title: Raised preoperative international normalised ratio (INR) identifies patients at high risk of perioperative death after simultaneous renal and cardiac surgery for tumours involving the peri-diaphragmatic inferior vena cava and right atrium.
abstract: To identify preoperative factors that predict 30-day mortality in patients undergoing simultaneous cardiac and renal surgery for urological tumours involving the peri-diaphragmatic vena cava and right atrium- The ability to predict mortality and therefore avoid surgery in those patients likely to die would be valuable.
  
  
  
  We retrospectively reviewed perioperative outcomes in patients managed between December 2007 and January 2016 by a single team. The relationships of outcome measurements were analysed using Fisher's exact and Mann-Whitney U-tests.
  
  
  
  Of the 46 patients identified, 41 (89%) underwent surgery (20 males and 21 females). The median (range) age was 65 (17-95) years. Histology confirmed 37 renal cell cancers, one adrenal cancer, two primitive neuroectodermal tumours, and one leiomyosarcoma. The overall 30-day mortality rate was 7% (three of 41 patients). The international normalised ratio (INR), age, and estimated glomerular filtration rate (eGFR) correlated significantly with 30-day mortality. The mortality rate was high in patients with an INR ≥1.5 and <1.5 (with three of the five patients dying) compared to those with an INR <1.5 (0/36 patients died; 30 day mortality 0%). The INR correlated with serious complications (≥Clavien-Dindo Grade III), which occurred in all five patients with an INR ≥1.5 and <1.5 vs 12/36 (33%) with an INR <1.5 (P < 0.002). The median (range) eGFR in those that died was 36 (26-37) mL/min/1.73 m2compared to 52 (24-154) mL/min/1.73 m2in those that survived (P = 0.018).
  
  
  
  In patients undergoing combined cardiac and renal tumour surgery raised preoperative INR is associated with a high risk of 30-day mortality when the patient is elderly (>70 years) and of significant post-operative complications in younger patients (<70 years). Surgery in patients with a normal INR is challenging but much safer.
authors.affiliation: Department of Urology, Guys and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: O'Brien
authors.affiliation: Department of Urology, Guys and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Archie
authors.initials: A
authors.lastname: Fernando
authors.affiliation: Department of Urology, Guys and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Kay
authors.initials: K
authors.lastname: Thomas
authors.affiliation: Division of Cancer Studies, Cancer Epidemiology Group, King's College London, London, UK.
authors.forename: Mieke
authors.initials: M
authors.lastname: Van Hemelrijck
authors.affiliation: Department of Anaesthesia, Guys and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Craig
authors.initials: C
authors.lastname: Bailey
authors.affiliation: Department of Cardiothoracic Surgery, Guys and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Conal
authors.initials: C
authors.lastname: Austin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006325:Heart Atria; D006338:Heart Neoplasms / Q000097:blood* / Q000601:surgery*; D006801:Humans; D019934:International Normalized Ratio / Q000706:statistics & numerical data*; D007680:Kidney Neoplasms / Q000097:blood* / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009378:Neoplasms, Multiple Primary / Q000097:blood* / Q000601:surgery*; D009360:Neoplastic Cells, Circulating; D011183:Postoperative Complications / Q000097:blood* / Q000401:mortality*; D011300:Preoperative Care; D012189:Retrospective Studies; D018570:Risk Assessment; D014682:Vena Cava, Inferior; D055815:Young Adult
keywords: INR; cardiopulmonary bypass; inferior vena cava; international normalised ratio; kidney cancer; renal cancer