Patroklos Pappas

The neutrophil to lymphocyte ratio in patients supported with extracorporeal membrane oxygenation

Introduction: The neutrophil to lymphocyte ratio (NLR) has proven to be a robust predictor of mortality in a wide range of cardiovascular diseases. This study investigated the predictive value of the NLR in patients supported by extracorporeal membrane oxygenation (ECMO) systems. Methods: This study included 107 patients who underwent ECMO implantation for cardiogenic shock. Median preoperative NLR was used to divide the cohort, with Group 1 NLR <14.2 and Group 2 with NLR ≥14.2. Survival, the primary outcome, was compared between groups. Results: The study cohort was composed of 64 (60%) males with an average age 53.1 ± 14.9 years. Patients in Group 1 had an average NLR of 7.5 ± 3.5 compared to 27.1 ± 19.9 in Group 2. Additionally, those in Group 2 had significantly higher preoperative blood urea nitrogen (BUN) and age. Survival analysis indicated a thirty-day survival of 56.2%, with significantly worsened mortality in patients with NLR greater than 14.2, p=0.047. Discussion: Our study shows the NLR has prognostic value in patients undergoing ECMO implantation. Leukocytes are known contributors to myocardial damage and neutrophil infiltration is associated with damage caused by myocardial ischemia.

Risk stratification with longitudinal neutrophil to lymphocyte ratio assessment after left ventricular assist device implantation

Introduction: Inflammatory processes are well-characterized risk factors in cardiovascular disease including advanced heart failure. Previous studies have utilized individual white cell subtypes in risk analysis, and a recent study has focused on the efficacy of the neutrophil-to-lymphocyte ratio in evaluating negative outcomes following left ventricular assist device implantation. To investigate the interaction between the left ventricular assist device and white cell counts, we assessed longitudinal changes in neutrophil-to-lymphocyte ratio following left ventricular assist device implantation. Methods: This retrospective study included 100 patients who underwent left ventricular assist device implantation between 2012 and 2013. The neutrophil-to-lymphocyte ratio was calculated prior to left ventricular assist device implantation, daily for the first 30 postoperative days, and at the first two postoperative outpatient visits. Preoperative demographic and clinical data were collected for all patients. Results: The mean neutrophil-to-lymphocyte ratio immediately before left ventricular assist device implantation was 5.2 ± 4.9. After surgery, the neutrophil-to-lymphocyte ratio decreased asymptotically, from a peak of 29.2 on postoperative day 1 to 4.1 at the second outpatient visit (p < 0.001). Lack of improvement in the neutrophil-to-lymphocyte ratio at postoperative day 10 was associated with increased length of stay, right heart failure, and a trend toward worsened survival. Conclusion: Our results indicate a significant inflammatory response to implantation of the left ventricular assist device, a known effect. The magnitude of this response may be effectively and easily monitored over time using the neutrophil-to-lymphocyte ratio. In general, approximately 30 days is required for the neutrophil-to-lymphocyte ratio to return to preoperative levels. After several months, the neutrophil-to-lymphocyte ratio improves to below preoperative levels. It is possible that this reduction reflects the reversal of various heart failure–mediated inflammatory processes following left ventricular assist device implantation.

INFLUENCE OF FAMILY HISTORY OF AORTIC DISEASE ON TYPE B AORTIC DISSECTION

Background: The genetic basis of thoracic aortic disease is well established. We sought to describe patients with Type B acute aortic dissection (TBAAD) with and without a family history (FH) of aortic disease and to compare the prevalence of FHbetween Type A and TBAAD. Methods: Patients enrolled

The impact of extreme obesity on outcomes after left ventricular assist device implantation

Background The association between extreme body mass index (BMI) and outcomes in left ventricular assist device (LVAD) patients has not been well established. With the commercial use of LVADs a larger number of patients with a BMI >40 have undergone device implantation. The purpose of this study was to evaluate the short and long-term outcomes of LVAD patients with extreme obesity. Methods A retrospective review of all patients (n=383) at our center who received a LVAD as primary implant between 2005-2015 was performed. Demographics, preoperative laboratory values, and postoperative outcomes were analyzed. Patients were divided into three groups based on BMI (kg/m2) classification (group 1: ≤25; group 2: 25 to 35; group 3: ≥35) and compared using one-way analysis of variance (ANOVA), Kruskal-Wallis and Chi-squared analysis as appropriate. Results Comparison of postoperative outcomes demonstrated an increased risk of respiratory failure and right ventricular (RV) failure in patients with a BMI ≥35 (range, 35-59). Length of stay, sternal infection, driveline/pocket infection, systemic infection, GI-bleeding, and neurological events within the first year of device therapy were not related to BMI. Survival at 30-day, 1- and 2-year was not significantly different among the three groups. The group with the smallest BMI demonstrated an increased risk for re-operative bleeding. Conclusions Despite an increased risk of early morbidity in patients with extreme obesity, long term survival was not significantly different between the BMI groups. Careful consideration is recommended when evaluating patients with an excessive BMI for LVAD therapy although it should not be a contraindication for device placement.