Chronobiology of Acute Aortic Dissection in the Marfan Syndrome (from the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions and the International Registry of Acute Aortic Dissection)

Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community

OBJECTIVE

The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years.

METHODS

IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents.

RESULTS

Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index.

CONCLUSIONS

IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.

Cardiothoracic surgery and peripheral endovascular intervention in cardiovascular damage from a cohort of orphan rheumatological diseases-epidemiological and survival analysis

Background

Aortic diseases in some orphan rheumatological diseases require medical, surgical or peripheral endovascular intervention because they can be catastrophic. Objectives: to analyze the main clinical and epidemiological characteristics of patients with Takayasu arteritis (TA), Marfan syndrome (MS) and similar conditions that were treated with cardiothoracic surgery and peripheral endovascular intervention.

Methods

Retrospective and descriptive cohort study that included patients of any age and gender with TA (as per the criteria of the American College of Rheumatology and EULAR/PRINTO), MS (according to Ghent criteria), and similar conditions who underwent cardiothoracic surgery or peripheral endovascular intervention. Data were collected from electronic charts.

Results

A total of 77 patients with TA and 135 patients with MS and similar conditions were included. The frequency of surgical or interventional requirements in patients with TA and MS/similar conditions was 77/364 (21.2%) and 135/300 (45%), respectively; such patients were followed for a median of 6 [2–12] and 3.29 (0.42–6.62) years, with (maximum follow-up range of 47 and 21.37 years, respectively). Aneurysms were present in 11 (14.3%) and 66 (48.9%) in patients with TA and MS/similar conditions, respectively. Aortic, mitral and tricuspid valve damage occurred in 8 (10.4%) patients, 4 (5.2%) patients and 1 (1.3%) patient with TA, respectively; corresponding frequencies in patients with MS/similar conditions were 98 (72.6%), 50 (37.0%) and 20 (14.8%). We identified that 20% of patients with TA died after 5.08 years (95% CI: 0.23–25.42 years) and 20 % of the patients with MS and other similar conditions died after 7.52 years (95% CI: 1.10–9.02 years).

Conclusions

The frequency of surgical intervention was low in this study. Long-term prognosis is good if surgery is performed in a timely manner. Epidemiological studies provide relevant information for public health decisions related to the management of orphan rheumatological diseases.

Aortic aneurysm disease-Make room for chronobiology

BACKGROUND

Aortic aneurysm (AA) is a common atherosclerotic condition, accounting for nearly 6000 deaths in England and up to 175,000 deaths globally each year. The pathological outward bulging of the aorta typically results from atherosclerosis or hereditary connective tissue disorders. AAs are usually asymptomatic until spontaneous rupture or detected on incidental screening. Eight in 10 patients do not survive the rupture and die either before reaching hospital or from complications following surgery. Similar to other cardiovascular pathologies, AA is thought to be subject to chronobiological patterns of varying incidence.

METHODS

We performed a literature review of the current literature to evaluate the association between circadian rhythms, seasonal variations, and genetic factors and the pathogenesis of AA, reviewing the impact of chronobiology.

RESULTS

The incidence of AA is found to peak in the early morning (6-11 a.m.) and colder months, and conversely troughs towards the evening and warmer months, exhibiting a similar pattern of chronobiological rhythm as other cerebrovascular pathologies, such as myocardial infarcts, or cerebrovascular strokes.

CONCLUSION

Literature suggests there exists a clear relationship between chronobiology and the incidence and pathogenesis of ruptured AA; incidence increases in the morning (6-11 a.m.), and during colder months (December-January). This is more pronounced in patients with Marfan syndrome, or vitamin D deficiency. The underlying pathophysiology and implications this has for chronotherapeutics, are also discussed. Our review shows a clear need for further research into the chronotherapeutic approach to preventing ruptured AA in the journey towards precision medicine.

Genetic aortic disease epidemiology, management principles, and disparities in care

Patients with syndromic and nonsyndromic heritable aortopathies (also known as genetic aortic disease) are a heterogeneous group of patients who present at younger ages with more rapid growth of aortic aneurysms and/or increased frequency of dissections compared with patients with atherosclerotic aortopathies. In this review, we describe the etiology, epidemiology, and appropriate care delivery for these conditions at each stage of management. Within each section, we discuss sex, gender, and race differences and highlight disparities in care and knowledge. We then discuss the role of the vascular team throughout the cycle of care and the evolving inclusion of patient input in research. This understanding is essential to the creation of effective health care policies that support equitable, appropriate, and patient-centered clinical practices.

99-Case Study of Sporadic Aortic Dissection by Whole Exome Sequencing Indicated Novel Disease-Associated Genes and Variants in Chinese Population

Background

In this study, the whole exome sequencing in human aortic dissection, a highly lethal cardiovascular disease, was investigated to explore the aortic dissection-associated genes and variants in Chinese population.

Methods

Whole exome sequencing was performed in 99 cases of aortic dissection. All single nucleotide polymorphisms (SNPs), insertions/deletions (InDels), and copy number variations (CNVs) were filtered to exclude the benign variants. Enrichment analysis and disease-gene correlation analysis were performed.

Results

3425873 SNPs, 685245 InDels, and 1177 CNVs were identified, and aortic dissection-associated SNPs, InDels, and CNVs were collected. After the disease correlation analysis, 20 candidate genes were identified. Part of these genes such as MYH11, FBN1, and ACTA2 were consistent with previous studies, while MLX, DAB2IP, EP300, ZFYVE9, PML, and PRKCD were newly identified as candidate aortic dissection-associated genes.

Conclusion

The pathogenic and likely pathogenic variants in most of AD-associated genes (FBN1, MYH11, EFEMP2, TGFBR2, FBN2, COL3A1, and MYLK) were identified in our cohort study, and pathogenic CNVs involved in MYH11, COL family, and FBN were also identified which are not detectable by other NGS analysis. The correlation between MLX, DAB2IP, EP300, ZFYVE9, PML, PRKCD, and aortic dissection was identified, and EP300 may play a key role in AD.

Chronobiological patterns of acute aortic dissection in central China

BACKGROUND

Acute aortic dissection (AAD) is a life-threatening emergency with poor clinical outcomes. Understanding the chronological patterns of AAD onset would be helpful for identifying the triggers of AAD and preventing this catastrophic event.

METHODS

We collected data from 2048 patients diagnosed with AAD at Tongji Hospital (Wuhan, China) from 2011 to 2018. The χ2 test was used to determine whether a specific period had significantly different seasonal/weekly distributions from other periods. Fourier models were used to analyse the rhythmicity in monthly/circadian distribution.

RESULTS

The mean age was 53.4±10.9 years, and 1161 patients (56.7%) were under 55 years. One thousand six hundred fifty-seven patients (80.9%) were male, and 935 cases (45.7%) were type A dissections. The proportions of patients with comorbid hypertension/diabetes were 60.3% (1234 cases) and 1.8% (36 cases), respectively. A peak was identified in colder periods (winter/December) and a trough in warmer periods (summer/June). No significant variation was observed in weekly distribution. Fourier analysis showed a statistically significant circadian variation (p<0.001) with a nocturnal trough in 2:00-3:00, a morning peak in 9:00-10:00, and an afternoon peak in 16:00-17:00. Subgroup analyses identified circadian rhythmicity in all subgroups except for the female group and younger group (younger than 55 years).

CONCLUSION

Our results confirmed that the onset of AAD exhibits significant seasonal, monthly and circadian patterns. Patients with AAD with different Stanford-type dissections, sexes, ages and hypertension statuses could present different circadian variations. These findings may provide novel perspectives for identifying the triggers of AAD and better preventing this catastrophic event.

Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research

Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. The International Registry of Acute Aortic Dissection was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment. Since then, >7300 cases have been included from >51 sites in 12 countries. Although presenting symptoms and physical findings have not changed significantly over this period, the use of computed tomography in the diagnosis has increased, and more patients are managed with interventional procedures: surgery in type A AAD and endovascular therapy in type B AAD; with these changes in care, there has been a significant decrease in overall in-hospital mortality in type A AAD but not in type B AAD. Herein, we summarized the key lessons learned from this international registry of patients with AAD over the past 20 years.

Meta-Analysis of Circadian Variation in the Onset of Acute Aortic Dissection

Circadian variation in the onset of acute aortic dissection (AAD) has been less investigated than other cardiovascular diseases. We performed a meta-analysis to assess the presence of an circadian rhythmic variability of AAD onset. Eligible studies were observational studies enrolling patients with AAD and reporting a circadian variation in AAD. Study-specific estimates, that is, 2-hour incidence of AAD, were combined using the random-effects model. Chronobiological analysis (analysis of circadian rhythmicity) was performed by applying a partial Fourier series to the pooled 2-hour incidence using the weighted least-squares method. We identified 7 eligible studies enrolling a total of 1,827 patients with AAD. Pooled 2-hour period incidence of AAD was 3.4% in 0:00 to 2:00, 4.8% in 2:00 to 4:00, 5.4% in 4:00 to 6:00, 9.6% in 6:00 to 8:00, 13.8% in 8:00 to 10:00, 11.1% in 10:00 to 12:00, 8.1% in 12:00 to 14:00, 8.9% in 14:00 to 16:00, 8.8% in 16:00 to 18:00, 7.0% in 18:00 to 20:00, 8.1% in 20:00 to 22:00), and 5.5% in 22:00 to 24:00. Chronobiological analysis (nonlinear Fourier rhythm analysis) identified a significant (p = 0.0082) circadian pattern in the occurrence of AAD with a peak in 8:00 to 10:00 and a nadir in 0:00 to 2:00. Pooled analysis demonstrated significantly more incidence in 8:00 to 10:00 than in 0:00 to 2:00 (risk ratio 3.59, 95% confidence interval 2.19 to 5.90, p<0.00001). The incidence of AAD was 8.8%, 15.5%, 25.0%, 17.7%, 16.1%, and 13.8% in 0:00 to 4:00, 4:00 to 8:00, 8:00 to 12:00, 12:00 to 16:00, 16:00 to 20:00, and 20:00 to 24:00, respectively. A significant circadian pattern was found in the occurrence of AAD with a peak in 8:00 to 10:00 and a nadir in 0:00 to 2:00.

Aortic dissection in patients with Marfan syndrome based on the IRAD data

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.

The IRAD and beyond: what have we unravelled so far?

Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality rates and a long history of challenges to both diagnose and manage this condition successfully. The International Registry of Acute Aortic Dissection (IRAD) was established in 1996 as a global database to understand this old disease better and improve care for dissection. IRAD initially targeted various areas including etiological factors of dissection, modes of presentation, clinical features, physical findings, imaging, management, and outcomes, and is currently branching out in more specific fields such as endovascular intervention, genetic profiling, and functional imaging. Although presenting symptoms and physical findings have not changed significantly over two decades, the widespread use of computed tomography is standard and has improved the diagnostic pathway. Moreover, more patients are managed with appropriate procedures, such as surgery in type A, and endovascular therapy in subsets of type B aortic dissection. With these ongoing improvements in swift diagnostic work-up and therapeutic care, fewer patients are not getting appropriate treatment and more patients survive once they reach hospital.

Meta-Analysis of Seasonal Incidence of Aortic Dissection

We performed the first meta-analysis to identify in which season incidence of aortic dissection is the most and least frequent. MEDLINE and EMBASE were searched through February 2017. Eligible studies were observational studies enrolling patients with aortic dissection and reporting seasonal or monthly incidence of aortic dissection. Study-specific estimates, incidence of aortic dissection in each season (number of aortic dissection in a season divided by that in a year) and risk ratios (RRs) for incidence of aortic dissection in a season versus another season, were combined using the random-effects model. We identified 18 eligible studies enrolling a total of 101,264 patients with aortic dissection. Pooled incidence was 20.6% in summer, 24.8% in autumn, 28.2% in winter, and 25.5% in spring. Pooled analysis demonstrated a statistically significant increase in incidence of aortic dissection in autumn than in summer (RR 1.18; p <0.0001), in winter than in summer (RR 1.37; p <0.0001), in spring than in summer (RR 1.24; p <0.0001), in winter than in spring (RR 1.11; p = 0.006), and in winter than in autumn (RR 1.17; p <0.001); and no statistically significant difference between spring and autumn (RR 1.04; p = 1.00). In conclusion, the incidence in winter (28.2%) was significantly more frequent than that in other seasons and that in summer (20.6%) was significantly less frequent than that in other seasons (winter > spring ≈ autumn > summer).