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Postoperative lactate trajectories predict in-hospital adverse outcomes and differ by surgical approach in cardiac
Duolikun Mutailifu1, Abudousaimi Aini1, Malike Mutailipu1
1Department of Cardiac Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
Background:
Totally thoracoscopic cardiac surgery (TTCS) employs peripheral cardiopulmonary bypass (CPB) with retrograde aortic perfusion, yet whether its net effect on early tissue perfusion is superior to open sternotomy remains uncertain. This study identified postoperative arterial lactate trajectory phenotypes, examined their association with surgical approach, and evaluated their prognostic value for in-hospital adverse outcomes.
Methods:
A single-centre, retrospective, propensity score-matched cohort study enrolled 1,264 patients (632 per group). Group-based trajectory modelling (GBTM) was applied to serial arterial lactate concentrations at nine postoperative time points (T0-T120h). Multinomial logistic regression examined surgical approach-trajectory associations. Exploratory path decomposition estimated the indirect contribution of lactate trajectory to the surgical approach-outcome association; a predictive model for major adverse cardiovascular events (MACE) was constructed from early postoperative lactate measurements.
Results:
GBTM identified three trajectory phenotypes: Low-Stable (65.8%), Moderate-Resolving (28.6%), and Persistently Elevated (PE; 5.6%). TTCS was independently associated with reduced odds of Moderate-Resolving (adjusted odds ratio [aOR] 0.70, 95% CI 0.54-0.90) and PE membership (aOR 0.27, 95% CI 0.15-0.49), with the protective association more pronounced for PE. PE trajectory independently predicted MACE (aOR 14.73, 95% CI 7.91-27.45) and mechanical ventilation exceeding 48 h (aOR 20.79). Exploratory path decomposition attributed 24.0%-42.3% of the total association to indirect pathways, though estimates were sensitive to unmeasured confounding. T2h lactate independently predicted MACE (aOR 2.18 per mmol/L; AUC 0.697; optimal cut-off 2.45 mmol/L). All five inflammatory and organ-function biomarkers showed trajectory-dependent responses, with inflammatory peaks preceding organ-injury markers.
Conclusions:
TTCS significantly reduced membership in high-risk lactate trajectory phenotypes. PE trajectory independently predicted in-hospital adverse outcomes and mirrored the postoperative inflammation-organ injury cascade. A T2h lactate ≥2.45 mmol/L provides a practical early bedside risk-stratification tool.
