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Objective To compare outcomes between intensivist-directed and cardiac surgeon-directed care delivery models. Design This retrospective, historical-control study was performed in a cohort of adult cardiac surgical patients at Zhongshan Hospital (Fudan University, China). During the first phase (March to August 2015), cardiac surgeons were in charge of postoperative care while intensivists were in charge during the second phase (September 2015–June 2016). Both phases were compared regarding successful extubation rate, intensive care unit (ICU) length of stay (LOS), and in-hospital mortality. Setting Tertiary Zhongshan Hospital (Fudan University, China). Patients Consecutive adult patients admitted to the cardiac surgical ICU (CSICU) after heart surgery. Interventions Phase I patients treated by cardiac surgeons, and phase II patients treated by intensivists. Main variables of interest Successful extubation, ICU LOS and in-hospital mortality. Results A total of 1792 (phase I) and 3007 patients (phase II) were enrolled. Most variables did not differ significantly between the two phases. However, patients in phase II had a higher successful extubation rate (99.17% vs. 98.55%; p = 0.043) and a shorter median duration of mechanical ventilation (MV) (18 vs. 19 h; p 48 h, those in phase II had a comparatively higher successful extubation rate (p = 0.033), shorter ICU LOS (p = 0.038) and a significant decrease in in-hospital mortality (p = 0.039). Conclusions The intensivist-directed care model showed improved rates of successful extubation and shorter MV durations after cardiac surgery.

Objectives. The present study aimed to evaluate prognostic value of inflammatory markers for in-hospital mortality and renal complication in patients undergoing surgery for acute type A aortic diss...

Objectives Cumulative fluid overload may influence acute kidney injury (AKI) diagnosis due to the dilution effect. The authors hypothesized a small increase of early postoperative serum creatinine (SCr) adjusted for fluid balance might have superior discrimination ability in subsequent AKI prediction. Design Retrospective analyses. Setting A single-center study in a university hospital. Participants The study comprised 1,016 adult patients who underwent elective isolated or combined valve surgery in 2015. Interventions None. Measurements and Main Results Baseline characteristics, intraoperative parameters, and intraoperative and postoperative fluid balance were collected through a retrospective chart review. Early postoperative SCr level was drawn within 12 hours of surgical completion and then measured daily. Early relative changes of SCr were categorized as a cutoff value of 10% with or without adjustment for cumulative fluid balance. Kidney Disease: Improving Global Outcomes criteria were used to detect AKI. Logistic analyses were performed to determine risk factors for subsequent AKI with the inclusion of measured or fluid-adjusted early relative changes of SCr, respectively. In this study, 355 patients (34.9%) developed AKI. Multivariate logistic analyses showed age, weight, European System for Cardiac Operative Risk Evaluation II, and cardiopulmonary bypass duration were associated independently with the development of AKI. Model discrimination for AKI prediction was improved significantly when the addition of measured (area under the receiver operating characteristic curve [AUROC] 0.830) and fluid-adjusted early changes of SCr to the basic model (AUROC 0.850). Conclusions Early fluid-adjusted relative changes of SCr could improve the predictive ability for subsequent development of AKI in valve surgery patients.

Background Three-dimensional color flow Doppler (3DCF) is a new convenient technique for cardiac output (CO) measurement. However, to date, no one has evaluated the accuracy of 3DCF echocardiography for CO measurement after cardiac surgery. Therefore, this single-center, prospective study was designed to evaluate the reliability of three-dimensional color flow and two-dimensional pulse wave Doppler (2D-PWD) transthoracic echocardiography for estimating cardiac output after cardiac surgery. Methods Post-cardiac surgical patients with a good acoustic window and a low dose or no dose of vasoactive drugs (norepinephrine

Background/Aims: To explore the association of body mass index (BMI) with the risk of developing acute kidney injury after cardiac surgery (CS-AKI) and for AKI requiring renal replacement therapy (AKI-RRT) after cardiac surgery. Methods: Clinical data of 8,455 patients undergoing cardiac surgery, including demographic preoperative, intraoperative, and postoperative data were collected. Patients were divided into underweight (BMI Results: The mean age of the patients was 53.2 ± 13.9 years. The overall CS-AKI incidence was 33.8% (n = 2,855) with a hospital mortality of 5.4% (n = 154). The incidence of AKI-RRT was 5.2% (n = 148) with a mortality of 54.1% (n = 80). For underweight, normal weight, overweight, and obese cardiac surgery patients, the AKI incidences were 29.9, 31.0, 36.5, and 46.0%, respectively (p < 0.001). The hospital mortality of AKI patients in the 4 groups was 9.5, 6.0, 3.8, and 4.3%, whereas the hospital mortality of AKI-RRT patients in the 4 groups was 69.2, 60.8, 36.4, and 58.8%, both significantly different (p < 0.05). Hospital and ICU stay durations were not significantly different in the 4 BMI groups. Conclusion: The hospital prognosis of AKI and AKI-RRT patients after cardiac surgery was best when their BMI was in the 24-28 range.

Background We aimed to investigate the relationship between the perioperative hemodynamic parameters and the occurrence of cardiac surgery-associated acute kidney injury. Methods A retrospective study was performed in patients who underwent cardiac surgery at a tertiary referral teaching hospital. Acute kidney injury was determined according to the KDIGO criteria. We investigated the association between the perioperative hemodynamic parameters and cardiac surgery-associated acute kidney injury to identify the independent hemodynamic predictors for acute kidney injury. Subgroup analysis was further performed in patients with chronic hypertension. Results Among 300 patients, 29.3% developed acute kidney injury during postoperative intensive care unit period. Multivariate logistic analysis showed the postoperative nadir diastolic perfusion pressure, but not mean arterial pressure, central venous pressure and mean perfusion pressure, was independently linked to the development of acute kidney injury after cardiac surgery (odds ratio 0.945, P = 0.045). Subgroup analyses in hypertensive subjects (n = 91) showed the postoperative nadir diastolic perfusion pressure and peak central venous pressure were both independently related to the development of acute kidney injury (nadir diastolic perfusion pressure, odds ratio 0.886, P = 0.033; peak central venous pressure, odds ratio 1.328, P = 0.010, respectively). Conclusions Postoperative nadir diastolic perfusion pressure was independently associated with the development of cardiac surgery-associated acute kidney injury. Furthermore, central venous pressure should be considered as a potential hemodynamic target for hypertensive patients undergoing cardiac surgery.

Objective The rarity of sensitive biomarkers for acute kidney injury (AKI) has impeded the timely therapy of AKI. Emerging evidence suggests that ion homeostasis may play pertinent roles in AKI. We aimed to screen out representative urinary ions and build a cardiac surgery-associated AKI indication model. Methods We performed urinary ionomic analysis from patients undergoing cardiac surgeries in Zhongshan Hospital, Fudan University, Shanghai, China (N = 261). By bioinformatics analysis, we identified differentially changed elements and established the AKI indication model we named the urinary ion index (UII). Follow-ups were performed to evaluate 30-day survival. Results The concentrations of most ions dynamically changed whether a patient developed AKI or not. A significant number of differentially changed elements between AKI and non-AKI groups were detected, especially at 2 hours after cardiac surgery, based on which we generated UII, with the area under the curve of 0.815 ± 0.006 and a cut-off value of 1.24. UII was associated with need for renal replacement therapy, with an area under the curve of 0.83 at a cutoff value of 1.62. Kaplan-Meier and log-rank methods, as well as Cox proportional hazards model, reflected that patients in the UII > 1.24 group had significantly higher risk of mortality within 30 days after surgery (hazard ratio, 5.15; P = .0097 and hazard ratio, 3.56; P = .033) than the UII ≤ 1.24 group. Conclusions Our data demonstrate that UII appears to be a novel and valid index of early cardiac surgery-associated AKI. UII > 1.24 at 2 hours after surgery indicates high risk of AKI and less 30-day survival.

High estimated pulmonary artery systolic pressure (ePASP) has been established as a detrimental predictor for adverse outcomes in patients with chronic kidney disease. However, the relation between preoperative high ePASP and the development of cardiac surgery associated acute kidney injury (CSA-AKI) has not been validated. We performed a retrospective cohort study of adult patients who underwent valve surgery in 2015 at Zhongshan Hospital, Fudan University. Right ventricular systolic pressure, a surrogate for pulmonary systolic pressure, was estimated in the study group of 1056 patients by preoperative echocardiography. CSA-AKI was defined based on the Kidney Disease Improving Global Outcomes criteria. The relation between preoperative ePASP and CSA-AKI was demonstrated with the use of multivariate analysis after adjusting for potential risk factors for CSA-AKI. Of these patients, preoperative ePASP was 44.5 ± 14.9 mm Hg. 401 (38%) patients developed CSA-AKI in which 73 patients (6.9%) suffered from severe AKI (stage II and III). Multivariate analysis showed that preoperative ePASP was independently associated with CSA-AKI (odds ratio per 10 mm Hg increment, 1.099; 95% confidence interval, 1.003 to 1.204; p = 0.042). Preoperative ePASP more than 60 mm Hg was found to be linked with the increasing incidence of AKI by 62% and in-hospital mortality by over 300%, but not linked with severe AKI or renal replacement therapy. In conclusion, an increase in preoperative ePASP was independently and significantly associated with the development of CSA-AKI in patients who underwent valve surgery. Such relation between preoperative ePASP and CSA-AKI could provide a novel therapeutic target against prevention of AKI.

Jia-Rui Xu,1–3 Ya-Min Zhuang,4 Lan Liu,4 Bo Shen,1–3 Yi-Mei Wang,1–3 Zhe Luo,4 Jie Teng,1–3,5 Chun-Sheng Wang,4 Xiao-Qiang Ding1–3 1Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, 2Shanghai Institute for Kidney and Dialysis, Shanghai, 3Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, 4Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, 5Department of Nephrology, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China Objective: To evaluate the impact of the renal dysfunction (RD) type and change of postoperative cardiac function on the risk of developing acute kidney injury (AKI) in patients who underwent cardiac valve surgery. Method: Reversible renal dysfunction (RRD) was defined as preoperative RD in patients who had not been initially diagnosed with chronic kidney disease (CKD). Cardiac function improvement (CFI) was defined as postoperative left ventricular ejection function – preoperative left ventricular ejection function (ΔEF) >0%, and cardiac function not improved (CFNI) as ΔEF ≤0%. Results: Of the 4,805 (94%) cardiac valve surgery patients, 301 (6%) were RD cases. The AKI incidence in the RRD group (n=252) was significantly lower than in the CKD group (n=49) (36.5% vs 63.3%, P=0.018). The AKI and renal replacement therapy incidences in the CFI group (n=174) were significantly lower than in the CFNI group (n=127) (33.9% vs 50.4%, P=0.004; 6.3% vs 13.4%, P=0.037). After adjustment for age, gender, and other confounding factors, CKD and CKD + CFNI were identified as independent risk factors for AKI in all patients after cardiac valve surgery. Multivariate logistic regression analysis showed that the risk factors for postoperative AKI in preoperative RD patients were age, gender (male), hypertension, diabetes, chronic heart failure, cardiopulmonary bypass time (every 1 min added), and intraoperative hypotension, while CFI after surgery could reduce the risk. Conclusion: For cardiac valve surgery patients, preoperative CKD was an independent risk factor for postoperative AKI, but RRD did not add to the risk. Improved postoperative cardiac function can significantly reduce the risk of postoperative AKI. Keywords: acute kidney injury, cardiac valve surgery, renal dysfunction, reversible renal dysfunction

Background Acute kidney injury (AKI) following cardiac surgery is common and associated with poor patient outcomes. Early risk assessment for development of AKI remains a challenge. The combination of urinary tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) has been shown to be an excellent predictor of AKI following cardiac surgery, but reported studies are for predominately non-Asian populations. Methods Adult patients were prospectively enrolled at Zhongshan hospital in Shanghai, China. The primary analysis was prediction of AKI and stage 2–3 AKI by [TIMP-2]*[IGFBP7] measured 4 h after postoperative ICU admission assessed using receiver operating characteristic curve (ROC) analysis. Kinetics of [TIMP-2]*[IGFBP7] following ICU admission were also examined. Results We prospectively enrolled 57 cardiac surgery patients, of which 20 (35%) developed AKI and 6 (11%) developed stage 2–3 AKI. The area under the ROC curve (AUC) of [TIMP-2]*[IGFBP7] at 4 h after ICU admission was 0.80 (95% confidence interval (CI): 0.68–0.91) for development of AKI and 0.83 (95% CI: 0.69–0.96) for development of stage 2–3 AKI. Urinary [TIMP-2]*[IGFBP7] values at 4 h after ICU admission were significantly (P

Rosuvastatin, a member of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, exerts various pharmacological activities. This study evaluated the cardioprotective effect of rosuvastatin on isoproterenol-induced myocardial infarction injury in rats. A rat model of myocardial infarction injury was induced by isoproterenol (ISO) for 2 consecutive days, rosuvastatin was administered for 8 weeks. The levels of myocardial infarct size, aspartate transaminase (AST), alanine transaminase (ALT), creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH) activities, as well as malondialdehyde (MDA) levels, superoxide dismutase (SOD), glutathione peroxidase (GPX), catalase (CAT) activities and reduced glutathione (GSH) concentrations were determined. Hematoxylin and eosin staining was used to observe cardiac histological changes. Interleukin-1β (IL-1β) and IL-18 levels in heart tissues were detected with ELISA kits. The mRNA and protein levels of NOD-like receptor superfamily, pyrin domain containing 3 (NLRP3) inflammasome were measured by qRT-PCR and western blot analysis, respectively. Our results showed that treatment with rosuvastatin reduced myocardial infract area, ameliorated histopathological alterations in myocardium, and decreased activities of myocardial injury marker enzymes in ISO-induced rats. In addition, rosuvastatin remarkably restored ISO-induced elevation of lipid peroxidation and decrease of antioxidants, significantly reduced myocardial pro-inflammatory cytokines concentrations in this animal model. Furthermore, rosuvastatin significantly inhibited the activation of NLRP3 inflammasome in this animal model. This study demonstrates that rosuvastatin significantly alleviates ISO-induced myocardial infarction injury. The mechanism is associated with attenuation of oxidative stress and inflammation, via the inhibition of NLRP3 inflammasome.

BackgroundCardiac surgery–associated acute kidney injury (CSA‐AKI) is a common complication with a poor prognosis. In order to identify modifiable perioperative risk factors forAKI, which existing risk scores are insufficient to predict, a dynamic clinical risk score to allow clinicians to estimate the risk ofCSA‐AKIfrom preoperative to early postoperative periods is needed.Methods and ResultsA total of 7233 cardiac surgery patients in our institution from January 2010 to April 2013 were enrolled prospectively and distributed into 2 cohorts. Among the derivation cohort, logistic regression was used to analyzeCSA‐AKIrisk factors preoperatively, on the day ofICUadmittance and 24 hours afterICUadmittance. Sex, age, valve surgery combined with coronary artery bypass grafting, preoperativeNYHAscore >2, previous cardiac surgery, preoperative kidney (without renal replacement therapy) disease, intraoperative cardiopulmonary bypass application, intraoperative erythrocyte transfusions, and postoperative low cardiac output syndrome were identified to be associated withCSA‐AKI. Among the other 1152 patients who served as a validation cohort, the point scoring of risk factor combinations led to area under receiver operator characteristics curves (AUROC) values forCSA‐AKIprediction of 0.74 (preoperative), 0.75 (on the day ofICUadmission), and 0.82 (postoperative), and Hosmer–Lemeshow goodness‐of‐fit tests revealed a good agreement of expected and observedCSA‐AKIrates.ConclusionsThe first dynamic predictive score system, with Kidney Disease: Improving Global Outcomes (KDIGO) AKI definition, was developed and predictive efficiency forCSA‐AKIwas validated in cardiac surgery patients.

The purpose of this study was to identify risk factors for acute kidney injury (AKI) and death of patients undergoing aortic arch surgery based on the RIFLE (risk, injury, failure, loss and end-stage kidney diseases) criteria. AKI was diagnosed according to the RIFLE criteria in patients undergoing aortic arch reconstruction with deep hypothermic circulatory arrest (DHCA). Clinical data of a total of 70 patients undergoing aortic arch reconstruction with DHCA from January 2009 to December 2009 were retrospectively reviewed. Known predictors (age, chronic kidney disease, surgery status, redo, diabetes, hypertension, blood transfusion, bypass, and deep hypothermic circulatory arrest time) were used in multivariate logistic regression analysis for acute kidney injury and in-hospital mortality. Thirty patients (42.9%) were diagnosed as Class I or F according to the RIFLE criteria, among which 10 patients (14.3%) required dialysis. The mortality rate was 11.4%. Risk factors for acute kidney injury included hypertension (odds ratio [OR] = 5.27), postoperative hypoxemia (OR = 13.36) and prolonged vasopressor dependence (OR = 12.49). Risk factors for mortality included AKI (RIFLE class F) (OR = 9.86), post liver dysfunction (OR = 6.42) and prolonged mechanical ventilation (OR = 11.76). AKI is a common complication after aortic arch surgery with DHCA. RIFLE classification provides with a useful diagnostic tool for AKI, and also the chance for further studies on prevention and treatment of AKI after DHCA. Key words: Deep hypothermic circulatory arrest, aortic arch surgery, risk factors, acute kidney injury.

Objective Cathepsin B is a prominent lysosomal protease and is involved in apoptosis as well as degradation of myofibrillar proteins in myocardial infarction. The aim of this study was to investigate myocardial cathepsin B expression in failing and non-failing human hearts. Methods: Tissue samples were taken from transplanted left ventricles from 20 patients with dilated cardiomyopathy and 5 non-failing donor hearts that could not be transplanted for technical reasons. Myocardial cathepsin B expression was determined by immunohistochemistry, the reverse transcription–polymerase chain reaction (RT–PCR) and Western blotting. Apoptosis was assessed by TUNEL staining. Results: Positive cathepsin B staining was found in failing and non-failing hearts. The expression of cathepsin B at mRNA and protein levels was significantly higher in failing hearts compared with non-failing hearts. Correlation analysis revealed that cathepsin B at mRNA and protein levels negatively correlated with EF (r=0.66, p=0.002 and r=0.492, p=0.028, respectively) in patients with heart failure. The apoptotic index was 0.015±0.006 in failing hearts and 0.002±0.001 in non-failing hearts (p

Although heart transplants have become more common, little is known about the psychological status of patients waiting for a heart transplant.Thirty-eight inpatients waiting for heart transplantation from October 2010 to December 2011 in a large general hospital in Shanghai were assessed by a psychiatrist using the Hamilton Depression Scale and the Hamilton Anxiety Scale at admission and weekly thereafter until the operation took place.The patients included 30 males and 8 females with a mean (sd) age of 44.7 (12.9) years who had been seriously limited due to their heart disease (i.e., Stage III heart disease) for a mean of 18.5 (24.0) months. Among them, 7.9% (3/38) were moderately or severely depressed and 47.4 % (18/38) had moderate or severe anxiety symptoms; only one (2.6%) had concurrent moderate to severe anxiety and depression. There was a slight but statistically significant increase in both anxiety and depressive symptoms during the first week of hospitalization. In the stepwise backward logistic regression, the reported level of anxiety was significantly associated with the duration of Stage III heart disease (less anxiety in those with longer Stage III disease), prior treatment in an intensive care unit (associated with less anxiety), age (anxiety increases with age), and prior emergency cardiac treatment (associated with greater anxiety). Multivariate linear regression analysis also found that longer duration of Stage III disease and higher educational status were associated with reporting less depressive symptoms, but a longer total duration of heart disease was associated with reports of more depressive symptoms.Unlike reports from other countries, we found that anxiety symptoms are more prevalent and more severe than depressive symptoms among inpatients waiting for heart transplantation in Shanghai. There is an inverse relationship between duration of disabling illness and the preoperative self-reports of anxiety and depressive symptoms: those who had had Stage III disease for over a year reported less severe anxiety and depressive symptoms than those who had had Stage III disease for less than a year.心脏移植术逐渐增多，但对等待心脏移植患者的情绪状态却知之甚少。2010年10月至2011年12月，由精神科医生对上海某大型综合性医院心外科住院等待心脏移植的38例患者进行汉密尔顿抑郁量表和汉密尔顿焦虑量表的评估，住院时评定一次，以后每周评估一次，直至手术。共入组男性30例，女性8例，平均年龄44.7（12.9）岁，因为心脏疾病使活动严重受限（即心功能III级）的平均病程为18.5（24.0）个月。这些患者中存在中度和严重抑郁症状的比例为7.9%（3/38），中度和严重焦虑症状的比例为47.4%（18/38），同时存在中重度抑郁和焦虑症状的仅有1人（2.6%）。住院第一周焦虑症状和抑郁症状均轻度加重。逐步logistic回归分析（向后法）显示患者自我报告的焦虑水平与以下因素相关，心功能III级的病程越长，焦虑越轻；既往住重症监护病房者，焦虑程度轻；随年龄增大焦虑加重；既往存在因心脏疾病而接受急诊抢救史者焦虑更明显。多元线性回归分析还发现心功能III级的病程越长、受教育程度越高，患者报告的抑郁症状越少，但是心脏疾病的总病程越长，患者报告的抑郁症状越明显。与国外的研究结果不同，我们发现在上海住院等待心脏移植者的焦虑症状比抑郁症状更为普遍、更为严重。疾病导致严重功能障碍的病程与术前自我报告的焦虑症状和抑郁症状的严重度负相关：心功能III级超过1年者报告的焦虑和抑郁症状要比不足1年者少。

Background The purpose of the research was to find out the factors which influence plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, then to assess whether preoperative plasma NT-proBNP levels could predict postoperative outcomes of cardiac surgery. Methods Between November 2008 and February 2010,225 patients who underwent cardiac surgery in our department were included in the study. The mean age was 61.25 ± 12.54 years, and 156 (69.3%) patients were male. NT-proBNP, CK-MB, cTnT and creatinine levels were measured preoperatively and 24 hours after operation. Postoperatively outcomes including ventilation time, length of stay in ICU and hospital, and mortality were closely monitored. The endpoints includes: 1) use of inotropic agents or intra-aortic balloon pump ≥24 h; 2) creatinine level elevated to hemodialysis; 3) cardiac events; 4) ICU stay ≥5d; 5) ventilation dependence ≥ 72 h; 6) deaths within 30 days of surgery. Results NT-proBNP concentrations (median [interquartile range]) increased from 728.4 pg/ml (IQR 213.5 to 2551 pg/ml) preoperatively to 1940.5 pg/ml (IQR 995.9 to 3892 pg/ml) postoperatively (P = 0.015). Preoperative atrial fibrillation, NYHA class III/IV, ejection fraction, pulmonary arterial pressure, left ventricle end-diastolic diameter (LVEDD), preoperative plasma creatinine and cTnT levels were significantly associated with preoperative NT-proBNP levels in univariate analysis. The preoperative NT-proBNP was closely related to ventilation time (P = 0.009), length of stay in ICU (P = 0.004) and length of stay in hospital (P = 0.019). Receiver operating characteristic curves demonstrated a cut-off value above 2773.5 pg/ml was the best cutoff (sensitivity of 63.6% and specificity of 80.8%) to predict the mortality within 30d of surgery. Conclusions Preoperative plasma NT-proBNP level presents a high individual variability in patients undergoing cardiac surgery. NYHA classification, ejection fraction, pulmonary arterial pressure, LVEDD, atrial fibrillation, preoperative plasma creatinine, and cTnT levels are significantly associated with preoperative NT-proBNP levels. Preoperative NT-proBNP is a valuable marker in predicting postoperative outcomes.