Retrospective Evaluation of Platelet-Leukocyte Indices and Cardiac Surgical Outcomes in Acyanotic Heart Disease Patients with Pulmonary Hypertension (REPLICA-PH)

Abstract

Introduction Acyanotic congenital heart disease (ACHD) patients with pulmonary hypertension (PH) are prone to postoperative complications, and characterization of the risk profile continues to fail in identifying inflammatory predilection. Our objective is to investigate the role of platelet-leukocyte indices (neutrophil-lymphocyte ratio [NLR], platelet-lymphocyte ratio [PLR], and systemic immune-inflammation index [SII] [neutrophil × platelet/lymphocyte]) in predicting poor outcomes following cardiac surgery in ACHD cohort with preoperative PH. Methods This single-center, retrospective risk-predictive study included ACHD patients undergoing surgical correction at our tertiary cardiac center between January 2015 and December 2019. Standard institutional perioperative management protocol was followed, and poor postoperative outcome was defined as ≥ 1 of: low cardiac output syndrome, new-onset renal failure, prolonged mechanical ventilation (MV > 24 hours), stroke, sepsis, and/or death. Results One hundred eighty patients out of 1,040 (17.3%) presented poor outcome. On univariate analysis, preoperative factors including right ventricular systolic pressure (RVSP) (PH-severity marker), congestive heart failure, albumin, NLR, PLR, SII, and aortic cross-clamping (ACC) and cardiopulmonary bypass (CPB) times predicted poor outcome. However, on multivariate analysis, RVSP, NLR, SII, and ACC and CPB times emerged as independent predictors. An NLR, SII prognostic cutoff of 3.33 and 860.6×103/mm3 was derived (sensitivity: 77.8%, 78.9%; specificity: 91.7%, 82.2%; area under the curve: 0.871, 0.833). NLR and SII values significantly correlated with postoperative MV duration, mean vasoactive-inotropic scores, and length of intensive care unit and hospital stay ( P <0.001). Conclusion Novel parsimonious, reproducible plateletleukocyte indices present the potential of stratifying the risk in congenital cardiac surgical patients with pre-existing PH.

Neutrophil–Lymphocyte Ratio in Congenital Heart Surgery: What Is Known and What Is New?

“…Preoperative NLR was found to be associated with prolonged ICU and hospital LOS in several studies. 27,29,30,32,33 The association of preoperative NLR with adverse outcomes is reflected in the ICU LOS and consequently in the hospital LOS. A longer stay increases hospital costs after congenital heart surgery.…”

“…This causes chronic subclinical inflammation in the preoperative period, even before fixed pulmonary arterial hypertension (PAH) is installed, which is reflected in the peripheral level of preoperative NLR. 30,32,40 The higher the PAH, the more inflammation the patient shows.…”

“…Two studies with the largest sample sizes composed of 370 patients with acyanotic CHD and PAH, demonstrated an association between high preoperative NLR and adverse outcomes. 30,32 The cutoff value ranged from 0.58 to >3.3; it was possible to predict liver dysfunction ( P < .001), AKI ( P = .02), LCOS ( P = .02), higher VIS ( P < .001), MV time ( P < .001), ICU LOS ( P < .001), and hospital LOS ( P < .001) using the preoperative NLR.…”

“…It was associated with adverse outcomes, such as a higher VIS, low cardiac output syndrome (LCOS), AKI, liver dysfunction, longer MV time, longer ICU LOS, total hospital LOS, and mortality. 24–33…”

“…It was associated with adverse outcomes, such as a higher VIS, low cardiac output syndrome (LCOS), AKI, liver dysfunction, longer MV time, longer ICU LOS, total hospital LOS, and mortality. [24][25][26][27][28][29][30][31][32][33] Although it presented promising results, there are still many gaps to be filled, such as the normal value for children, the ideal cutoff value to predict adverse outcomes, the wide variation and its correlation with other biomarkers, and if it is a modifiable risk factor.…”