Preoperative anaemia and outcome after elective cardiac surgery:a Dutch national registry analysis

Background: Previous studies have shown that preoperative anaemia in patients undergoing cardiac surgery is associated with adverse outcomes. However, most of these studies were retrospective, had a relatively small sample size, and were from a single centre. The aim of this study was to analyse the relationship between the severity of preoperative anaemia and short- and long-term mortality and morbidity in a large multicentre national cohort of patients undergoing cardiac surgery. Methods: A nationwide, prospective, multicentre registry (Netherlands Heart Registration) of patients undergoing elective cardiac surgery between January 2013 and January 2019 was used for this observational study. Anaemia was defined according to the WHO criteria, and the main study endpoint was 120-day mortality. The association was investigated using multivariable logistic regression analysis. Results: In total, 35 484 patients were studied, of whom 6802 (19.2%) were anaemic. Preoperative anaemia was associated with an increased risk of 120-day mortality (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI]: 1.4–1.9; P<0.001). The risk of 120-day mortality increased with anaemia severity (mild anaemia aOR 1.6; 95% CI: 1.3–1.9; P<0.001; and moderate-to-severe anaemia aOR 1.8; 95% CI: 1.4–2.4; P<0.001). Preoperative anaemia was associated with red blood cell transfusion and postoperative morbidity, the causes of which included renal failure, pneumonia, and myocardial infarction. Conclusions: Preoperative anaemia was associated with mortality and morbidity after cardiac surgery. The risk of adverse outcomes increased with anaemia severity. Preoperative anaemia is a potential target for treatment to improve postoperative outcomes

Abdominal aortic aneurysm is associated with a variant in low-density lipoprotein receptor-related protein 1

Abdominal aortic aneurysm (AAA) is a common cause of morbidity and mortality and has a significant heritability. We carried out a genome-wide association discovery study of 1866 patients with AAA and 5435 controls and replication of promising signals (lead SNP with a p value &lt; 1 × 10-5) in 2871 additional cases and 32,687 controls and performed further follow-up in 1491 AAA and 11,060 controls. In the discovery study, nine loci demonstrated association with AAA (p &lt; 1 × 10-5). In the replication sample, the lead SNP at one of these loci, rs1466535, located within intron 1 of low-density-lipoprotein receptor-related protein 1 (LRP1) demonstrated significant association (p = 0.0042). We confirmed the association of rs1466535 and AAA in our follow-up study (p = 0.035). In a combined analysis (6228 AAA and 49182 controls), rs1466535 had a consistent effect size and direction in all sample sets (combined p = 4.52 × 10-10, odds ratio 1.15 [1.10-1.21]). No associations were seen for either rs1466535 or the 12q13.3 locus in independent association studies of coronary artery disease, blood pressure, diabetes, or hyperlipidaemia, suggesting that this locus is specific to AAA. Gene-expression studies demonstrated a trend toward increased LRP1 expression for the rs1466535 CC genotype in arterial tissues; there was a significant (p = 0.029) 1.19-fold (1.04-1.36) increase in LRP1 expression in CC homozygotes compared to TT homozygotes in aortic adventitia. Functional studies demonstrated that rs1466535 might alter a SREBP-1 binding site and influence enhancer activity at the locus. In conclusion, this study has identified a biologically plausible genetic variant associated specifically with AAA, and we suggest that this variant has a possible functional role in LRP1 expression

Perioperative inflammation and hypotension

Despite advances in surgical and anesthetic techniques in the past decades, complications are common after major surgery. The negative impact of postoperative complications on outcome is of significant concern to patients and their clinicians. The pathophysiological mechanisms of complications after surgery, however, are largely unknown. This thesis described the relation between two possible determinants of adverse events after major surgery: perioperative inflammation and hypotension. The association of systemic inflammation and outcome was assessed in major abdominal and cardiac surgery. The development of the systemic inflammatory response syndrome (SIRS) in 121 patients undergoing transapical transcatheter aortic valve implantation (TAVI) was associated with an independently increased risk of any adverse event (adjusted odds ratio (AOR) 4.0, 95% confidence interval (CI); 1.6 - 9.6). In a subsequent exploratory analysis, an association between perioperative tissue hypoperfusion (a potential cause of tissue/reperfusion injury) and SIRS was not observed. In 135 patients undergoing major abdominal surgery, an interleukin-6 (IL-6) level of >432 pg/ml was an independent predictor of postoperative complications (AOR 3.3, 95% CI; 1.3 – 8.5). The diagnostic accuracy of IL-6 on day one (area under the curve (AUC) 0.67) was comparable to the diagnostic accuracy of CRP on day three (AUC 0.73). In patients undergoing cardiac surgery preoperative statin therapy was associated with a 67% reduced risk of infectious complications (AOR 0.3, 95% CI; 0.2 - 0.6). The association of intraoperative hypotension (IOH) and postoperative renal function was studied in patients undergoing major abdominal surgery and coronary artery bypass grafting (CABG). None of the investigated IOH definitions (i.e. several absolute and relative mean arterial pressure (MAP) thresholds and the AUC below several absolute MAP thresholds) were associated with a change in the estimated glomerular filtration rate (eGFR) after major abdominal surgery. In patients undergoing CABG none of the IOH definitions investigated were associated with AKI. In conclusion, perioperative systemic inflammation after major surgery is commonly observed an important factor in the development of adverse outcome. Perioperative inflammation may be used as a predictive marker for postoperative complications. In addition, it can be used as a therapeutic target for improving outcome. The role of IOH in the development of AKI after major surgery seems limited

Perioperative inflammation and hypotension

Despite advances in surgical and anesthetic techniques in the past decades, complications are common after major surgery. The negative impact of postoperative complications on outcome is of significant concern to patients and their clinicians. The pathophysiological mechanisms of complications after surgery, however, are largely unknown. This thesis described the relation between two possible determinants of adverse events after major surgery: perioperative inflammation and hypotension. The association of systemic inflammation and outcome was assessed in major abdominal and cardiac surgery. The development of the systemic inflammatory response syndrome (SIRS) in 121 patients undergoing transapical transcatheter aortic valve implantation (TAVI) was associated with an independently increased risk of any adverse event (adjusted odds ratio (AOR) 4.0, 95% confidence interval (CI); 1.6 - 9.6). In a subsequent exploratory analysis, an association between perioperative tissue hypoperfusion (a potential cause of tissue/reperfusion injury) and SIRS was not observed. In 135 patients undergoing major abdominal surgery, an interleukin-6 (IL-6) level of >432 pg/ml was an independent predictor of postoperative complications (AOR 3.3, 95% CI; 1.3 – 8.5). The diagnostic accuracy of IL-6 on day one (area under the curve (AUC) 0.67) was comparable to the diagnostic accuracy of CRP on day three (AUC 0.73). In patients undergoing cardiac surgery preoperative statin therapy was associated with a 67% reduced risk of infectious complications (AOR 0.3, 95% CI; 0.2 - 0.6). The association of intraoperative hypotension (IOH) and postoperative renal function was studied in patients undergoing major abdominal surgery and coronary artery bypass grafting (CABG). None of the investigated IOH definitions (i.e. several absolute and relative mean arterial pressure (MAP) thresholds and the AUC below several absolute MAP thresholds) were associated with a change in the estimated glomerular filtration rate (eGFR) after major abdominal surgery. In patients undergoing CABG none of the IOH definitions investigated were associated with AKI. In conclusion, perioperative systemic inflammation after major surgery is commonly observed an important factor in the development of adverse outcome. Perioperative inflammation may be used as a predictive marker for postoperative complications. In addition, it can be used as a therapeutic target for improving outcome. The role of IOH in the development of AKI after major surgery seems limited

Perioperative inflammation and hypotension

Despite advances in surgical and anesthetic techniques in the past decades, complications are common after major surgery. The negative impact of postoperative complications on outcome is of significant concern to patients and their clinicians. The pathophysiological mechanisms of complications after surgery, however, are largely unknown. This thesis described the relation between two possible determinants of adverse events after major surgery: perioperative inflammation and hypotension. The association of systemic inflammation and outcome was assessed in major abdominal and cardiac surgery. The development of the systemic inflammatory response syndrome (SIRS) in 121 patients undergoing transapical transcatheter aortic valve implantation (TAVI) was associated with an independently increased risk of any adverse event (adjusted odds ratio (AOR) 4.0, 95% confidence interval (CI); 1.6 - 9.6). In a subsequent exploratory analysis, an association between perioperative tissue hypoperfusion (a potential cause of tissue/reperfusion injury) and SIRS was not observed. In 135 patients undergoing major abdominal surgery, an interleukin-6 (IL-6) level of >432 pg/ml was an independent predictor of postoperative complications (AOR 3.3, 95% CI; 1.3 – 8.5). The diagnostic accuracy of IL-6 on day one (area under the curve (AUC) 0.67) was comparable to the diagnostic accuracy of CRP on day three (AUC 0.73). In patients undergoing cardiac surgery preoperative statin therapy was associated with a 67% reduced risk of infectious complications (AOR 0.3, 95% CI; 0.2 - 0.6). The association of intraoperative hypotension (IOH) and postoperative renal function was studied in patients undergoing major abdominal surgery and coronary artery bypass grafting (CABG). None of the investigated IOH definitions (i.e. several absolute and relative mean arterial pressure (MAP) thresholds and the AUC below several absolute MAP thresholds) were associated with a change in the estimated glomerular filtration rate (eGFR) after major abdominal surgery. In patients undergoing CABG none of the IOH definitions investigated were associated with AKI. In conclusion, perioperative systemic inflammation after major surgery is commonly observed an important factor in the development of adverse outcome. Perioperative inflammation may be used as a predictive marker for postoperative complications. In addition, it can be used as a therapeutic target for improving outcome. The role of IOH in the development of AKI after major surgery seems limited

Postoperative interleukin-6 level and early detection of complications after elective major abdominal surgery

Objective: To assess the association of systemic inflammation and outcome after major abdominal surgery. Background: Major abdominal surgery carries a high postoperative morbidity and mortality rate. Studies suggest that inflammation is associated with unfavorable outcome. Methods: Levels of C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-a and the systemic inflammatory response syndrome (SIRS) were assessed in 137 patients undergoing major abdominal surgery. Blood samples were drawn on days 0, 1, 3, and 7, and SIRS was scored during 48 hours after surgery. Primary outcome was a composite of mortality, pneumonia, sepsis, anastomotic dehiscence, wound infection, noncardiac respiratory failure, atrial fibrillation, congestive heart failure, myocardial infarction, and reoperation within 30 days of surgery. Results: An IL-6 level more than 432 pg/mL on day 1 was associated with an increased risk of complications (adjusted odds ratio: 3.3; 95% confidence interval [CI]: 1.3-8.5) and a longer median length of hospital stay (7 vs 12 days, P <0.001). As a single test, an IL-6 cut-off level of 432 pg/mL on day 1 yielded a specificity of 70% and a sensitivity of 64% for the prediction of complications (area under the curve: 0.67; 95% CI: 0.56-0.77). Levels of CRP started to discriminate from day 3 onward with a specificity of 87% and a sensitivity of 58% for a cut-off level of 203 mg/L (AUC: 0.73; 95% CI: 0.63-0.83). Conclusions: A high IL-6 level on day 1 is associated with postoperative complications. Levels of IL-6 help distinguish between patients at low and high risk for complications before changes in levels of CRP