Relationship of Platelet Counts and Inflammatory Markers to 30-Day Mortality Risk in Patients with Acute Type A Aortic Dissection

Associations between static and dynamic changes of platelet counts and in-hospital mortality in critical patients with acute heart failure

To investigate the predictive value of baseline platelet count and its short-term dynamic changes in the prognosis of patients with acute heart failure (AHF) in the intensive care unit. Patients diagnosed with AHF in the medical information mart for intensive care III and their clinical data were retrospectively filtered. Patients were divided into survivor and non-survivor groups based on their prognosis during hospitalization, and differences in baseline data between groups were compared. Logistic regression models and restricted cubic spline (RCS) plots were performed to evaluate the relationship between baseline platelet counts and in-hospital mortality. Changes and trends in platelet counts were compared between the survivor and non-survivor groups after adjusting for confounders with the generalized additive mixing model (GAMM). A total of 2930 critical patients with acute heart failure were included, of which 2720 were survivors and 210 were non-survivors. Multiple logistic regression models revealed that baseline platelet count was an independent factor in hospital mortality (OR 0.997, 95% CI 0.994-0.999, P-value = 0.018). The RCS plot demonstrated a U-shaped dose-response relationship between baseline platelet count and in-hospital mortality. GAMM analysis suggested that the platelet counts decreased and then increased in the survivor group and gradually decreased in the non-survivor group, with a gradual increase of difference between two groups. After adjusting for confounders, the mean daily increase was -6.014 (95% CI -7.076-4.953, P-value < 0.001). Baseline platelet demonstrated a U-shaped dose-response relationship with adverse outcomes in critical patients with AHF. Early elevation of platelet was correlated with higher in-hospital mortality, indicating that tracking early changes in platelet might help determine the short-term prognosis of critical patients with AHF.

MALT1 Positively Relates to T Helper 1 and T Helper 17 cells, and Serves as a Potential Biomarker for Predicting 30-Day Mortality in Stanford Type A Aortic Dissection Patients

Mucosa-associated lymphoid tissue 1 (MALT1) regulates inflammation and T helper (Th) cell differentiation, which may participate in the progression of Stanford type A aortic dissection (TAAD). This study intended to assess the association of MALT1 expression with prognosis in TAAD patients. In this prospective study, MALT1 expression was measured by reverse transcription-quantitative polymerase chain reaction assay from peripheral blood samples in 100 TAAD patients and 100 non-AD controls (non-AD patients with chest pain) before treatment. Besides, Th1, Th2, and Th17 cells of TAAD patients before treatment were measured by flow cytometry assay, and their 30-day mortality was recorded. MALT1 expression was ascended in TAAD patients vs. non-AD controls (P < 0.001). In TAAD patients, elevated MALT1 expression was linked with hypertension complication (P = 0.009), increased systolic blood pressure (r = 0.291, P = 0.003), C-reactive protein (CRP) (r = 0.286, P = 0.004), and D-dimer (r = 0.359, P < 0.001). Additionally, MALT1 expression was positively correlated with Th1 cells (r = 0.312, P = 0.002) and Th17 cells (r = 0.397, P < 0.001), but not linked with Th2 cells (r = -0.166, P = 0.098). Notably, the 30-day mortality of TAAD patients was 28.0%. MALT1 expression [odds ratio (OR) = 1.936, P = 0.004], CRP (OR = 1.108, P = 0.002), D-dimer (OR = 1.094, P = 0.003), and surgery timing (emergency vs. selective) (OR = 8.721, P = 0.024) independently predicted increased risk of death within 30 days in TAAD patients. Furthermore, the combination of the above-mentioned independent factors had an excellent ability in predicting 30-day mortality with the area under curve of 0.949 (95% confidence interval: 0.909-0.989). MALT1 expression relates to increased Th1 cells, Th17 cells, and 30-day mortality risk in TAAD patients.

Postoperative thrombocytopenia and subsequent consequences in acute type A aortic dissection

OBJECTIVES

To ascertain if postoperative thrombocytopenia following open aortic surgery with a median sternotomy can predict early- and intermediate-term morbidity and mortality.

METHODS

From January 2018 to December 2022, a comparison was made between patients who had and didn't have postoperative thrombocytopenia (defined as a nadir < 75 × 103/μL after 72 h of open aortic surgery with median sternotomy). Intermediate-term mortality during follow-up was the main result, with cerebrovascular accident and acute renal injury requiring dialysis as secondary events. Inverse probability treatment weighting (IPTW) was used to account for selection bias between groups. The Kaplan-Meier method with the log-rank test was used to assess intermediate-term survivals following IPTW modification. To identify the nonlinear link between platelet nadir and mortality probability, a generalized additive mix model was applied. To help increase power in testing for the overall effect of platelet nadir on outcomes in the generalized additive mix model, the hazard ratios and 95% CIs for each subgroup and their interactions were examined.

RESULTS

The study included 457 patients, 347 male (75.9%), with mean age of 54 ± 12 years. The last follow-up was done on April 14th, 2023 and the median follow-up time was 16 (6-31) months. Following IPTW, patient characteristics were balanced among cohorts. Platelet nadir was found to be significantly inversely related to early-term mortality (IPTW-adjusted hazard ratio = 0.968 (0.960, 0.977), p < 0.001), and AKI requiring dialysis (IPTW-adjusted hazard ratio = 0.979 (0.971, 0.986), p < 0.001). A nonlinear relationship between platelet nadir and mortality risk probability during follow-up visually showed that the likelihood of mortality decreased with platelet nadir increased. In confounder-adjusted survival ('postoperative thrombocytopenia not acquired' vs 'postoperative thrombocytopenia'; HR: 0.086 [95% CI: 0.045-0.163]; p < 0.01) analysis, non-acquired postoperative thrombocytopenia was associated with a lower risk of mortality, and the treatment benefit was validated in IPTW-adjusted analysis, which showed an HR of 0.067.

CONCLUSIONS

Early postoperative thrombocytopenia following type A aortic dissection surgery is a risk factor for morbidity and mortality. Because postoperative thrombocytopenia can indicate a poor prognosis, monitoring early postoperative platelets helps identify individuals who may develop late postoperative problems, which is performed by this affordable biomarker.

The creation and validation of predictive models to assess the risk of unfavorable outcomes following hybrid total arch repair for Stanford type A aortic dissection

BACKGROUND

The objective of this study was to develop and validate a nomogram for the individualized prediction of adverse events in patients with Stanford type A aortic dissection (TAAD) undergoing hybrid total aortic arch repair.

METHODS

From April 2019 to April 2022, we conducted a comprehensive review of the medical records of Stanford type A aortic dissection patients who underwent hybrid total aortic arch repair surgery at our hospital. Patients were separated into two groups based on whether or not a composite adverse event occurred following surgery. Using univariate and multivariate analyses of logistic regression, the prediction model was created. Construct risk prediction models utilizing nomograms and evaluate their precision, discrimination, and clinical utility.

RESULTS

Age, platelets, serum blood urea nitrogen, and ascending aortic diameter were the variables included in the nomogram by univariate and multivariate analysis. The risk model performed well in internal validation, with an area under the curve (AUC) of 0.829. The calibration curve demonstrated good agreement between predicted and actual probabilities (Hosmer-Lemeshow test, P = 0.22). Clinical decision analysis curves demonstrate predictive nomograms' clinical utility.

CONCLUSION

This study created and validated a nomogram for predicting the risk of composite endpoint events in TAAD patients undergoing hybrid total aortic arch repair. The nomogram can help determine the severity of a patient's condition and provide a more personalized diagnosis and treatment.

Prognostic Value of the Systemic Immune Inflammation Index after Thoracic Endovascular Aortic Repair in Patients with Type B Aortic Dissection

The study aimed at investigating the association between postoperative inflammatory scores and aorta-related adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) for patients with type B aortic dissection (TBAD). This single-centre, retrospective cohort included all patients who underwent TEVAR for TBAD between November 2016 and November 2020 at a university hospital. The risk factors for AAEs were analyzed by Cox proportional hazards model regression. Prediction accuracy was assessed using the area under the receiver operating characteristic curves. This study included 186 patients with a mean age of 58.5 years and a median follow-up period of 26 months. A total of 68 patients developed AAEs. Age and postoperative systemic immune inflammation index (SII) (>2893) were associated with post-TEVAR AAEs (hazard ratio (HR) 1.03, p = 0.003; HR 1.88, p = 0.043, respectively). Increased postoperative SII and age are independent risk factors for AAE post-TEVAR in patients with TBAD.

Short- and Mid-Term Survival Prediction in Patients with Acute Type A Aortic Dissection Undergoing Surgical Repair: Based on the Systemic Immune-Inflammation Index

Purpose

The postoperative survival of patients with acute type A aortic dissection (aTAAD) remains unsatisfactory. The current study developed an easy-to-use survival prediction model and calculator.

Methods

A total of 496 patients with aTAAD undergoing surgical repair were included in this study. The systemic immune-inflammation index (SII) and other clinical features were collected and subjected to logistic and Cox regression analyses. The survival prediction model was based on Cox regression analyses and exhibited as a nomogram. For convenience of use, the nomogram was further developed into calculator software.

Results

We demonstrated that a higher preoperative SII was associated with in-hospital death (OR: 4.116, p < 0.001) and a higher postoperative overall survival rate (HR: 2.467, p < 0.001) in aTAAD patients undergoing surgical repair. A survival prediction model and calculator based on SII and four other clinical features were developed. The overall C-index of the model was 0.743. The areas under the curves (AUCs) of the 1- and 3-month and 1- and 3-year survival probabilities were 0.73, 0.71, 0.71 and 0.72, respectively. The model also showed good calibration and clinical utility.

Conclusion

Preoperative SII is significantly associated with postoperative survival. Based on SII and other clinical features, we created the first easy-to-use prediction model and calculator for predicting the postoperative survival rate in aTAAD patients, which showed good prediction performance.

Preoperative systemic inflammatory response index predicts long-term outcomes in type B aortic dissection after endovascular repair

Objectives

Inflammation is a hallmark of the initial development and progression of aortic dissection. This study aimed to investigate the value of preoperative inflammatory biomarkers in predicting aorta-related adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection.

Methods

We included all patients who underwent TEVAR for type B aortic dissection between November 2016 and November 2020 in this single-center, retrospective cohort study. Patients were divided into two groups: the AAEs group (n = 75) and the non-AAEs group (n = 126). Preoperative inflammatory biomarkers were recorded, including neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic immune inflammation index (SII), and systemic inflammatory response index (SIRI). Patients were followed-up for the development of AAEs. Prediction accuracy of inflammatory biomarkers for AAEs were evaluated using the area under the receiver operating characteristic curves.

Results

This study included 201 patients, of whom 80.0% were men, with a mean age of 59.1 ± 12.5 years. A total of 75 patients developed AAEs after TEVAR. The AUCs of NLR, MLR, PLR, SII, and SIRI for AAEs were.746,.782,.534,.625 and.807, respectively. Age and SIRI were independent risk factors for the AAEs after TEVAR (HR 3.264, p <.001; HR 4.281, p <.001, respectively). Survival analysis revealed significantly lower AAE-free status in patients with preoperative SIRI > = 4 (p <.001).

Conclusion

Increased preoperative SIRI and age are independent risk factors for AAEs after TEVAR in type B aortic dissection.

The prognostic value of admission lymphocyte-to-monocyte ratio in critically ill patients with acute myocardial infarction

BACKGROUND

Inflammation plays a critical role in acute myocardial infarction (AMI). Recent studies have shown the value of hematologic indicators in MI risk stratification and prognostic assessment. However, the association between lymphocyte-to-monocyte ratio (LMR) and the long-term mortality of critically ill MI patients remains unclear.

METHODS

Clinical data were extracted from the Medical Information Mart for Intensive Care III database. Patients diagnosed with AMI on admission in the intensive care units were include. The optimal cutoff value of LMR was determined by X-tile software. The Cox proportional hazard model was applied for the identification of independent prognostic factors of 1-year mortality and survival curves were estimated using the Kaplan-Meier method. In order to reduce selection bias, a 1:1 propensity score matching (PSM) method was performed.

RESULTS

A total of 1517 AMI patients were included in this study. The cutoff value for 1-year mortality of LMR determined by X-Tile software was 3.00. A total of 534 pairs of patients were matched after PSM. Multivariate analysis (HR = 1.369, 95%CI 1.110-1.687, P = 0.003) and PSM subgroups (HR = 1.299, 95%CI 1.032-1.634, P = 0.026) showed that 1-year mortality was significantly higher in patients with LMR < 3.00 than patients with LMR ≥ 3.00 in Cox proportional hazard models. The survival curves showed that patients with LMR < 3.00 had a significantly lower 1-year survival rate before (63.83 vs. 81.03%, Log rank P < 0.001) and after PSM (68.13 vs. 74.22%, Log rank P = 0.041).

CONCLUSION

In this retrospective cohort analysis, we demonstrated that a low admission LMR (< 3.00) was associated with a higher risk of 1-year mortality in critically ill patients with AMI.

Efficacy of CRP in combination with D-dimer in predicting adverse postoperative outcomes of patients with acute Stanford type A aortic dissection

Purpose

The present study evaluated the efficacy of C-reactive protein (CRP) and D-dimer and the combination of them as prognostic indicators for patients with acute type A aortic dissection (ATAAD).

Methods

This is a retrospective cohort study. From January 2019 to December 2021, patients with ATAAD admitted to the emergency medicine center of our hospital within 24 h after symptoms (chest pain, back pain, abdominal pain and so on) onset were enrolled in our study. Serum concentration of CRP and D-dimer were measured during hospitalization. Logistic regression was used to evaluate the association between these two biomarkers and in-hospital adverse outcomes (IAO) by adjusting confounding factors. Predictive efficacy was assessed by area under the curve (AUC) of receiver operating characteristic curve.

Results

A total of 199 patients with ATAAD were finally enrolled. They were categorized as Non-IAO group (n = 146) and IAO group (n = 53) according to postoperative outcomes. After controlling for potentially confounding variables, we found categorized variables that admission CRP > 54.28 mg/L, admission D-dimer > 8.45 mg/L and peak D-dimer > 24.89 mg/L were independent predictors of in-hospital adverse outcomes. Multiple Logistic regression analysis revealed that the odd ratios were 2.9 for admission D-dimer > 8.45 [95% Confidence Interval (CI) 1.11–7.5, p = 0.03], 4.9 for admission CRP > 54.28 (95% CI 1.6–14.9, p = 0.005) and 5.7 for peak D-dimer > 24.89 (95% CI 2.49–13, p < 0.001). The predictive accuracy of the combination of three categorized variables (AUC: 0.867, 95% CI 0.813–0.921, p < 0.001) was superior to that of any other one alone.

Conclusion

Admission D-dimer > 8.45 mg/L, peak D-dimer > 24.89 mg/L and admission CRP > 54.28 mg/L are independent predictors of in-hospital adverse outcomes in patients with ATAAD. Combination of these three markers will improve the predictive efficacy.

The David Operation Offers Shorter Hemostasis Time Than the Bentall in Case of Acute Aortic Dissection Type A

Background

The aim of the present study was to compare the clinical outcome of the David operation and the Bentall operation in patients with Stanford type A acute aortic dissection (AADA) from the viewpoint of hemostasis.

Methods

Between April 2016 and April 2020, 235 patients underwent emergent surgery for AADA. Of them, 38 patients required aortic root replacement (ARR: The David operation 17, the Bentall operation 21). The mean age was 59.3±12.6 years. In the present series, the David operation was the first choice for relatively young people, and the Bentall operation was performed for relatively elderly patients and cases in which valve-sparing seemed impossible.

Results

Between the David and the Bentall group, the 30-day mortality rate did not differ significantly. However, hemostasis time (144.6±50.3 vs. 212.5±138.1 min, p=0.047), defined as the interval from the cessation of cardio-pulmonary bypass (CPB) to the end of the operation, and total operation time (477.8±85.7 vs. 578.3±173.6 min, p=0.027) were significantly shorter in the David group than in the Bentall group, and the amount of blood transfusion was less in the David group than in the Bentall group (red blood cells: 3.5±3.6 vs. 9.2±5.9 units, p=0.013; fresh frozen plasma: 4.1±4.7 vs 9.4±5.1 units, p=0.002; platelet concentrate: 33.2±11.3 vs 42.2±12.0 units, p=0.025).

Conclusion

David operation offers a shorter hemostasis time and consequently shorter operation time than the Bentall operation in the setting of AADA, probably due to double suture lines, despite its surgical complexity.

U-shaped relationship between platelet-lymphocyte ratio and postoperative in-hospital mortality in patients with type A acute aortic dissection

Background

The platelet-lymphocyte ratio (PLR), a novel inflammatory marker, is generally associated with increased in-hospital mortality risk. We aimed to investigate the association between PLR and postoperative in-hospital mortality risk in patients with type A acute aortic dissection (AAAD).

Methods

Patients (n = 270) who underwent emergency surgery for AAAD at Xiangya Hospital of Central South University between January 2014 and May 2019 were divided into three PLR-based tertiles. We used multiple regression analyses to evaluate the independent effect of PLR on in-hospital mortality, and smooth curve fitting and a segmented regression model with adjustment of confounding factors to analyze the threshold effect between PLR and in-hospital mortality risk.

Results

The overall postoperative in-hospital mortality was 13.33%. After adjusting for confounders, in-hospital mortality risk in the medium PLR tertile was the lowest (Odds ratio [OR] = 0.20, 95% confidence interval [CI] = 0.06–0.66). We observed a U-shaped relationship between PLR and in-hospital mortality risk after smoothing spline fitting was applied. When PLR < 108, the in-hospital mortality risk increased by 10% per unit decrease in PLR (OR = 0.90, P = 0.001). When the PLR was between 108 and 188, the mortality risk was the lowest (OR = 1.02, P = 0.288). When PLR > 188, the in-hospital mortality risk increased by 6% per unit increase in PLR (OR = 1.06, P = 0.045).

Conclusions

There was a U-shaped relationship between PLR and in-hospital mortality in patients with AAAD, with an optimal PLR range for the lowest in-hospital mortality risk of 108–188. PLR may be a useful preoperative prognostic tool for predicting in-hospital mortality risk in patients with AAAD and can ensure risk stratification and early treatment initiation.

Development and evaluation of an early death risk prediction model after acute type A aortic dissection

Background

The purpose of the study was to assess the relationship between preoperative laboratory examination, clinical imaging data, and postoperative death of patients with acute type A aortic dissection (ATAAD) and to establish a prediction model of hospital death risk after the operation.

Methods

A total of 224 cases of acute Standford A aortic dissection were treated by total arch replacement using a tetrafurcate graft with stented elephant trunk implantation in Tianjin Chest Hospital. Based on preoperative laboratory examination and clinical imaging data of patients with ATAAD, the independent risk factors of postoperative hospital death were obtained using logistic analysis, and a risk prediction model of postoperative hospital death was developed.

Results

Independent risk factors of postoperative death in patients with ATAAD were: body mass index (BMI), preoperative neutrophil to lymphocyte ratio (NLR), mean platelet volume (MPV), creatinine (Cr), D-dimer, high-sensitive cardiac troponin T (hs-CTnT), apolipoprotein A1, left subclavian artery involvement, and iliac artery involvement. The regression equation of postoperative death risk was: logitP1 = −9.584 + 1.060 × NLR + 1.586 × MPV + 1.009 × Cr + 1.067 × D-dimer + 2.023 × hs-CTnT; the regression equation of postoperative death risk was: logitP2 = −3.296 + 3.242 × left subclavian artery involved + 4.564 × iliac artery involved; the regression equation of postoperative death risk was: logitP3 = −12.864 + 1.149 × BMI + 4.731 × left subclavian artery involved + 4.150 × iliac artery involved + 1.064 × NLR + 1.011 × Cr + 1.084 × D-dimer + 2.242 × hs-CTnT + 3.233 × apolipoprotein A1.

Conclusions

BMI, NLR, MPV, Cr, D-dimer, hs-CTnT, apolipoprotein A1, left subclavian artery involvement and iliac artery involvement can affect the hospital mortality rate of aortic dissection undergoing Sun’s operation to varying degrees, which may be helpful to guide the design of the perioperative treatment strategy.

Low postoperative blood platelet count may be a risk factor for 3-year mortality in patients with acute type A aortic dissection

Background

Mortality and complications remain high after acute type A aortic dissection (ATAAD) open surgery and are associated with coagulation dysfunction. Platelets play an important role in the process of coagulation. This study explored the relationship between postoperative platelet counts and 3-year mortality after operation in patients with ATAAD undergoing open aortic repair surgery.

Methods

Patients with ATAAD who underwent Total Arch Replacement and Frozen Elephant Trunk in Fuwai Hospital from 2011 to 2015 were selected for this study. The perioperative data were collected and sorted through the electronic clinical case system. Multivariate Logistic regression was used to analyze the risk factors for death within three years after surgery.

Results

A total of 495 patients were included in the analysis. After correction for confounding factors, decreased postoperative platelet count remained an independent factor that was associated with lower mortality (OR = 0.918, 95% CI 0.853–0.988, P = 0.023).

Conclusions

The study indicated that decreased postoperative platelet count may lead to increased 3-year mortality, in patients with ATAAD who underwent open aortic repair surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01623-7.

Association of Lymphocyte to Monocyte Ratio and Risk of in-Hospital Mortality in Patients with Cardiogenic Shock: A Propensity Score Matching Study

Background

Lymphocyte to monocyte ratio (LMR) has been long implicated in the prediction of many inflammatory-related diseases. However, the possible value as prognostic marker of LMR have not been evaluated in cardiogenic shock (CS) patients. The aim of the study was to assess the relationship between LMR on admission and in-hospital mortality in CS patients.

Methods

Data on patients diagnosed with CS were extracted from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. We performed a single-institution, retrospective study of 1487 CS patients and determined the optimal cut-off for LMR by X-tile software. Propensity score matching (PSM) and inverse probabilities of treatment weighting (IPTW) were conducted to control confounders. Cox proportional hazards model was performed to evaluate the relationship between LMR and in-hospital mortality. Kaplan-Meier curves and receiver operating characteristics (ROC) analysis were applied to assess the prognostic value of LMR.

Results

The optimal cut-off value for LMR was 0.9. Cox proportional hazards model demonstrated that lower LMR (< 0.9) was independently associated with in-hospital mortality with hazard ratio (HR) of 1.40 (1.12-1.74, P = 0.003). The results were consistent with survival analyses (P < 0.001, Log rank test). Adding LMR< 0.9 to the sequential organ failure assessment (SOFA) score improved discrimination and risk stratification for in-hospital mortality.

Conclusion

Lower level of LMR is related to higher risk of in-hospital mortality of patients with CS. As an easily available biomarker, LMR can independently predict the in-hospital mortality in CS patients.

Elevated preoperative neutrophil-to-lymphocyte ratio predicts early adverse outcomes in uncomplicated type B aortic dissection undergoing TEVAR

BACKGROUND

Thoracic aortic endovascular repair (TEVAR) of uncomplicated type B aortic dissection (uTBAD) has favorable long-term outcomes but higher early adverse events compared with the optimal medical treatment. Recently, clinical evidence concerning vascular surgery indicates that elevated preoperative systemic inflammatory response predicts adverse clinical events. The aim of our study was to evaluate the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR) and early outcomes of uTBAD patients undergoing TEVAR.

RESULTS

216 patients diagnosed with uTBAD were included in this retrospective study between January 2015 and December 2018. The median (IQR) follow-up period was 21 (15-33) months. An early adverse event was defined as occurring within 2 years after the procedure. Median patient age was 60 (IQR, 48-68) years and 78.7 % were male. Early adverse events occurred in 24 patients (11.1 %). In the multivariable analysis, preoperative NLR (HR per SD, 1.98; 95 % CI, 1.14-3.44; P = 0.015) was associated with 2-year adverse events.

CONCLUSIONS

NLR is an independent predictive factor of early adverse events in uTBAD patients undergoing TEVAR.