Ascending aortic dissection in weight lifters with cystic medial degeneration

Variation in provider compliance with sports restriction guidelines in children with an isolated bicuspid aortic valve

BACKGROUND

Published guidelines for sports restriction for children with a bicuspid aortic valve remain controversial. We sought to describe practice variation and factors influencing sports restrictions in these children.

METHODS

This retrospective single-centre study included children (7-18 years old) with an isolated bicuspid aortic valve at baseline from 1 January, 2005 to 31 December, 2014. Sports restrictions, factors potentially influencing decision-making, and outcomes were collected. Descriptive statistics and multivariable mixed-effects logistic regression models were performed with providers and patients as random effects. Provider variation was estimated using intraclass correlation coefficients. Odds ratios, 95% confidence intervals, and p-values were reported from the models.

RESULTS

In 565 encounters (253 children; 34 providers), 41% recommended no sports restrictions, 40% recommended high-static and high-dynamic restrictions, and 19% had no documented recommendations. Based on published guidelines, 22% of children were inappropriately restricted while 30% were not appropriately restricted. The paediatric cardiology provider contributed to 37% of observed practice variation (p < 0.001). Sports restriction was associated with older age, males, greater ascending aorta z-score, and shorter follow-up interval. There were no aortic dissections or deaths and one cardiac intervention.

CONCLUSION

Physicians frequently fail to document sports restrictions for children with a bicuspid aortic valve, and documented recommendations often conflict with published guidelines. Despite this, no adverse outcomes occurred. Providers accounted for a significant proportion of the variation in sports restrictions. Further research to provide evidence-based guidelines may improve provider compliance with activity recommendations in this population.

Study on the relationship among typhoon, climate change, and acute Stanford type A aortic dissection in southern of Zhejiang in China

BACKGROUND

The aim of this study was to investigate the relationship between typhoon, climate change, and acute Stanford type A aortic dissection (TAAD) in southern of Zhejiang Province in China.

METHOD

371 patients with TAAD were admitted to three hospitals (the aortic dissection center) in southern of Zhejiang Province, China from January 2015 to December 2020, and data were retrospectively collected, the data included (1) the number of patients admitted in different months and seasons, (2) daily meteorological data in southern of Zhejiang Province, and (3) typhoon information were retrospectively analyzed.

RESULTS

The number of TAAD occurred in winter was the highest and in summer was the lowest. The incidence of TAAD was correlated with minimum temperature, maximum wind speed, mean wind speed, and water vapor pressure (P < 0.05). Maximum wind speed (RR 0.37; 95% CI 0.17 to 0.80, P = 0.01) and water vapor pressure (RR 0.96; 95% CI 0.92 to 1, P = 0.03) were the protective factor. The occurrence incidence of TAAD under the influence of typhoon climate was less than that during the period not affected by typhoon (P < 0.05).

CONCLUSION

There was a correlation between typhoon, climate change, and the occurrence of TAAD in southern Zhejiang Province. Wind speed, vapor pressure, and typhoon may be protective factors.

Spontaneous Coronary Artery Dissection: an Overview

Spontaneous coronary artery dissection (SCAD) is a non-inflammatory, non-atherosclerotic cause of acute myocardial infarction (AMI) that, by definition, is not iatrogenic or due to trauma. It is a condition that predominantly affects pre- or perimenopausal women without the traditional risk factors for cardiovascular disease. PURPOSE OF REVIEW: In this review, we will discuss the epidemiology, diagnosis, and management of this condition, with an emphasis on the ongoing research needed to better understand how to care for patients with SCAD. RECENT FINDINGS: There is a paucity of data related to this condition. However, an American Heart Association consensus statement has recently been released that provides helpful insight. There has also been better characterization of pregnancy-associated SCAD. We have learned much about SCAD over the last decade and greatly increased the identification of this condition by first responders and physicians through research and patient advocacy. However, there is much we still do not know about this condition, and further research, using larger numbers of patients, is greatly needed to better understand this condition.

Survivors of Aortic Dissection: Activity, Mental Health, and Sexual Function

BACKGROUND

Currently no research exists assessing lifestyle modifications and emotional state of acute aortic dissection (AAD) survivors. We sought to assess activity, mental health, and sexual function in AAD survivors.

HYPOTHESIS

Physical and sexual activity will decrease in AAD survivors compared to pre-dissection. Incidence of anxiety and depression will be significant after AAD.

METHODS

A cross sectional survey was mailed to 197 subjects from a single academic medical center (part of larger IRAD database). Subjects were ≥18 years of age surviving a type A or B AAD between 1996 and 2011. 82 surveys were returned (overall response rate 42%).

RESULTS

Mean age ± SD was 59.5 ± 13.7 years, with 54.9% type A and 43.9% type B patients. Walking remained the most prevalent form of physical activity (49 (60%) pre-dissection and 47 (57%) post-dissection). Physical inactivity increased from 14 (17%) before AAD to 20 (24%) after AAD; sexual activity decreased from 31 (38%) to 9 (11%) mostly due to fear. Most patients (66.7%) were not exerting themselves physically or emotionally at AAD onset. Systolic blood pressure (SBP) at 36 months post-discharge for patients engaging in ≥2 sessions of aerobic activity/week was 126.67 ± 10.30 vs. 141.10 ± 11.87 (p-value 0.012) in those who did not. Self-reported new-onset depression after AAD was 32% and also 32% for new-onset anxiety.

CONCLUSIONS

Alterations in lifestyle and emotional state are frequent in AAD survivors. Clinicians should screen for unfounded fears or beliefs after dissection that may reduce function and/or quality of life for AAD survivors.

Exercise and Physical Activity for the Post-Aortic Dissection Patient: The Clinician's Conundrum

Despite the paucity of evidence, it is often presumed, and is physiologically plausible, that sudden, acute elevations in blood pressure may transiently increase the risk of recurrent aortic dissection (AD) or rupture in patients with a prior AD, because a post-dissection aorta is almost invariably dilated and may thus experience greater associated wall stress as compared with a nondilated aorta. Few data are available regarding the specific types and intensities of exercise that may be both safe and beneficial for this escalating patient population. The purpose of this editorial/commentary is to further explore this conundrum for clinicians caring for and counseling AD survivors. Moderate-intensity cardiovascular activity may be cardioprotective in this patient cohort. It is likely that severe physical activity restrictions may reduce functional capacity and quality of life in post-AD patients and thus be harmful, underscoring the importance of further exploring the role of physical activity and/or structured exercise in this at-risk patient population.

Aortic Dissection in a Healthy Male Athlete: A Unique Case with Comprehensive Literature Review

A young otherwise healthy 27-year-old male who has been using anabolic steroids for a long time developed Type I aortic dissection associated with heavy weightlifting. The patient did not have a recent history of trauma to the chest, no history of hypertension, and no illicit drug use. He presented with severe chest pain radiating to back and syncopal event with exertion. Initial vitals were significant for blood pressure of 80/50 mmHg, pulse of 80 beats per minute, respirations of 24 per minute, and oxygen saturation of 92% on room air. Physical exam was significant for elevated jugular venous pressure, muffled heart sounds, and cold extremities with diminished pulses in upper and absent pulses in lower extremities. Bedside echocardiogram showed aortic root dilatation and cardiac tamponade. STAT computed tomography (CT) scan of chest revealed dissection of ascending aorta. Cardiothoracic surgery was consulted and patient underwent successful repair of ascending aorta. Hemodynamic stress of weightlifting can predispose to aortic dissection. Aortic dissection is a rare but often catastrophic condition if not diagnosed and managed acutely. Although rare, aortic dissection needs to be in the differential when a young weightlifter presents with chest pain as a delay in diagnosis may be fatal.

Biaxial rupture properties of ascending thoracic aortic aneurysms

Although hundreds of samples obtained from ascending thoracic aortic aneurysms (ATAA) of patients undergoing elective surgical repair have already been characterized biomechanically, their rupture properties were always derived from uniaxial tensile tests. Due to their bulge shape, ATAAs are stretched biaxially in vivo. In order to understand the biaxial rupture of ATAAs, our group developed a novel methodology based on bulge inflation and full-field optical measurements. The objective of the current paper is threefold. Firstly, we will review the failure properties (maximum stress, maximum stretch) obtained by bulge inflation testing on a cohort of 31 patients and compare them with failure properties obtained by uniaxial tension in a previously published study. Secondly, we will investigate the relationship between the failure properties and the age of patients, showing that patients below 55years of age display significantly higher strength. Thirdly, we will define a rupture risk based on the extensibility of the tissue and we will show that this rupture risk is strongly correlated with the physiological elastic modulus of the tissue independently of the age, ATAA diameter or the aortic valve phenotype of the patient.

STATEMENT OF SIGNIFICANCE

Despite their medical importance, rupture properties of ascending thoracic aortic aneurysms (ATAA) subjected to biaxial tension were inexistent in the literature. In order to address this lack, our group developed a novel methodology based on bulge inflation and full-field optical measurements. Here we report rupture properties obtained with this methodology on 31 patients. It is shown for the first time that rupture occurs when the stretch applied to ATAAs reaches the maximum extensibility of the tissue and that this maximum extensibility correlates strongly with the elastic properties. The outcome is a better detection of at-risk individuals for elective surgical repair.

Seasonal incidence of hospital admissions for Stanford type A aortic dissection

The objective of this study was to test the hypothesis that there is seasonal variation in the incidence of Stanford type A aortic dissection (SA-AoD) among patients admitted to our cardiovascular surgical service. A sinusoidal logistic regression model was used to analyze event data for 6081 calendar days. A cyclic peak risk for SA-AoD was observed for calendar day 304 (p=0.019). The odds ratios for the 3- and 6-month window surrounding this peak were 1.6 (p=0.054) and 1.7 (p=0.0040), respectively. Our results suggest than a seasonal variation exists in the incidence of SA-AoD.

The characteristics of acute aortic dissection among young Chinese patients: a comparison between Marfan syndrome and non-Marfan syndrome patients

PURPOSE

Aortic dissection (AoD) is one of the most common catastrophes involving the aorta. Nevertheless, early diagnosis remains to be a challenge in the Emergency Department (ED), particularly in young individuals. In this study, we attempted to identify the characteristics of acute AoD among young individuals, particular in patients with Marfan syndrome.

MATERIALS AND METHODS

This was an retrospective chart-review study conducted in a tertiary referring hospital. The hospital database was queried for the combination of AoD and patients under age of 40 years. The medical charts were reviewed to obtain demographic data, clinical data and laboratory characteristics by using a standardized data collection sheet. A comparison between Marfan syndrome and non-Marfan syndrome patients was performed.

RESULTS

During the 10-years period, 18 of 344 patients with acute AoD were younger than 40 years-old. Patients with Marfan syndrome developed acute AoD at a younger age than patients without Marfan syndrome. The mean diastolic blood pressure was significantly lower in patients with Marfan syndrome upon presenting to the ED than those without. Patients with Marfan syndrome had trends toward higher risk of development of type A AoD, increased recurrence rate and higher mortality rate than those without. However, statistical significance was not present.

CONCLUSION

ED physicians should have high alert to acute AoD in young patients presenting with severe unexplained chest and back pain, particularly in those patients with a history of heart diseases, hypertension, and Marfan syndrome or featuring Marfanoid habitus. Acute coronary syndrome, unexplained abdominal symptoms, and sudden cardiac arrest could be the initial manifestation of AoD in young patients. A low threshold to perform enhanced computed tomography may facilitate early diagnosis and timely treatment in this patient population.

Aortic dissection type I in a weightlifter with hypertension: A case report

Acute aortic dissection can occur at the time of intense physical exertion in strength-trained athletes like weightlifters, bodybuilders, throwers, and wrestlers.

Rapid rise in blood pressure and history of hypertension are the most common causes of aortic dissection in athletes. It is a very tragic event because of its high mortality rate of about 32% in young patients. We report a case of aortic dissection in a young weightlifter with an extensive intimal tear of the aorta, from the sinus of Valsalva to the abdominal aorta.

Dissecting aneurysms involving both anterior cerebral artery and aorta

Non-traumatic intracranial dissecting aneurysm (IDA) has been recently reported with increasing frequency and is recognized as a possible cause of subarachnoid hemorrhage. However, the pathogenesis of this disease is still unclear. Cystic medial necrosis (CMN) is known to be a cause of aortic dissection, especially in Marfan's syndrome. Presented herein is the case of a 49-year-old man who had IDA of the right anterior cerebral artery and abdominal aortic dissection without Marfan's syndrome. Histological examination showed medial degenerative changes with the accumulation of acid mucopolysaccharides in various intra- and extracranial arteries. Coexistence of dissecting aneurysms in the anterior cerebral artery and aorta suggests the presence of underlying pathogenesis that is common to these two dissection processes.

Weight Lifting and Aortic Dissection: More Evidence for a Connection

BACKGROUND/AIMS

In 2003, we reported on a small number of patients in whom acute aortic dissection appeared to be causally related to intense weight lifting. If additional cases could be identified, the phenomenon of weight lifting induced aortic dissection would be further substantiated. We now report a substantially larger number of cases in which aortic dissection is associated with intense physical exertion.

METHODS

Additional cases of acute aortic dissection occurring at the time of intense physical exertion were accumulated and analyzed. Cases were culled from retrospective review of a large university data base and from reports forwarded to our attention from around the country. We determined type of activity bringing on symptoms, age and sex of the patients, location of the dissection (ascending or descending aorta), aortic size, therapy, and survival.

RESULTS

We identified 31 patients in whom acute aortic dissection occurred in the context of severe physical exertion, predominantly weight lifting or similar activities. All patients except one were males. Mean age was 47.3 (range = 19-76). All except four dissections were in the ascending aorta. Only three patients (9.7%) had a family history of aortic disease. Mean aortic diameter on the initial imaging study was 4.63 cm. Twenty-six of the 31 cases were diagnosed ante-mortem and 5 post-mortem. Overall, 10 of the 31 patients (32.2%) died. Of 24 patients reaching surgical therapy, 20 (83.3%) survived.

CONCLUSION

Weight lifting related acute aortic dissection appears to be a real phenomenon, with increasing evidence for the association of extreme exertion with this catastrophic aortic event. Moderate aortic dilatation confers vulnerability to exertion-related aortic dissection. Individuals with known aortic dilatation should be cautioned to refrain from weight lifting or strenuous exertion. Routine echocardiographic screening of individuals engaging in heavy strength training should be considered, in order to prevent this tragic loss of life.

Acute aortic dissection

Acute aortic dissection is an uncommon but lethal cause of acute chest, back, and abdominal pain. Establishing a timely diagnosis is paramount, as mortality from acute aortic dissection rises by the hour. Physical findings are protean and may include acute aortic valve insufficiency, peripheral pulse deficits, a variety of neurologic deficits, or end-organ ischemia. The keys to establishing a timely diagnosis are maintaining a high index of suspicion and quickly obtaining a diagnostic study. CT angiography, magnetic resonance imaging, transesophageal echocardiography, and, to a lesser extent, aortography are all highly accurate imaging modalities. The choice of study should be driven by the clinical stability of the patient, the information required and the resources available at presentation. Proximal dissections are surgical emergencies, but distal dissections are generally treated medically. Endovascular stents are gaining favor for use in the repair of both acute and chronic distal dissections. Long-term outcome data for endovascular stenting are still limited, and it remains unclear when stenting should be favored over surgery or medical therapy.

Stress testing in the medical evaluation for hazardous materials duty: results and consequences in three groups of candidates

OBJECTIVE

The objective of this study was to determine the yield of exercise stress testing (GXT) and other methods for evaluating candidates for HAZMAT duty.

METHODS

The authors conducted an analysis of prior and current records of GXTs, medical examinations, blood tests, chest radiographs, spirometry, and audiometry in 190 candidates. The authors also conducted scrutiny of GXT results, using Duke Treadmill Score (DTS), Chronotropic Index (CI), and Heart Rate Recovery (HRR).

RESULTS

Seven candidates were disapproved by history and/or physical examination. Twenty-one others were deferred for GXT-induced, marked hypertension, and/or ST depression >/=2 mm. The latter appeared to be false-positive indications of ischemia, low risks confirmed by DTS, CI, and HRR. Heat stress was not induced in 26 subjects so evaluated.

CONCLUSIONS

GXT identified marked hypertension in 12 HAZMAT candidates and ischemic ST changes in 10, the latter appearing to be false-positives. Other testing yielded useful baselines, rarely disqualifying.

A rare sign of intracranial internal carotid artery dissection causing cerebral infarction: a case report and review of the literature

We describe a patient with CT-proven ischemic infarction of the left middle cerebral artery (MCA) territory. The emergency CT, on admission, was suggestive of intracranial internal carotid artery dissection by demonstrating gaseous gap defects in the arterial wall and a subsequent thromboembolic process in the MCA. To our knowledge, there is no previous report regarding radiologically detected gas within the vessel wall or lumen secondary to dissection. We discuss this uncommon radiologic sign and its possible pathogenesis with a review of the literature.

Aortic dissection in a weight lifter with nodular fasciitis of the aorta

We report a case of spontaneous aortic dissection in a young weight lifter without aortic medial disease but with a myofibroblastic proliferation of the aortic adventitia consistent with nodular fasciitis. Successful treatment included ascending aorta replacement with Dacron graft and aortic valve resuspension. We believe that the underlying aortic pathology most likely contributed to the development of the aortic dissection.

Etiologic factors of acute aortic dissection in children and young adults

Current concepts in the pathophysiology and predisposing conditions of acute aortic dissection in children, adolescents, and young adults are presented. Timely diagnosis is required for this life-threatening condition. Most children and adolescents with aortic dissection have congenital cardiovascular anomalies. Certain heritable disorders involving connective tissue also predispose to this disorder. Newer associations include cocaine abuse and weight lifting. To facilitate early diagnosis, the salient physical findings of the known predisposing conditions are reviewed. Clinical presentation and diagnostic imaging of aortic dissection are briefly summarized. Physicians working in an acute care setting, particularly in the emergency room, should be aware of disorders predisposing to acute aortic dissection in the pediatric and young adult population. Practitioners conducting school or college preparticipation sports evaluations can make use of such information in their assessment of risk for sudden death.

Aortic dissection

The presentation of aortic dissection in the emergency department may be more subtle than the classic description of a shocked patient with "ripping" chest pain. The epidemiology, variation in presentation, investigation, and management of aortic dissection are reviewed.

Aortic valve thickening associated with power training: is it pressure overload?

This is a first report of aortic valve thickening secondary to intermittent hypertensive episodes experienced with weight lifting.

Weight training injuries: part 1: diagnosing and managing acute conditions

When patients present with acute weight training injuries, familiarity with the demands of the activity can help physicians get the most out of the patient history. Probable risk factors for injury include errors in technique (described in a sidebar), skeletal immaturity, and anabolic steroid abuse. Common acute injuries in weight training include sprains, strains, tendon avulsions, and compartment syndrome. Possible nonmusculoskeletal problems include retinal hemorrhage, radiculopathy, and various cardiovascular complications. Treatment of acute musculoskeletal injuries varies, but usually includes sports medicine mainstays such as prompt RICE. Chronic weight training injuries will be described in part 2 of this series.

Multiple aneurysms and aortic dissection: an unusual manifestation of Marfan's syndrome

Annuloaortic ectasia and dissection of the ascending aorta are common cardiovascular complications of Marfan's syndrome. True aneurysms of the subclavian arteries in these patients are rare. We present an unusual case of a 37-year-old woman who over the span of 10 years sequentially developed an aneurysm of the ascending aorta (annuloaortic ectasia), a right subclavian artery aneurysm, a left axillary-subclavian artery aneurysm, and a dissection of the aortic arch. Aside from the aortic dissection, the aneurysms produced no symptoms. All vascular complications were detected with computed tomography and managed successfully. This case emphasizes the need for close postoperative surveillance in patients with Marfan's syndrome who have had one cardiovascular complication of the disease.