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Fibrinogen Albumin Ratio and Ischemic Stroke During Venoarterial Extracorporeal Membrane Oxygenation

Acharya, Prakash*; Jakobleff, William A.; Forest, Stephen J.; Chinnadurai, Thiru*; Mellas, Nicolas; Patel, Snehal R.*; Kizer, Jorge R.; Billett, Henny H.§; Goldstein, Daniel J.; Jorde, Ulrich P.*; Saeed, Omar*

doi: 10.1097/MAT.0000000000000992
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Fibrinogen is a clotting factor and a major determinant of platelet aggregation. Albumin, on the other hand, inhibits platelet function and thrombus formation. Taken together, an elevated fibrinogen albumin ratio (FAR) has been described as a marker of disease severity during prothrombotic conditions. We evaluated the association of FAR and ischemic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. A single center, retrospective study was performed including all adult patients placed on VA ECMO. FAR was calculated from fibrinogen and albumin measurements in the first 24 hours of VA-ECMO initiation. Patients were categorized into high (≥125) and low (<125) FAR groups and the risk of eventual ischemic stroke was determined. There were 201 patients who underwent VA ECMO placement and 157 had a FAR. They were 56 ± 14 years old and 66 (42%) had a high FAR. Patients with a high FAR had lower survival free from an ischemic stroke during VA ECMO (log rank p < 0.001; adjusted hazard ratio 5.51; 95% CI: 1.8–16.5). In tertile analysis, the level of FAR was associated with an incrementally higher likelihood of eventual ischemic stroke (log rank p = 0.004). Those with a high FAR had greater mean platelet volume (10.8[10.4–12] vs. 10.5[10.2–11.9]fl, p = 0.004). An elevated FAR during the first 24 hours of VA ECMO placement is associated with a greater risk of a subsequent ischemic stroke. Our findings suggest that assessment of FAR soon after VA ECMO placement may assist with early stratification of patients at risk for an ischemic stroke.

From the *Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

§Department of Medicine, Division of Hematology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

Cardiology Section, San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California.

Submitted for consideration August 2018; accepted for publication in revised form February 2019.

Disclosure: The authors have no conflicts of interest to report.

This work was supported by the following grants from the National Institute for Health, K23HL145140 (Saeed), K24HL135413 (Kizer).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.asaiojournal.com).

Correspondence: Omar Saeed, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, MAP Building 7th floor, Bronx, NY 10467. Email: osaeed@montefiore.org.

Copyright © 2019 by the American Society for Artificial Internal Organs