The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair.
BACKGROUND
There remains concern that moderate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) may provide suboptimal distal organ protection compared with deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (RCP). We compared postoperative acute kidney injury (AKI) in in patients who underwent elective hemiarch repair with either DHCA/RCP or MHCA/ACP.


METHODS
This was a retrospective review of all patients undergoing elective aortic hemiarch reconstruction for aneurysmal disease between 2009 and 2014. Patients were stratified according to the use of DHCA/RCP versus MHCA/ACP. The primary outcome was the occurrence of AKI at 48 hours, as defined by the Risk, Injury, Failure, Loss, End-Stage (RIFLE ) criteria. A multivariable logistic regression identified risk factors for AKI.


RESULTS
One hundred eighteen patients who underwent ACP and 471 patients who underwent RCP were included. The mean lowest temperature was 26.4°C in patients who underwent MHCA/ACP and 17.5°C in patients who underwent DHCA/RCP. Baseline demographics were similar except that patients who underwent DHCA/RCP were more likely to have peripheral arterial disease or bicuspid aortic valves. Cardiopulmonary bypass and aortic cross-clamp times were shorter in the MHCA/ACP group. AKI occurred in 19 (16.2%) patients who underwent MHCA/ACP and 67 (14.3%) patients who underwent DHCA/RCP. Four (0.8%) patients who underwent DHCA/RCP required postoperative dialysis. In-hospital mortality tended to increase with increasing RIFLE classification (RIFLE class-0 (No AKI) = 0.41%; Risk = 1.35%, and Injury = 10.0%; p = 0.09). On multivariable analysis, the lowest temperature and cerebral perfusion strategy were not significant predictors of AKI. Lower baseline glomerular filtration rate (GFR), lower preoperative ejection fraction, and longer cardiopulmonary bypass (CPB) time were independently associated with higher AKI.


CONCLUSIONS
We applied the sensitive RIFLE criteria to examine AKI in patients undergoing elective aortic hemiarch replacement for aneurysmal disease. Baseline renal dysfunction, lower ejection fraction, and longer CPB time are independent predictors of AKI. Compared with DHCA/RCP, our data suggest that an MHCA/ACP cerebral protection strategy does not appear to be associated with worse postoperative renal outcomes.
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
George J
GJ
Arnaoutakis
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Prashanth
P
Vallabhajosyula
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Joseph E
JE
Bavaria
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Ibrahim
I
Sultan
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Mary
M
Siki
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Suveeksha
S
Naidu
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Rita K
RK
Milewski
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Matthew L
ML
Williams
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
W Clark
WC
Hargrove
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Nimesh D
ND
Desai
Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: wilson.szeto@uphs.upenn.edu.
Wilson Y
WY
Szeto
D058186:Acute Kidney Injury / Q000209:etiology / Q000503:physiopathology; D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D002423:Cause of Death; D002560:Cerebrovascular Circulation / Q000502:physiology; D050792:Circulatory Arrest, Deep Hypothermia Induced / Q000009:adverse effects / Q000379:methods*; D015331:Cohort Studies; D016208:Databases, Factual; D017558:Elective Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007036:Hypothermia, Induced / Q000009:adverse effects / Q000379:methods; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010477:Perfusion / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome