D-dimer as a prognostic factor in patients admitted to a tertiary care intensive coronary care unit

Introduction

D-dimer is a small protein fragment and is a product of fibrinolysis. A high levels of D-dimer have been suggested as a prognostic factor in cancerous and other critically ill patients. We aimed to evaluate D-dimer levels and outcomes of critically ill patients admitted to a tertiary care intensive coronary care unit (ICCU).

Material and method

All patients admitted to the ICCU at our Medical Center between January 1, 2020 and December 31, 2020 were included in the study. Patients were divided into 2 groups according to their D-dimer level on admission. Low D-dimer level <500 ng/ml, and high D-dimer level ≥500 ng/ml. Survival, in-hospital interventions and complications were compared.

Results and discussion

Overall 1,082 consecutive patients were included, mean age was 67 (±16), 70% were males. Of them 296 (27.4%) had low D-dimer level and 663 (61.3%) had high D-dimer level. Patients with high D-dimer level were older as compared to patients with low D-dimer level (mean age 70.4±15 and 59±13 years respectively, p=0.004), had significantly higher rate of female gender (35.9% vs 15.9% respectively, p<0.0001) and significantly higher rate of any prior cardiac interventions prior to their admission (26.7% vs 4.4% respectively, p<0.0001). Interestingly, patients with high D-dimer level had significantly lower rate of any acute coronary syndrome (ACS) as compared with the low D-dimer group (25.7 vs 66.4% respectively, p<0.0001) and lower rate of smokers (22.5 vs 45.6% respectively, p<0.0001). All 11 post-COVID-19 patients had high D-dimer level on admission.

A multivariate Cox proportional hazards analysis for mortality, adjusted for age, gender, risk factors for cardiovascular disease, ejection fraction<40 found that high D-dimer level was independently associated with higher mortality rates (HR=5.8; 95% CI; 1.7–19.1; p=0.004) as shown in Figure 1.

Conclusion

Elevated D-dimer levels on admission in ICCU patients is a poor prognostic factor of in-hospital morbidity and mortality in the first year following hospitalization.

Funding Acknowledgement

Type of funding sources: None. Cumulative survival according to d-Dimer

MitraClip therapy in patients with acute severe mitral regurgitation

Background

There is a lack of data to support the optimal management of high-risk patients with acute severe mitral regurgitation (MR). The role of the MitraClip implantation in treatment of acute severe mitral regurgitation (MR) is undetermined.

Methods

We screened all patients who underwent MitraClip implantation at the Hadassah Medical Center between October 2015 and December 2019. We evaluated immediate, 30-day and 1-year outcomes after the procedure. We evaluated patients with severe MR due to ruptured cord because of degenerative disease and acute-on-chronic functional MR due to ischemic (after a recent myocardial infarction (MI)) or non-ischemic etiology (secondary to decompensated HF).

Results

From a cohort of 151 patients, who underwent MitraClip implantation in our center, we identified 35 patients (23.2%) with acute severe mitral regurgitation (4+) and decompensated refractory heart failure. Patients' mean age was 74.15 years, 66.9% - were males. One, 2, or 3 clips were implanted. Reduction of MR from 4+ to 1+ was achieved in 34 patients (66.7%). Twenty-eight patients (80%) had acute-on-chronic severe MR and refractory heart failure including 6 cases after recent MI, other 7 patients presented with heart failure and acute severe MR secondary to ruptured cord due to degenerative disease. After MitraClip implantation, reduction of MR severity was achieved in all patients. Seven patients were withdrawn from intravenous therapy and intra-aortic balloon pump 2–3 days after the procedure. Four patients died during hospitalization, three of them due to sepsis. 30-day follow-up showed improvement of NYHA functional class and a tendency toward improvement in left ventricle systolic function with signs of reverse remodeling. Nevertheless, we observed high 30-day and 1-year mortality rate (11.4 and 23.8% respectively).

Conclusions

MitraClip therapy could be an alternative option for treatment of patients with acute and acute-on-chronic severe MR of ischemic and non-ischemic etiology.

Funding Acknowledgement

Type of funding source: None

Echocardiographic and clinical outcomes of MitraClip therapy in patients with severe mitral regurgitation

Background

MitraClip implantation improves mitral regurgitation (MR), however its impact on pulmonary hypertension (PHT) is not fully elucidated. Our hypothesis was that changes in pulmonary pressure after MitraClip implantation might predict outcomes.

Methods

We studied a cohort of 149 consecutive patients who underwent MitraClip implantation between August 2015 and September 2019. We compared echocardiographic and clinical variables between a group with not-severe PHT and a group with severe PHT according to Pulmonary artery systolic pressure (PASP) >55 mmHg.

Results

Mean age of the cohort was 73±10 years, 75% were men, and 80% had functional MR. There are no differences in baseline characteristics between the two groups. There was a significant reduction of 13.6 mmHg in PASP at the severe PHT group from 68.2±10.9 mmHg before the procedure to 54.6±14.9 after (P=0.001) compared to the absence of a significant change in the second group. This reduction was maintained in the 6 months follow-up. Although PHT is considered a poor prognostic measure, and the severe PHT group had a baseline PASP higher than the not-severe group (P<0.001), however the Kaplan Meier curve did not show any significant difference in overall survival (p=0.468), and there is also no difference in one-year survival.

Conclusions

MitraClip therapy improves PASP in patients with severe MR and severe PHT. These patients showed the same survival as patients with not-severe PHT. MitraClip is a safety and effective procedure even for patients with severe PHT, that should not be excluded.

Funding Acknowledgement

Type of funding source: None