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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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Risk factors for the in-hospital mortality of CRRT-therapy patients with cardiac surgery-associated AKI: a single-center clinical study in China. Clin Exp Nephrol 2022; 26:1233-1239. [PMID: 36083528 DOI: 10.1007/s10157-022-02274-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/27/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE We retrospectively analyzed risk factors on in-hospital mortality in CRRT-therapy patients with open cardiac surgery (CS)-induced acute kidney injury (AKI), to provide the clinical basis for predicting and lowering the in-hospital mortality after CS. METHODS 84 CS-AKI patients with CRRT were divided into survival and death groups according to discharge status, and the perioperative data were analyzed with R version 4.0.2. RESULTS There were significant differences between the two groups, including: urea nitrogen, Sequential Organ Failure Assessment (SOFA) score and vasoactive-inotropic score (VIS) on the first day after operation; VIS just before CRRT; SOFA score and negative balance of blood volume 24 h after CRRT; the incidence rate of bleeding, severe infection and MODS after operation; and the interval between AKI and CRRT. Univariate logistic regression analysis showed that SOFA score and VIS on the first day after operation; VIS just before CRRT; VIS and negative balance of blood volume 24 h after CRRT; the incidence rate of bleeding, infection and multiple organ dysfunction syndrome (MODS) after operation; bootstrap resampling analysis showed that SOFA score and VIS 24 h after CRRT, as well as the incidence of bleeding after operation were the independent risk factors. CONCLUSION Maintaining stable hemodynamics and active prevention of bleeding are expected to decrease the in-hospital mortality.
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Han H, Wen Z, Wang J, Zhang P, Gong Q, Ge S, Duan J. Prediction of Short-Term Mortality With Renal Replacement Therapy in Patients With Cardiac Surgery-Associated Acute Kidney Injury. Front Cardiovasc Med 2021; 8:738947. [PMID: 34746256 PMCID: PMC8566707 DOI: 10.3389/fcvm.2021.738947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022] Open
Abstract
Objective: We aimed to: (1) explore the risk factors that affect the prognosis of cardiac surgery-associated acute kidney injury (CS-AKI) in patients undergoing renal replacement therapy (RRT) and (2) investigate the predictive value of the Acute Physiology and Chronic Health Evaluation (APACHE) III score, Sequential Organ Failure Assessment (SOFA) score, and Vasoactive-Inotropic Score (VIS) for mortality risk in patients undergoing RRT. Methods: Data from patients who underwent cardiac surgery from January 2015 through February 2021 were retrospectively reviewed to calculate the APACHE III score, SOFA score, and VIS on the first postoperative day and at the start of RRT. Various risk factors influencing the prognosis of the patients during treatment were evaluated; the area under the receiver operating characteristics curve (AUCROC) was used to measure the predictive ability of the three scores. Independent risk factors influencing mortality were analyzed using multivariable binary logistic regression. Results: A total of 90 patients were included in the study, using 90-day survival as the end point. Of those patients, 36 patients survived, and 54 patients died; the mortality rate reached 60%. At the start of RRT, the AUCROC of the APACHE III score was 0.866 (95% CI: 0.795-0.937), the VIS was 0.796 (95% CI: 0.700-0.892), and the SOFA score was 0.732 (95% CI: 0.623-0.842). The AUCROC-value of the APACHE III score on the first postoperative day was 0.790 (95% CI: 0.694-0.885). After analyzing multiple factors, we obtained the final logistic regression model with five independent risk factors at the start of RRT: a high APACHE III score (OR: 1.228, 95% CI: 1.079-1.397), high VIS (OR: 1.147, 95% CI: 1.021-1.290), low mean arterial pressure (MAP) (OR: 1.170, 95% CI: 1.050-1.303), high lactate value (OR: 1.552, 95% CI: 1.032-2.333), and long time from AKI to initiation of RRT (OR: 1.014, 95% CI: 1.002-1.027). Conclusion: In this study, we showed that at the start of RRT, the APACHE III score and the VIS can accurately predict the risk of death in patients undergoing continuous RRT for CS-AKI. The APACHE III score on the first postoperative day allows early prediction of patient mortality risk. Predictors influencing patient mortality at the initiation of RRT were high APACHE III score, high VIS, low MAP, high lactate value, and long time from AKI to the start of RRT.
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Affiliation(s)
| | | | | | | | | | - Shenglin Ge
- Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingsi Duan
- Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, China
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Vekstein AM, Yerokun BA, Jawitz OK, Doberne JW, Anand J, Karhausen J, Ranney DN, Benrashid E, Wang H, Keenan JE, Schroder JN, Gaca JG, Hughes GC. Does deeper hypothermia reduce the risk of acute kidney injury after circulatory arrest for aortic arch surgery? Eur J Cardiothorac Surg 2021; 60:314-321. [PMID: 33624004 DOI: 10.1093/ejcts/ezab044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The impact of hypothermic circulatory arrest (HCA) temperature on postoperative acute kidney injury (AKI) has not been evaluated. This study examined the association between circulatory arrest temperatures and AKI in patients undergoing proximal aortic surgery with HCA. METHODS A total of 759 consecutive patients who underwent proximal aortic surgery (ascending ± valve ± root) including arch replacement requiring HCA between July 2005 and December 2016 were identified from a prospectively maintained institutional aortic surgery database. The primary outcome was AKI as defined by Risk, Injury, Failure, Loss, End Stage Renal Disease (ESRD) criteria. The association between minimum nasopharyngeal (NP) and bladder temperatures during HCA and postoperative AKI was assessed, adjusting for patient-level factors using multivariable logistic regression. RESULTS A total of 85% (n = 645) of patients underwent deep hypothermia (14.1-20.0°C), 11% (n = 83) low-moderate hypothermia (20.1-24.0°C) and 4% (n = 31) high-moderate hypothermia (24.1-28.0°C) as classified by NP temperature. When analysed by bladder temperature, 59% (n = 447) underwent deep hypothermia, 22% (n = 170) low-moderate, 16% (n = 118) high-moderate and 3% mild (n = 24) (28.1-34.0°C) hypothermia. The median systemic circulatory arrest time was 17 min. The incidence of AKI did not differ between hypothermia groups, whether analysed using minimum NP or bladder temperature. In the multivariable analysis, the association between degree of hypothermia and AKI remained non-significant whether analysed as a categorical variable (hypothermia group) or as a continuous variable (minimum NP or bladder temperature) (all P > 0.05). CONCLUSIONS In patients undergoing proximal aortic surgery including arch replacement requiring HCA, degree of systemic hypothermia was not associated with the risk of AKI. These data suggest that moderate hypothermia does not confer increased risk of AKI for patients requiring circulatory arrest, although additional prospective data are needed.
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Affiliation(s)
- Andrew M Vekstein
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Babtunde A Yerokun
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oliver K Jawitz
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Julie W Doberne
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jatin Anand
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jorn Karhausen
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - David N Ranney
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hanghang Wang
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey E Keenan
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob N Schroder
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey G Gaca
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
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Wang Z, Ge M, Chen T, Chen C, Zong Q, Lu L, Wang D. Acute kidney injury in patients operated on for type A acute aortic dissection: incidence, risk factors and short-term outcomes. Interact Cardiovasc Thorac Surg 2020; 31:697-703. [PMID: 32851399 DOI: 10.1093/icvts/ivaa164] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/29/2020] [Accepted: 07/12/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Acute kidney injury (AKI) is a relatively common complication after an operation for type A acute aortic dissection and is indicative of a poor prognosis. We examined the risk factors for and the outcomes of developing AKI in patients being operated on for thoracic aortic diseases. METHODS We retrospectively analysed 712 patients with acute type A dissection who had deep hypothermic circulatory operations from January 2014 to December 2018, emphasizing those who developed AKI. Logistic regression models were used to identify predisposing factors for the postoperative development of AKI. RESULTS Among all enrolled patients, 359 (50.4%) had AKI; of these, 133 were diagnosed as stage 1 (18.7%), 126 were stage 2 (17.7%) and 100 were stage 3 (14.0%). Postoperative haemodialysis was required in 111 patients (15.9%). The development of AKI after aortic surgery contributed to the higher mortality rate within 30 days after surgery (P < 0.001), longer stay in the intensive care unit (P = 0.01) and longer hospital stay (P < 0.001). Binary logistic regression analysis showed that preoperative cystatin C levels [odds ratio (OR) 2.615, 95% confidence interval (CI) 1.139-6.002; P = 0.023] and postoperative ventilation time (OR 1.019, 95% CI 1.005-1.034; P = 0.009) were independent risk factors for developing AKI. Multiple ordinal logistic regression analyses showed that the preoperative cystatin C level (OR 2.921, 95% CI 1.542-5.540; P = 0.001) was an independent risk factor associated with the severity of AKI. CONCLUSIONS Our data suggested that the development of AKI after surgery for type A acute aortic dissection was common and associated with an increased short-term mortality rate. The preoperative cystatin C level was identified as an indicator for the occurrence and severity of AKI postoperatively. Furthermore, we discovered that longer postoperative ventilation time was also associated with the development of AKI.
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Affiliation(s)
- Zhigang Wang
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Min Ge
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Tao Chen
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Cheng Chen
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qiuyan Zong
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lichong Lu
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Dongjin Wang
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Ghincea CV, Reece TB, Eldeiry M, Roda GF, Bronsert MR, Jarrett MJ, Pal JD, Cleveland JC, Fullerton DA, Aftab M. Predictors of Acute Kidney Injury Following Aortic Arch Surgery. J Surg Res 2019; 242:40-46. [DOI: 10.1016/j.jss.2019.03.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/06/2019] [Accepted: 03/22/2019] [Indexed: 12/20/2022]
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8
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Natanov R, Gueler F, Falk CS, Kühn C, Maus U, Boyle EC, Siemeni T, Knoefel AK, Cebotari S, Haverich A, Madrahimov N. Blood cytokine expression correlates with early multi-organ damage in a mouse model of moderate hypothermia with circulatory arrest using cardiopulmonary bypass. PLoS One 2018; 13:e0205437. [PMID: 30308065 PMCID: PMC6181365 DOI: 10.1371/journal.pone.0205437] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/25/2018] [Indexed: 12/12/2022] Open
Abstract
Cardiopulmonary bypass (CPB) with moderate hypothermic cardiac arrest (MHCA) is essential for prolonged complex procedures in cardiac surgery and is associated with postoperative complications. Although cytokine release provoked through MHCA under CPB plays a pivotal role in postoperative organ damage, the pathomechanisms are unclear. Here, we investigated the cytokine release pattern and histological organ damage after MHCA using a recently described mouse CPB model. Eight BALB/c mice underwent 60 minutes of circulatory arrest under CPB, were successively rewarmed and reperfused. Blood cytokine concentrations and liver and kidney function parameters were measured and histological changes to these organs were compared to control animals. Our results showed a marked increase in proinflammatory cytokines and histological changes in the kidney, lung, and liver after CPB. Furthermore, clinical chemistry showed signs of hemolysis and acute kidney injury. These results suggest early onset of solid organ injury which correlates with increased leukocyte infiltration. A better understanding of the interplay between pro-inflammatory cytokine activation and solid organ injury in this model of CBP with MHCA will inform strategies to reduce organ damage during cardiac surgeries in the clinic.
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Affiliation(s)
- Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Faikah Gueler
- Department of Nephrology, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Christine S. Falk
- Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Ulrich Maus
- Department of Pneumology, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Erin C. Boyle
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Ann-Katrin Knoefel
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Serghei Cebotari
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Nodir Madrahimov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
- * E-mail:
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Tarola CL, Losenno KL, Gelinas JJ, Jones PM, Fernandes P, Fox SA, Kiaii B, Chu MWA. Whole body perfusion strategy for aortic arch repair under moderate hypothermia. Perfusion 2017; 33:254-263. [PMID: 29103365 DOI: 10.1177/0267659117724864] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Aortic arch reconstruction under moderate hypothermia is commonly performed with antegrade cerebral perfusion (ACP) for brain protection; however, hypothermia alone is often solely relied upon for visceral and lower body protection. We investigated whether the addition of simultaneous lower body perfusion to ACP (whole body perfusion - WBP) may ameliorate the metabolic derangements of moderate hypothermic circulatory arrest (MHCA). METHODS Between 2008 and 2014, 106 consecutive patients underwent elective or emergent aortic arch surgery with MHCA, with either ACP only (44 patients, 66±12 years, 30% female) or WBP (62 patients, 61±15 years, 31% female). Primary outcomes included 30-day/in-hospital mortality, intensive care unit (ICU) and hospital lengths of stay (LOS) and specific parameters of metabolic recovery. RESULTS There were no significant differences between the groups in 30-day/in-hospital mortality (ACP: 3 (6.8%), WBP: 2 (3.2%); p=0.65), stroke (ACP: 1 (2.3%), WBP: 1 (1.6%); p=1.0) or renal failure (ACP: 2 (4.5%), WBP: 1 (1.5%); p=0.57). In the WBP group, we identified a significant reduction in lactate level at ICU admission (ACP 5.5 vs. WBP 3.5 mmol/L; p=0.002), time to lactate normalization (p=0.014) and median ICU length-of-stay (ACP 3 vs. WBP 1 days; p=0.049). There was no difference in post-operative creatinine (ACP: 104, WBP: 107 μmol/L; p=0.66). After multivariable regression adjustment, perfusion strategy no longer remained an independent predictor of ICU discharge time (p=0.09), however, cardiopulmonary bypass time (p=0.02), age (p=0.012) and emergent surgery (p=0.02) were. CONCLUSIONS A WBP strategy during aortic arch reconstruction with MHCA may be associated with more rapid normalization of metabolic parameters and reduced ICU length of stay compared to using ACP alone. Further evaluation with a randomized trial is warranted.
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Affiliation(s)
| | - Katie L Losenno
- 1 Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Jill J Gelinas
- 1 Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Philip M Jones
- 2 Departments of Anesthesia & Perioperative Medicine and Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Philip Fernandes
- 1 Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Stephanie A Fox
- 1 Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Bob Kiaii
- 1 Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Michael W A Chu
- 1 Division of Cardiac Surgery, Western University, London, Ontario, Canada
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Abstract
Patients undergoing aortic arch surgery are at high risk for stroke, delirium, low cardiac output, respiratory failure, renal failure, and coagulopathy. A significantly higher mortality is seen in patients experiencing any of these complications when compared with those without complications. As surgical, perfusion, and anesthetic techniques improve, the incidence of major complications have decreased. A recent paradigm shift in cardiac surgery has focused on rapid postoperative recovery, and a similar change has affected the care of patients after arch surgery. Nevertheless, a small subset of patients experience significant morbidity and mortality after aortic arch surgery, and rapid identification of any organ dysfunction and appropriate supportive care is critical in these patients. In this article, the current state of postoperative care of the patient after open aortic arch surgery will be reviewed.
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Mourad F, Srivastava V, Duncan A. Aortic arch surgery using selective antegrade cerebral perfusion and mild hypothermia. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.jescts.2016.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Prediction and Prevention of Acute Kidney Injury after Cardiac Surgery. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2985148. [PMID: 27419130 PMCID: PMC4935903 DOI: 10.1155/2016/2985148] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 12/17/2022]
Abstract
The incidence of acute kidney injury after cardiac surgery (CS-AKI) ranges from 33% to 94% and is associated with a high incidence of morbidity and mortality. The etiology is suggested to be multifactorial and related to almost all aspects of perioperative management. Numerous studies have reported the risk factors and risk scores and novel biomarkers of AKI have been investigated to facilitate the subclinical diagnosis of AKI. Based on the known independent risk factors, many preventive interventions to reduce the risk of CS-AKI have been tested. However, any single preventive intervention did not show a definite and persistent benefit to reduce the incidence of CS-AKI. Goal-directed therapy has been considered to be a preventive strategy with a substantial level of efficacy. Many pharmacologic agents were tested for any benefit to treat or prevent CS-AKI but the results were conflicting and evidences are still lacking. The present review will summarize the current updated evidences about the risk factors and preventive strategies for CS-AKI.
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Zhao H, Pan X, Gong Z, Zheng J, Liu Y, Zhu J, Sun L. Risk factors for acute kidney injury in overweight patients with acute type A aortic dissection: a retrospective study. J Thorac Dis 2015; 7:1385-90. [PMID: 26380764 DOI: 10.3978/j.issn.2072-1439.2015.07.19] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 07/09/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND To identify risk factors for acute kidney injury (AKI) in overweight patients who underwent surgery for acute type A aortic dissection (TAAD). METHODS A retrospective study including 108 consecutive overweight patients [body mass index (BMI) ≥24] between December 2009 and April 2013 in Beijing Anzhen Hospital has been performed. AKI was defined by Acute Kidney Injury Network (AKIN) criteria, which is based on serum creatinine (sCr) or urine output. RESULTS The mean age of the patients was 43.69±9.66 years. Seventy-two patients (66.7%) developed AKI during the postoperative period. A logistic regression analysis was performed to identify two independent risk factors for AKI: elevated preoperative sCr level and 72-h drainage volume. Renal replacement therapy (RRT) was required in 15 patients (13.9%). The overall postoperative mortality rate was 7.4%, 8.3% in AKI group and 5.6% in non-AKI group. There is no statistically significant difference between the two groups (P=0.32). CONCLUSIONS A higher incidence of AKI (66.7%) in overweight patients with acute TAAD was confirmed. The logistic regression model identified elevated preoperative sCr level and 72-h drainage volume as independent risk factors for AKI in overweight patients. We should pay more attention to prevent AKI in overweight patients with TAAD.
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Affiliation(s)
- Honglei Zhao
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Aortic Disease Center, Beijing 100029, China
| | - Xudong Pan
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Aortic Disease Center, Beijing 100029, China
| | - Zhizhong Gong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Aortic Disease Center, Beijing 100029, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Aortic Disease Center, Beijing 100029, China
| | - Yongmin Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Aortic Disease Center, Beijing 100029, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Aortic Disease Center, Beijing 100029, China
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Aortic Disease Center, Beijing 100029, China
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Risk factors for acute kidney injury after surgery of the thoracic aorta using antegrade selective cerebral perfusion and moderate hypothermia. J Thorac Cardiovasc Surg 2015; 150:127-33.e1. [DOI: 10.1016/j.jtcvs.2015.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 03/16/2015] [Accepted: 04/02/2015] [Indexed: 11/18/2022]
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Reduction in the incidence of acute kidney injury after aortic arch surgery with low-dose atrial natriuretic peptide: a randomised controlled trial. Eur J Anaesthesiol 2015; 31:381-7. [PMID: 24384584 DOI: 10.1097/eja.0000000000000035] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) after surgery is associated with an increased risk of adverse events and death. Atrial natriuretic peptide (ANP) dilates the preglomerular renal arteries and inhibits the renin-angiotensin axis. A low-dose ANP infusion increases glomerular filtration rate after cardiovascular surgery, but it is not known whether it reduces the incidence of AKI or the mortality rate. OBJECTIVE To evaluate whether an intravenous ANP infusion prevents AKI in patients undergoing aortic arch surgery requiring hypothermic circulatory arrest. DESIGN A randomised controlled study. SETTING Operating room and intensive care unit at Kawasaki Saiwai Hospital, Kanagawa, Japan. PATIENTS Forty-two patients with normal preoperative renal function undergoing elective repair of an aortic arch aneurysm. INTERVENTION Patients were assigned randomly to receive a fixed dose of ANP (0.0125 μg (-1) kg(-1) min) or placebo. The infusion was started after induction of anaesthesia and continued for 24 h postoperatively. MAIN OUTCOME MEASURES The primary end-point was the incidence of AKI within 48 h after surgery. RESULTS AKI developed in 30% of patients who received ANP compared with 73% of patients who received placebo (P = 0.014). Intraoperative urine output was almost 1 l greater in patients who received ANP (1865 ± 1299 versus 991 ± 480 ml in the control group, P = 0.005). However, there were no differences in mean arterial pressure or number of episodes of hypotension between the groups. Length of hospital and intensive care stays were not significantly different, nor was there a difference in 30-day mortality. No patients required haemodialysis or continuous renal replacement therapy. CONCLUSION We found that an intravenous infusion of ANP at 0.0125 μg kg(-1) min(-1) is an effective intervention for reducing the incidence of postoperative AKI, and appears to afford a degree of renal protection during and after cardiovascular surgery. TRIAL REGISTRATION Kawasaki ANP trial, UMIN Clinical Trials Registry ID: UMIN000011650.
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Kim WH, Park MH, Kim HJ, Lim HY, Shim HS, Sohn JT, Kim CS, Lee SM. Potentially modifiable risk factors for acute kidney injury after surgery on the thoracic aorta: a propensity score matched case-control study. Medicine (Baltimore) 2015; 94:e273. [PMID: 25590836 PMCID: PMC4602544 DOI: 10.1097/md.0000000000000273] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Perioperative risk factors were identified for acute kidney injury (AKI) defined by the RIFLE criteria (RIFLE = risk, injury, failure, loss, end stage) after surgery on the thoracic aorta with cardiopulmonary bypass (CPB) in this case-control study. A retrospective review was completed for 702 patients who underwent surgery on the thoracic aorta with CPB. A total of 183 patients with AKI were matched 1:1 with patients without AKI by a propensity score. Matched variables included age, gender, body-mass index, preoperative creatinine levels, estimated glomerular filtration rate, a history of hypertension, diabetes mellitus, cerebrovascular accident, smoking history, or chronic obstructive pulmonary disease to exclude the influence of patient demographics, preoperative medical status, and baseline renal function. Multivariate logistic regression analysis was used to evaluate for independent risk factors in the matched sample of 366 patients. The incidence of AKI was 28.6% and 5.9% of patients from the entire sample required renal replacement therapy. AKI was associated with a prolonged postoperative hospital stay and a higher one-month and one-year mortality both in the entire and matched sample set. Independent risk factors for AKI were a left ventricular ejection fraction <55%, preoperative hemoglobin level <10 g/dL, albumin <4.0 g/dL, diagnosis of dissection, operation time >7 hours, deep hypothermic circulatory arrest (DHCA) time >30 min, pRBC transfusion >1000 mL, and FFP transfusion >500 mL. Although the incidence of poor glucose control (blood glucose >180 mg/dL) was higher in patients with AKI in matched sample, it was not an independent risk factor.AKI was still associated with a poor clinical outcome in the matched sample. Potentially modifiable risk factors included preoperative anemia and hypoalbuminemia. Efforts to minimize operation time and DHCA time along with transfusion amount may protect patients undergoing aortic surgery against AKI.
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Affiliation(s)
- Won Ho Kim
- From the Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea (WHK, HSS); Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (MHP, HJK, H-YL, CSK, SML); and Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea (J-TS)
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Low levels of urinary liver-type fatty acid-binding protein may indicate a lack of kidney protection during aortic arch surgery requiring hypothermic circulatory arrest. J Clin Anesth 2014; 26:118-24. [PMID: 24582841 DOI: 10.1016/j.jclinane.2013.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 07/18/2013] [Accepted: 07/31/2013] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To examine the change in liver-type fatty acid-binding protein (L-FABP) levels in patients undergoing aortic arch surgery and the correlation between L-FABP and postoperative acute kidney injury. DESIGN Prospective observational study. SETTING Operating room of a general hospital. PATIENTS 36 adult patients. INTERVENTIONS AND MEASUREMENTS Urine samples were obtained to measure urinary L-FABP at initiation of cardiopulmonary bypass (CPB) and 5 minutes after termination of hypothermic circulatory arrest. MAIN RESULTS 22 (61.1%) patients developed acute kidney injury within a 48-hour period. L-FABP increases more than a thousand-fold were found. In patients who subsequently developed acute kidney injury, significant increases in L-FABP were noted from 2.9 (3.6) ng/mg of creatinine before CPB to 62.1 (995.6) ng/mg of creatinine 5 minutes after termination of circulatory arrest. Values in patients who did not develop acute kidney injury increased from 1.1 (5.7) ng/mg before CPB to 1133.0 (6358.8) ng/mg of creatinine showing a significant mean difference (P = 0.011). The area under the L-FABP receiver operating characteristic curve at 5 minutes after termination of circulatory arrest was 0.758. A cutoff value of 75.13 ng/mg of creatinine yielded both good sensitivity (1.000) and specificity (0.546) for detecting non-acute kidney injury. Patients who developed acute kidney injury after aortic arch surgery demonstrated lower levels of urinary L-FABP. CONCLUSIONS Low levels of urinary L-FABP may indicate kidney injury and lack of renal protection.
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Shin S, Han Y, Park H, Chung YS, Ahn H, Kim CS, Cho YP, Kwon TW. Risk factors for acute kidney injury after radical nephrectomy and inferior vena cava thrombectomy for renal cell carcinoma. J Vasc Surg 2013; 58:1021-7. [DOI: 10.1016/j.jvs.2013.02.247] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 02/20/2013] [Accepted: 02/27/2013] [Indexed: 11/24/2022]
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Kim WH, Lee SM, Choi JW, Kim EH, Lee JH, Jung JW, Ahn JH, Sung KI, Kim CS, Cho HS. Simplified clinical risk score to predict acute kidney injury after aortic surgery. J Cardiothorac Vasc Anesth 2013; 27:1158-66. [PMID: 24050856 DOI: 10.1053/j.jvca.2013.04.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The authors identified risk factors for acute kidney injury (AKI) defined by risk, injury, failure, loss, end-stage (RIFLE) criteria after aortic surgery with cardiopulmonary bypass and constructed a simplified risk score for the prediction of AKI. DESIGN Retrospective and observational. SETTING Single large university hospital. PARTICIPANTS Patients (737) who underwent aortic surgery with cardiopulmonary bypass between 1997 and 2010. MAIN RESULTS Multivariate logistic regression analysis was used to evaluate risk factors. A scoring model was developed in a randomly selected derivation cohort (n = 417), and was validated on the remaining patients. The scoring model was developed with a score based on regression β-coefficient, and was compared with previous indices as measured by the area under the receiver operating characteristic curve (AUC). The incidence of AKI was 29.0%, and 5.8% required renal replacement therapy. Independent risk factors for AKI were age older than 60 years, preoperative glomerular filtration rate <60 mL/min/1.73 m(2), left ventricular ejection fraction <55%, operation time >7 hours, intraoperative urine output <0.5 mL/kg/h, and intraoperative furosemide use. The authors made a score by weighting them at 1 point each. The risk score was valid in predicting AKI, and the AUC was 0.74 [95% confidence interval (CI): 0.69 to 0.79], which was similar to that in the validation cohort: 0.74 (95% CI: 0.69 to 0.80; p = 0.97). The risk-scoring model showed a better performance compared with previously reported indices. CONCLUSIONS The model would provide a simplified clinical score stratifying the risk of postoperative AKI in patients undergoing aortic surgery.
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Affiliation(s)
- Won Ho Kim
- Department of Anesthesiology and Pain Medicine
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Leshnower BG, Myung RJ, Chen EP. Aortic arch surgery using moderate hypothermia and unilateral selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2:288-95. [PMID: 23977596 DOI: 10.3978/j.issn.2225-319x.2013.02.02] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 02/18/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND Cerebral protection and circulatory management remains a controversial issue in aortic arch surgery. The present study reported surgical outcomes of arch repair using moderate hypothermic circulatory arrest (MHCA) and unilateral selective antegrade perfusion (uSACP). METHODS From January 2004 and December 2012, 500 patients underwent hemiarch repair (HARCH) and 124 underwent total arch replacement (TARCH) utilizing moderate hypothermic circulatory arrest with unilateral selective antegrade cerebral perfusion of the right axillary artery. Emergent surgery was required in 142 (28.4%) of HARCH patients and 18 (14.5%) of TARCH patients. Mean arrest temperature ranged from 25.6-27.2 °C for elective and emergent operations in both groups. Mean circulatory arrest was 26.8 minutes for hemiarch repairs and 54.2 minutes for total arch replacement. RESULTS Overall mortality was 6.6% for hemiarch repairs and 9.7% for total arch replacements. Hospital mortality was 4.5% (16/358) and 10.4% (11/106) in elective cases, and 12% (17/142) and 5.6% (1/18) in elective cases, for hemiarch and total arch replacements respectively. Permanent neurological deficit (PND) occurred in 3 total arch replacement cases (2.4%). Multivariate analysis demonstrated that temperature was not found to be an independent risk factor during hemiarch or total arch replacements for mortality, permanent or neurological deficits, or renal failure. CONCLUSIONS Our approach for hemiarch and total arch repair utilizing MHCA and uSACP via the right axillary artery was associated excellent neurological and survival outcomes. Moderate hypothermia did not adversely impact cerebral or visceral organ protection.
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Affiliation(s)
- Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Hu Y, Li Z, Chen J, Shen C, Song Y, Zhong Q. The effect of the time interval between coronary angiography and on-pump cardiac surgery on risk of postoperative acute kidney injury: a meta-analysis. J Cardiothorac Surg 2013; 8:178. [PMID: 23915489 PMCID: PMC3750660 DOI: 10.1186/1749-8090-8-178] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/01/2013] [Indexed: 11/10/2022] Open
Abstract
Background Reports of the association between the time interval from coronary angiography (CAG) to cardiac surgery and risk of postoperative acute kidney injury (AKI) are controversial. We attempted to examine this association by conducting a meta-analysis. Methods We searched the Pubmed, MEDLINE, EMBASE, Web of Science databases, and the Cochrane Library from January 1966 to March 2013. A meta-analysis of studies reporting data for 1-day and 3-day time intervals between CAG and cardiac surgery was conducted after evaluation of heterogeneity and publication bias. Study-specific estimates were combined with inverse variance-weighted averages of logarithmic odds ratios (ORs) in fixed-effects models. Results From 8 studies involving 11542 persons, the pooled OR of AKI associated with an interval of 1 day or less between CAG and surgery was 1.21 (95% confidence interval (CI), 1.04 to 1.39) relative to an interval of more than 1 day. From 4 studies involving 5420 persons in the cardiopulmonary-bypass subgroup, the pooled OR of AKI associated with an interval of 3 days or less between CAG and surgery was 1.25 (95% CI, 1.07 to 1.43) relative to an interval of more than 3 days. The adjusted OR of the study in the cardiopulmonary bypass/ deep hypothermic circulatory arrest subgroup was 0.35 (95% CI, 0.17 to 0.73). Conclusions A time interval of 1 day or less between CAG and on-pump cardiac surgery was significantly associated with increased risk of AKI. A delay of on-pump cardiac surgery until 24 hours after CAG can potentially decrease postoperative AKI.
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Outcome of elective total aortic arch replacement in patients with non-dialysis-dependent renal insufficiency stratified by estimated glomerular filtration rate. J Thorac Cardiovasc Surg 2013; 147:966-972.e2. [PMID: 23507123 DOI: 10.1016/j.jtcvs.2013.02.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 02/07/2013] [Accepted: 02/14/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Little is known about the impact of preoperative renal function stratified by estimated glomerular filtration rate (eGFR) on outcomes of total aortic arch replacement (TAR). The current study addressed this issue and identified a cutoff value of eGFR for the requirement of postoperative renal replacement therapy. METHODS From January 2000 to May 2011, 229 consecutive patients who did not require preoperative hemodialysis were retrospectively studied after elective TAR. Patients were grouped into the following categories: those with normal renal function (eGFR >90 mL/min/1.73 m(2); n = 11) and those with mild (eGFR, 60-90 mL/min/1.73 m(2); n = 86), moderate (eGFR, 30-59 mL/min/1.73 m(2); n = 111), or severe (eGFR <30 mL/min/1.73 m(2); n = 21) renal dysfunction. Linear trend tests demonstrated that the lower categories of eGFR were associated with a higher age, hypertension, coronary artery disease, peripheral arterial disease, and a higher EuroSCORE II. RESULTS The overall hospital mortality was 2.2%. A lower categories of eGFR were an independent risk factor for hospital mortality (odds ratio, 0.91; P = .002) and postoperative renal replacement therapy (odds ratio, 0.94; P < .002). A cutoff value for the requirement of postoperative renal replacement therapy was 26.0 mL/min/1.73 m(2). Patients in the lower categories of eGFR had significantly higher hospital mortality (P = .03) and more morbidities, such as renal replacement therapy (P < .01), postoperative permanent neurologic deficits (P = .013), and prolonged mechanical ventilatory support (P < .01). Midterm survival and freedom from major adverse cerebrocardiovascular events were worse across the levels of the lower categories of eGFR. CONCLUSIONS Preoperative eGFR is a strong predictor of short- and midterm outcomes in contemporary TAR.
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Thomas M, Li Z, Cook DJ, Greason KL, Sundt TM. Contemporary results of open aortic arch surgery. J Thorac Cardiovasc Surg 2012; 144:838-44. [DOI: 10.1016/j.jtcvs.2011.09.069] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/13/2011] [Accepted: 09/21/2011] [Indexed: 10/14/2022]
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Augoustides JG. The Inflammatory Response to Cardiac Surgery With Cardiopulmonary Bypass: Should Steroid Prophylaxis Be Routine? J Cardiothorac Vasc Anesth 2012; 26:952-8. [DOI: 10.1053/j.jvca.2012.05.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Indexed: 11/11/2022]
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Patel PA, Ramakrishna H, Andritsos M, Wyckoff T, Riha H, Augoustides JGT. The year in Cardiothoracic and Vascular Anesthesia: selected highlights from 2011. J Cardiothorac Vasc Anesth 2012; 26:3-10. [PMID: 22221506 DOI: 10.1053/j.jvca.2011.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Indexed: 11/11/2022]
Abstract
There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive valve surgery has shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for percutaneous coronary intervention in acute coronary syndromes but significantly reduces the risk of local vascular complications. Recent trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. The past year has witnessed major advances in cardiovascular practice with new drugs, new devices, and new guidelines. The coming year most likely will advance these achievements to enhance the care of patients.
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Affiliation(s)
- Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Fernandes P, Cleland A, Adams C, Chu MWA. Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery. Perfusion 2012; 27:493-501. [DOI: 10.1177/0267659112453753] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgical repair of transverse aortic arch aneurysms frequently employ hypothermia and antegrade cerebral perfusion as protective strategies during circulatory arrest. However, prolonged mesenteric and lower limb ischemia can lead to significant lactic acidosis and end organ dysfunction, which remains a significant cause of post-operative morbidity and mortality. We report our experience with additive warm mesenteric and lower body perfusion (1-3 L/min, 30°C) in addition to continuous cerebral and myocardial perfusion in 5 patients who underwent total aortic arch replacement with trifurcated head vessel re-implantation and distal elephant trunk reconstruction. Concomitant surgical procedures included re-operations (2), aortic root operations (2), coronary artery bypass (2) and descending thoracic aortic replacement (1). Serum lactate levels demonstrated a rapid decline from a peak 9.9±2.6 post circulatory arrest to 3.4±2.0 in the intensive care unit (ICU). The lowest serum bicarbonate levels were 19.3±3.5 mmol/L, intra-operatively, which normalized to 28.4±2.4 mmol/L on return to the ICU. The lowest pH levels were 7.25±0.10, corrected to 7.43±0.04 on return to the ICU. Mean cardiopulmonary bypass and aortic cross-clamp times were 361±104 and 253±85 minutes, respectively. Mean cerebral and lower body circulatory arrest times were 0 (0) and 50±35 minutes, respectively. The mean time required for systemic rewarming was 95±66 minutes. There were no in-hospital mortalities and no patient experienced any neurological, mesenteric, renal or lower limb ischemic complications. Two patients required mechanical ventilation >24 hours, and one patient returned for reoperation for bleeding. Median intensive care unit and total hospital lengths of stay were 5 and 16 days, respectively. Our results suggest early serum lactate clearance, normalization of acidosis, and metabolic recovery when utilizing a simultaneous cerebral perfusion and warm body protection strategy for complex aortic arch surgery. This additive perfusion strategy may attenuate visceral and lower body ischemia that normally develops during periods of deep hypothermic circulatory arrest.
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Affiliation(s)
- P Fernandes
- Clinical Perfusion Services, Cardiac Care, University of Western Ontario, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - A Cleland
- Clinical Perfusion Services, Cardiac Care, University of Western Ontario, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - C Adams
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - MWA Chu
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
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Roh GU, Lee JW, Nam SB, Lee J, Choi JR, Shim YH. Incidence and risk factors of acute kidney injury after thoracic aortic surgery for acute dissection. Ann Thorac Surg 2012; 94:766-71. [PMID: 22727320 DOI: 10.1016/j.athoracsur.2012.04.057] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/12/2012] [Accepted: 04/16/2012] [Indexed: 01/30/2023]
Abstract
BACKGROUND Previous studies have reported a high incidence of acute kidney injury (AKI) after thoracic aortic surgery in heterogeneous patient cohorts, including various aortic diseases and the use of deep hypothermic circulatory arrest. Moderate hypothermia with cerebral perfusion makes deep hypothermia nonessential, but can make end organs susceptible to ischemia during circulatory arrest. We investigated the incidence and risk factors of AKI after thoracic aortic surgery with and without moderate hypothermic circulatory arrest for acute dissection. METHODS We reviewed the medical records of 98 patients undergoing graft replacement of the thoracic aorta for acute dissection between 2008 and 2011 at a university hospital. Acute kidney injury was defined by RIFLE criteria, which is based on serum creatinine or glomerular filtration rate. RESULTS The mean age was 55±15 years. The surgical procedures, 96% of which were emergencies, involved the ascending aorta (67%), aortic arch (41%), descending aorta (41%), and aortic valve (5%). Moderate hypothermic circulatory arrest was performed in 75%. The overall incidence of AKI was 54%, and 11% of 98 patients required renal replacement therapy. Thirty-day mortality increased with AKI severity (p=0.002). Independent risk factors for AKI were long cardiopulmonary bypass duration (>180 minutes; odds ratio, 7.50; p=0.008) and preoperative serum creatinine level (odds ratio, 8.43; p=0.016). CONCLUSIONS Acute kidney injury was common after thoracic aortic surgery for acute dissection with or without moderate hypothermic circulatory arrest and worsened 30-day mortality. Prolonged cardiopulmonary bypass and increased preoperative serum creatinine were independent risk factors for AKI, but moderate hypothermic circulatory arrest was not.
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Affiliation(s)
- Go Un Roh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Matsuyama S, Tabata M, Shimokawa T, Matsushita A, Fukui T, Takanashi S. Outcomes of total arch replacement with stepwise distal anastomosis technique and modified perfusion strategy. J Thorac Cardiovasc Surg 2012; 143:1377-81. [DOI: 10.1016/j.jtcvs.2011.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/10/2011] [Accepted: 07/13/2011] [Indexed: 11/27/2022]
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Mariscalco G, Nicolini F, Scannapieco A, Gherli R, Serraino F, Dominici C, Renzulli A, Gherli T, Sala A, Beghi C. Acute kidney injury after composite valve-graft replacement for ascending aorta aneurysms. Heart Vessels 2012; 28:229-36. [PMID: 22411492 DOI: 10.1007/s00380-012-0239-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 02/03/2012] [Indexed: 10/28/2022]
Abstract
Acute kidney injury (AKI) following cardiac surgery is a continuing source of morbidity and mortality. Although several studies have attempted to determine its etiology and prophylactic measures, limited data exist after thoracic aortic surgery. The aim of this study was to evaluate the incidence and predictors of AKI in patients undergoing aortic root replacement (ARR) with valve conduit for ascending aorta aneurysms. A multi-center observational study of 414 patients undergoing ARR with a valve conduit was conducted, focusing on clinical outcome and AKI defined by consensus RIFLE (risk, injury, failure, loss of function, end-stage renal disease) criteria. Mean age was 62.5 years (range: 21-82 years) with 327 males (79%). Emergent operations were performed in 5% of the cases, while concomitant surgical procedures were performed in 24.9%. Postoperative AKI (all RIFLE classes) occurred in 69 (16.7%) patients, while eight (1.9%) required dialysis. Independent AKI predictors were packed red blood cells (pRBCs) >4 units (OR 2.28; 95% CI 1.20-4.30), cardiopulmonary bypass (CPB) time longer than 180 min (OR, 2.08; 95% CI, 1.16-3.73), and concomitant surgical procedures (OR, 1.85; 95% CI, 1.04-3.29). The severity of RIFLE class was associated with longer ICU stay, hospitalization, and higher hospital mortality (p < 0.001 for each variable). AKI after ARR operations with valve conduit for ascending aorta aneurysms increases utilization of health resources and is associated with adverse events. Concomitant surgical procedures, prolonged CPB-time, and pRBCs >4 units as independent AKI predictors merit further researches enhancing possible preventive strategies.
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Affiliation(s)
- Giovanni Mariscalco
- Department of Surgical and Morphological Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria, Varese, Italy.
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Andersen ND, Williams JB, Fosbol EL, Shah AA, Bhattacharya SD, Mehta RH, Hughes GC. Cardiac catheterization within 1 to 3 days of proximal aortic surgery is not associated with increased postoperative acute kidney injury. J Thorac Cardiovasc Surg 2012; 143:1404-10. [PMID: 22341657 DOI: 10.1016/j.jtcvs.2012.01.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/17/2011] [Accepted: 01/24/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Cardiac catheterization shortly before coronary artery bypass grafting or valve surgery has been associated with increased postoperative acute kidney injury. The relationship between catheterization timing and acute kidney injury after proximal aortic surgery remains unknown. METHODS Between August 2005 and February 2011, a total of 285 consecutive patients underwent cardiac catheterization before elective proximal aortic surgery with cardiopulmonary bypass at a single institution. The association between timing of catheterization and postoperative acute kidney injury (defined as postoperative increase in serum creatinine ≥ 50% of baseline) was assessed using logistic regression analysis. RESULTS Of 285 patients, 152 (53%) underwent catheterization on preoperative days 1 to 3 and 133 (47%) underwent catheterization on preoperative day 4 or before. Acute kidney injury occurred in 88 (31%) patients, 3 (1.1%) requiring dialysis. Acute kidney injury occurred in 37 (24%) patients catheterized on preoperative days 1 to 3, and 51 (38%) patients catheterized on preoperative day 4 or before. Catheterization on preoperative days 1 to 3 was not associated with an increased risk of acute kidney injury relative to catheterization on preoperative day 4 or before (unadjusted odds ratio, 0.52; 95% confidence interval, 0.31-0.86; P = .01; adjusted odds ratio, 0.35; 95% confidence interval, 0.17-0.73; P = .005). CONCLUSIONS Cardiac catheterization within 1 to 3 days of elective proximal aortic surgery appears safe and should be considered acceptable practice for patients at low risk of acute kidney injury.
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Affiliation(s)
- Nicholas D Andersen
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Schloss B, Gulati P, Yu L, Abdel-Rasoul M, O'Brien W, Von Visger J, Awad H. Impact of aprotinin and renal function on mortality: a retrospective single center analysis. J Cardiothorac Surg 2011; 6:103. [PMID: 21878108 PMCID: PMC3178482 DOI: 10.1186/1749-8090-6-103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 08/30/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An estimated up to 7% of high-risk cardiac surgery patients return to the operating room for bleeding. Aprotinin was used extensively as an antifibrinolytic agent in cardiac surgery patients for over 15 years and it showed efficacy in reducing bleeding. Aprotinin was removed from the market by the U.S. Food and Drug Administration after a large prospective, randomized clinical trial documented an increased mortality risk associated with the drug. Further debate arose when a meta-analysis of 211 randomized controlled trials showed no risk of renal failure or death associated with aprotinin. However, only patients with normal kidney function have been studied. METHODS In this study, we look at a single center clinical trial using patients with varying degrees of baseline kidney function to answer the question: Does aprotinin increase odds of death given varying levels of preoperative kidney dysfunction? RESULTS Based on our model, aprotinin use was associated with a 3.8-fold increase in odds of death one year later compared to no aprotinin use with p-value = 0.0018, regardless of level of preoperative kidney dysfunction after adjusting for other perioperative variables. CONCLUSIONS Lessons learned from our experience using aprotinin in the perioperative setting as an antifibrinolytic during open cardiac surgery should guide us in testing future antifibrinolytic drugs for not only efficacy of preventing bleeding, but for overall safety to the whole organism using long-term clinical outcome studies, including those with varying degree of baseline kidney function.
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Affiliation(s)
- Brian Schloss
- Department of Anesthesiology, The Ohio State University Medical Center, (410 West 10th Avenue), Columbus, (43210), USA
| | - Parul Gulati
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - Lianbo Yu
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - William O'Brien
- Perfusion Services, The Ohio State University Medical Center, (452 W. 10th Avenue), Columbus, (43210), USA
| | - Jon Von Visger
- Department of Nephrology, The Ohio State University Medical Center, (395 West 12th Avenue), Columbus, 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, The Ohio State University Medical Center, (410 West 10th Avenue), Columbus, (43210), USA
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Mori Y, Sato N, Kobayashi Y, Ochiai R. Acute kidney injury during aortic arch surgery under deep hypothermic circulatory arrest. J Anesth 2011; 25:799-804. [PMID: 21847704 DOI: 10.1007/s00540-011-1210-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Accepted: 08/04/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of this investigation was to describe the renal outcome and to identify risk factors for acute kidney injury (AKI), as defined by the Acute Kidney Injury Network (AKIN), during aortic arch surgery (AAS) under deep hypothermic circulatory arrest (DHCA). METHODS A retrospective and observational study has been performed. One hundred thirty-five patients requiring AAS under DHCA were studied. RESULTS Seventy-one patients (52.6%) developed AKI during the postoperative period. A logistic regression analysis identified three independent risk factors for AKI: preoperative hypertension (HT), emergency surgery, and duration of DHCA. Renal replacement therapy (RRT) was required in four patients (3.0%). The postoperative mortality rate among the patients with AKI was 2.8%, which was not statistically different from the rate of 1.6% observed in the non-AKI group (P = 0.62). CONCLUSIONS A high incidence of AKI during AAS under DHCA was confirmed. Because AKI is highly associated with aortic surgery, novel approaches for protecting the kidneys other than deep hypothermia are needed. The logistic regression model identified HT, emergency surgery, and duration of DHCA as independent risk factors for AKI.
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Affiliation(s)
- Yosuke Mori
- The First Department of Anesthesiology, Toho University, School of Medicine, 6-11-1, Ohmori-Nishi, Ohta-ku, Tokyo, 143-8541, Japan
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Englberger L, Suri RM, Greason KL, Burkhart HM, Sundt TM, Daly RC, Schaff HV. Deep hypothermic circulatory arrest is not a risk factor for acute kidney injury in thoracic aortic surgery. J Thorac Cardiovasc Surg 2011; 141:552-8. [DOI: 10.1016/j.jtcvs.2010.02.045] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 01/28/2010] [Accepted: 02/28/2010] [Indexed: 11/25/2022]
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Leshnower BG, Myung RJ, Kilgo PD, Vassiliades TA, Vega JD, Thourani VH, Puskas JD, Guyton RA, Chen EP. Moderate Hypothermia and Unilateral Selective Antegrade Cerebral Perfusion: A Contemporary Cerebral Protection Strategy for Aortic Arch Surgery. Ann Thorac Surg 2010; 90:547-54. [DOI: 10.1016/j.athoracsur.2010.03.118] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 03/28/2010] [Accepted: 03/30/2010] [Indexed: 11/28/2022]
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Kim JH, Lee JS, Lee SH, Bae WK, Kim NH, Kim KA, Moon YS. Renal Dysfunction Induced by Bacterial Infection other than Spontaneous Bacterial Peritonitis in Patients with Cirrhosis: Incidence and Risk Factor. Gut Liver 2009; 3:292-7. [PMID: 20431763 PMCID: PMC2852737 DOI: 10.5009/gnl.2009.3.4.292] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 11/20/2009] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Deterioration of renal function in cirrhotic patients with spontaneous bacterial peritonitis (SBP) is a predictor for in-hospital mortality; however, the clinical significance of renal dysfunction during bacterial infection other than SBP is unknown. The aim of this study was to investigate the prevalence and clinical significance of renal dysfunction due to bacterial infections other than SBP in patients with liver cirrhosis. Methods Retrospective data from inpatients with bacterial infections other than SBP were analyzed. Results Eighty patients were recruited for the analysis. The types of infections included that of urinary tract (37.5%), pneumonia (23.8%), biliary tract (20%), cellulitis (12.5%), and bacteremia of unknown origin (6.3%). Renal dysfunction developed in 29 patients (36.3%), of which 11 patients had irreversible renal dysfunction. The initial MELD score, neutrophil count, albumin, and blood pressure were significant risk factors in the univariate analysis, whereas only the MELD score was an independent risk factor for the development of renal dysfunction (p<0.001) after multivariate analysis. Conclusions The prevalence of renal dysfunction during bacterial infection other than SBP in patients with liver cirrhosis was 36.3%, and its development was related to the severity of the liver disease. Occurrence of irreversible renal dysfunction seemed to affect the prognosis of these patients.
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Affiliation(s)
- Jong Hoon Kim
- Department of Inetrnal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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Lei Q, Chen L, Jin M, Ji H, Yu Q, Cheng W, Li L. Preoperative and intraoperative risk factors for prolonged intensive care unit stay after aortic arch surgery. J Cardiothorac Vasc Anesth 2009; 23:789-94. [PMID: 19729322 DOI: 10.1053/j.jvca.2009.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study was performed to evaluate preoperative and intraoperative risk factors for prolonged intensive care unit (ICU) stay after aortic arch surgery. DESIGN A retrospective study. Prolonged ICU stay was defined as >5 days (120 hours). SETTING Cardiovascular operating rooms and the ICU. PARTICIPANTS Adults requiring aortic arch surgery with deep hypothermic circulatory arrest plus antegrade selective cerebral perfusion. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After 11 patients who underwent 1-stage total or subtotal aortic replacement were excluded, 298 patients were enrolled in the study. The average age of patients was 44.9 +/- 10.7 years with male predominance (74.8%). Sixty-one patients (20.5%) stayed longer than 5 days in the ICU. Univariate analyses found age, body mass index, New York Heart Association classification, preoperative serum creatinine, creatinine clearance, emergency, inotropes, cardiopulmonary bypass time, myocardial ischemia time, and fresh-frozen plasma transfused intraoperatively were significantly associated with prolonged ICU stay (p < 0.05). Independent risk factors for prolonged ICU stay were found to be New York Heart Association classification (class III and IV), emergency, inotropes used intraoperatively, and prolonged cardiopulmonary bypass time (p < 0.05). CONCLUSION The authors identified 4 preoperative and intraoperative risk factors for prolonged ICU stay. This is helpful to identify patients with increased risk for prolonged ICU stay, implement specific strategies, and allocate medical resources.
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Affiliation(s)
- Qian Lei
- Department of Anesthesiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lei Q, Chen L, Zhang Y, Fang N, Cheng W, Li L. Predictors of Prolonged Mechanical Ventilation After Aortic Arch Surgery With Deep Hypothermic Circulatory Arrest Plus Antegrade Selective Cerebral Perfusion. J Cardiothorac Vasc Anesth 2009; 23:495-500. [DOI: 10.1053/j.jvca.2008.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Indexed: 11/11/2022]
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Abstract
Aprotinin is a polypeptide serine protease inhibitor used to prevent bleeding and need for transfusions in patients having heart surgery. A recent analysis of an observational study data set suggested the use of aprotinin was associated with an increased risk of developing renal failure. The present article reviews the data from basic science studies in tissues, animals and man together with the data from observational studies and randomised controlled trials. The interpretation of the data is hampered owing to the use of different endpoints to describe mild/moderate renal impairment. Nonetheless, the evidence points to aprotinin use being associated with a transient small rise in plasma creatinine concentration in certain patients. There is no evidence for an increased risk of developing new renal failure requiring dialysis/renal replacement therapy.
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Affiliation(s)
- Marie Bosman
- Royal Brompton and Harefield NHS Trust, Harefield Hospital, Hill End Road, Harefield, UB9 6JH, UK
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Filsoufi F, Rahmanian PB, Castillo JG, Silvay G, Carpentier A, Adams DH. Predictors and Early and Late Outcomes of Dialysis-Dependent Patients in Contemporary Cardiac Surgery. J Cardiothorac Vasc Anesth 2008; 22:522-9. [DOI: 10.1053/j.jvca.2008.01.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Indexed: 11/11/2022]
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Augoustides JG. RIFLE criteria in aortic arch surgery: The further role of surgical subgroup. J Thorac Cardiovasc Surg 2008; 136:233; author reply 233. [DOI: 10.1016/j.jtcvs.2007.12.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 12/24/2007] [Indexed: 11/25/2022]
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RIFLE criteria for acute kidney injury in aortic arch surgery. J Thorac Cardiovasc Surg 2007; 134:1554-60; discussion 1560-1. [PMID: 18023682 DOI: 10.1016/j.jtcvs.2007.08.039] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Revised: 08/07/2007] [Accepted: 08/15/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The RIFLE criteria are new international consensus definitions for acute kidney injury introduced to facilitate research across disciplines. We identified risk factors for acute kidney injury, renal replacement therapy, and mortality using the RIFLE criteria (RIFLE = risk, injury, failure, loss, end stage) in patients undergoing deep hypothermic circulatory arrest for aortic arch reconstruction. METHODS A single-center retrospective cohort study of 267 patients undergoing aortic arch surgery with deep hypothermic circulatory arrest was conducted between July 2001 and October 2005. Known predictors (age, chronic kidney disease, surgery status, redo, diabetes, hypertension, blood transfusion, bypass, and deep hypothermic circulatory arrest time) were used in multivariate logistic regression models for acute kidney injury, renal replacement therapy, and mortality. RESULTS Mean age was 64 years (range 23-89 years) with 166 men (62%). Seventy-five (28%) had RIFLE scores of I or F, and 22 (8%) required dialysis. Risk factors for acute kidney injury were hypertension (odds ratio [OR] = 2.17; 95% confidence intervals [CI], 1.14-4.15), chronic kidney disease (OR = 9.04; 95% CI, 1.97-41.59), packed red blood cells greater than 5 units (OR = 2.37; 95% CI, 1.20-4.69), and admission creatinine/Modification of Diet in Renal Disease predicted creatinine ratio greater than 1 (OR = 3.54; 95% CI, 1.95-6.45). Risk factors for mortality were age (per 10 years) (OR = 2.35; 95% CI, 1.35-4.06), AKI (RIFLE class R, I, or F) (OR = 4.60; 95% CI, 1.34-15.77), and cerebrovascular accident (OR = 19.1; 95% CI, 4.96-73.58). Mortality increased with each RIFLE stratification (RIFLE class 0 = 3%, R = 9%, I = 12%, and F = 38%). CONCLUSIONS Acute kidney injury as defined according to the RIFLE classification is a risk factor for mortality and will be useful in future studies of renal dysfunction in thoracic aortic surgery.
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McEvoy MD, Reeves ST, Reves JG, Spinale FG. Aprotinin in Cardiac Surgery: A Review of Conventional and Novel Mechanisms of Action. Anesth Analg 2007; 105:949-62. [PMID: 17898372 DOI: 10.1213/01.ane.0000281936.04102.9f] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Induction of the coagulation and inflammatory cascades can cause multiorgan dysfunction after cardiopulmonary bypass (CPB). In light of these observations, strategies that can stabilize the coagulation process as well as attenuate the inflammatory response during and after cardiac surgery are important. Aprotinin has effects on hemostasis. In addition, aprotinin may exert multiple biologically relevant effects in the context of cardiac surgery and CPB. For example, it decreases neutrophil and macrophage activation and chemotaxis, attenuates release and activation of proinflammatory cytokines, and reduces oxidative stress. Despite these perceived benefits, the routine use of aprotinin in cardiac surgery with CPB has been called into question. In this review, we examined this controversial drug by discussing the classical and novel pathways in which aprotinin may be operative in the context of cardiac surgery.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
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Augoustides JGT. Con: Aprotinin should not be used in cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2007; 21:302-4. [PMID: 17418754 DOI: 10.1053/j.jvca.2007.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Indexed: 11/11/2022]
Affiliation(s)
- John G T Augoustides
- Department of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
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Augoustides JGT. Limitations with aprotinin in thoracic aortic surgery: understanding the clinical outcome beyond bleeding. J Thorac Cardiovasc Surg 2007; 134:269; author reply 269. [PMID: 17599543 DOI: 10.1016/j.jtcvs.2006.11.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 11/14/2006] [Indexed: 11/24/2022]
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Augoustides JGT, Szeto W, Ochroch EA, Cowie D, Weiner J, Gambone AJ, Pinchasik D, Bavaria JE. Atrial Fibrillation After Aortic Arch Repair Requiring Deep Hypothermic Circulatory Arrest: Incidence, Clinical Outcome, and Clinical Predictors. J Cardiothorac Vasc Anesth 2007; 21:388-92. [PMID: 17544892 DOI: 10.1053/j.jvca.2006.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To delineate the incidence, outcome impact, and clinical predictors of atrial fibrillation (AF) after adult aortic arch repair requiring deep hypothermic circulatory arrest (AAR-DHCA) AIMS: To determine the incidence of AF after AAR-DHCA, to determine whether AF after AAR-DHCA affects mortality or stay in the intensive care unit (ICU), to determine multivariate predictors for AF after AAR-DHCA, and to determine whether aprotinin protects against AF after AAR-DHCA. STUDY DESIGN Retrospective and observational. STUDY SETTING Single large university hospital. PARTICIPANTS All adults undergoing AAR-DHCA in 2000 and 2001. MAIN RESULTS The cohort size was 144. Antifibrinolytic exposure was 100%, aprotinin 66% and aminocaproic acid 34%. The incidence of AF was 34.0%. AF was not significantly associated with increased mortality or prolonged ICU stay. Advanced age was a multivariate risk factor for AF. Lower temperature nadir during DHCA was protective against postoperative AF. Aprotinin had no demonstrable effect on AF after AAR-DHCA. CONCLUSIONS AF after AAR-DHCA is common but does not independently increase mortality or ICU stay. The risk of AF after AAR-DHCA increases with age but decreases with the degree of hypothermia during DHCA. Aprotinin does not appear to affect the risk of AF after AAR-DHCA.
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Affiliation(s)
- John G T Augoustides
- Department of Anesthesiology and Critical Care, Hospital of University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
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