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 Sciences, 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 association between D-dimer levels within 2 hours of admission and in-hospital major adverse events (MAEs) in patients with acute type A aortic dissection (ATAAD) who underwent total arch replacement combined with frozen elephant trunk (FET) implantation. Methods This retrospective study included patients with ATAAD who underwent total arch replacement with FET implantation at Fuwai Yunnan Cardiovascular Hospital from September 2017 to December 2022. Patients were divided into two groups based on the occurrence of in-hospital MAEs: a MAEs group and a non-MAEs group (control). Perioperative data were compared between the two groups. Univariate and multivariate logistic regression analyses were performed to identify risk factors for in-hospital MAEs, which included in-hospital death, gastrointestinal bleeding, paraplegia, acute kidney injury, low cardiac output syndrome, stroke, respiratory failure, multiple organ dysfunction syndrome, and severe infection. The predictive value of D-dimer was evaluated using the area under the receiver operating characteristic curve (AUC). Results A total of 218 patients were included (157 males, 61 females), with a mean age of (51.54±9.79) years. There were 152 patients in the non-MAEs group and 66 in the MAEs group. The overall incidence of in-hospital MAEs was 30.3%, and the in-hospital mortality rate was 2.8% (6/218). Compared to the non-MAEs group, the MAEs group had significantly higher levels of D-dimer and lactate, as well as longer cardiopulmonary bypass time, aortic cross-clamp time, and ICU length of stay (all P<0.05). Multivariate logistic regression analysis identified D-dimer as an independent risk factor for in-hospital MAEs [OR=1.077, 95%CI (1.020, 1.137), P=0.013]. The AUC for the D-dimer level within 2 hours of admission to predict in-hospital MAEs was 0.83 [95%CI (0.736, 0.870), P<0.001]. The optimal cutoff value was 2.2 μg/mL, with a sensitivity of 84.8% and a specificity of 73.0%. Conclusion The serum D-dimer level is an independent risk factor for in-hospital MAEs in patients with ATAAD following total arch replacement with FET implantation. D-dimer levels on admission can help clinicians optimize risk stratification and perioperative management, potentially reducing the incidence of 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.Tian L, Fan XH, Zhu J, et al. Relationship between level of plasma D-dimer and in-hospital mortality in patients with type A acute aortic dissection. 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, 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.	Weber T, Rammer M, Auer J, et al. Plasma concentrations of D-dimer predict mortality in acute type A aortic dissection. Heart, 2006, 92(6): 836-837.
20.	Ohlmann P, Faure A, Morel O, et al. Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. Crit Care Med, 2006, 34(5): 1358-1364.
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.Tian L, Fan XH, Zhu J, et al. Relationship between level of plasma D-dimer and in-hospital mortality in patients with type A acute aortic dissection. 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, 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. Weber T, Rammer M, Auer J, et al. Plasma concentrations of D-dimer predict mortality in acute type A aortic dissection. Heart, 2006, 92(6): 836-837.
20. Ohlmann P, Faure A, Morel O, et al. Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. Crit Care Med, 2006, 34(5): 1358-1364.
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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