ABSTRACT
A minority of patients with heart failure present in a high-output state. We described an uncommon case of high-output heart failure caused by an iliac arteriovenous fistula (IAVF), a rare but serious complication after lumbar discectomy surgery (LDS). A 44-year-old man with no notable medical condition except a history of herniated nucleus pulposus necessitating the L4-L5 LDS 5 years ago presented with clinical signs of progressive high-output heart failure. Physical examination revealed wide pulse pressure with bruit and systolic thrill at the right inguinal region. Computed tomographic angiography confirmed the IAVF from the right common iliac artery to the left common iliac vein. There was a significant shunting to the venous system, causing severe dilatation of the inferior vena cava. Notably, the preoperative lumbar magnetic resonance imaging performed 5 years ago demonstrated that the herniated disc was located at the L4-L5 level, which corresponded to the location of IAVF. The patient successfully underwent endovascular closure by covered stent leading to the gradual resolution of symptoms and hemodynamic parameters. Although vascular complications from the LDS are very uncommon, most patients develop severe symptoms from worsening high-output heart failure. This case highlights the essence of careful history taking, physical examinations, and appropriate investigations in guiding the diagnosis and contemplating the treatment strategy.
ABSTRACT
INTRODUCTION: The inflammatory response plays a potential role for the pathogenesis and adverse outcomes of heart failure (HF). We aimed to explore the predictive role of baseline neutrophil-to-lymphocyte ratio (NLR) and mean platelet volume-to-lymphocyte ratio (MPVLR) on cardiovascular events (CVEs) in patients hospitalized with acute HF. MATERIALS AND METHODS: A retrospective cohort study was conducted in 321 patients with HF between January 2017 and December 2019. The association between their NLR, MPVLR, and combined NLR and MPVLR and CVEs, rehospitalization for HF, in-hospital death, and a composite outcome was explored by survival analysis using a Cox proportional hazard model. They were separately investigated and compared with the area under the receiver operating characteristics curve (AUC). RESULTS: Up to the end of the 3-year follow-up, 96 (29.9%) had CVEs, 106 (33.0%) died, 62 (19.3%) were rehospitalized with HF, and 21 (6.5%) died during admission. The NLR and MPVLR were significantly associated with CVEs (adjusted HR for NLR ≥ 3.29, 3.11; 95% CI, 1.98-4.89; MPVLR ≥ 8.57, 2.86; 95% CI, 1.87-4.39), readmissions for HF (adjusted HR for NLR ≥ 3.58, 2.70; 95% CI, 1.58-4.61; MPVLR ≥ 6.43, 2.84; 95% CI,1.59-5.07), in-hospital mortality (adjusted HR for NLR ≥ 3.29, 9.54; 95% CI, 2.19-41.40; MPVLR ≥ 8.57, 7.87; 95% CI, 2.56-24.19), and composite outcome (adjusted HR for NLR ≥ 3.32, 4.76; 95% CI, 3.29-6.89; MPVLR ≥ 7.07, 3.64; 95% CI, 2.58-5.15). The AUC of NLR and MPVLR for CVEs were 0.67 (95% CI, 0.61-0.72) and 0.63 (95% CI, 0.58-0.69). Combined NLR and MPVLR increased the AUC to 0.77 (95% CI, 0.72-0.83) with statistical significance. CONCLUSION: The elevated NLR and MPVLR on admission in patients with acute HF were independently associated with worse CVEs, rehospitalization for HF, in-hospital death, and composite outcomes. These economical biomarkers should be considered in the management and follow-up care of patients with acute HF.
