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An increased prothrombin time-international normalized ratio in patients with acute type A aortic dissection: contributing factors and their influence on outcomes

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Abstract

Purpose

We investigated factors contributing to coagulopathy in patients with acute type A aortic dissection (ATAAD) and coagulopathy’s influence on patient outcomes.

Methods

We grouped 420 patients who underwent ATAAD repair—none under anticoagulation therapy or with liver disease—by the prothrombin time-international normalized ratio (PT-INR) at admission:  <  1.2 (no coagulopathy, n  =  371), 1.2–1.49 (mild coagulopathy, n  =  33), or  ≥  1.5 (severe coagulopathy, n  =  16). We then compared the clinical presentation, dissection morphology, and outcomes among the groups. We assessed the PT-INR in relation to the preoperative hemodynamics and searched for factors predictive of a PT-INR  ≥  1.2.

Results

The transfusion volume and operation time were increased among patients with coagulopathy (P  <  0.05). The in-hospital mortality (15.2–37.5% vs. 5.1%, P  < 0.001) and 5-year survival (61.1–74.4% vs. 87.6%) were relatively poor for these patients. The median PT-INR was 1.03 (0.97–1.1) for patients with stable hemodynamics (n  =  318), 1.11 (1.02–1.21) for those in shock (blood pressure  <  80 mmHg) not given cardiopulmonary resuscitation (CPR) (n  =  81), and 1.1 (1.0–1.54) for those in shock given CPR (n  =  21) (P  < 0.001). A multivariable analysis identified shock (P  <  0.001), a partially thrombosed false lumen (P  =  0.006), and mesenteric malperfusion (P  =  0.016) as predictive variables.

Conclusions

Shock, a partially thrombosed false lumen, and mesenteric malperfusion appear to be predictive of dissection-related coagulopathy, which influences outcomes negatively.

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References

  1. Liu Y, Han L, Li J, Gong M, Zhang H, Guan X. Consumption coagulopathy in acute aortic dissection: principles of management. J Cardiothorac Surg. 2017;12:50.

    Article  Google Scholar 

  2. Guan XL, Wang XL, Liu YY, Lan F, Gong M, Li HY, et al. Changes in the hemostatic system of patients with acute aortic dissection undergoing aortic arch surgery. Ann Thorac Surg. 2016;101:945–51.

    Article  Google Scholar 

  3. Guan X, Li J, Gong M, Lan F, Zhang H. The hemostatic disturbance in patients with acute aortic dissection: a prospective observational study. Medicine. 2016;95:e4710.

    Article  Google Scholar 

  4. Paparella D, Rotunno C, Guida P, Malvindi PG, Scrascia G, De Palo M, et al. Hemostasis alterations in patients with acute aortic dissection. Ann Thorac Surg. 2011;91:1364–9.

    Article  Google Scholar 

  5. Nomura F, Tamura K, Yoshitatsu M, Katayama A, Katayama K, Ihara K. Changes in coagulation condition, cytokine, adhesion molecule after repair of type A aortic dissection. Eur J Cardiothorac Surg. 2004;26:348–50.

    Article  CAS  Google Scholar 

  6. Johansson PI, Stensballe J, Ostrowski SR. Shock induced endotheliopathy (SHINE) in acute critical illness—a unifying pathophysiologic mechanism. Crit Care. 2017;21:25.

    Article  Google Scholar 

  7. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54:1127–30.

    Article  Google Scholar 

  8. Holcomb JB, Minei KM, Scerbo ML, Radwan ZA, Wade CE, Kozar RA, et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients. Ann Surg. 2012;256:476–86.

    Article  Google Scholar 

  9. Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008;65:748–54.

    CAS  PubMed  Google Scholar 

  10. Chang R, Cardenas JC, Wade CE, Holcomb JB. Advances in the understanding of trauma-induced coagulopathy. Blood. 2016;128:1043–9.

    Article  CAS  Google Scholar 

  11. Frith D, Goslings JC, Gaarder C, Maegele M, Cohen MJ, Allard S, et al. Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations. J Thromb Haemost. 2010;8:1919–25.

    Article  CAS  Google Scholar 

  12. Oshiro A, Yanagida Y, Gando S, Henzan N, Takahashi I, Makise H. Hemostasis during the early stages of trauma: comparison with disseminated intravascular coagulation. Crit Care. 2014;18:R61.

    Article  Google Scholar 

  13. Itagaki R, Kimura N, Mieno M, Hori D, Itoh S, Akiyoshi K, et al. Characteristics and treatment outcomes of acute type A aortic dissection with elevated D-dimer concentration. J Am Heart Assoc. 2018;7:e009144.

    Article  CAS  Google Scholar 

  14. Kawahito K, Kimura N, Yamaguchi A, Aizawa K, Misawa Y, Adachi H. Early and late surgical outcomes of acute type A aortic dissection in octogenarians. Ann Thorac Surg. 2018;105:137–43.

    Article  Google Scholar 

  15. Kusadokoro S, Kimura N, Hori D, Hattori M, Matsunaga W, Itagaki R, et al. Utility of double arterial cannulation for surgical repair of acute type A dissection. Eur J Cardiothorac Surg. 2020;57:1068–75.

    Article  Google Scholar 

  16. Kimura N, Aizawa K, Kawahito K, Itagaki R, Yamaguchi A, Misawa Y, et al. Outcomes of early-onset acute type A aortic dissection—influence of etiologic factors. Circ J. 2019;83:285–94.

    Article  Google Scholar 

  17. Hazui H, Nishimoto M, Hoshiga M, Negoro N, Muraoka H, Murai M, et al. Young adult patients with short dissection length and thrombosed false lumen without ulcer-like projections are liable to have false-negative results of D-dimer testing for acute aortic dissection based on a study of 113 cases. Circ J. 2006;70:1589–601.

    Article  Google Scholar 

  18. Ohlmann P, Faure A, Morel O, Kindo M, Jesel L, Radulescu B, et al. Lower circulating Sta-Liatest D-Di levels in patients with aortic intramural hematoma compared with classical aortic dissection. Crit Care Med. 2009;37:899–901.

    Article  Google Scholar 

  19. Nagaoka K, Sadamatsu K, Yamawaki T, Shikada T, Sagara S, Ohe K, et al. Fibrinogen/fibrin degradation products in acute aortic dissection. Intern Med. 2010;49:1943–7.

    Article  CAS  Google Scholar 

  20. Roedl K, Spiel AO, Nurnberger A, Horvatits T, Drolz A, Hubner P, et al. Hypoxic liver injury after in- and out-of-hospital cardiac arrest: risk factors and neurological outcome. Resuscitation. 2019;137:175–82.

    Article  Google Scholar 

  21. Pan E, Wallinder A, Peterstrom E, Geirsson A, Olsson C, Ahlsson A, et al. Outcome after type A aortic dissection repair in patients with preoperative cardiac arrest. Resuscitation. 2019;144:1–5.

    Article  Google Scholar 

  22. Nakai C, Izumi S, Haraguchi T, Kikuta S, Nakayama S, Okita Y, et al. Acute type A aortic dissection with cardiopulmonary arrest at presentation. Ann Thorac Surg. 2021;112:1210–6.

    Article  Google Scholar 

  23. Davenport R, Khan S. Management of major trauma haemorrhage: treatment priorities and controversies. Br J Haematol. 2011;155:537–48.

    Article  CAS  Google Scholar 

  24. Di Eusanio M, Trimarchi S, Patel HJ, Hutchison S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013;145:385-901 e1.

    Article  Google Scholar 

  25. Kawahito K, Kimura N, Yamaguchi A, Aizawa K. Malperfusion in type A aortic dissection: results of emergency central aortic repair. Gen Thorac Cardiovasc Surg. 2019;67:594–601.

    Article  Google Scholar 

  26. Yang B, Norton EL, Rosati CM, Wu X, Kim KM, Khaja MS, et al. Managing patients with acute type A aortic dissection and mesenteric malperfusion syndrome: a 20-year experience. J Thorac Cardiovasc Surg. 2019;158:675-87.e4.

    Article  Google Scholar 

  27. Liu J, Sun LL, Wang J, Ji G. The relationship between fibrinogen and in-hospital mortality in patients with type A acute aortic dissection. Am J Emerg Med. 2018;36:741–4.

    Article  Google Scholar 

  28. Huang B, Tian L, Fan X, Zhu J, Liang Y, Yang Y. Low admission platelet counts predicts increased risk of in-hospital mortality in patients with type A acute aortic dissection. Int J Cardiol. 2014;172:e484–6.

    Article  Google Scholar 

  29. Huang B, Yang Y, Lu H, Zhao Z, Zhang S, Hui R, et al. Impact of d-Dimer levels on admission on in-hospital and long-term outcome in patients with type A acute aortic dissection. Am J Cardiol. 2015;115:1595–600.

    Article  CAS  Google Scholar 

  30. Girdauskas E, Kempfert J, Kuntze T, Borger MA, Enders J, Fassl J, et al. Thromboelastometrically guided transfusion protocol during aortic surgery with circulatory arrest: a prospective, randomized trial. J Thorac Cardiovasc Surg. 2010;140:1117-24. e2.

    Article  Google Scholar 

  31. St-Onge S, Lemoine E, Bouhout I, Rochon A, El-Hamamsy I, Lamarche Y, et al. Evaluation of the real-world impact of rotational thromboelastometry-guided transfusion protocol in patients undergoing proximal aortic surgery. J Thorac Cardiovasc Surg. 2019;157:1045-54. e4.

    Article  Google Scholar 

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Funding

This work was supported by a Grant-in Aid for Scientific Research C (#17K10768 to M.T.) from the Ministry of Education, Culture, Sports, Science and Technology, Japan.

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Authors and Affiliations

  1. Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanumacho, Omiya-ku, Saitama, 330-8503, Japan

    Tomonari Fujimori, Naoyuki Kimura, Daijiro Hori, Sho Kusadokoro & Atsushi Yamaguchi

  2. Department of Medical Informatics, Center for Information, Jichi Medical University, Shimotsuke, Japan

    Makiko Mieno

  3. Department of Cardiovascular Surgery, School of Medicine, Nihon University, Tokyo, Japan

    Masashi Tanaka

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  1. Tomonari Fujimori
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  2. Naoyuki Kimura
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Correspondence to Naoyuki Kimura.

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Fujimori, T., Kimura, N., Mieno, M. et al. An increased prothrombin time-international normalized ratio in patients with acute type A aortic dissection: contributing factors and their influence on outcomes. Surg Today 52, 431–440 (2022). https://doi.org/10.1007/s00595-021-02399-y

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  • DOI: https://doi.org/10.1007/s00595-021-02399-y

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