Mild to moderate renal dysfunction. creatinine clearance versus serum creatinine as a risk factor for perioperative mortality and morbidity after isolated coronary artery bypass surgery

Risk stratification algorithms for coronary artery bypass grafting [CABG] do not include a weighting for preoperative mild and moderate renal impairment defined as a serum Creatinine 130 to 179 micromol/L [1.47 to 2.1 mg/dL], which may impact mortality and morbidity after CABG. Renal dysfunction [RD] is one of the predictors of mortality and morbidity in cardiac surgery. Creatinine clearance can be easily estimated by the Cockcroft and Gault equation from serum creatinine, gender, age and body weight. In this work we examine whether this estimation of the glomerular filtration rate can advantageously replace the serum creatinine in the preoperative risk assessment, and whether this calculated creatinine clearance could be used as a predictor of early mortality and postoperative complications in patients undergoing coronary artery bypass grafting. Three hundred ninety six consecutive patients without dialysis- dependent renal insufficiency undergoing a first isolated coronary artery bypass grafting were included. Preoperative serum creatinine concentrations and creatinine clearance calculated by using the Cockroft-Gault formula were related to early perioperative mortality and morbidity. The in-hospital mortality was 2.5% [10 of 396], the need for new dialysis/hemofiltration was 1.5% [6 of 396]. Using serum Creatinine, only 9.5% of our patient population was stratified as having preoperative mild to moderate RD versus 48.3% using calculated Creatinine clearance [CrCl]. Operative mortality was higher in the mild renal dysfunction group and increased with increasing preoperative serum Creatinine level. While we were able to find strong correlation using CrCl estimates, peri-operative mortality was higher in the mild [0.5% versus 3.7%; P = 0.03] and moderate RD group [0.5% versus 6.7%; P < 0.001], with S.Cr estimates, this correlation was only found in those who had preoperative mild RD. Similar finding has been found regarding the incidence of dialysis/hemoflitration [according to CrCl, 0.5% versus 1.4%; P = 0.387 in mild RD, and 0.5%, versus 5%; P = 0.003, in moderate RD]. Creatinine Clearance estimates were stronger predictor of mortality and dialysis/hemnofiltration than serum Creatinine. Mortality rate among patients who had dialysis/hemnofiltration was 66.6% versus an overall mortality of 2.5%. Mild and moderate renal insufficiency could increases the risk of early death and dialysis/hemoflitration with its associated morbidity after coronary artery bypass grafting. Our results indicate that calculated creatinine clearance is a stronger predictor of early mortality and morbidity postoperatively than serum creatinine level. We also could suggest that creatinine clearance should be applied to estimate the preoperative renal function instead of serum creatinine

Staged versus combined approaches for concomitant carotid and coronary artery disease. perioperative morbidity and mortality

There is a continuing controversy about the management of patients with concomitant occlusive disease of the coronary and carotid arteries. The options vary from combined to staged approach. The efficacy and safety of each method can be measured, essentially, by the global mortality, and morbidity. 33 of 1490 [2.21%] consecutive patients who were referred for isolated CABG were found to have significant carotid disease and underwent isolated coronary artery bypass graft [CABG] and carotid endarterectomy [CEA]. 23 patients had the staged approach [CEA, and subsequently CABG], while 10 patients had the combined approach [simultaneous CEA and CABG]. For these high-risk patients, there were 3 in-hospital mortalities, 1 patient in staged group [4.3%], and 2 patients [20%] in the combined group. While no patients in the staged group had stroke, 2 cases of disabling stroke were encountered in the combined group. One of these 2 cases was disabling stroke and death [Stroke related mortality]. Both patients who experienced postoperative stroke had a previous history of CVA. No patients in either group had Perioperative myocardial infarction. Staged approach is a good and safe alternative surgical option for patients with concomitant carotid and coronary artery disease. Our current approach is to favor staged carotid and coronary surgery, based on our operative experience and our Risk analyses [lower perioperative mortality and morbidity rates]. A rapid staged procedure may be a safe option to decrease the hospital stay