Utility of measuring C-reactive protein for prediction of in-hospital events in patients with acute aortic dissection

Efficacy of prognostic nutrition index in combination with D-dimer in predicting postoperative clinical adverse events after acute type A aortic dissection: a single center retrospective study

Background

The aim of this study was to identify the predictive factors for adverse clinical events after surgery in patients with acute type A aortic dissection (AAAD), and to explore the predictive value of preoperative prognostic nutritional index (PNI) combined with D-dimer for these events.

Methods

This study was a retrospective analysis of clinical data of 153 patients with AAAD who underwent emergency surgery at our center from January 2019 to January 2022. Patients were divided into adverse event group and non-adverse event group based on whether they experienced adverse clinical events after surgery. Univariate and multivariable logistic regression analyses were performed to identify the risk factors for adverse events, and the predictive efficacy was evaluated by the area under the receiver operating characteristic curve (ROC-AUC).

Results

A total of 153 AAAD patients were included in the study, and were divided into the adverse event group (n = 46) and the non-adverse events group (n = 107) based on whether or not they experienced clinical adverse events after surgery. The optimal cutoff value was determined using ROC curves, and multivariate logistic regression analysis was performed. Ultimately, it was found that preoperative PNI < 42.45 and D-dimer > 15.05 were independent predictors of postoperative clinical adverse events in AAAD patients. The odd ratios (OR) value for preoperative PNI < 42.45 is 3.596 [95% Confidence Interval (CI): 1.508-8.923, p = 0.004], while the OR value for D-dimer > 15.05 is 7.572 [95% CI: 3.094-20.220, p < 0.001]. The combination of these two indicators has a high predictive value (AUC = 0.843, 95% CI: 0.774-0.912, p < 0.001) and is superior to using either variable alone.

Conclusion

Preoperative PNI < 42.45 and D-dimer > 15.05 are independent predictive factors for postoperative adverse events during hospitalization in patients with AAAD. The combination of these two indicators can improve the predictive accuracy, which is superior to using either variable alone.

Efficacy of CRP in combination with D-dimer in predicting adverse postoperative outcomes of patients with acute Stanford type A aortic dissection

Purpose

The present study evaluated the efficacy of C-reactive protein (CRP) and D-dimer and the combination of them as prognostic indicators for patients with acute type A aortic dissection (ATAAD).

Methods

This is a retrospective cohort study. From January 2019 to December 2021, patients with ATAAD admitted to the emergency medicine center of our hospital within 24 h after symptoms (chest pain, back pain, abdominal pain and so on) onset were enrolled in our study. Serum concentration of CRP and D-dimer were measured during hospitalization. Logistic regression was used to evaluate the association between these two biomarkers and in-hospital adverse outcomes (IAO) by adjusting confounding factors. Predictive efficacy was assessed by area under the curve (AUC) of receiver operating characteristic curve.

Results

A total of 199 patients with ATAAD were finally enrolled. They were categorized as Non-IAO group (n = 146) and IAO group (n = 53) according to postoperative outcomes. After controlling for potentially confounding variables, we found categorized variables that admission CRP > 54.28 mg/L, admission D-dimer > 8.45 mg/L and peak D-dimer > 24.89 mg/L were independent predictors of in-hospital adverse outcomes. Multiple Logistic regression analysis revealed that the odd ratios were 2.9 for admission D-dimer > 8.45 [95% Confidence Interval (CI) 1.11–7.5, p = 0.03], 4.9 for admission CRP > 54.28 (95% CI 1.6–14.9, p = 0.005) and 5.7 for peak D-dimer > 24.89 (95% CI 2.49–13, p < 0.001). The predictive accuracy of the combination of three categorized variables (AUC: 0.867, 95% CI 0.813–0.921, p < 0.001) was superior to that of any other one alone.

Conclusion

Admission D-dimer > 8.45 mg/L, peak D-dimer > 24.89 mg/L and admission CRP > 54.28 mg/L are independent predictors of in-hospital adverse outcomes in patients with ATAAD. Combination of these three markers will improve the predictive efficacy.

Systemic immune-inflammation index predicted the clinical outcome in patients with type-B aortic dissection undergoing thoracic endovascular repair

BACKGROUND

The systemic immune-inflammation index (SII) has been reported to have prognostic ability in various cardiovascular diseases; however, it has not been studied in type-B aortic dissection (TBAD). We aimed to explore the relation of SII with short-term and long-term outcomes in TBAD patients undergoing thoracic endovascular repair (TEVAR).

METHODS

We performed a retrospective analysis of a prospectively maintained database from 2010 to 2017. The patients were divided into two groups (high SII and low SII) as per the optimal cut-off value determined using the receiver operating characteristic curve. Multivariate logistic and Cox regression analyses were performed to analyse the relationship between the SII and the short-term and long-term outcomes.

RESULTS

A total of 805 TBAD patients who underwent TEVAR were enrolled. Twenty-six (3.2%) patients died during hospitalisation. At the end of a median follow-up duration of 48.80 mon, 70 (9.8%) patients had died. The patients were divided into the high-SII group [n = 333 (41.4%%)] and the low-SII group [n = 472 (58.6%)] as per the optimal cut-off value of 1,062. Multivariable logistic analyses showed that a high-SII score was independently associated with major adverse cardiovascular events (MACEs) in-hospital (odd ratio [OR], 1.67; 95% confidence interval [CI], 1.13-2.47; p = .01). In addition, multivariable Cox analyses showed that a high-SII score could be an independent indicator for follow-up adverse events (hazard ratio [HR], 1.70; 95% CI, 1.14-2.56, p = .01).

CONCLUSIONS

Systemic immune-inflammation index is associated with both in-hospital and long-term outcomes in patients with TBAD undergoing TEVAR. Therefore, SII may serve as valuable tool for risk stratification before intervention.

Preoperative high lymphocyte-to-monocyte ratio is associated with intraoperative type I endoleak in patients with TAA with TEVAR

OBJECTIVES

Various inflammatory factors are closely associated with the incidence of thoracic aortic aneurysms (TAAs). Furthermore, the severity of inflammation is closely related to the absolute value and proportion of each leukocyte subgroup. Only few reports have analyzed the importance of lymphocyte-monocyte ratio (LMR) as a potential inflammatory marker in vascular diseases. Therefore, we aimed to investigate the effect of peripheral blood LMR on thoracic endovascular aortic repair (TEVAR) in patients with TAA.

METHODS

A retrospective study of the clinical data collected in our hospital between January 2016 and January 2021 was performed on 162 patients with TAA treated with TEVAR, based on the inclusion and exclusion criteria for patient selection. Based on whether the patient had the clinical symptoms at admission and the occurrence of type I endoleaks during operation, patients were divided into two groups, respectively: an intraoperative type I endoleak group (n = 34) and a group without intraoperative type I endoleak (n = 128), and a group with clinical symptoms (n = 31) and a group without clinical symptoms (n = 131). The clinical data of these two groups were compared, the free from second intervention rates related to endoleak and the preoperatively LMR of the two groups was calculated. LMR was calculated preoperatively. Receiver-operating characteristic curve analysis was used to determine the cut-off for preoperative LMR values. Based on the cut-off point, patients were divided into a high LMR group (n = 34) and a low LMR group (n = 128). The clinical data of the two groups were compared, and further stratified analysis was performed.

RESULTS

A total of 162 patients were included in the analysis. All patients were successfully implanted with a thoracic aorta stent graft. The preoperative LMR level and postoperative endoleak-related secondary intervention rate were higher in the type I endoleak group than those in the group without intraoperative type I endoleaks. The preoperative C-reactive protein (CRP) level of patients with TAA with clinical symptoms was higher than that of asymptomatic patients. There was a negative correlation between preoperative CRP and LMR levels. In addition, in symptomatic or asymptomatic patients, the LMR level was associated with the occurrence of intraoperative type I endoleaks. After excluding the influence of type of endografts, our results showed that the clinical symptoms did not affect the occurrence of the intraoperative type I endoleak, and patients with intraoperative type I endoleak had a higher rate of postoperative secondary intervention.

CONCLUSION

Patients with TAA with type I endoleaks during TEVAR had an increased rate of secondary intervention related to endoleaks. Patients with TAA with high LMR levels before TEVAR were more likely to have endoleaks during operation.

Increased Circulating Angiopoietin-Like Protein 8 Levels Are Associated with Thoracic Aortic Dissection and Higher Inflammatory Conditions

Purpose

Thoracic aortic dissection (TAD) is characterized by an inflammatory response. Angiopoietin-like protein 8 (ANGPTL8) is a hormone involved in the regulation of lipid metabolism and inflammation. However, the relationship between ANGPTL8 and TAD remains unknown.

Methods

This case-control study included 78 TAD patients and 72 controls. The aortic diameter was evaluated by computed tomography and used to assess TAD severity. Circulating ANGPTL8 levels were measured by enzyme-linked immunosorbent assay. Associations of ANGPTL8 with TAD were determined by multivariate logistic regression.

Results

Serum ANGPTL8 levels were significantly higher in TAD patients compared with controls (562.50 ± 20.84 vs. 419.70 ± 22.65 pg/mL, respectively; P < 0.001). After adjusting for confounding factors, circulating ANGPTL8 levels were an independent risk factor for TAD (odds ratio = 1.587/100 pg ANGPTL8, 95% confidence interval [CI] = 1.121–2.247, P < 0.001) and positively associated with diameter (β = 1.081/100 pg ANGPTL8, 95% CI = 0.075–2.086, P = 0.035) and high-sensitivity C-reactive protein (hs-CRP) (β = 0.845/100 pg ANGPTL8, 95% CI = 0.020–1.480, P = 0.009). The area under the curve (AUC) on receiver operating characteristic (ROC) analysis of the combination of ANGPTL8, hs-CRP, and D-dimer was 0.927, and the specificity and sensitivity were 98.46% and 79.49%, respectively. ANGPTL8 was significantly increased in TAD tissue compared with controls. In vitro, ANGPTL8 was increased in angiotensin II (AngII)-treated macrophages and vascular smooth muscle cells (VSMCs), while ANGPTL8 siRNA-mediated knockdown decreased inflammatory factors in AngII-treated macrophages and decreased apoptosis in AngII-treated VSMCs.

Conclusion

ANGPTL8 is associated with TAD occurrence and development, which may involve pro-inflammatory effects on macrophages. ANGPTL8 combined with D-dimer and hs-CRP might be a useful clinical predictor of TAD.

Trial Registration

ChiCTR-COC-17010792 http://www.chictr.org.cn/showproj.aspx?proj=18288

Electronic supplementary material

The online version of this article (10.1007/s10557-019-06924-7) contains supplementary material, which is available to authorized users.

Relationship of Platelet Counts and Inflammatory Markers to 30-Day Mortality Risk in Patients with Acute Type A Aortic Dissection

Markers of prothrombotic state and inflammation are associated with the prognosis of patients with acute type A aortic dissection (AAAD). However, it is unclear that the relationship between these biomarkers and their combined impact on risk stratification. The present study evaluated the prognostic value of platelet counts, lymphocyte to neutrophil ratio (LNR), and lymphocyte to monocyte ratio (LMR), alone and in combination. A retrospective analysis of clinical data of 744 AAAD patients was conducted to identify whether these biomarkers were related to the 30-day mortality risk. A Kaplan-Meier analysis and log-rank test were used to compare survival between groups. A Cox hazard regression multivariable analysis was performed for 30-day mortality. Individual biomarker (platelet count, LNR, or LMR) was unable to predict 30-day mortality. However, combinations of all three biomarkers provided additive predictive value over either marker alone, the receiver operating characteristic (ROC) model had a prediction probability of 0.739 when platelet counts, LNR, and LMR were included. Cox hazard regression multivariable analysis showed that combinations of all three biomarkers were the strongest predictor of 30-day mortality (p < 0.021). Combined with these three easily measurable biomarkers at admission, they could help identify AAAD patients with a high risk of 30-day mortality.

A nomogram for predicting in-hospital mortality in acute type A aortic dissection patients

Background

Although there are several biomarkers for identifying in-hospital mortality in acute type A aortic dissection (AAD), timely as well as perfect prediction in-hospital mortality is still not attained. Herein, we intend to develop as well to validate an in-hospital mortality risk independent predictive nomogram for AAD patients.

Methods

From January 2014 to December 2018, 703 individuals with AAD were involved in this study. They were indiscriminately categorized into training (n=520) and validation (n=183) sets. The univariate and multivariate analyses were used to screen in-hospital mortality predictors from the entire training set data. The predictors were used to establish a nomogram which was confirmed via internal as well as external authentication. This validation included discriminative capacity defined by the receiver operating characteristic (ROC) curve area under the curve (AUC) and the predictive precision via calibration curves.

Results

There was 33.43% in-hospital mortality overall incidence. The uric acid, D-dimer, C-reactive protein and management were individually related to in-hospital mortality as per multivariate logistic regression. On the basis of four variables with internal of AUC 0.901 and external validation of AUC 0.903, a nomogram was established. Calibration plots showed that the predicted and actual in-hospital mortality probabilities were fitted well on both internal and external validation.

Conclusions

This recommended nomogram can calculate the specific possibility of in-hospital mortality with good precision, high discrimination, and probable clinical application in AAD patients.

Prognostic Role of Admission C-Reactive Protein Level as a Predictor of In-Hospital Mortality in Type-A Acute Aortic Dissection: A Meta-Analysis

BACKGROUND

Acute aortic dissection (AD) is a lethal vascular disease, accounting for over 90% cases of acute aortic syndrome. Despite advances in understanding associated risk factors, the long-term prognosis for AD patients is still poor. Several prognostic biomarkers have been used for AD as per the IRAD, such as older age (>70 years), onset of chest pain and hypotension, but they are not effective in all patients. Instead, C-reactive protein (CRP) is a consistent inflammatory marker. CRP levels are abnormally increased in AD. However, the prognostic value of serum CRP level in AD remains unclear.

OBJECTIVE

To perform a systematic review and meta-analysis (registration no CRD42017056205) to evaluate whether CRP is a biomarker associated with in-hospital mortality in type-A AD.

METHODS

PubMed, Web of Science, CNKI, SciELO, and EMBASE were searched for papers published from January 2000 to October 2017 for studies on the prognostic role of CRP at admission in type-A AD patients. Outcome data were extracted and pooled hazard ratios (HRs) were calculated.

RESULTS

18 (N = 2875 patients) studies met the inclusion criteria. Elevated CRP level was associated with a significantly increased risk of in-hospital mortality in patients with type-A AD (HR = 1.15, 95% CI: 1.06-1.25, p = 0.001). The pooled sensitivity of CRP in type-A AD patients was 77% (95% CI 69%-84%, p < 0.001), and the specificity was 72% (95% CI 66%-78%, p < 0.001).

CONCLUSION

Elevated CRP level is significantly associated with increased risks of in-hospital mortality in patients with type-A AD. CRP is a convenient prognostic factor in type-A AD patients.

Serum levels of matrix metalloproteinase 9 and toll-like receptor 4 in acute aortic dissection: a case-control study

Background

Matrix metalloproteinase 9 (MMP9) and Toll-like receptor 4 (TLR4) play important roles in aortic pathophysiology. However, there is lacking research on serum TLR4 levels in acute aortic dissection (AAD) patients, and the performance of serum MMP9 and TLR4 for the diagnosis of AAD is still unknown. This study aimed to evaluate the serum levels of MMP9 and TLR4 in AAD patients, identify their associations with circulating C-reactive protein (CRP) and D-dimer, which are well-known classical biomarkers of AAD, and further explore the potential diagnostic role of MMP9 and TLR4 in AAD.

Methods

Serum levels of MMP9 and TLR4 were measured by enzyme-linked immunosorbent assay (ELISA) in 88 AAD patients and 88 controls. The clinical test related information was collected from patients’ electronic medical records.

Results

Serum MMP9 and TLR4 levels were significantly higher in AAD patients than those in healthy controls in the general and stratified comparisons. Either serum MMP9 or TLR4 was independently associated with the risk of AAD (all p < 0.001). There was a positive significant association between serum MMP9 and TLR4 (r = 0.518, p < 0.001). Both MMP9 and TLR4 levels were statistically correlated with circulating CRP, but not D-dimer. Based on receiver-operating characteristic (ROC) analysis, the area under the curves (AUCs) of MMP9 and TLR4 alone for the diagnosis of AAD were 0.810 and 0.799 with optimal cut-off points of 379.47 ng/ml and 7.83 ng/ml, respectively. Moreover, a combination of serum MMP9 and TLR4 increased the AUC to 0.89 with a sensitivity of 60.2% and specificity of 94.3%.

Conclusions

Serum MMP9 and TLR4 could be potential biomarkers for identifying AAD, while the combined diagnostic value was higher in safely ruling out AAD.

Inflammation is related to preoperative hypoxemia in patients with acute Stanford type A aortic dissection

Background

Preoperative hypoxemia is a frequent complication of acute Stanford type A aortic dissection (ATAAD). The aim of the present study was to determine which factors were associated with hypoxemia.

Methods

A series of data were collected in a statistical analysis to evaluate preoperative hypoxemia in patients with ATAAD. After retrospectively analyzing data for 172 patients, we identified the risk factors for preoperative hypoxemia. Hypoxemia was defined by an arterial partial pressure of oxygen to fraction of inspired oxygen (PaO₂/FiO₂) ratio of 200 or lower. Subsequent to identifying the patient population, a prospective study was conducted using ulinastatin as a preoperative intervention. The ulinastatin group received ulinastatin at a total dose of 300,000 units prior to surgery. All the pertinent factors were investigated through univariate and multiple logistic regression analysis.

Results

The factors associated with preoperative hypoxemia in ATAAD comprised the following: body mass index (BMI) ≥25; white blood cell count (WBC) and neutrophil counts; levels of C-reactive protein (CRP), D-dimer, and interleukin-6 (IL-6); ATAAD involving the celiac trunk, renal artery, or mesenteric artery. Logistic regression analysis showed that CRP and IL-6 levels were independent predictive factors. We found that ulinastatin effectively could improve oxygenation, since compared to the control group the oxygenation in the ulinastatin group was significantly improved.

Conclusions

Systemic inflammatory reactions played a vital role in preoperative hypoxemia after the onset of ATAAD. The oxygenation of the patient could be improved significantly by inhibiting the inflammatory response prior to surgery.

Association of Thyroid Function with Early/Mid-term Aorta-Related Adverse Events and Readmissions after Thoracic Endovascular Aortic Repair

The prognosis of patients after thoracic endovascular aortic repair (TEVAR) is affected by several clinical characteristics. This study aimed to evaluate whether thyroid hormones predicts early (30 days) and mid-term (12 months) aorta-related adverse events (ARAE) and readmissions (ARAR) in patients after TEVAR. A total of 338 continuous patients who underwent TEVAR were included and stratified based on quartile of free thyroxine (FT4) levels examined before surgery. The relationship of FT4 levels with early or mid-term ARAE and ARAR were assessed using univariate and multiple logistic regression analysis. The incidence of ARAE and ARAR were 2.7% and 4.1% within 30 days, and 8.9% and 13.5% within 12 months, respectively. After adjusting for confounders, the lowest FT4 quartile group were noted to be at significantly greater risk than the highest FT4 quartile group in early (OR 10.105, 95% CI 1.103 to 92.615, P = 0.041) and mid-term (OR 5.687, 95% CI 1.708 to 18.935, P = 0.005) ARAR, but not significantly different in early (OR 2.097, 95% CI 0.228 to 19.307, P = 0.513) and mid-term (OR 0.695, 95% CI 0.207 to 2.332, P = 0.556) ARAE. Thus, patients with low-normal FT4 levels after TEVAR are at greater risk of ARAR, but not ARAE, in both the early and the mid-term follow-up periods.

Significance of the thrombo-inflammatory status-based novel prognostic score as a useful predictor for in-hospital mortality of patients with type B acute aortic dissection

Background

Inflammation and thrombosis are associated with development and progression of acute aortic dissection (AAD). The aim of this study was to assess the prognostic significance of Simplified Thrombo-Inflammatory Prognostic Score (sTIPS), in patients with early phase type B AAD.

Methods

We retrospectively reviewed 491 patients with type B AAD between November 2012 and September 2015. sTIPS was calculated from the white blood cell count (WBC) and mean platelet volume to platelet count (MPV/PC) ratio, at the time of admission. Patients with both, WBC > 10 (10⁹/L) and MPV/PC ratio > 7.5 (10²fL/10⁹L^-1) were assigned a score of 2, while patients with high levels of either one or none of the above markers, were assigned scores of 1 and 0 respectively. Multivariable Cox regression analyses were used to investigate the associations between the score and hospital survival.

Results

Of the 491 type B AAD patients included in this analysis, 24 patients (4.9%) died during hospitalization. Kaplan-Meier analysis revealed that the cumulative mortality was significantly higher in patients with higher sTIPS (P = 0.001). Multivariable Cox regression analysis further indicated that higher sTIPS was a strong predictor of in-hospital mortality after eliminating all confounding factors (sTIPS 2: hazard ratio 4.704, 95%; confidence interval [CI] 1.184-18.685; P = 0.028; sTIPS 1: hazard ratio 1.918, 95%; CI 1.134-3.537; P = 0.045).

Conclusions

sTIPS at admission was a useful tool for stratifying the risk in type B AAD patients, for outcomes such as in-hospital mortality in the early phase.

Association of Plasma Pentraxin-3 Levels on Admission with In-hospital Mortality in Patients with Acute Type A Aortic Dissection

BACKGROUND

Acute aortic dissection is a life-threatening cardiovascular emergency. Pentraxin-3 (PTX3) is proposed as a prognostic marker and found to be related to worse clinical outcomes in various cardiovascular diseases. This study sought to investigate the association of circulating PTX3 levels with in-hospital mortality in patients with acute Type A aortic dissection (TAAD).

METHODS

A total of 98 patients with TAAD between January 2012 and December 2015 were enrolled in this study. Plasma concentrations of PTX3 were measured upon admission using a high-sensitivity enzyme-linked immunosorbent assay system. Patients were divided into two groups as patients died during hospitalization (Group 1) and those who survived (Group 2). The clinical, laboratory variables, and imaging findings were analyzed between the two groups, and predictors for in-hospital mortality were evaluated using multivariate analysis.

RESULTS

During the hospital stay, 32 (33%) patients died and 66 (67%) survived. The patients who died during hospitalization had significantly higher PTX3 levels on admission compared to those who survived. Pearson's correlation analysis demonstrated that PTX3 correlated positively with high-sensitivity C-reactive protein (hsCRP), maximum white blood cell count, and aortic diameter. Multivariate logistic regression analysis demonstrated that PTX3 levels, coronary involvement, cardiac tamponade, and a conservative treatment strategy are significant independent predictors of in-hospital mortality in patients with TAAD. The receiver operating characteristic curve analysis further illustrated that PTX3 levels on admission were strong predictors of mortality with an area under the curve of 0.89. A PTX3 level ≥5.46 ng/ml showed a sensitivity of 88% and a specificity of 79%, and an hsCRP concentration ≥9.5 mg/L had a sensitivity of 80% and a specificity of 69% for predicting in-hospital mortality.

CONCLUSION

High PTX3 levels on admission are independently associated with the in-hospital mortality in patients with TAAD.

Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database

This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.

Aortic dissection

Aortic dissection is a life-threatening condition caused by a tear in the intimal layer of the aorta or bleeding within the aortic wall, resulting in the separation (dissection) of the layers of the aortic wall. Aortic dissection is most common in those 65-75 years of age, with an incidence of 35 cases per 100,000 people per year in this population. Other risk factors include hypertension, dyslipidaemia and genetic disorders that involve the connective tissue, such as Marfan syndrome. Swift diagnostic confirmation and adequate treatment are crucial in managing affected patients. Contemporary management is multidisciplinary and includes serial non-invasive imaging, biomarker testing and genetic risk profiling for aortopathy. The choice of approach for repairing or replacing the damaged region of the aorta depends on the severity and the location of the dissection and the risks of complication from surgery. Open surgical repair is most commonly used for dissections involving the ascending aorta and the aortic arch, whereas minimally invasive endovascular intervention is appropriate for descending aorta dissections that are complicated by rupture, malperfusion, ongoing pain, hypotension or imaging features of high risk. Recent advances in the understanding of the underlying pathophysiology of aortic dissection have led to more patients being considered at substantial risk of complications and, therefore, in need of endovascular intervention rather than only medical or surgical intervention.

Acute myocardial infarction due to spontaneous, localized, acute dissection of the sinus of Valsalva detected by intravascular ultrasound and electrocardiogram-gated computed tomography

A 58-year-old man was referred to our hospital because of chest pain. The 12-lead electrocardiogram (ECG) revealed ST-segment elevation in II, III, and a Vf with advanced heart block. Transthoracic echocardiography demonstrated aortic root dilatation at the sinus of Valsalva, moderate aortic regurgitation, and decreased wall motion in the inferior part of the left ventricle. Non-ECG-gated enhanced computed tomography (CT) did not reveal an aortic dissection. The patient underwent emergent coronary angiography, which revealed a severely narrowed ostium of the right coronary artery (RCA). Percutaneous coronary intervention (PCI) was performed under intravascular ultrasound (IVUS) guidance. IVUS images demonstrated an intimal flap extending from the aortic wall to the proximal RCA, suggesting that a periaortic hematoma in the false lumen compressed the ostium of the RCA, leading to acute myocardial infarction. To recover hemodynamic stability, the RCA ostium was stented. Subsequent ECG-gated enhanced CT clearly depicted the entry point and extension of the dissection localized within the sinus of Valsalva. The dissection likely involved the left main coronary artery and an emergent Bentall procedure was performed. Intraoperative findings confirmed an intimal tear and extension of the dissection. Thus, ECG-gated CT can clearly depict the entry site and extension of a dissection occurring in the localized area that cannot be detected by conventional CT.

Neutrophil to lymphocyte ratio: a novel marker for predicting hospital mortality of patients with acute type A aortic dissection

Introduction:

The inflammatory process has been reported to be associated with aortic dissection (AD) from the development to the prognosis. The aim of the study was to investigate a relationship between the neutrophil to lymphocyte ratio (NLR) and in-hospital outcomes in patients with acute aortic dissection (AAD) who underwent surgical repair.

Methods:

One hundred and eighty-four patients who were admitted with the diagnosis of type A AAD who underwent surgical repair at two large tertiary hospitals. According to their NLR, 91 patients had high NLR (>6.0) and 93 patients had low NLR (⩽6.0).

Results:

The frequency of major bleeding, hospital-related infection, multi-organ dysfunction and mortality in hospital were higher in the high NLR group compared to the low NLR group. NLR, WBC count and operation duration were found to be independent predictors for in-hospital mortality.

Conclusions:

The novel inflammatory marker NLR may be used to predict worse outcomes and hospital mortality in patients with AAD treated by surgical repair.

C-reactive protein, not cardiac troponin T, improves risk prediction in hypertensives with type A aortic dissection

BACKGROUND

The aim of the study was to evaluate prognostic role of inflammatory biomarkers, cardiac troponin T (cTnT) and D-dimer in type A acute aortic dissection (AAD) and to examine whether they might help in risk stratification beyond values of International Registry of Acute Aortic Dissection (IRAD) score.

METHODS

Baseline biomarkers were determined in 54 consecutive predominantly hypertensive patients with type A AAD and evaluated for in-hospital mortality.

RESULTS

After multivariable adjustment, the independent predictors of outcome were age (OR = 1.09; 95% CI 1.02-1.18), treatment strategy (OR = 0.11; 95% CI 0.02-0.06) and C-reactive protein (CRP) either as binary (OR = 7.06; 95% CI 1.34-37.36) or continuous variable (OR = 1.10; 95% CI 1.01-1.21). cTnT did not independently influence mortality. Receiver- operating characteristic (ROC) curve analysis showed significant link between CRP and outcome (area under the ROC curve, AUC = 0.79; p < 0.01). Values of CRP > 9.8 mg/l had 83% sensitivity and 80% specificity for predicting in-hospital mortality. Addition of CRP to IRAD score improved prediction of short-term outcome, AUC increased from 0.74 to 0.89 (p = 0.004).

CONCLUSION

Admission CRP has independent prognostic value in type A AAD and the addition of CRP to IRAD score improved discriminative capacity of in-hospital mortality irrespective of symptom duration and treatment strategy.

Time-dependent changes of plasma inflammatory biomarkers in type A aortic dissection patients without optimal medical management

Objectives

To investigate the time-dependent changes in plasma levels of interleukin-6, C-reactive protein, and tumor necrosis factor-α in patients with type A aortic dissection (TAAD) who received unoptimal medical management since the onset of dissections.

Design and methods

Plasma levels of interleukin-6, C-reactive protein, and tumor necrosis factor-α were detected by ELISA and immuno-turbidimetric assay in 92 TAAD patients at hospital admission. Blood samples from 78 patients with uncontrolled hypertension and 82 healthy volunteers were also analyzed as controls. The occurrence of TAAD-related complication and its relationship with the plasma levels of these inflammatory biomarkers was also investigated.

Results

The concentrations of inflammatory mediators were significant higher in TAAD than those in the uncontrolled hypertension and the healthy group. The time to peak plasma level of IL-6.and TNF-α was shorter than that of CRP in TAAD group. In the TAAD group, 51 patients suffered TAAD-related complications, and their plasma level of CRP was significantly higher than that in patients without TAAD-related complications (94.5 ± 58.8 mg/L versus 47.4 ± 47.8 mg/L, p < 0.001). Also, CRP levels strongly correlated with the value of PaO₂/FiO₂ ratio (r = −0.69, p < 0.001) and creatinine (r = 0.60, p < 0.001). The time to the peak level of CRP was shorter and the duration of persistently high CRP level was longer in the complication group than those in the complication-free group.

Conclusions

Elevated and persistently high levels of plasma CRP, IL-6 and TNF-α were associated with progressively development of the TAAD. The changing pattern of CRP might be a marker for diagnosis and prophylactic treatment of complications. Our findings suggested a critical role of the inflammation in the progression of dissection and TAAD-related complications.

Biomarkers for the diagnosis of aortic dissection

This review discusses the role of biomarkers for both diagnoses and disease monitoring before, during, and after treatment of aortic dissection.

Implications of pentraxin 3 levels in patients with acute aortic dissection

Acute aortic dissection (AAD) causes transient inflammation with occasional pleural fluid (PF) accumulation. Although pentraxin 3 (PTX3) is a vascular inflammation-related biomarker, little is known about PTX3 levels in patients with AAD. We explored the serial changes in plasma PTX3 levels and the association of peak levels with the amount of PF accumulation. Consecutive patients (n = 41) with Stanford type B AAD were enrolled, and blood samples for the measurements of serum albumin, plasma PTX3 and high-sensitivity C-reactive protein (CRP) were collected daily until 7 days after symptom onset. PF accumulation on computed tomography imaging on the third hospital day was divided into 3 grades (I: none or slight, II: mild in the uni- or bilateral pleural cavity, III: moderate or more). PTX3 and CRP levels were analyzed after logarithmic transformation because of their skewed distributions. Peak PTX3 and CRP levels were observed at 4.3 ± 2.1 and 4.7 ± 2.0 days after symptom onset, and their values were 12.2 [interquartile range (IQR), 8.2-20.9] ng/mL and 12.0 (IQR, 8.6-15.2) mg/dL, respectively. On univariate analysis, the peak level of PTX3 had a negative correlation with the minimum level of serum albumin, and a positive correlation with PF grade and duration of intensive care unit stay. On multivariate analysis, the peak level of PTX3 was correlated with PF grade (P = 0.037). In conclusion, the peak level of PTX3 in patients with AAD was associated with the amount of transient PF accumulation, which may be associated with inflammatory vascular permeability.

Slowly progressive and painless thoracic aortic dissection presenting with a persistent Fever in an elderly patient: the usefulness of combined measurement of biochemical parameters

Aortic dissection is a fatal medical condition that requires urgent diagnosis and appropriate intervention. Because acute aortic dissection often manifests as sudden onset excruciating chest pain, physicians can easily reach a proper diagnosis. However, some patients with aortic dissection present with varied clinical manifestations without exhibiting typical chest pain, leading to a delayed diagnosis and possible fatality. We herein present the case of an elderly subject with a fever of unknown origin who was ultimately diagnosed with aortic dissection. In the present case, a negative procalcitonin test, increased D-dimer and serum creatinine phosphokinase-BB levels, and reelevation of the CPR level led us to the correct diagnosis.