Retrospective Evaluation of the Pre- and Postoperative Neutrophil-Lymphocyte Ratio as a Predictor of Mortality in Patients Who Underwent Coronary Artery Bypass Grafting
Neutrophil-lymphocyte Ratio and Coronary Artery Bypass Grafting
Keywords:Coronary artery bypass, Off-pump, Coronary artery bypass grafting, Inflammation, Neutrophil, Lymphocyte
Background: We aimed to investigate the neutrophil-lymphocyte ratio (NLR) as a predictor of mortality in patients, who had undergone on-pump and off-pump coronary artery bypass grafting (CABG).
Methods: This retrospective study comprised of 457 patients, who underwent CABG (323 on-pump and 134 off-pump) between January 2014 and October 2019. Preoperative, postoperative (PO) 1st hour, PO 1st day, and PO 5th day neutrophil-lymphocyte ratios were calculated. The patients were compared, according to demographic, laboratory, and clinical data. A receiver operating characteristics curve was applied to estimate a cut-off value of NLR for mortality.
Results: The on-pump group was older (P = 0.001), had a lower Euroscore II (P = 0.036), had a higher graft number (P < 0.001), intensive care unit stay (P = 0.001), and all PO NLRs, except preoperative NLR. There were 14 (3.06%) patients with mortality. Overall (N = 457), PO 1st hour (P = 0.001), PO 1st day (P < 0.001), and PO 5th day (P = 0.016) NLRs were considerably higher in patients with mortality. While none of the NLRs revealed a significant difference in the off-pump group, PO 1st hour (P = 0.004) PO 1st day (P < 0.001), and PO 5th day (P = 0.007) NLRs were higher in patients with mortality in the on-pump group. The increase in odds ratio of PO NLR was higher in patients with mortality in the overall group of PO 1st day and in the on-pump group of PO 1st hour and PO 1st day. The best combination of sensitivity and specificity was reached at a cut-off value of 6.4 for PO 1st hour NLR and 31.8 for PO 1st day NLR.
Conclusions: As in indicator of inflammatory state, NLR readily can be used as a predictor of mortality. Regardless of the CABG technique used, postoperative 1st hour and postoperative 1st day NLR >6.4 and 31.8, respectively, are highly related to mortality.
Butler J, Rocker GM, Westaby S. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg. 1993;55(2):552-559.
Buffolo E, de Andrade CS, Branco JN, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg. 1996;61(1):63-66.
Calafiore AM, Di Mauro M, Contini M, et al. Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome. Ann Thorac Surg. 2001;72(2):456-462; discussion 462-453.
Plomondon ME, Cleveland JC, Jr., Ludwig ST, et al. Off-pump coronary artery bypass is associated with improved risk-adjusted outcomes. Ann Thorac Surg. 2001;72(1):114-119.
Abanoz M, Engin M. The effect of the relationship between post-cardiotomy neutrophil/lymphocyte ratio and platelet counts on early major adverse events after isolated coronary artery bypass grafting. Turk Gogus Kalp Dama. 2021;29(1):36-44.
Ünal EU, Durukan AB, Özen A, et al. Neutrophil/lymphocyte ratio as a mortality predictor following coronary artery bypass graft surgery. Turk Gogus Kalp Dama. 2013;21(3):588-593.
Aldemir M, Baki ED, Adali F, Carsanba G, Tecer E, Tas HU. Comparison of neutrophil:lymphocyte ratios following coronary artery bypass surgery with or without cardiopulmonary bypass. Cardiovasc J Afr. 2015;26(4):159-164.
Şişli E, Yalçınbaş YK, Türkekul Y, A. Y, Saygılı A, Sarıoğlu CT. Does preoperative neutrophil-lymphocyte ratio indicate postoperative morbidity after repair of tetralogy of Fallot? Turk Gogus Kalp Dama. 2016;24(2):220-226.
Weedle RC, Da Costa M, Veerasingam D, Soo AWS. The use of neutrophil lymphocyte ratio to predict complications post cardiac surgery. Ann Transl Med. 2019;7(23):778.
Erdolu B, As AK, Engin M. The Relationship between the HATCH Score, Neutrophil to Lymphocyte Ratio and Postoperative Atrial Fibrillation After Off-Pump Coronary Artery Bypass Graft Surgery. Heart Surg Forum. 2020;23(1):E088-E092.
Gibson PH, Croal BL, Cuthbertson BH, et al. Preoperative neutrophil-lymphocyte ratio and outcome from coronary artery bypass grafting. Am Heart J. 2007;154(5):995-1002.
Zouridakis EG, Garcia-Moll X, Kaski JC. Usefulness of the blood lymphocyte count in predicting recurrent instability and death in patients with unstable angina pectoris. Am J Cardiol. 2000;86(4):449-451.
Arruda-Olson AM, Reeder GS, Bell MR, Weston SA, Roger VL. Neutrophilia predicts death and heart failure after myocardial infarction: a community-based study. Circ Cardiovasc Qual Outcomes. 2009;2(6):656-662.
Nashef SA, Roques F, Sharples LD, et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41(4):734-744; discussion 744-735.
Shahian DM, O'Brien SM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3--valve plus coronary artery bypass grafting surgery. Ann Thorac Surg. 2009;88(1 Suppl):S43-62.
Kim WH, Park JY, Ok SH, Shin IW, Sohn JT. Association Between the Neutrophil/Lymphocyte Ratio and Acute Kidney Injury After Cardiovascular Surgery: A Retrospective Observational Study. Medicine (Baltimore). 2015;94(43):e1867.
Giakoumidakis K, Fotos NV, Patelarou A, et al. Perioperative neutrophil to lymphocyte ratio as a predictor of poor cardiac surgery patient outcomes. Pragmat Obs Res. 2017;8:9-14.
Sinan Guvenc T, Ekmekci A, Uluganyan M, et al. Prognostic Value of Neutrophil-to-Lymphocyte Ratio for Patients Undergoing Heart Valve Replacement. J Heart Valve Dis. 2016;25(3):389-396.
Silberman S, Abu-Yunis U, Tauber R, et al. Neutrophil-Lymphocyte Ratio: Prognostic Impact in Heart Surgery. Early Outcomes and Late Survival. Ann Thorac Surg. 2018;105(2):581-586.
Wada H, Dohi T, Miyauchi K, et al. Pre-procedural neutrophil-to-lymphocyte ratio and long-term cardiac outcomes after percutaneous coronary intervention for stable coronary artery disease. Atherosclerosis. 2017;265:35-40.
Giacinto O, Satriano U, Nenna A, et al. Inflammatory Response and Endothelial Dysfunction Following Cardiopulmonary Bypass: Pathophysiology and Pharmacological Targets. Recent Pat Inflamm Allergy Drug Discov. 2019;13(2):158-173.
Moen O, Hogasen K, Fosse E, et al. Attenuation of changes in leukocyte surface markers and complement activation with heparin-coated cardiopulmonary bypass. Ann Thorac Surg. 1997;63(1):105-111.
Ehsan A, Shekar P, Aranki S. Innovative Surgical Strategies: Minimally Invasive CABG and Off-pump CABG. Curr Treat Options Cardiovasc Med. 2004;6(1):43-51.
Mathison M, Edgerton JR, Horswell JL, Akin JJ, Mack MJ. Analysis of hemodynamic changes during beating heart surgical procedures. Ann Thorac Surg. 2000;70(4):1355-1360; discussion 1360-1351.
Magee MJ, Coombs LP, Peterson ED, Mack MJ. Patient Selection and Current Practice Strategy for Off-pump Coronary Artery Bypass Surgery. Circulation. 2003;108(10_suppl_1):II-9-II-14.
Azab B, Shariff MA, Bachir R, Nabagiez JP, McGinn JT, Jr. Elevated preoperative neutrophil/lymphocyte ratio as a predictor of increased long-term survival in minimal invasive coronary artery bypass surgery compared to sternotomy. J Cardiothorac Surg. 2013;8:193.
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