Prediction Of Early Postoperative Death Risk In Patients With Acute Type A Aortic Dissection Based On Preoperative MELD Score

Objective:Preoperative model of end-stage liver disease(MELD)score was used to explore the relationship between preoperative hepatic insufficiency and the early outcome after total aortic arch replacement and descending aorta stent elephant trunk artificial vessel implantation(Sun’s procedure)in patients with acute Stanford type A aortic dissection(AAAD).To explore the risk factors of early postoperative death in these patients,and use preoperative MELD score combined with other risk factors to predict early postoperative death in AAAD patients with Sun’s procedure.Methods:The clinical data of patients who underwent Sun’s procedure for AAAD at Department of Cardiovascular Surgery,Qilu Hospital of Shandong University during December 2017 to December 2021 were retrospectively analyzed.According to the preoperative MELD value,the patients were divided into two groups:normal liver function group(MELD<10)and liver dysfunction group(MELD≥10).The perioperative clinical data of the two groups were compared.The primary outcome variable was early postoperative death,and the secondary outcome was early postoperative major adverse clinical events(MACE).The risk factors of early postoperative death were analyzed by univariate analysis,and the related risk factors were included in the multivariate Logistic regression to construct a new prediction model and Bootstrap resampling method was repeated 1000 times for internal verification.The predictive efficiency of the model was evaluated by calculating the area under the curve(AUC)of the receiver operating curve(ROC).The postoperative ICU stay time and postoperative ventilator-assisted ventilation time of patients with liver dysfunction group were significantly longer than those of patients with normal liver function group(P<0.05).Results:A total of 297 patients were included in the final study,and there was no significant differences between the two groups in age,gender,smoking history,alcoholism history and past chronic disease history(P>0.05).The preoperative levels of alanine aminotransferase,aspartate aminotransferase,serum creatinine,serum urea nitrogen,cystatin C,total bilirubin and international standardized ratio in the high MELD group were significantly higher than those in the low MELD group(P<0.001).There were no significant differences in operation time,extracorporeal circulation time,aortic occlusion time,lower body stop circulation time,root treatment and other cardiac operations between the two groups(P>0.05).The postoperative ICU stay time and postoperative ventilator-assisted ventilation time of patients with liver dysfunction group were significantly longer than those of patients with normal liver function group(P<0.05).A total of 52(17.5%)patients died within 30 days after surgery,including 19(9.5%)in the normal liver function group and 33(33.7%)in the hepatic insufficiency group and the mortality in the liver insufficiency group was significantly higher than that in the normal liver function group(P<0.001).A total of 198 patients(66.7%)had MACE within 30 days after operation,including 122(61.3%)in the normal liver function group and 76(77.6%)in the liver dysfunction group.The incidence of MACE in the liver dysfunction group was also significantly higher than that in the normal liver function group(P=0.005).Multivariate Logistic regression analysis showed that preoperative MELD score≥10(odds ratio OR:2.767;95%confidence interval CI:1.198-6.392;P=0.017),preoperative cystatin C(OR:2.025;95%CI:1.072-3.827;P=0.030)and cardiopulmonary bypass time(OR:1.008;95%CI:1.002-1.013,P=0.004)were independent risk factors for early postoperative mortality.Preoperative MELD score alone was used to predict early postoperative mortality and the ROC curve was drawn,and the AUC was 0.649(95%CI:0.564-0.734).The sensitivity was 55.4%,the specificity was 73.0%,and the cut-off value was 10.01.The predictive model was established based on preoperative MELD score combined with preoperative cystatin C and presented in a line graph.The correction graph showed better results after internal verification.The ROC curve was drawn,and the AUC was calculated to be 0.727(95%CI:0.634-0.819),sensitivity was 60.5%,and specificity was 84.1%.Conclusions:Liver dysfunction defined as preoperative MELD≥10 is significantly associated with early postoperative mortality,complication rate,ICU stay time and ventilator assisted ventilation time in AAAD patients undergoing Sun’s procedure.The optimized prediction model based on preoperative MELD score combined with preoperative cystatin C and cardiopulmonary bypass time has a good predictive efficacy in predicting the risk of early death after Sun’s procedure in AAAD patients.