CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 AFRICA 299 A new biomarker to predict atrial fibrillation and its adverse events after coronary artery bypass surgery: red blood cell distribution volume Hüseyin Şaşkın, Durmuş Alper Görür Abstract Objective: Recent studies suggest that increased red blood cell distribution width may be associated with increased risk of atrial fibrillation. This study aimed to evaluate the relationship between pre-operative and postoperative erythrocyte distribution volume, postoperative atrial fibrillation and related adverse events in patients undergoing isolated coronary artery bypass surgery. Methods: A total of 790 patients (611 males, mean age 58.3 ± 6.2 years) in pre-operative sinus rhythm, who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass at the same centre and by the same surgical team between January 2015 and December 2021, were enrolled retrospectively. Two groups were created, group 1 (n = 183) and group 2 (n = 607), with regard to the occurrence of atrial fibrillation in the early postoperative period or not, respectively. Clinical and demographic data, biochemical and complete blood count parameters, and intra-operative and postoperative data of the patients were recorded. Univariate and subsequent multivariate logistic regression analysis was done to determine significant clinical factors and independent predictors of postoperative atrial fibrillation. Results: Among the patients, 182 (23.2%) developed atrial fibrillation during the 72 hours postoperatively. Pre-operative and postoperative first-, third- and seventh-day red blood cell distribution volume (p = 0.0001), C-reactive protein (p = 0.0001) and erythrocyte sedimentation rate (p = 0.0001) were significantly increased in group 1. Multivariate logistic regression analysis showed elevated pre-operative and postoperative first-, third- and seventh-day red blood cell distribution volume, erythrocyte sedimentation rate and C-reactive protein as independent predictors of early postoperative atrial fibrillation. Conclusion: Pre-operative and postoperative red blood cell distribution volume was found to be an independent predictor of atrial fibrillation and associated adverse events in the early postoperative period of isolated coronary artery bypass grafting. Keywords: coronary artery bypass grafting surgery, red blood cell distribution volume, atrial fibrillation Submitted 31/10/22, accepted 21/11/22 Published online 11/1/23 Cardiovasc J Afr 2023; 34: 299–306 www.cvja.co.za DOI: 10.5830/CVJA-2022-063 Coronary artery bypass grafting (CABG) is an effective coronary revascularisation method increasingly used in the treatment of coronary artery disease (CAD).1 As a result of developments in cardiopulmonary bypass (CPB) technology, CABG can be performed with lower mortality and morbidity rates.2 Postoperative atrial fibrillation (POAF), the most common arrhythmic sequel of cardiac surgery, is a serious complication that has plagued postoperative management for decades.3 The incidence of POAF varies according to the type of surgery and is seen in 3% of unselected adults aged 45 years and older who undergo non-cardiac surgery, 30% after thoracic surgery, and 20–50% especially after valve and bypass surgery.4 Mahoney et al., in their retrospective study involving 10 550 patients, reported that POAF developed in 33.8% of patients after CABG and heart valve surgery.5 Studies have shown that POAF is associated with many factors, including valvular heart disease, gender, age, obesity, obstructive sleep apnoea, chronic obstructive pulmonary disease and increased epicardial adipose tissue.6 Age is the only systematically proven risk factor for POAF in the literature, and findings regarding other possible pre-operative risk factors are being discussed.5 The exact pathophysiology of POAF is unclear, and there are numerous studies showing that its onset and development are associated with inflammation, oxidative stress, cardiac ischaemia and sympathetic activation.7 POAF not only increases the length of hospital stay and hospitalisation costs, but also increases the incidence of peri-operative complications, stroke and mortality, leading to a poor prognosis, but its long-term effects are not fully known.8 Therefore, it is very important to find specific biomarkers to predict, prevent and treat POAF before poor outcomes after cardiac surgery.9 Because biomarkers are dynamic, their inclusion in the management of patients with AF is highly recommended.10 Unfortunately, an accurate scoring tool has not been defined for estimating POAF.5 The search for haematological determinants of AF began in 1987, reported in a publication by Imataka et al., which showed significant impairment of plasma volume and erythrocyte biology in patients with AF.11 Various inflammatory biomarkers including white blood cell (WBC) count, leukocyte subtypes, platelets, mean platelet volume (MPV), C-reactive protein (CRP), neutrophil-tolymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been reported to be important prognostic determinants in cardiovascular disease.12 Previous studies have reported the association of mediators such as CRP, tumour necrosis factor-α (TNF-α), interleukin 2 (IL-2), IL-6, IL-8 and monocyte chemoattractant protein 1 (MCP-1) with POAF.13 Recently, AF has been associated with routine biomarkers of inflammation and oxidative stress, such as uric acid, red blood cell distribution width (RDW) and γ‐glutamyl transferase (γ-GT).14 Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey Hüseyin Şaşkın, MD, sueda_hs@yahoo.com Durmuş Alper Görür, MD
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