Can Preoperative C-Reactive Protein Predict Bleeding After On-Pump Coronary Artery Bypass Grafting?

Naples prognostic score as a predictor of mortality in surgical aortic valve replacement

Aim: Investigating the impact of nutritional and inflammatory status, assessed by the Naples-Prognostic-Score (NPS), on postoperative mortality in 173 older adults undergoing surgical aortic valve replacement(SAVR) for aortic stenosis(AS).Methods: Retrospective study calculating NPS from neutrophils/lymphocytes, lymphocytes/monocytes, total cholesterol and serum albumin.Results: Mean age was 69.39 ± 6.153 with 45.1% females. The post-operative mortality was 23.7% over a follow-up period of 50 ± 31 months. The 1-month mortality rate is 2.89%. High NPS significantly associated with increased mortality; multivariate logistic regression confirmed its independence (odds-ratio:3.494, 95% confidence-interval:1.555-7.849, p = 0.002). NPS cutoff of 2 showed 73.2% sensitivity, 56.8% specificity and area-under-the-curve of 0.758 for predicting all-cause mortality. Kaplan-Meier analysis supported lower NPS correlating with better survival.Conclusion: NPS independently predicts postoperative mortality in SAVR patients.

Impact of Bleeding Risk and Inflammation on Cardiovascular Outcomes After Percutaneous Coronary Intervention

BACKGROUND

Markers of systemic inflammation, such as high-sensitivity C-reactive protein (hsCRP), have been associated with the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) in patients undergoing percutaneous coronary intervention (PCI). Whether this risk varies according to the presence of high bleeding risk (HBR) conditions is unclear.

OBJECTIVES

The aim of this study was to evaluate the impact of systemic inflammation, as measured by hsCRP levels and cardiovascular outcomes in patients stratified by HBR status following PCI.

METHODS

Consecutive patients undergoing PCI between 2012 and 2019 with baseline hsCRP levels were included. High hsCRP was defined as >3 mg/L, and HBR was defined per the Academic Research Consortium HBR criteria. The primary outcome was MACCE, including all-cause death, myocardial infarction, or stroke at 1 year. All bleeding was assessed as a secondary outcome.

RESULTS

A total of 15,150 patients were included, and 40.4% (n = 6,125) qualified as HBR. The adjusted risk for MACCE was consistently higher in patients with high hsCRP in both HBR (adjusted HR [aHR]: 1.49; 95% CI: 1.18-1.87) and non-HBR (aHR: 1.87; 95% CI: 1.31-2.66) subgroups, with no interaction between HBR status and hsCRP level (Pinteraction = 0.26). Conversely, although bleeding risk was higher in the HBR cohort, hsCRP did not predict the occurrence of bleeding in either the HBR (aHR: 1.04; 95% CI: 0.82-1.31) or the non-HBR (aHR: 0.99; 95% CI: 0.71-1.39) subgroup (Pinteraction = 0.539).

CONCLUSIONS

Elevated hsCRP at the time of PCI is associated with a higher risk for ischemic but not bleeding events, irrespective of HBR status.

Role and intervention of PAD4 in NETs in acute respiratory distress syndrome

BACKGROUND

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Acute respiratory distress syndrome (ARDS) is a common sepsis-associated injury that can increase postoperative mortality but the mechanism is still unclear.

MAIN TEXT

The role of neutrophils in the pathophysiology of sepsis was deeply challenged after the discovery of NETosis, a process resulting in neutrophil extracellular traps (NETs) release. NETs can support thrombin generation and the concept of immunothrombosis has emerged as a new innate response to infection. Immunothrombosis leads to thrombosis in microvessels and supports immune cells together with specific thrombus-related molecules. ARDS is a common sepsis-associated organ injury. Immunothrombosis participates in thrombosis in pulmonary capillaries. Intervention regarding immunothrombosis in ARDS is a key scientific problem. PAD4 is the key enzyme regulating the NET skeleton protein histone H3 to citrulline histone to form NETs in immune thrombosis. This review summarizes NETosis and immunohaemostasis, ARDS and therapeutic opportunities targeting PAD4 via PAD4 inhibitors and lncRNAs potentially, providing future therapies.

CONCLUSIONS

We identified and summarized the fundamental definition of ARDS and the concept of immune thrombosis and its composition. NETs activation has become particularly relevant in the formation of immune thrombosis. The taskforce highlighted the intervention targets of PAD4, including noncoding RNAs, potentially providing future therapeutic targets to confront the high postoperative mortality of ARDS.

Preoperative inflammatory markers predict postoperative clinical outcomes in patients undergoing heart valve surgery: A large-sample retrospective study

Introduction

Preoperative inflammation affects the postoperative outcomes of patients undergoing heart valve surgery. This study aimed to explore the role and predictive effects of preoperative inflammation on the primary outcomes after valvular cardiac surgery.

Methods

This retrospective study utilized a medical recording system to screen 5075 patients who underwent heart valve surgery. Data on the C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), and neutrophil-to-lymphocyte ratio (NLR) before heart valve surgery were collected from the hospital’s medical system. Postoperative hepatic insufficiency, acute kidney injury, heart failure, and myocardial damage were assessed using blood indicators. Patients with and without prolonged mechanical ventilation, extended intensive care unit stays, prolonged hospital stays, and death within 30 days after surgery (considered the primary outcome in this study) were compared. Group comparisons, receiver operating characteristic (ROC) curve analyses, and logistic analyses were performed to determine the associations between preoperative inflammation and outcomes after heart valve surgery.

Results

A total of 3249 patients were included in the analysis. Significant differences in CRP level, ESR, and NLR were found between patients with and without postoperative adverse outcomes. ROC analysis showed that CRP levels >5 mg/L effectively predicted postoperative heart failure, and NLR >3.5 had a good predictive effect on all-cause mortality within 30 days after surgery. Patients with CRP levels >5 mg/L had a higher incidence of postoperative heart failure than other patients (20.7% vs. 12.6%, P<0.001), with a relative risk of 1.447 (95% confidence interval: 1.155–1.814). Patients with NLR >3.5 had a higher incidence of death within 30 days after surgery (5.3% vs. 1.2%, P<0.001), with a relative risk of 3.236 (95% confidence interval: 1.773–5.906).

Conclusion

Preoperative inflammation can affect postoperative outcomes in patients undergoing heart valve surgery. CRP level >5 mg/L and NLR >3.5 can effectively predict postoperative heart failure and death within 30 days after surgery, respectively.

Hyperglycemia may increase deep vein thrombosis in trauma patients with lower limb fracture

Diabetes mellitus is associated with prothrombotic states and thrombotic events. This study examined the association between preoperative glucose levels and deep vein thrombosis (DVT) in trauma patients undergoing surgery for lower limb fracture. Data from 1,591 patients who underwent fracture surgery between January 2017 and March 2022 at the Affiliated Hospital of Qingdao University were queried from institutional electronic medical records. A total study population of 1,086 patients was identified, comprising 138 patients who experienced DVT and 948 controls. The primary outcome was DVT. Multiple logistic regression analyses were performed and a receiver operating characteristic (ROC) curve was generated. Age, D-dimer level, preoperative RBC count, and preoperative glucose level were independent predictors of DVT. The two highest categories of D-dimer level (≥ 960, < 2,102; ≥ 2,102 ng/ml) increased the odds ratio for DVT by 4.215 times [95% confidence interval (CI) 1.820–9.761] and 7.896 times (95% CI 3.449–18.074), respectively, compared with the lowest reference category (< 490 ng/ml). The area under the curve (AUC) for the preoperative glucose level was 0.605. Hyperglycemia (glucose ≥ 6.1, < 7.0 mmol/l) increased the odds of DVT by 1.889-fold [95% CI (1.085–3.291); p < 0.0001] compared with euglycemia (glucose < 6.1 mmol/l). We therefore observed an association between preoperative hyperglycemia and DVT in patients with lower limb fractures. There are several modalities for controlling hyperglycemia, offering potential targets for future improvement.

Can C-reactive protein predict coagulation in off pump coronary artery bypass grafting? A cohort study

Background

Previous study found that C-reactive protein (CRP) can predict bleeding after on-pump CABG. To evaluate whether preoperative C-reactive protein (CRP) can be a novel marker of postoperative bleeding in patients having off-pump coronary artery bypass grafting (CABG).

Methods

This is a retrospective cohort study. Multiple variable regression analyses were performed. 537 patients undergoing off-pump isolated primary CABG at Fuwai Hospital from September 2017 to July 2018 were recorded. The primary endpoint was bleeding volume within 24 h after surgery.

Results

Data of 537 patients undergoing off-pump isolated primary CABG at Fuwai Hospital were recorded. The correlations between bleeding volume within 24 h after surgery and preoperative data were analyzed with univariate and multivariate linear regression. Much more preoperative CRP concentration (B = −0.089, P < 0.05) was associated with less postoperative bleeding volume and fibrinogen (B = 0.594, p < 0.001).

Conclusions

Preoperative CRP concentration is independently correlated with the postoperative volume of bleeding within 24 h. CRP may become a novel coagulation index in coronary artery atherosclerotic disease.

Fibrinogen and Bleeding in Adult Cardiac Surgery: A Review of the Literature

Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.

MiR-223 levels predicting perioperative bleeding in off-pump coronary artery bypass grafting

Background

To investigate the predictive value of platelet-related microRNAs (miRNAs) for bleeding during and after off-pump coronary artery bypass grafting (OPCABG) and the influence of dual antiplatelet therapy (DAPT) on miRNAs.

Methods

This prospective study included 59 patients scheduled for OPCABG. The plasma miR-126 and miR-223 levels were measured and platelet aggregation was determined by thromboelastography during DAPT. The plasma miRNA levels were compared between patients treated with ticagrelor or clopidogrel. Multivariable logistic regression analysis was performed to determine the independent risk factors for bleeding during and after surgery. Active bleeding was defined as a blood loss >1.5 mL/kg/h for 6 consecutive hours within the first 24 hours or in case of reoperation during the first 12 postoperative hours. Severe perioperative bleeding was defined using the universal definition of perioperative bleeding in adult cardiac surgery.

Results

Higher circulating miR-223 levels [odds ratio (OR) =1.348, 95% confidence interval (CI): 1.001–1.814, P=0.047] and lower body mass index (OR =0.648, 95% CI: 0.428–0.980, P=0.040) were independent predictors for severe perioperative bleeding in OPCABG. Ticagrelor treatment led to significant increases in circulating miR-223 levels compared with clopidogrel treatment.

Conclusions

The plasma miR-223 levels served as a predictor for bleeding during and after OPCABG. Circulating miR-223 levels were significantly elevated with ticagrelor treatment compared with clopidogrel treatment. MiR-223 may be a novel biomarker for bleeding in cardiac surgery and can help explain the different efficacies of ticagrelor and clopidogrel.