title: Descending aortic calcification increases renal dysfunction and in-hospital mortality in cardiac surgery patients with intraaortic balloon pump counterpulsation placed perioperatively: a case control study.
abstract: BACKGROUND
  Acute kidney injury (AKI) after cardiac surgery increases length of hospital stay and in-hospital mortality. A significant number of patients undergoing cardiac surgical procedures require perioperative intra-aortic balloon pump (IABP) support. Use of an IABP has been linked to an increased incidence of perioperative renal dysfunction and death. This might be due to dislodgement of atherosclerotic material in the descending thoracic aorta (DTA). Therefore, we retrospectively studied the correlation between DTA atheroma, AKI and in-hospital mortality.
  
  
  METHODS
  A total of 454 patients were retrospectively matched to one of four groups: -IABP/-DTA atheroma, +IABP/-DTA atheroma, -IABP/+DTA atheroma, +IABP/+DTA atheroma. Patients were then matched according to presence/absence of DTA atheroma, presence/absence of IABP, performed surgical procedure, age, gender and left ventricular ejection fraction (LVEF). DTA atheroma was assessed through standard transesophageal echocardiography (TEE) imaging studies of the descending thoracic aorta.
  
  
  RESULTS
  Basic patient characteristics, except for age and gender, did not differ between groups. Perioperative AKI in patients with -DTA atheroma/+IABP was 5.1% versus 1.7% in patients with -DTA atheroma/-IABP. In patients with +DTA atheroma/+IABP the incidence of AKI was 12.6% versus 5.1% in patients with +DTA atheroma/-IABP. In-hospital mortality in patients with +DTA atheroma/-IABP was 3.4% versus 8.4% with +DTA atheroma/+IABP. In patients with +DTA atheroma/+IABP in hospital mortality was 20.2% versus 6.4% with +DTA atheroma/-IABP. Multivariate logistic regression identified DTA atheroma>1 mm (P=*0.002, odds ratio (OR)=4.13, confidence interval (CI)=1.66 to 10.30), as well as IABP support (P=*0.015, OR=3.04, CI=1.24 to 7.45) as independent predictors of perioperative AKI and increased in-hospital mortality. DTA atheroma in conjunction with IABP significantly increased the risk of developing acute kidney injury (P=0.0016) and in-hospital mortality (P=0.0001) when compared to control subjects without IABP and without DTA atheroma.
  
  
  CONCLUSIONS
  Perioperative IABP and DTA atheroma are independent predictors of perioperative AKI and in-hospital mortality. Whether adding an IABP in patients with severe DTA calcification increases their risk of developing AKI and mortality postoperatively cannot be clearly answered in this study. Nevertheless, when IABP and DTA are combined, patients are more likely to develop AKI and to die postoperatively in comparison to patients without IABP and DTA atheroma.
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: Martina
authors.initials: M
authors.lastname: Nowak-Machen
authors.forename: James D
authors.initials: JD
authors.lastname: Rawn
authors.forename: Prem S
authors.initials: PS
authors.lastname: Shekar
authors.forename: Aya
authors.initials: A
authors.lastname: Mitani
authors.forename: Sagun
authors.initials: S
authors.lastname: Tuli
authors.forename: Tobias M
authors.initials: TM
authors.lastname: Bingold
authors.forename: Garrett
authors.initials: G
authors.lastname: Lawlor
authors.forename: Holger K
authors.initials: HK
authors.lastname: Eltzschig
authors.forename: Stanton K
authors.initials: SK
authors.lastname: Shernan
authors.forename: Peter
authors.initials: P
authors.lastname: Rosenberger
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology / Q000401:mortality*; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000473:pathology*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D016022:Case-Control Studies; D015908:Counterpulsation / Q000009:adverse effects; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007423:Intra-Aortic Balloon Pumping / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000009:adverse effects* / Q000379:methods; D012189:Retrospective Studies; D061205:Vascular Calcification / Q000150:complications / Q000401:mortality*