit more pronounced and prolonged oxidative stress resulting in protracted lipid peroxidation in the early postoperative period compared to patients with normal kidney function.

Succesful Continuous Renal Replacement Therapy (CRRT) for Acute Kidney Injury (AKI) with Septic Shock Underwent Long Coronary Artery Bypass Graft Procedure (CABG)

Background : AKI occurs in significant numbers of patients undergoing cardiopulmonary bypass surgery for coronary artery disease. Patient with AKI requiring renal replacement therapy (RRT) after cardiac surgery were at a higher risk of postoperative mortality. One of mode of RRT is CRRT. CRRT can keep hemodynamic of the patient stable, excellent control of azotemia, sypport beneficial immunomodulation,increase clearance of inflammatory mediators and potentially less ongoing or repeated renal ischaemia. As an alternative to traditional intermittent hemodialysis, CRRT has now emerged as the leading form of RRT for patients with AKI post CABG because the CRRT can keep hemodynamic still stable. Case: We report a case report of patient who had long aorta cross clamp in CABG procedure. He got AKI with shock condition during hospitalization in ICU, had been done with CRRT and had good response after the procedure. Discussion: The incidence of AKI after cardiac surgery in this patient may increase with several risk factors, such as surgical bleeding, diabetes mellitus, pre operative renal dysfunction, low LVEF, the use of CPB machine and infection. An imbalance between renal oxygen supply and oxygen demand will induce AKI. This patient had done CRRT and showed good clinical and laboratory condition after that. Conclusion : CRRT is a good choice for AKI patient post CABG procedure with shock condition.

Surgical Treatment of Active Endocarditis Pre- and Post-COVID-19 Pandemic Onset.

Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life-threatening condition. The impact of COVID-19 on the diagnosis and outcome of the surgical treatment of IE is uncertain. The aim of this study was to analyze the incidence, characteristics, and outcomes of surgically treated IE before and after the COVID-19 pandemic. This study retrospectively analyzed the data of 535 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided into two groups depending on the date of their operation: before (n = 393) and after (n = 142) COVID-19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied. Weighted univariate logistic regressions were reported for outcomes; weights were derived from IPTW. Interrupted time series analysis (ITSA) according to Linden's method was used to evaluate the changes in the manifestation of IE after 11 March 2020. Patients from the post-COVID-19 cohort (after 11 March 2020) had a greater number of comorbidities such as diabetes (29.6% vs. 16.3% p = 0.001), hypertension (71.1% vs. 59.5% p = 0.015), and preoperative kidney injury requiring dialysis (9.2% vs. 2.5% p = 0.002), but the median additive and logistic EuroSCORE were not statistically different. In the post-COVID-19 group, we observed a greater prevalence of Staphylococcus aureus-related endocarditis (24.5% vs. 15.4% p = 0.026), a consequent reduction in Staphylococcus non aureus-related endocarditis (12.2% vs. 20.1% p = 0.048), and a decrease in aortic valve replacements (43.0% vs. 53.9%), while the number of mitral valve replacements and repair was greater (21.1% vs. 15.0% and 6.3% vs. 4.3%, respectively). No differences were found in the two groups concerning early death, death, or relapse at 1 year after surgery. Data obtained by multivariable analysis identified preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality via stratifying by time periods in analysis. The incidence of surgically treated IE significantly increases after the COVID-19 pandemic with a higher incidence of mitral valve involvement with respect to the aortic valve. Although a delay in surgical timing occurred during the COVID-19 pandemic, data in terms of mortality and outcomes were largely unaffected.

Combined Liver Transplant and Cardiac Surgery: Long-Term Outcomes and Predictors of Success.

We aim to report our institutional outcomes of single-staged combined liver transplantation (LT) and cardiac surgery (CS). Concurrent LT and CS is a potential treatment for combined cardiac dysfunction and end-stage liver disease, yet only 54 cases have been previously reported in the literature. Thus, the outcomes of this approach are relatively unknown, and this approach has been previously regarded as extremely risky. Thirty-one patients at our institution underwent combined cardiac surgery and liver transplant. Patients with at least one-year follow-up were included. The Leave-One-Out Cross-Validation (LOOCV) machine-learning approach was used to generate a model for mortality. Median follow-up was 8.2 years (IQR 4.6-13.6y). One- and five-year survival was 74.2% (N=23) and 55% (N=17), respectively. Negative predictive factors of survival included recipient age>60 years (P=0.036), NASH-cirrhosis (P=0.031), Coronary Artery Bypass-Graft (CABG)-based CS (P=0.046) and pre-operative renal dysfunction (P=0.024). The final model demonstrated that renal dysfunction had a relative weighted impact of 3.2 versus CABG (1.7), age ≥60y (1.7) or NASH (1.3). Elevated LT+CS risk score was associated with an increased five-year mortality after surgery (AUC=0.731, P=<0.001). Conversely, the widely accepted STS-PROM calculator was unable to successfully stratify patients according to 1- (P>0.99) or 5-year (P=0.695) survival rates. This is the largest series describing combined LT+CS, with joint surgical management appearing feasible in highly selected patients. CABG and pre-operative renal dysfunction are important negative predictors of mortality. The four-variable LT+CS score may help predict patients at high risk for post-operative mortality.

Comparison of the effect of surgical versus transcatheter aortic valve replacement on the development of postoperative acute kidney injury.

Acute kidney injury (AKI) frequently occurs after cardiac surgery. Recently, transcatheter aortic valve implantation (TAVI), a less invasive option for aortic stenosis (AS), has been increasingly performed, particularly in elderly patients. We retrospectively investigated and compared the incidence and risk factors of postoperative AKI in patients who underwent surgical aortic valve replacement (SAVR) and TAVI. This was a retrospective single-center study. Seven days postoperatively, data were obtained from medical records. Patients were classified into SAVR and TAVI groups based on age, according to the policy of the Japanese Circulation Society. A total of 155 patients underwent surgery for AS between January 2020 and December 2021. Variables included age, sex, risk score, preoperative left ventricular ejection fraction, hypertension, and renal dysfunction. AKI was defined in accordance with the Kidney Disease: Improving Global Outcomes criteria. A total of 33 SAVR and 79 TAVI procedures were included in this study. The incidences of AKI in the SAVR and TAVI groups were 45.5% and 43.0%, respectively. No significant differences existed between the two groups. Weight (p = 0.0392) and pre-renal dysfunction (p = 0.0308) affected the incidence of AKI in the SAVR group, whereas no such variables were identified in the TAVI group. Within the current age-based treatment selection criteria for AS, no significant difference in the incidence of AKI was observed between the two procedures.Although preoperative renal function may be associated with postoperative AKI, further studies are required to select the optimal surgical procedure for patients with renal dysfunction.

Postoperative acute kidney injury after on-pump cardiac surgery in patients with connective tissue disease.

Patients with connective tissue disease have a poor prognosis after receiving cardiac surgery. This study described the clinical scenarios and investigated factors correlated with acute kidney injury (AKI) after on-pump cardiac surgery in patients with systemic lupus erythematosus (SLE) or vasculitis. Patients with SLE or vasculitis who underwent on-pump cardiac surgery from March 2002 to March 2022 were enrolled, while patients with preoperative renal dysfunction were excluded. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Uni- and multivariable analyses were performed to identify potential factors associated with postoperative AKI. Among 123 patients enrolled, 39 (31.7%) developed AKI within seven days after receiving on-pump cardiac surgery. Four patients died in the hospital, resulting in an overall in-hospital mortality of 3.3%, and all deaths occurred in the AKI group. Patients in the AKI group also had longer ICU stays (median difference 3.0 day, 95% CI: 1.0-4.0, P < 0.001) and extubation time (median difference 1.0 days, 95% CI: 0-2.0, P < 0.001) than those in the non-AKI group. Multivariable logistic regression revealed that BMI over 24 kg/m2 (OR: 3.00, 95% CI: 1.24-7.28) and comorbid SLE (OR: 4.73, 95% CI: 1.73-12.93) were independently correlated with postoperative AKI. Factors potentially correlated with AKI following on-pump cardiac surgery in patients with connective tissue disease were explored. Clinicians should pay more attention to preoperative evaluation and intraoperative management in patients with risk factors.

Perioperative risk factors impact on intensive care unit length of stay (ICU length of stay) in oral squamous cell carcinoma

BackgroundThe trend in postoperative care for free flap patients is to deescalate from routine ICU admission into a specialty recovery unit. This study aims to investigate the predictive parameters in a routine perioperative clinical assessment that are expected to be directly correlated with prolonged ICU length of stay in at-risk patients who received oral reconstructive surgery for squamous cell carcinoma (OSCC).MethodsAll patients who underwent ablative surgery for OSCC with free flap reconstruction and were managed in the ICU were included in this study. The primary outcome was ICU-length of stay. Perioperative, operative and postoperative parameters were analyzed using single test ( t-test, ANOVA analysis, correlation coefficients, effect size) and multivariate regression test. The P-value was set as < 0.005 to be considered statically significant.ResultsThe study included 136 homogeneous patients, with a mean ICU length of stay of 4.5 (± 4.43 day). Patients with pre-operative positive renal dysfunction (P = 0.004), peripheral vascular disease (P < 0.001), postoperative complications (P = 0.028) or positive heart failure class III (P < 0.001 ) were recognized as at-risk patients for a significantly longer ICU length of stay.ConclusionPatients with perioperative severe renal dysfunction, peripheral vascular disease, postoperative complication or high NYHA class are prone to have a significantly longer ICU length of stay. Several factors were considered as confounders contributing to increased ICU management time in combination with other variables. Additionally, in highly risk patient, the presence of the highly trained medical support, including the appropriate nursing care, is more critical than those patients without these risk factors.

Renal dysfunction due to surgical stress and its effects on survival in patients aged 90 and over

Background/Aim: Published studies of surgical outcomes in patients aged 90 years and older have mostly focused on specific surgeries such as hip fractures. Unlike previous reports, our study includes all surgical procedures in patient groups aged 90 and over for eight years in our hospital. We aim to be able to predict the responses of an older adult’s kidney due to surgical stress by using the values of plasma urea and creatine, which are preoperative and postoperative routine laboratory parameters, and to predict its effect on mortality. Methods: Our study was conducted as a retrospective cohort study with 284 patients whose ages ranged from 90 to 119 and who had undergone a surgical operation. The patients were divided into four groups according to preoperative and postoperative creatinine values: preoperative and postoperative creatinine &lt;1.25 mmol/L RFT-I group; preoperative creatinine &lt;1.25 mmol/L but postoperative creatinine &gt;1.25 mmol/L RFT-II group; preoperative creatinine &gt;1.25 mmol/L but postoperative creatinine &lt;1.25 mmol/L RFT-III group; and preoperative and postoperative creatinine &gt;1.25 mmol/L RFT-IV group. Results: Of the 284 cases, 62% required intensive care after surgery. While 95.4% of the patients were discharged, 4.6% did not survive. No renal dysfunction was observed in the RFT-I group (68.7%, n=195) (preoperative and postoperative creatinine &lt;1.25 mmol/L). In the RFT-II group (17.6%, n=50), renal dysfunction (creatinine &gt;1.25 mmol/L) developed due to postoperative surgical stress (creatinine &lt;1.25 mmol/L). In patients in the RFT-III group (6%, n=17), preoperative renal dysfunction (creatinine &gt;1.25 mmol/L) improved with postoperative care (creatinine &lt;1.25 mmol/L). In the RFT-IV group (7.7%, n=22), preoperative renal dysfunction (creatinine &gt;1.25 mmol/L) did not improve postoperative renal dysfunction despite appropriate perioperative fluid replacement. Conclusion: Our study observed an increase in postoperative urea and creatinine values due to surgical stress in our patient group aged 90 and over, who had limited physiological reserves. However, it has been shown that improvement in renal function tests can be achieved with appropriate fluid replacement and postoperative intensive care treatment in patients with postoperative or preoperative renal dysfunction. Our rates of postoperative renal dysfunction due to surgical stress were lower and did not change mortality.

Pretransplant Renal Dysfunction Negatively Affects Prognosis After Living Donor Liver Transplantation: A Single-Center Retrospective Study

To evaluate the influence of preoperative renal function on prognosis after living donor liver transplantation (LDLT). Living donor liver transplantation cases were categorized into 3 groups as follows: renal failure with hemodialysis (HD; n=42), renal dysfunction (RD; n=94) (glomerular filtration rate <60 mL/min/1.73 m2), and normal renal function (NF; n=421). The study used no prisoners, and participants were neither coerced nor paid. The manuscript complies with the Helsinki Congress and the Declaration of Istanbul. Five-year overall survival (OS) rates were 59.0%, 69.3%, and 80.0% in the HD, RD, and NF groups, respectively (P < .01). The frequency of bacteremia within 90 days after LDLT was 76.2%, 37.2%, and 34.7%, respectively (P < .01 in HD vs RD and HD vs NF). Patients with bacteremia showed a worse outcome than those without (1-year OS, 65.6% vs 93.3%), thus corroborating the poor prognosis in the HD group. The high frequency of bacteremia in the HD group was mainly attributable to health care-associated bacterium, such as coagulase-negative Staphylococci, Enterococcus spp., and Pseudomonas aeruginosa. In the HD group, HD was started within 50 days before LDLT for acute renal failure in 35 patients, of which 29 (82.9%) successfully withdrew from HD after LDLT and demonstrated better prognosis (1-year OS, 69.0% vs 16.7%) than those who continued HD. Preoperative renal dysfunction is associated with poor prognosis after LDLT, possibly due to a high incidence of health care-associated bacteremia.

Factors Associated With Spinal Cord Ischemia After Thoracic, Abdominal, and Thoracoabdominal Endovascular Aortic Repairs

Spinal cord ischemia (SCI) is a challenging complication after endovascular aortic repair throughout the full extent of the aorta. However, data on factors associated with postoperative SCI development that are specific to the treatment extent are scarce. Therefore, we examined factors associated with SCI after thoracic endovascular aortic repair (TEVAR), complex endovascular aortic repair (cEVAR), and thoracoabdominal endovascular repairs (TAARs). All patients who underwent thoracic, abdominal, or TAAR from 2014 to 2019 were identified in the Vascular Quality Initiative linked with Medicare Claims. Procedures were classified into three subgroups based on repair extent: descending thoracic aortic repair (TEVAR), paravisceral segment of the abdominal aorta grouped as cEVAR, and TAAR. Logistic regression was used to identify factors associated with SCI within each group. Cox regression was used to evaluate the impact of SCI on 5-year survival. A total of 6591 patients were included (50% TEVAR, 42% cEVAR, and 8% TAAR). SCI incidence rates were 3.6%, 2.5%, and 11% for TEVAR, cEVAR, and TAAR, respectively. After TEVAR, preoperative renal dysfunction (odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.6-3.9; P < .001), ruptured presentation (OR: 3.9, 95% CI: 2.0-7.2; P < .001), and more extensive coverage (for each zone covered: OR: 1.5, 95% CI: 1.1-2.1; P = .008) were associated with higher odds of SCI. Left subclavian artery revascularization was associated with lower odds of SCI (OR: 0.48, 95% CI: 0.23-0.95; P = .041) (Table I). After cEVAR, patients with prior open (OR: 2.5, 95% CI: 1.1-5.1; P = .012) and endovascular (OR: 2.3, 95% CI: 1.1-4.8; P = .020) aortic surgery, longer operative times (for each hour: OR: 1.4, 95% CI: 1.2-1.5; P < .001), and more extensive coverage (for each zone covered: OR: 1.2, 95% CI: 1.0-1.4; P = .025) had higher odds of SCI (Table II). Notably, coverage extent and staged repair were not found to be significantly associated with SCI after TAAR (Table III). SCI was associated with higher 5-year mortality among all repairs (TEVAR: adjusted hazard ratio [aHR]: 2.1, CI: 1.6-2.9; P < .001; cEVAR: aHR: 3.4, CI: 2.4-4.7; P < .001; and TAAR: aHR: 2.1, CI: 1.3-3.2; P < .001). The extent of aortic zone coverage was associated with SCI after TEVAR and cEVAR, whereas prior aortic surgery was associated with SCI after cEVAR. Notably, left subclavian artery revascularization was associated with lower odds of SCI after TEVAR. In contrast to previous reports, staged repair was not associated with lower SCI risk after TAAR. Future studies should focus on procedure-specific risk factors to identify patients at higher risk of SCI and understand the optimal preventive strategy within specific procedures.Table ILogistic regression analysis for factors associated with SCI after TEVAR, cEVAR, or TAAACharacteristicTEVARcEVARTAAROR95% CIP valueOR95% CIP valueOR95% CIP valueAge1.000.98-1.0.901.00.99-1.0.111.00.95-1.0.9Gender (female)0.900.59-1.3.600.950.52-1.6.900.660.34-1.2.2White0.910.58-1.4.700.690.37-1.3.200.820.39-1.8.6Hypertension1.80.77-5.1.201.20.51-3.5.700.860.28-3.3.8Smoking history1.30.83-2.2.202.20.84-7.7.151.60.65-4.6.3Prior aortic surgery NoneRef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Open0.590.28-1.1.122.51.1-5.1.0121.30.61-2.8.30 Endovascular0.440.17-0.97.0672.31.1-4.8.0200.510.18-1.2.20 Both1.70.41-5.3.401.60.25-6.5.501.10.29-3.6.80COPD1.40.89-2.2.141.10.67-1.9.601.70.90-3.3.10Prior MI1.20.72-2.0.400.840.43-1.5.601.10.46-2.5.80Baseline eGFR <60 mL/min/1.73 m22.51.6-3.9<.0010.960.56-1.6.901.20.67-2.4.40Pathology TAARef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Accute dissection1.70.94-3.1.077–––––– CTBAD + PDA1.60.74-3.2.20–––––– Traumatic––––––––– PAU + IMH + (PAU + IMH)1.20.65-2.1.60–––––– Other–––1.40.33-4.6.501.10.50-2.6.70Presentation AsymptomaticRef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Symptomatic1.30.77-2.3.301.00.49-2.1.90.830.39-1.7.60 Rupture3.92.0-7.2<.0011.10.26-3.6.82.00.56-6.4.20Total procedure time, hours1.10.99-1.2.0671.41.2-1.5<.0011.00.95-1.2.20Estimated blood loss, 100 mL1.00.98-1.0.201.00.99-1.0.31.041.0-1.08.026Left subclavian artery treatment NoneRef.Ref.Ref.–––Ref.Ref.Ref. Occlusion0.830.43-1.5.50–––0.290.04-1.1.12 Revascularization0.480.23-0.95.041–––0.810.34-1.8.6Celiac involvement Infraceliac sealingRef.Ref.Ref.Ref.Ref.Ref. Supraceliac sealing1.60.90-3.1.110.790.38-1.6.5Hypogastric involvement None–––Ref.Ref.Ref.––– Hypogastric artery involvement–––0.710.14-2.6.6–––Staged aortic treatment––––––0.880.45-1.7.70Length of coverage (zones)1.51.1-2.1.0081.21.0-1.4.0251.050.89-1.2.6cEVAR, Complex endovascular aortic repair; CI, confidence interval; COPD, chronic obstructive pulmonary disease; CTBAD, complicated type B aortic dissection; eGFR, estimated glomerular filtration rate; IMH, intramural hematoma; MI, myocardial infarction; OR, odds ratio; PAU, penetrating aortic ulcer; PDA, patent ductus arteriosus; TAA, thoracic aortic aneurysm; TAAR, thoracoabdominal endovascular repair; TEVAR, thoracic endovascular aortic repair.Boldface P values represent statistical significance. Open table in a new tab

Long-term outcome of acute type A aortic dissection repair in chronic kidney disease patients.

Preoperative renal dysfunction is associated with mortality in patients with acute type A aortic dissection (ATAAD) repair. However, the long-term outcome of chronic kidney dysfunction (CKD) in ATAAD is unclear. The study aimed to evaluate the long-term outcome of CKD in patients with ATAAD repair. We retrospectively studied patients with ATAAD repair using data from the Taiwan's National Health Insurance Research Database between July 1, 2004, and December 31, 2013. The outcomes of interest included all-cause mortality, readmission due to any cause, redo aortic surgery, major adverse cardiac and cerebrovascular events, and liver and renal outcomes. There were 3328 patients who received ATAAD repair. These patients were divided into CKD and non-CKD groups. In-hospital mortality in the CKD group was significantly higher than that in the non-CKD group (32.5% vs 18.8%, respectively, odds ratio 2.14, 95% confidence interval [CI] 1.37-3.36). During long-term follow-up, patients with CKD had higher risks of all-cause mortality including in-hospital death (52.6% vs 32.5%; hazard ratio 1.83, 95% CI 1.32-2.55), mortality after discharge (29.7% vs 16.8%; hazard ratio 2.09, 95% CI 1.02-4.29), and readmission rates (67.1% vs 51.6%; subdistribution hazard ratio 2.00, 95% CI 1.43-2.79). However, no significant difference was observed between the dialysis and non-dialysis groups. On the basis of our results, patients with CKD carry a poor long-term outcome after ATAAD repair. Cardiac surgeons should be aware of this condition when dealing with ATAAD repair.

Kompanse Böbrek Yetmezlikli Hastalarda Koroner Bypass Morbiditesini Azaltan bir Teknik; Peroperatif Ultrafiltrasyon

INTRODUCTION: Preoperative renal dysfunction is one of the most important risk factors affecting postoperative morbidity and mortality in patients undergoing cardiac surgery. While patients with end-stage renal disease and dialysis-dependent constitute 1-3% of the renal failure spectrum, it should not be forgotten that coronary revascularization surgery is performed at a rate of 2-5% in the remaining asymptomatic majority. However, an optimal perioperative strategy has not been developed for this group of patients who have not yet undergone hemodialysis. In our study, conventional ultrafiltration was applied with a modified peroperative heart-lung machine and it was aimed to decrease mortality and morbidity. METHOD: 6303 patients who underwent coronary bypass surgery with the cardiopulmonary bypass technique between 2004 and 2011 at Başkent University Adana Hospitals were examined, and 99 patients with a preoperative serum creatinine level higher than 1.5 mg/dl were included in this retrospective study. 99 patients were divided into two groups as UF performed (35) and not performed (64); They were evaluated in terms of drainage amounts, length of hospital stay, early/late mortality and morbidity, and newly developing dialysis needs. RESULTS: There was no significant difference between the groups in terms of post-operative hemodialysis need, length of hospital stay and major complications. However; Peroperative ultrafiltration in obese, diabetic, recent MI, COPD and congestive heart failure patients; postoperatively less inotrope (P=0.0001), less diuretic requirement (P=0.0001), less colloidal fluid replacement (p=0.009), and relatively fewer minor complications. DISCUSSION AND CONCLUSION: Ultrafiltration to be applied during cardiopulmonary bypass in order to create a more balanced intravascular volume in patients with compensated renal failure, to reduce the need for volume expander fluid used for this purpose, to remove inflammation mediators that occur during cardiopulmonary bypass, and therefore to protect renal functions without the need for additional medication, especially COPD. We recommend it in the diabetic and obese patient group.

Risk factors for in-hospital mortality after total arch procedure in patients with acute type A aortic dissection.

Knowledge about the risk factors of in-hospital mortality for acute type A aortic dissection (ATAAD) patients who received total arch procedure is limited. This study aims to investigate preoperative and intraoperative risk factors of in-hospital mortality of these patients. From May 2014 to June 2018, 372 ATAAD patients received the total arch procedure in our institution. These patients were divided into survival and death groups, and patients` in-hospital data were retrospectively collected. Receiver operating characteristic curve analysis was adopted to determine the optimal cut-off value of continuous variables. Univariate and multivariable logistic regression analyses were used to detect independent risk factors for in-hospital mortality. A total of 321 patients were included in the survival group and 51 in the death group. Preoperative details showed that patients in the death group were older (55.4 ± 11.7 vs. 49.3 ± 12.6, P = 0.001), had more renal dysfunction (29.4% vs. 10.9%, P = 0.001) and coronary ostia dissection (29.4% vs. 12.2%, P = 0.001), and decreased left ventricular ejection fraction (LVEF) (57.5 ± 7.9% vs. 59.8 ± 7.3%, P = 0.032). Intraoperative results showed that more patients in the death group experienced concomitant coronary artery bypass grafting (35.3% vs. 15.3%, P = 0.001) with increased cardiopulmonary bypass (CPB) time (165.7 ± 39.0 vs. 149.4 ± 35.8 min, P = 0.003), cross-clamp time (98.4 ± 24.5 vs. 90.2 ± 26.9 min, P = 0.044), and red blood cell transfusion (913.7 ± 629.0 vs. 709.7 ± 686.6 ml, P = 0.047). Logistic regression analysis showed that age >55 years, renal dysfunction, CPB time >144 min, and RBC transfusion >1,300 ml were independent risk factors for in-hospital mortality in patients with ATAAD. In the present study, we identified that older age, preoperative renal dysfunction, long CPB time, and intraoperative massive transfusion were risk factors for in-hospital mortality in ATAAD patients with the total arch procedure.

Effect of Gender on Postoperative Outcome and Duration of Ventilation After Coronary Artery Bypass Grafting (CABG).

The studyassessed coronary artery bypass grafting (CABG) postoperative outcomes and associated factors in Saudi male and female patients. This was a retrospective cohort of patients who underwent CABG at the King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, from January 2015 to December 2022. Results: We included 392 patients, of whom 63 (16.1%) were female. Female undergoing CABG were significantly older (p=0.0001), had a significantly higher incidence of diabetes (p=0.0001), obesity (p=0.001), hypertension (p=0.001), and congestive heart failure (p=0.005), with a smaller body surface area (BSA) (p=0.0001) thanmale. Though renal dysfunction, previous cerebrovascular accident/transient ischemic attack (CVA/TIA), and myocardial infarction (MI), incidences were similar in both genders. Females were at significantly higher risk of mortality (p=0.0001), longer hospital stay (p=0.0001), and prolonged ventilation (p=0.0001). Preoperative renal dysfunction was the only statistically significant predictor of postoperative complications (p=0.0001). Female gender and preoperative renal dysfunction, were significant independent predictors of postoperative mortality and prolonged ventilation (p=0.005). This study's findings indicated that females have worse CABG outcomes and a higher risk of morbidities and complications. Uniquely our study showed a higherincidence of prolonged ventilation in females postoperatively.

Effect of angiography timing on acute kidney injury after cardiac surgery in patients with preoperative renal dysfunction

BackgroundCardiac surgery-associated acute kidney injury (AKI) is one of the common complications of cardiac surgery. Preoperative angiography helps assess heart disease but may increase the risk of AKI. Although more and more patients with preoperative renal dysfunction can undergo cardiac surgery with the advances in surgical techniques, there is little research on the effect of angiography on postoperative AKI in these patients. This study investigates whether angiography increases the risk of AKI after cardiac surgery in patients with preoperative renal dysfunction (15 ≤ eGFR < 60 ml/min/1.73m2).MethodsPatients with preoperative renal dysfunction (15 ≤ eGFR < 60 ml/min/1.73m2) who underwent angiography and cardiac surgery successively from January 2015 to December 2020 were retrospectively enrolled in this study. The primary outcome was postoperative AKI, defined as the Kidney Disease: Improving Global Outcomes Definition and Staging (KDIGO) criteria. Univariate analysis and multivariate regression were performed to identify the association between angiography timing and AKI.ResultsA total of 888 consecutive eligible patients with preoperative renal dysfunction (15 ≤ eGFR < 60 ml/min/1.73m2) were enrolled in this study. The incidence of AKI was 48.31%. Male (OR = 1.903), the interval between angiography and surgery (0-2d OR = 2.161; 3-6d OR = 3.291), cross-clamp duration (OR = 1.009), were identified as predictors for AKI. The interval between angiography and surgery was also associated with AKI in the patients with 15 ≤ eGFR < 30ml/min/1.73m2 (0-2d OR = 4.826; 3-6d OR = 5.252), 30 ≤ eGFR < 45 ml/min/1.73m2 (0-2d OR = 2.952; 3-6d OR = 3.677), but not associated with AKI in patients with 45 ≤ eGFR < 60 ml/min/1.73m2.ConclusionsIn patients with preoperative renal dysfunction, the interval between angiography and cardiac surgery (0-2d and 3-6d) was associated with AKI. For patients with poorer preoperative renal function, the interval between angiography and cardiac surgery is of great concern.

Proteinuria is a risk factor for acute kidney injury after cardiac surgery in patients with stages 3–4 chronic kidney disease: a case control study

BackgroundAcute kidney injury (AKI) is a common complication after cardiac surgery, and preoperative renal dysfunction is an important risk factor. Proteinuria indicates renal structural damage, but there are few studies on proteinuria and the risk of AKI after cardiac surgery in patients with renal dysfunction. This study aimed to elucidate whether proteinuria can predict AKI after cardiac surgery in patients with renal dysfunction.MethodsPatients with stages 3–4 chronic kidney disease (CKD) who underwent cardiac surgery were included in this retrospective study. AKI was defined according to the KDIGO criteria. The association between proteinuria and AKI in patients with CKD stages 3–4 was investigated.ResultsThe incidence of AKI in the entire cohort (n = 1546) was 53.55%. The in-hospital mortality of patients with was higher than patients without AKI (AKI vs. no AKI, 4.7 vs. 0.8%, P < 0.001). Multivariate logistic regression analysis showed that proteinuria was an independent risk factor for AKI (trace to 1+ OR 2.37; 2+ –3+ OR 5.16) and AKI requiring renal replacement therapy (AKI-RRT) (trace to 1+ OR 3.64; 2+–3+ OR 5.71). Mild proteinuria (trace to 1+ OR 2.59) was also an independent risk factor for in-hospital death. In patients with diabetes mellitus, mild proteinuria (OR 1.925), instead of severe proteinuria (2–3+), was a risk factor of AKI in patients with kidney dysfunction and diabetes.ConclusionsIn the population of patients with renal dysfunction, the incidence of AKI was high, which significantly compromised renal and overall prognosis. As a simple and inexpensive routine test, preoperative proteinuria still has value in predicting AKI in patients with impaired renal function.

Early and midterm outcomes after off pump coronary artery bypass surgery.

There has been debate whether off pump coronary artery bypass surgery (OPCAB) has results comparable to conventional on pump bypass surgery. This has led to the low uptake of OPCAB in the West. In India, OPCAB is the default mode of coronary revascularization. However, there is scarce data on mid-term outcomes of OPCAB in our patients. This study aims to evaluate both short and mid-term mortality and analyze factors associated with mortality. This is a single center study of all consecutive patients undergoing isolated OPCAB from October 2014 to December 2019. Patient data was collected from hospital records and follow-up was from the hospital electronic medical records and telephone interviews. Mortality and factors contributing to survival were analyzed. Operative mortality was 2.3%. Mid-term mortality was 5.5%. Preoperative renal dysfunction, post-operative renal failure, use of the intra-aortic balloon pump (IABP), re-exploration for bleeding, postoperative stroke, ventilation > 24h, and postoperative atrial fibrillation were associated with operative mortality. Factors associated with mid-term mortality were age > 62years, postoperative renal failure, IABP usage, ventilation time > 24h, and postoperative atrial fibrillation. The mean survival time was 2343.55 + / - 15.27days and 6-year survival was 88.7%. OPCAB can safely be performed with satisfactory short and mid-term outcomes. Further corroborative studies from different regions of the country or a multi-center study will help to establish the suitability of the technique in Indian patients.

Mortality and reoperation rate of biological versus mechanical Bentall-De Bono operation: a propensity-matched study

Objective: To assess follow-up mortality and reoperation rate in patients undergoing Bentall-De Bono operation according to the type of composite valve graft used. Methods: All consecutive adult patients operated on between May 1997 and December 2019 at our institution were included in the analysis and classified according to the use of a biological or a mechanical composite valve graft (bCVG or mCVG). The primary outcomes were follow-up mortality and reoperation rate. Secondary outcomes were operative mortality and major adverse events (MAEs) including operative mortality, myocardial infarction, cerebrovascular accident, dialysis, tracheostomy, and re-exploration for bleeding. Kaplan-Meier and competing risk analyses were used. Propensity matching analysis was used to balance differences in baseline characteristics between procedures. Results: Of 1,210 included patients, 798 received a bCVG and 412 a mCVG. The mean follow-up was 6.64 ± 0.21 years. The ten-year mortality rate was higher in the mCVG group (25.3% vs. 16.4%, P = 0.023). The ten-year reoperation rate was higher in the bCVG group (7.4% vs. 1.1%, P &lt; 0.001). Overall operative mortality was 0.7%, and MAEs occurred in 6.2% of patients, with no significant differences between groups. Older age (hazard ratio [HR] 1.06, 95% confidence interval [CI: 1.04-1.08], P &lt; 0.01), chronic obstructive pulmonary disease (HR 1.63, 95%CI: [1.01-2.64], P = 0.04), preoperative renal dysfunction (HR 3.08, 95%CI: [1.98-4.78], P &lt; 0.001), New York Heart Association Class III/IV (HR 1.48, 95%CI: [1.04-2.10], P = 0.031), and mCVG (HR 2.15, 95%CI: [1.42-3.26], P &lt; 0.001) were associated with higher risk of follow-up mortality. After propensity matching, the differences in mortality and reoperation remained significant. Conclusions: The Bentall-De Bono operation can be performed with consistently good results in experienced centers. Early outcomes are excellent regardless of the valve choice. In our study, the Bentall-De Bono operation with bCVG was associated with lower 10-year mortality but carried a higher risk of aortic reoperation. While the risk of reoperation is largely tied to valve choice, follow-up mortality is more likely to be influenced by patient comorbidities and risk factors.