Is preoperative serum creatinine a reliable indicator of outcome in patients undergoing coronary artery bypass surgery?

ObjectiveEvaluating renal function by calculating creatinine clearance as an alternative measure to serum creatinine may give a better estimation of postoperative renal function in patients undergoing coronary artery bypass grafting.MethodsUsing our database, we conducted a retrospective review of the records of all 11,884 patients aged 21 years or older undergoing pure bypass grafting who required cardiopulmonary bypass. Preoperative renal function was categorized as normal renal function (serum creatinine ≤1.1 mg/dL and creatinine clearance > 60 mL/min), occult renal insufficiency (serum creatinine ≤ 1.1 mg/dL and creatinine clearance ≤ 60 mL/min), mild renal insufficiency (1.1 mg/dL < serum creatinine ≤ 1.5 mg/dL and creatinine clearance ≤ 60 mL/min) or moderate renal insufficiency (serum creatinine > 1.5 mg/dL and creatinine clearance ≤ 60 mL/min).ResultsOut of 11,884 patients in the sample, 7856 (66.1%) had normal renal function, and 706 (5.9%) had occult renal insufficiency. The rate of postoperative mortality, renal failure, atrial fibrillation, prolonged ventilation, intra-aortic balloon pump usage, and prolonged hospital stay (>7 days) was higher in patients with occult renal insufficiency than in the normal group in univariable analysis. Multivariable logistic regression analysis demonstrated that patients with occult renal insufficiency compared with the group with normal renal function were at higher risk for mortality (odds ratio = 2.59, 95% confidence interval 1.15–5.86; P = .022) and prolonged hospital stay (>7 d) (odds ratio = 1.30, 95% confidence interval 1.08–1.57; P = .005).ConclusionsTo identify higher-risk patients requiring special intensive care, and in whom new interventions can be performed to improve outcome, we recommend the preoperative calculation of creatinine clearance, especially in older women with a lower body mass index

Predictors and Early Outcome of Prolonged Mechanical Ventilation in Contemporary Heart valve Surgery

Background: During last decades mechanical ventilation has been an important support in the postoperative management of patients undergoing cardiac surgery. This study was designed to determine the predictors of prolonged mechanical ventilation (PMV) in patients undergoing heart valve surgery. Methods: This retrospective study considered of 1056 patients who underwent isolated valve surgery at Tehran Heart Center from March 2002 to March 2009. PMV is considered as mechanical ventilation period of ≥24 hours at postoperative hospital stay in this study. Results: PMV occurred in 6.6% of patients. Initial ventilation hours, atrial fibrillation, cardiac arrest and reintubation were the most prevalent postoperative complications. Preoperative renal failure, postoperative stroke, intra aortic balloon pump insertion, emergent operation, complete heart block, longer perfusion time were independent predictors of PMV in our patients. Conclusion: PMV is associated with significant comorbidities and increased hospital mortality. Strategies to delineate the patients at risk and to modify these risk factors by prophylactic measures should probably lead to a lower incidence of prolonged mechanical ventilation for patients undergoing isolated valve surgery

Early outcome of off-pump versus on-pump coronary revascularization

Introduction: The use of coronary artery bypass surgery (CABG) with cardiopulmonary bypass (CPB) or without CPB technique (off-pump) can be associated with different mortality and morbidity and their outcomes remain uncertain. The goal of this study was to evaluate the early outcome of on-pump versus off-pump CABG. Methods: We conducted a retrospective database review of 13866 patients (13560 patients undergoing onpump CABG and 306 patients undergoing off-pump CABG) at Tehran Heart Center between January 2002 and January 2007. We compared preoperative, operative, and postoperative  characteristics between them. Results: In-hospital mortality in the on-pump group was 0.8% compared to 0.7% in the off-pump group (P=0.999) and in-hospital morbidity was 11.7% and 6.5%, respectively  (OR: 1.533, 95%CI: 0.902-2.605, P=0.114). Postoperative atrial fibrillation was more prevalent in on-pump versus off-pump surgery (6.0% vs 3.0%, P=0.028), however there were no statistical significant differences in other postoperative   complications with regard to cardiac arrest (P=0.733), prolonged ventilation (P=0.363), brain stroke   (P=0.999), renal failure (P=0.525), and postoperative bleeding (P=0.999). The mean length of stay in hospital (P=0.156) and in ICU (P=0.498) was also similar between the two groups.Conclusion: The results from an Iranian population-based study showed similar early mortality and morbidity of off-pump CABG in comparison to on-pump surgery.Key words: Coronary artery bypass grafting, Off-pump, Cardiopulmonary bypass, Outcom

Type B Aortic Dissection: Management Updates

Acute aortic dissection (AAD) is the most frequent catastrophic event of the aorta; it occurs nearly three times as frequently as the rupture of abdominal aortic aneurysm. Sixty percent of dissection cases are classified as proximal or type A and 40% as distal or type B, according to the Stanford Classification. The most frequent causes of death in acute type B dissection are aortic rupture and malperfusion syndrome.We herein review recent data suggesting different management modalities of type B aortic dissection, including medical, surgical, and endovascular treatments. Although medical therapy is still the standard approach in uncomplicated cases, there are subgroups of patients who may benefit from endovascular management. Endovascular techniques or surgery are valuable options for complicated cases. Hybrid suites, multidisciplinary approaches, and good imaging techniques can be considered as the key to success in this regard

Bifurcating Radial Artery: a Useful Anatomic Variation for Coronary Artery Bypass Grafting

A 56-year-old man with a two year history of chronic stable angina underwent elective coronary artery bypass grafting (CABG) due to angiographic report of three vessel disease and tight stenosis at proximal part of left anterior descending artery (LAD). While harvesting of radial artery (RA), the distal half of radial artery was found to bifurcate to two parallel branches with equal size. We used this as a single conduit to bypass the first and second obtuse marginal (OM) branches. The patient had a smooth post-operative course and uneventful recovery

National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer.

BACKGROUND: Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission. METHODS: All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest. RESULTS: Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs$54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32). CONCLUSIONS: AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level

Screening of Carotid Artery Stenosis in Coronary Artery Bypass Grafting Patients

Background: We sought to evaluate the routine echo-Doppler screening of carotid artery stenosis in patients undergoing coronary artery bypass grafting.Methods: A total of 2179 consecutive patients who underwent coronary artery bypass grafting alone or with other cardiacsurgery at Tehran Heart Center, Tehran-Iran, between January 2005 and January 2006 were included in this retrospective study. Carotid Doppler was performed for 1604 (81.48%) of these patients.Results: The patients’ age ranged between 20 and 84 years (mean: 58.33, SD: 10.08 years). Of the 1604 patients studied,1186 (73.9%) were men, 592 (36.9%) had diabetes, 598 (37.3%) were smokers, and 194 (12.1%) cases had significant left main stenosis. Twenty-one (1.3%) patients had significant carotid stenosis (> 60% stenosis), which constituted 0.9% of all the bypass surgery candidates. Post-operative cerebrovascular accident was not detected in any of the patients with significant carotid stenosis, but cerebrovascular accident occurred in 22 (1.4%) of the patients without carotid stenosis. Magnetic resonance angiography (MRA) was conducted in 15 patients. In our univariate analysis, female gender (p value = 0.023),hypertension (p value = 0.055), peripheral vascular disease (p value < 0.001), and age (p value = 0.001) were significantin the development of carotid stenosis.Conclusion: Pre-operative duplex carotid screening seems to be necessary in patients when there is hypertension, peripheral vascular disease, female gender, and advanced age