Prognostic factors and prediction models for acute aortic dissection: a systematic review

Correlation analysis of gamma-glutamyl transferase to lymphocyte ratio and patients with acute aortic syndrome in China: a propensity score-matched analysis

Background and objectives

Acute aortic syndrome (AAS) is a life-threatening condition in which there is a fracture in the integrity of the aortic wall. gamma-glutamyl transferase to lymphocyte ratio (GLR) is recognized as a risk factor for liver cirrhosis, fibrosis, and hepatocellular carcinoma. However, there are no clinical reports of GLR and AAS. We attempted to determine whether GLR level is associated with AAS in patients from the Chaoshan region of southern China.

Methods

A total of 2,384 patients were recruited in this study and were divided into AAS and no-AAS groups according to the results of CT angiography of the thoracoabdominal aorta. Univariate and multivariate logistic regression was performed to identify risk factors for the occurrence of AAS. ROC was applied to assess the value of D-Dimer, GLR alone, or in combination for the diagnosis of AAS. And a 1:1 propensity score-matched analysis was performed.

Results

Multivariate logistics regression analysis indicated that male, age, hypertension, diabetes, creatinine, D-dimer, and GLR were independent risk factors of AAS patients in the before propensity score-matching cohort. After propensity score-matching, it showed that D-dimer, GLR [OR 3.558(1.891, 6.697); p < 0.001] were independent risk factors of AAS patients. Before propensity score-matching, the area under the curve (AUC) was 0.822 of GLR and 0.767 of D-dimer. When both clinical backgrounds were adjusted, the AUC was 0.773 of GLR and 0.631 of D-dimer. GLR showed high specificity (80.5% and 77.1%), and D-dimer showed high sensitivity (84.7% and 73.6%) in the before and after propensity score-matching cohort.

Conclusion

GLR and D-dimer were independent risk factors of acute aortic syndrome. D-dimer in combination with GLR is more valuable than a single indicator for diagnosing acute aortic syndrome.

Short- and Long-term survival prediction in patients with acute type A aortic dissection undergoing open surgery

BACKGROUND

Acute Type A aortic dissection (ATAAD) is a life-threatening cardiovascular disease associated with high mortality rates, where surgical intervention remains the primary life-saving treatment. However, the mortality rate for ATAAD operations continues to be alarmingly high. To address this critical issue, our study aimed to assess the correlation between preoperative laboratory examination, clinical imaging data, and postoperative mortality in ATAAD patients. Additionally, we sought to establish a reliable prediction model for evaluating the risk of postoperative death.

METHODS

In this study, a total of 384 patients with acute type A aortic dissection (ATAAD) who were admitted to the emergency department for surgical treatment were included. Based on preoperative laboratory examination and clinical imaging data of ATAAD patients, logistic analysis was used to obtain independent risk factors for postoperative in-hospital death. The survival prediction model was based on cox regression analysis and displayed as a nomogram.

RESULTS

Logistic analysis identified several independent risk factors for postoperative in-hospital death, including Marfan syndrome, previous cardiac surgery history, previous renal dialysis history, direct bilirubin, serum phosphorus, D-dimer, white blood cell, multiple aortic ruptures and age. A survival prediction model based on cox regression analysis was established and presented as a nomogram. The model exhibited good discrimination and significantly improved the prediction of death risk in ATAAD patients.

CONCLUSIONS

In this study, we developed a novel survival prediction model for acute type A aortic dissection based on preoperative clinical features. The model demonstrated good discriminatory power and improved accuracy in predicting the risk of death in ATAAD patients undergoing open surgery.

Analysis of serum calcium change trajectories and prognostic factors in patients with acute type A aortic dissection

OBJECTIVES

This study aimed to analyze the correlation between serum calcium changes and short-term prognosis of patients with acute type A aortic dissection.

METHODS

Patients who underwent acute type A aortic dissection surgery at Fujian Heart Medical Center between June 2019 and June 2021 were retrospectively analyzed.

RESULTS

A total of 383 patients were enrolled. According to the changing track of serum calcium in patients after acute type A aortic dissection, three potential category tracks were determined: high-level (n = 85), medium-level (n = 259), and continuous low-level groups (n = 39). Using the medium-level group as the control, regression analysis showed that poor prognosis risk was increased in the group with continuous low serum calcium (odds ratio = 2.454, P < 0.05) and in the group with continuous low serum calcium > 48 h (odds ratio = 3.595, P < 0.05). Age (odds ratio = 1.063, P < 0.001), body mass index (odds ratio = 1.138, P < 0.05), hypertension (odds ratio = 3.697, P < 0.05), and the highest lactic acid within 72 h after surgery(odds ratio = 1.093, P < 0.05) were independent risk factors for poor prognosis after aortic dissection.

CONCLUSION

Continuous low serum calcium was an independent predictor of poor prognosis in patients with acute type A aortic dissection.

Integrated bulk and scRNA sequence identified anoikis-related diagnostic biomarkers and potential association with immune infiltration in type A aortic dissection

Type-A aortic dissection (TAAD) is common life-threatening cardiovascular diseases with high-morbidity and mortality but the concrete etiology of disease remains unclear, which might disturb or delay the early diagnosis for TAAD. Anoikis is a special form of programmed cell-death (PCD) induced by detachment of anchorage-dependent cells from the extracellular matrix (ECM) or neighboring cells, and has been widely applied to identify anoikis-related biomarkers for the prediction and prognosis in oncological fields. However, the specific roles of anoikis-related genes (ARGs) in TAAD remain unclear. In this study, we first identified and validated eight diagnostic ARGs for TAAD based on multiple RNA-sequence datasets, including CHEK2, HIF1A, HK2, HMGA1, SERPINA1, PTPN1, SLC2A1 and VEGFA. The comprehensive functional annotation was evaluated by the integrated functional enrichments analysis. We identified the activation of inflammatory-related pathways, metabolic reprogramming and angiogenesis, and the inhibition of cardiovascular development pathways in TAAD. Immune cell infiltration (ICI) analysis further demonstrated that innate immune-cells were more dominant than adaptive immune-cells in TAAD tissues, especially in macrophages, monocytes, activated-DC, NKT cells and CD56+dim NK cells. The cellular landscape was further validated by single-cell RNA sequence technology with significant associations with anoikis in TAAD patients. Four vital ARGs (HIF1A, HMGA1, SERPINA1 and VEGFA) were ultimately identified along with the changes of differentiation trajectory, and major expressions were conformably concentrated on Macro1-3, Mono1-2 and Mono4 subtypes. These findings provide a promising diagnostic biomarker for the accurately diagnosing the disease and would be helpful to further explore the potential pathogenesis with anoikis process for TAAD.

Association of troponin I and macrophages in cardiac tamponade with Stanford type A aortic dissection

Background

Acute aortic dissection has a high mortality rate, especially for Stanford type A with a dissected ascending aorta. Cardiac tamponade is one of the most common complications of acute type A aortic dissection (ATAAD) and can cause death. However, the pathogenesis is often unclear. We aimed to examine laboratory findings at the onset of disease and macrophage involvement.

Methods

Hematological and biochemical parameters, and D-dimer, brain natriuretic peptide (BNP), and high-sensitivity troponin I (hs-cTnI) levels in 70 patients with ATAAD at our hospital were investigated. Additionally, the myocardium and aorta after autopsy of an ATAAD case with cardiac tamponade were pathologically examined.

Results

Forty-four ATAAD cases were complicated by cardiac tamponade. The mean age of patients with cardiac tamponade and proportion of patients over 70 years of age were both significantly higher than for those without cardiac tamponade. Evaluable D-dimer values were higher than 0.5 μg/mL in all patients. Significantly elevated laboratory parameters in patients with cardiac tamponade included: lactate dehydrogenase, aspartate aminotransferase, C-reactive protein, lactate, BNP, and hs-cTnI. However, multivariate analysis showed only hs-cTnI was significantly associated with cardiac tamponade. Histological examination revealed numerous M2-like macrophages infiltrating the myocardium and dissecting aorta, expressing CC chemokine ligand (CCL)2 together with vascular endothelial growth factor-C and matrix metalloproteinase-9. The peripheral monocyte-to-neutrophil ratio (MNR) was also significantly higher in cardiac tamponade.

Conclusions

In ATAAD patients with cardiac tamponade, hs-cTnI was significantly elevated and CCL2 expression was observed, which may be involved in the expression of M2-like macrophages via an increased MNR.

Clinical Characteristics and Outcomes of Aortic Arch Emergencies: Takayasu Disease, Fibromuscular Dysplasia, and Aortic Arch Pathologies: A Retrospective Study and Review of the Literature

Non-atherosclerotic aortic arch pathologies (NA-AAPs) and anatomical variants are characterized as rare cardiovascular diseases with a low incidence rate, below 1 case per 2000 population, but enormous heterogeneity in terms of anatomical variants, i.e., Takayasu disease (TAK) and fibromuscular dysplasia (FMD). In specific clinical scenarios, NA-AAPs constitute life-threatening disorders.

METHODS

In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed.

RESULTS

The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11-1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59-0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74-9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis.

CONCLUSIONS

This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients.

TG/HDL-C ratio predicts in-hospital mortality in patients with acute type A aortic dissection

Background

In recent years, abnormalities in serum lipids and lipoproteins have been shown to be associated with cardiovascular disease risk. However, their prognostic value for acute type A aortic dissection is unclear. This study analyzed the correlation between triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) ratio and in-hospital mortality in patients with AAAD, and aimed to investigate the clinical significance of preoperative blood lipids and lipoproteins on the prognosis of acute type A aortic dissection.

Methods

A total of 361 patients who underwent type A aortic dissection surgery in Fujian Cardiac Medical Center from June 2018 to March 2020 were retrospectively collected. According to the baseline TG/HDL-C ratio, the patients were divided into 3 groups according to the tertile method, the low TG/HDL-C ratio T1 group (< 1.18) and the middle TG/HDL-C ratio T2 group (1.18–1.70). T3 group with high TG/HDL-C ratio (> 1.70). Kaplan–Meier was used for survival analysis, and Cox proportional hazards regression model was used to analyze the factors affecting the prognosis of patients. The receiver operating characteristic (ROC) curve was used for the diagnostic efficacy.

Results

Among the 361 patients in this study, the mean age was 52.4 ± 11.3 years, 73 (20.2%) were female, and 82 (22.7%) died in hospital. Kaplan–Meier curve showed that with the increase of TG/HDL-C ratio, the risk of in-hospital death gradually increased (P < 0.001). Multivariate Cox regression analysis showed that age (HR = 1.031), body mass index (HR = 1.052), hypertension (HR = 3.491), white blood cells (HR = 1.073), TG/HDL-C ratio (HR = 1.604), MODS (HR = 1.652) was positively correlated with in-hospital mortality (P < 0.05). After adjusting for age, sex, and other risk factors, a significant association was found between the TG/HDL-C ratio and in-hospital mortality for acute type A aortic dissection (HR = 1.472, 95% CI, 1.354–3.451, P = 0.019).

Conclusion

Patients with type A aortic dissection have obvious abnormal blood lipid metabolism, and serum TG/HDL-C levels are positively correlated with in-hospital mortality in patients with AAAD.

Outpatient management of patients after surgical operations for acute aortic dissection of type A

Acute aortic dissection of type A is still one of the most difficult diseases faced by doctors of all specialties. The current review is based on an analysis of current literature data and clinical guidelines. It covers various aspects of outpatient patient management and focuses on conservative therapy. The lack of an adequate diagnostic algorithm often leads to complications and, ultimately, death. The dynamic nature of the disease, the variability of clinical manifestations and the course of the pathological process require special attention. Both short-term and long-term survival of the patient depends on careful observation. Postoperative management of patients with acute aortic dissection of type A is entirely entrusted to the outpatient unit, which, due to the absence of the main aspects of the strategy in modern clinical recommendations, is not always prepared for the curation of this complex cohort of patients. The lack of experience in managing this pathology by outpatient hospital doctors causes significant difficulties in interpreting instrumental diagnostic methods, which leads to further erroneous tactics with the development of long-term complications. Due to the lack of a unified scheme of drug therapy, the question of prescribing drugs in these patients, who often receive a fairly large range of medications for concomitant pathology, remains open. These factors contribute to polyprogmasia or vice versa – insufficient volume of drug therapy, which further leads to the progression of the disease. As a result of insufficient emphasis on the basics of outpatient management of this cohort of patients, a whole complex of problems arises, leading to unsatisfactory treatment results and increased healthcare costs for their subsequent solution. The purpose of the review is to highlight the main problems of this issue from the point of view of evidence-based medicine.

Preliminary evaluation of the Chinese version of the patient-reported outcomes measurement information system 29-item profile in patients with aortic dissection

BACKGROUND

The Patient-Reported Outcomes Measurement Information System 29-item Profile (PROMIS-29) has been widely used to measure health outcomes from the patient's perspective. It has not been validated in adults with aortic disease. The aim of this study was to explore the reliability and validity of the Chinese PROMIS-29 among patients undergoing surgery for aortic dissection (AD).

METHODS

A cross-sectional design was applied. Eligible patients completed a questionnaire that contained the PROMIS-29 and legacy measures, including the Short Form-12 Health Survey (SF-12), 8-item Somatic Symptom Scale (SSS-8), Generalized Anxiety Disorder-2 (GAD-2), and Patient Health Questionnaire-2 (PHQ-2). The structural validity of the PROMIS-29 was evaluated using confirmatory factor analysis (CFA). Reliability was evaluated with Cronbach's α. Construct validity was assessed by calculating Spearman's rank correlations and comparing known-group differences.

RESULTS

In total, a sample of 327 AD patients was included in the final analysis. Most of them were male (89%) with a mean age of 52.7 (± 10.3). CFA revealed good model fit of the seven-factor structure within PROMIS-29, as well as most domains in single-factor analysis. Reliability was confirmed with Cronbach's α > 0.90. Correlations between comparable domains of the PROMIS-29 and those of legacy questionnaires and most know-group comparisons were observed as hypothesized.

CONCLUSIONS

This study found evidence for acceptable structural validity, construct validity and internal consistency of the PROMIS-29 in a sample of AD patients. It can be applied to AD survivors by researchers or clinicians, measuring outcomes after surgery and identifying those with worse health status.

Early Prediction Model of Acute Aortic Syndrome Mortality in Emergency Departments

Purpose

Acute aortic syndrome is a constellation of life-threatening medical conditions for which rapid assessment and targeted intervention are important for the prognosis of patients who are at high risk of in-hospital death. The current study aims to develop and externally validate an early prediction mortality model that can be used to identify high-risk patients with acute aortic syndrome in the emergency department.

Patients and Methods

This retrospective multi-center observational study enrolled 1088 patients with acute aortic syndrome admitted to the emergency departments of two hospitals in China between January 2017 and March 2021 for model development. A total of 210 patients with acute aortic syndrome admitted to the emergency departments of Peking University Third Hospital between January 2007 and December 2021 was enrolled for model validation. Demographics and clinical factors were collected at the time of emergency department admission. The predictive variables were determined by referring to the results of previous studies and the baseline analysis of this study. The study’s endpoint was in-hospital death. To assess internal validity, we used a fivefold cross-validation method. Model performance was validated internally and externally by evaluating model discrimination using the area under the receiver-operating characteristic curve (AUC). A nomogram was developed based on the binary regression results.

Results

In the development cohort, 1088 patients with acute aortic syndromes were included, and 88 (8.1%) patients died during hospitalization. In the validation cohort, 210 patients were included, and 20 (9.5%) patients died during hospitalization. The final model included the following variables: digestive system symptoms (OR=2.25; P=0.024), any pulse deficit (OR=7.78; P<0.001), creatinine (µmol/L)(OR=1.00; P=0.018), lesion extension to iliac vessels (OR=4.49; P<0.001), pericardial effusion (OR=2.67; P=0.008), and Stanford type A (OR=10.46; P<0.001). The model’s AUC was 0.838 (95% CI 0.784–0.892) in the development cohort and 0.821 (95% CI 0.750–0.891) in the validation cohort, and the Hosmer–Lemeshow test showed p=0.597. The fivefold cross-validation demonstrated a mean accuracy of 0.94, a mean precision of 0.67, and a mean recall of 0.13.

Conclusion

This risk prediction tool uses simple variables to provide robust prediction of the risk of in-hospital death from acute aortic syndrome and validated well in an independent cohort. The tool can help emergency clinicians quickly identify high-risk acute aortic syndrome patients, although further studies are needed for verifying the prospective data and the results of our study.