Abstract
Objective
Acute renal failure after valve surgery carries significant morbidity and mortality. Preoperative cardiac catheterization is the standard of care. For convenience, catheterization just before surgery is simplest for patients. However, it is not known if this timing of radiocontrast administration significantly affects renal function. We hypothesized that preoperative cardiac catheterization within 24 hours of valve surgery is associated with the development of acute renal failure.
Methods
A retrospective case-control study was performed of all patients undergoing valve surgery between 2003 and 2008 at the University of Virginia. Patients with preoperative renal dysfunction were excluded. Patients with postoperative acute renal failure were matched to those without acute renal failure according to age, gender, year of surgery, New York Heart Association functional class, elective status, concomitant coronary artery bypass grafting, and type of valve procedure. A logistic regression model examined the effects of perioperative risk factors on the development of acute renal failure.
Results
Of 1287 patients undergoing valve surgery, 61 with acute renal failure were matched to 136 without acute renal failure. Cardiac catheterization within 24 hours of surgery was significantly greater in patients with acute renal failure (31.2% vs 8.8%, P = .013). The risk of acute renal failure was more than 5 times higher for patients undergoing catheterization within 24 hours of surgery (odds ratio, 5.3; P = .004). The number of postoperative vasopressors was significantly associated with acute renal failure (odds ratio, 1.7; P = .007).
Conclusions
Although catheterization is often performed for patient convenience, catheterization within 24 hours of valve surgery is significantly associated with the development of acute renal failure. Current practices should be adjusted to ensure that more than 24 hours have passed from the time of cardiac catheterization to valve surgery in elective settings.
Acute renal failure (ARF) is a serious and unfortunately common complication after cardiac surgery occurring in up to 30% of patients.1–6 Furthermore, valvular heart surgery is an independent risk factor for ARF, conferring a 2.7-fold increased risk compared with coronary artery bypass grafting (CABG) alone.7 Contrast-induced nephropathy accounts for a significant number of cases of hospital-acquired ARF,8–10 and ARF is associated with a 20% mortality rate after cardiac catheterization.11,12 Previous studies have suggested a temporal relationship between the timing of cardiac catheterization and the development of ARF in patients undergoing CABG and combination cardiac procedures.13–15
It is unclear whether timing of radiocontrast administration for cardiac catheterization significantly affects renal function after heart valve surgery. Elective cardiac catheterization is often performed the day before surgery for convenience. We hypothesized that preoperative cardiac catheterization within 24 hours of heart valve surgery is associated with the development of ARF.
MATERIALS AND METHODS
Data Source and Patient Population
Approval for this investigation was obtained from the human investigation committee of the University of Virginia Health System, including a waiver of the need to obtain patient consent. All patients undergoing cardiac surgery at the University of Virginia were prospectively entered into the Society of Thoracic Surgeons (STS) database.
A retrospective review was performed of all patients who underwent heart valve surgery (repair or replacement) from August 2003 to December of 2008. The 1287 patients identified were stratified as those with postoperative ARF (ARF group) and without postoperative ARF (no ARF group). All patients with preoperative renal failure or renal dysfunction were excluded from the study.
Variables Examined and Outcomes Measured
Renal failure or dysfunction was defined on the basis of accepted STS definitions.16 Postoperative ARF was defined as any patient with an increase of serum creatinine to greater than 2.0 mg/dL and 2 times the most recent preoperative creatinine level or the requirement for dialysis postoperatively. Preoperative renal failure or dysfunction was defined as a documented history of renal failure, a history of a creatinine level greater than 2.0 mg/dL, or the need for current dialysis.
Patient demographic characteristics, preoperative risk factors, operative features, and postoperative outcomes were examined. STS definitions were used to describe all preoperative variables, postoperative complications, and outcomes.16 In this population, epinephrine was commonly used during low cardiac output and norepinephrine/vasopressin/phenylephrine was used for a vasoplegic state. Mortality was defined as any patient death that occurred before hospital discharge or within 30 days of operation. A major complication included the composite incidence of postoperative stroke, mortality, infection, and prolonged ventilation. Timing of cardiac catheterization to surgery was defined as less than 24 hours, 24 to 48 hours, 48 to 72 hours, and greater than 72 hours. The following postoperative vasopressor administration was recorded for each patient during the first 6 hours after surgery: epinephrine, norepinephrine, vasopressin, and phenylephrine. Each patient’s preoperative hemoglobin (grams/deciliter) and lowest intraoperative hemoglobin (grams/deciliters) were collected and subsequently used to calculate change in intraoperative hemoglobin (grams/deciliters). In addition, the highest rewarming temperature (degrees Celsius) was recorded for each patient after cardiopulmonary bypass (CPB).
The primary end point was the development of ARF after heart valve surgery. The influence of perioperative variables on the development of ARF was studied.
Statistical Analysis
A case-control study was performed on the 1287 patients who underwent heart valve surgery. Patients with ARF were matched to patients without ARF according to age, gender, year of surgery, New York Heart Association functional class, elective versus emergent/urgent operative status, concomitant CABG, and type of valve procedure (aortic, mitral, tricuspid, and pulmonic valves). Year of surgery was matched to within 1 year, and age of the patient at the time of surgery was matched to within 5 years. Case-control matching was performed using Bergstralh and colleagues’ algorithm.17 Up to 3 controls were matched to each case in the study population to maximize the balance achieved across criteria in the available population.18 The adequacy of the balance achieved between cases and controls was formally assessed using the chi-square test statistic for all categoric matching criteria and the t test statistic to assess the significance of the difference in mean age.
Patient demographic, preoperative risk factors, operative features, and postoperative outcomes were compared using a univariate analysis. Categoric variables were compared using the chi-square or Fisher’s exact test where appropriate. Continuous variables were compared using a 2-sided t test.
A multivariable conditional logistic regression was performed to assess the statistical significance of the association between ARF and a series of exposures of interest.19 The following variables were entered as covariates: preoperative angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use, timing of cardiac catheterization before surgery (within 24 hours, 24–48 hours, 48–72 hours, or ≥72 hours), intraoperative aprotinin use, number of postoperative vasopressors, lowest intraoperative hemoglobin, change in hemoglobin, and highest CPB rewarming temperature and CPB time. These covariates were chosen a priori on the basis of the literature and clinical knowledge. CPB time was significantly different between the ARF and no ARF groups and therefore included in the logistic regression to account for that difference. Other established risk factors for ARF (age, diabetes, degree of heart failure, urgent/emergent operative status) were controlled for in the case-control analysis. Patients in the ARF group and the no ARF group were equal according to these established risk factors and therefore not included in the multivariable analysis.
Conditional logistic regression was performed using the discrete logistic form of the Cox proportional hazards model with strata formed for each matched set. Cases and controls were compared and assessed for significant differences on each exposure of interest using the Wald chi-square test statistic. The magnitude of differences in renal failure complications for each exposure was measured by calculating odds ratios (ORs), and 95% confidence intervals (CI) were calculated to assess the statistical significance of the difference in odds between cases and controls. Data manipulation and analysis were performed with SAS version 9.1.3 software (SAS Institute, Inc, Cary, NC)
RESULTS
From August 2003 to December 2008, 1287 patients underwent heart valve surgery at the University of Virginia. Of this cohort, 83 patients (6.6%) had postoperative ARF and 52%of these patients required dialysis. Records for patients without ARF were searched to find patients of identical age, gender, New York Heart Association functional class, elective status or emergent/urgent operative status, concomitant CABG, year of surgery, and type of valve procedure. A total of 61 patients with ARF were matched to 136 patients without ARF, with 61 cases matched to at least 1 control, 44 cases matched twice, and 31 cases matched to 3 controls. Of the 83 patients with ARF, 22 were excluded from the study because there was no suitable match to a patient without ARF according to our matching criteria.
Preoperative Risk Factors and Operative Features
As seen in Table 1, balance was achieved across all matching criteria, such that no statistically significant differences were observed in the proportional distributions or mean values of the matching covariates. The number of patients in the ARF group was equal to the number of patients in the no ARF group according to elective versus emergent/urgent operative status (emergent/urgent status: 41% vs 37.5%, P = .76).
TABLE 1.
Summary of matching criteria for patients with and without acute renal failure
| ARF (n = 61) (%) | No ARF (n = 136) (%) | P value* | |
|---|---|---|---|
| Age at operation (y, mean ± SD) | 67 ± 13.9 | 67.7 ± 13.7 | .77 |
| Male | 29 (47.5%) | 68 (50.0%) | .75 |
| Year of surgery | .61 | ||
| 2003 | 2 (3.3%) | 3 (2.2%) | |
| 2004 | 5 (8.2%) | 17 (12.5%) | |
| 2005 | 10 (16.4%) | 13 (9.6%) | |
| 2006 | 6 (9.8%) | 21 (15.4%) | |
| 2007 | 18 (29.5%) | 38 (27.9%) | |
| 2008 | 20 (32.8%) | 44 (32.4%) | |
| NYHA functional class | .92 | ||
| 1 | 23 (37.7%) | 55 (40.4%) | |
| 2 | 7 (11.5%) | 18 (13.2%) | |
| 3 | 12 (19.7%) | 22 (16.2%) | |
| 4 | 19 (31.2%) | 41 (30.2%) | |
| Operative status | .76 | ||
| Elective surgery | 36 (59.0%) | 85 (62.5%) | |
| Emergent/urgent surgery | 25 (41.0%) | 51 (37.5%) | |
| CABG | 25 (41.0%) | 58 (42.7%) | .83 |
| Type of valve surgery (repair or replacement) | |||
| Aortic | 42 (68.9%) | 100 (73.5%) | .50 |
| Mitral | 20 (32.8%) | 37 (27.2%) | .42 |
| Pulmonic | 1 (1.6%) | 1 (0.74%) | .56 |
| Tricuspid | 3 (4.9%) | 5 (3.7%) | .68 |
ARF, Acute renal failure; NYHA, New York Heart Association; CABG, coronary artery bypass grafting.
Significance<.05.
Preoperative creatinine was not significantly different between the ARF and no ARF groups (1.21 ± 0.04 mg/dL vs 1.12 ± 0.02 mg/dL, P = .06). Preoperative risk factors in patients with ARF were equivalent to patients without ARF (Table 2). There was no statistically significant difference in STS-predicted risk between patients with and without ARF (8%± 8%vs 6%± 6%, P = .31). There was no difference in diabetes (24%vs 30.2%, P =.42), hypertension (73.8%vs 72.1%, P =.80), or dyslipidemia (68.9%vs 66.9%, P =.79). Patients with ARF differed from patients without ARF on several perioperative factors (Table 3). Patients with ARF were more likely to have their cardiac catheterization less than 24 hours from the time of surgery (31.2% vs 8.8%, P < .0001). CPB time was longer in the ARF group (156.2 ± 73.4 minutes vs 133.7 ± 46.4 minutes, P = .03). In the first 6 postoperative hours, patients with ARF were more likely to receive norepinephrine (61.7% vs 38.7%, P = .002) and vasopressin (60%vs 37.3%, P = .003).
TABLE 2.
Preoperative risk factors for patients with and without acute renal failure after valve surgery
| ARF (n = 61) (%) | No ARF (n = 136) (%) | P value* | |
|---|---|---|---|
| Ethnicity | .73 | ||
| Caucasian | 58 (96.7%) | 123 (94.0%) | |
| African-American | 2 (3.3%) | 8 (6.1%) | |
| History of tobacco | 25 (41.0%) | 57 (41.9%) | .90 |
| Dyslipidemia | 42 (68.9%) | 91 (66.9%) | .79 |
| Peripheral artery disease | 10 (16.7%) | 16 (11.8%) | .37 |
| Cerebrovascular disease | 12 (20.0%) | 29 (21.2%) | .79 |
| Chronic lung disease | 10 (16.4%) | 27 (19.9%) | .57 |
| Previous CVA | 9 (14.8%) | 17 (12.5%) | .67 |
| Diabetes | 15 (24.0%) | 41 (30.2%) | .42 |
| Hypertension | 45 (73.8%) | 98 (72.1%) | .80 |
| Preoperative creatinine (mg/dL, mean ± SD) | 1.21 ± 0.02 | 1.12 ± 0.04 | .06 |
| ACE inhibitor/ARB use | 23 (37.7%) | 55 (40.4%) | .72 |
| Immunosuppressive Medication | 5 (8.2%) | 10 (7.4%) | .78 |
| Previous CABG | 5 (8.2%) | 11 (8.1%) | 1 |
| Previous valve procedure | 6 (9.8%) | 15 (11.0%) | .80 |
| Arrhythmia | 15 (25.6%) | 37 (27.2%) | .70 |
| Angina | 14 (23.0%) | 39 (28.7%) | .40 |
| Heart failure | 33 (54.1%) | 59 (43.4%) | .16 |
ARF, Acute renal failure; CVA, cerebrovascular accident; ACE, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; SD, standard deviation; CABG, coronary artery bypass grafting.
Significance<.05.
TABLE 3.
Perioperative features for patients undergoing valve surgery
| ARF (n = 61) (%) | No ARF (n = 136) (%) | P value* | |
|---|---|---|---|
| STS predicted risk (mean ± SD) | 8 ± 8.0% | 6 ± 6.0% | .31 |
| IABP | 8 (13.1%) | 11 (8.1%) | .27 |
| Cardiac catheterization within 24 h | 19 (31.2%) | 12 (8.8%) | <.0001* |
| Cardiac catheterization within 24–48 h | 2 (3.3%) | 25 (18.4%) | .003* |
| Cardiac catheterization within 48–72 h | 7 (11.5%) | 8 (5.9%) | .24 |
| Cardiac catheterization >72 h before | 33 (54.1%) | 90 (66.2%) | .11 |
| CPB time (min, mean ± SD) | 156.2 ± 73.4 | 133.7 ± 46.4 | .03* |
| Aprotinin | 17 (27.9%) | 24 (17.7%) | .10 |
| Epinephrine | 50 (80.0%) | 102 (74.3%) | .24 |
| Norepinephrine | 37 (60.7%) | 53 (39.0%) | .005* |
| Vasopressin | 37 (60.7%) | 50 (36.8%) | .002* |
| Phenylephrine | 4 (6.6%) | 6 (4.4%) | .50 |
| Intraoperative change in hemoglobin (mean ± SD) | 5.5 ± 1.9 | 5.41 ± 1.9 | .76 |
| Lowest intraoperative hemoglobin (mean ± SD) | 7 ± 1.5 | 7.2 ± 1.2 | .21 |
| Highest post-CPB re-warming temperature | 36.9 ± 0.86 | 36.6 ± 0.64 | .04* |
ARF, Acute renal failure; IABP, intra-aortic balloon pump; CPB, cardiopulmonary bypass; STS, Society of Thoracic Surgeons; SD, standard deviation.
Significance<.05.
Association Between Acute Renal Failure and Postoperative Outcomes
After valve surgery, patients with ARF had significantly worse postoperative complications compared with patients without ARF. Patients with ARF were more likely to undergo reoperation secondary to postoperative bleeding or tamponade (16.4% vs 5.9%, P = .02). These patients were also more likely to have postoperative sepsis, pneumonia, a gastrointestinal complication, and noncardiac reoperation (Table 4). ARF was associated with prolonged ventilation (68.3% vs 16.2%, P<.0001), longer intensive care unit stays (384.7 ± 444.3 hours vs 79.2 ± 72.7 hours, P < .0001), and longer length of stays in the hospital (24.3 ± 21.3 days vs 8 ± 4.8 days, P<.0001).
TABLE 4.
Postoperative outcomes after valve surgery
| ARF (n = 61) (%) | No ARF (n = 136) (%) | P value* | |
|---|---|---|---|
| Sepsis | 11 (18.0%) | 4 (2.9%) | <.0001* |
| Deep sternal wound infection | 1 (1.6%) | 0 (0) | .31 |
| Stroke | 7 (11.5%) | 10 (7.4%) | .34 |
| Reoperation for bleeding or tamponade | 10 (16.4%) | 8 (5.9%) | .02* |
| Noncardiac reoperation | 14 (23.0%) | 5 (3.7%) | <.0001* |
| Gastrointestinal event | 13 (21.7%) | 2 (1.5%) | <.001* |
| Pneumonia | 18 (29.5%) | 6 (4.4%) | <.001* |
| Prolonged ventilation | 42 (68.3%) | 22 (16.2%) | <.000* |
| Length of stay (d, mean ± SD) | 24.3 ± 21.3 | 8 ± 4.8 | <.0001* |
| ICU stay (h, mean ± SD) | 384.7 ± 444.3 | 79.2 ± 72.7 | <.0001* |
| Mortality (30 d) | 11 (18.3%) | 7 (5.1%) | .004* |
ICU, Intensive care unit; SD, standard deviation.
Significance<.05.
Overall major complication rates were significantly higher in patients with acute ARF (20% vs 5.1%, P = .003). The 30-day mortality was significantly higher in patients with ARF (18.3% vs 5.1%, P = .004).
Risk Factors for Acute Renal Failure
The logistic regression identifies 2 risk factors associated with the development of postoperative ARF (Table 5). The risk of ARF was more than 5 times higher for patients who underwent cardiac catheterization within 24 hours of their valve surgery compared with patients who underwent cardiac catheterization more than 72 hours before valve surgery (OR, 5.3; CI, 1.9–15.2; P = .004). The administration of vasopressors in the first 6 postoperative hours was also significantly associated with the development of ARF. The risk of ARF increased 2-fold for every additional vasopressor given (OR, 1.7; CI, 1.2–2.4; P = .007).
TABLE 5.
Conditional logistic regression model: Predictors of acute renal failure
| Odds ratio | 95% Confidence interval | P value* | |
|---|---|---|---|
| Cardiac catheterization within 24 h | 5.3 | 1.4–19.0 | .01* |
| Cardiac catheterization within 24–48 h | 0.4 | 0.1–2.8 | .47 |
| Cardiac catheterization within 48–72 h | 3.1 | 0.8–12.3 | .11 |
| Cardiac catheterization >72 h before | REF | REF | REF |
| No. of postoperative vasopressors (in first 6 h) | 1.7 | 1.2–2.4 | .007* |
| Preoperative ACE inhibitors/ARB | 1.0 | 0.5–2.1 | .37 |
| Aprotinin | 1.3 | 0.3–2 | .61 |
| Change in hemoglobin | 1.0 | 0.8–1.2 | .96 |
| Lowest intraoperative hemoglobin | 0.8 | 0.6–1.1 | .23 |
| Highest post-CPB rewarming temperature (°C) | 1.4 | 0.9–2.3 | .18 |
| CPB time | 1 | 1.0–1.1 | .56 |
ACE, Angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; CPB, cardiopulmonary bypass. REF indicates no effect was estimated, because this value serves as the reference standard for the covariate’s measure of effect.
Significance<.05.
DISCUSSION
ARF is a potentially devastating complication after heart valve surgery. It is often associated with a complicated clinical course and holds significant morbidity for patients, with increased resource use, longer hospital stays, and increased risk of infection. Patients requiring dialysis have exceptionally high mortality rates ranging from 20% to 64%,3,20,21 and even small increases in serum creatinine are associated with an increase in 30-day mortality.22
In this study, ARF developed in 6.6% of patients undergoing valve surgery with no history of renal dysfunction, and more than 50% of these patients progressed to dialysis. Of these patients, 6% had a major postoperative complication with an 18% 30-day mortality rate. Similar to patients described in the literature,1–3,6,23–25 patients with ARF in this study had significantly worse postoperative outcomes. Patients with ARF also had longer CPB times, and therefore CPB time was included in the multivariable logistic regression to eliminate it as a confounder. They had higher rates of infection, longer intensive care unit stays, and overall longer hospitalizations (Table 4). Given the significant postoperative complications associated with ARF after valve surgery, identifying methods of prevention of renal injury is imperative.
Preoperative cardiac catheterization is the standard of care before valve surgery, and many patients commonly undergo both catheterization and valve surgery sequentially in a single hospitalization for convenience. The American College of Cardiology and American Heart Association Guidelines recommend preoperative cardiac catheterization before valve surgery in any man or postmenopausal woman aged 35 years or more and in any premenopausal woman with risk factors. They also recommend catheterization in mild to moderate valve disease if there is evidence of angina, ischemia, decreased left ventricular function, or overt congestive heart failure.26 Currently, the temporal relationship between cardiac catheterization and surgery on the development of ARF has primary focused on CABG and combination cardiac procedures. We lack specific insight on the nature of this relationship for patients undergoing valve repair and replacement procedures.
In patients undergoing CABG, Medalion and colleagues,14 as well as others,13 reported surgery within 5 days of cardiac catheterization was as an independent predictor of postoperative ARF. Ranucci and colleagues15 found that delaying cardiac surgery more than 24 hours from the time of cardiac catheterization decreased the incidence of postoperative ARF by 3-fold. On the other hand, Brown and colleagues27 suggest in a select population that same-day coronary angiography may be safe before valve surgery.
Our study focuses on this temporal relationship in patients undergoing valve surgery and collaborates the findings after CABG and combined cardiac procedures. The timing of cardiac catheterization was a significant predictor of ARF. Catheterization within 24 hours of surgery was significantly greater in patients with ARF than in patients without ARF (31.2% vs 8.8%, P = .01). The risk of ARF was more than 5 times higher for patients who underwent cardiac catheterization within 24 hours of surgery compared with patients who underwent catheterization more than 72 hours before surgery (OR, 5.3; CI, 1.9–15.2; P = .004).
Contrast-induced nephropathy after cardiac catheterization and ARF after valve surgery have been well described in the literature. Contrast administration and valve surgery likely have synergistic effects on the kidney, causing renal dysfunction. Contrast administration likely decreases the functional reserve of the kidneys (“first hit”), making patients less likely to withstand a “second hit,” which is either the valve procedure itself or any postoperative complication such as bleeding or a need for vasopressors. Increasing the time between cardiac catheterization and valve surgery may limit this multiple hit phenomenon. When feasible, performing cardiac catheterization more than 24 hours before the time of valve surgery is recommended.
Notably, the administration of postoperative vasopressors was significantly associated with the development of ARF after valve surgery. The use of these agents has been associated with the development of postoperative renal failure after cardiac surgery.28–31 However, previous studies have failed to identify postoperative vasopressor use as a significant independent predictor of ARF.28,30 In our study, patients with ARF were more likely to receive norepinephrine and vasopressin than patients without ARF. Furthermore, postoperative vasopressor use was found to be predictive of ARF, with a 2-fold increased risk for every additional vasopressor given (OR, 1.7; CI, 1.2–2.4; P = .007).
Cardiac performance has been described as one of the critical factors in the development of ARF after cardiac surgery.31 The conflicting results between our study and others may be explained by patient selection. Currently it is ambiguous whether vasopressor use is the cause of ARF or a marker of severity of illness in these patients. Unlike other studies, our study controlled for the degree of heart failure and overall severity of preoperative illness, and the patients in the ARF and no ARF groups were identical. Therefore, in our study we concluded that vasopressor administration is predictive of ARF independently of heart failure and overall severity of illness in the patient.
Limitations
This is a small retrospective, case-control study, and therefore it is limited by its inherent biases and inability to indicate absolute risk. We recognize there are other potential modifiable risk factors for ARF that were not addressed in our analysis. One potential confounder in this study is the significant difference in postoperative complications between patients with and without ARF. Patients with ARF had higher rates of postoperative complications. This may be the cause of ARF in some patients; however, on the basis of these data, it is difficult to tease out which came first: ARF or the other postoperative complications.
ARF was defined on the basis of STS database criteria; however, they are several other definitions of renal failure (Risk Injury Failure Loss ESKD/RIFLE/Acute Kidney Injury Network) that could be used to describe this population. However, STS definitions are widely accepted and followed in our field. The difference of 1.1 and 1.2 was not significant, although it was close. In a young patient, that difference might not be of importance, whereas in an older patient a difference of 0.1 might be significant. However, in this study our patients were well matched on age and other comorbidities; therefore, this difference is likely not significant overall. However, STS definitions are well established and the definition of ARF is a conservative one; therefore, we think our conclusions are accurate and appropriate. We also recognize that it is not always feasible to delay the time from cardiac catheterization to valve surgery in all patients; however, a concerted effort should be made.
CONCLUSIONS
ARF is a significant complication after heart valve surgery. Cardiac catheterization is often performed less than 24 hours before valve surgery for convenience. However, we demonstrate that catheterization within 24 hours of valve surgery is independently associated with the development of ARF. When feasible, current practice should be adjusted to ensure that more than 24 hours have passed from the time of cardiac catheterization to the time of valve surgery.
Acknowledgments
The project described was supported by Award Number T32HL007849 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health.
Abbreviations and Acronyms
- ARF
acute renal failure
- CABG
coronary artery bypass grafting
- CI
confidence interval
- CPB
cardiopulmonary bypass
- OR
odds ratio
- STS
Society of Thoracic Surgeons
Footnotes
Disclosures: Gorav Ailawadi: Consultant for Atricure, Carbomedic, St Jude, and Honoraria: Atricure, Abbott. Irving L. Kron: Consultant for Edwards Life Sciences, St Jude.
Read at the 90th Annual Meeting of The American Association for Thoracic Surgery, May 1–5, 2010, Toronto, Ontario, Canada.
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