51
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Tinelli G, Ferraresi M, Watkins AC, Hertault A, Soler R, Azzaoui R, Fabre D, Sobocinski J, Haulon S. Aortic treatment in connective tissue disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:518-525. [PMID: 29943958 DOI: 10.23736/s0021-9509.18.10443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Connective tissue disease (CTD) represents a group of genetic conditions characterized by disruptive matrix remodeling. When this process involves aortic and vascular wall, patients with CTD have a high risk of developing arterial aneurysms, dissections and ruptures. Open surgical repair is still the gold standard therapy for patients with CTD with reasonable morbidity and mortality risk. The surgical treatment of CTD often requires multiple operations. In the endovascular era, fenestrated and branched stent grafts may play a role in reducing the complications of multiple open operations. Although the long-term results of endovascular treatment in the setting of CTD are unknown, it is generally accepted that endovascular treatment is restricted to selected patients with high surgical risk. In an emergency setting, endovascular intervention can serve as a lifesaving bridge to elective open aortic repair. Aortic centers performing a large volume of complex open and endovascular aortic repairs have started to combine these two techniques in a staged fashion. The goal is to reduce the morbidity and mortality associated with extensive aortic repairs in CTD patients. For this reason, recommend endovascular therapy when a "graft-to-graft" approach is possible. In this scenario, the surgeon who performs the open repair must take into consideration future interventions. Surgical repair in any aortic segment should allow creation of proximal and distal landing zones over 4 cm to secure the sealing of a future stent graft. Connective tissue disease should be treated with a multidisciplinary approach, in high volume centers. Endovascular treatment represents a potential option in patients at high risk for open repair. Staged hybrid procedures have emerged as a way to reduce spinal cord ischemia and avoid multiple open surgeries. The aim of this article is to discuss the management of aortic diseases in CTD, focusing on to the role of standard open surgery and emerging endovascular treatment, and to give an overview of the few series published regarding this topic with a small number of patients.
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Affiliation(s)
- Giovanni Tinelli
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy -
| | - Marco Ferraresi
- Vascular Unit, Department of Cardiovascular Surgery, Gemelli Foundation IRCCS, School of Medicine, Sacred Heart Catholic University, Rome, Italy
| | - Amelia C Watkins
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | | | - Raphael Soler
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
| | | | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Paris Sud University, Le Plessis Robinson, France
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52
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Jassar AS, Sundt TM. How should we manage type A aortic dissection? Gen Thorac Cardiovasc Surg 2018; 67:137-145. [DOI: 10.1007/s11748-018-0957-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/08/2018] [Indexed: 02/06/2023]
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53
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Extensive aortic repair in acute aortic dissection: Not much bang for the buck? J Thorac Cardiovasc Surg 2018; 156:949-950. [PMID: 29724596 DOI: 10.1016/j.jtcvs.2018.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 04/05/2018] [Indexed: 11/24/2022]
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54
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Michaud CJ, Trethowan B. Valsartan Effective for Malignant Hypertension after Aortic Dissection with Renal Artery Involvement. Pharmacotherapy 2018; 38:e25-e28. [DOI: 10.1002/phar.2100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | - Brian Trethowan
- Department of Cardiac Anesthesia; Spectrum Health; Grand Rapids Michigan
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55
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Chen Y, Ma WG, Zheng J, Liu YM, Zhu JM, Sun LZ. Total arch replacement and frozen elephant trunk for type A aortic dissection after Bentall procedure in Marfan syndrome. J Thorac Dis 2018; 10:2377-2387. [PMID: 29850143 DOI: 10.21037/jtd.2018.03.79] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background We seek to report the long-term outcomes of the total arch replacement and frozen elephant trunk (TAR + FET) technique for type A aortic dissection (TAAD) following prior Bentall procedure in patients with Marfan syndrome (MFS). Methods Between 2003 and 2015, we performed TAR + FET for 26 patients with MFS who developed TAAD following a prior Bentall procedure. Mean age at FET 36.9±9.7 years and 24 were males. TAAD was acute in 8 (30.8%, all new dissections from precious root aneurysm) and chronic in 18 (69.2%, 15 residual and 3 new). The interval from Bentall procedure to FET averaged 6.4±5.8 years, which was significantly longer in the acute group (10.3±6.3 vs. 4.6±4.9, P=0.021). The early and long-term outcomes were compared between two groups and risk factors identified for late adverse events. Results Operative mortality was 11.5% (3/26). Stroke, lower limb ischemia and reexploration for bleeding occurred in 1 patient each (3.8%). Follow-up was complete in 100% (23/23) at mean 5.1±2.3 years (range, 0.9-11.2 years). The maximal diameter (DMax) of distal aorta in the chronic group was significantly greater at the unstented descending aorta [DA, (56.4±15.5 vs. 35.6±12.2 mm, P=0.006)] compared to acute patients. The false lumen was obliterated in 95.7% across the FET and 56.5% in the unstented DA. Distal aortic dilation occurred in 13 patients (11 chronic, 68.8%). Of those 11 patients, 4 underwent an open thoracoabdominal aortic repair and 3 died of distal aortic rupture. Late death occurred in 7 patients at mean 3.9±2.5 years. At 6 years, the incidence was 18% for death, 11% for distal aortic reoperation, and 71% for reoperation-free survival. Survival did not differ between two groups (75.0% vs. 71.3%, P=0.851), while acute patients had significantly higher freedom from late rupture and reoperation at 6 years (100% vs. 61.9%, P=0.046). Hypertension was the sole risk factor for distal aortic dilatation [hazard ratio (HR) =7.271; 95% confidence interval (CI), 1.814-29.143; P=0.005]. Risk factors for late adverse events were hypertension (HR =6.712; 95% CI, 1.201-37.503; P=0.030) and age <35 years (HR =6.760; 95% CI, 1.154-39.587; P=0.034). Conclusions The TAR and FET technique was feasible and efficacious for TAAD following previous Bentall procedure in patients with MFS. Early and late survival did not differ with acute and chronic dissections, while freedom from late rupture and reoperation is significantly higher in patients with acute TAAD. Patients with hypertension and aged <35 years are at higher risk for late distal aortic dilation, reoperation and death.
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Affiliation(s)
- Yu Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China
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56
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Puluca N, Burri M, Cleuziou J, Krane M, Lange R. Consecutive operative procedures in patients with Marfan syndrome up to 28 years after initial aortic root surgery. Eur J Cardiothorac Surg 2018; 54:504-509. [DOI: 10.1093/ejcts/ezy065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/17/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nazan Puluca
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julie Cleuziou
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Markus Krane
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
- German Heart Center Munich-DZHK Partner Site Munich Heart Alliance, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Department of Cardiovascular Surgery, Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technische Universität München, Munich, Germany
- German Heart Center Munich-DZHK Partner Site Munich Heart Alliance, Munich, Germany
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57
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Schoenhoff FS, Carrel TP. Re-interventions on the thoracic and thoracoabdominal aorta in patients with Marfan syndrome. Ann Cardiothorac Surg 2017; 6:662-671. [PMID: 29270378 DOI: 10.21037/acs.2017.09.14] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The advent of multi-gene panel genetic testing and the discovery of new syndromic and non-syndromic forms of connective tissue disorders have established thoracic aortic aneurysms as a genetically mediated disease. Surgical results in patients with Marfan syndrome (MFS) provide an important benchmark for this patient population. Prophylactic aortic root surgery prevents acute dissection and has contributed to the improved survival of MFS patients. In the majority of patients, re-interventions are driven by a history of dissection. Patients undergoing elective root repair have a low risk for re-interventions on the root itself. Experienced centers have results after valve-sparing procedures at 10 years comparable with those seen after a modified Bentall procedure. In patients where only the ascending aorta was replaced during the initial surgery, re-intervention rates are high as the root continues to dilate. The fate of the aortic arch in MFS patients presenting with dissection is strongly correlated with the extent of the initial surgery. Not replacing the entire ascending aorta and proximal aortic arch results in a high rate of re-interventions. Nevertheless, the additional burden of replacing the entire aortic arch during emergent proximal repair is not very well defined and makes comparisons with patients undergoing elective arch replacement difficult. Interestingly, replacing the entire aortic arch during initial surgery for acute dissection does not protect from re-interventions on downstream aortic segments. MFS patients suffering from type B dissection have a high risk for re-interventions ultimately leading up to replacement of the entire thoracoabdominal aorta even if the dissection was deemed uncomplicated by conventional criteria. While current guidelines do not recommend the implantation of stent grafts in MFS patients, implantation of a frozen-elephant-trunk to create a stable proximal landing zone for future endovascular or open procedures has emerged as a means to address aortic arch and descending aortic pathologies.
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Affiliation(s)
- Florian S Schoenhoff
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
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58
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de Beaufort HWL, Trimarchi S, Korach A, Di Eusanio M, Gilon D, Montgomery DG, Evangelista A, Braverman AC, Chen EP, Isselbacher EM, Gleason TG, De Vincentiis C, Sundt TM, Patel HJ, Eagle KA. Aortic dissection in patients with Marfan syndrome based on the IRAD data. Ann Cardiothorac Surg 2017; 6:633-641. [PMID: 29270375 DOI: 10.21037/acs.2017.10.03] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Between January 1996 and May 2017, the International Registry on Acute Aortic Dissections has collected information on a total of 6,424 consecutive patients with acute aortic dissection, including 258 individuals with a diagnosis of Marfan syndrome. Patients with Marfan syndrome presented at a significantly younger age compared to patients without Marfan syndrome (38.2±13.2 vs. 63.0±14.0 years; P<0.001) and in general had fewer comorbidities, although they more frequently had a known aortic aneurysm and history of prior cardiac surgery. We noted significantly larger diameters of the aortic annulus and root in the Marfan syndrome cohort, but no larger diameters more distally. The in-hospital mortality in type A dissection was not significantly different in patients with or without Marfan syndrome, despite the differences in age and comorbidities and the lower incidence of aortic rupture in the Marfan syndrome cohort. In contrast, the in-hospital mortality of Marfan syndrome patients with type B dissection appears to be lower than that of patients without Marfan syndrome. The Marfan syndrome cohort that was treated with open surgery for type B dissection seemed to do especially well, with a 0% mortality rate (n=27). Follow-up data for type A and B dissections combined show an estimated five-year survival rate of 80.1% and an estimated reintervention rate of 55.3% in patients with Marfan syndrome. Such a high rate of reinterventions highlights the need for careful surveillance and treatment for patients with Marfan syndrome surviving the acute phase of aortic dissection.
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Affiliation(s)
- Hector W L de Beaufort
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
| | - Amit Korach
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Marco Di Eusanio
- Department of Cardiac Surgery, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Dan Gilon
- Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Daniel G Montgomery
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Arturo Evangelista
- Department of Cardiology, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Alan C Braverman
- Cardiovascular Division, Department of Medicine, Washington University of Medicine, Saint Louis, MO, USA
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
| | - Eric M Isselbacher
- Thoracic Aortic Center and Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carlo De Vincentiis
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Kim A Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
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59
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Ma WG, Zhang W, Zhu JM, Ziganshin BA, Zhi AH, Zheng J, Liu YM, Elefteriades JA, Sun LZ. Long-term outcomes of frozen elephant trunk for type A aortic dissection in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2017; 154:1175-1189.e2. [DOI: 10.1016/j.jtcvs.2017.04.088] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 03/20/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
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60
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Chiu P, Trojan J, Tsou S, Goldstone AB, Woo YJ, Fischbein MP. Limited root repair in acute type A aortic dissection is safe but results in increased risk of reoperation. J Thorac Cardiovasc Surg 2017; 155:1-7.e1. [PMID: 29042100 DOI: 10.1016/j.jtcvs.2017.08.137] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/28/2017] [Accepted: 08/24/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Management of the aortic root is a challenge for surgeons treating acute type A aortic dissection. METHODS We performed a retrospective review of the acute type A aortic dissection experience at Stanford Hospital between 2005 and 2015 and identified patients who underwent either limited root repair or aortic root replacement. Differences in baseline characteristics were balanced with inverse probability weighting to estimate the average treatment effect on the controls. Weighted logistic regression was used to evaluate in-hospital mortality. Weighted Cox proportional hazards regression was used to evaluate differences in the hazard for mid-term death. Reoperation was evaluated with death as a competing risk with the Fine-Gray subdistribution hazard. RESULTS After we excluded patients managed either nonoperatively or with definitive endovascular repair, there were 293 patients without connective tissue disease who underwent either limited root repair or aortic root replacement. There was no difference in weighted perioperative mortality, odds ratio 0.89 (95% confidence interval [CI], 0.44-1.76, P = .7), and there was no difference in weighted survival, hazard ratio 1.12 (95% CI, 0.54-2.31, P = .8). Risk of reoperation was greater in limited root repair (11.8%, 95% CI, 0.0%-23.8%) than for root replacement (0%), P < .001. CONCLUSIONS Limited root repair was associated with increased risk of late reoperation after repair of acute type A aortic dissection. Surgeons with adequate experience may consider aortic root replacement in well-selected patients. However, given good outcomes after limited root repair, surgeons should not feel compelled to perform this more-complex operation.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif; Division of Health Research and Policy, Stanford University, School of Medicine, Stanford, Calif
| | - Jeffrey Trojan
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - Sarah Tsou
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - Andrew B Goldstone
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif; Division of Health Research and Policy, Stanford University, School of Medicine, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif.
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61
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Baciewicz FA. When should the elephant (frozen elephant trunk) enter the room (aorta)? J Thorac Cardiovasc Surg 2017; 154:1190-1191. [PMID: 28666667 DOI: 10.1016/j.jtcvs.2017.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/05/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Frank A Baciewicz
- Cardiothoracic Surgery Section, Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Mich.
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62
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Rylski B, Pérez M, Beyersdorf F, Reser D, Kari FA, Siepe M, Czerny M. Acute non-A non-B aortic dissection: incidence, treatment and outcome. Eur J Cardiothorac Surg 2017; 52:1111-1117. [DOI: 10.1093/ejcts/ezx142] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/07/2017] [Indexed: 01/16/2023] Open
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63
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Isselbacher EM, Bonaca MP, Di Eusanio M, Froehlich J, Bassone E, Sechtem U, Pyeritz R, Patel H, Khoynezhad A, Eckstein HH, Jondeau G, Ramponi F, Abbasi M, Montgomery D, Nienaber CA, Eagle K, Lindsay ME. Recurrent Aortic Dissection. Circulation 2016; 134:1013-1024. [DOI: 10.1161/circulationaha.115.019359] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 08/23/2016] [Indexed: 01/01/2023]
Abstract
Background:
Improved medical care after initial aortic dissection (AD) has led to increased survivorship and a population of individuals at risk for further cardiovascular events, including recurrent AD. Reports describing recurrent ADs have been restricted to small numbers of patients from single institutions. We used the IRAD (International Registry of Acute Aortic Dissection) database to examine the clinical profiles and outcomes of patients with recurrent AD.
Methods:
We identified 204 patients enrolled in IRAD with recurrent AD. For the primary analysis, patient characteristics, interventions, and outcomes were analyzed and compared with 3624 patients with initial AD. Iterative logistic modeling was performed to investigate variables associated with recurrent AD. Cox regression analyses were used to determine variables associated with 5-year survival. A subset of recurrent AD patients was analyzed for anatomic and demographic details of initial and recurrent ADs.
Results:
Patients with recurrent AD were more likely to have Marfan syndrome (21.5% versus 3.1%;
P
<0.001) but not bicuspid aortic valve (3.6% versus 3.2%;
P
=0.77). Descending aortic dimensions were greater in patients with recurrent AD than in patients with initial AD independently of sentinel dissection type (type A: 4.3 cm [3.5–5.6 cm] versus 3.3 cm [2.9–3.7 cm],
P
<0.001; type B: 5.0 cm [3.9–6.0 cm] versus 4.0 cm [3.5–4.8 cm],
P
<0.001), and this observation was accentuated among patients with Marfan syndrome. In multivariate analysis, the diagnosis of Marfan syndrome independently predicted recurrent AD (hazard ratio, 8.6; 95% confidence interval, 5.8–12.8;
P
<0.001). Patients with recurrent AD who presented with proximal followed by distal AD were younger than patients who experienced distal followed by proximal dissection AD (42.1±16.1 versus 54.3±14.8 years;
P
=0.004).
Conclusions:
Among those suffering acute aortic dissection, 5% have a history of a prior aortic dissection. Recurrent AD is strongly associated with Marfan syndrome.
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Affiliation(s)
- Eric M. Isselbacher
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Marc P. Bonaca
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Marco Di Eusanio
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - James Froehlich
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Eduardo Bassone
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Udo Sechtem
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Reed Pyeritz
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Himanshu Patel
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Ali Khoynezhad
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Hans-Henning Eckstein
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Guillaume Jondeau
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Fabio Ramponi
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Mohammad Abbasi
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Daniel Montgomery
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Christoph A. Nienaber
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Kim Eagle
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
| | - Mark E. Lindsay
- From Thoracic Aortic Center (E.M.I., M.A., M.E.L.), Cardiology Division, Department of Medicine (E.M.I., M.E.L.), Cardiovascular Research Center (M.A., M.E.L.), and Pediatric Cardiology Division, Department of Pediatrics (M.E.L.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Cardiology Division, Boston, MA (M.P.B.); Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy (M.D.E.); Cardiovascular Center (J.F., D.M., K.E.) and
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Liu O, Xie W, Qin Y, Jia L, Zhang J, Xin Y, Guan X, Li H, Gong M, Liu Y, Wang X, Li J, Lan F, Zhang H. MMP-2 gene polymorphisms are associated with type A aortic dissection and aortic diameters in patients. Medicine (Baltimore) 2016; 95:e5175. [PMID: 27759651 PMCID: PMC5079335 DOI: 10.1097/md.0000000000005175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Matrix metalloproteinases-2 (MMP-2) plays an important role in the pathogenesis of type A aortic dissection (AD). The aim of this study was to evaluate the association of 3 single nucleotide polymorphisms (SNPs) in the MMP-2 gene with type A AD risk and aortic diameters in patients. We performed a case-control study with 172 unrelated type A AD patients and 439 controls. Three SNPs rs11644561, rs11643630, and rs243865 were genotyped through the MassARRAY platform. Allelic associations of SNPs and SNP haplotypes with type A AD and aortic diameters in patients were evaluated. The frequency of the G allele of the rs11643630 polymorphism was significantly lower in type A AD patients than in control subjects (odds ratio 0.705, 95% confidence interval 0.545-0.912, P = 0.008). The association remained significant after adjusting for clinical covariates (P = 0.008). Carriers of the GG genotype of the rs11643630 polymorphism had significantly smaller aortic diameters than those with GT genotype or TT genotype (P = 0.02). Further haplotype analysis identified 1 protective haplotype (GC; P = 0.008) for development of type A AD. Again, a significant correlation was observed between haplotype GC and AD size (P = 0.020). Our results suggest that MMP-2 gene polymorphisms contribute to type A AD susceptibility. In addition, MMP-2 gene SNPs are associated with AD size, which could be used as a target for the development of new drug therapy.
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Affiliation(s)
- Ou Liu
- Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wuxiang Xie
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Yanwen Qin
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Lixin Jia
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jing Zhang
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yi Xin
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Xinliang Guan
- Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haiyang Li
- Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ming Gong
- Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuyong Liu
- Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaolong Wang
- Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jianrong Li
- Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Feng Lan
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Hongjia Zhang
- Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Correspondence: Hongjia Zhang, Department of Cardiovascular Surgery, Beijing Lab for Cardiovascular Precision Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China (e-mail: )
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65
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Chiu P, Miller DC. Evolution of surgical therapy for Stanford acute type A aortic dissection. Ann Cardiothorac Surg 2016; 5:275-95. [PMID: 27563541 DOI: 10.21037/acs.2016.05.05] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA, USA
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Abstract
BACKGROUND Marfan syndrome is associated with morbidity and mortality due to aortic dilatation and dissection. Preventive aortic root replacement has been the standard treatment in Marfan syndrome patients with aortic dilatation. In this study, we present aortic event data from a nationwide Marfan syndrome cohort. METHOD The nationwide cohort of Danish Marfan syndrome patients was established from the Danish National Patient Registry and the Cause of Death Register, where we retrieved information about aortic surgery and dissections. We associated aortic events with age, sex, and Marfan syndrome diagnosis prior or after the first aortic event. RESULTS From the total cohort of 412 patients, 150 (36.4 %) had an aortic event. Fifty percent were event free at age 49.6. Eighty patients (53.3 %) had prophylactic surgery and seventy patients (46.7 %) a dissection. The yearly event rate was 0.02 events/year/patient in the period 1994-2014. Male patients had a significant higher risk of an aortic event at a younger age with a hazard ratio of 1.75 (CI 1.26-2.42, p = 0.001) compared with women. Fifty-three patients (12.9 %) were diagnosed with MFS after their first aortic event which primarily was aortic dissection [n = 44 (83.0 %)]. CONCLUSION More than a third of MFS patients experienced an aortic event and male patients had significantly more aortic events than females. More than half of the total number of dissections was in patients undiagnosed with MFS at the time of their event. This emphasizes that diagnosing MFS is lifesaving and improves mortality risk by reducing the risk of aorta dissection.
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67
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Stephens EH, Borger MA. Getting to the root of the matter: management of the aortic root in Type A aortic dissection. Eur J Cardiothorac Surg 2016; 50:230-1. [DOI: 10.1093/ejcts/ezw085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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68
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Muiesan ML, Salvetti M, Amadoro V, di Somma S, Perlini S, Semplicini A, Borghi C, Volpe M, Saba PS, Cameli M, Ciccone MM, Maiello M, Modesti PA, Novo S, Palmiero P, Scicchitano P, Rosei EA, Pedrinelli R. An update on hypertensive emergencies and urgencies. J Cardiovasc Med (Hagerstown) 2016; 16:372-82. [PMID: 25575271 DOI: 10.2459/jcm.0000000000000223] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Severe acute arterial hypertension is usually defined as 'hypertensive crisis', although 'hypertensive emergencies' or 'hypertensive urgencies', as suggested by the Joint National Committee and the European Society of Hypertension, have completely different diagnostic and therapeutic approaches.The prevalence and demographics of hypertensive emergencies and urgencies have changed over the last four decades, but hypertensive emergencies and urgencies are still associated with significant morbidity and mortality.Different scientific societies have repeatedly produced up-to-date guidelines; however, the treatment of hypertensive emergencies and urgencies is still inappropriate, with potential clinical implications.This review focuses on hypertensive emergencies and urgencies management and treatment, as suggested by recent data.
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Affiliation(s)
- Maria Lorenza Muiesan
- aDepartment of Clinical and Experimental Sciences University of Brescia, 25100 Spedali Civili, Brescia bDepartment of Medical-Surgery Sciences and Translational Medicine, Emergency Department, University La Sapienza, Sant'Andrea Hospital Rome, Rome cDepartment of Internal Medicine and Therapeutics, University of Pavia, Lombardy dDepartment of Internal Medicine 1, USL12 Veneziana, Venice eDepartment of Medicine, University of Padua, Padova fDepartment of ScienzeMediche e Chirurgiche, S.Orsola-Malpighi University Hospital, Bologna gDivision of Cardiology, Department of Medicina Clinica e Molecolare, University Roma 'Sapienza' - Azienda Ospedaliera Sant'Andrea, and IRCCS Neuromed, Rome hDivision of Cardiology, AOU Sassari, Sassari iDepartment of Cardiovascular Diseases, University of Siena, Tuscany jCardiovascular Disease Section, Department of Emergency and Organ Tranplantation, University of Bari, Bari kAS Department of Cardiology, Brindisi District, Brindisi lDepartment of Clinical and Experimental Medicine, University of Florence, Florence mDepartment of Internal Medicine and Cardiovascular Diseases, University of Palermo, Palermo nDipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Università di Pisa, Pisa, Italy
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Overview of current surgical strategies for aortic disease in patients with Marfan syndrome. Surg Today 2015; 46:1006-18. [DOI: 10.1007/s00595-015-1278-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/02/2015] [Indexed: 01/16/2023]
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Martín M, García Iglesias D, Rozado J, Padrón RR, García-Campos A, Morís C, Alvarez Cabo R. Type A Aortic Dissection: The Controversy of the Root Replacement. Ann Thorac Surg 2015; 100:1136-7. [PMID: 26354662 DOI: 10.1016/j.athoracsur.2015.03.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 03/22/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Affiliation(s)
- María Martín
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain.
| | - Daniel García Iglesias
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - José Rozado
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - Remigio R Padrón
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - Ana García-Campos
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - César Morís
- Department of Cardiology, Hospital Universitario Central de Asturias, Avda Pedro Masaveu, 27, 4L 33007 Oviedo, Asturias, Spain
| | - Rubén Alvarez Cabo
- Department of Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Ge YP, Li CN, Chen L, Liu W, Cheng LJ, Liu YM, Zheng J, Ma WG, Zhu JM, Sun LZ. Is Previous Cardiac Surgery a Risk Factor for Short and Mid-term Mortality Following Total Aortic Arch Replacement in Patients with Stanford Type A Aortic Dissection? Heart Lung Circ 2015; 24:1111-7. [PMID: 25981359 DOI: 10.1016/j.hlc.2015.04.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 03/02/2015] [Accepted: 04/06/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. METHODS Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test. RESULTS The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p<0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test). CONCLUSIONS PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection.
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Affiliation(s)
- Yi-Peng Ge
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Cheng-Nan Li
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Lei Chen
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Wei Liu
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Li-Jian Cheng
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Yong-Min Liu
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Jun Zheng
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Wei-Guo Ma
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
| | - Jun-Ming Zhu
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University.
| | - Li-Zhong Sun
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University
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Marfan syndrome is associated with recurrent dissection of the dissected aorta. Ann Thorac Surg 2015; 99:1616-23. [PMID: 25818572 DOI: 10.1016/j.athoracsur.2014.12.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/16/2014] [Accepted: 12/23/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recurrent dissection of a previously dissected aortic segment has been reported as a rare, late complication in single case reports. The infrequency of this event makes informed risk assessment in an individual patient challenging. METHODS To investigate this issue we examined the database of the Massachusetts General Hospital Thoracic Aortic Center between January 1, 2003 and December 31, 2012. A retrospective review was performed to identify patients with both (1) an acute aortic dissection after a prior aortic dissection and (2) evidence of a new dissection within a previously dissected aortic segment creating a triple lumen aorta. Data were reviewed to identify factors predisposing to dissection of a previously dissected aortic segment. RESULTS Over a 10-year period we identified 5 cases of aortic dissection within a previously dissected aortic segment presenting as a new acute aortic syndrome. On average, the recurrent dissection occurred 1 decade after the first aortic dissection (mean = 9.8 ± 1.9 years). Patients identified in this series were significantly younger at first dissection and more likely to carry the diagnosis of Marfan syndrome. Aortic aneurysm diameter was quantified before and after the new dissection event and demonstrated a marked increase in aneurysmal size (mean increase = 1.6 ± 0.3 cm). CONCLUSIONS We conclude that medial degeneration, as seen in the Marfan aorta, represents a predisposing factor for recurrent dissection of the dissected aorta. Our data indicate that double aortic dissections cause significant arterial destabilization and a low threshold for surgical intervention is appropriate.
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Rylski B, Beyersdorf F, Desai ND, Euringer W, Siepe M, Kari FA, Vallabhajosyula P, Szeto WY, Milewski RK, Bavaria JE. Distal aortic reintervention after surgery for acute DeBakey type I or II aortic dissection: open versus endovascular repair. Eur J Cardiothorac Surg 2014; 48:258-63. [DOI: 10.1093/ejcts/ezu488] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 10/30/2014] [Indexed: 11/14/2022] Open
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Kim JB, Sundt TM. Best surgical option for arch extension of type B aortic dissection: the open approach. Ann Cardiothorac Surg 2014; 3:406-12. [PMID: 25133105 DOI: 10.3978/j.issn.2225-319x.2014.06.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 05/27/2014] [Indexed: 12/21/2022]
Abstract
Arch extension of aortic dissection (AD) is reported to occur in 4-25% of patients presenting with acute type B AD. The DeBakey and Stanford classifications do not specifically account for this subset, however, recent studies have demonstrated that the prognosis of patients with arch extension in acute type B AD is virtually identical to that of others with type B AD. In this sense, it seems reasonable to extend the general management principles that are applied to classic acute type B AD even to patients with arch extension. This may be because even in patients with arch extension, most complications occur at locations distal to the arch, and therefore treatment of these patients is similar to that of complicated type B AD, namely thoracic endovascular aortic repair (TEVAR). Conversely, 10% of patients with acute type B AD and arch extension develop complications that are directly related to the arch pathology. This clinical scenario generally necessitates surgical arch repair through a sternotomy approach. The frozen elephant trunk technique combined with arch repair is a very reasonable option to treat this unique clinical entity that involves relatively distal locations of the aortic diseases. Combined arch and descending aorta replacement through thoracotomy is an alternative option particularly when the anatomical features of the target lesions are not suitable for a sternotomy approach or TEVAR. Nonetheless, the reported mortality associated with this approach has been exceedingly high. Hybrid arch repair is another consideration in treating these patients to reduce the treatment-related mortality and morbidity, especially when the arch pathology is limited to the distal part. Nevertheless, the safety and efficacy of this procedure in cases with more extensive arch involvement needs to be assessed in further studies in comparison with other treatment modalities.
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Affiliation(s)
- Joon Bum Kim
- 1 Division of Cardiac Surgery and Thoracic Aorta Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA ; 2 Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Thoralf M Sundt
- 1 Division of Cardiac Surgery and Thoracic Aorta Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA ; 2 Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Rylski B, Bavaria JE, Milewski RK, Vallabhajosyula P, Moser W, Kremens E, Pochettino A, Szeto WY, Desai ND. Long-Term Results of Neomedia Sinus Valsalva Repair in 489 Patients With Type A Aortic Dissection. Ann Thorac Surg 2014; 98:582-8; discussion 588-9. [DOI: 10.1016/j.athoracsur.2014.04.050] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 03/20/2014] [Accepted: 04/01/2014] [Indexed: 11/27/2022]
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