Inflammatory biomarkers to predict adverse outcomes in postoperative patients with acute type A aortic dissection

Influence of false lumen status on systemic inflammatory response triggered by acute aortic dissection

We investigated the influence of false lumen (FL) status on the systemic inflammatory response triggered by acute aortic dissection (AAD) using cytokine profiling. The study included 44 patients with AAD. Patients were divided between those with a thrombosed FL (Group T, n = 21) and those with a non-thrombosed FL (Group P, n = 23). On-admission serum concentrations of 29 cytokines were compared between unmatched and propensity-score matched (n = 10 pairs) FL groups and a control group (non-ruptured thoracic aortic aneurysm, Group C, n = 20). Unmatched analysis showed 12 cytokines differed between groups and fell into three categories: Category A (increased expression in both FL groups: IL-6, IL-10, IL-15, G-CSF); Category B (increased expression only in Group P: IL-1Ra, IL-1β, IL-8, IL-12p70, GM-CSF); and Category C (others: IP-10, VEGF-A, eotaxin). The increases in Category A and Category B cytokines in Group T were attenuated, but not significantly, compared to their increases in Group P. Propensity-score matching analysis revealed a similar expression pattern with respect to all four Category A cytokines, four Category B cytokines (IL-1β, IL-1Ra, IL-12p70, and GM-CSF), and two Category C cytokines (IP-10 and VEGF-A). A robust inflammatory response occurs in patients with AAD, but the response is attenuated when the FL is thrombosed.

The Nephroprotective Effect of Nitric Oxide during Extracorporeal Circulation: An Experimental Study

This study aims to determine the effectiveness of administering 80 ppm nitric oxide in reducing kidney injury, mitochondrial dysfunction and regulated cell death in kidneys during experimental perfusion. Twenty-four sheep were randomized into four groups: two groups received 80 ppm NO conditioning with 90 min of cardiopulmonary bypass (CPB + NO) or 90 min of CPB and hypothermic circulatory arrest (CPB + CA + NO), while two groups received sham protocols (CPB and CPB + CA). Kidney injury was assessed using laboratory (neutrophil gelatinase-associated lipocalin, an acute kidney injury biomarker) and morphological methods (morphometric histological changes in kidney biopsy specimens). A kidney biopsy was performed 60 min after weaning from mechanical perfusion. NO did not increase the concentrations of inhaled NO2 and methemoglobin significantly. The NO-conditioning groups showed less severe kidney injury and mitochondrial dysfunction, with statistical significance in the CPB + NO group and reduced tumor necrosis factor-α expression as a trigger of apoptosis and necroptosis in renal tissue in the CPB + CA + NO group compared to the CPB + CA group. The severity of mitochondrial dysfunction in renal tissue was insignificantly lower in the NO-conditioning groups. We conclude that NO administration is safe and effective at reducing kidney injury, mitochondrial dysfunction and regulated cell death in kidneys during experimental CPB.

Short- and Long-term survival prediction in patients with acute type A aortic dissection undergoing open surgery

BACKGROUND

Acute Type A aortic dissection (ATAAD) is a life-threatening cardiovascular disease associated with high mortality rates, where surgical intervention remains the primary life-saving treatment. However, the mortality rate for ATAAD operations continues to be alarmingly high. To address this critical issue, our study aimed to assess the correlation between preoperative laboratory examination, clinical imaging data, and postoperative mortality in ATAAD patients. Additionally, we sought to establish a reliable prediction model for evaluating the risk of postoperative death.

METHODS

In this study, a total of 384 patients with acute type A aortic dissection (ATAAD) who were admitted to the emergency department for surgical treatment were included. Based on preoperative laboratory examination and clinical imaging data of ATAAD patients, logistic analysis was used to obtain independent risk factors for postoperative in-hospital death. The survival prediction model was based on cox regression analysis and displayed as a nomogram.

RESULTS

Logistic analysis identified several independent risk factors for postoperative in-hospital death, including Marfan syndrome, previous cardiac surgery history, previous renal dialysis history, direct bilirubin, serum phosphorus, D-dimer, white blood cell, multiple aortic ruptures and age. A survival prediction model based on cox regression analysis was established and presented as a nomogram. The model exhibited good discrimination and significantly improved the prediction of death risk in ATAAD patients.

CONCLUSIONS

In this study, we developed a novel survival prediction model for acute type A aortic dissection based on preoperative clinical features. The model demonstrated good discriminatory power and improved accuracy in predicting the risk of death in ATAAD patients undergoing open surgery.

Anti-inflammatory response-based risk assessment in acute type A aortic dissection: A national multicenter cohort study

Background

Early identification of patients at high risk of operative mortality is important for acute type A aortic dissection (TAAD). We aimed to investigate whether patients with distinct risk stratifications respond differently to anti-inflammatory pharmacotherapy.

Methods

From 13 cardiovascular hospitals, 3110 surgically repaired TAAD patients were randomly divided into a training set (70%) and a test set (30%) to develop and validate a risk model to predict operative mortality using extreme gradient boosting. Performance was measured by the area under the receiver operating characteristic curve (AUC). Subgroup analyses were performed by risk stratifications (low versus middle-high risk) and anti-inflammatory pharmacotherapy (absence versus presence of ulinastatin use).

Results

A simplified risk model was developed for predicting operative mortality, consisting of the top ten features of importance: platelet-leukocyte ratio, D-dimer, activated partial thromboplastin time, urea nitrogen, glucose, lactate, base excess, hemoglobin, albumin, and creatine kinase-MB, which displayed a superior discrimination ability (AUC: 0.943, 95 % CI 0.928-0.958 and 0.884, 95 % CI 0.836-0.932) in the derivation and validation cohorts, respectively. Ulinastatin use was not associated with decreased risk of operative mortality among each risk stratification, however, ulinastatin use was associated with a shorter mechanical ventilation duration among patients with middle-high risk (defined as risk probability >5.0 %) (β -1.6 h, 95 % CI [-3.1, -0.1] hours; P = 0.048).

Conclusion

This risk model reflecting inflammatory, coagulation, and metabolic pathways achieved acceptable predictive performances of operative mortality following TAAD surgery, which will contribute to individualized anti-inflammatory pharmacotherapy.

Inflammatory profiles define phenotypes with clinical relevance in acute type A aortic dissection

Association of distinct inflammatory profiles with short-term mortality is little known in type A aortic dissection (TAAD). Latent class analysis was used to identify distinct inflammatory profiles based on leukocyte, neutrophils, monocyte, lymphocytes, platelet, fibrinogen, D-dimer, neutrophils-lymphocyte ratio, platelet-lymphocyte ratio, and lymphocyte-monocyte ratio. We identified 193 patients with median age of 56 (IQR 47-63) years and 146 males. Patients were divided as hyper-inflammatory profiles (84 [43.5%]) and hypo-inflammatory profiles (109 [56.5%]). Although baseline characteristics were not different, hyper-inflammatory patients had higher 6-month mortality (20 [23.8%] vs. 11 [10.1%]; P = 0.014) and 30-day mortality (18 [21.4%] vs. 9 [8.3%], P = 0.009) than hypo-inflammatory patients. After adjustment for potential confounders, hyper-inflammatory profiles remain associated with higher risk of 6-month mortality than hypo-inflammatory profiles (adjusted OR 2.427 [95%CI 1.154, 5.105], P = 0.019). Assessment of preoperative inflammatory profiles adds clarity regarding the extent of inflammatory response to TAAD aetiopathologies, highlighting individual anti-inflammatory pharmacotherapy for TAAD. ClinicalTrials.gov Identifier: NCT04398992.

Angiogenesis inhibitor-specific hypertension increases the risk of developing aortic dissection

Aortic dissection is an adverse event of angiogenesis inhibitors; however, the association between the drugs and aortic dissection is unclear. Therefore, we investigated if and how angiogenesis inhibitors increase the onset of aortic dissection using pharmacologically-induced aortic dissection-prone model (LAB) mice, cultured endothelial cells, and real-world databases, which is a novel integrated research approach. Disproportionality analysis was performed and calculated using the reporting odds ratio as a risk signal using a worldwide database of spontaneous adverse events to estimate the risk of adverse events. Angiogenesis inhibitors, but not other hypertension-inducing drugs, showed significant risk signals for aortic aneurysms and dissection. A retrospective cohort analysis using JMDC, a medical receipt database in Japan, showed that the history of atherosclerosis and dyslipidemia, but not hypertension, were significantly associated with the onset of aortic dissection during angiogenesis inhibitor medication administration. For in vivo studies, sunitinib (100 mg/kg/day) was administered to LAB mice. Sunitinib increased systolic blood pressure (182 mmHg vs. 288 mmHg with sunitinib; p＜0.01) and the incidence of aortic dissection (40% vs. 59% with sunitinib; p = 0.34) in mice. In vivo and in vitro studies revealed that sunitinib increased endothelin-1 expression and induced endothelial cell damage evaluated by intracellular- and vascular cell adhesion molecule-1 expressions. The increased risk of developing aortic dissection with angiogenesis inhibitors is associated with the development of drug-specific hypertension via endothelial cell damage and endothelin-1 expression. Our findings are invaluable in establishing safer anticancer therapies and strategies to prevent the development of vascular toxicity in high-risk patients.

Effect of glucocorticoid for patients with type A aortic dissection undergoing surgical repair with deep hypothermic circulatory arrest: A single-center, retrospective study

BACKGROUND

Postoperative patients with Type A aortic dissection (TAAD) often experience severe inflammatory responses caused by multiple factors perioperatively. However, the effect of postoperative glucocorticoid (GC) use, which is a potent anti-inflammatory agent, on complications or all-cause mortality is unclear.

METHODS

Patients with TAAD who underwent surgical repair requiring deep hypothermic circulatory arrest between January 2020 and December 2021 were included in the study. Characteristics of patients treated with and without GCs were compared. The primary outcome was in-hospital mortality, and a composite secondary outcome was defined as in-hospital death or any major complications. Propensity score matching was used to balance baseline differences between groups. Kaplan-Meier curves were used to compare survival probability.

RESULTS

A total of 393 postoperative patients with TAAD were included in the study. Forty of them (10.2%) received GC treatment at a median daily methylprednisolone-equivalent dose of 0.6 mg/kg (0.4-0.7) for a median period of 2 (1-3) days. Patients on GCs had more intraoperative blood transfusions, higher postoperative APACHE II (12 vs 9, p = .004) and SOFA (9 vs 6, p < .001) scores, worse perioperative hepatic, renal and cardiac function. The in-hospital mortality in the matched cohort did not differ between groups [GC n = 11/40 (27.5%) versus Non-GC n = 19/80 (23.8%); p = .661].

CONCLUSIONS

The propensity to use GCs correlated with the critical status of the patient. However, low dose and short-term postoperative GC treatment did not reduce in-hospital mortality rates among patients with TAAD. A more appropriate regimen should be further investigated.

A prediction model to predict in-hospital mortality in patients with acute type B aortic dissection

BACKGROUND

Acute type B aortic dissection (ABAD) is a life-threatening cardiovascular disease. A practicable and effective prediction model to predict and evaluate the risk of in-hospital death for ABAD is required. The present study aimed to construct a prediction model to predict the risk of in-hospital death in ABAD patients.

METHODS

A total of 715 patients with ABAD were recruited in the first affiliated hospital of Xinjiang medical university from April 2012 to May 2021. The information on the demographic and clinical characteristics of all subjects was collected. The logistic regression analysis, receiver operating characteristic (ROC) curve analysis, and nomogram were applied to screen the appropriate predictors and to establish a prediction model for the risk of in-hospital mortality in ABAD. The receiver operator characteristic curve and calibration plot were applied to validate the performance of the prediction model.

RESULTS

Of 53 (7.41%) subjects occurred in-hospital death in 715 ABAD patients. The variables including diastolic blood pressure (DBP), platelets, heart rate, neutrophil-lymphocyte ratio, D-dimer, C-reactive protein (CRP), white blood cell (WBC), hemoglobin, lactate dehydrogenase (LDH), procalcitonin, and left ventricular ejection fraction (LVEF) were shown a significant difference between the in-hospital death group and the in-hospital survival group (all P < 0.05). Furthermore, all these factors which existed differences, except CRP, were associated with in-hospital deaths in ABAD patients (all P < 0.05). Then, parameters containing LVEF, WBC, hemoglobin, LDH, and procalcitonin were identified as independent risk factors for in-hospital deaths in ABAD patients by adjusting compound variables (all P < 0.05). In addition, these independent factors were qualified as predictors to build a prediction model (AUC > 0.5, P < 0.05). The prediction model was shown a favorable discriminative ability (C index = 0.745) and demonstrated good consistency.

CONCLUSIONS

The novel prediction model combined with WBC, hemoglobin, LDH, procalcitonin, and LVEF, was a practicable and valuable tool to predict in-hospital deaths in ABAD patients.

Postoperative glucocorticoids in patients with acute type A aortic dissection (GLAD): study protocol for a prospective, single-center, randomized controlled trial

BACKGROUND

Patients receiving surgical treatment of acute type A Aortic Dissection (aTAAD) are common to suffer organ dysfunction in the intensive care unit due to overwhelming inflammation. Previous studies have revealed that glucocorticoids may reduce complications in certain patient groups, but evidence between postoperative glucocorticoids administration and improvement in organ dysfunction after aTAAD surgery are lacking.

METHODS

This study will be an investigator-initiated, prospective, single-blind, randomized, single-center study. Subjects with confirmed diagnosis of aTAAD undergoing surgical treatment will be enrolled and 1:1 randomly assigned to receive either glucocorticoids or normal treatment. All patients in the glucocorticoids group will be given methylprednisolone intravenously for 3 days after enrollment. The primary endpoint will be the amplitude of variation of Sequential Organ Failure Assessment score on post-operative day 4 compared to baseline.

DISCUSSION

The trial will explore the rationale for postoperative application of glucocorticoids in patients after aTAAD surgery.

TRIAL REGISTRATION

This study has been registered on ClinicalTrials.gov (NCT04734418).

Risk factors for early death after surgery in patients with acute Stanford type A aortic dissection: A systematic review and meta-analysis

BACKGROUND

There are many risk factors related to early death after surgery among patients with acute Stanford type A aortic dissection (ATAAD) that have been analyzed in previous studies, but no evidence-based study has been conducted to confirm these risk factors.

AIMS

The aims of this study were to investigate risk factors for early death after surgery in patients with ATAAD via systematic review and meta-analysis and assess evidence-based strategies for preventing adverse events.

METHODS

The protocol for this study was prospectively registered with PROSPERO (CRD 42022332772). The authors systematically searched PubMed, Ovid, Scopus, Web of Science and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines from database construction to May 2021. Studies that met the selection criteria were determined by two independent researchers, and the odds ratios (ORs) and 95% confidence intervals (95% CIs) were reported for the risk factors and were pooled using Stata 15.0.

RESULTS

A total of 23 studies including 5510 patients met the inclusion criteria, and 10 risk factors were analyzed in this meta-analysis. The preoperative risk factors for early death after surgery in patients with ATAAD were age [(OR: 1.03, 95% CI (1.01, 1.06)], male sex [(OR: 1.43, 95% CI (1.06, 1.92)], shock [(OR: 1.91, 95% CI (1.06, 3.45)], malperfusion [(OR: 3.45, 95% CI (2.24, 5.31)] and cardiac tamponade [(OR: 3.89, 95% CI (1.17, 12.98)].

CONCLUSION

Patients with ATAAD who have an older age, male sex, shock, malperfusion and cardiac tamponade have a higher risk for early death after surgery. However, more highly homogenous studies are needed to demonstrate these results. Clinical staff should pay more attention to these factors and take individual actions to reduce mortality after surgery in patients with ATAAD.

Post-operative uric acid: a predictor for 30-days mortality of acute type A aortic dissection repair

Background

Hyperuricemia is associated with aortic dissection and cardiovascular diseases. The implication of high serum uric acid (UA) level after acute aortic dissection repair remains unknown. The aim of this study is to explore the role of peri-operative serum UA level in predicting 30-days mortality with acute type A aortic dissection (AAAD) patients, who underwent surgery.

Methods

This study retrospectively enrolled 209 consecutive patients with AAAD, who underwent surgery in Xiangya Hospital from 2017 to 2020. Post-operative laboratory examinations were measured within 24 h after surgery. Univariate analysis and logistic regression analysis were used for predictor finding.

Results

209 consecutive AAAD patients were included, 14.3% (n = 30) were dead within 30 days after surgery. By univariate analysis, we found AAAD repair patients with 30-days mortality had a higher prevalence of cerebral malperfusion, lower pre-operative fibrinogen, longer cardiopulmonary bypass and aortic crossclamp time, and higher post-operative day 1 (POD1) creatinine and urea levels. Both pre-operative (433.80 ± 152.59 vs. 373.46 ± 108.31 mmol/L, p = 0.038) and POD1 (559.78 ± 162.23 vs. 391.29 ± 145.19 mmol/L, p < 0.001) UA level were higher in mortality group than in survival group. In regression model, only cerebral malperfusion (OR, 7.938, 95% CI 1.252–50.323; p = 0.028) and POD1 UA level (OR, 2.562; 95% CI 1.635–4.014; p < 0.001) were independent predictors of 30-days mortality in AAAD repair patients. According to the ROC curve, the POD1 UA level provided positive value for 30-days mortality in AAAD repair patients with 0.799 areas under the curve. The optimum cutoff value selected by ROC curve was 500.15 mmol/L, with a sensitivity of 65% and a specificity of 86%.

Conclusion

Pre- and post-operative hyperuricemia are potentially associated with worsened outcomes in AAAD surgery patients. The POD1 UA level has a predictive role in 30-days mortality in AAAD repair patients.

Predicting postoperative hypoxemia risk factors in the patients after triple-branched stent graft implantation surgery with acute type A aortic dissection: A retrospective study

OBJECTIVE

To evaluate the risk factors of postoperative hypoxemia in patients after triple-branched stent graft implantation surgery with acute type A aortic dissection by conducting a nomogram.

METHODS

We evaluated 97 patients with acute type A aortic dissection (2020-2021), who underwent triple-branched stent graft implantation surgery. The independent risk factors were screened using univariate and multivariate logistic regression. We integrated significant factors as well as potential interference factors to build the nomogram model. The accuracy of the nomogram model was determined by using receiver operating characteristic curves (ROC), decision curve analyses (DCA), and calibration plots. Internal verification was evaluated using bootstrap validation.

RESULTS

Logistic regression analysis illustrated that the postoperative lactic acid, postoperative creatinine, and intraoperative aortic occlusion time were all independent risk factors for hypoxemia. Age, sex, and body mass index (BMI) were clinically relevant for predicting postoperative hypoxemia. We established a nomogram based on these six risk factors. The ROC (area under the curve [AUC] = 0.765), DCA, and calibration confirmed good discriminatory applicability and accuracy of the nomogram. Bootstrap validation (AUC = 0.76) verified the applicability of the nomogram.

CONCLUSIONS

The nomogram model could serve as a tool for the prediction of postoperative hypoxemia in patients after modified triple-branched stent graft implantation surgery with acute type A aortic dissection.

Serum Oxylipin Profiles Identify Potential Biomarkers in Patients with Acute Aortic Dissection

Aortic dissection (AD) is a life-threatening cardiovascular disease with a dismal prognosis. Inflammation plays an important role in AD. Oxylipins are bioactive lipids involved in the modulation of inflammation and may be involved in the pathogenesis and progression of AD. This study aims to identify possible metabolites related to AD. A total of 10 type A Aortic dissection (TAAD) patients, 10 type B Aortic dissection (TBAD) patients and 10 healthy controls were included in this study. Over 100 oxylipin species were identified and quantified by liquid chromatography with tandem mass spectrometry (LC-MS/MS) analysis. Our investigation demonstrated substantial alterations in 91 oxylipins between AD and healthy individuals. Patients with TAAD had 89 entries accessible compared to healthy controls. According to orthogonal partial least squares discriminant analysis (OPLS-DA), fitness (R²X = 0.362 and R²Y = 0.807, p = 0.03) and predictability (Q² = 0.517, p = 0.005) are the validation parameters between the two groups. Using multivariate logistic regression, 13-HOTrE and 16(17)-EpDPE were the risk factors in the aortic patients group compared to healthy people (OR = 2.467, 95%CI:1.256–7.245, p = 0.035; OR = 0.015, 95%CI:0.0002–0.3240, p = 0.016, respectively). In KEGG enrichment of differential metabolites, the arachidonic acid metabolism pathway has the most metabolites involved. We established a diagnostic model in distinguishing between AD and healthy people. The AUC was 0.905. Oxylipins were significantly altered in AD patients, suggesting oxylipin profile is expected to exploit a novel, non-invasive, objective diagnosis for AD.

Procalcitonin, Interleukin-6 and C-reactive Protein Levels Predict Renal Adverse Outcomes and Mortality in Patients with Acute Type A Aortic Dissection

Background

Acute type A aortic coarctation (AAAD) is a highly deadly and serious life-threatening disease. The purpose of this study was to estimate the predictive value of peak procalcitonin, interleukin-6, and C-reactive protein levels on adverse renal outcomes and mortality in patients undergoing surgery for AAAD.

Methods

Perioperative peak PCT, CRP, and IL-6 levels were retrospectively collected in 331 patients hospitalized with AAAD from 2009 to 2021. The primary endpoints were AKI stage 2–3 and mortality. The receiver operating characteristic (ROC) curves were used to compare the predictive values of peak PCT, CRP, and IL-6 for different clinical outcomes. Multivariable logistic regression analysis was used to find risk factors for AKI and 30-day mortality.

Results

The incidence of AKI stage 2–3 following AAAD was 50.8% (168/331). The 30-day and overall mortality were significantly greater in the AKI 2–3 group than in the AKI 0–1 group (P = 0.000). ROC curve analysis showed that peak PCT, with an area under the ROC curve (AUC) of 0.712, was a more accurate predictor of adverse renal outcomes than peak IL-6 and CRP. Multivariable logistic regression analysis revealed that PCT > 0.39 ng/mL was an independent risk factor for AKI stage 2–3. Peak IL-6 > 259 pg/mL was found to be an independent risk factor for 30-day mortality.

Conclusion

In patients with surgery for AAAD, peak PCT provides a well-predictive indicator of AKI stage 2–3 and peak IL-6 indicates a favorable predictor of 30-day mortality.

The association between lymphocyte-monocyte ratio and postoperative acute kidney injury in patients with acute type A aortic dissection

BACKGROUND

The aim of this study was to investigate the relationship between baseline lymphocyte-monocyte ratio (LMR) and postoperative acute kidney injury (AKI) in patients with acute type A aortic dissection (ATAAD).

METHODS

ATAAD patients undergoing surgery in Nanjing First Hospital were enrolled from January 2019 to April 2021. Lymphocyte and monocyte were measured on admission. Multivariable logistic regression analyses were performed to explore the relationship between LMR and postoperative AKI. We also used receiver operating characteristic (ROC), net reclassification index (NRI) and integrated discrimination improvement (IDI) analyses to assess the predictive ability of LMR.

RESULTS

Among the 159 recruited patients, 47 (29.6%) were diagnosed with AKI. Univariate logistic regression analysis indicated that ATAAD patients with higher levels of LMR were prone to have lower risk to develop AKI (odds ratio [OR], 0.493; 95% confidence interval [CI] 0.284-0.650, P = 0.001). After adjustment for the potential confounders, LMR remained an independent related factor with postoperative AKI (OR 0.527; 95% CI 0.327-0.815, P = 0.006). The cutoff value for LMR to predict AKI was determined to be 2.67 in the ROC curve analysis (area under curve: 0.719). NRI and IDI further confirmed the predictive capability of LMR in postoperative AKI.

CONCLUSION

Elevated baseline LMR levels were independently associated with lower risk of postoperative AKI in ATAAD patients.

Bibliometric analysis of the inflammatory mechanism in aortic disease

BACKGROUND

In view of the key role of inflammation in the pathogenesis of aortic disease, we visually analyzed the research hotspots of inflammatory mechanism in aortic disease in this work through the method of bibliometrics from the Web of Science (WOS) Core database over the past three decades.

METHODS

A visual bibliometric network of research articles on inflammatory mechanisms in aortic disease was obtained from VOSviewer and Citespace based on the WOS Core Collection.

RESULTS

A total of 1278 documents from January 1990 to February 2021 were selected for analysis. The United States and China had the highest percentage of articles, comprising 34.01% and 24.92% of articles worldwide, respectively. Harvard University has published the most articles in this field, followed by the University of Michigan and Huazhong University of Science and Technology. The top 3 research hotspots were atherosclerosis, oxidative stress, and macrophages. The journal with the most articles in this area was Arteriosclerosis Thrombosis and Vascular Biology, followed by Atherosclerosis and PLOS One. The research trend on inflammatory mechanisms in the aortic system has 5 distinct directions: (1) atherosclerosis, NF-κB, expression, smooth muscle cell, and oxidative stress; (2) coronary artery disease, C-reactive protein, risk factors, endothelial dysfunction, and aortic stenosis; (3) abdominal aortic aneurysm, matrix metalloproteinases, macrophage, and pathogenesis; (4) cholesterol, metabolism, low-density lipoprotein, gene expression, and a therosclerotic lesions; and (5) calcific aortic valve disease, interstitial cells, calcification, and stenosis.

CONCLUSIONS

Inflammatory mechanism research has shown a tendency to rise gradually in the aortic field. Numerous studies have explored the role of inflammatory responses in aortic disease, which may increase the risk of endothelial dysfunction (aortic fibrosis and stiffness) and induce plaque formation. Among them, NFκB activation, nitric-oxide synthase expression, and oxidative stress are particularly essential.

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.

Predictive Ability of Procalcitonin for Acute Kidney Injury: A Narrative Review Focusing on the Interference of Infection

Acute kidney injury (AKI) is a common yet complicated clinical entity with high morbidity and mortality. An essential strategy to improve AKI patients’ prognoses is finding optimal biomarkers to identify AKI in a timely manner. Procalcitonin (PCT), a well-recognized biomarker for diagnosing infection and guiding antibiotics therapy, has been proposed to predict AKI development and recovery in many clinical settings. The current review provides comprehensive and updated information from relevant studies to evaluate PCT’s AKI-predictive ability and the influence of infection on this predictive ability. PCT has demonstrated optimal predictive ability for AKI in various populations irrespective of infection. However, the predictive ability seems to be blunted by infection since infection and inflammation have a more potent influence than AKI on PCT elevation. We furthermore explain the complicated association between elevated PCT levels and AKI in infection and inflammation situations and recommend directions for further investigations to clarify the essential issue. In conclusion, although conflicting data exist, serum PCT level is a potential biomarker for predicting AKI in many clinical settings regardless of infection. Nevertheless, further studies are warranted to clarify the association between PCT, infection, and AKI and to confirm the utilization of PCT for AKI prediction.

Patterns of Immune Infiltration and the Key Immune-Related Genes in Acute Type A Aortic Dissection in Bioinformatics Analyses

Background

Immune-inflammatory mechanisms contribute greatly to the complex process leading to type A aortic dissection (TAAD). This study aims to explore immune infiltration and key immune-related genes in acute TAAD.

Methods

ImmuCellAI algorithm was applied to analyze patterns of immune infiltration in TAAD samples and normal aortic vessel samples in the GSE153434 dataset. Differentially expressed genes (DEGs) were screened. Immune-related genes were obtained from overlapping DEGs of GSE153434 and immune genes of the ImmPort database. The hub genes were obtained based on the protein–protein interaction (PPI) network. The hub genes in TAAD were validated in the GSE52093 dataset. The correlation between the key immune-related genes and infiltrating immune cells was further analyzed.

Results

In the study, the abundance of macrophages, neutrophils, natural killer T cells (NKT cells), natural regulatory T cells (nTreg), T-helper 17 cells (Th17 cells) and monocytes was increased in TAAD samples, whereas that of dendritic cells (DCs), CD4 T cells, central memory T cells (Tcm), mucosa associated invariant T cells (MAIT cells) and B cells was decreased. Interleukin 6 (IL-6), C-C motif chemokine ligand 2 (CCL2) and hepatocyte growth factor (HGF) were identified and validated in the GSE52093 dataset as the key immune-related genes. Furthermore, IL-6, CCL2 and HGF were correlated with different types of immune cells.

Conclusion

In conclusion, several immune cells such as macrophages, neutrophils, NKT cells, and nTreg may be involved in the development of TAAD. IL-6, CCL2 and HGF were identified and validated as the key immune-related genes of TAAD via bioinformatics analyses. The key immune cells and immune-related genes have the potential to be developed as targets of prevention and immunotherapy for patients with TAAD.

Perioperative management after elective cardiac surgery: the predictive value of procalcitonin for infective and noninfective complications

Objective: Procalcitonin (PCT) has been associated with adverse outcomes after cardiac surgery. Nevertheless, there is no consensus on thresholds and timing of PCT measurement to predict adverse outcomes. Materials & methods: A total of 960 patients undergoing elective cardiac surgery were retrospectively evaluated. PCT levels were measured from the first to the seventh postoperative day (POD). The onset of complications was recorded. Results: Complications occurred in 421 (44%) patients. PCT on the third POD was associated with the occurrence of any kind of complications (odds ratio: 1.06; p: 0.037), and noninfectious complications (odds ratio: 1.05; p: 0.035), after adjusting. PCT above the median value at the third POD (>0.33 μg/l) predicted postoperative complications (incidence rate ratio: 1.13; p = 0.035). Conclusion: PCT seems to predict postoperative complications in cardiac surgery. The determination at the third POD yields the greatest sensitivity and specificity.

Meta-analysis of procalcitonin as a predictor for acute kidney injury

BACKGROUND

Procalcitonin (PCT) was used for predicting the development of acute kidney injury (AKI) in several studies recently. We aimed to investigate the accuracy of PCT for predicting AKI in this study.

METHODS

Studies that assessed the predictive performance of PCT for the development of AKI in adult patients were searched from Medline, Embase, and the Cochrane Library from inception to June 2020. We calculated the pooled sensitivities and specificities and the area under the summary receiver-operating characteristic (SROC) curves. I2 was used to test the heterogeneity and the potential heterogeneity was investigated by meta-regression.

RESULTS

In total, 9 of 119 studies with 4852 patients were included, 1272 were diagnosed with AKI. In the overall analysis, the area under the SROC curve was 0.82 (95% CI, 0.79-0.85) and the pooled sensitivity and specificity were 0.76 (95% confidence interval [CI], 0.64-0.85) and 0.75 (95% CI, 0.61-0.86), respectively. In the subgroup analysis among septic patients, the pooled sensitivity and specificity were 0.59 (95% CI, 0.29-0.84) and 0.53 (95% CI, 0.31-0.74), and the area under the SROC was 0.57 (95% CI, 0.53-0.62).

CONCLUSION

PCT may be a potential predictor for the development of AKI.

Predictors for the development of preoperative oxygenation impairment in acute aortic dissection in hypertensive patients

BACKGROUND

Acute aortic dissection (AAD) is an acute life-threatening cardiovascular disease, which is frequently complicated with oxygenation impairment (OI). We aim to investigate predictors of the development of OI in the patients with AAD.

METHODS

We retrospectively collected clinical data of AAD in hypertensive patients from July 2012 to March 2020. The patients included in this study were divided into OI (+) group (oxygenation index≤200) and OI (-) group (oxygenation index> 200). Both groups were compared according to demographic and clinical characteristics, and laboratory findings. Characteristics of hypertension in the patients with AAD were described. Predictors for the development of OI were assessed. And cutoff values were determined by receiver operating characteristics (ROC) curve.

RESULTS

A total of 208 patients were included in this study and the incidence of OI was 32.2%. In OI (+) group, patients had significantly higher peak body temperature (37.85 ± 0.60 vs 37.64 ± 0.44 °C, P = .005), higher levels of CRP (42.70 ± 28.27 vs 13.90 ± 18.70 mg/L, P = .000) and procalcitonin (1.07 ± 3.92 vs 0.31 ± 0.77μg/L, P = .027), and lower levels of albumin (34.21 ± 5.65 vs 37.73 ± 4.70 g/L, P = .000). Spearman's rank correlation test showed that the minimum oxygenation index was positively correlated with albumin, and was negatively correlated with the peak body temperature, serum CRP, procalcitonin, BNP and troponin. The stepwise multiple linear regression analysis showed that the peak body temperature, serum CRP and albumin were independently associated with development of OI. An optimal cutoff value for CRP for predicting OI was ≥9.20 mg/L, with a sensitivity of 91.0% and a specificity of 61.0%.

CONCLUSIONS

The peak body temperature, serum CRP and albumin were independent predictors of OI development in the patients with AAD. The serum CRP on admission≥9.20 mg/L might be a valuable and reliable indicator in predicting the development of OI.