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• W2749488969 abstract "Central MessageAn association of elevated preoperative levels of D-dimer with increased arterial and venous graft occlusion should be viewed cautiously.See Article page 200. An association of elevated preoperative levels of D-dimer with increased arterial and venous graft occlusion should be viewed cautiously. See Article page 200. In their study in this issue of the Journal, Parolari and associates1Fields J.M. Goyal M. Venothromboembolism.Emerg Med Clin North Am. 2008; 26 (viii): 649-683Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar have attempted to look at the relationship between circulating biomarkers of inflammation and short-term graft patency in patients undergoing coronary artery bypass grafting. A prospective observational study at a single institution was done with a total enrollment of 330 patients. Blood levels of a variety of inflammatory biomarkers, such as C-reactive protein, thrombin-antithrombin complex, D-dimer, and α1-antichymotrypsin were obtained 1 to 3 days before the operation and about 1 week after the operation. Patients were then asked to return to undergo coronary computed tomographic angiography, which occurred 15 to 21 months after their surgery. Analysis revealed that the only significant difference between those patients with patent grafts and those with 1 or more occluded grafts with regards to the biomarkers was an increased level of D-dimer at baseline in those with an occluded graft. In assessing the significance and validity of this finding, several points need to be considered. The sample size is small, and the analysis even smaller, given that of the 330 patients initially entered into the study, only slightly more than half (179) underwent the follow-up coronary computed tomographic angiography. The short-term occlusion rate of left internal thoracic artery grafts was 6.3%, and that of right internal thoracic artery grafts was 26.3%, higher than in many published series. This raises questions about both the conduct of the operation, as well as the validity of the coronary computed tomographic angiographic assessment. This is acknowledged in the limitations section.1Fields J.M. Goyal M. Venothromboembolism.Emerg Med Clin North Am. 2008; 26 (viii): 649-683Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Numerous factors, such as the technique of graft harvest, quality or extent of disease in the coronary targets, and degree of stenosis before the grafted area, are not accounted for in this analysis. This further clouds the picture, because these factors are well known to have effects on graft patency. With regard to the specific finding, a proposed mechanism is not clear. D-dimers are specific crosslinked fibrin derivatives that are the product of plasmin-mediated fibrinolytic degradation (Figure 1). They are considered to be a marker of fibrinolytic activity and have been studied as indicators of such conditions as venous thromboembolism, atrial thrombus associated with atrial fibrillation, and aortic dissection, although with varying degrees of sensitivity and specificity.1Fields J.M. Goyal M. Venothromboembolism.Emerg Med Clin North Am. 2008; 26 (viii): 649-683Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 2Wakai A. Gleeson A. Winter D. Role of fibrin D-dimer testing in emergency medicine.Emerg Med J. 2003; 20: 319-325Crossref PubMed Google Scholar, 3Sutherland A. Escano J. Coon T.P. D-dimer as the sole screening test for acute aortic dissection: a review of the literature.Ann Emerg Med. 2008; 52: 339-343Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar In the study of Parolari and associates,4Parolari A. Cavallotti L. Andreini D. Myasoedova V. Banfi C. Camera M. et al.D-dimer is associated with arterial and venous coronary artery bypass grafts occlusion.J Thorac Cardiovasc Surg. 2018; 155: 200-207.e3Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar it is hard to understand how the preoperative levels of D-dimer could predict or be associated with short-term graft patency. Of note, the levels at baseline were elevated in both groups. The normal level is lower than 500 ng/mL. In the “patent graft” group, levels begin at 642 ng/mL; in the “occluded graft” group, at 888 ng/mL. They then rise quite significantly, to more than 8 times the baseline (5239 ng/mL and 5262 mL, respectively) in the postoperative period. If the effect, as measured by the D-dimer levels, is thought to play a role, it would seem that the preoperative state would be overwhelmed by that of the postoperative state. In perusing all the biomarker data, no other patterns emerge. In fact, with the exception of an increase in C-reactive protein, there appears to be very little difference in all the other biomarkers, not only between the patency groups but also between the preoperative and postoperative values. As acknowledged, the study only claims an association of the elevated biomarker level and increased short-term arterial and venous graft occlusion. One wonders, however, whether this is just a spurious result. At best, much further investigation is required, as is often the case. D-dimer is associated with arterial and venous coronary artery bypass graft occlusionThe Journal of Thoracic and Cardiovascular SurgeryVol. 155Issue 1PreviewIn this observational prospective study, we assessed the role of clinical variables and circulating biomarkers in graft occlusion at 18 months to identify a signature for graft occlusion. Full-Text PDF Open Archive" @default.
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• W2749488969 date "2018-01-01" @default.
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• W2749488969 title "D-dimer and early coronary graft closure: Not so fast" @default.
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• W2749488969 doi "https://doi.org/10.1016/j.jtcvs.2017.07.056" @default.
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