Prediction of early in-hospital major adverse events by D-dimer level in patients with acute type A aortic dissection: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG Yu ¹ , WANG Xiaoqi ² , ZHANG Heng ² , ZHANG Xinyi ¹ , XU Mian ¹ , GUO Yi ¹ ,  CHANG Shuo ³

1. Adult Cardiac Surgery Intensive Care Unit, Fuwai Yunnan Cardiovascular Hospital, Kunming, 650102, P. R. China;
2. Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Kunming, 650102, P. R. China;
3. Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, 100037, P. R. China;

Corresponding author：

CHANG Shuo, Email: cschl@126.com

Keywords：

D-dimer; acute type A aortic dissection; aortic arch replacement; frozen elephant trunk implantation; in-hospital major adverse events

DOI：

10.7507/1007-4848.202310045

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Objective To investigate the correlation between D-dimer level within 2 hours on admission and early in-hospital major adverse events (MAEs) in patients with acute type A aortic dissection undergoing arch replacement and the frozen elephant trunk (FET) implantation. Methods The patients with acute type A aortic dissection undergoing arch replacement and the FET implantation, who hospitalized in our hospital from September 2017 to December 2022, were included in this retrospective study. Grouping based on the occurrence of in-hospital major adverse events (MAEs) after total arch replacement and FET implantation, with no in-hospital MAEs as a control group and in-hospital MAEs as an observation group. The perioperative data were compared between the two groups. Univariate and multivariate analyses were used to investigate the risk factors for MAEs (in-hospital mortality, gastrointestinal bleeding, paraplegia, acute kidney failure, reopening the chest, low cardiac output syndrome, cerebrovascular accident, respiratory insufficiency, multiple organ dysfunctionsyndrome, gastrointestinal bleeding, and severe infection). Receiver operating characteristic (ROC) curve was used to evaluate the predictive value of the prediction area under the ROC curve (AUC). Results Finally 218 patients were collected, including 157 males and 61 females with an average age of 51.54±9.79 years. There were 152 patients in the control group and 66 patients in the observation group. In-hospital mortality was 2.8% (6/218). The level of D-dimer, lactic acid, cardiopulmonary bypass time, aortic cross-clamping time, ventilator-assisted time and ICU stay in the observation group were higher or longer than those in the control group (P=0.013). Multivariate logistic analysis showed that D-dimer (OR=1.077, 95%CI 1.020-1.137, P＜0.05) was an independent risk factor for MAEs in hospital. The level of D-dimer within 2 hours admission predicted that the AUC of MAEs in hospital was 0.83 (95%CI 0.736-0.870, P＜0.05), and the optimal critical point was 2.2 μg/mL, with sensitivity and specificity of 84.8% and 73.0%, respectively. Conclusion Increased D-dimer levels at admission are associated with early in-hospital MAEs in the patients with acute type A aortic dissection undergoing arch replacement and FET. These results may help clinicians optimize the risk evaluation and perioperative clinical management to reduce early adverse events.

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2.	Salmasi MY, Al-Saadi N, Hartley P, et al. The risk of misdiagnosis in acute thoracic aortic dissection: A review of current guidelines. Heart, 2020, 106(12): 885-891.
3.	Ahmed Y, Houben IB, Figueroa CA, et al. Endovascular ascending aortic repair in type A dissection: A systematic review. J Card Surg, 2021, 36(1): 268-279.
4.	田力, 樊晓寒, 朱俊, 等. A型急性主动脉夹层患者血浆D二聚体浓度和住院死亡的关系. 中国循环杂志, 2013, 28(6): 450-454.
5.	Yan TD, Tian DH, LeMaire SA, et al. Standardizing clinical end points in aortic arch surgery: A consensus statement from the International Aortic Arch Surgery Study Group. Circulation, 2014, 129(15): 1610-1616.
6.	Sen I, Erben YM, Franco-Mesa C, et al. Epidemiology of aortic dissection. Semin Vasc Surg, 2021, 34(1): 10-17.
7.	Zhu Y, Lingala B, Baiocchi M, et al. Type A aortic dissection-experience over 5 decades: JACC historical breakthroughs in perspective. J Am Coll Cardiol, 2020, 76(14): 1703-1713.
8.	Feng W, Wang Q, Li C, et al. Significant prediction of in-hospital major adverse events by D-dimer level in patients with acute type A aortic dissection. Front Cardiovasc Med, 2022 Feb 24: 9: 821928.
9.	Sievers HH, Rylski B, Czerny M, et al. Aortic dissection reconsidered: Type, entry site, malperfusion classification adding clarity and enabling outcome prediction. Interact Cardiovasc Thorac Surg, 2020, 30(3): 451-457.
10.	Dagenais F. Commentary: How aggressive should we be in replacing the aortic root during type A dissection? J Thorac Cardiovasc Surg, 2022, 163(3): 911-912.
11.	Pupovac SS, Hemli JM, Seetharam K, et al. Acute type A aortic dissection repair after hours: Does it influence outcomes? Ann Thorac Surg, 2020, 110(5): 1622-1628.
12.	Zhang Y, Chen T, Chen Q, et al. Development and evaluation of an early death risk prediction model after acute type A aortic dissection. Ann Transl Med, 2021, 9(18): 1442.
13.	Liu T, Zheng J, Zhang YC, et al. Association between D-dimer and early adverse events in patients with acute type A aortic dissection undergoing arch replacement and the frozen elephant trunk implantation: A retrospective cohort study. Front Physiol, 2020, 10: 1627.
14.	Nezu T, Kitano T, Kubo S, et al. Impact of D-dimer levels for short-term or long-term outcomes in cryptogenic stroke patients. J Neurol, 2018, 265(3): 628-636.
15.	Faller N, Limacher A, Méan M, et al. Predictors and causes of long-term mortality in elderly patients with acute venous thromboembolism: A prospective cohort study. Am J Med, 2017, 130(2): 198-206.
16.	Freund Y, Cohen-Aubart F, Bloom B. Acute pulmonary embolism: A review. JAMA, 2022, 328(13): 1336-1345.
17.	Ha SH, Kim YJ, Heo SH, et al. Prediction of deep vein thrombosis by ultrasonography and D-dimer in Asian patients with ischemic stroke. BMC Neurol, 2020, 20(1): 257.
18.	Fan YN, Ke X, Yi ZL, et al. Plasma D-dimer as a predictor of intraluminal thrombus burden and progression of abdominal aortic aneurysm. Life Sci, 202, 240: 117069.
19.	Huang M, Lian Y, Zeng Z, et al. D-dimer, C-reactive protein and matrix metalloproteinase 9 for prediction of type A aortic dissection patient survival. ESC Heart Fail, 2024, 11(1): 147-154.
20.	Yao J, Bai T, Yang B, et al. The diagnostic value of D-dimer in acute aortic dissection: A meta-analysis. J Cardiothorac Surg, 2021, 16(1): 343.
21.	Xie N, Zhang W, Li H, et al. Admission values of plasma biomarkers predict the short-term outcomes in acute aortic dissection. Heart Surg Forum, 2021, 24(1): E048-E054.
22.	Huang B, Yang Y, Lu H, et al. Impact of D-dimer levels on admission on inhospital and long-term outcome in patients with type A acute aortic dissection. Am J Cardiol, 2015, 115(11): 1595-1600.
23.	Itagaki R, Kimura N, Mieno M, et al. Characteristics and treatment outcomes of acute type A aortic dissection with elevated D-dimer concentration. J Am Heart Assoc, 2018, 7(14): e009144.
24.	Tang Z, Liu H, Shao Y. Efficacy of CRP in combination with D-dimer in predicting adverse postoperative outcomes of patients with acute Stanford type A aortic dissection. J Cardiothorac Surg, 2022, 17(1): 71.
25.	Han L, Dai L, Li HY, et al. Elevated D-dimer increases the risk of dialysis after surgery in patients with Stanford A aortic dissection through the impact of the coagulation system. J Thorac Dis, 2018, 10(12): 6783-6793.
26.	Yin ZQ, Han H, Yan X, et al. Research progress on the pathogenesis of aortic dissection. Curr Probl Cardiol, 2023, 48(8): 101249.
27.	Li M, Xu S, Yan Y, et al. Association of biomarkers related to preoperative inflammatory and coagulation with postoperative in-hospital deaths in patients with type A acute aortic dissection. Sci Rep, 2021, 11(1): 18775.
28.	Chen Y, Lin Y, Zhang H, et al. Relationship of platelet counts and inflammatory markers to 30-day mortality risk in patients with acute type A aortic dissection. Biomed Res Int, 2020, 2020: 1057496.
29.	Otani T, Abe T, Ichiba T, et al. D-dimer measurement is useful irrespective of time from the onset of acute aortic syndrome symptoms. Am J Emerg Med, 2023, 71: 7-13.
30.	Wang D, Chen J, Sun J, et al. The diagnostic and prognostic value of D-dimer in different types of aortic dissection. J Cardiothorac Surg, 2022, 17(1): 194.

1. Gudbjartsson T, Ahlsson A, Geirsson A, et al. Acute type A aortic dissection—A review. Scand Cardiovasc J, 2020, 54(1): 1-13.
2. Salmasi MY, Al-Saadi N, Hartley P, et al. The risk of misdiagnosis in acute thoracic aortic dissection: A review of current guidelines. Heart, 2020, 106(12): 885-891.
3. Ahmed Y, Houben IB, Figueroa CA, et al. Endovascular ascending aortic repair in type A dissection: A systematic review. J Card Surg, 2021, 36(1): 268-279.
4. 田力, 樊晓寒, 朱俊, 等. A型急性主动脉夹层患者血浆D二聚体浓度和住院死亡的关系. 中国循环杂志, 2013, 28(6): 450-454.
5. Yan TD, Tian DH, LeMaire SA, et al. Standardizing clinical end points in aortic arch surgery: A consensus statement from the International Aortic Arch Surgery Study Group. Circulation, 2014, 129(15): 1610-1616.
6. Sen I, Erben YM, Franco-Mesa C, et al. Epidemiology of aortic dissection. Semin Vasc Surg, 2021, 34(1): 10-17.
7. Zhu Y, Lingala B, Baiocchi M, et al. Type A aortic dissection-experience over 5 decades: JACC historical breakthroughs in perspective. J Am Coll Cardiol, 2020, 76(14): 1703-1713.
8. Feng W, Wang Q, Li C, et al. Significant prediction of in-hospital major adverse events by D-dimer level in patients with acute type A aortic dissection. Front Cardiovasc Med, 2022 Feb 24: 9: 821928.
9. Sievers HH, Rylski B, Czerny M, et al. Aortic dissection reconsidered: Type, entry site, malperfusion classification adding clarity and enabling outcome prediction. Interact Cardiovasc Thorac Surg, 2020, 30(3): 451-457.
10. Dagenais F. Commentary: How aggressive should we be in replacing the aortic root during type A dissection? J Thorac Cardiovasc Surg, 2022, 163(3): 911-912.
11. Pupovac SS, Hemli JM, Seetharam K, et al. Acute type A aortic dissection repair after hours: Does it influence outcomes? Ann Thorac Surg, 2020, 110(5): 1622-1628.
12. Zhang Y, Chen T, Chen Q, et al. Development and evaluation of an early death risk prediction model after acute type A aortic dissection. Ann Transl Med, 2021, 9(18): 1442.
13. Liu T, Zheng J, Zhang YC, et al. Association between D-dimer and early adverse events in patients with acute type A aortic dissection undergoing arch replacement and the frozen elephant trunk implantation: A retrospective cohort study. Front Physiol, 2020, 10: 1627.
14. Nezu T, Kitano T, Kubo S, et al. Impact of D-dimer levels for short-term or long-term outcomes in cryptogenic stroke patients. J Neurol, 2018, 265(3): 628-636.
15. Faller N, Limacher A, Méan M, et al. Predictors and causes of long-term mortality in elderly patients with acute venous thromboembolism: A prospective cohort study. Am J Med, 2017, 130(2): 198-206.
16. Freund Y, Cohen-Aubart F, Bloom B. Acute pulmonary embolism: A review. JAMA, 2022, 328(13): 1336-1345.
17. Ha SH, Kim YJ, Heo SH, et al. Prediction of deep vein thrombosis by ultrasonography and D-dimer in Asian patients with ischemic stroke. BMC Neurol, 2020, 20(1): 257.
18. Fan YN, Ke X, Yi ZL, et al. Plasma D-dimer as a predictor of intraluminal thrombus burden and progression of abdominal aortic aneurysm. Life Sci, 202, 240: 117069.
19. Huang M, Lian Y, Zeng Z, et al. D-dimer, C-reactive protein and matrix metalloproteinase 9 for prediction of type A aortic dissection patient survival. ESC Heart Fail, 2024, 11(1): 147-154.
20. Yao J, Bai T, Yang B, et al. The diagnostic value of D-dimer in acute aortic dissection: A meta-analysis. J Cardiothorac Surg, 2021, 16(1): 343.
21. Xie N, Zhang W, Li H, et al. Admission values of plasma biomarkers predict the short-term outcomes in acute aortic dissection. Heart Surg Forum, 2021, 24(1): E048-E054.
22. Huang B, Yang Y, Lu H, et al. Impact of D-dimer levels on admission on inhospital and long-term outcome in patients with type A acute aortic dissection. Am J Cardiol, 2015, 115(11): 1595-1600.
23. Itagaki R, Kimura N, Mieno M, et al. Characteristics and treatment outcomes of acute type A aortic dissection with elevated D-dimer concentration. J Am Heart Assoc, 2018, 7(14): e009144.
24. Tang Z, Liu H, Shao Y. Efficacy of CRP in combination with D-dimer in predicting adverse postoperative outcomes of patients with acute Stanford type A aortic dissection. J Cardiothorac Surg, 2022, 17(1): 71.
25. Han L, Dai L, Li HY, et al. Elevated D-dimer increases the risk of dialysis after surgery in patients with Stanford A aortic dissection through the impact of the coagulation system. J Thorac Dis, 2018, 10(12): 6783-6793.
26. Yin ZQ, Han H, Yan X, et al. Research progress on the pathogenesis of aortic dissection. Curr Probl Cardiol, 2023, 48(8): 101249.
27. Li M, Xu S, Yan Y, et al. Association of biomarkers related to preoperative inflammatory and coagulation with postoperative in-hospital deaths in patients with type A acute aortic dissection. Sci Rep, 2021, 11(1): 18775.
28. Chen Y, Lin Y, Zhang H, et al. Relationship of platelet counts and inflammatory markers to 30-day mortality risk in patients with acute type A aortic dissection. Biomed Res Int, 2020, 2020: 1057496.
29. Otani T, Abe T, Ichiba T, et al. D-dimer measurement is useful irrespective of time from the onset of acute aortic syndrome symptoms. Am J Emerg Med, 2023, 71: 7-13.
30. Wang D, Chen J, Sun J, et al. The diagnostic and prognostic value of D-dimer in different types of aortic dissection. J Cardiothorac Surg, 2022, 17(1): 194.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesPrediction of early in-hospital major adverse events by D-dimer level in patients with acute type A aortic dissection: A retrospective cohort study

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