Abstract: Background: Fluid overload (FO) and acute kidney injury (AKI) after CABG surgery are due to multiple perioperative etiologies associated with high failure to rescue rates (FTR) and associated with poor outcomes  1-,3. Diuretics, fluid restriction, ultrafiltration (UF) and renal replacement therapies are the treatment modalities implemented as monotherapy or in combination to address this severe complication. There is limited data on the use of simplified UF therapy as a fluid management strategy in post-operative cardiac surgery patients. Methods: A retrospective review of our post operative isolated CABG patients was done from Jan 1 st, 2020 to July 31 st, 2021. Those subjected to a simplified UF protocol incorporating Goal Directed Therapy (GDT) to treat fluid overload and/or acute kidney injury were evaluated for 30-day survival and readmission rates. Results: A total of 254 isolated CABG procedures were performed during this period. Ultrafiltration was used in 17 (6.7%) patients. The 30-day mortality for the entire CABG cohort was 5/254 (2.0%) patients and in the UF group 0/17 (0%). The mean age of UF therapy patients was 65.8 years (Range 41-89). The mean Society of Thoracic Surgeons STS mortality score of UF patients was 5.7% (Range 0.6-50.0). The 30-day survival for the 17 patients placed on UF therapy was 100% and their readmission rate was 2/17 (11.7%). Conclusions: The use of ultrafiltration in this patient population with relatively high STS scores provided a safe and effective modality to manage fluid balance but further studies are needed.

The Impella 5.5 with SmartAssist (Abiomed; Danvers, MA) is a life-saving treatment option in acute heart failure which utilizes a continuous heparin purge solution to prevent thrombosis. In patients with contraindications to heparin, alternative anticoagulation strategies are required. We describe the stepwise management of anticoagulation in a coagulopathic patient with persistent cardiogenic shock following a coronary artery bypass procedure who underwent Impella 5.5 placement. A direct thrombin inhibitor-based purge solution was utilized while evaluating for heparin-induced thrombocytopenia. Use of a novel bicarbonate-based purge solution (BBPS) was successfully used due to severe coagulopathy. There were no episodes of pump thrombosis or episodes of severe bleeding on the BBPS and systemic effects of alkalosis and hypernatremia were minimal.