title: Systemic inflammatory response syndrome after transcatheter or surgical aortic valve replacement.
abstract: OBJECTIVE
  An inflammatory response after cardiac surgery is associated with worse clinical outcomes, but recent trials to attenuate it have been neutral. We evaluated the association between systemic inflammatory response syndrome (SIRS) and mortality after transcatheter (TAVR) and surgical aortic valve replacement (SAVR) for aortic stenosis (AS) and evaluated whether diabetes influenced this relationship.
  
  
  METHODS
  Patients (n=747) with severe AS treated with TAVR (n=264) or SAVR (n=483) between January 2008 and December 2013 were included and 37% had diabetes mellitus. SIRS was defined by four criteria 12-48 h after aortic valve replacement (AVR): (1) white blood cell count <4 or >12; (2) heart rate >90; (3) temperature <36 or >38°C; or (4) respiratory rate >20. Severe SIRS was defined as meeting all four criteria. The primary endpoint was 6-month all-cause mortality (60 deaths occurred by 6 months). Inverse probability weighting (IPW) was performed on 44 baseline and procedural variables to minimise confounding.
  
  
  RESULTS
  Severe SIRS developed in 6% of TAVR patients and 11% of SAVR patients (p=0.02). Six-month mortality tended to be higher in those with severe SIRS (15.5%) versus those without (7.4%) (p=0.07). After adjustment, severe SIRS was associated with higher 6-month mortality (IPW adjusted HR 2.77, 95% CI 2.04 to 3.76, p<0.001). Moreover, severe SIRS was more strongly associated with increased mortality in diabetic (IPW adjusted HR 4.12, 95% CI 2.69 to 6.31, p<0.001) than non-diabetic patients (IPW adjusted HR 1.74, 95% CI 1.10 to 2.73, p=0.02) (interaction p=0.007). The adverse effect of severe SIRS on mortality was similar after TAVR and SAVR.
  
  
  CONCLUSIONS
  Severe SIRS was associated with a higher mortality after SAVR or TAVR. It occurred more commonly after SAVR and had a greater effect on mortality in diabetic patients. These findings may have implications for treatment decisions in patients with AS, may help explain differences in outcomes between different AVR approaches and identify diabetic patients as a high-risk subgroup to target in clinical trials with therapies to attenuate SIRS.
authors.affiliation: Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Brian R
authors.identifier: http://orcid.org/0000-0002-6879-5343
authors.initials: BR
authors.lastname: Lindman
authors.affiliation: Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Jacob S
authors.initials: JS
authors.lastname: Goldstein
authors.affiliation: Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Nassif
authors.affiliation: Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Alan
authors.initials: A
authors.lastname: Zajarias
authors.affiliation: Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Novak
authors.affiliation: Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Anjan
authors.initials: A
authors.lastname: Tibrewala
authors.affiliation: Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Anna M
authors.initials: AM
authors.lastname: Vatterott
authors.affiliation: Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Cassandra
authors.initials: C
authors.lastname: Lawler
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Ralph J
authors.initials: RJ
authors.lastname: Damiano
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Marc R
authors.initials: MR
authors.lastname: Moon
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Lawton
authors.affiliation: Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Lasala
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Hersh S
authors.initials: HS
authors.lastname: Maniar
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000601:surgery*; D003925:Diabetic Angiopathies / Q000150:complications; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D015994:Incidence; D008297:Male; D012189:Retrospective Studies; D018746:Systemic Inflammatory Response Syndrome / Q000453:epidemiology / Q000209:etiology*; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects