Impact of Lipoprotein(a) Levels on Perioperative Outcomes in Cardiac Surgery

Paul Philipp Heinisch, Maks Mihalj, Markus Huber, Joerg C Schefold, Alexander Hartmann, Michael Walter, Elisabeth Steinhagen-Thiessen, Juerg Schmidli, Frank Stüber, Lorenz Räber, Markus M Luedi, Paul Philipp Heinisch, Maks Mihalj, Markus Huber, Joerg C Schefold, Alexander Hartmann, Michael Walter, Elisabeth Steinhagen-Thiessen, Juerg Schmidli, Frank Stüber, Lorenz Räber, Markus M Luedi

Abstract

Altered lipid metabolism has been shown to be of major importance in a range of metabolic diseases, with particular importance in cardiovascular disease (CVD). As a key metabolic product, altered lipoprotein(a) (Lp(a)) levels may be associated with adverse clinical outcomes in high-risk cardiovascular patients undergoing cardiac surgery. We aimed to investigate the impact of the important metabolite Lp(a) on complications and clinical outcomes in high-risk patients. A prospective observational cohort study was performed. Data were derived from the Bern Perioperative Biobank (ClinicalTrials.gov NCT04767685), and included 192 adult patients undergoing elective cardiac surgery. Blood samples were collected at 24 h preoperatively, before induction of general anaesthesia, upon weaning from cardiopulmonary bypass (CPB), and the first morning after surgery. Clinical endpoints included stroke, myocardial infarction, and mortality within 30 days after surgery or within 1 year. Patients were grouped according to their preoperative Lp(a) levels: <30 mg/dL (n = 121; 63%) or >30 mg/dL (n = 71, 37%). The groups with increased vs. normal Lp(a) levels were comparable with regard to preoperative demographics and comorbidities. Median age was 67 years (interquartile range (IQR) 60.0, 73.0), with median body mass index (BMI) of 23.1 kg/m2 (23.7, 30.4), and the majority of patients being males (75.5%). Over the observational interval, Lp(a) levels decreased in all types of cardiac surgery after CPB (mean decline of approximately -5 mg/dL). While Lp(a) levels decreased in all patients following CPB, this observation was considerably pronounced in patients undergoing deep hypothermic circulatory arrest (DHCA) (decrease to preoperative Lp(a) levels by -35% (95% CI -68, -1.7), p = 0.039). Increased Lp(a) levels were neither associated with increased rates of perioperative stroke or major adverse events in patients undergoing cardiac surgery, nor with overall mortality in the perioperative period, or at one year after surgery. Other than for cohorts in neurology and cardiology, elevated Lp(a) might not be a risk factor for perioperative events in cardiac surgery.

Keywords: cardiac surgery; cardiopulmonary bypass; cardiovascular disease; lipoprotein(a).

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow diagram displaying the inclusion of patients. Only non-emergency patients undergoing cardiac surgery with the use of cardiopulmonary bypass (CPB) were included. The inclusion was limited by the operating hours of the institutional biobank, accepting blood samples between 8 a.m. and 4:30 p.m.
Figure 2
Figure 2
Time series of Lp(a): geometric means and their associated 95% confidence intervals are shown for all patients (in black), high-Lp(a) patients (preoperative Lp(a) ≥30 mg/dL; in red), and low-Lp(a) patients (preoperative Lp(a)

Figure 3

Bivariate associations of surgical characteristics…

Figure 3

Bivariate associations of surgical characteristics with the change in Lp(a) from preoperative to…

Figure 3
Bivariate associations of surgical characteristics with the change in Lp(a) from preoperative to postoperative values. Boxplots are shown for categorical variables (A,B), and locally estimated scatterplot smoothing (LOESS) estimates and their associated 95% confidence intervals (grey shading) are depicted for continuous variables (C–F). Each dot represents the change in Lp(a) for an individual patient.
Figure 3
Figure 3
Bivariate associations of surgical characteristics with the change in Lp(a) from preoperative to postoperative values. Boxplots are shown for categorical variables (A,B), and locally estimated scatterplot smoothing (LOESS) estimates and their associated 95% confidence intervals (grey shading) are depicted for continuous variables (C–F). Each dot represents the change in Lp(a) for an individual patient.

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