Adverse Events Following Coronary Angiography And Cardiac Surgery

Having a major adverse renal or cardiac event (MARCE) is a calculable risk following cardiac surgery. As techniques for percutaneous coronary interventions (PCI) have improved over time, so too has PCI utilization, rendering cardiac surgery more appropriate for cases too complicated for PCI. As surgeons take on increasingly difficult cases, they look for new ways to improve surgical outcomes.

The interval from coronary angiography to cardiac surgery may be one such factor; however, there are conflicting reports as to an ideal waiting time.[1,2] This is partially due to performing analyses without controlling for contrast medium, which has an effect on the risk of contrast-induced acute kidney injury (CI-AKI).[3]

In a recently published article entitled, Major Adverse Renal and Cardiac Events After Coronary Angiography and Cardiac Surgery, a team of researchers from the Baylor Scott & White Health Care System, led by Drs. Kristen M. Tecson and Peter A. McCullough, evaluated the impact of the waiting period between angiography and cardiac surgery on the outcome of MARCE in subjects who received iodixanol, an iso-osmolar contrast, during angiography at their center.[4]

To accomplish this task, Baylor Scott & White Health Care System partnered with the Dallas Fort Worth Hospital Council (DFWHC) to access a dataset of local hospitalization records across approximately 90 hospitals from January 1, 2008-June 30, 2015. [5] CI-AKI was determined using Kidney Disease: Improving Global Outcomes guidelines for up to 1 week following coronary angiogram or until cardiac surgery, whichever occurred first. [6] MARCE was the composite of renal replacement therapy, myocardial infarction, stroke, heart failure, renal/cardiac hospitalization, and death.

Using nearly 1000 records of high-risk cases, they found that 13% of patients developed CI-AKI between angiogram and surgery and that 26% developed MARCE in the year following surgery. They also found that patients who had cardiac surgery within 1 day of angiogram were at a 68% elevated risk of MARCE than those who waited 2-4 days. The effect of wait-time was removed after adjusting for clinical factors in all cardiac surgeries; however, a subgroup analysis using patients who underwent isolated coronary artery bypass graft surgery revealed that such a quick turnaround from angiogram to surgery conferred 2.3 times the risk for MARCE compared to those who waited 2-4 days. Further, they discovered that these MARCE outcomes were exacerbated by the presence of CI-AKI. For example, 8.6% of patients without CI-AKI who had surgery within 1 day developed 1-year MARCE, compared with 18.2% of patients who had surgery in the same timeframe but also had antecedent CI-AKI. Importantly, 72% of cases performed within 1 day could have potentially waited longer, as they were not emergent. [4]

While this was the first study to consider the impact of wait-time on the outcome of MARCE, this work expanded on conflicting previous reports which considered wait-time as a factor for other procedural outcomes. For example, Mehta et al. found a modest relation between mortality and wait-time from angiography to elective CABG, without controlling for contrast media. [1] Others dichotomized wait-time by < or ≥7 days and observed no difference in post-surgical AKI development.[7] Another study considering nonionic contrast cases indicated that waiting 6+ days to have cardiac surgery had a protective effect against acute renal dysfunction development.[8]

As the general population becomes increasingly comorbid and surgical cases become correspondingly more complicated, surgeons may look to operation timing as one factor to improve surgical outcomes. While there is no consensus regarding the optimal time for cardiac surgery following angiography, these results suggest that CABG within 24 hours of angiography negatively impacts MARCE, especially if antecedent CI-AKI occurs. In cases where surgery cannot be delayed, AKI preventive measures prior to and during surgery should be employed.

These findings are described in the article entitled, “Major Adverse Renal and Cardiac Events After Coronary Angiography and Cardiac Surgery,” recently published in the Annals of Thoracic Surgery. This work was conducted by a team of Ph.D. and MD researchers from the Baylor Scott and White Health System, Dallas, TX.

Acknowledgments: The original article was partially funded by GE Healthcare and The Baylor Health Care System Foundation. Data were provided by the DFWHC ERF Information Quality Services Center Regional Data, [quarter 4 2015]. Dallas-Fort Worth Hospital Council Educations and Research Foundation, Information and Quality Services Center, Irving, Texas.

References:

1. Mehta RH, Honeycutt E, Patel UD, Lopes RD, Williams JB, Shaw LK, O’Brien SM, Califf RM, Hughes GC, Sketch MH Jr. Relationship of the time interval between cardiac catheterization and elective coronary artery bypass surgery with postprocedural acute kidney injury. Circulation. 2011 Sep 13;124(11 Suppl):S149-55. doi:10.1161/CIRCULATIONAHA.110.011700.
2. Andersen ND, Williams JB, Fosbol EL, Shah AA, Bhattacharya SD, Mehta RH, Hughes GC. Cardiac catheterization within 1 to 3 days of proximal aortic surgery is not associated with increased postoperative acute kidney injury. J Thorac Cardiovasc Surg. 2012 Jun;143(6):1404-10. doi:10.1016/j.jtcvs.2012.01.069.
3. McCullough PA, Choi JP, Feghali GA, Schussler JM, Stoler RM, Vallabahn RC, Mehta A. Contrast-Induced Acute Kidney Injury. J Am Coll Cardiol. 2016 Sep 27;68(13):1465-73. doi:10.1016/j.jacc.2016.05.099. Review.
4. Tecson KM, Brown D, Choi JW, Feghali G, Gonzalez-Stawinski GV, Hamman BL, Hebeler R, Lander SR, Lima B, Potluri S, Schussler JM, Stoler RC, Velasco C, McCullough PA. Major Adverse Renal and Cardiac Events After Coronary Angiography and Cardiac Surgery. Ann Thorac Surg. 2018 Jun;105(6):1724-1730. doi: 10.1016/j.athoracsur.2018.01.010. Epub 2018 Feb 2. PubMed PMID: 29408241.
5. Jacobs JP, Shahian DM, He X, O’Brien SM, Badhwar V, Cleveland JC Jr, Furnary AP, Magee MJ, Kurlansky PA, Rankin JS, Welke KF, Filardo G, Dokholyan RS, Peterson ED, Brennan JM, Han JM, McDonald D, Schmitz D, Edwards FH, Prager RL, Grover FL. Penetration, Completeness, and Representativeness of The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2016 Jan;101(1):33-41; discussion 41. doi:10.1016/j.athoracsur.2015.08.055.
6. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1–138.
7. Kim K, Joung KW, Ji SM, Kim JY, Lee EH, Chung CH, Choi IC. The effect of coronary angiography timing and use of cardiopulmonary bypass on acute kidney injury after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg. 2016 Jul;152(1):254-261.e3. doi:10.1016/j.jtcvs.2016.02.063.
8. Baloria KA, Pillai BS, Goel S, Selot N. Acute renal dysfunction: time from coronary angiography to cardiac surgery. Asian Cardiovasc Thorac Ann. 2013 Dec;21(6):649-54. doi:10.1177/0218492312465421.