Increased risk of acute kidney injury in patients undergoing tricuspid valve surgery

OBJECTIVES We aimed to determine which patients undergoing tricuspid valve (TV) surgery are at increased risk for acute kidney injury (AKI). METHODS We reviewed 951 patients [mean age 67 ± 13 years, 573 (60%) female] having TV surgery between 2000 and 2007. Analysis focused on clinical outcome; AKI was defined by the consensus RIFLE criteria (risk, injury, failure). RESULTS Surgical procedures included isolated TV surgery in 224 (24%) and TV surgery in conjunction with another cardiac operation in 727 (76%) patients. TV surgery involved redo surgery in 395 (42%). The incidence of postoperative AKI was 30% (n = 285), and 75 (7.9%) of these patients required renal replacement therapy. AKI stratified by increased RIFLE class was associated with worse postoperative outcomes (prolonged intubation, length of hospital stay and mortality; P < 0.001 for each variable). For patients with AKI, odds ratio for mortality was 4.2 [95% confidence interval (CI) 3.2-5.4, P < 0.001; area under receiver operating curves 0.85 (95% CI 0.80-0.91)], and 2.3 (95% CI 1.9-2.9, P < 0.001) for prolonged intubation for each increase in RIFLE class. Independent risk factors for AKI were older age, male gender, previous surgery, preoperative anaemia, length of cardiopulmonary bypass and TV replacement. Importantly, preoperative creatinine and pulmonary artery pressure were not independently associated with AKI. CONCLUSIONS TV surgery carries a high incidence of postoperative AKI that is associated with adverse outcome. The use of the RIFLE criteria allows comparison with prior studies and is an important predictor of early mortality. The estimation of patient risk for AKI should be based on multivariable predictio

Two-year outcomes after transcatheter or surgical aortic-valve replacement.

BACKGROUND: The Placement of Aortic Transcatheter Valves (PARTNER) trial showed that among high-risk patients with aortic stenosis, the 1-year survival rates are similar with transcatheter aortic-valve replacement (TAVR) and surgical replacement. However, longer-term follow-up is necessary to determine whether TAVR has prolonged benefits. METHODS: At 25 centers, we randomly assigned 699 high-risk patients with severe aortic stenosis to undergo either surgical aortic-valve replacement or TAVR. All patients were followed for at least 2 years, with assessment of clinical outcomes and echocardiographic evaluation. RESULTS: The rates of death from any cause were similar in the TAVR and surgery groups (hazard ratio with TAVR, 0.90; 95% confidence interval [CI], 0.71 to 1.15; P=0.41) and at 2 years (Kaplan-Meier analysis) were 33.9% in the TAVR group and 35.0% in the surgery group (P=0.78). The frequency of all strokes during follow-up did not differ significantly between the two groups (hazard ratio, 1.22; 95% CI, 0.67 to 2.23; P=0.52). At 30 days, strokes were more frequent with TAVR than with surgical replacement (4.6% vs. 2.4%, P=0.12); subsequently, there were 8 additional strokes in the TAVR group and 12 in the surgery group. Improvement in valve areas was similar with TAVR and surgical replacement and was maintained for 2 years. Paravalvular regurgitation was more frequent after TAVR (P<0.001), and even mild paravalvular regurgitation was associated with increased late mortality (P<0.001). CONCLUSIONS: A 2-year follow-up of patients in the PARTNER trial supports TAVR as an alternative to surgery in high-risk patients. The two treatments were similar with respect to mortality, reduction in symptoms, and improved valve hemodynamics, but paravalvular regurgitation was more frequent after TAVR and was associated with increased late mortality. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.)

Transcatheter or surgical aortic-valve replacement in intermediate-risk patients

BACKGROUND: Previous trials have shown that among high-risk patients with aortic stenosis, survival rates are similar with transcatheter aortic-valve replacement (TAVR) and surgical aorticvalve replacement. We evaluated the two procedures in a randomized trial involving intermediate-risk patients. METHODS: We randomly assigned 2032 intermediate-risk patients with severe aortic stenosis, at 57 centers, to undergo either TAVR or surgical replacement. The primary end point was death from any cause or disabling stroke at 2 years. The primary hypothesis was that TAVR would not be inferior to surgical replacement. Before randomization, patients were entered into one of two cohorts on the basis of clinical and imaging findings; 76.3% of the patients were included in the transfemoral-access cohort and 23.7% in the transthoracic-access cohort. RESULTS: The rate of death from any cause or disabling stroke was similar in the TAVR group and the surgery group (P=0.001 for noninferiority). At 2 years, the Kaplan–Meier event rates were 19.3% in the TAVR group and 21.1% in the surgery group (hazard ratio in the TAVR group, 0.89; 95% confidence interval [CI], 0.73 to 1.09; P=0.25). In the transfemoralaccess cohort, TAVR resulted in a lower rate of death or disabling stroke than surgery (hazard ratio, 0.79; 95% CI, 0.62 to 1.00; P=0.05), whereas in the transthoracic-access cohort, outcomes were similar in the two groups. TAVR resulted in larger aortic-valve areas than did surgery and also resulted in lower rates of acute kidney injury, severe bleeding, and new-onset atrial fibrillation; surgery resulted in fewer major vascular complications and less paravalvular aortic regurgitation. CONCLUSIONS: In intermediate-risk patients, TAVR was similar to surgical aortic-valve replacement with respect to the primary end point of death or disabling stroke. (Funded by Edwards Lifesciences; PARTNER 2 ClinicalTrials.gov number, NCT01314313

Emergent Cardiopulmonary Bypass during Cardiac Surgery

During orientation to the cardiac surgery operating room, new staff may not be exposed to emergent situations. Allowing team members the opportunity to practice their roles during less common, high-stakes emergency cardiac surgical scenarios may better prepare them when crises do arise in the OR. The Emergency Cardiopulmonary Bypass Course was developed to meet the needs of new staff starting in cardiac surgery. Recently, the course has expanded to include experienced staff. This communication describes a high fidelity simulation based course that includes four emergent cardiac surgery scenarios