Ahmet Barış DURUKAN, Nevriye SALMAN, Cem YORGANCIOĞLU, Halil İbrahim UÇAR, Murat TAVLAŞOĞLU, Hasan Alper GÜRBÜZ, Fatih Tanzer SERTER

Perioperative Management of Chronic Dialysis Patients Undergoing Cardiac Surgery

Giriş: Kronik böbrek hastalığı belirgin kardiyovasküler morbidite ve mortaliteye sahiptir. Yüksek perioperatif komplikasyon oranları ve mortalite sebebiyle diyaliz yapılan hastalarda kalp cerrahisi oldukça zordur. Bu çalışmanın amacı kalp cerrahisi yapılan son dönem böbrek hastalarında tedavi sonuçlarının ortaya konması ve perioperatif hasta idare stratejilerinin etkisinin araştırılmasıdır. Hastalar ve Yöntem: Ocak 2011-Kasım 2012 tarihleri arasında opere edilen hemodiyaliz (n= 17) ya da periton diyalizi (n= 2) uygulanan son dönem böbrek hastaları retrospektif olarak incelendi. İzole koroner baypas, koroner baypasla beraber mitral kapak prosedürleri ya da mitral ve/veya triküspid kapak cerrahisi uygulandı. Postoperatif değişkenler, mortalite ve sağkalım oranları çalışıldı.Bulgular: Hastaların ortalama yaşı 56.32 ± 12.97 yıl idi. Erkek/kadın hasta oranı 10/9 idi. Ortalama hemodiyaliz süresi 4.07 ± 1.89 yıl, ortalama periton diyalizi süresi ise 1.5 ± 0.7 yıl idi. Ortalama kros-klemp süresi 57.63 ± 21.56 dakika, ortalama kardiyopulmoner baypas süresi ise 87.89 ± 24.66 dakika idi. İntraoperatif dönemde ortalama 1610.53 ± 607.26 mL ultrafi ltrasyon yapıldı. Üç (%15.8) hasta hastane yatışı sırasında kaybedildi. Ortanca takip süresi 16 aydı ve sağkalım %84.2 idi. Sonuç: Perioperatif morbidite ve mortalitenin düşürülmesi amaçlı preoperatif ve postoperatif hemodiyaliz planlaması, kardiyopulmoner baypasın kullanılması ya da kullanımından kaçınılması ve intraoperatif ultrafi ltrasyon uygulaması gibi perioperatif hasta idaresiyle beraber iyi planlanmış bir cerrahi strateji belirlenmelidir

Kalp Cerrahisi Uygulanan Kronik Diyaliz Hastalarında Perioperatif İdare

Introduction: Chronic kidney disease is associated with signifi cant cardiovascular morbidity and mortality. Cardiac surgery in patients undergoing dialysis is still challenging due to increased perioperative complication rates and mortality. The aim of this study is to document the outcomes of cardiac surgery in end stage renal disease patients and analyze the impact of perioperative management strategies. Patients and Methods: Nineteen patients with end-stage renal disease undergoing hemodialysis (n= 17) or peritoneal dialysis (n= 2) operated between January 2011 and November 2012 were studied retrospectively. Isolated coronary bypass, coronary bypass concomitant with mitral valve procedures or mitral and/or tricuspid valve surgery were performed. Postoperative variables, mortality and survival rates were studied.Results: The mean age of the patients was 56.32 ± 12.97 years. Male to female ratio was 10/9. The mean duration of preoperative hemodialysis was 4.07 ± 1.89 and peritoneal dialysis was 1.5 ± 0.7 years. Mean cross-clamp time was 57.63 ± 21.56 minutes and cardiopulmonary bypass time was 87.89 ± 24.66 minutes. Mean amount of ultrafi ltration performed intraoperatively was 1610.53 ± 607.26 mL. Three (15.8%) in-hospital mortalities were noted. The median follow-up was 16 months and survival rate was 84.2%.Conclusion: A well planned surgical strategy and perioperative medical management including the timing of pre and postoperative hemodialysis, use or avoidance of cardiopulmonary bypass and the use of intraoperative ultrafi ltration should be documented to decrease perioperative morbidity and mortality

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1. Erek E, Suleymanlar G, Serdengecti K. Registry of the Nephrology Dialysis and Transplantation in Turkey (Registry 2004).Turk Nefroloji Derneği Yayınları, 2005.
2. U.S. Renal Data System, USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2011.
3. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu Y. Chronic kidney disease and risks of death, cardiovascular events and hospitalization. N Engl J Med 2005;353:2643-53.
4. Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, et al. Chronic kidney disease and mortality risk: a systematic review. J An Soc Nephrol 2006;17:2034-47.
5. Zheng H, Xue S, Lian F, Huang RT, Hu ZL, Wang YY. Meta-analysis of clinical studies comparing coronary artery bypass grafting with percutaneous coronary intervention in patients with endstage renal disease. Eur J Cardiothorac Surg 2013;43:459-67.
6. Hage FD, Vankataraman R, Zoghbi GJ, Perry GJ, DeMattos AM, Iskandrian AM. The scope of coronary heart disease in patients with chronic kidney disease. J Am Coll Cardiol 2009;53:2129-40.
7. Coca SG, Krumhols HM, Garg AX, Parikh CR. Underpresentation of renal disease in randomized controlled trials of cardiovascular disease. JAMA 2006;296:1377-84.
8. Tanaka K, Tajima K, Tkami Y, Okada N, Terazawa S, Usui A, et al. Early and late outcomes of aortic valve replacement in dialysis patients. Ann Thorac Surg 2010;89:65-70.
9. Nashef SAM, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, et al. EuroSCORE II. Eur J Cardiothorac Surg 2012;41:734-44.
10. Kogan A, Medalion B, Kornowski R, Raanani E, Sharoni E, Stamler A, et al. Cardiac surgery in patients on chronic hemodialysis: short and long-term survival. Thorac Cardiovasc Surg 2008;56:123-7.
11. Kobayashi J, Ikebuchi M, Fajita Y, Irie H. Early postoperative recovery by chronic dialysis patients after coronary artery bypass grafting. Ann Thorac Surg 2009;15:243-6.
12. Kumar VA, Ananthakrishnan S Rasgon SA, Yan E, Burchette R, Dewar K. Comparing cardiac surgery in peritoneal dialysis and hemodialysis patients: perioperative outcomes and two-year survival. Perit Dial Int 2012;32:137-41.
13. Yamauchi T, Miyata H, Sakaguchi T, Miyagawa S, Yoshikawa Y, Takeda K, et al. Coronary artery bypass grafting in hemodialysisdependent patients. Circ J 2012;76:1115-20. 14. Nicolini F, Fragnito C, Molardi A, Agostinelli A, Campodonico R, Spaggiari I, et al. Heart surgery in patients on chronic dialysis: is there still room for improvement in early and long-term outcome? Heart Vessels 2011;26:46-54.
15. Jayasekera H, Pinto N, Mundy J, Wood A, Beller E, Griffi n R, et al. Cardiac surgery in the presence of dialysis: effect on mid-term outcomes and quality of life. Heart Lung Circ 2011;20:105-10.
16. Erentug V, Akinci E, Kirali K, Kayalar N, Kaynak E, Ogus H et al. Complete off-pump coronary revascularization in patients with dialysis dependent renal disease. Tex Heart Inst J 2004;31:153-6.
17. Bruschi G, Colombo T, Botta L, Colombo P, Pelenghi S, Trunfi o S, et al. Off-pump coronary revascularization in chronic dialysisdependent patients: early outcomes at a single institution. J Cardiovasc Med 2010;11:481-7.
18. Ünlü A, Çapcı S, Yıldız O, Paşaoğlu İ, Demircin M. Effects of preoperative homocysteine levels on postoperative outcomes and adverse events in patients undergoing on-pump cardiac surgery. Journal-CVS 2013;1. Available from: http://www.scopemed.org/ fulltextpdf.php?mno=32456. Accessed date: 21.02.2013.
19. Zhang L, Boyce SW, Hill PC, Sun X, Lee A, Haile E, et al. Offpump coronary artery bypass grafting improves in-hospital mortality in patients with dialysis-dependent renal failure. Cardiovasc Revasc Med 2009;10:12-6.
20. Abud B, Yetkin U, Beşir Y, Gökalp O, Tulukoğlu E, Göktoğan T, et al. The results of conventional coronary artery bypass and beating-heart coronary artery bypass grafting in patients with hemodialysis-dependent end-stage renal failure. Türk Göğüs Kalp Dama 2008;16:155-61.
21. Durukan AB, Gurbuz HA, Durukan E, Tavlasoglu M, Unal EU, Serter FT, et al. Atrial fi brillation following surgical management of ischemic heart disease; 1 year, single center, single surgeon results. Kosuyolu Kalp Derg 2012;15:65-74.
22. Osaka S. CABG for patients on hemodialysis: comments at present. Ann Thorac Cardiovasc Surg 2010;16:69-71.
23. Kato H, Ikawa S, Hayashi A, Yokoyama K. Internal mammary artery steal in a dialysis patient. Ann Thorac Surg 2003;75:270-1.
24. Crowley SD, Butterly DW, Peter RH, Schwab SJ. Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fi stula. Am J Kidney Dis 2002;40:852-5.
25. Baciewicz FA Jr. Recommendation for IMA use in dialysis patients with ipsilateral fi stula. Ann Thorac Surg 2004;77:1134-5.

ISSN: 2149-2972
Yayın Aralığı: Yılda 3 Sayı
Başlangıç: 1990
Yayıncı: Sağlık Bilimleri Üniversitesi, Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi