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Safety of Same-Day Coronary Angiography in Patients Undergoing Elective Valvular Heart Surgery
ORIGINAL ARTICLE SAME-DAY CORONARY ANGIOGRAPHY AND ELECTIVE VALVULAR HEART SURGERY
Safety of Same-Day Coronary Angiography in Patients Undergoing Elective Valvular Heart Surgery MORGAN L. BROWN, MD; DAVID R. HOLMES, MD; A. JAMIL TAJIK, MD; MAURICE E. SARANO, MD; AND HARTZELL V. SCHAFF, MD OBJECTIVE: To maximize patient convenience, we developed a protocol for coronary angiography the same day as elective valvular surgery. PATIENTS AND METHODS: We analyzed the medical records from a single surgical service of 226 consecutive patients who had undergone cardiac catheterization on the day of elective valvular repair or replacement between August 1, 2000, and August 30, 2004. The rates of renal failure (creatinine >2.0 mg/dL and 2 times the preoperative level), hemodialysis, continuous renal replacement therapy, and mortality were evaluated. RESULTS: Patients undergoing same-day angiography had a mean age of 65.6±12.1 years, and 33% were female. Of the study patients, 11.1% were diabetic, with a mean ejection fraction of 61%±10%, and 28.3% had coronary artery disease severe enough to require bypass grafting. One patient died within 30 days of surgery; the overall mortality was 0.4%. Postoperatively, serum creatinine levels increased an average of 0.1 mg/dL (P<.001) in patients undergoing same-day coronary angiography. Four patients had transient renal failure (1.8%), 2 of whom required temporary hemodialysis. CONCLUSION: In properly selected patients, same-day coronary angiography is safe and has little impact on renal function. This protocol offers a simple way to reduce the number of hospital visits required by patients undergoing elective valvular surgery.
Mayo Clin Proc. 2007;82(5):572-574
V
alvular heart disease is a growing problem in today’s aging population. Almost 48,000 heart valve replacements or repairs were registered with the Society of Thoracic Surgeons National Database in 2005.1 Current American Heart Association guidelines recommend preoperative coronary angiography for all patients considered at risk for coronary artery disease. An outpatient procedure, coronary angiography is frequently performed several days to even weeks before a cardiac operation. That timing can prove inconvenient and expensive for patients who depend on health care at tertiary care facilities located at considerable distance from their homes. In an effort to decrease the required visits before heart valvular replacement or repair, Mayo Clinic developed a protocol for performing coronary
From the Division of Cardiovascular Surgery (M.L.B., H.V.S.) and Division of Cardiovascular Diseases (D.R.H., M.E.S.), College of Medicines, Mayo Clinic, Rochester, Minn; and Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic, Scottsdale, Ariz (A.J.T.). Individual reprints of this article are not available. Address correspondence to Hartzell V. Schaff, MD, Division of Cardiovascular Surgery, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: [email protected]). © 2007 Mayo Foundation for Medical Education and Research
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angiography the morning of surgery. This review evaluates the safety of that protocol. PATIENTS AND METHODS After obtaining Mayo Clinic Institutional Review Board approval, we reviewed the medical records of 226 consecutive patients with valvular heart disease who had undergone cardiac catheterization on the day of elective valve repair or replacement. All patients were managed on a single surgical service between August 1, 2000, and August 30, 2004. Using the electronic medical record, we collected patient data including age at time of surgery, history of diabetes, and ejection fraction. We also documented the preoperative or baseline creatinine and the peak creatinine value observed during the postoperative period. Events within the first 30 days including hemodialysis, renal failure (defined as creatinine levels of >2.0 mg/dL and 2 times the preoperative value), continuous renal replacement therapy, and death were recorded. All variables were assessed for a normal distribution and reported as appropriate. The peak creatinine value was compared with the preoperative creatinine value using a paired t test. The statistical software program JMP (SAS Institute Inc, Cary, NC) was used for all calculations. At Mayo Clinic, all patients with valvular heart disease undergoing elective valve repair or replacement are assessed for suitability for the same-day coronary angiography protocol. If deemed suitable for this protocol, patients undergo same-day coronary angiography, as the first case of the day when possible. Catheterization is limited to selective coronary angiography without left ventriculography. Patients are not routinely given sodium bicarbonate or N-acetylcysteine. Surgery is begun within 4 hours after completion of the imaging procedure. For our study, we excluded patients with significant renal dysfunction (defined as a serum creatinine level >1.8 mg/dL). For patients with a creatinine level greater than 1.5 mg/dL, we administered an iso-osmolar contrast agent (iodixanol). RESULTS In our analysis of 226 consecutive patients, the 2 most common operations were aortic valve replacement (41.2%)
May 2007;82(5):572-574
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
SAME-DAY CORONARY ANGIOGRAPHY AND ELECTIVE VALVULAR HEART SURGERY
TABLE 1. Description of Surgical Procedures Performed in 226 Patients Type of surgery
1.6
No. (%) of patients
Aortic valve replacement Mitral valve repair Aortic and mitral valve procedures Mitral valve replacement Tricuspid valve repair Tricuspid and pulmonary valve procedure Mitral valve and tricuspid valve procedures Aortic, mitral, and tricuspid valve procedure Aortic valve repair
93 90 18 13 3 3 2 2 2
1.4
(41.2) (39.8) (8.0) (5.8) (1.3) (1.3) (0.9) (0.9) (0.9)
1.2
1.3 1.2
1.1
1.0 0.8 Preoperative
Peak value
Dismissal
Mean creatinine (mg/dL)
FIGURE 1. Creatinine values.
and mitral valvular repair (39.8%). Other procedures included mitral valve replacement, tricuspid valve replacement or repair, and double or triple valve procedures (Table 1). The mean ± SD age of patients at the time of surgery was 65.6±12.1 years. Of the study patients, 33.2% were female, and 11.1% were diabetic. The mean ± SD preoperative ejection fraction was 61%±10%. The mean ± SD cardiopulmonary bypass time was 48±20 minutes, and the mean cross-clamp time was 34±14 minutes. Coronary artery disease was considered sufficiently serious in 28.3% of patients to require coronary artery bypass, with most patients needing bypass of 1 or 2 coronary vessels (Table 2). Only 1 (0.4%) death occurred in the first 30 days. Among all patients, serum creatinine values increased by an average of 0.1 mg/dL (95% confidence interval, 0.030.14, P<.001) (Figure 1). Four patients (1.8%) developed renal failure postoperatively (Table 3), one of whom required temporary venovenous hemofiltration, and one of whom underwent hemodialysis before dying of multiorgan failure. One patient required bilateral below-knee amputations but not as a result of the femoral catheterization. There were no cases of femoral artery dissection or bleeding complications requiring further investigation or treatment. DISCUSSION Preoperative coronary angiography is recommended for patients undergoing valvular surgery who have chest pain, evidence of ischemia, or a history of myocardial infarction TABLE 2. Variables for the 226 Study Patients Variables
Values
Mean ± SD age (y) Mean ± SD ejection fraction (%) Diabetes, No. (%) Concomitant coronary bypass grafting, No. (%) Reoperative procedures, No. (%) Mean ± SD cross-clamp time (min) Mean ± SD cardiopulmonary bypass time (min)
65.6±12.1 61±10 25 (11.1) 64 (28.3) 28 (12.4) 34±14 48±20
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and coronary artery disease. It is also indicated in men 35 years of age and older, postmenopausal women, and premenopausal women older than 35 years with risk factors for coronary artery disease such as hypertension and diabetes mellitus. Moreover, decreased left ventricular systolic function, history of coronary artery disease, and presence of coronary risk factors are indications for preoperative coronary angiography.2 Thus, most patients who undergo valvular surgery will require preoperative coronary angiography. Coronary angiography requires radiocontrast, which is associated with radiocontrast-induced nephropathy, a common cause of acute renal failure.3 When radiocontrastinduced nephropathy occurs, serum creatinine levels begin to increase after 24 to 72 hours, peak within 3 to 5 days, and return to baseline within another 3 to 5 days. Several potential methods, including administration of N-acetylcysteine4 and bicarbonate5, have been proposed for decreasing the incidence of radiocontrast-induced nephropathy. Low osmolar contrast media is somewhat protective against radiocontrast-induced nephropathy,6 with iso-osmolar agents having less renal toxicity than low osmolar contrast media.7,8 For patients with renal insufficiency (creatinine level ≥1.5 mg/dL), we use one of several lowosmolar contrast agents or an iso-osmolar agent (iodixanol) The average volume of contrast used in each procedure is approximately 80 mL but can vary depending on imaging requirements. Patients participating in this same-day angiography protocol are admitted to the hospital immediately before coronary angiography and do not routinely receive either N-acetylcysteine or bicarbonate. To minimize the risk of femoral complications in patients admitted for same-day coronary angiography, 4F or 5F femoral sheaths are used. The sheaths generally remain in place throughout the surgical procedure and are removed in the intensive care unit the evening after surgery. Although no femoral complications occurred in our study, it is important to be vigilant for such complications in all patients who have undergone coronary angiography. Risk factors for postoperative renal dysfunction include valvular surgery,9 intra-aortic balloon pumps, low-output
May 2007;82(5):572-574
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
573
SAME-DAY CORONARY ANGIOGRAPHY AND ELECTIVE VALVULAR HEART SURGERY
TABLE 3. Description of Patients Who Developed Renal Failure Postoperatively
Patient No./ age (y)/sex 1/74/M 2/77/M 3/83/M 4/86/M
Creatinine (mg/dL)
Diabetes
Ejection fraction (%)
X-clamp time (min)
CPB time (min)
Preoperative
Maximum
No Yes No No
65 20 70 63
43 41 18 40
57 84 34 52
1.3 1.7 1.2 1.3
2.7 5.2 2.6 2.6
*CPB = cardiopulmonary bypass.
syndrome, advanced age, preoperative renal dysfunction, diabetes mellitus, and emergency surgery.9-12 Acute renal failure is an important independent predictor of death after cardiac surgery, and mortality rates have been reported as high as 44.4% to 63.7%.11,13 Hence, determining any increased risk of renal failure in patients who undergo sameday coronary angiography is important. In our study, the rate of renal failure was 2.2%, a finding consistent with previously reported rates of 1.1% to 3.7%.11,13,14 Some patients and surgeons may prefer to know before the day of surgery whether coronary artery bypass will be required. However, in our study same-day angiography did not result in excessive operating times or overly complex surgery because only 28% of patients required bypass grafts, with the vast majority of those (89%) needing only 1 or 2 grafts. The protocol has been well received by patients, who feel comfortable learning of the results of the angiography immediately before surgery. Patients who did not want to undergo an operation and angiography on the same day were always accommodated. Close cooperation between cardiologists in the angiography suite and the surgical team in the operating room is crucial for the success of the protocol. Cardiologists must also be willing to perform angiography in selected patients as the first cases in the morning. Prompt and clear communication of catheterization results is critical if the proper decisions regarding revascularization are to be made. CONCLUSION No significant renal impairment was observed in our study patients, although they underwent coronary angiography and cardiopulmonary bypass, 2 potential renal insults, on the same day. Rates of renal failure, dialysis, and mortality after valvular procedures were all within acceptable ranges. When properly coordinated with the interven-
574
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tional cardiologists, same-day performance of coronary angiography and cardiopulmonary bypass can significantly benefit the patient by reducing the number of required hospital visits. REFERENCES 1. Society of Thoracic Surgeons. Executive summary: STS Spring 2006 report. Available at: www.sts.org/documents/pdf/STS-ExecutiveSummarySpring2006.pdf. Accessed March 13, 2007. 2. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2006;114:450-527. 3. Weisbord SD, Palevsky PM. Radiocontrast-induced acute renal failure. J Intensive Care Med. 2005;20:63-75. 4. Tepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med. 2000;343:180-184. 5. Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. 2004;291:2328-2334. 6. Asif A, Preston RA, Roth D. Radiocontrast-induced nephropathy. Am J Ther. 2003;10:137-147. 7. Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ, NEPHRIC Study Investigators. Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med. 2003;328:491-499. 8. Ilkhanoff L, Carver J. Contrast-induced nephropathy and cardiac catheterization: evidence in support of using the iso-osmolar contrast agent iodixanol in patients with renal dysfunction. J Invasive Cardiol. 2005;17:216217. 9. Grayson AD, Khater M, Jackson M, Fox MA. Valvular heart operation is an independent risk factor for acute renal failure. Ann Thorac Surg. 2003;75: 1829-1835. 10. Abrahamov D, Tamariz M, Fremes S, et al. Renal dysfunction after cardiac surgery. Can J Cardiol. 2001;17:565-570. 11. Zanardo G, Michielon P, Paccagnella A, et al. Acute renal failure in the patient undergoing cardiac operation: prevalence, mortality rate, and main risk factors. J Thorac Cardiovasc Surg. 1994;107:1489-1495. 12. Andersson LG, Ekroth R, Bratteby LE, Hallhagen S, Wesslen O. Acute renal failure after coronary surgery—a study of incidence and risk factors in 2009 consecutive patients. Thorac Cardiovasc Surg. 1993;41:237-241. 13. Chertow GM, Levy EM, Hammermeister KE, Grover F, Daley J. Independent association between acute renal failure and mortality following cardiac surgery Am J Med. 1998;104:343-348. 14. Mangano CM, Diamondstone LS, Ramsay JG, Aggarwal A, Herskowitz A, Mangano DT. Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. Ann Intern Med. 1998;128:194-203.
May 2007;82(5):572-574
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Safety of Same-Day Coronary Angiography in Patients Undergoing Elective Valvular Heart Surgery MORGAN L. BROWN, MD; DAVID R. HOLMES, MD; A. JAMIL TAJIK, MD; MAURICE E. SARANO, MD; AND HARTZELL V. SCHAFF, MD OBJECTIVE: To maximize patient convenience, we developed a protocol for coronary angiography the same day as elective valvular surgery. PATIENTS AND METHODS: We analyzed the medical records from a single surgical service of 226 consecutive patients who had undergone cardiac catheterization on the day of elective valvular repair or replacement between August 1, 2000, and August 30, 2004. The rates of renal failure (creatinine >2.0 mg/dL and 2 times the preoperative level), hemodialysis, continuous renal replacement therapy, and mortality were evaluated. RESULTS: Patients undergoing same-day angiography had a mean age of 65.6±12.1 years, and 33% were female. Of the study patients, 11.1% were diabetic, with a mean ejection fraction of 61%±10%, and 28.3% had coronary artery disease severe enough to require bypass grafting. One patient died within 30 days of surgery; the overall mortality was 0.4%. Postoperatively, serum creatinine levels increased an average of 0.1 mg/dL (P<.001) in patients undergoing same-day coronary angiography. Four patients had transient renal failure (1.8%), 2 of whom required temporary hemodialysis. CONCLUSION: In properly selected patients, same-day coronary angiography is safe and has little impact on renal function. This protocol offers a simple way to reduce the number of hospital visits required by patients undergoing elective valvular surgery.
Mayo Clin Proc. 2007;82(5):572-574
V
alvular heart disease is a growing problem in today’s aging population. Almost 48,000 heart valve replacements or repairs were registered with the Society of Thoracic Surgeons National Database in 2005.1 Current American Heart Association guidelines recommend preoperative coronary angiography for all patients considered at risk for coronary artery disease. An outpatient procedure, coronary angiography is frequently performed several days to even weeks before a cardiac operation. That timing can prove inconvenient and expensive for patients who depend on health care at tertiary care facilities located at considerable distance from their homes. In an effort to decrease the required visits before heart valvular replacement or repair, Mayo Clinic developed a protocol for performing coronary
From the Division of Cardiovascular Surgery (M.L.B., H.V.S.) and Division of Cardiovascular Diseases (D.R.H., M.E.S.), College of Medicines, Mayo Clinic, Rochester, Minn; and Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic, Scottsdale, Ariz (A.J.T.). Individual reprints of this article are not available. Address correspondence to Hartzell V. Schaff, MD, Division of Cardiovascular Surgery, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: [email protected]). © 2007 Mayo Foundation for Medical Education and Research
572
Mayo Clin Proc.
•
angiography the morning of surgery. This review evaluates the safety of that protocol. PATIENTS AND METHODS After obtaining Mayo Clinic Institutional Review Board approval, we reviewed the medical records of 226 consecutive patients with valvular heart disease who had undergone cardiac catheterization on the day of elective valve repair or replacement. All patients were managed on a single surgical service between August 1, 2000, and August 30, 2004. Using the electronic medical record, we collected patient data including age at time of surgery, history of diabetes, and ejection fraction. We also documented the preoperative or baseline creatinine and the peak creatinine value observed during the postoperative period. Events within the first 30 days including hemodialysis, renal failure (defined as creatinine levels of >2.0 mg/dL and 2 times the preoperative value), continuous renal replacement therapy, and death were recorded. All variables were assessed for a normal distribution and reported as appropriate. The peak creatinine value was compared with the preoperative creatinine value using a paired t test. The statistical software program JMP (SAS Institute Inc, Cary, NC) was used for all calculations. At Mayo Clinic, all patients with valvular heart disease undergoing elective valve repair or replacement are assessed for suitability for the same-day coronary angiography protocol. If deemed suitable for this protocol, patients undergo same-day coronary angiography, as the first case of the day when possible. Catheterization is limited to selective coronary angiography without left ventriculography. Patients are not routinely given sodium bicarbonate or N-acetylcysteine. Surgery is begun within 4 hours after completion of the imaging procedure. For our study, we excluded patients with significant renal dysfunction (defined as a serum creatinine level >1.8 mg/dL). For patients with a creatinine level greater than 1.5 mg/dL, we administered an iso-osmolar contrast agent (iodixanol). RESULTS In our analysis of 226 consecutive patients, the 2 most common operations were aortic valve replacement (41.2%)
May 2007;82(5):572-574
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
SAME-DAY CORONARY ANGIOGRAPHY AND ELECTIVE VALVULAR HEART SURGERY
TABLE 1. Description of Surgical Procedures Performed in 226 Patients Type of surgery
1.6
No. (%) of patients
Aortic valve replacement Mitral valve repair Aortic and mitral valve procedures Mitral valve replacement Tricuspid valve repair Tricuspid and pulmonary valve procedure Mitral valve and tricuspid valve procedures Aortic, mitral, and tricuspid valve procedure Aortic valve repair
93 90 18 13 3 3 2 2 2
1.4
(41.2) (39.8) (8.0) (5.8) (1.3) (1.3) (0.9) (0.9) (0.9)
1.2
1.3 1.2
1.1
1.0 0.8 Preoperative
Peak value
Dismissal
Mean creatinine (mg/dL)
FIGURE 1. Creatinine values.
and mitral valvular repair (39.8%). Other procedures included mitral valve replacement, tricuspid valve replacement or repair, and double or triple valve procedures (Table 1). The mean ± SD age of patients at the time of surgery was 65.6±12.1 years. Of the study patients, 33.2% were female, and 11.1% were diabetic. The mean ± SD preoperative ejection fraction was 61%±10%. The mean ± SD cardiopulmonary bypass time was 48±20 minutes, and the mean cross-clamp time was 34±14 minutes. Coronary artery disease was considered sufficiently serious in 28.3% of patients to require coronary artery bypass, with most patients needing bypass of 1 or 2 coronary vessels (Table 2). Only 1 (0.4%) death occurred in the first 30 days. Among all patients, serum creatinine values increased by an average of 0.1 mg/dL (95% confidence interval, 0.030.14, P<.001) (Figure 1). Four patients (1.8%) developed renal failure postoperatively (Table 3), one of whom required temporary venovenous hemofiltration, and one of whom underwent hemodialysis before dying of multiorgan failure. One patient required bilateral below-knee amputations but not as a result of the femoral catheterization. There were no cases of femoral artery dissection or bleeding complications requiring further investigation or treatment. DISCUSSION Preoperative coronary angiography is recommended for patients undergoing valvular surgery who have chest pain, evidence of ischemia, or a history of myocardial infarction TABLE 2. Variables for the 226 Study Patients Variables
Values
Mean ± SD age (y) Mean ± SD ejection fraction (%) Diabetes, No. (%) Concomitant coronary bypass grafting, No. (%) Reoperative procedures, No. (%) Mean ± SD cross-clamp time (min) Mean ± SD cardiopulmonary bypass time (min)
65.6±12.1 61±10 25 (11.1) 64 (28.3) 28 (12.4) 34±14 48±20
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and coronary artery disease. It is also indicated in men 35 years of age and older, postmenopausal women, and premenopausal women older than 35 years with risk factors for coronary artery disease such as hypertension and diabetes mellitus. Moreover, decreased left ventricular systolic function, history of coronary artery disease, and presence of coronary risk factors are indications for preoperative coronary angiography.2 Thus, most patients who undergo valvular surgery will require preoperative coronary angiography. Coronary angiography requires radiocontrast, which is associated with radiocontrast-induced nephropathy, a common cause of acute renal failure.3 When radiocontrastinduced nephropathy occurs, serum creatinine levels begin to increase after 24 to 72 hours, peak within 3 to 5 days, and return to baseline within another 3 to 5 days. Several potential methods, including administration of N-acetylcysteine4 and bicarbonate5, have been proposed for decreasing the incidence of radiocontrast-induced nephropathy. Low osmolar contrast media is somewhat protective against radiocontrast-induced nephropathy,6 with iso-osmolar agents having less renal toxicity than low osmolar contrast media.7,8 For patients with renal insufficiency (creatinine level ≥1.5 mg/dL), we use one of several lowosmolar contrast agents or an iso-osmolar agent (iodixanol) The average volume of contrast used in each procedure is approximately 80 mL but can vary depending on imaging requirements. Patients participating in this same-day angiography protocol are admitted to the hospital immediately before coronary angiography and do not routinely receive either N-acetylcysteine or bicarbonate. To minimize the risk of femoral complications in patients admitted for same-day coronary angiography, 4F or 5F femoral sheaths are used. The sheaths generally remain in place throughout the surgical procedure and are removed in the intensive care unit the evening after surgery. Although no femoral complications occurred in our study, it is important to be vigilant for such complications in all patients who have undergone coronary angiography. Risk factors for postoperative renal dysfunction include valvular surgery,9 intra-aortic balloon pumps, low-output
May 2007;82(5):572-574
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
573
SAME-DAY CORONARY ANGIOGRAPHY AND ELECTIVE VALVULAR HEART SURGERY
TABLE 3. Description of Patients Who Developed Renal Failure Postoperatively
Patient No./ age (y)/sex 1/74/M 2/77/M 3/83/M 4/86/M
Creatinine (mg/dL)
Diabetes
Ejection fraction (%)
X-clamp time (min)
CPB time (min)
Preoperative
Maximum
No Yes No No
65 20 70 63
43 41 18 40
57 84 34 52
1.3 1.7 1.2 1.3
2.7 5.2 2.6 2.6
*CPB = cardiopulmonary bypass.
syndrome, advanced age, preoperative renal dysfunction, diabetes mellitus, and emergency surgery.9-12 Acute renal failure is an important independent predictor of death after cardiac surgery, and mortality rates have been reported as high as 44.4% to 63.7%.11,13 Hence, determining any increased risk of renal failure in patients who undergo sameday coronary angiography is important. In our study, the rate of renal failure was 2.2%, a finding consistent with previously reported rates of 1.1% to 3.7%.11,13,14 Some patients and surgeons may prefer to know before the day of surgery whether coronary artery bypass will be required. However, in our study same-day angiography did not result in excessive operating times or overly complex surgery because only 28% of patients required bypass grafts, with the vast majority of those (89%) needing only 1 or 2 grafts. The protocol has been well received by patients, who feel comfortable learning of the results of the angiography immediately before surgery. Patients who did not want to undergo an operation and angiography on the same day were always accommodated. Close cooperation between cardiologists in the angiography suite and the surgical team in the operating room is crucial for the success of the protocol. Cardiologists must also be willing to perform angiography in selected patients as the first cases in the morning. Prompt and clear communication of catheterization results is critical if the proper decisions regarding revascularization are to be made. CONCLUSION No significant renal impairment was observed in our study patients, although they underwent coronary angiography and cardiopulmonary bypass, 2 potential renal insults, on the same day. Rates of renal failure, dialysis, and mortality after valvular procedures were all within acceptable ranges. When properly coordinated with the interven-
574
Mayo Clin Proc.
•
tional cardiologists, same-day performance of coronary angiography and cardiopulmonary bypass can significantly benefit the patient by reducing the number of required hospital visits. REFERENCES 1. Society of Thoracic Surgeons. Executive summary: STS Spring 2006 report. Available at: www.sts.org/documents/pdf/STS-ExecutiveSummarySpring2006.pdf. Accessed March 13, 2007. 2. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2006;114:450-527. 3. Weisbord SD, Palevsky PM. Radiocontrast-induced acute renal failure. J Intensive Care Med. 2005;20:63-75. 4. Tepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med. 2000;343:180-184. 5. Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. 2004;291:2328-2334. 6. Asif A, Preston RA, Roth D. Radiocontrast-induced nephropathy. Am J Ther. 2003;10:137-147. 7. Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ, NEPHRIC Study Investigators. Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med. 2003;328:491-499. 8. Ilkhanoff L, Carver J. Contrast-induced nephropathy and cardiac catheterization: evidence in support of using the iso-osmolar contrast agent iodixanol in patients with renal dysfunction. J Invasive Cardiol. 2005;17:216217. 9. Grayson AD, Khater M, Jackson M, Fox MA. Valvular heart operation is an independent risk factor for acute renal failure. Ann Thorac Surg. 2003;75: 1829-1835. 10. Abrahamov D, Tamariz M, Fremes S, et al. Renal dysfunction after cardiac surgery. Can J Cardiol. 2001;17:565-570. 11. Zanardo G, Michielon P, Paccagnella A, et al. Acute renal failure in the patient undergoing cardiac operation: prevalence, mortality rate, and main risk factors. J Thorac Cardiovasc Surg. 1994;107:1489-1495. 12. Andersson LG, Ekroth R, Bratteby LE, Hallhagen S, Wesslen O. Acute renal failure after coronary surgery—a study of incidence and risk factors in 2009 consecutive patients. Thorac Cardiovasc Surg. 1993;41:237-241. 13. Chertow GM, Levy EM, Hammermeister KE, Grover F, Daley J. Independent association between acute renal failure and mortality following cardiac surgery Am J Med. 1998;104:343-348. 14. Mangano CM, Diamondstone LS, Ramsay JG, Aggarwal A, Herskowitz A, Mangano DT. Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. Ann Intern Med. 1998;128:194-203.
May 2007;82(5):572-574
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.