Obstructive Sleep Apnea Syndrome: A Risk Factor for Stanford's Type B Aortic Dissection

Population risk profile analysis of acute uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair

BACKGROUND

Uncomplicated type B aortic dissection (unTBAD) comprises the estimated majority of type B aortic dissection (TBAD), presenting without any of the complications associated with complicated TBAD (coTBAD). Although first-line treatment for coTBAD is thoracic endovascular aortic repair (TEVAR), and despite the fact that TEVAR has proven its safety and effectiveness in the treatment of unTBAD, unTBAD is still being predominantly managed conservatively with medical therapy, with a small proportion of patients being offered TEVAR.

AIMS

The main scope of this review is to highlight the evidence in the literature of the demographic characteristics and associated co-morbidities of unTBAD patients undergoing TEVAR in order to produce a risk stratification system to achieve favourable outcomes.

METHODS

A comprehensive literature search was conducted using multiple electronic databases including PubMed, Ovid, Scopus, and EMBASE.

RESULTS

Multiple demographic characteristics and associated co-morbidities of unTBAD patients affecting TEVAR outcomes were identified, assessed, and investigated, including age, gender, race, genetics, medical conditions, such as hypertension and diabetes, and lifestyle factors such as smoking. Most factors were associated with increased risks of mortality and morbidity, while others, such as race, were identified as being protective against those when it comes to TEVAR.

CONCLUSION

Despite the favourable results yielded by TEVAR in unTBAD, there remains a grey area concerning its management. Thus, it is important to incorporate the demographics and co-morbidities of unTBAD patients' when into clinical judgement when assessing indications for TEVAR intervention to ensure optimum results can be achieved.

Impact of obstructive sleep apnea on aortic disease occurrence: a meta-analysis

Objective

Aortic diseases, mainly including aortic dilatation, aortic aneurysm (AA) and aortic dissection (AD), have high morbidity and mortality. Many studies have suggested that obstructive sleep apnea (OSA) acts as a candidate risk factor for aortic diseases. Thus, we performed a meta-analysis to explore comprehensively the effect of OSA on the risk of aortic disease occurrence.

Methods

We searched PubMed, Embase and Cochrane Library databases from inception to February 2022 to identify studies investigating the association between OSA and aortic diameter dilatation, the prevalence of OSA in individuals with or without AA/AD and the incidence of AA/AD in individuals with or without OSA. The Newcastle-Ottawa Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) were respectively used to evaluate the quality of the included cohort and cross-sectional studies. A random or fixed effect model was used to generate pooled effects according to interstudy heterogeneity. Sensitivity analyses were performed to test the robustness of the results.

Results

We identified 10 observational publications with 214,127 participants in this meta-analysis. OSA was significantly associated with increased aortic diameter (WMD = 1.46, 95% CI, 1.10–1.83, p < 0.001). OSA prevalence was higher in patients with AA/AD compared to their counterparts without AA/AD (OR = 1.90, 95% CI, 1.30–2.76, p = 0.001). No significant difference in the incidence of AA/AD was observed in individuals with or without OSA (RR = 0.85, 95% CI, 0.62–1.16, p = 0.307). Sensitivity analyses did not modify these results.

Conclusions

This meta-analysis suggests that OSA is associated with aortic diameter dilatation but does not affect AA/AD occurrence.

Sleep apnea predicts cardiovascular death in patients with Marfan syndrome: a cohort study

Background

Surgical replacement of the aortic root is the only intervention that can prevent aortic dissection and cardiovascular death in Marfan syndrome (MFS). However, in some individuals, MFS also causes sleep apnea. If sleep apnea predicts cardiovascular death, a new target for predictive, preventive, and personalized medicine (PPPM) may emerge for those individuals with MFS who have sleep apnea.

Methods

This is an investigator-initiated study with long-term follow-up data of 105 individuals with MFS. All individuals were screened for sleep apnea regardless of symptoms. Cardiovascular death served as a primary endpoint, and aortic events as a secondary outcome.

Results

Sleep apnea with an apnea–hypopnea index (AHI) > 5/h was observed in 21.0% (22/105) with mild sleep apnea in 13% (14/105) and moderate to severe sleep apnea in 7.6% (8/105). After a median follow-up of 7.76 years (interquartile range: 6.84, 8.41), 10% (10/105) had died, with cardiovascular cause of death in 80% (8/10). After adjusting for age and body mass index (BMI), the AHI score emerged as an independent risk factor for cardiovascular death (hazard ratio 1.712, 95% confidence interval [1.061–2.761], p = 0.0276). The secondary outcome of aortic events occurred in 33% (35/105). There was no effect of the AHI score on aortic events after adjusting for age and BMI (hazard ratio 0.965, 95% confidence interval [0.617–1.509]), possibly due to a high number of patients with prior aortic surgery.

Interpretation

Sleep apnea is emerging as an independent predictor of cardiovascular death in MFS. It seems mandatory to screen all individuals with MFS for sleep apnea and to include these individuals, with both MFS and sleep apnea, in further studies to evaluate the impact of preventive measures with regard to cardiovascular death.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-022-00291-4.

Obstructive sleep apnea in patients with acute aortic dissection

Background

Obstructive sleep apnea (OSA) imposes an afterload burden on the left ventricle and increases the pressure gradient across the aortic wall. Thus, OSA may increase the risk for aortic dissection (AD).

Methods

This study enrolled 40 subjects with acute AD from four institutions; 37 completed the modified Berlin Questionnaire and 31 underwent attended overnight polysomnography. Aortic diameter was measured on a computed tomography scan at seven locations from the sinotubular junction to the diaphragm.

Results

Twenty‐seven subjects had type A dissection; 13 had type B. In those who had polysomnography apnea–hypopnea index (AHI) ranged from 0.7 to 89. Prevalence of OSA (AHI ≥ 5) was 61%. Nocturnal presentation (10 p.m.–7 a.m.) did not differ by presence/absence of OSA. The modified Berlin Questionnaire was not predictive of the presence of OSA. Among type A subjects with polysomnography (n = 23), aortic diameters at all locations were greater in the OSA group though differences were not statistically significant. Summating aortic diameters at the seven locations also yielded a numerically larger mean value in the OSA group versus the non‐OSA group.

Conclusions

In this sample of patients with acute dissection, OSA was prevalent but was not associated with a nocturnal presentation. The presence of underlying OSA may be associated with larger aortic diameters at the time of dissection compared to patients without OSA. Though differences did not meet statistical significance the current series is limited by small numbers.

Obstructive Sleep Apnoea in Stanford Type B Aortic Dissection Is Associated With Multiple Imaging Signs Related to Late Aortic Events

Background: Obstructive sleep apnoea (OSA) is highly prevalent in patients with Stanford type B aortic dissection (TBAD). Few studies have evaluated the effects of OSA on vascular changes in TBAD patients. This study aimed to explore the effect of OSA on aortic morphological changes in TBAD patients and its relation to late aortic events (LAEs).

Methods: This case-control study included 143 TBAD patients. The diameters of different parts of the aorta were measured based on computed tomography angiography (CTA). According to the apnoea-hypopnoea index (AHI), OSA was classified as mild (5 ≤ AHI ≤ 15), moderate (15 < AHI ≤ 30), or severe (AHI > 30). The false lumen (FL) status was evaluated and classified as partially thrombosed, patent, or completely thrombosed.

Results: The OSA prevalence in TBAD patients was 64.3%, and image differences related to LAEs between TBAD patients with and without OSA included the maximum aortic diameter at onset (37.3 ± 3.9 vs. 40.3 ± 4.5 mm, p < 0.001), the FL diameter of the proximal descending thoracic aorta (16.0 ± 6.8 vs. 20.3 ± 4.7 mm, p < 0.001), and the proportion of the FL that was partially thrombosed (39.2 vs. 64.1%, p = 0.004). Additionally, in the multivariable analysis of patients with OSA, the risks of an aortic diameter ≥40 mm, a proximal descending aorta FL ≥ 22 mm and a partially thrombosed FL were 4.611 (95% CI: 1.796–11.838, p = 0.001), 2.544 (95% CI: 1.050–6.165, p = 0.039), and 2.565 (95% CI: 1.167–5.637, p = 0.019), respectively, after adjustment for confounding factors. Trend tests showed that the risks of an aortic diameter ≥40 mm and a partially thrombosed FL increased with increasing OSA severity.

Conclusions: TBAD patients with moderate to severe OSA have aortic dilatation in different parts of the aorta. OSA is an independent risk factor for multiple imaging signs related to LAEs, suggesting that OSA is an important factor affecting the prognosis of TBAD patients.

Diabetes Mellitus Lowers the Risk of Aortic Dissection: a Systematic Review and Meta-Analysis

BACKGROUND

This systematic review and meta-analysis aimed to investigate the association between diabetes mellitus and aortic dissection.

METHODS

The PubMed and Embase databases were searched until December 2019 to identify all articles reporting diabetes mellitus and aortic dissection. The pooled odds ratio and 95% confidence interval were calculated using random-effects model.

RESULTS

A total of 14 articles with 15,794 participants, of which 2133 diabetes mellitus patients, were eligible and included in this meta-analysis. The data suggested that diabetes mellitus decreased the risk of aortic dissection. In the subgroup analysis, this association was significant in worldwide studies except for the Chinese cohort and in studies adjusted for confounding factors. The results were stable after sensitivity analysis and no evidence of publication bias was found among studies.

CONCLUSIONS

The result of this meta-analysis indicated that diabetes mellitus was associated with a lower risk of aortic dissection.

Quantitative evaluation of retinal microvascular circulation in patients with obstructive sleep apnea-hypopnea using optical coherence tomography angiography

PURPOSE

To compare capillaries perfusion in macular areas at different layers and peripapillary region in radial peripapillary capillaries (RPC) between healthy subjects and subjects with obstructive sleep apnea-hypopnea (OSA) using spectral-domain optical coherence tomography angiography (OCTA).

METHODS

Totally 16 eyes with mild-to-moderate OSA, 14 eyes with severe OSA and 22 control eyes were enrolled in this study. Every subject filled out the Berlin questionnaire and received a comprehensive ocular and physical examination. The clinical characteristics were collected, OCT and OCTA scans using OCTA RT XR Avanti (AngioVue software, Optovue Inc., Fremont, CA, USA) were performed and analyzed.

RESULTS

Compared to the control group, the severe group had significantly higher VD in parafovea and perifoveal regions (p = 0.031; p = 0.029) at the level of deep capillary plexus (DCP), whereas the mild-to-moderate group had a significantly lower VD in the peripapillary region on RPC network in disc areas (p = 0.013).

CONCLUSIONS

Blood flow changes in macular areas might first appear at the DCP layer in OSA patients. Reduced VD in the peripapillary region at the RPC layer might be associated with OSA and cause subsequent RNFL changes.

Prevalence of Obstructive Sleep Apnea in Patients with Thoracic Aortic Aneurysm: A Prospective, Parallel Cohort Study

BACKGROUND

The pathogenesis and etiology of thoracic aortic aneurysms (TAA) are largely unknown. Preliminary data from patients with aortic dissection and abdominal aneurysms suggest a causal link of obstructive sleep apnea (OSA) on aortic disease.

OBJECTIVES

The aim of the study was to assess the prevalence of OSA in patients with TAA compared to a matched control group.

METHOD

In this prospective parallel-cohort study, we 2-to-1 matched 208 patients with verified TAA (at the aortic sinus and/or ascending aorta) to 104 controls without TAA according to sex, age, height, weight, and left ventricular ejection fraction. All participants underwent an ultrasound of the thoracic aorta and a level III respiratory polygraphy. OSA was defined as apnea-hypopnea index ≥5/h. The prevalence of OSA was compared with conditional logistic regression and controlling for the matching variables.

RESULTS

A total of 312 patients (mean age 65 ± 11 years, 82% male, mean body mass index 27 ± 4 kg/m2) were successfully 2-to-1 matched in the final model. Prevalence of OSA was significantly higher in the TAA-group when compared to the matched control group (63 vs. 47%; odds ratio 1.87 [95% CI 1.05-3.34]; p = 0.03). When applying a higher apnea-hypopnea index threshold (≥15/h), the odds ratio increased to 3.25 (95% CI 1.65-6.42; p < 0.001). The median apnea-hypopnea index was higher in patients with TAA (9.2/h [3.3-20.0] vs. 4.5/h [2.2-11.1], p < 0.001).

CONCLUSIONS

Patients with TAA have a higher prevalence of OSA when compared to the general population. Since OSA is effectively treatable and might contribute to the pathogenesis of TAA, further longitudinal trials are needed to assess the association between OSA and TAA.

Analysis of Aortic Remodeling and Stiffness in Patients with Obstructive Sleep Apnea Syndrome: Preliminary Results

Obstructive sleep apnea (OSA) is a well-known risk factor for cardiovascular diseases. Several studies have shown that OSA is associated with vessel remodeling, but few studies have examined aorta.

AIM

to analyse aortic remodelling in OSA.

METHODS

Thirty consecutive OSA patients (22 males and 8 females, aged 58.5 ± 13.2 years) were studied. All patients underwent a morning blood gas analysis, a full cardiorespiratory evaluation, including nocturnal polygraphy and echocardiography, that assessed aortic root diameter (ARD) and aortic stiffness index (ASI). Patients were grouped as follows: Group 1, non-severe OSA (Apnea-Hypopnea Index; AHI <30, 14 patients); Group 2, severe OSA (AHI ≥30, 16 patients).

RESULTS

No difference was found between the groups in ARD as absolute value (Group 1, 33.64 ± 0.91 mm; Group 2, 33.64 ± 1.02, p = ns) and as normalized value for the body surface area - ARDi (Group 1, 16.72 ± 0.63 mm/m²; Group 2, 16.09 ± 0.44, p = ns). Moreover, no difference was found in the ASI (Group 1, 14.04 ± 2.26; Group 2, 13.41 ± 2.22, p = ns). Considering all OSA patients, AHI showed an inverse correlation with ARDi (p = 0.018) and ASI (p = 0.0449). Moreover, the ASI showed a direct correlation with ARDi (p = 0.01) and morning PaO2 (p = 0.0349) as well as an inverse correlation with the oxygen desaturation index (ODI, p = 0.031) and total time with apnea and hypopnea (p = 0.039).

CONCLUSION

No difference was found between severe and non-severe OSA in ARD. Surprisingly, the data show that the severity of OSA correlates inversely with the ASI and ARDi. The relation between PaO2 and stiffness might be explained by a feedback mechanism that tries to overcome the reduction of aortic elasticity due to night desaturation. These findings need to be investigated in further studies with a larger study population.

Obstructive sleep apnea syndrome promotes the progression of aortic dissection via a ROS- HIF-1α-MMPs associated pathway

Aims: Obstructive sleep apnea syndrome (OSAS) has been increasingly recognized as an independent risk factor for aortic dissection (AD) and it is strongly associated with the extent of intermittent hypoxia and re-oxygenation (IH). This study aimed to clarify role of ROS- HIF-1α-MMPs pathway in the pathogenesis of AD and whether the HIF-1α inhibitor attenuates AD formation. Methods and results: 8-week-old male ApoE-/- mice were given β-aminopropionitrile at a concentration of 0.1 % for 3 weeks and infused via osmotic mini pumps with either saline or 2,500 ng/min/kg angiotensin II (Ang II) for 2 weeks. To mimic the OSAS, one group was exposed to IH, which consisted of alternating cycles of 20.9% O2/8% O2 FiO2 (30 episodes per hour) with 20 s at the nadir FiO2 during the 12-h light phase, 2 weeks before Ang II infusion. After Ang II infusion, we assessed remodeling in the aorta by echocardiography, histological and immunohistochemical analysis. IH treatment resulted in significant enlargement of the luminal area, destruction of the media, marked thickening of the adventitia, higher incidence of AD formation and lower survival rate in compared with the Ang II only group. Moreover, IH exposure markedly increased the aortic ROS production and subsequent HIF-1α expression, which in turn promoted the expressions of VEGF, MMP2 and MMP9 and finally leading to the progression of AD. Besides, in vitro study confirmed that IH induced HIF-1α expression plays an important role in the induction of MMPs and that is regulated by the PI3K/AKT/FRAP pathway. Intriguingly, a selective HIF-1α inhibitor KC7F2 could significantly ameliorate IH exposure induced aforementioned deleterious effects in vitro and in vivo.Conclusion: OSAS induced IH can promote the occurrence and progression of AD via a ROS- HIF-1α-MMPs associated pathway. The selective HIF-1α inhibitor KC7F2 could be a novel therapeutic agent for AD patient with OSAS.

Obstructive sleep apnea and risk of aortic dissection: A meta-analysis of observational studies

Objectives Obstructive sleep apnea acts as a potential risk factor for the development of cardiovascular disease. We undertook collaborative meta-analyses to clarify the risk of aortic dissection among adults suffering obstructive sleep apnea. Methods A systematic search of the databases (PubMed, Embase, and Cochrane Library) was performed. Studies reporting on the association between obstructive sleep apnea and aortic dissection were included. Information on 424 cases of aortic dissection in 56,291 patients from one cohort, four case-controls, and two cross-sectional studies were included in this study. Results The summary suggested that patients with obstructive sleep apnea are associated with an overall significant 60% increase in the risk of aortic dissection, compared to unexposed patients (odds ratios 1.60; 95% confidence interval 1.01-2.53), with a significantly higher apnea-hypopnea index (mean difference 10.71; 95% confidence interval 7.46-13.96). Moreover, a greater relation was found between moderate-to-severe obstructive sleep apnea and aortic dissection (odds ratios 4.43; 95% confidence interval 2.59-7.59). Adverse outcomes obtained by sleep study such as oxygen desaturation index (mean difference 10.51; 95% confidence interval 7.54-13.48), average SaO₂ (-1.36; 95% confidence interval -2.63 to -0.09), and minimum SaO₂ (-3.63; 95% confidence interval -5.27 to -1.98) were correspondingly related to patients with aortic dissection. Conclusions Obstructive sleep apnea, especially moderate-to-severe obstructive sleep apnea, may impose an additional risk of suffering from aortic dissection with a potential mechanism including intermittent hypoxia.

The Prevalence of Sleep Apnea in Type B Aortic Dissection: Implications for False Lumen Thrombosis

Introduction

Obstructive sleep apnea (OSA) has been implicated in aortic dissection. Thrombosis of the false lumen is associated with a prognosis of type B aortic dissection (AoD), and partial thrombosis has been reported to be an independent predictor of mortality. This study sought to explore whether the severity of OSA is associated with false lumen thrombosis.

Aims and Methods

In this observational study, 151 type B AoD patients were recruited consecutively from 2013 to 2015. The status of the false lumen was classified as patent, partially thrombosed, or completely thrombosed based on a computer tomography angiography image. Patients were divided into non-OSA group (apnea-hypopnea index [AHI] < 5), and mild (5 ≤ AHI ≤ 15), moderate (15 < AHI ≤ 30), and severe OSA groups (AHI > 30) using the AHI.

Results

The prevalence of OSA in type B dissection was 66.2%. Among 151 cases, 51 patients (33.8%) were in the non-OSA group, 56 (37.1%) were in the mild group, 21 (13.9%) were in the moderate group, and 23 (15.2%) were in the severe group. Additionally, a partially thrombosed false lumen was observed in 88 patients (58.3%). Multivariable analysis revealed that OSA severity was positively associated with partial thrombosis (odds ratio, 1.784, 95% confidence interval: 1.182-2.691, P = .006) after adjusting for other confounding factors.

Conclusions

OSA was present in two-thirds of patients with type B AoD. The severity of OSA was significantly associated with an increased risk of partial false lumen thrombosis. OSA may therefore be implicated in both the etiology and prognosis of AoD.

[Acute aortic syndromes and sleep apnea]

Obstructive sleep apnea (OSA) is a common disease, often present in "cardiovascular or metabolic patients". OSA favours the occurrence of arterial lesions, all the more if severe. There is a strong relationship between OSA and acute aortic syndromes (AAS). This relationship is in part explained by aortic dilatation linked to OSA. The presence of repeated episodes of sudden variation of transmural pressure applied on aortic wall seems to play a major role in this dilatation. All OSA patients should have a search of aortic dilatation by ultrasound (at a thoracic and abdominal level). Also, screening of OSA should be systematically performed in patients with aortic disease. The effect of continuous positive airway pressure in apneic patients with AAS has not been studied.

Adaptive servo-ventilation suppresses elevation of C-reactive protein and sympathetic activity in acute uncomplicated type B aortic dissection

OBJECTIVES

The aim of this prospective, randomized study was to investigate the effects of adaptive servo-ventilation (ASV), based on haemodynamic parameters, sympathetic status and respiratory conditions in patients with acute uncomplicated type B aortic dissection.

METHODS

We enrolled 28 patients with acute uncomplicated type B aortic dissection requiring antihypertensive therapies, who had been admitted within 24 h from onset. Study subjects were randomly assigned either to the ASV group (n = 14) or to the non-ASV group (n = 14).

RESULTS

Antihypertensive therapy at an acute phase led to significant reduction in blood pressure in both groups. Heart rate significantly dropped in the ASV group. In the non-ASV group, noradrenaline (746 ± 343 to 912 ± 402 pg/ml, P = 0.033) and dopamine (30 ± 21 to 42 ± 28 pg/ml, P = 0.015) significantly increased at 1 h after admission. Low frequency/high frequency ratios significantly decreased in the ASV group (2.1 ± 1.6 to 1.7 ± 1.1, P = 0.045). During follow-up at the subacute period, pleural effusion significantly increased in the non-ASV group (649 ± 611 vs 190 ± 292%, P = 0.033). Peak C-reactive protein (CRP) had a significant positive correlation with pleural effusion volume (P = 0.039) and was significantly greater in the non-ASV group (15.5 ± 6.3 vs 8.5 ± 6.1 mg/dl, P= 0.009).

CONCLUSIONS

In acute type B aortic dissection, ASV was considered to have suppressed the development of sympathetic nervous activity, pleural effusion and elevation of peak CRP.

Aortic Dissection Limited to Abdominal Aorta: an Underrecognized Entity?

BACKGROUND

Aortic dissection limited to the abdominal aorta is a rare clinical entity with non-specific clinical features. Optimal treatment, as well as natural history and progression of the disease, remain unclear. In 1992 we -reported 5 cases of isolated abdominal aortic dissection (IAAD) and in the present paper we update our series with 5 additional patients. A concise literature review is also provided.

METHODS

Between 1992 and 2014, we diagnosed 5 patients with IAAD (4 men, mean age 60.6 years, range 45-77). No patient presented with acute onset of symptoms. One patient was diagnosed with a periumbilical bruit, and diagnosis was made with magnetic resonance (MR)-angiography. Other diagnoses were incidental findings on computed tomographic (CT) scanning. Dissection was located infrarenally in four cases and at the celiac trunk in one case.

RESULTS

All cases were treated conservatively with hypertension control and close follow-up. Follow-up period ranged from 10 months to 20 years and was performed yearly by CT- or MR-angiography and blood pressure monitoring. All patients remained symptom-free, all dissection lengths remained stable. Slowly increasing post-dissection aneurysmal dilatation was encountered in two patients. We combined results of these five new patients with five previously diagnosed and reported patients at our center. Treatment was surgical in only one out of 10 patients. There was no disease-related mortality during follow-up.

CONCLUSIONS

Based on our case series, IAAD remains a rare clinical condition with relative benign clinical course. Treatment was almost exclusively conservative. Recent publications state IAAD might be underrecognized and under-diagnosed compared to thoracic aortic dissections.

The impact of obstructive sleep apnoea on the aorta

Obstructive sleep apnoea (OSA) has been shown to be a causal factor in the pathogenesis of vascular dysfunction and hypertension, conditions which can promote dilation and subsequent aortic dissection and rupture. The objective of this review is to summarise the current literature on the possible association between OSA and aortic disease and delineate the underlying mechanisms.

Relevant studies were found by searching for terms including “obstructive sleep apnoea” in combination with “aortic aneurysm, dissection, and dilation” in the MEDLINE and EMBASE databases.

Observational studies consistently reported that OSA is highly prevalent among patients with aortic aneurysms and aortic dissections. Patients with co-occurring OSA and Marfan's syndrome as well as patients at the more severe end of the spectrum of OSA seem to be especially vulnerable to aortic disease.

Several mechanisms are discussed concerning the link between OSA and aortic disease: nocturnal negative intrathoracic pressure surges leading to mechanical stretching of the aorta and ultimately aortic distension; arousal-induced reflex sympathetic activation with subsequent hypertension; and intermittent hypoxia associated with autonomic nervous system activation and consequently increased oxidative stress. Further well controlled studies are needed in order to define the exact role of OSA as a risk factor for aortic disease.