Summary
Background
Coronary artery bypass (CAB) surgery triggerssystemic inflammatory response syndrome (SIRS) via severalmechanisms. Moreover, age is directly correlated with SIRS.We evaluated the effect of age on SIRS and postoperativeoutcome after CAB surgery.
Methods
We retrospectively reviewed the records of 229 patients who had undergone CAB surgery. The patients were divided into three groups according to age: group 1, < 40 years (n = 61); group 2, 40–75 years (n = 83); and group 3, > 75 years old (n = 85). Pre- and peri-operative data were assessed in all patients. SIRS was diagnosed according to the criteria established by Boehme.
Results
The average pre-operative EuroSCORE value in group 3 was higher than in the other groups and body surface areas were significantly lower in group 3 than in the other groups (p < 0.05). The postoperative SIRS rates were 68.9% in group 1, 84.3% in group 2 and 91.8% in group 3 (group 1 vs group 3; p < 0.05). Mortality rates were not significantly different between the groups (p > 0.05). The predictive factors for SIRS were age, EuroSCORE rate, on-pump CAB surgery and intra-aortic balloon pump use.
Conclusion
Age was an important risk factor for SIRS during the postoperative period after CAB.
Keywords: systemic, inflammation, coronary, bypass
Background
Coronary artery bypass grafting (CABG) is the conventional treatment for coronary artery disease (CAD). Previously, CABG was primarily performed in patients between the ages of 60 and 75 years. However, because of increased life expectancy and the need to re-perform the procedure, CABG is now commonly performed in patients over 75 years of age.1–3 As a result of this age-related shift in CABG recipients, some postoperative outcome parameters have changed.
Systemic inflammatory response syndrome (SIRS) is an inflammatory process that can be triggered during openheart surgery. SIRS is produced by the release of several pro-inflammatory mediators and affects postoperative outcome after open-heart surgery.3,4 The recent marked increase in SIRS after CABG may be due to age-related changes in the immune system.5,6 We therefore investigated the correlation between age and SIRS after CABG.
Methods
Ethics committee approval was obtained for the study. Patient medical records were obtained from the hospital automation system and archived files.
We retrospectively evaluated 229 patients who had undergoneCABG. The patients were divided into three groups accordingto age: group 1 patients were under 40 years old (n = 61), group 2 were 40–75 years (n = 83), and group 3 were over 75 years old(n = 85).
We compared the incidence of SIRS and several clinicalparameters among the groups. SIRS was diagnosed by thecriteria used by Boehme.7 According to these criteria, theexistence of two of the following symptoms was sufficient forthe diagnosis of SIRS: fever < 36°C or > 38°C, heart rate >90 beats/min, respiratory rate > 20 breaths/min or PaCO2 < 32mmHg, leukocytes < 4 000 cells/μl or > 12 000 cells/μl or > 10%polymorphonuclear leukocytes for at least 24 hours. All patientswere cooled to 32°C during cardiopulmonary bypass (CPB).
Patients who underwent emergent CABG or simultaneous valve/vascular surgery were excluded from the study. In addition, patients given postoperative anti-inflammatory drugs were also excluded from the study.
Statistical analysis
All of the statistical tests were conducted using the Statistical Package for the Social Sciences for Windows version 22 (SPSS Inc, Chicago, IL, USA). Group comparisons of categorical data were assessed using Pearson’s chi-squared and Fisher’s exact tests and chi-squared trend analysis. Because the permanent variables did not have normal distributions (Kolmogorov–Smirnov test, p < 0.05), the Mann–Whitney U-test was used to compare the two groups, and the Kruskal–Wallis H-test (post hoc Bonferroni corrected Mann–Whitney U-test) was used to compare multiple groups. The associations between SIRS and other variables were evaluated using Spearman’s rho correlation analysis.
Results
We found no statistically significant differences among the groups regarding gender, incidence of diabetes, chronic obstructive lung disease, chronic renal failure or prior open-heart surgery (p > 0.05). Smoking rates, pre-operative haemoglobin levels, and body surface area were significantly lower in group 3 than in the other groups, and the incidence of hypertension was significantly lower in group 1 compared to the other groups (p < 0.05). The average EuroSCORE value was higher in group 3 than in the other groups (p < 0.05; Table 1).
Table 1. Demographic data.
| Parameters | Group 1(n = 61) n (%) | Group 2 (n = 83) n (%) | Group 3 (n = 85) n (%) | p-value |
| Age (years) | 36.7 | 61.3 | 77.9 | |
| Male gender | 49 (80.3) | 63 (75.9) | 55 (64.7) | 0.083 |
| Diabetes mellitus | 14 (23) | 36 (43.4) | 21 (24.7) | 0.937 |
| COPD | 1 (1.6) | 3 (3.6) | 6 (7.1) | 0.107 |
| Hypertension | 17 (27.9) | 49 (59) | 54 (63.5) | 0.000 |
| CRF | 4 (6.6) | 3 (3.6) | 1 (1.2) | 0.082 |
| Smoking | 35 (57.4) | 42 (50.6) | 24 (28.2) | 0.001 |
| Redo surgery | 0 | 0 | 2 (2.4) | 0.107 |
| EuroSCORE | 1.95 ± 2.07 | 3.69 ± 2.24 | 5.2 ± 1.7 | 0.000 |
| Pre-operative Hb | 13.02 ± 1.89 | 12.57 ± 1.71 | 11.93 ± 1.49 | 0.000 |
| BSA | 1.88 ± 0.18 | 1.77 ± 0.16 | 1.68 ± 0.16 | 0.000 |
COPD: chronic obstructive pulmonary disease, CRF: chronic renal failure, Hb: haemoglobin, BSA: body surface area.
Comparisons of off-pump bypass surgery rates, CPB time, cross-clamping time, intra-aortic balloon pump use and revision ratios revealed no statistically significant differences among the groups (p > 0.05). However, the amount of postoperative drainage and peri-operative blood transfusions were significantly hign her in group 2 than ithe other groups (p < 0.05; Table 2).
Table 2. Peri-operative data.
| Parameters | Group 1(n = 61) n (%) | Group 2(n = 83) n (%) | Group 3(n = 85) n (%) | p-value |
| Off-pump CABG | 15 (24.6) | 20 (24.1) | 19 (22.4) | 0.745 |
| CPB time (min) | 82.21 ± 49.45 | 88.05 ± 29.05 | 83.58 ± 29.76 | 0.105 |
| Cross-clamping time (min) | 45.9 ± 30.62 | 46.53 ± 19.17 | 43.72 ± 18.78 | 0.536 |
| Revision | 5 (8.2) | 8 (9.6) | 11 (12.9) | 0,343 |
| Drainage (ml) | 581 ± 294 | 480 ± 268 | 670 ± 501 | 0.004 |
| Blood transfusion (IU) | 2.25 ± 1.45 | 1.7 ± 0.95 | 3.26 ± 3.38 | 0.045 |
| IABP | 8 (13.1) | 6 (7.2) | 15 (17.6) | 0.321 |
CABG: coronary artery bypass graft, CPB: cardiopulmonary bypass, IABP: intra-aortic balloon pump.
We found no significant differences in length of intensive care unit or hospital stay, incidence of neurological complications, and mortality rates among the groups (p > 0.05). However, the incidence of SIRS was significantly higher in group 3 than in group 1 (p < 0.05; Table 3), and the weaning period was significantly shorter in group 1 than in the other groups (p < 0.05).
Table 3. Postoperative data.
| Parameters | Group 1 (n = 61) n (%) | Group 2 (n = 83) n (%) | Group 3 (n = 85) n (%) | p-value |
| Weaning period (h) | 10.67 ± 7.55 | 13.9 ± 10.01 | 14.28 ± 10.25 | 0.000 |
| ICU stay (day) | 2.92 ± 1.45 | 3.2 ± 2.69 | 3.52 ± 2.42 | 0.346 |
| Hospital stay (day) | 7.41 ± 3.96 | 8.59 ± 12.22 | 7.32 ± 3.12 | 0.736 |
| Neurological complications | 1 (1.6) | 2 (2.4) | 2 (2.4) | 0.786 |
| Mortality | 3 (4.9) | 5 (6.0) | 12 (14.1) | 0.083 |
| SIRS | 42 (68.9) | 70 (84.3) | 78 (91.8) | 0.000 |
ICU: intensive care unit, SIRS: systemic inflammatory response syndrome.
Analysis of the predictive factors for SIRS revealed a statistically significant but weak positive correlation of SIRS with age, EuroSCORE value, on-pump CABG and intra-aortic balloon pump use. By contrast, we found a statistically significant but weak negative correlation of SIRS with pre-operative haemoglobin levels and off-pump CABG (p < 0.05). No other statistically significant relationships were found between SIRS and the other variables (p > 0.05; Table 4).
Table 4. Predictive factors for SIRS following CABG.
| SIRS | ||
| Parameters | r | p-value |
| Age | 0.254 | 0.000 |
| Diabetes mellitus | 0.103 | 0.121 |
| COPD | –0.017 | 0.799 |
| Smoking | 0.028 | 0.672 |
| CRF | –0.040 | 0.544 |
| Hypertension | 0.103 | 0.119 |
| Redo surgery | –0.082 | 0.216 |
| EuroSCORE | 0.179 | 0.007 |
| Ejection fraction | –0.037 | 0.580 |
| Neurological complications | 0.068 | 0.308 |
| Hospital stay | –0.015 | 0.837 |
| Pre-operative haemoglobin level | –0.164 | 0.013 |
| Body surface area | –0.073 | 0.272 |
| Off-pump CABG | –0.186 | 0.005 |
| On-pump CABG | 0.208 | 0.002 |
| CPB period | 0.140 | 0.062 |
| Cross-clamping period | 0.138 | 0.065 |
| Intra-aortic balloon pump use | 0.138 | 0.037 |
| Drainage amount | 0.048 | 0.471 |
| Blood transfusion | 0.060 | 0.531 |
| Revision | –0.035 | 0.602 |
COPD: chronic obstructive pulmonary disease, CRF: chronic renal failure, CABG: coronary artery bypass grafting, CPB: cardiopulmonary bypass, SIRS: systemic inflammatory response syndrome.
Discussion
CPB itself may trigger systemic inflammation; however its role is controversial because inflammation may be induced by several factors other than CPB. Tissue damage, endotoxaemia and contact of blood with a non-endothelial surface during CBP are thought to trigger systemic inflammation during open-heart surgery,8,9 which may lead to SIRS.
The reported incidence of SIRS during the 24-hour postoperative period widely varies from 27 to 96%; this variability may be explained by the different diagnostic criteria, such as clinical parameters versus the measurement of pro-inflammatory mediators,7 used in the various studies. For instance, Sasse et al.10 found a SIRS incidence of 39% in paediatric patients with a history of prior cardiac surgery, whereas MacCallum et al.11 reported that the incidence of SIRS was 96.2% in an adult cardiothoracic intensive care unit. Our finding that the incidence of SIRS was 83% in all age groups is consistent with that of MacCallum et al.11
Given the wide range in age of the patients undergoing CABG, marked differences in postoperative outcomes have been observed in the different age groups. Several studies have reported widely varying results, particularly those including octogenarians. Therefore, although some studies have found a poor postoperative outcome in older compared to younger adult patients, others found that CABG was a safe procedure for octogenarian patients. For example, Sumin et al.12 assessed postoperative outcomes according to age in patients who underwent CABG. The authors found that the rates of hospital mortality and postoperative complications were significantly higher in patients older than 70 years compared to those younger than 60 years. Similarly, Wilson et al.13 reported that the rates of mortality and postoperative complications were higher in patients older than 75 years than in younger patients.
In a similar study, Arıtürk et al.14 reported that advanced age was a risk factor for 30-day mortality in patients who underwent CABG and mitral valve repair as a result of ischaemic mitral regurgitation. Moreover, an investigation of risk factors predicting neurological complications following CABG found that advanced age was a significant risk factor.15 Conversely, several investigators have reported that age had no effect on postoperative outcomes after CABG. In a study of 8 890 patients, Karimi et al.16 found that age was not a predictive factor for mortality. A meta-analysis of 12 697 older patients found that the CABG postoperative outcomes were satisfactory.17 An investigation of arterial graft use for CABG in patients older than 70 years found that CABG was safe and effective for older individuals.18
We found no significant differences in mortality or neurological complication rates among the age groups in our study. Our finding that the average EuroSCORE value was higher in older (group 3) than younger (groups 1 and 2) patients is noteworthy because high EuroSCORE values predict poor early and late postoperative outcomes.19
Aging is associated with increased inflammatory activity;20 however, the role of aging on the immune response to various stimuli is controversial. Krabbe et al.20 reviewed studies investigating the role of gene polymorphisms in inducing inflammation. Some studies found no association between age and systemic inflammatory mediators,21,22 whereas others reported a marked increase in inflammatory cytokines; in particular, interleukin-1 (IL1), IL6 and tumour necrosis factoralpha (TNF-α) levels were higher in older than in younger patients.23,24 We used clinical parameters but not markers of inflammation to evaluate the effects of age on SIRS. We found that the incidence of SIRS was significantly higher in patients older than 75 years than in those younger than 40 years. Few studies have used clinical parameters to investigate the correlation between age and SIRS in the postoperative period after CABG.
Previous investigations of predictive factors for SIRS have yielded important findings both in terms of identifying and preventing risk factors; however, it is surprising that so few studies have investigated the risk factors associated with SIRS in open-heart surgery, and of those, none have focused on CABG. A study investigating the correlation between intraoperative blood transfusion and SIRS found that intra-operative blood transfusion, low pre-operative functional capacity, liver dysfunction, chronic obstructive pulmonary disease, male gender, pre-operative steroid therapy, history of pre-operative haemodialysis and being older than 74 years were risk factors for postoperative SIRS.25,26 An investigation of SIRS in patients who had undergone transaortic valve implantation found that the predictive factors for SIRS were contrast amount, major bleeding, major vascular trauma and blood transfusion.27
A study of patients who underwent paediatric heart surgery found that predictive factors for SIRS were age, low body weight, and CBP and cross-clamping times.8 A similar study in a paediatric population found that CPB time, low body weight (< 10 kg) and right-to-left shunt were predictive factors for SIRS. Our findings that age, pre-operative haemoglobin levels, EuroSCORE value, on-pump CABG and intra-aortic balloon pump use were predictive factors for SIRS are consistent with those of previous studies. Our sample size was adequate; however, a limitation of our study is that pro-inflammatory mediators were not used to diagnose SIRS.
Conclusion
We found that age was a risk factor for SIRS in patients undergoing CABG. For this reason, it should be borne in mind that the risk of developing SIRS in elderly patients increases, and accordingly, precautionary measures must be taken. Nevertheless, larger randomised clinical studies in patients undergoing CABG are needed to clarify the relationship between age and SIRS.
Contributor Information
Gokalp Orhan, Department of Cardiovascular Surgery, Faculty of Medicine, İzmir Katip Celebi University, İzmir, Turkey.
Besir Yuksel, Email: , Department of Cardiovascular Surgery, Faculty of Medicine, İzmir Katip Celebi University, İzmir, Turkey.
Yilik Levent, Department of Cardiovascular Surgery, Faculty of Medicine, İzmir Katip Celebi University, İzmir, Turkey.
Gurbuz Ali, Department of Cardiovascular Surgery, Faculty of Medicine, İzmir Katip Celebi University, İzmir, Turkey.
Karakas Yesilkaya Nihan, Department of Cardiovascular Surgery, Ataturk Training and Research Hospital, İzmir Katip Celebi University, İzmir,Turkey.
Iner Hasan, Department of Cardiovascular Surgery, Ataturk Training and Research Hospital, İzmir Katip Celebi University, İzmir,Turkey.
Durmaz Huseyin, Department of Cardiovascular Surgery, Ataturk Training and Research Hospital, İzmir Katip Celebi University, İzmir,Turkey.
Gokkurt Yasar, Department of Cardiovascular Surgery, Ataturk Training and Research Hospital, İzmir Katip Celebi University, İzmir,Turkey.
Lafci Banu, Department of Cardiovascular Surgery, Ataturk Training and Research Hospital, İzmir Katip Celebi University, İzmir,Turkey.
Bozok Sahin, Email: sahinboz@yahoo.com, Department of Cardiovascular Surgery, Bahcesehir University, İstanbul, Turkey.
Gokalp Gamze, Department of Pediatric Emergency, İzmir Tepecik Training and Research Hospital, İzmir, Turkey.
References
- 1.Kirsch M, Guesnier L, LeBesnerais P, Hillion L, Debauchez M, Seguin J. et al. Cardiac operations in octogenarians: Perioperative risk factorsfor death and impaired autonomy. Ann Thorac Surg. 1998;66(1):60–67. doi: 10.1016/s0003-4975(98)00360-9. [DOI] [PubMed] [Google Scholar]
- 2.Fruitman DS, MacDougall CE, Ross DB. Cardiac surgery in octogenarians:Can elderly patients benefit? Quality of life after cardiac surgery. Ann Thorac Surg. 1999;68(6):2129–2135. doi: 10.1016/s0003-4975(99)00818-8. [DOI] [PubMed] [Google Scholar]
- 3.Gümüş F, Erkalp K, Kayalar N, Alagöl A. Cardiac surgery and anesthesiaapproach in an elderly patient population. Turk Gogus Kalp Dama. 2013;21(1):250–255. [Google Scholar]
- 4.Sürer S, Bolat A, Koç M, Gülbahar O, Kutsal A. Investigation of theeffects of leukocyte filtration in congenital heart surgery. Turk GogusKalp Dama. 2014;22(2):298–304. [Google Scholar]
- 5.Martin GS, Mannino DM. The effect of age on the developmentand outcome of adult sepsis. Crit Care Med. 2006;34(1):15–15. doi: 10.1097/01.ccm.0000194535.82812.ba. [DOI] [PubMed] [Google Scholar]
- 6.Walley KR. Aging and the intramyocardial inflammatory response. CritCare. 2014;18(6):638–638. doi: 10.1186/s13054-014-0638-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Boehme AK, Hays AN, Kicielinski KP, Arora K, Kapoor N, Lyerly MJ. et al. Systemic ınflammatory response syndrome and outcomes inıntracerebral hemorrhage. Neurocrit Care. 2016;25(1):133–140. doi: 10.1007/s12028-016-0255-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Soares LC, Ribas D, Spring R, Silva JM, Miyague NI. Clinical profileof systemic inflammatory response after paediatric cardiac surgery withcardiopulmonary bypass. Arq Bras Cardiols. 2010;94(1):127–133. doi: 10.1590/s0066-782x2010000100019. [DOI] [PubMed] [Google Scholar]
- 9.Laffey JG, Boylan JF, Cheng DC. The systemic inflammatory responseto cardiac surgery: Implications for the anesthesiologist. Anesthesiology. 2002;97:215–252. doi: 10.1097/00000542-200207000-00030. [DOI] [PubMed] [Google Scholar]
- 10.Sasse M, Dziuba F, Jack T, Köditz H, Kaussen T, Bertram H. et al. In-line filtration decreases systemic inflammatory response syndrome,renal and hematologic dysfunction in paediatric cardiac intensive carepatients. Pediatr Cardiol. 2015;36(6):1270–1278. doi: 10.1007/s00246-015-1157-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.MacCallum NS, Finney SJ, Gordon SE, Quinlan GJ, Evans TW. Modified criteria for the systemic inflammatory response syndromeimproves their utility following cardiac surgery. Chest. 2014;145(6):1197–1203. doi: 10.1378/chest.13-1023. [DOI] [PubMed] [Google Scholar]
- 12.Sumin AN, Gaĭfulin RA, Bezdenezhnykh NA, Ivanov SV, Barbarash OL, Barbarash LS. Factors affecting results of coronary bypass surgeryin elderly patients. Kardiologia. 2013;53(1):56–64. [PubMed] [Google Scholar]
- 13.Wilson MF, Baig MK, Ashraf H. Quality of life in octagenarians aftercoronary artery bypass grafting. Am J Cardiol. 2005;95(6):761–764. doi: 10.1016/j.amjcard.2004.11.031. [DOI] [PubMed] [Google Scholar]
- 14.Aritürk C, Ökten M, Gülllü U, Şenay Ş, Buturak A, Görmez S. et al. Mitral valve repair for ischemic mitral insufficiency: An increased earlypostoperative risk for the elderly. Turk Gogus Kalp Dama. 2015;23(2):239–244. [Google Scholar]
- 15.Coskun I, Colkesen Y, Demirturk OS, Tunel HA, Giray S, Gulcan O. Pre- and perioperative risk factors predicting neurologic outcomes aftercoronary artery bypass surgery in patients with pre-existing neurologicevents. J Stroke Cerebrovasc Dis. 2013;22(8):1340–1349. doi: 10.1016/j.jstrokecerebrovasdis.2013.01.010. [DOI] [PubMed] [Google Scholar]
- 16.Karimi A, Ahmadi H, Davoodi S, Movahedi N, Marzban M, Abbasi K. et al. Factors affecting postoperative morbidity and mortality in isolatedcoronary artery bypass graft surgery. Surg Today. 2008;38(10):890–898. doi: 10.1007/s00595-007-3733-z. [DOI] [PubMed] [Google Scholar]
- 17.Dhurandhar V, Saxena A, Parikh R, Vallely MP, Wilson MK, Butcher JK. et al. Comparison of the safety and efficacy of on-pump (ONCAB)versus off-pump (OPCAB) coronary artery bypass graft surgery in theelderly: A review of the ANZSCTS database. Heart Lung Circ. 2015;24(12):1225–1232. doi: 10.1016/j.hlc.2015.04.162. [DOI] [PubMed] [Google Scholar]
- 18.Medalion B, Mohr R, Ben-Gal Y, Nesher N, Kramer A, Eliyahu S. et al. Arterial coronary artery bypass grafting is safe and effective in elderlypatients. J Thorac Cardiovasc Surg. 2015;150(3):607–612. doi: 10.1016/j.jtcvs.2015.06.032. [DOI] [PubMed] [Google Scholar]
- 19.O’Boyle F, Mediratta N, Fabri B, Pullan M, Chalmers J, McShane J. et al. Long-term survival after coronary artery bypass surgery stratified byEuroSCORE. Eur J Cardiothorac Surg. 2012;42(1):101–106. doi: 10.1093/ejcts/ezr253. discussion 106–107. [DOI] [PubMed] [Google Scholar]
- 20.Krabbe KS, Pedersen M, Bruunsgaard H. Inflammatory mediators inthe elderly. Exp Gerontol. 2004;39(5):687–699. doi: 10.1016/j.exger.2004.01.009. [DOI] [PubMed] [Google Scholar]
- 21.Roubenoff R, Harris TB, Abad LW, Wilson PF, Dallal GE, Dinarello CA. Monocyte cytokine production in an elderly population: Effect ofage and inflammation. J Gerontol Med Sci. 1998;53(1):M20–M26. doi: 10.1093/gerona/53a.1.m20. [DOI] [PubMed] [Google Scholar]
- 22.Wang XY, Hurme M, Jylhä M, Hervonen A. Lack of associationbetween human longevity and polymorphisms of IL-1 cluster, IL-6,IL-10 and TNF-alpha genes in Finnish nonagenarians. Mech Ageing Dev. 2001;123(1):29–38. doi: 10.1016/s0047-6374(01)00338-4. [DOI] [PubMed] [Google Scholar]
- 23.Gabriel P, Cakman I, Rink L. Overproduction of monokines byleukocytes after stimulation with lipopolysaccharide in the elderly. Exp Gerontol. 2002;37(2–3):235–247. doi: 10.1016/s0531-5565(01)00189-9. [DOI] [PubMed] [Google Scholar]
- 24.Born J, Uthgenannt D, Dodt C, Nünninghoff D, Ringvolt E, Wagner T. et al. Cytokine production and lymphocyte subpopulations in agedhumans: An assessment during nocturnal sleep. Mech Ageing Dev. 1995;84(2):113–126. doi: 10.1016/0047-6374(95)01638-4. [DOI] [PubMed] [Google Scholar]
- 25.Ferraris VA, Ballert EQ, Mahan A. The relationship between intraoperativeblood transfusion and postoperative systemic inflammatoryresponse syndrome. Am J Surg. 2013;205(4):457–465. doi: 10.1016/j.amjsurg.2012.07.042. [DOI] [PubMed] [Google Scholar]
- 26.Gunes T, Bozok S, Kestelli M, Yurekli I, Ilhan G, Ozpak B. et al. α-Tocopherol and ascorbic acid in early postoperative period of cardiopulmonarybypass. J Cardiovasc Med (Hagerstown) 2012;13(11):691–699. doi: 10.2459/JCM.0b013e328356a2dc. [DOI] [PubMed] [Google Scholar]
- 27.Sinning JM, Scheer AC, Adenauer V, Ghanem A, Hammerstingl C, Schueler R. et al. Systemic inflammatory response syndrome predictsincreased mortality inpatients after transcatheter aortic valve implantation. Eur Heart J. 2012;33(12):1459–1468. doi: 10.1093/eurheartj/ehs002. [DOI] [PubMed] [Google Scholar]