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In Mayo Clinic proceedings. Innovations, quality & outcomes

Objective : To develop an inflammation-based risk stratification tool for operative mortality in patients with acute type A aortic dissection.

Methods : Between January 1, 2016 and December 31, 2021, 3124 patients from Beijing Anzhen Hospital were included for derivation, 571 patients from the same hospital were included for internal validation, and 1319 patients from other 12 hospitals were included for external validation. The primary outcome was operative mortality according to the Society of Thoracic Surgeons criteria. Least absolute shrinkage and selection operator regression were used to identify clinical risk factors. A model was developed using different machine learning algorithms. The performance of the model was determined using the area under the receiver operating characteristic curve (AUC) for discrimination, calibration curves, and Brier score for calibration. The final model (5A score) was tested with respect to the existing clinical scores.

Results : Extreme gradient boosting was selected for model training (5A score) using 12 variables for prediction-the ratio of platelet to leukocyte count, creatinine level, age, hemoglobin level, prior cardiac surgery, extent of dissection extension, cerebral perfusion, aortic regurgitation, sex, pericardial effusion, shock, and coronary perfusion-which yields the highest AUC (0.873 [95% confidence interval (CI) 0.845-0.901]). The AUC of 5A score was 0.875 (95% CI 0.814-0.936), 0.845 (95% CI 0.811-0.878), and 0.852 (95% CI 0.821-0.883) in the internal, external, and total cohort, respectively, which outperformed the best existing risk score (German Registry for Acute Type A Aortic Dissection score AUC 0.709 [95% CI 0.669-0.749]).

Conclusion : The 5A score is a novel, internally and externally validated inflammation-based tool for risk stratification of patients before surgical repair, potentially advancing individualized treatment.

Trial Registration : Identifier: NCT04918108.

Liu Hong, Qian Si-Chong, Zhang Ying-Yuan, Wu Ying, Hong Liang, Yang Ji-Nong, Zhong Ji-Sheng, Wang Yu-Qi, Wu Dong Kai, Fan Guo-Liang, Chen Jun-Quan, Zhang Sheng-Qiang, Peng Xing-Xing, Shao Yong-Feng, Li Hai-Yang, Zhang Hong-Jia


5A, Additive Anti-inflammatory Action for Aortopathy & Arteriopathy, ATAAD, acute type A aortic dissection, AUC, area under the receiver operating characteristics curve, AVR, aortic valve regurgitation, CT, computed tomography, GERAADA, German Registry for Acute Type A Aortic Dissection, ICU, intensive care unit, KNN, K-nearest neighbor, LASSO, least absolute shrinkage and selection operator, NB, naïve Bayes, RF, random forest, STI, systemic thrombo-inflammatory, SVM, support vector machine, WBC, white blood cell