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Nguyen TD, Morjan M, Ali K, Breitenbach I, Harringer W, El-Essawi A. Influence of minimal invasive extracorporeal circuits on dialysis dependent patients undergoing cardiac surgery. Perfusion 2023:2676591231216794. [PMID: 37977566 DOI: 10.1177/02676591231216794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Cardiac surgery in patients on chronic renal dialysis is associated with significant morbidity and mortality. Minimally invasive extracorporeal circuits (MiECC) have shown a positive impact on patient outcome in different high-risk populations. This retrospective study compares the outcome of these high-risk patients undergoing heart surgery either with a MiECC or a conventional extracorporeal circulation (CECC). METHODS This is a single-center experience including 131 consecutive dialysis dependent patients undergoing cardiac surgery between January 2006 and December 2016. A propensity score matching was employed leaving 30 matched cases in each group. RESULTS After propensity score matching the 30-day mortality was significantly lower in the MiECC group (n = 3 (10%) vs n = 10 (33%) in the CECC group, p = .028). Further, intraoperative transfused units of packed red blood cells were lower in the MiECC group (1.4 ± 1.8 units vs 2.8 ± 1.7, p < .001). CONCLUSIONS There are evident advantages to using MiECC in dialysis dependent patients, especially regarding mortality. These findings necessitate additional research in MiECC usage in high-risk populations.
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Affiliation(s)
- Thai Duy Nguyen
- Clinic for Pediatric & Congenital Heart Surgery, Children's Heart Center, University Hospital RWTH Aachen, Germany
| | - Mohammed Morjan
- Department of Cardiovascular Surgery, University Hospital Düsseldorf, Germany
| | - Khaldoun Ali
- Department of Thoracic and Cardiovascular surgery, Braunschweig Municipal Hospital Germany
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular surgery, Braunschweig Municipal Hospital Germany
| | - Wolfgang Harringer
- Department of Thoracic and Cardiovascular surgery, Braunschweig Municipal Hospital Germany
| | - Aschraf El-Essawi
- Department of Thoracic and Cardiovascular surgery, University Medical Center Göttingen, Germany
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2
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Shell D. Coronary Artery Bypass Grafting in Dialysis-Dependent Patients - Key Peri-Operative Considerations. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 54:73-80. [PMID: 37183155 DOI: 10.1016/j.carrev.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/26/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023]
Abstract
Cardiovascular disease represents the leading cause of mortality in dialysis-dependent (DD) patients, with the great majority of these patients afflicted by severe coronary artery disease. As rates of end-stage renal disease increase worldwide, DD patients represent a growing proportion of the coronary artery bypass grafting (CABG) cohort. Yet, these patients are complex, with crucial changes in their haemodynamic and physiologic profiles that complicate revascularisation surgery. First, this comprehensive literature review explores the outcomes and prognostic factors for DD patients undergoing CABG. We then summarise the intricacies relating to important peri-operative decisions such as use of cardio-pulmonary bypass and choice of conduit.
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Affiliation(s)
- Daniel Shell
- Department of Cardiothoracic Surgery, St Vincent's Hospital - Melbourne, St Vincent's Health Australia, Melbourne, Australia.
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3
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Perioperative transfusion and long-term mortality after cardiac surgery: a meta-analysis. Gen Thorac Cardiovasc Surg 2023; 71:323-330. [PMID: 36884106 DOI: 10.1007/s11748-023-01923-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVES Cardiac surgical procedures are associated with a high incidence of periprocedural blood loss and blood transfusion. Although both may be associated with a range of postoperative complications there is disagreement on the impact of blood transfusion on long-term mortality. This study aims to provide a comprehensive review of the published outcomes of perioperative blood transfusion, examined as a whole and by index procedure. METHODS A systematic review of perioperative blood transfusion cardiac surgical patients was conducted. Outcomes related to blood transfusion were analysed in a meta-analysis and aggregate survival data were derived to examine long-term survival. RESULTS Thirty-nine studies with 180,074 patients were identified, the majority (61.2%) undergoing coronary artery bypass surgery. Perioperative blood transfusions were noted in 42.2% of patients and was associated with significantly higher early mortality (OR 3.87, p < 0.001). After a median of 6.4 years (range 1-15), mortality remained significantly higher for those who received a perioperative transfusion (OR 2.01, p < 0.001). Pooled hazard ratio for long-term mortality similar for patients who underwent coronary surgery compared to isolated valve surgery. Differences in long-term mortality for all comers remained true when corrected for early mortality and when only including propensity matched studies. CONCLUSIONS Perioperative red blood transfusion appears to be associated with a significant reduction in long-term survival for patients after cardiac surgery. Strategies such as preoperative optimisation, intraoperative blood conservation, judicious use of postoperative transfusions, and professional development into minimally invasive techniques should be utilised where appropriate to minimise the need for perioperative transfusions.
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4
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Schoonen A, van Klei WA, van Wolfswinkel L, van Loon K. Definitions of low cardiac output syndrome after cardiac surgery and their effect on the incidence of intraoperative LCOS: A literature review and cohort study. Front Cardiovasc Med 2022; 9:926957. [PMID: 36247457 PMCID: PMC9558721 DOI: 10.3389/fcvm.2022.926957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesLow cardiac output syndrome (LCOS) is a serious complication after cardiac surgery. Despite scientific interest in LCOS, there is no uniform definition used in current research and clinicians cannot properly compare different study findings. We aimed to collect the LCOS definitions used in literature and subsequently applied the definitions obtained to existing data to estimate their effect on the intraoperative LCOS incidences in adults, children and infants.DesignThis is a literature review, followed by a retrospective cohort study.SettingThis is a single-institutional study from a university hospital in the Netherlands.ParticipantsPatients from all ages undergoing cardiac surgery with cardiopulmonary bypass between June 2011 and August 2018.InterventionsWe obtained different definitions of LCOS used in the literature and applied these to data obtained from an anesthesia information management system to estimate intraoperative incidences of LCOS. We compared intraoperative incidences of LCOS in different populations based on age (infants, children and adults).Measurements and main resultsThe literature search identified 262 LCOS definitions, that were applied to intraoperative data from 7,366 patients. Using the 10 most frequently published LCOS definitions, the obtained incidence estimates ranged from 0.4 to 82% in infants, from 0.6 to 56% in children and from 1.5 to 91% in adults.ConclusionThere is an important variety in definitions used to describe LCOS. When applied to data obtained from clinical care, these different definitions resulted in large distribution of intraoperative LCOS incidence rates. We therefore advocate for standardization of the LCOS definition to improve clinical understanding and enable adequate comparison of outcomes and treatment effects both in daily care and in research.
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Affiliation(s)
- Anna Schoonen
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, Netherlands
- *Correspondence: Anna Schoonen
| | - Wilton A. van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, Netherlands
- Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, Toronto General Hospital, Toronto, ON, Canada
| | - Leo van Wolfswinkel
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Kim van Loon
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, Netherlands
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Yamamoto T, Endo D, Shimada A, Matsushita S, Asai T, Amano A. Surgical treatment of acute aortic dissection in a patient with SLE and prior antiphospholipid syndrome on therapy for over 30 years: a case report. BMC Cardiovasc Disord 2022; 22:216. [PMID: 35562652 PMCID: PMC9103044 DOI: 10.1186/s12872-022-02659-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In patients with systemic lupus erythematosus (SLE), lengthy treatment and long-term steroid use are the main risk factors for developing aortic aneurysms or aortic dissections. In patients with cardiac tamponade, hemodynamic collapse may lead to acute renal and hepatic failure. CASE PRESENTATION We report the successful treatment of a 55-year-old woman with SLE since the age of 21. She suddenly felt chest pain approximately 2 weeks before developing fever and vomiting and was admitted to our hospital. Initially, she had severe liver dysfunction and was admitted to the hepatology department, where treatment for fulminant hepatitis was initiated. However, computed tomography (CT) showed an acute aortic dissection (DeBakey type II) and severe bloody pericardial effusion. Therefore, we performed emergency pericardial drainage. Plasma exchange therapy was initiated as emergency aortic surgery was deemed impossible due to impaired liver function tests and coagulation. Ten days later, the patient developed peritonitis due to small bowel perforation, and laparotomy was performed for abscess drainage and perforation closure. She had received steroid pulse therapy at the age of 21. At 40 years of age, she developed deep vein thrombosis due to antiphospholipid antibodies and was prescribed prednisolone. She was ambulatory at 3 months after the onset of acute aortic dissection, and CT revealed a rapidly enlarging true aneurysm in the distal arch. We performed elective aortic surgery. Although there were no antiphospholipid antibodies, surgery could have led to a devastating antiphospholipid syndrome. Therefore, we decided to treat the patient with triple therapy. Methylprednisolone was intravenously administered intraoperatively and at 1 day postoperatively. The patient was discharged without complications after returning to her usual oral prednisolone regimen. CONCLUSIONS The patient described herein had a systemic circulatory failure due to cardiac tamponade, accompanied by liver failure. This condition is a significant cause of death in patients with aortic dissection-associated SLE and is extremely dangerous. However, multi-specialty intervention helped the patient recover, and she has been attending the outpatient clinic. Aortic surgery requiring hypothermia in SLE patients with antiphospholipid syndrome and a history of thrombocytopenia or thrombosis requires a multi-disciplinary treatment team, including cardiac surgeons and medical experts.
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Affiliation(s)
- Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo Nerima Hospital, Takanodai 3-1-10, Nerima- Ku, Tokyo, 177-8521, Japan.
| | - Daisuke Endo
- Department of Cardiovascular Surgery, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akie Shimada
- Department of Cardiovascular Surgery, Juntendo Nerima Hospital, Takanodai 3-1-10, Nerima- Ku, Tokyo, 177-8521, Japan
| | - Satoshi Matsushita
- Department of Cardiovascular Surgery, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsushi Amano
- Department of Cardiovascular Surgery, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
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Blumenfeld O, Dichtiar R, Sharoni E, Leviner DB. Outcomes of cardiac surgery in patients with end-stage renal disease: Insights from the Israel national registries. J Card Surg 2022; 37:760-768. [PMID: 35112395 DOI: 10.1111/jocs.16254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/17/2021] [Accepted: 11/02/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND End-stage renal disease (ESRD) has been shown to be associated with increased mortality in patients undergoing cardiac surgery. We aimed to compare the short- and mid-term mortality after cardiac surgery of patients with dialysis-dependent ESRD (DD-ESRD) to patients with normal renal function (NRF), using national registries: the ESRD registry, the adult cardiac surgery registry (ACSR), and the National Mortality Registry. METHODS The study population comprised 8207 adult patients who underwent either isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement (MVR), or CABG + valve-related procedure, between January 2017 and April 2019. Data were retrospectively extracted and reported to the ACSR by the department of medical records of each medical center. RESULTS One hundred and four DD-ESRD patients (mean age 63.2 ± 8.8 years, 83.7% males) were compared with 8103 NRF patients (mean age 64.9 ± 9.8 years, 77.6% males). Median follow-up for the total cohort was of 32.0 months (IQR; 25.0, 40.0). In DD-ESRD compared to NRF patients, 30-day mortality was higher (14.4% vs. 2.3%, respectively, p = 0.0001) and 4-year survival was significantly lower (44% ± 0.06 vs. 91% ± 0.04, respectively, p = 0.0001). Fifty-three percent of DD-ESRD 30-day mortality was caused by sepsis. Risk factors associated with reduced midterm survival included: DD-ESRD patients (HR = 4.7, 95% CI; 1.2-18.2), MVR procedure (HR = 1.5, 95% CI; 1.04-2.1) and combined CABG + valve-related procedure (HR = 1.6, 95% CI; 1.2-2.04). CONCLUSIONS Preoperative DD-ESRD was associated with a significant increase in 30-day and mid-term mortality after cardiac surgery. The highest mortality rate was observed in valvular and combined procedures.
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Affiliation(s)
- Orit Blumenfeld
- Israel Center for Disease Control, Ministry of Health, Jerusalem, Israel
| | - Rita Dichtiar
- Israel Center for Disease Control, Ministry of Health, Jerusalem, Israel
| | - Erez Sharoni
- Cardiac surgery department, Carmel Medical center, Haifa, Israel
| | - Dror B Leviner
- Cardiac surgery department, Carmel Medical center, Haifa, Israel
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7
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Rosenfeld ES, Trachiotis GD, Sparks AD, Napolitano MA, Lee KB, Wendt D, Kieser TM, Puskas JD, DiGiammarco G, Taggart DP. Intraoperative surgical strategy changes in patients with chronic and end-stage renal disease undergoing coronary artery bypass grafting. Eur J Cardiothorac Surg 2021; 59:1210-1217. [PMID: 33675642 DOI: 10.1093/ejcts/ezab104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/09/2020] [Accepted: 12/28/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Factors such as more diffuse atherosclerosis, plaque instability and accelerated vascular calcification in patients with chronic and end-stage renal disease (ESRD) can potentially present intraoperative challenges in coronary artery bypass grafting (CABG) procedures. We evaluated whether patients with chronic and ESRD experienced more surgical strategy changes and/or graft revisions than patients with normal renal function when undergoing CABG procedures according to a protocol for intraoperative high-frequency ultrasound and transit-time flow measurement (TTFM). METHODS Outcomes of CABG for patients with chronic and ESRD and patients with normal renal function enrolled in the multicentre prospective REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study were compared retrospectively. The primary end point was frequency of intraoperative surgical strategy changes. The secondary end point was post-protamine TTFM parameters. RESULTS There were 95 patients with chronic and ESRD and 921 patients with normal renal function. Patients with chronic and ESRD undergoing CABG according to a protocol for intraoperative high-frequency ultrasound and TTFM had a higher rate of strategy changes overall [33.7% vs 24.3%; odds ratio (OR) = 1.58; 95% confidence interval (CI) = 1.01-2.48; P = 0.047] and greater revisions per graft (7.0% vs 3.4%; odds ratio = 2.14; 95% CI = 1.17-3.71; P = 0.008) compared to patients with normal renal function. Final post-protamine graft TTFM parameters were comparable between cohorts. CONCLUSIONS Patients with chronic and ESRD undergoing CABG procedures with high-frequency ultrasound and TTFM experience more surgical strategy changes than patients with normal renal function while achieving comparable graft flow. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT02385344.
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Affiliation(s)
- Ethan S Rosenfeld
- Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.,Department of Surgery, George Washington University, Washington, DC, USA
| | - Gregory D Trachiotis
- Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.,Department of Surgery, George Washington University, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Michael A Napolitano
- Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.,Department of Surgery, George Washington University, Washington, DC, USA
| | - K Benjamin Lee
- Division of Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA.,Department of Surgery, George Washington University, Washington, DC, USA
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Teresa M Kieser
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA
| | - Gabriele DiGiammarco
- Department of Cardiac Surgery, Università degli Studi "G. D'Annunzio" Chieti-Pescara, Chieti, Italy
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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8
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Saito Y, Yamamoto H, Fukuda I, Miyata H, Minakawa M, Motomura N. The results of aortic arch replacement using antegrade cerebral perfusion in haemodialysis patients: analysis of the Japan cardiovascular surgery database. Eur J Cardiothorac Surg 2021; 61:162-169. [PMID: 34148088 DOI: 10.1093/ejcts/ezab252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES There have been limited data available regarding aortic arch replacement in dialysis patients. The purpose of this study was to examine real-world data and to determine the impact of preoperative dialysis status and other risks on surgical aortic arch replacement using the Japan Cardiovascular Surgery Database. METHODS A total of 5044 patients who underwent elective, isolated aortic arch replacement using antegrade cerebral perfusion during 2014-2017 were eligible for the study. Of these, 89 patients received haemodialysis preoperatively. The patients were divided into 6 groups according to their preoperative estimated glomerular filtration rate and dialysis status for comparison. Preoperative and postoperative data were examined using a multivariable regression model. RESULTS The overall surgical mortality rates of non-Chronic Kidney Disease (CKD) (estimated glomerular filtration rate >60 ml/min/1.73 m2), stage 3A, stage 3B, stage 4, stage 5 CKD and dialysis patients were 2.6%, 3.1%, 6.8%, 11.6%, 16.7% and 13.5%, respectively. After risk adjustment, dialysis was shown to be strongly associated with surgical mortality (odds ratio 4.39 and 95% confidence interval 2.22-8.72) and have a trend to be associated with postoperative stroke (odds ratio 2.02, 95% confidence interval 1.00-4.10, P = 0.051) when compared to the non-CKD group. As predictors of mortality, male sex, peripheral arterial disease, preoperative liver dysfunction and impaired left ventricular function were identified. CONCLUSIONS The Japanese nationwide database revealed the outcomes of aortic arch replacement in dialysis patients. Appropriate counselling and an alternative strategy should be considered for such patients with multiple risks for mortality.
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Affiliation(s)
- Yoshiaki Saito
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | - Ikuo Fukuda
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | - Masahito Minakawa
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Noboru Motomura
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
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Yamaoka H, Yamamoto T, Endo D, Shimada A, Matsushita S, Asai T, Amano A. Rapid decline in cardiac function in diabetic patients with calcified coronary artery disease undergoing hemodialysis: two case reports. BMC Cardiovasc Disord 2021; 21:271. [PMID: 34082711 PMCID: PMC8173516 DOI: 10.1186/s12872-021-02076-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 05/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical symptoms of patients on dialysis do not match the signs of coronary disease progression, making the prediction of the true progression of their medical condition in clinical settings difficult. Emergency and concomitant surgeries are significant risk factors of mortality following open-heart surgery in patients on hemodialysis. CASE PRESENTATION We report two cases of successful coronary artery bypass grafting (CABG) in patients on dialysis with a history of cardiac surgery. The first case describes a 65-year-old woman who had undergone aortic valve replacement 2 years ago and was hospitalized urgently, because of a sudden decline in heart function and hypotension. She had moderate mitral regurgitation with right ventricular pressure of 66 mmHg and poor left ventricular function [left ventricular ejection fraction (LVEF), 40%]. Cineangiography revealed an increase in the rate of stenosis in the left main trunk, from 25 to 99% at admission, in addition to 100% occlusion in proximal left anterior descending artery (LAD) and 99% stenosis in the proximal left circumflex artery (LCX). We inserted an intra-aortic balloon pump preoperatively and performed emergency surgery (Euro II risk score, 61.7%; Society of Thoracic Surgeons (STS) risk score, 56.3%). The second case described a 78-year-old man who had undergone surgery for left atrial myxoma 4 years ago and was hospitalized urgently due to dyspnea, chest discomfort, and an LVEF of 44% (Euro II risk score, 40.7%; STS risk score, 33.2%). Cineangiography revealed an increase in the rate of stenosis in the proximal LAD, from 25% (4 years ago) to 90% at admission, in addition to 99% stenosis in proximal LCX and 95% stenosis in the posterolateral branch of LCX. Both patients underwent emergency CABG due to unstable hemodynamics and decreased left ventricular function despite regular dialysis. The surgeries were successful, and the patients were discharged without any complications. CONCLUSIONS In patients with multiple comorbidities and those who undergo dialysis treatment, calcified lesions in coronary arteries can progress severely and rapidly without any symptoms, including chest pain. Close outpatient management involving nephrologists and the cardiovascular team is necessary for patients on dialysis.
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Affiliation(s)
- Hironobu Yamaoka
- Department of Cardiovascular surgery, Edogawa Hospital, Higashi Koiwa 2-24-18, Edogawa-ku, Tokyo, 133-0052, Japan
| | - Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Daisuke Endo
- Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akie Shimada
- Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Satoshi Matsushita
- Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsushi Amano
- Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
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10
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Hess NR, Seese LM, Hong Y, Afflu D, Wang Y, Thoma FW, Kilic A. Gastrointestinal complications after cardiac surgery: Incidence, predictors, and impact on outcomes. J Card Surg 2021; 36:894-901. [PMID: 33428223 DOI: 10.1111/jocs.15321] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/28/2020] [Accepted: 12/30/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the incidence, predictors, and long-term impact of gastrointestinal (GI) complications following adult cardiac surgery. METHODS Index Society of Thoracic Surgeons (STS) adult cardiac operations performed between January 2010 and February 2018 at a single institution were included. Patients were stratified by the occurrence of postoperative GI complications. Outcomes included early and late survival as well as other associated major postoperative complications. A subanalysis of propensity score-matched patients was also performed. RESULTS A total of 10,285 patients were included, and the overall rate of GI complications was 2.4% (n = 246). Predictors of GI complications included dialysis dependency, intra-aortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, and longer aortic cross-clamp times. Thirty-day (2.6% vs. 24.8%), 1- (6.3% vs. 41.9%), and 3-year (11.1% vs. 48.4%) mortality were substantially higher in patients who experienced GI complications (all p < .001). GI complication was associated with a threefold increased hazard for mortality (hazard ratio = 3.1, 95% confidence interval = 2.6-3.7) after risk adjustment, and there was an association between the occurrence of GI complications and increased rates of renal failure (39.4% vs. 2.5%), new dialysis dependency (31.3% vs. 1.5%), multisystem organ failure (21.5% vs .1.0%), and deep sternal wound infections (2.6% vs. 0.2%; all p < .001). These results persisted in propensity-matched analysis. CONCLUSION GI complications are infrequent but have a profound impact on early and late survival, and often occur in association with other major complications. Risk factor modification, heightened awareness, and early detection and management of GI complications appear warranted.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Laura M Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yeahwa Hong
- Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Derek Afflu
- Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd W Thoma
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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11
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Latz CA, Boitano LT, Wang LJ, DeCarlo C, Pendleton AA, Waller HD, Lee CJ, Dua A. Perioperative outcomes for carotid revascularization on asymptomatic dialysis-dependent patients meet Society for Vascular Society guidelines. J Vasc Surg 2020; 74:195-202. [PMID: 33340696 DOI: 10.1016/j.jvs.2020.11.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The current Society for Vascular Surgery practice guidelines recommend carotid revascularization for asymptomatic disease in patients with at least a 3-year life expectancy and stenosis >60% when the expected perioperative stroke and death rate is <3%. Based on this recommendation, it was previously determined that asymptomatic patients who require dialysis would not meet the perioperative stroke and death thresholds nor the long-term survival benchmarks to justify carotid surgery. To determine whether carotid surgery for patients requiring dialysis is appropriate, the present study compared the perioperative outcomes after carotid revascularization for dialysis-dependent patients relative to nondialysis patients in a contemporary, national cohort. METHODS The targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who undergone carotid endarterectomy or carotid artery stenting for asymptomatic carotid disease from 2011 to 2018. The cohort was categorized as requiring or not requiring dialysis. The primary 30-day outcomes included mortality and the composite of stroke/death and stroke/death/myocardial infarction (MI). Univariate analyses were performed using the Fisher exact test and Wilcoxon rank sum test. Multivariable analyses were used to assess the independent associations of the estimated glomerular filtration rate and dialysis dependence with the stroke/death rate. RESULTS A total of 17,579 patients met the inclusion criteria. Of these patients, 226 (1.3%) required dialysis at revascularization. No difference was found in the degree of severe stenosis (80%-99%) demonstrated by 69% of the dialysis cohort and 72% of the nondialysis cohort (P = .9). Of the dialysis and nondialysis cohorts, 5% and 3.6% underwent carotid artery stenting (P = .3). The dialysis-dependent patients were younger (68 vs 71 years; P < .001) and were more likely to have insulin-dependent diabetes (47% vs 12%; P < .001), congestive heart failure (8.4% vs 1.4%; P < .001), and severe chronic obstructive pulmonary disease (15% vs 10%; P = .03). In the dialysis and nondialysis cohort, 2 (0.9%) and 88 (0.5%) patients died (P = .3); 4 (1.8%) and 247 (1.4%) experienced strokes (P = .6); and 3 (1.3%) and 185 (1.1%) patients experienced MI (P = .5), respectively. The composite outcomes of stroke/death and stroke/death/MI was 2.2% (n = 5) and 1.8% (n = 319; P = .6) and 3.5% (n = 8) and 2.8% (n = 479; P = .4) in the dialysis and nondialysis cohorts, respectively. After multivariable analysis, neither the estimated glomerular filtration rate (adjusted odds ratio, 1.0; 95% confidence interval, 1.00-1.01; P = .26) nor dialysis dependence (adjusted odds ratio, 0.21; 95% confidence interval, 0.03-1.57; P = .13) was independently associated with the composite outcome of stroke/death. CONCLUSIONS The 30-day carotid revascularization outcomes for asymptomatic disease in dialysis-dependent patients met the Society for Vascular Surgery guidelines in this national cohort and might be better than previously surmised. Hence, vascular surgeons could consider carotid revascularization for select dialysis-dependent patients with the appropriate expected longevity and perioperative risk.
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Affiliation(s)
- Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anna A Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Cheong J Lee
- Division of Vascular Surgery, NorthShore University Health System, Evanston, Ill
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
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Pang PYK, Teow CKJ, Huang MJ, Naik MJ, Lim SL, Chao VTT, Tan TE, Chua YL, Sin YK. Long-term prognosis in patients with end-stage renal disease after coronary artery bypass grafting. J Thorac Dis 2020; 12:6722-6730. [PMID: 33282373 PMCID: PMC7711392 DOI: 10.21037/jtd-20-2046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Cardiovascular disease is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Coronary artery bypass grafting (CABG) is beneficial in selected patients with ESRD. This study investigates the survival outcomes and prognostic factors in ESRD patients who underwent CABG. Methods A retrospective analysis was performed for 149 patients with ESRD who underwent isolated CABG between 2006 and 2015. Results Mean age was 59.4±8.7 years and 106 patients (71.1%) were male. Operative mortality occurred in 20 patients (13.4%). Overall survival was 81.1%±3.2% at 1 year, 41.5%±4.3% at 5 years and 19.2%±4.2% at 10 years. Median survival was 4.3 years. Multivariable analysis identified age [P=0.001, odds ratio (OR): 1.15 per 1-year increase, 95% confidence interval (CI): 1.06-1.25], preoperative left ventricular ejection fraction (LVEF) (P=0.020, OR: 0.94, 95% CI: 0.89-0.99) and non-elective status of operation (P=0.049, OR: 3.34, 95% CI: 1.00-11.1) as predictors of operative mortality. Cox regression analysis identified age [P<0.001, hazard ratio (HR): 1.05 per 1-year increase, 95% CI: 1.03-1.08], New York Heart Association (NYHA) class III or IV status (P=0.010, HR: 1.75, 95% CI: 1.15-2.67) and the use of a left internal mammary artery (LIMA) to left anterior descending artery (LIMA-LAD) graft (P=0.029, HR: 0.42, 95% CI: 0.19-0.92) as factors influencing long-term survival. Conclusions CABG is associated with high operative mortality and poor long-term survival in ESRD patients. Age and NYHA class influenced late survival. LIMA-LAD grafting conferred a long-term survival advantage.
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Affiliation(s)
- Philip Y K Pang
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Christopher K J Teow
- Ministry of Health Holdings, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ming Jie Huang
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Madhava J Naik
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - See Lim Lim
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Victor T T Chao
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Teing Ee Tan
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Yeow Leng Chua
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Yoong Kong Sin
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
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13
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Cao Y, Fu C, Wang X, Yu C. Correlation Between Neutrophil Count and Prognosis in STEMI Patients with Chronic Renal Dysfunction: A Retrospective Cohort Study. Open Life Sci 2019; 14:659-665. [PMID: 33817205 PMCID: PMC7874805 DOI: 10.1515/biol-2019-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 08/21/2019] [Indexed: 12/01/2022] Open
Abstract
Neutrophil is a key element in inflammation and stress disease, which are associated with poor clinical outcomes in various cardiac diseases. However, the clinical availability of neutrophil in patients with ST-elevation myocardial infarction (STEMI) and chronic renal dysfunction has not been known. Accordingly, we designed this retrospective cohort study to evaluate the differences of major adverse cardiovascular events incidence between renal dysfunctional STEMI patients with normal and high neutrophil levels. The primary end point was all-cause mortality. We analyzed 377 consecutive STEMI patients with chronic renal dysfunction. The results showed that during 12-48 months follow-up, death from any-cause occurred in 1.4% patients (4 of 290) in normal-level neutrophil group, as compared with 3.4% in high-level neutrophil group (3 of 87) (hazard ratio, 2.174 95% confidence interval, 1.024-10.248; P = 0.025). Kaplan-Meier survival analysis showed that there were significant differences between the two groups with respect to the risk of death (P=0.018), and heart failure (P=0.037).
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Affiliation(s)
- Yuhan Cao
- Department of Nephrology, Yi Ji Shan Hospital Affiliated to Wannan Medical College, 92 West Zheshan Road, Wuhu 241001, Anhui, China.,Department of Nephrology, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Cong Fu
- Departments of Cardiology, Yijishan Hospital Affiliated to Wannan Medical College, Wuhu, China.,Department of Cardiology, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Xin Wang
- Department of Cardiology, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Chaojun Yu
- Department of Cardiology, Jiang Yin Peoples' hospital, Jiang Yin, China
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