This prospective, observational study was conducted in a university hospital to verify that intraoperative worsening of right ventricular function causes cardiac surgery-associated acute kidney injury. Adult patients undergoing cardiac surgery under mid-sternal incision with cardiopulmonary bypass were included. Echocardiographic right and left ventricular function parameters were measured before and after bypass and compared using the Wilcoxon signedrank test. Perioperative serum creatinine values at baseline and within the first 48 hours postoperatively were measured for the diagnosis of acute kidney injury. Spearman rank-order correlation (ρ) and receiver operating characteristic analysis were used to reveal relationships. Thirty-four patients were evaluated. Right ventricular ejection fraction (56.2±7.0 vs. 51.6±7.2%; P=0.0002), right ventricular fractional area change (49.1±6.4 vs. 46.6±5.3%; P=0.0201), and left ventricular ejection fraction (57.4±6.1 vs. 51.7±6.2%; P<0.0001) were significantly decreased. Central venous pressure was significantly increased (7.2±3.5 vs. 9.7±3.7; P=0.0001). Serum creatinine values increased from 0.82[0.70-1.08] to 0.99[0.82-1.54] mg/dL (P<0.0001). Changes in right ventricular ejection fraction, fractional area change, and right ventricular strain during cardiovascular surgery were significantly correlated with changes in serum creatinine values.Fractional area change exhibited the strongest correlation (ρ=-0.61, P<0.0001). Change in fractional area change showed an area under the curve of 0.902 and a cutoff value of -2.1, which predicted acute kidney injury with 92% sensitivity, 73% specificity, and 79% accuracy. The functions of both ventricles were decreased after cardiopulmonary bypass. Worsening right ventricular function was independently correlated with postoperative renal dysfunction, and fractional area change was the strongest predictor of cardiac surgery-associated acute kidney injury.
A 66-year-old man presented with a hepatocellular carcinoma with a tumor thrombus extending into the right atrium and was scheduled for en bloc hepatectomy and resection of the thrombus under cardiopulmonary bypass (CPB) . The patient had previously undergone a coronary artery bypass graft, and we were concerned that there was a risk of accidental dissection of mediastinal adhesions or the bypass graft itself. We therefore decided to operate under cardiopulmonary bypass and deep hypothermic circulatory arrest without redoing a midline median sternotomy. The surgery was successfully performed. Echocardiography was employed intraoperatively to monitor the movement of the tumor thrombus in the right atrium and position of the venous cannulae for the CPB and central venous catheter. The post-operative course was uneventful.
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