A prospective, controlled study on the utility of rotational thromboelastometry in surgery for acute type A aortic dissection

Postoperative hyper-inflammation as a predictor of poor outcomes in patients with acute type A aortic dissection (ATAAD) undergoing surgical repair

BACKGROUND

Postoperative hyper-inflammation is a frequent event in patients with acute Stanford type A aortic dissection (ATAAD) after surgical repair. This study's objective was to determine which inflammatory biomarkers could be used to make a better formula for identifying postoperative hyper-inflammation, and which risk factors were associated with hyper-inflammation.

METHODS

A total of 405 patients were enrolled in this study from October 1, 2020 to April 1, 2023. Of these patients, 124 exhibited poor outcomes. In order to investigate the optimal cut-off values for poor outcomes, logistic and receiver operating characteristic analyses were performed on the following parameters on the first postoperative day: procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6), and systemic immune-inflammation index (SII). These cut-off points were used to separate the patients into hyper-inflammatory (n = 52) and control (n = 353) groups. Finally, the logistic were used to find the risk factors of hyper-inflammatory.

RESULTS

PCT, CRP, IL-6, and SII were independent risk factors of poor outcomes in the multivariate logistic model. Cut-off points of these biomarkers were 2.18 ng/ml, 49.76 mg/L, 301.88 pg/ml, 2509.96 × 109/L respectively. These points were used to define postoperative hyper-inflammation (OR 2.97, 95% CI 1.35-6.53, P < 0.01). Cardiopulmonary bypass (CPB) > 180 min, and deep hypothermia circulatory arrest (DHCA) > 40 min were the independent risk factors for hyper-inflammation.

CONCLUSIONS

PCT > 2.18, CRP > 49.76, IL-6 > 301.88, and SII < 2509.96 could be used to define postoperative hyper-inflammation which increased mortality and morbidity in patients after ATAAD surgery. Based on these findings, we found that CPB > 180 min and DHCA > 40 min were separate risk factors for postoperative hyper-inflammation.

Risk factor prediction of severe postoperative acute kidney injury at stage 3 in patients with acute type A aortic dissection using thromboelastography

Objective

Perioperative blood transfusions and postoperative drainage volume not only are the commonly recognized risk factors for acute kidney injury (AKI) but also are indirect indicators of coagulopathy in patients with acute type A aortic dissection (ATAAD). However, standard laboratory tests fail to accurately reflect and assess the overall coagulopathy profile in patients with ATAAD. Thus, this study aimed to explore the association between the hemostatic system and severe postoperative AKI (stage 3) in patients with ATAAD using thromboelastography (TEG).

Methods

We selected 106 consecutive patients with ATAAD who underwent emergency aortic surgery at Beijing Anzhen Hospital. All participants were categorized into the stage 3 and non-stage 3 groups. The hemostatic system was evaluated using routine laboratory tests and TEG preoperatively. We undertook univariate and multivariate stepwise logistic regression analyses to determine the potential risk factors for severe postoperative AKI (stage 3), with a special investigation on the association between hemostatic system biomarkers and severe postoperative AKI (stage 3). The receiver operating characteristic (ROC) curves were generated to assess the predictive ability of hemostatic system biomarkers for severe postoperative AKI (stage 3).

Results

A total of 25 (23.6%) patients developed severe postoperative AKI (stage 3), including 21 patients (19.8%) who required continuous renal replacement therapy (RRT). Multivariate logistic regression analysis demonstrated that the preoperative fibrinogen level (OR, 2.02; 95% CI, 1.03 to 3.00; p = 0.04), platelet function (MA level) (OR, 1.23; 95% CI, 1.09 to 1.39; p = 0.001), and cardiopulmonary bypass (CPB) time (OR, 1.01; 95% CI, 1.00 to 1.02; p = 0.02) were independently associated with severe postoperative AKI (stage 3). The cutoff values of preoperative fibrinogen and platelet function (MA level) for predicting severe postoperative AKI (stage 3) were determined to be 2.56 g/L and 60.7 mm in the ROC curve [area under the curve (AUC): 0.824 and 0.829; p < 0.001].

Conclusions

The preoperative fibrinogen level and platelet function (measured by the MA level) were identified as potential predictive factors for developing severe postoperative AKI (stage 3) in patients with ATAAD. Thromboelastography could be considered a potentially valuable tool for real-time monitoring and rapid assessment of the hemostatic system to improve postoperative outcomes in patients.