Malperfusion in Acute Type A Aortic Dissection: Development of a Predictive Diagnostic Model

Abstract

Objective

To investigate the clinical predictors of malperfusion in patients with acute type A aortic dissection (ATAAD) and to construct a diagnostic model to identify high-risk individuals.

Methods

A retrospective analysis of 553 ATAAD patients from Tongji Hospital divided into malperfusion and non-malperfusion groups was conducted. Logistic regression was used to identify independent predictors of the outcome. Model performance via the Hosmer–Lemeshow test, decision curve analysis (DCA), the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and predictive values.

Results

Malperfusion was observed in 28.4% of ATAAD patients. Significant predictors included elevated lactate dehydrogenase (LDH) (OR: 1.0019, 95% CI: 1.0002–1.0036, P = 0.027), alanine aminotransferase (ALT) (OR: 0.9936, 95% CI: 0.987–1.000, P = 0.046) and estimated glomerular filtration rate (eGFR) (OR: 0.9877, 95% CI: 0.977–0.998, P = 0.021), suggesting roles for tissue ischemia and impaired renal or hepatic function. Other variables, such as D-dimer, uric acid, creatinine, and NT-proBNP, showed trends toward significance but did not reach the 0.05 threshold. The model demonstrated good calibration (Hosmer–Lemeshow P = 0.318), moderate discriminatory power (AUC = 0.725), high specificity (93.62%), and low sensitivity (26.75%).

Conclusion

The model based on routine biochemical markers provides a practical approach for the early identification of malperfusion in ATAAD patients. It shows strong specificity and clinical utility, although its limited sensitivity highlights the need for further refinement. Future improvements should focus on incorporating additional clinical or imaging data to increase diagnostic accuracy.

Keywords

Acute type A aortic dissection / Malperfusion / Diagnosis / Biomarkers

References

[1] GudbjartssonT, AhlssonA, GeirssonA, et al.. Acute type A aortic dissection–a review. Scand Cardiovasc J., 2020, 54(1): 1-13.

[2] NortonEL, KhajaMS, WilliamsDM, et al.. Type A aortic dissection complicated by malperfusion syndrome. Curr Opin Cardiol., 2019, 34(6): 610-615.

[3] BerrettaP, TrimarchiS, PatelHJ, et al.. Malperfusion syndromes in type A aortic dissection: what we have learned from IRAD. J Vis Surg., 2018, 465.

[4] YagdiT, AtayY, EnginC, et al.. Impact of organ malperfusion on mortality and morbidity in acute type A aortic dissections. J Card Surg., 2006, 21(4): 363-369.

[5] CzernyM, SchoenhoffF, ZiererA. The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection. J Am Coll Cardiol., 2015, 65(24): 2629-2635.

[6] NakaiC, IzumiS, HaraguchiT, et al.. Impact of time from symptom onset to operation on outcome of repair of acute type A aortic dissection with malperfusion. J Thorac Cardiovasc Surg., 2021, 165(3): 984-991.

[7] GrimmJC, MagruderJT, CrawfordTC, et al.. Differential outcomes of type A dissection with malperfusion according to affected organ system. Ann Cardiothorac Surg., 2016, 5(3): 202-208.

[8] Jaffar-KarballaiM, TranTT, OremakindeO, et al.. Malperfusion in Acute Type A Aortic Dissection: Management Strategies. Vasc Endovascular Surg., 2021, 55(7): 721-729.

[9] HeH, ChaiX, ZhouY, et al.. Association of Lactate Dehydrogenase with In-Hospital Mortality in Patients with Acute Aortic Dissection: A Retrospective Observational Study. Int J Hypertens, 2020, 20201347165.

[10] WuX, YeJ, CaiW, et al.. LDHA mediated degradation of extracellular matrix is a potential target for the treatment of aortic dissection. Pharmacol Res, 2022, 176106051.

[11] GianniniEG, TestaR, SavarinoV. Liver enzyme alteration: a guide for clinicians.. CMAJ, 2005, 172(3): 367-379.

[12] RuhlCE, EverhartJE. The association of low serum alanine aminotransferase activity with mortality in the US population. Am J Epidemiol, 2013, 17812. 821928

[13] HenrionJ, SchapiraM, LuwaertR, et al.. Hypoxic hepatitis: clinical and hemodynamic study in 142 consecutive cases Medicine (Baltimore). Medicine (Baltimore), 2003, 82(6): 392-406.

[14] Vespasiani-GentilucciU, De VincentisA, FerrucciL, et al.. Low alanine aminotransferase levels in the elderly population: frailty, disability, sarcopenia, and reduced survival. J Gerontol A Biol Sci Med Sci, 2018, 73(7): 925-930.

[15] RamatyE, MaorE, Peltz-SinvaniN, et al.. Low ALT blood levels predict long-term all-cause mortality among adults: a historical prospective cohort study. Eur J Intern Med, 2014, 25(10): 919-921.

[16] WuZN, GuanXL, XuSJ, et al.. Does preoperative serum creatinine affect the early surgical outcomes of acute Stanford type A aortic dissection?. J Chin Med Assoc., 2020, 83(3): 266-271.

[17] EghbalzadehK, SabashnikovA, WeberC, et al.. Impact of preoperative elevated serum creatinine on long-term outcome of patients undergoing aortic repair with Stanford A dissection: a retrospective matched pair analysis. Ther Adv Cardiovasc Dis., 2018, 12(11): 289-298.

[18] ZhouT, LiJ, SunY, et al.. Surgical and early outcomes for type A aortic dissection with preoperative renal dysfunction stratified by estimated glomerular filtration rate. Eur J Cardiothorac Surg, 2018, 54(5): 940-945.

[19] Van BakelPAJ, HenryM, KimKM, et al.. Imaging features of renal malperfusion in aortic dissection. Eur J Cardiothorac Surg, 2022, 61(4): 805-813.

[20] GhoreishiM, SundtTM, CameronDE, et al.. Factors associated with acute stroke after type A aortic dissection repair: an analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database. J Thorac Cardiovasc Surg, 2020, 159(6): 2143-2154.

[21] LuehrM, Merkle-StormsJ, GerferS, et al.. Evaluation of the GERAADA score for prediction of 30-day mortality in patients with acute type A aortic dissection. Eur J Cardiothorac Surg, 2021, 59(5): 1109-1114.

[22] PisanoC, BalistreriC, TorrettaF, et al.. Penn classification in acute aortic dissection patients. Acta Cardiol, 2016, 71(2): 185-190.

RIGHTS & PERMISSIONS

The Author(s), under exclusive licence to Huazhong University of Science and Technology