A preoperative mortality risk assessment model for Standford type A acute aortic dissection

doi:10.21203/rs.3.rs-25905/v1

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Research article

A preoperative mortality risk assessment model for Standford type A acute aortic dissection

https://doi.org/10.21203/rs.3.rs-25905/v1

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published 03 Dec, 2020

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OBJECTIVES

Acute aortic dissection type A is a life-threatening disease required emergency surgery during acute phase. Different clinical manifestations: laboratory tests: and imaging features of patients with acute aortic dissection type A are the risk factors of preoperative mortality. This study aims to establish a simple and effective preoperative mortality risk assessment model for patients with acute aortic dissection type A.

METHODS

A total of 508 Chinese patients with acute aortic dissection type A who were admitted to our hospital were retrospectively included. All patients were unable to receive surgically treatment within 3 days from the onset of disease. Multivariable analysis was used to investigate predictors of preoperative mortality and to develop a prediction model.

RESULTS

Among the 508 patients: 394 patients survived (77.56%) and 114 patients died (22.44%). The following independent variables increased preoperative mortality: initial pain site: chest (OR = 7.536: P = 0.021): D-Dimmer ≥ 12000 ng/ml (OR = 2.982: P < 0.001): the average ascending diameter measured by transthoracic echocardiography ≥ 55 mm (OR = 4.226: P < 0.001): moderate or massive pericardial effusion (OR = 2.534: P = 0.040): electrocardiographic myocardial ischemia (OR = 3.355: P < 0.001): patent false lumen (OR = 2.808: P < 0.001): right common carotid artery involvement (OR = 4.415: P < 0.001): false lumen /true lumen of abdominal aorta ≥ 0.75 (OR = 2.310: P = 0.011). Our data suggest that a simple and effective preoperative death risk assessment model has been established.

CONCLUSIONS

Using a simple and effective risk assessment model can help clinicians quickly identify high-risk patients and make appropriate medical decisions.

Cardiac & Cardiovascular Systems

Cardiothoracic Surgery

type A aortic dissections

preoperative mortality

scoring model

Acute aortic dissection (AAD) is a rare life-threatening disease: and its diagnosis and treatment still remain a challenge. According to the Stanford classification: patients with AAD involving the ascending aorta are classified as having type A disease ^[1]. Acute aortic dissection type A (AADA) usually requires emergency surgery in the acute phase. Without surgery: 50% of patients die within 24 hours of onset: and the mortality rate is about 1–2% per hour ^[2]. The absence of mortality risk assessment may affect medical decision-making and resource allocation for high-risk patients and even hinder treatment: because only timely surgical management benefits the most patients in this group ^[3]. Moreover: risk stratification helps eliminate bias in high-risk patients ^[4]. By establishing a mortality risk assessment model: we can comprehensively assess the risk of surgery preoperatively and select the best treatment strategy: thereby reducing mortality and the incidence of complications.

According to current research: many preoperative risk assessment models for cardiac surgery have been developed: such as the Parsonnet model ^[5]: the European System for Cardiac Operative Risk Evaluation (Euro SCORE) ^[6]: and Euro SCORE II ^[7]. These were widely used to assess early preoperative mortality in various cardiac procedures. However: these scoring systems for patients undergoing conventional cardiac surgery were not suitable for patients with AADA ^{[8: 9]}. Although there have been some risk prediction models for aorta-related surgery established in recent years: these models cannot be widely adapted due to limited sample sizes and inappropriate selection of variables: rendering their predictive performance questionable. Besides: these models were based on patients in developed countries: and they have focused on the analysis of surgical risk in patients receiving surgical treatment ^{[3: 10–12]}. However: a comprehensive risk assessment has rarely been performed on preoperative patients or patients awaiting surgery in the emergency department. Compared with foreign literature reports: the diagnosis and treatment of aortic dissection (AD) in China have the following characteristics: diversified clinical manifestations: younger age of onset: higher mortality during hospitalization and preoperatively: and more complications in clinical treatment ^[13]. In addition: it usually takes a longer time from the onset to surgical treatment for patients with AD in developing countries such as China (2–7 days) than for those in developed countries (4.5 hours on average) ^[14]. The preoperative mortality rate of patients with AADA has not been clearly evaluated in large samples. Therefore: a preoperative mortality risk scoring system suitable for Chinese patients is urgently required to predict the risk of early death and establish emergency room guidelines in various institutions. In the present study: a simple and effective preoperative death risk assessment model has been established based on 508 patients with AADA within 3 days from the onset of the disease.

In total: 508 consecutive patients with AADA admitted to Guangdong Provincial People’s Hospital between September 2017 and November 2019 were recruited: including local newly diagnosed patients in the hospital and those who were transferred to our center from other hospitals. Patients who did not undergo acute surgical treatment within 3 days from symptom onset were included. We defined the time of onset as the time when the patient first complained of severe pain in the chest or other parts: or when patients without pain complaint underwent examination and had a diagnosis of AADA. All patients were diagnosed by transthoracic echocardiography (TTE) and computed tomography angiography (CTA). Patient data: including general conditions: past history: clinical manifestations: comorbidities: physical examination: laboratory tests: and imaging data: were collected (Tables 1 & 2 & 3). All patient data from our institution were given priority. If transferred patients were unable to undergo examination at our institution due to their critical condition: the data from other institutions would be collected.

Table 1

Demographic data: history: and presenting symptoms of patients with preoperative acute aortic dissection type A
Variable	Alive (n = 394)	Deceased (n = 114)	Total (n = 508)	P value
DeBakeyⅡ	56 (14.21)	17 (14.91)	73 (14.37)	0.851
Age: y	53.64 ± 13.21	56.18 ± 12.46	54.21 ± 13.07	0.068
Female	64 (16.24)	22 (19.30)	86 (16.93)	0.444
Initial pain site	372 (94.42)	112 (98.25)	484 (95.28)	0.002
Chest	235 (59.64)	88 (77.19)	323 (63.58)	0.065
Other areas	137 (34.77)	24 (21.05)	161 (31.69)	0.503
Hypertension	235 (59.64)	68 (59.65)	303 (59.65)	0.999
Neurological disease	31 (7.87)	9 (7.89)	40 (7.87)	0.993
Marfan syndrome	25 (6.35)	6 (5.26)	31 (6.10)	0.671
Prior cardiovascular diseases	34 (8.63)	9 (7.89)	43 (8.46)	0.804
Prior cardiovascular surgery	30 (7.61)	8 (7.02)	38 (7.48)	0.831
Smoking	130 (32.99)	37 (32.46)	167 (32.87)	0.914
Anticoagulant and antiplatelet medication within the past month	36 (9.14)	3 (2.63)	39 (7.68)	0.026
Inotropic support	25 (9.14)	40 (35.09)	65 (12.80)	< 0.001
Ventilation	9 (2.28)	12 (10.53)	21 (4.13)	< 0.001
Continuous variables are reported as mean and standard deviation: and categorical variables are reported as numbers (%).

Table 2

Laboratory data of patients with preoperative acute aortic dissection type A
Variable	Alive (n = 394)	Deceased (n = 114)	Total (n = 508)	P value
Lac in ABG ≥ 3 mmol/L	90 (22.84)	41 (35.96)	131 (25.79)	0.004
cTnT ≥ 200 pg/ml	30 (7.61)	17 (14.91)	47 (9.25)	0.009
WBC ≥ 15 × 10⁹/L	116 (29.44)	44 (38.60)	160 (31.50)	0.045
RBC < 3.5 × 10¹²/L	25 (6.35)	15 (13.16)	40 (7.87)	0.014
Hb < 90 g/L	11 (2.79)	8 (7.02)	19 (3.74)	0.032
ALT ≥ 200 U/L	14 (3.55)	18 (15.79)	32 (6.30)	< 0.001
AST ≥ 120 U/L	37 (9.39)	31 (27.19)	68 (13.39)	< 0.001
CREA ≥ 177 umol/L	47 (11.93)	28 (24.56)	75 (14.76)	< 0.001
APTT ≥ 55 sec	25 (6.35)	14 (12.28)	39 (7.68)	0.029
D-dimmer ≥ 12:000 ng/ml	152 (38.58)	73 (64.04)	225 (44.29)	< 0.001
Continuous variables are reported as mean and standard deviation: and categorical variables are reported as numbers (%).
Lac: lactic acid; ABG: arterial blood gas; cTnT: Troponin T; WBC: white blood cell; RBC: red blood cell; Hb: hemoglobin; ALT: alanine aminotransferase; AST: aspartate aminotransferase; CREA: serum creatinine; APTT: activated partial thromboplastin time

Table 3

Imaging features of patients with acute aortic dissection type A
Variable	Alive (n = 394)	Deceased (n = 114)	Total (n = 508)	P value
EF ≤ 50%	10 (2.54)	16 (14.04)	26 (5.12)	< 0.001
Average ascending aorta diameter by TTE ≥ 55 mm	38 (9.64)	25 (21.93)	63 (12.40)	< 0.001
Aortic insufficiency	256 (64.97)	92 (80.70)	348 (68.50)	0.005
Severe	48 (12.18)	17 (14.91)	65 (12.80)	0.193
Moderate	62 (15.74)	21 (18.42)	83 (16.34)	0.080
Minor	146 (37.06)	54 (47.37)	200 (39.37)	0.049
Moderate or massive pericardial effusion	24 (6.09)	18 (15.79)	42 (8.27)	0.001
Electrocardiographic myocardial ischemia	41 (10.41)	31 (27.19)	72 (14.17)	< 0.001
Sinotubular junction diameter by CTA ≥ 55 mm	13 (3.30)	14 (12.28)	27 (5.31)	< 0.001
Ascending aorta diameter by CTA ≥ 55 mm	56 (14.21)	23 (20.18)	79 (15.55)	0.123
FL/TL of the ascending aorta ≥ 0.75	80 (20.30)	40 (35.09)	120 (23.62)	0.001
FL/TL of the thoracic aorta ≥ 0.75	55 (13.96)	32 (28.07)	87 (17.13)	< 0.001
FL/TL of the abdominal aorta ≥ 0.75	31 (7.87)	19 (16.67)	50 (9.84)	0.005
Patent false lumen	149 (37.82)	75 (65.79)	224 (44.09)	< 0.001
Right common carotid artery involvement	48 (12.18)	31 (27.19)	79 (15.55)	< 0.001
Innominate artery involvement	174 (44.16)	75 (65.79)	249 (49.02)	< 0.001
Superior mesenteric artery involvement	110 (27.92)	52 (45.61)	162 (31.89)	< 0.001
Renal artery involvement	211 (53.55)	79 (69.30)	290 (57.09)	0.003
Common iliac artery involvement	189 (47.97)	73 (64.04)	262 (51.57)	0.002
Abdominal aortic aneurysm	16 (4.06)	4 (3.51)	20 (3.94)	0.787
Continuous variables are reported as mean and standard deviation: and categorical variables are reported as numbers (%).
EF: ejection fraction; TTE: transthoracic echocardiography; CTA: computed tomography angiography; FL: false lumen; TL: true lumen

Statistical Analysis

The patients included in the study were divided into the survivor and deceased groups: respectively: and the endpoint event was preoperative death. Normally: continuous variables were reported as mean and standard deviation and compared by a two-tailed t-test. Non-normally distributed continuous variables were reported as median and quartile ranges and compared using the Mann-Whitney U test. Categorical variables were reported as frequency and percentage and analyzed by χ² or Fisher’s exact test as needed. Odds ratios (OR) were presented with corresponding 95% confidence intervals (CI) and P values; P < 0.05 was considered statistically significant. By entering the variables with P < 0.05 into the logistic regression multivariate analysis: the formula was as follows: logit p = ln [p/(1-p)] = B₀X₀ + B₁X₁ + ⋯+ B_kX_k. In this formula: p denotes preoperative death: and each B value was expressed as an OR to an independent risk factor in the final model of a particular risk. The area under the receiver operating characteristic (ROC) curve was used to assess model discrimination. Calibration was evaluated using the Hosmer-Lemeshow goodness-of-fit test. Both age and sex were forced into the model. Statistical data analysis was performed using IBM SPSS Statistics for Windows: Version 25.0 (Armonk: NY: IBM Corp).

Univariate Risk Factors for Death

Among 508 patients: 114 (22.4%) patients died prior to surgery within 3 days after the onset of the disease. There were 422 male (83.07%) and 86 female (16.93%) patients: with an average age of 53.64 (± 13.21) years. A total of 323 (63.58%) patients complained of chest pain: whereas 161 (31.69%) patients complained of pain in other areas (back: abdomen: etc.). The complications included 303 cases of hypertension (59.65%): and 40 cases of neurological disease (7.87%): as well as 38 cases with prior cardiovascular surgery (7.48%) and 96 cases with a family history of cardiovascular disease (18.90%). The variables including patient’s initial pain site: and use of anticoagulant and antiplatelet medications within the past month were related to preoperative death (Table 1). Other statistically significant univariate risk factors included lactic acid in arterial blood gas (Lac in ABG) ≥ 3 mmol/L: Troponin T (cTnT) ≥ 200 pg/ml: white blood cell count (WBC) ≥ 15 × 10⁹/L: D-dimmer ≥ 12:000 ng/ml: ejection fraction (EF) ≤ 50%: moderate or massive pericardial effusion: electrocardiographic myocardial ischemia: sinotubular junction diameter by CTA ≥ 55 mm: patent false lumen: right common carotid artery involvement: etc. (Tables 2 & 3). Although the average age of death was higher than that of surviving groups: the difference was not statistically significant [(56.18 ± 12.46) years old vs. (53.64 ± 13.21) years old: P = 0.068]. In the ascending aorta diameter measured by CTA ≥ 55 mm: the survivor and deceased groups had no statistically significant difference [56 (14.21%) vs. 23 (20.18%): P = 0.123]. However: in the average ascending aorta diameter measured by TTE: there was a statistically significant difference between the diameters [38 (9.64%) vs. 25 (21.93%): P < 0.001]. Prior cardiovascular disease and prior cardiovascular surgery were variables that did not appear to be associated with an increased risk of preoperative death. Preoperative death was strongly associated with false lumen (FL)/ true lumen (TL) ≥ 75% of the ascending aorta: thoracic aorta: and abdominal aorta. Complications from AD had a significant impact on preoperative mortality.

Preoperative Prediction Model

In the multivariate logistic regression analysis: the following independent variables increased preoperative mortality: initial pain site at the chest (OR = 7.536: P = 0.021): D-dimmer ≥ 12000 ng/ml (OR = 2.982: P < 0.001): the average ascending aorta diameter measured by TTE ≥ 55 mm (OR = 4.226: P < 0.001): moderate or massive pericardial effusion (OR = 2.534: P = 0.040): electrocardiographic myocardial ischemia (OR = 3.355: P < 0.001): patent false lumen (OR = 2.808: P < 0.001): right common carotid artery involvement (OR = 4.415: P < 0.001): and FL/TL of the abdominal aorta ≥ 0.75 (OR = 2.310: P = 0.011) (Table 4). Based on the results of the multiple regression analysis: a risk scoring model was established. The preoperative death risk score formula was as follows: log p = ln [p/(1-p)]=-10.614 + 0.013 × (age) + 0.374 × (female) + 2.020 × (initial pain site: chest) + 0.973 × (initial pain site: other areas) + 1.093 × (D-dimmer ≥ 12:000 ng/ml) + 1.441 × (average ascending aorta diameter measured by TTE ≥ 55 mm) + 0.930 × (moderate or massive pericardial effusion) + 1.210 × (electrocardiographic myocardial ischemia) + 1.032 × (patent false lumen) + 1.485 × (right common carotid artery involvement) + 0.837 × (FL/TL of the thoracic aorta ≥ 0.75). The Hosmer-Lemeshow goodness of fit for the logistic regression model was not significant (χ² = 8.058: df = 8: P = 0.428). The ROC curve of the model demonstrated good prediction accuracy (95% CI: 0.788–0.870) (Fig. 1).

Table 4

Preoperative prediction model

Variable

95% CI

Coefficient & score

assigned

P value

Age

1.013

0.992–1.035

0.013

0.227

Female

1.454

0.740–2.858

0.374

0.278

Initial pain site

0.001

Chest

7.536

1.348–42.134

2.020

0.021

Other areas

2.646

0.458–15.267

0.973

0.277

D-dimmer ≥ 12:000 ng/ml

2.982

1.710–5.199

1.093

< 0.001

Average ascending aorta diameter by TTE ≥ 55 mm

4.226

2.041–8.753

1.441

< 0.001

Moderate or massive pericardial effusion

2.534

1.043–6.156

0.930

0.040

Electrocardiographic myocardial ischemia

3.355

1.740–6.470

1.210

< 0.001

Patent false lumen

2.808

1.633–4.827

1.032

< 0.001

Right common carotid artery involvement

4.415

2.221–8.778

1.485

< 0.001

FL/TL of the thoracic aorta ≥ 0.75

2.310

1.216–4.387

0.837

0.011

CI: confidence interval; OR: odds ratio; TTE: transthoracic echocardiography

AADA is an urgent surgical disease: and its different clinical manifestations and timely surgical treatment determine the clinical results. In the present study: we identified the clinical manifestations: laboratory tests: and imaging features that were significantly associated with AADA preoperative deaths. We provided a simple and quick bedside scoring model: by which surgeons can quickly perform preoperative risk assessments: reasonably arrange the operation: and establish fast channels to more effectively treat patients with AADA: especially in those deemed to be at high risk for preoperative death. For patients with poor prognosis: model predictions are not necessarily used to deny aggressive treatment.

In agreement with the general cardiac surgery findings ^{[15: 16]}: in this study: ALT ≥ 200 U/L and AST ≥ 120 U/L were associated with preoperative death (P < 0.001). However: serum albumin level: a widely used evaluation indicator of liver dysfunction: was not measured in most patients in the present study and therefore was not included in the variables.

D-dimmer: a specific end product of fibrin hydrolysis: increases with the activation of the fibrinolytic system. Thus: the level of D-dimmer indicates whether the body is in a hypercoagulable state or when acute thrombosis is formed. AD is caused by aortic intimal rupture: in which blood forms hematoma through intimal incision. The damaged arterial wall activates the exogenous coagulation system: and pseudocavity thrombosis activates the endogenous coagulation cascade reaction: which in turn activates the fibrinolytic system and results in elevated levels of plasma D-dimmer. The time from the onset of symptoms to the consultation could affect the plasma D-dimmer concentration in patients with AD ^[17]: and its increase also showed a strong correlation with hospital mortality in patients with AAD ^[18]. The OR of this variable in the model also supports this finding (OR = 2.982: P < 0.001).

The model included variables with electrocardiographic myocardial ischemia. Electrocardiography is very important for the early differential diagnosis of patients with acute severe chest pain due to its simplicity and convenience. AD and coronary heart disease (CHD) are both high-risk cardiovascular diseases: and the case of acute myocardial ischemia (AMI) combined with AD is a clinically rare critical illness: with a reported incidence of only 1–5% ^{[19: 20]}. It is generally believed that AD can cause AMI. The mechanism is that the intima of the AD can extend to the coronary openings: or the false lumen compresses the coronary artery: resulting in acute myocardial ischemia and hypoxia leading to AMI ^{[21: 22]}. The variable CHD was not included in this study: because only a small proportion of patients were diagnosed using coronary angiography or other objective methods; also: the definition of CHD and its application in retrospectively collected data may also affect the results in terms of prevalence. In addition: in this study: cTnT ≥ 200 pg/ml was associated with preoperative death (P = 0.009). Considering that most patients with angina pectoris had more severe vascular disease: coronary artery stenosis and thrombosis caused greater myocardial and vascular damage: which increased the cTnT.

In the present study: the FL/TL of the ascending aorta: the thoracic aorta: and the abdominal aorta were all ≥ 0.75 and statistically significant in the univariate analysis; however: only the FL/TL of the thoracic aorta ≥ 0.75 was selected among the results of the logistic regression multivariate analysis. Vessel malperfusion could lead to severe complications ^[12]. The ascending aorta connects the three branches of the aortic arch upward and connects the aortic root downward; the abdominal aorta consists of important abdominal blood vessels: but only the thoracic aorta has none. This was an interesting finding. According to current research: wall shear stress was used to evaluate each section of the aorta: and it was found that the aortic arch was in the position prone to rupture ^{[23: 24]}. We speculated that thoracic aorta malperfusion might be the high-risk factor associated with rupture. Further study is needed to support this finding.

In support of the results of Pape’s study: an ascending aorta diameter ≥ 55 mm measured by CTA was not statistically significant ^[25]: but in the present study: an average ascending aorta diameter ≥ 55 mm measured by TTE increased the preoperative mortality. This may be related to the differences in the measurement methods of the ascending aorta diameter between TTE and CTA. In addition: it is difficult to measure the diameter of the aorta prior to the development of AD: and further research is needed to explore the connection between the diameter of the aorta and the pathogenesis of AD.

In this study: age was not a predictive factor: which was different from the findings of previous studies ^{[11: 26–27]}. The age of the patients ranged from 9 to 91 years old: and only three patients were younger than 20 years old; thus: the model prediction results for those with younger age might not be accurate. This might be related to the longer average time for patients with AADA to undergo surgical treatment in China ^[14]. In China: due to the uneven distribution of medical resources: many regional hospitals cannot carry out surgical treatment of AD by themselves; therefore: they can only refer to higher-level hospitals or request experts in higher-level hospitals for assistance in consultation and surgical treatment. Thus: the vast majority of patients with AADA admitted in our hospital were transferred from other hospitals. These patients had undergone a preliminary examination at the regional hospital since the onset of the disease and were considered to be diagnosed with AD: and then they were referred to our hospital for treatment: awaiting the completion of relevant examinations and preparations prior to surgery. This process took an average of about 3 days: which was why we set the entry criteria for being unable to undergo surgical treatment within 3 days from the onset of disease. According to reports: the mortality rate of patients with AADA who did not undergo surgical treatment had increased dramatically over time: with an hourly mortality rate of 1% and a 90-day expected mortality rate of 70–90% ^{[10: 28]}.

Ventilation: inotropic support: cardiopulmonary resuscitation: and preoperative syncope are related to in-hospital death ^[11]. However: the number of patients who had undergone these management methods in this study was small and does not qualify for inclusion as a variable in the model. Since most patients were referrals from other hospitals: some patients who received support due to their critical condition might not be able to transfer. This may explain why the number of patients was relatively small.

Limitations

This study is a single-center retrospective study: which is subject to selection bias. We used an endpoint time of preoperative death within 3 days: which was the sole outcome. However: it should not lessen the importance of other outcome variables such as nonfatal adverse events: complications: patient functional status: etc. Further study is required to analyze these outcomes.

In the present study: we analyzed the individual risk factors for preoperative mortality in patients with AADA and established a simple and effective risk assessment method to help clinicians quickly identify high-risk patients and make appropriate medical decisions. It would be essential for the prospective data to be verified in future multicenter studies.

AAD: Acute aortic dissection; AADA: Acute aortic dissection type A; Euro SCORE: European System for Cardiac Operative Risk Evaluation; AD: Aortic dissection; TTE: Transthoracic echocardiography; CTA: Computed tomography angiography; Lac: lactic acid; ABG: arterial blood gas; cTnT: Troponin T; WBC: white blood cell; RBC: red blood cell; Hb: hemoglobin; ALT: alanine aminotransferase; AST: aspartate aminotransferase; CREA: serum creatinine; APTT: activated partial thromboplastin time; EF: ejection fraction; FL: false lumen; TL: true lumen; OR: Odds ratios; CI: confidence intervals; ROC: receiver operating characteristic; CHD: coronary heart disease; AMI: acute myocardial ischemia

Acknowledgements

Not applicable.

Funding statement

Supported by National Key Research and Development Program of China (2017YFC1308003). All the authors have nothing to disclose.

Availability of data and materials

All data are freely available for scientific purpose. The data can be found

from authors.

Authors’ contributions

KJT and YJ, contributions to conceptualization and design, or acquisition of data, or analysis and interpretation of data, involved in drafting, reviewing and editing the manuscript; WQJ, contributions to acquisition of data, involved in reviewing and editing the manuscript; LY and YCJ, analysis and interpretation of data, involved in reviewing and editing the manuscript; FRX, revising it critically for important intellectual content. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This retrospective study was approved by the ethics committee of Guangdong Provincial People’s Hospital: Guangdong Academy of Medical Sciences: Guangzhou: China (No.GDREC2018322H(R2)).

Consent for publication

Not applicable.

Conflict of Interest

None declare.

Arthur Information（e-mail）:

Juntao Kuang: [email protected];

Jue Yang: [email protected];

Qiuji Wang: [email protected];

Changjiang Yu: [email protected];

Ying Li: [email protected];

Ruixin Fan: [email protected]

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published 03 Dec, 2020

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Editorial decision: Major revision
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A preoperative mortality risk assessment model for Standford type A acute aortic dissection

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Journal Publication

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Abstract

OBJECTIVES

METHODS

RESULTS

CONCLUSIONS

Figures

Introduction

Patients And Methods

Statistical Analysis

Results

Univariate Risk Factors for Death

Preoperative Prediction Model

Discussion

Limitations

Conclusions

Abbreviations

Declarations

References

Status:

Journal Publication

Version 1