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Ann Thorac Surg 2008;86:350. doi:10.1016/j.athoracsur.2008.02.067
© 2008 The Society of Thoracic Surgeons
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Correspondence

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Michele Di Mauro, MD, Antonio M. Calafiore, MD

Department of Cardiac Surgery, University of Catania, Ferrarotto Hospital, Via Citelli, Catania 95124, Italy

(Email: mdimauro{at}unich.it).

To the Editor:

We read with extreme interest the comments by Lema and coworkers [1]. To answer the first point, a significant hemodynamic instability during anesthesia induction, chest opening, or graft harvesting was observed in only 10 patients (0.5%). In 8 patients, cardiopulmonary bypass (CPB) was established; in 2 patients, myocardial revascularization started off-pump were both converted to CPB because of a new episode of instability. Only 1 patient had postoperative renal failure, whereas creatinine value slightly increased in 3 patients. It is possible that preoperative reduced plasma flow can affect renal function, even in off-pump surgery, but this was not our experience. Moreover, we do not agree with the idea that hemodynamic measurements are more closely taken care off in off-pump surgery. We take the same care and use the same protocol for on-pump and off-pump surgery. As already reported in our article, there are two possible explanations for postoperative increment of creatinine in off-pump surgery (ie, the inflammatory response, which is similar in both surgical options [2, 3] and transient circulatory failure, which occurs during lateral wall revascularization); the latter hypothesis was supported by our results [4]. Patients with preoperative renal impairment have a higher trend to having postoperative renal failure develop, whereas the patients with normal preoperative renal function show only a slight postoperative creatinine increment, more often without any clinical consequence.

Concerning the second comment, we strongly believe that the incidence of patients with preoperative hemodynamic instability causing renal damage is too low to be addressed as the main cause of renal dysfunction after CPB. On the contrary, there are many evidences that plasma dilution, strong inflammatory response, nonpulsatile flow, and relative organs hypoperfusion during CPB can be the main causes of renal damage after CPB.

We used creatinine value because it is routinely assessed every day, and even if it is not a perfect marker, it is commonly used to evaluate the EuroSCORE value [5]. There is no general agreement in the literature concerning which creatinine value can identify renal dysfunction. Therefore, we decided to use 1.5 mg/dL according to our laboratory and to other authors [6].


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 References
 

  1. Lema G, Canessa R, Urzua J. Off-pump surgery, cardiopulmonary bypass and renal dysfunction(letter) Ann Thorac Surg 2008;86:349-350.[Free Full Text]
  2. Biglioli P, Cannata A, Alamanni F, et al. Biological effects of off-pump vs on-pump coronary artery surgery: focus on inflammation, haemostasis and oxidative stress Eur J Cardiothorac Surg 2003;24:260-269.[Abstract/Free Full Text]
  3. Wehlin L, Vedin J, Vaage J, Lundahl J. Activation of complement and leukocyte receptors during on-pump and off-pump coronary artery bypass surgery Eur J Cardiothorac Surg 2004;25:35-42.[Abstract/Free Full Text]
  4. Di Mauro M, Gagliardi M, Iaco AL, et al. Does off-pump coronary surgery reduce postoperative acute renal failure?. The importance of preoperative renal function. Ann Thorac Surg 2007;84:1496-1503.[Abstract/Free Full Text]
  5. Roques F, Nashef SAM, Michel P, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients Eur J Cardiothorac Surg 1999;15:816-823.[Abstract/Free Full Text]
  6. Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification Circulation 1997;95:878-884.[Abstract/Free Full Text]

Related Article

Off-Pump Surgery, Cardiopulmonary Bypass, and Renal Dysfunction
Guillermo Lema, Roberto Canessa, and Jorge Urzua
Ann. Thorac. Surg. 2008 86: 349-350. [Extract] [Full Text] [PDF]




This Article
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Antonio M. Calafiore
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