Impact of Preoperative Inflammatory Indices and Postoperative Pneumonia on Postoperative Atrial Fibrillation in Patients with Non-Small Cell Lung Cancer: A Retrospective Study

doi:10.21203/rs.3.rs-3892525/v1

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Impact of Preoperative Inflammatory Indices and Postoperative Pneumonia on Postoperative Atrial Fibrillation in Patients with Non-Small Cell Lung Cancer: A Retrospective Study

https://doi.org/10.21203/rs.3.rs-3892525/v1

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published 22 Jul, 2024

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Background: This study aimed to evaluate the impact of preoperative inflammatory indices and postoperative pneumonia (POP) on postoperative atrial fibrillation (POAF) in non–small cell lung cancer (NSCLC) patients.

Methods: All consecutive patients who underwent pulmonary resection at our hospital (January 2016-October 2019) were enrolled. Preoperative inflammatory indices, demographic data, surgical details, and postoperative conditions were analyzed. Univariate and multivariate analyses of risk factors associated with POAF were also conducted.

Results: Among the 382 patients included in the study, 32 (8.38%) developed POAF. Approximately 31 patients (96.9%) developed atrial fibrillation within three days after surgery. The POAF group had a significantly greater mean age (68 years) than did the non-POAF group (62 years) (P=0.002). Additionally, compared with non-POAF patients, POAF patients exhibited an increased number of mediastinal lymph nodes (P<0.001) and mediastinal lymph node stations (P<0.001). The POAF group also had a greater intraoperative blood volume (P=0.006), longer surgical duration (P=0.022), greater incidence of POP (P=0.09), and greater drainage volume (P=0.003). TNM stage (P<0.001) and type of lung resection (P=0.049) were also associated with POAF. Compared to those in the non-POAF group, the POAF group had longer postoperative hospital stays (10.54 days vs. 9 days; P=0.001) and longer drainage times (7 days vs. 5 days; P=0.004). Multivariate analysis revealed age, POP grade, and TNM stage as independent predictors of POAF in NSCLC patients.

Conclusion: Preoperative inflammatory indices were not significantly associated with POAF, but age, POP, and TNM stage were identified as independent predictors. Early-stage NSCLC patients may have a greater susceptibility to POAF than early-stage patients, although further validation is needed. Additionally, POAF was linked to a longer postoperative hospital stay.

Non-Small Cell Lung Cancer

Pulmonary Surgery

Postoperative Atrial Fibrillation

Preoperative Inflammatory Indices

Postoperative Pneumonia.

Postoperative atrial fibrillation (POAF) is a common cardiac complication after lung cancer surgery, the reported incidence of which ranges from 3.5–8.6%^[1–4]. It can result in life-threatening events such as cardiopulmonary complications, including heart failure, pulmonary embolism, stroke, and fatality, leading to prolonged hospitalization, heightened mortality, and unfavorable prognosis^[5]. Therefore, investigating the risk factors for POAF following lung cancer surgery is crucial.

Previous studies have linked the occurrence of POAF after lung surgery to factors such as age, type of lung resection, sex, clinical stage, history of coronary artery disease, and lymph node dissection^[1–7]. However, the relationships between POAF development and preoperative and intraoperative risk factors have not yet been firmly established. Moreover, there is limited research on the impact of preoperative inflammatory indices and postoperative pneumonia (POP) on POAF. Therefore, it is important to re-evaluate the risk factors for POAF in recent lung cancer surgeries. The purpose of this study was to characterize the influence of preoperative inflammatory indices, mediastinal lymph node status, and POP on the development of POAF in patients with non-small cell lung cancer (NSCLC).

This retrospective cohort study primarily analyzed patients who underwent pulmonary resection at our hospital from January 2016 to October 2019. All pulmonary resections were performed by the same thoracic surgical team throughout the study. The inclusion criteria for patients were as follows: (1) had pulmonary resection and (2) had a postoperative pathological diagnosis of NSCLC. Exclusion criteria included: (1) repeat surgery; (2) benign pathology; (3) nonprimary lung tumors; (4) antibiotics or hormone therapy; (5) preoperative radiotherapy, chemotherapy, immunotherapy, targeted therapy, or other treatments; (6) consecutive surgeries within one month; (7) transfer to another hospital; (8) history of atrial fibrillation; (9) stage IV or palliative surgery. Blood samples were collected from all patients before surgery for inflammatory index evaluation.

All patients were restaged according to the eighth edition of the tumor, node, and metastasis (TNM) classification of lung cancer established by the International Association for the Study of Lung Cancer (IASLC)^[8].

The study was approved by the Ethics Committee of The First People’s Hospital of Jiande. Due to the retrospective nature of the data used in this study and because the patient's name was not available, there was no issue infringing on patient privacy; therefore, the study was exempted from the Ethics Committee.

Data collection

Demographics, clinicopathologic features and operative details of the patients, including sex, age, BMI, smoking history, medical history (hypertension, diabetes, coronary heart disease, emphysema, chronic obstructive pulmonary disease), surgical approach, TNM stage, resection sites and type of lung resection, electrocardiogram, 24-hour Holter monitoring, number of mediastinal lymph nodes retrieved and nodal stations explored, surgical duration, intraoperative bleeding volume, drainage time and volume, postoperative hospital stay, POP, pathological types and TNM stages, were retrospectively collected.

The preoperative inflammatory indices evaluated in this study included the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and systemic immune inflammation index (SII), calculated as follows: SII = platelet * neutrophil/lymphocyte. These indices were used to assess the patients' preoperative systemic inflammatory status.

Electrocardiographic (ECG) monitoring

All patients were obligated to undergo ECG monitoring for 24 to 72 hours after surgery. In the case of arrhythmias or if patients experience symptoms such as palpitations or chest tightness, bedside electrocardiography will be performed to confirm the diagnosis.

Definition of POAF

POAF was defined as the occurrence of new-onset atrial fibrillation confirmed by an ECG at least once between the thoracic procedure and discharge from the hospital^[9]. The diagnosis of POAF is based on an ECG assessment.

Definition of POP

A diagnosis of POP met at least three of the following criteria:

(1) Chest plain film or chest CT showing lung exudation and consolidation;

(2) Temperature > 38°C;

(3) WBC > 10000/mm³ or < 3000/mm³;

(4) Pathogens were detected in sputum, or purulent secretions were detected via bronchoscopy.

Statistical analysis

The data are presented as the mean and standard deviation or median (P25, P75). Student’s t test was used for normally distributed data, while the Wilcoxon rank-sum test was used for nonnormally distributed data. The frequency (%) was calculated for categorical data and was analyzed using the chi-square test or Fisher's exact probability method. Univariate and multivariate analyses were performed using the binary logistic regression model. Variables with P < 0.1 in the single factor analysis were included in the multiple factor analysis, and P < 0.05 was considered to indicate statistical significance. IBM SPSS Statistics Version 26 software (SPSS, Chicago, IL, USA) was used for all the data analyses.

Demographic and baseline characteristics

Between January 2016 and October 2019, approximately 585 pulmonary resections were performed at our hospital. After excluding 203 patients, 382 patients remained for analysis (Figure 1). A total of 199 females and 183 males were included. The median age was 65 years (range: 57-70), and the median body mass index (BMI) was 22.7 kg/m² (range: 20.9-24.9). The average preoperative inflammatory markers were as follows: pSII, 431.76 (range: 292.73-623.18); PLR, 128.71 (range: 97.27-172.78); NLR, 2.57 (range: 1.84-3.46); and LMR, 4 (range: 3-5.21). The median surgical duration was 138 minutes (range: 99-180), and the average intraoperative bleeding volume was 100 ml (range: 50-100). Among the patients, 316 had adenocarcinoma, 47 had squamous cell carcinoma, and 19 had other rare NSCLC subtypes. Postoperative TNM stages were as follows: IA1 (31.9%), ⅠA2 (35.9%), ⅠA3 (16.2%), ⅠB (4.2%), ⅡA (1.0%), ⅡB (4.2%), ⅢA (5.3%), and ⅢB (1.2%). Pulmonary resections included pneumonectomy (1.3%), wedge resection (17.8%), segmental resection (18.1%), and lobectomy (62.8%). The median mediastinal lymph node and node station counts were 5 (range: 0-10) and 2 (range: 0-3), respectively. The median drainage time and postoperative hospital stay were 5 days (range: 3.2-9) and 9.4 days (range: 6.4-12.4), respectively. POP was the most common postoperative complication and affected approximately 66 patients. The detailed data are available in Table 1.

POAF outcome

Among the 382 NSCLC patients, 32 (8.4%) developed POAF. No in-hospital POAF-related deaths occurred. POAF symptoms developed within a median of 1 day (range: 1-3) postsurgery and lasted approximately 1 day on average. Approximately 65.6% of the POAF patients exhibited symptoms on the first postoperative day. Symptoms improved with treatment, and 90.6% of the patients returned to a normal rhythm. At discharge, 3 patients still had POAF and were prescribed anticoagulants. Among these patients, 3 reported palpitations and chest discomfort, while the others were asymptomatic. Blood flow dynamics were normal across all patients.

Comparison of clinical data between the POAF and non-POAF groups

The study revealed differences in factors between the POAF and non-POAF groups. The average age was greater in the POAF group than in the non-POAF group (68.94±7.808 years vs. 63.00±10.435 years, P = 0.002). More mediastinal lymph nodes and stations were retrieved in the POAF group [median nodes: 9.5 (5.5, 14) vs. 4 (0, 9), P<0.001; average node stations: (3.28±2.004) vs. (1.94±1.766), P<0.001]. Furthermore, the duration of surgery (P=0.022), intraoperative bleeding volume (P=0.006), postoperative hospital stay (P= 0.001), drainage volume (P=0.003), and drainage time (P=0.004) were significantly greater in patients with POAF than in patients without POAF. Additionally, TNM stage (P<0.001) and the type of lung resection (P=0.049) differed between the two groups.

However, there were no differences in preoperative inflammatory factor levels, such as the pSII, PLR, NLR, or LMR, between the two groups. Similarly, comorbidities such as hypertension, diabetes, coronary heart disease, chronic obstructive pulmonary disease, and emphysema had minimal impacts on POAF, and these two conditions were not significantly different between the groups. Smoking status and BMI were also not significantly different (P>0.05). Other factors, including sex, pathological type, type of lung resection, surgical approach, left atrial size, ejection fraction, antibiotics, and preoperative and postoperative ALB concentrations, also did not exhibit substantial variation (P>0.05). The detailed results are available in Table 2 and Table 3.

Risk factor analysis for POAF

We conducted univariate and multivariate logistic regression analyses of the clinical data. Univariate analysis revealed significant differences (P<0.1) in age, TNM stage, mediastinal lymph node stations and nodes, surgery duration, drainage volume and time, postoperative hospitalization, type of lung resection, and POP. Importantly, multivariate logistic regression analysis (P<0.1) revealed that age (OR=0.938, 95% CI=0.889–0.99, p=0.021), TNM stage (OR=0.747, 95% CI=0.602–0.928, p=0.008), and POP (OR=2.627, 95% CI=1.038–6.649, p=0.042) were found to be independent predictors of POAF in patients with NSCLC (Tables 4 and 5).

Despite ongoing efforts to reduce POAF, it remains a significant complication after pulmonary resection. Our study revealed an 8.4% incidence of NSCLC, supporting the prevalence of POAF^[1–4]. While research on POAF has decreased in recent years, this topic remains important. By analyzing preoperative inflammatory markers, POP incidence, and other risk factors, we found that POP incidence, age, and TNM stage were significant factors affecting POAF. These findings validate the findings of previous research and provide guidance for prevention and treatment.

Previous studies have suggested that local inflammation is a risk factor for POAF^[9–11]. Earlier research has linked the occurrence of POAF to interleukin-2, interleukin-6, and C-reactive protein^[11–13]. Boons et al.^[10] reported associations between prolonged ventilation and pneumonia combined with POAF in cardiothoracic surgery patients. Preventive measures such as low-flow oxygen inhalation may reduce the incidence of POAF, although this remains controversial^[14]. In our study, POP accounted for the highest proportion of complications, approximately 55.5% (66/119). Additionally, a greater proportion of POP was observed in the POAF group than in the non-POAF group (28.1% vs. 16.3%, p = 0.09), indicating a correlation between POP and POAF occurrence. Through multivariate analysis, we obtained preliminary evidence that POP is indeed an independent risk factor for POAF (P = 0.042).

On the other hand, preoperative inflammatory markers, such as white blood cell count, are widely recognized as predictive factors for POAF^[15–16]. However, related research on the impact of preoperative inflammatory indices on the development of POAF following lung cancer surgery is rare. In this study, the main preoperative inflammatory indices used were the pSII, PLR, NLR, and LMR. To some extent, they represent the preoperative inflammatory level in patients. Additionally, there is evidence that these indices can predict the occurrence of POP^[17]. Although this study revealed no impact of inflammatory indices on POAF, further research is needed to determine whether these indices can predict the occurrence of POP, which in turn may affect the development of POAF.

Age has consistently emerged as the most significant factor influencing POAF incidence, with its incidence increasing with age. In 2002, Amar's study emphasized that the incidence of POAF increases with age in patients aged > 60 years who underwent thoracic surgery, identifying this age group as a risk factor^[18]. In our study, the average age of patients in the POAF group (68 years) was significantly greater than that of patients in the non-POAF group (63 years) (p < 0.002). The results of the multivariate analysis further corroborated the impact of age on POAF, which was consistent with the findings of previous research^{[1, 5, 7, 18]}.

In 2014, a study conducted by Jelena Ivanovic et al.^[19] revealed that out of 274 patients, 43 had atrial fibrillation. Based on the 2009 AJCC 7th edition staging system, patients were categorized into stages IA/IB, IIA/IIB, IIIA/IIIB, and IV. The results revealed a statistically significant difference between the two groups (p = 0.05). Additionally, there was a significant difference among the patients in the stage IV subgroup (P < 0.05). In 2010, Onaitis et al.^[20] conducted a study utilizing the Thoracic Surgeons General Thoracic Surgery Database, focusing on patients with lung cancer who underwent lobectomy or pneumonectomy. Patients were categorized based on TNM staging into those with pathological stages less than stage II and those with pathological stages greater than stage II. Multivariate analysis indicated that patients with higher-stage or larger tumors were more prone to developing POAF. Thus, TNM staging is indeed related to POAF. In our study, we also found a relationship between TNM stage and POAF (P < 0.001). Multivariate analysis revealed that TNM staging is an independent risk factor for POAF. However, it is quite peculiar that early-stage lung cancer patients were more prone to developing POAF than advanced-stage patients were among those with stages I to III. Upon analyzing the data, we believe that this discrepancy may be attributed to selection bias, as stage I patients accounted for 88.2% of the sample. Therefore, the data distribution in our study is inconsistent. Nevertheless, we can conclude that TNM staging does have an impact on POAF. However, further research is needed to understand the specific circumstances involved.

Research has suggested that the volume of the resected lung may affect POAF. One study^[3] revealed that the incidence of POAF was lower in patients who underwent segmental resection (1.4%) than in those who underwent lobectomy resection (2.8%). Furthermore, early studies^{[2, 21]} identified pulmonary resection surgery as an independent risk factor for POAF. Several studies have proposed a potential association between tissue loss during pulmonary resection, postoperative reduction in lung function, myocardial hypoxia, and POAF^{[4, 7]}. In our study, the results revealed a statistically significant difference between the POAF and non-POAF groups (P = 0.049). However, multivariate analysis revealed that the type of lung resection was not an independent risk factor for POAF. Interestingly, no patients in the POAF group underwent pneumonectomy. Only 5 (1.3%) of the included patients underwent left-sided pneumonectomy. However, pneumonectomy has been reported as a risk factor for POAF^[19]. Therefore, the type of lung resection may impact the occurrence of POAF, but the limited number of patients who underwent pneumonectomy restricts this comparison.

Mediastinal lymph node dissection may cause direct damage to the cardiac nerve plexus at the aortic arch and tracheal bifurcation, thereby affecting the incidence of POAF. Some experts^{[1, 2, 22]} have hypothesized that mediastinal lymph node dissection could trigger atrial fibrillation, increasing the risk of POAF. However, a study^[23] argued that there is no significant association between them.

We separately analyzed the number of mediastinal lymph nodes and the number of lymph node stations explored. The POAF group had a significantly greater median number of mediastinal lymph nodes (9 vs 4) and average number of detected lymph node stations (3 vs 2) than did the non-POAF group (P < 0.05). However, multivariate analysis demonstrated that the impact of the number of lymph nodes and the number of explored lymph node stations on POAF was minimal. Therefore, further research is still needed to investigate whether omitting mediastinal lymph node dissection reduces the occurrence of POAF.

Both the type of lung resection and mediastinal lymph node dissection can influence the duration of surgery. Previous research has indicated an increased incidence of POAF when the surgical duration exceeds 180 minutes^[24]. In our study, the average surgical durations for the POAF and non-POAF groups were approximately 166 minutes and 141 minutes, respectively. Although there was a statistically significant difference between the two groups (p = 0.022), multivariate analysis showed that it had no impact on POAF. This finding is consistent with the aforementioned research since the average surgical duration in both groups did not exceed 180 minutes. Therefore, we still recommend attempting to maintain the surgical duration within 180 minutes whenever possible.

Previous studies have consistently reported a correlation between POAF and prolonged postoperative hospital stay^[2]. Our research revealed that patients who developed POAF had a median postoperative hospital stay of approximately 11 days, whereas patients who did not develop POAF had a median hospital stay of 9 days (p = 0.001). Additionally, the drainage time in the POAF group was significantly prolonged, and the drainage volume was greater. Univariate analysis also demonstrated correlations between postoperative hospital stay (P = 0.001), drainage time (P < 0.001), drainage volume (P < 0.001), and POAF. Although multivariate analysis did not reveal drainage time or volume to be independent risk factors for POAF, prolonged drainage time and increased drainage volume during hospitalization can lead to a longer hospital stay, which can also have an impact on POAF incidence. Therefore, further multicenter data collection and prospective studies are necessary.

Previous studies have consistently indicated that POAF often occurs within three days after surgery^[1–2]. Our research revealed that the incidence of POAF was highest on the first day after surgery (65.6%), with 31 out of 32 cases occurring within three days after surgery. This early occurrence may be exacerbated by increased sputum production within 24–72 hours after surgery, potentially leading to acute hypoxemia. Pain and anesthesia directly affect respiratory and cough reflexes, increasing the incidence of POAF. Notably, POAF typically diminishes over time and is usually transient after pulmonary resection surgery. It is often caused by surgical trauma, hypoxemia, or other stressors rather than organic heart disease. Therefore, POAF following pulmonary resection surgery is typically transient.

Amiodarone and digoxin have been recommended by researchers for the effective management of POAF^[9]. Our study assessed the efficacy of these agents in the treatment of POAF. Among the 26 patients treated with amiodarone or digoxin, clinical improvement was observed in all patients. Of the 32 patients, 29 had a restored sinus rhythm before discharge, while 3 continued to have atrial fibrillation and received anticoagulant therapy after discharge. Some patients reported symptoms of palpitations and chest discomfort, but all patients maintained hemodynamic stability and did not experience significant discomfort.

This study has several strengths. First, there is limited research on preoperative inflammatory indices, and this study innovatively incorporated preoperative inflammatory indices into the analysis. Although the results showed no correlation with POAF, the inclusion of preoperative inflammatory indices opens up a new avenue for future research as our understanding of inflammatory indices deepens. Second, this study included anti-inflammatory drugs as a variable of interest, providing further insights into the management of these drugs.

This study has several limitations. First, due to the retrospective enrollment of patients from a single center, there is a possibility of selection bias, potentially resulting in the exclusion or underdetection of patients with POAF. Second, incomplete data were collected for outcomes such as lung function and pain, limiting their examination. Third, the sample size was small, and the incidence of POAF was limited, which affected the comprehensive analysis of risk factors. Fourth, for the indicators of anti-inflammatory drugs, we did not conduct further detailed analysis, such as the type, dosage, or duration of treatment. Therefore, in our future work, we will delve into these aspects to gain a better understanding of their impact on postoperative recovery.

In summary, the results of this study demonstrated no significant association between preoperative inflammatory indices and the POA. However, TNM stage, age, and POP were identified as independent predictors of POAF. Preliminary findings regarding TNM staging suggest that early-stage NSCLC patients may be more prone to developing POAF than early-stage patients, but further validation is needed. Additionally, POAF was found to be associated with prolonged hospital stays.

POAF, postoperative arterial fibrillation; NSCLC, non-small cell lung cancer; BMI, body mass index; POP, postoperative pneumonia; pSII, preoperative systemic immune inflammation index; NLR, neutrophil-to-lymphocyte ratio; PLR, platelet-to-lymphocyte ratio; LMR, lymphocyte-to-monocyte ratio; TNM, tumor, node, and metastasis; IASLC, International Association for the Study of Lung Cancer; ECG, electrocardiography.

Ethical approval

The Ethics Committee of The First People’s Hospital of Jiande approved this study, and the human data used were in accordance with the Declaration of Helsinki. Informed consent was waived by the First People’s Hospital of Jiande.

Consent for publication

Written informed consent was obtained from the patient or her family for the publication of this report and any accompanying images.

AI and AI-assisted Technologies

In the preparation of this work, the authors did not utilize any AI technology for editing the manuscript. The authors take full responsibility for the content of the publication.

CRediT authorship contribution statement

Yingding Ruan: Conceptualization, Methodology, Investigation, Data curation, Writing– original draft, writing– review & editing. Jianwei Han: Supervision, Writing – review & editing. Aiming Yang: Methodology, Investigation, Data curation. Qingguo Ding: Methodology, Investigation, Data curation. Ting Zhang: Conceptualization, supervision, writing – review & editing.

Declaration of competing interests

The authors have no relevant financial or nonfinancial interests to disclose.

Funding

This research was supported by the Jiande Municipal Science and Technology Bureau, including Grant No. 2023YW05 and Grant No. 2023SJZX22.

Availability of Data

Any researchers interested in this study could contact us to request the data.

Declaration of generative AI in scientific writing

None

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Table 1：Patient Characteristics, Incidence of POAF,[n(%),M(QR)]
Characteristics	Date
Incidence of POAF(n, %)	32(8.4)
Time of incidence(d)	1(1,3)
Sex(n,%)
Male	183(47.5)
Female	199(52.5)
Age(years)	65(57, 70)
BMI(kg/m2)	22.7(20.3, 24.9)
Postoperative hospital stay(days)	9.4(6.4, 12.4)
Smoking(n,%)	122(31.9)
Comorbidities(n,%)
Hypertension	92(24.1)
Diabetes	6(1.6)
Coronary heart disease	4(1.0)
Chronic Obstructive Pulmonary Disease	21(5.5)
Comorbidities of Hypertension, Diabetes, Cardiac History, and Pulmonary History	35(9.2)
Pathologic staging*(n,%)
Stage IA1	122(31.9)
Stage IA2	137(35.9)
Stage IA3	62(16.2)
Stage IB	16(4.2)
Stage IIA	4(1.0)
Stage IIB	16(4.2)
Stage IIIA	20(5.3)
Stage IIIB	5(1.2)
Approaches(n,%)
U-VATS	212(55.5)
M-VATS	159(41.6)
Thoracotomy	11(2.9)
Type of lung resection(n,%)
Lobectomy	240(62.8)
Segmental	69(18.1)
Wedge	68(17.8)
Pneumonectomy	5(1.3)
Resection Site(n,%)
Right upper	122(31.9)
Right middle	26(6.8)
Right lower	76(19.9)
Left upper	91(23.8)
Left lower	62(16.2)
Pneumonectomy(n,%)	5(1.3)
Duration of surgery (min)	138(99, 180)
Intraoperative bleeding volume (mL)	100(50, 100)
Pathological Types(n,%)
Adenocarcinoma	316(82.7)
Squamous Cell Carcinoma	47(12.3)
Rare NSCLC	19(5.0)
Number of Mediastinal lymph nodes retrieved	5(0, 10)
Mediastinal lymph node stations explored	2(0, 3)
Postoperative Complications(n, %)	119(31.2)
Drainage volume (ml)	860(527.5, 1417.5)
Drainage time (days)	5(3.2,9)
Antibiotics(%)	338(88.5)
pSII	431.76(292.73,623.18)
PLR	128.71(97.27,172.78)
NLR	2.57(1.84,3.46)
LMR	4.00(3.00,5.21)
preoperative albumin level	43.15(39.8,46.5)
postoperative albumin level	33.80(30.6, 36.6)
Echocardiography ejection fraction(%)	67.7(63.38, 73)
Echocardiography left atrial size(mm)	31.5(28.7, 35.7)
Postoperative Pneumonia(%)	66(17.3)
U-VATS, Uniportal Video-assisted Thoracoscopic Surgery; M-VATS, Multiportal Video-assisted Thoracoscopic Surgery; pSII, Preoperative Systemic Immune Inflammation indices; NLR, Meutrophil-to-Lymphocyte Ratio; PLR, Platelet-to-Lymphocyte Ratio; LMR, Lymphocyte-to-Monocyte Ratio;

Table 2: Categorical data analysis of the two groups
Categorical data	POAF(n=32)	non-POAF(n=350)	P Value
Sex (n, %)			0.537
Male	17(53.1)	166(47.4)
Female	15(46.9)	184(52.6)
Smoking (n, %)			0.271
Yes	13(40.6)	109(31.3)
No	19(59.4)	241(68.9)
TNM Stage*(n, %)			<0.001
Stage IA1	2(6.3)	120(34.3)
Stage IA2	12(37.5)	125(35.7)
Stage IA3	4(12.5)	58(16.6)
Stage IB	4(12.5)	12(3.4)
Stage IIA	0(0.0)	4(1.1)
Stage IIB	2(6.3)	14(4.0)
Stage IIIA	6(18.8)	14(4.0)
Stage IIIB	2(6.3)	3(0.9)
Pathological types(n, %)			0.755
Adenocarcinoma	26(81.3)	290(82.9)
Squamous cell carcinoma	5(15.6)	42(12.0)
Rare NSCLC	1(3.1)	18(5.1)
Lobectomy(n, %)			0.648
Right upper	11(34.4)	111(31.7)
Right middle	4(12.5)	22(6.3)
Right lower	4(12.5)	72(20.6)
Left upper	7(21.9)	84(24.0)
Left lower	6(18.8)	56(16.0)
Pneumonectomy	0（0.0）	5(1.4)
Type of lung resection			0.049
Lobectomy	27(84.4)	213(60.9)
Segmental	4(12.5)	65(18.6)
Wedge	1(3.1)	67(19.1)
Pneumonectomy	0(0.0)	5(1.4)
Approach			0.144
U-VATS	13(40.6)	199(56.9)
M-VATS	17(53.1)	142(40.6)
Thoracotomy	2(6.3)	9(2.5)
Comorbidities			0.774
Yes	14(43.8)	144(41.1)
No	18(56.3)	206(59.9)
Antibiotics			0.447
Yes	27(84.4)	311(88.9)
No	5(15.6)	39(11.1)
Postoperative Pneumonia			0.09
Yes	9(28.1)	57(16.3)
No	23(71.9)	293(83.7)
*8th edition TNM stage grouping;

Table 3: Patient Characteristics, Incidence of Intraoperative Atrial Fibrillation, and Statistical Analysis[mean±standard deviation,M(P25,P75)]
Continuous Data	POAF(n=32)	non-POAF(n=350)	t/Z	P Value
Age(years)	68.94±7.808	63.00±10.435	3.138	0.002
*BMI(kg/m2)	22.23±3.867	22.79±3.571	-0.849	0.397
Duration of surgery	166.22±61.458	141.23±58.363	2.309	0.022
Mediastinal lymph node stations explored	3.28±2.004	1.94±1.766	4.073	<0.001
LMR	4.42±1.906	4.26±1.778	0.489	0.625
preoperative albumin level	41.73±6.148	43.15±4.488	-1.647	0.213
postoperative albumin level	32.80±3.664	33.76±4.309	-1.223	0.222
Echocardiography ejection fraction(%)	67.13±8.749	68.48±7.134	-0.999	0.318
Echocardiography left atrial size(mm)	32.98±4.651	31.85±5.519	1.125	0.261
Intraoperative bleeding volume (mL)	100(100, 200)	100(50, 100)	-2.745	0.006
Postoperative hospital stay(days)	10.54(8.44, 15.36)	9(5.91, 12.40)	-3.293	0.001
Number of Mediastinal lymph nodes retrieved	9.5(5.5, 14)	4(0, 9)	-3.873	<0.001
Drainage volume (ml)	1150(791.25, 2192.50)	820(543.75, 1400)	-2.977	0.003
Drainage time (days)	7(5, 10.75)	5(3.03, 9)	-2.865	0.004
pSII	368.24(225.37, 599.49)	436.15(303.05, 624.03)	-1.507	0.132
PLR	118.86(92.57, 158.21)	129.21(97.27, 174.72)	-0.835	0.404
NLR	2.47(1.75, 3.31)	2.57(1.86, 3.47)	-0.553	0.58
*BMI:Body Mass Index

Table 4:Results of univariate logistic regression analyses for POAF
						95%Exp(B) CI
Variables	B	SE	Wald	P	Exp(B)	Down	Up
Sex	0.228	0.37	0.38	0.538	1.256	0.608	2.595
Age	-0.071	0.023	9.52	0.002	0.931	0.89	0.974
Pathological Types	0.015	0.357	0.002	0.966	1.015	0.505	2.042
Pathologic staging*	-0.374	0.084	19.799	<0.001	0.688	0.583	0.811
BMI	0.045	0.053	0.723	0.395	1.046	0.943	1.162
Intraoperative bleeding volume	-0.001	0.001	5.371	0.02	0.999	0.998	1
Duration of surgery	-0.007	0.003	5.151	0.023	0.993	0.988	0.999
Postoperative hospital stay	-0.092	0.028	11.276	0.001	0.912	0.864	0.962
Resection Site	0.053	0.121	0.194	0.66	1.055	0.832	1.337
Type of lung resection	0.934	0.369	6.4	0.011	2.544	1.234	5.245
Approach	-0.609	0.317	3.694	0.055	0.544	0.293	1.012
Comorbidities	-0.056	0.372	0.023	0.88	0.945	0.456	1.96
Number of Mediastinal lymph nodes retrieved	-0.088	0.024	13.605	<0.001	0.916	0.874	0.96
Mediastinal lymph node stations explored	-0.376	0.099	14.358	<0.001	0.687	0.565	0.834
Postoperative Pneumonia	0.699	0.419	2.782	0.095	2.011	0.885	4.572
Drainage volume	0	0	7.402	0.007	1	0.999	1
Drainage time	-0.068	0.031	4.844	0.028	0.934	0.879	0.993
pSII	0	0	0.567	0.451	1	0.999	1.001
PLR	0.002	0.003	0.491	0.483	1.002	0.996	1.008
NLR	0.105	0.12	0.757	0.384	1.11	0.877	1.406
LMR	-0.049	0.1	0.24	0.624	0.952	0.782	1.159
preoperative albumin level	0.063	0.039	2.681	0.102	1.065	0.988	1.149
postoperative albumin level	0.052	0.043	1.492	0.222	1.053	0.969	1.145
Smoking	-0.414	0.378	1.199	0.273	0.661	0.315	1.387
Antibiotics	-0.39	0.516	0.572	0.45	0.677	0.246	1.86
Echocardiography ejection fraction	0.026	0.026	0.999	0.317	1.026	0.975	1.08
Echocardiography left atrial size	-0.038	0.034	1.263	0.261	0.963	0.902	1.028

Table 5:Results of multivariable logistic regression analyses for POAF
						95%Exp(B) CI
Variables	B	SE	Wald	P	Exp(B)	Down	Up
Age	-0.064	0.027	5.365	0.021	0.938	0.889	0.99
Pathologic staging*	-0.291	0.11	6.956	0.008	0.747	0.602	0.928
Intraoperative bleeding volume	-0.001	0.001	0.454	0.5	0.999	0.998	1.001
Duration of surgery	0.002	0.005	0.163	0.687	1.002	0.993	1.011
Type of lung resection	0.363	0.323	1.261	0.261	1.438	0.763	2.709
Approach	0.137	0.38	0.13	0.719	1.147	0.544	2.417
Number of Mediastinal lymph nodes retrieved	-0.054	0.034	2.495	0.114	0.948	0.887	1.013
Mediastinal lymph node stations explored	-0.094	0.149	0.399	0.528	0.91	0.68	1.218
Postoperative Pneumonia	0.966	0.474	4.154	0.042	2.627	1.038	6.649
Drainage volume	0	0	0.318	0.573	1	1	1
Drainage time	0.008	0.048	0.025	0.874	1.008	0.918	1.106

No competing interests reported.

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Impact of Preoperative Inflammatory Indices and Postoperative Pneumonia on Postoperative Atrial Fibrillation in Patients with Non-Small Cell Lung Cancer: A Retrospective Study

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Abstract

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Introduction

Materials and Methods

Data collection

Electrocardiographic (ECG) monitoring

Definition of POAF

Definition of POP

Statistical analysis

Results

Discussion

Abbreviations

Declarations

References

Tables

Additional Declarations

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