Is SYNTAX Score Predictive of Atrial Fibrillation after On-Pump Coronary Artery Bypass Graft Surgery?

Bidirectional Causal Association Between Chronic Obstructive Pulmonary Disease and Cardiovascular Diseases: A Mendelian Randomization Study

Background

A large number of studies have demonstrated links between chronic obstructive pulmonary disease (COPD) and cardiovascular diseases (CVDs). However, the causal relationship between COPD and CVDs and the reverse causality remains divergent.

Methods

Exposure and outcome data from the largest available genome-wide association studies were extracted for Mendelian randomization (MR) studies. Univariate MR analysis was performed using IVW as the primary analysis method, and multiple sensitivity analyses were used to enhance the robustness of the results. Furthermore, this was followed by mediation MR analysis of positive results after excluding confounding factors with multivariable MR analysis.

Results

The MR estimation based on IVW method indicated a strong association between genetically determined COPD and heart failure (HF) (OR = 1.117, 95% CI: 1.066-1.170, p <0.001), coronary heart disease (CHD) (OR = 1.004, 95% CI: 1.002-1.006, p <0.001), essential hypertension (EH) (OR = 1.009, 95% CI: 1.005-1.013, p <0.001) as well as Stroke (OR = 1.003, 95% CI: 1.001-1.004, p <0.001). The results of multivariable MR analysis revealed that COPD is not significantly associated with CHD after adjusting for IL-6, LDL, or total cholesterol (p>0.05). Our findings indicated that BMI, smoking initiation, smoking status, obesity, and FEV1 played a role in the causal effect of COPD on HF, EH, and Stroke.

Conclusion

We found positive causal relationships between COPD and HF, EH, and Stroke essentially unaffected by other confounding factors. The causal relationship exhibited between COPD and CHD was influenced by confounding factors. BMI, obesity, initiation of smoking, smoking status, and FEV1 were the mediators between COPD and CVDs.

A nomogram for individualized prediction of new-onset postoperative atrial fibrillation in acute type A aortic dissection patients: a retrospective study

Objective

The objective of this study is to explore the risk factors associated with new-onset postoperative atrial fibrillation (POAF) following Sun's surgery(total arch replacement using a tetrafurcate graft with stented elephant trunk implantation) for acute type A aortic dissection(AAAD) and to develop a predictive model for assessing the likelihood of new-onset POAF in patients undergoing Sun's surgery for AAAD.

Methods

We reviewed the clinical parameters of patients diagnosed with AAAD who underwent Sun's surgery at Qilu Hospital between December 1, 2017 and December 31, 2022. The data was analyzed through univariable and multivariable logistic regression analysis. Variance inflation factor was used to investigate for variable collinearity. A nomogram for predicting new-onset POAF was developed and verified by bootstrap resampling. In addition, the calibration of our model was evaluated by the calibration curve and Hosmer-Lemeshow test. Furthermore, the clinical utility of our model was evaluated using the net benefit curve.

Results

This study focused on a cohort of 242 patients with AAAD, among whom 42 experienced new-onset POAF, indicating an incidence rate of 17.36%. Age, left atrial diameter (LA), right atrial diameter (RA), preoperative red blood cells (RBC), and previous acute coronary syndrome (preACS) emerged as independent influences on new-onset POAF following Sun's surgery, as identified by univariable and multivariable logistic regression analysis. Collinearity analysis with demonstrated no collinearity among the variables. A user-friendly prediction nomogram for new onset POAF following Sun's surgery was formulated. The model demonstrated commendable diagnostic accuracy with an area under the curve (AUC) of 0.7852. Validation of the model through bootstrapping (1,000 repetitions) yielded an AUC of 0.8080 (95% CI: 0.8056-0.8104). affirming its robustness. Additionally, the model exhibited favorable fit, calibration, and positive net benefits in decision curve analysis.

Conclusions

Drawing upon these findings, we have developed a predictive model for the occurrence of new-onset POAF. These results suggest the potential efficacy of this prediction model for identifying patients at risk of developing POAF. The visualization of this model empowers healthcare professionals to conveniently and promptly assess the risk of AF in patients, thereby facilitating the timely intervention implementation.

Optimising risk factors for atrial fibrillation post-cardiac surgery

Postoperative atrial fibrillation (POAF) is an ongoing complication following cardiac surgery, with an incidence of 15%-60%. It is associated with substantial mortality and morbidity, as well increased hospital stays and healthcare costs. The pathogenesis is not fully understood, but the literature suggests that POAF occurs when transient, postoperative triggers act on vulnerable atrial tissue produced by preoperative, procedure-induced and postoperative processes such as inflammation, oxidative stress, autonomic dysfunction and electrophysiological remodelling of the atrial tissues. This sets the stage for arrhythmogenic mechanisms, such as ectopic firing secondary to triggered activity and re-entry mechanisms generating POAF. Preoperative factors include advanced age, sex, ethnicity, cardiovascular risk factors, preoperative drugs, electrocardiogram and echocardiogram abnormalities. Procedural factors include: the use of cardiopulmonary bypass and aortic cross clamp, type of cardiac surgery, use of hypothermia, left ventricular venting, bicaval cannulation and exclusion of the left atrial appendage. Postoperative factors include postoperative drugs, electrolyte and fluid balance and infection. This review explores the pathogenesis of POAF and the contribution of these perioperative factors in the development of POAF. Patients can be risk stratified for targeted treatment and prophylaxis, and how these factors can be attenuated to improve POAF outcomes following cardiac surgery.

Investigation of the Effect of HATCH Score and Coronary Artery Disease Complexity on Atrial Fibrillation after On-Pump Coronary Artery Bypass Graft Surgery

OBJECTIVE

Postoperative atrial fibrillation (PoAF) is the most frequently encountered rhythm problem after coronary artery bypass graft (CABG) surgery. This situation decreases the capacity of the patients with respect to functional exercise and creates a risk for stroke. In this study, we aimed to determine the effect of coronary artery disease extensiveness and HATCH score on PoAF in patients undergoing CABG surgery with cardiopulmonary bypass.

SUBJECTS AND METHODS

Patients who underwent CABG between December 2014 and December 2018 were included retrospectively. Preoperative demographic characteristics, laboratory parameters, and operative parameters of the patients were recorded retrospectively.

RESULTS

Of the 352 patients, 274 had HATCH scores ≤2 (71.1% male, mean age: 61.7 ± 12.4 years), and 78 had HATCH scores >2 (69.2% male, mean age: 65.9 ± 11.7 years). Significant differences were found between the 2 groups in terms of the age (p = 0.014), presence of hypertension (p = 0.012), PoAF (p < 0.001), and SYNTAX (synergy between percutaneous coronary intervention with taxus and cardiac surgery) score I (p = 0.001). A HATCH score >2 and SYNTAX score I were identified as independent predictors of PoAF (OR: 1.022, 95% CI: 1.004-1.128, p = 0.032, and OR 1.098, 95% CI 1.035-1.164, p = 0.002, respectively). For predicting PoAF, the cutoff level in the ROC curve analysis was 19.7 for SYNTAX score (AUC 0.647, 95% CI 0.581-0.714, p < 0.001, 72.2% sensitivity and 66.4% specificity), and the cutoff level for HATCH score was 2 (AUC 0.656, 95% CI 0.595-0.722, p < 0.001, 69.4% sensitivity and 56.8% specificity) Conclusions: HATCH and SYNTAX scores are predictors of PoAF.

[Progression of precerebral atherosclerosis and predictors of ischemic complications in cardiac patients]

OBJECTIVE

To identify predictors of progression of precerebral atherosclerosis in long-term period after coronary artery bypass surgery.

MATERIAL AND METHODS

There were 97 procedures of carotid endarterectomy in patients after previous coronary artery bypass grafting for the period from 2006 to 2017. Inclusion criteria were previous CABG, no significant (over 60%) stenosis of internal carotid arteries at discharge after CABG. The control group included 447 patients without progression of precerebral atherosclerosis in long-term period after CABG.

RESULTS

Careful monitoring of progression of precerebral atherosclerosis and therapeutic prevention of ischemic stroke are required in patients with mild-to-moderate ICA stenosis after CABG. The most significant predictors of progression of precerebral atherosclerosis after CABG were AF (OR=1.97, 95% CI 1.04-3.73), previous occlusion of stent (OR=7.89, 95% CI=2.3-27.0), chronic brain ischemia grade II or III (OR=22.45, 95% CI=11.9-42.3), chronic kidney disease (OR=15.8, 95% CI=5.04-49.5).

CONCLUSION

It was revealed that the majority of predictors of adverse ischemic cerebral and myocardial events are indirectly associated with atrial fibrillation.

The Prognostic Value of Elevated Perioperative Neutrophil-Lymphocyte Ratio in Predicting Postoperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) is an emerging inflammatory perioperative biomarker which has been studied to predict the incidence of postoperative atrial fibrillation (POAF) after cardiac surgery. This systematic review and meta-analysis aimed to evaluate the prognostic accuracy of elevated perioperative NLR in predicting POAF after cardiac surgery.

METHODS

Multiple databases were searched from inception to May 2019 for prognostic studies on perioperative NLR and POAF following cardiac surgery. Maximally adjusted odds ratios (OR) with associated confidence intervals were obtained from each included study and pooled using random effects inverse variance modelling for preoperative NLR measurements, while standardised mean differences were pooled for postoperative NLR values. The significance of inter- and intra-study heterogeneity was explored using meta-regression.

RESULTS

1,799 unique studies satisfied selection criteria, from which 12 studies incorporating 9,262 participants were included. Elevated preoperative NLR significantly predicted POAF, with a pooled OR of 1.42 (95% CI 1.16-1.72). Multiple predefined covariates contributed to inter-study heterogeneity; however, only prevalence of hypertension (p=0.0055), history of congestive cardiac failure (p=0.0282) and average ejection fraction (p=0.0359) were significant effect modifiers. Elevated postoperative NLR was not a significant predictor of POAF (standardised mean difference 1.60 [95% CI -0.56-3.77] between POAF+ and POAF- groups).

CONCLUSIONS

Elevated preoperative NLR is a promising prognostic biomarker for POAF, but residual sources of heterogeneity remain. Larger scale validation studies are required to justify the integration of preoperative NLR testing into routine clinical practice.

Worse clinical outcomes following percutaneous coronary intervention with a high SYNTAX score: A systematic review and meta-analysis

BACKGROUND

The synergy between percutaneous coronary intervention (PCI) with TAXUS and Cardiac Surgery (SYNTAX) score is an angiographic tool which is used to determine the complexity of coronary artery disease (CAD). We aimed to compare PCI versus coronary artery bypass surgery (CABG) in patients with a high SYNTAX score in order to confirm with evidence whether the former is really association with worse clinical outcomes.

METHODS

The National database of medical research articles (MEDLINE/PubMed), EMBASE database, and the Cochrane library were searched for publications comparing PCI versus CABG in patients with a high SYNTAX score, respectively. Death, myocardial infarction (MI), stroke, repeated revascularization, and a combined outcome death/stroke/MI were considered as the clinical endpoints. RevMan software was used to analyze the data, whereby odds ratios (OR) with 95% confidence intervals (CI) were used as the statistical parameters.

RESULTS

A total number of 1074 patients were included (455 patients with a high SYNTAX score were classified in the PCI group and 619 other patients with a high SYNTAX score were classified in the CABG group). A SYNTAX score cut-off value of ≥33 was considered relevant. Compared with CABG, mortality was significantly higher with a high SYNTAX score following PCI with OR: 1.79, 95% CI: 1.18 to 2.70; P = .006, I = 0%. The combined outcome death/stroke/MI was also significantly higher following PCI with a high SYNTAX score, with OR: 1.69, 95% CI: 1.24 to 2.30; P = .0009, I = 0%. In addition, PCI was also associated with significantly higher MI and repeated revascularization when compared with CABG, with OR: 3.72, 95% CI: 1.75 to 7.89; P = .0006, I = 0% and OR: 4.33, 95% CI: 1.71 to 10.94; P = .002, I = 77%, respectively. However, stroke was not significantly different.

CONCLUSIONS

Compared with CABG, worse clinical outcomes were observed following PCI in patients with a high SYNTAX score, confirming with evidence, published clinical literatures. Therefore, CABG should be recommended to CAD patients who have been allotted a high SYNTAX score.

Chronic obstructive pulmonary disease and atrial fibrillation: An unknown relationship

Chronic obstructive pulmonary disease (COPD) is independently associated with atrial fibrillation (AF). Decreased oxygenation, hypercapnia, pulmonary hypertension, diastolic dysfunction, oxidative stress, inflammation, changes in atrial size by altered respiratory physiology, increased arrhythmogenicity from nonpulmonary vein foci commonly located in the right atrium, and respiratory drugs have been implicated in the pathogenesis of AF in COPD. The understanding of the relationship between COPD and AF is of particular importance, as the presence of the arrhythmia has significant impact on mortality, especially in COPD exacerbations. On the other hand, COPD in AF is associated with AF progression, success of cardioversion, recurrence of AF after catheter ablation, and increased cardiovascular and all-cause mortality. Treatment of the underlying pulmonary disease and correction of hypoxia and acid-base imbalance represents first-line therapy for COPD patients who develop AF. Cardioselective β-blockers are safe and can be routinely used in COPD. In addition, AF ablation was proved to be efficient and safe, and improves quality of life in these patients. This review presents the association between COPD and AF, describes the pathophysiological mechanisms implicated in AF development in COPD, underlines the prognostic significance of AF in COPD patients and vice versa, and highlights emerging therapeutic approaches in this setting.