Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the American Society of Echocardiography and the European Association of Cardiovascular Imaging

Inflammatory Markers and Aortic Aneurysms: Exploring the Role of Hs-CRP and MHR in Ascending Aortic Aneurysm Development

Background

Aortic aneurysms, particularly those affecting the ascending aorta, pose significant health risks due to their potential to cause life-threatening complications such as rupture and dissection. While the etiology of ascending aortic aneurysms has traditionally been associated with non-inflammatory processes, emerging evidence suggests a potential role of inflammation in their development.

Methods

This study investigates the relationship between inflammatory markers and ascending aortic aneurysms, focusing on high-sensitivity C-reactive protein (hs-CRP) and the monocyte-to-HDL ratio (MHR). A total of 135 patients with ascending aortic aneurysms and 40 control subjects underwent comprehensive evaluations, including echocardiography, computed tomography imaging, and serum biomarker measurements.

Results

The results indicate significantly elevated levels of hs-CRP and MHR in patients with ascending aortic aneurysms compared to the control group, suggesting a potential inflammatory component in the pathogenesis of these aneurysms. However, the precise mechanisms underlying this association remain to be elucidated.

Conclusion

Despite limitations such as the cross-sectional study design and relatively small sample size, this study provides valuable insights into the potential involvement of inflammation in ascending aortic aneurysms. Further research, including longitudinal studies and histopathological analysis of aortic tissue, is warranted to confirm these findings and explore the utility of inflammatory markers as diagnostic and prognostic indicators in this patient population.

Advanced Imaging Techniques for Complex Endovascular Aortic Repair: Pre-Operative, Intra-Operative and Post-Operative Advancements

OBJECTIVES

Endovascular aortic repair requires extensive preoperative, intraoperative, and postoperative imaging for planning, surveillance, and detection of endo-leaks. There have been many advancements in imaging modalities to achieve this purpose. This review discussed different imaging modalities used at different stages of treatment of complex endovascular aortic repair.

METHODS

We conducted a literature review of all the imaging modalities utilized in endovascular aortic repair by searching various databases.

RESULTS

Pre-operative techniques include analysis of images obtained via modified central line using analysis software and intravascular ultrasound. Fusion imaging, CO2 angiography, intravascular ultrasound, and Fiber Optic RealShape technology have been crucial in obtaining real-time imaging for the detection of endo-leaks during operative procedures. Conventional imaging modalities like CT Angiography and MR Angiography are still employed for post-operative surveillance along with computational fluid dynamics and contrast-enhanced ultrasound. The advancements in artificial intelligence have been the breakthrough in developing robust imaging applications.

CONCLUSIONS

This review explains the advantages, disadvantages, and side-effect profile of the abovementioned imaging modalities.

2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults

Transthoracic echocardiography (TTE) is the most widely available and utilised imaging modality for the screening, diagnosis, and serial monitoring of all abnormalities related to cardiac structure or function. The primary objectives of this document are to provide (1) a guiding framework for treating clinicians of the acceptable indications for the initial and serial TTE assessments of the commonly encountered cardiovascular conditions in adults, and (2) the minimum required standard for TTE examinations and reporting for imaging service providers. The main areas covered within this Position Statement pertain to the TTE assessment of the left and right ventricles, valvular heart diseases, pericardial diseases, aortic diseases, infective endocarditis, cardiac masses, pulmonary hypertension, and cardiovascular diseases associated with cancer treatments or cardio-oncology. Facilitating the optimal use and performance of high quality TTEs will prevent the over or under-utilisation of this resource and unnecessary downstream testing due to suboptimal or incomplete studies.

The Year in Aortic Surgery: Selected Highlights From 2023

This article reviews the recent and relevant literature to the field of aortic surgery. Specific areas highlighted include outcomes of Stanford type A dissection, management of acute aortic syndromes, management of aortic aneurysms, and traumatic aortic injury. Although the focus was on articles from 2023, literature from prior years also was included, given that this article is the first of a series. Notably, the pertinent sections from the 2022 American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management Aortic Disease are discussed.

Computed Tomography Angiography for Aortic Diseases

Aortic pathologies encompass a heterogeneous group of disorders, including acute aortic syndrome, traumatic aortic injury , aneurysm, aortitis, and atherosclerosis. The clinical manifestations of these disorders can be varied and non-specific, ranging from acute presentations in the emergency department to chronic incidental findings in an outpatient setting. Given the non-specific nature of their clinical presentations, the reliance on non-invasive imaging for screening, definitive diagnosis, therapeutic strategy planning, and post-intervention surveillance has become paramount. Commonly used imaging modalities include ultrasound, computed tomography (CT), and MR imaging. Among these modalities, computed tomography angiography (CTA) has emerged as a first-line imaging modality owing to its excellent anatomic detail, widespread availability, established imaging protocols, evidence-proven indications, and rapid acquisition time.

A Deformable Constraint Transport Network for Optimal Aortic Segmentation From CT Images

Aortic segmentation from computed tomography (CT) is crucial for facilitating aortic intervention, as it enables clinicians to visualize aortic anatomy for diagnosis and measurement. However, aortic segmentation faces the challenge of variable geometry in space, as the geometric diversity of different diseases and the geometric transformations that occur between raw and measured images. Existing constraint-based methods can potentially solve the challenge, but they are hindered by two key issues: inaccurate definition of properties and inappropriate topology of transformation in space. In this paper, we propose a deformable constraint transport network (DCTN). The DCTN adaptively extracts aortic features to define intra-image constrained properties and guides topological implementation in space to constrain inter-image geometric transformation between raw and curved planar reformation (CPR) images. The DCTN contains a deformable attention extractor, a geometry-aware decoder and an optimal transport guider. The extractor generates variable patches that preserve semantic integrity and long-range dependency in long-sequence images. The decoder enhances the perception of geometric texture and semantic features, particularly for low-intensity aortic coarctation and false lumen, which removes background interference. The guider explores the geometric discrepancies between raw and CPR images, constructs probability distributions of discrepancies, and matches them with inter-image transformation to guide geometric topology in space. Experimental studies on 267 aortic subjects and four public datasets show the superiority of our DCTN over 23 methods. The results demonstrate DCTN's advantages in aortic segmentation for different types of aortic disease, for different aortic segments, and in the measurement of clinical indexes.

Complex aortic plaques: hidden danger in aortic stenosis. Role of transesophageal echocardiography

Aortic stenosis is associated with aortic plaques in up to 85% of cases because they share risk factors and pathogenic pathways. Intrinsically, complex aortic plaques carry a high risk of stroke, which has also been demonstrated in the context of aortic stenosis, especially in patients who underwent percutaneous or surgical replacement. Transesophageal echocardiography (TEE) is the imaging test of choice to detect plaques in the thoracic aorta and classify them as complex plaques. Furthermore, the 3D modality allows us to better specify its dimensions and anatomical characteristics, such as added thrombi or the presence of ulcers inside. This review aims to evaluate the use of TEE to detect complex aortic plaques in patients with an indication for percutaneous or surgical aortic valve replacement. To highlight the association between aortic stenosis and complex aortic plaques, we attached to the review some TEE studies from our experience.

Refining the upper limit of normal for the ascending aorta: In search of optimal criteria -- a large database study of normal individuals

OBJECTIVES

The cutoff for dilated mid-ascending aorta (mAA) is controversial and has several definitions. The present study was carried out to determine the prevalence of mAA dilation based on published definitions and to identify the optimal cutoff.

METHODS

Echocardiographic studies of patients >15 years of age performed at a large tertiary care center over 4 years, n = 49,330, were retrospectively evaluated. Leading-edge-to-leading-edge technique was used to measure the mAA in diastole. Several cutoff criteria were included. In addition, we defined normals in our database as those who, after 28 causes of dilated aorta were excluded, were normal both clinically and echocardiographically (n = 2334).

RESULTS

The mean age was 64.2 ± 17.1 years, and 31.5% were men. The prevalence of dilated mAA based on absolute criteria with sex stratification varied between 17% and 23% and based on relative criteria (to age, body surface area, and sex) varied between 6% and 11%. It further decreased to 7.6% on the addition of narrow age stratification (10 year intervals) performed on normals in our database. The multivariate adjusted R2 (for variation in mAA diameter) was 0.25 for age, decreasing to 0.12 for weight and 0.07 for sex and height.

CONCLUSIONS

The lowest prevalence of 7.6% probably represents the optimal cutoff for dilated mAA because it includes age, which explains most of the variation in mAA, in narrow (10 year) intervals only performed in our normals, which represents the largest sample size to date.

Role of Imaging Modalities in the Quantitative Assessment of Atherosclerotic Plaques in the Thoracic Aorta

AIM

Comparative analysis of the height of atherosclerotic plaques (AP) in the descending thoracic aorta (TA) according to two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE), and contrast-enhanced multislice computed tomography (MSCT).

MATERIAL AND METHODS

The TA was examined using 2D, 3D TEE and contrast-enhanced MSCT in 34 patients (20 men and 14 women aged 68 [62; 71] years). AP heights were compared using the Bland-Altman method and the Spearman correlation analysis. This was a blinded comparative study which assessed the AP morphometry using each of the radiation modalities without knowing the results of the method being compared.

RESULTS

100 APs were examined in the descending TA. The mean height of all analyzed APs in the descending TA was 2.2 mm [2; 2.7] for 2D TEE, 3.1 mm [2.7; 3.55] for 3D TEE, and 3.05 mm [2.55; 3.55] for MSCT. The AP heights measured with 2D TEE was statistically significantly smaller than the heights of similar APs measured either with 3D TEE or MSCT. The mean difference (bias) was 0.88±0.34 mm between 2D and 3D TEE, and 0.83±0.41 mm between 2D TEE and MSCT. The correlation coefficients for the AP heights were r=0.87 (p<0.001) between 2D and 3D TEE and r=0.86 (p<0.001) between 2D TEE and MSCT. There were no differences in the height of similar APs between 3D TEE and MSCT.

CONCLUSION

The three-dimensional reconstruction of AP in the TA by TEE is more accurate for quantitative assessment of AP than a two-dimensional study.

Frequency of extracardiac findings on "negative" CT coronary angiography studies

AIM

To evaluate the prevalence and nature of extracardiac findings identified on computed tomography (CT) coronary angiography (CTCA) in patients with chest pain but without evidence of coronary artery disease (CAD).

MATERIALS AND METHODS

CTCA studies in patients referred to the hospital between January 2017 to February 2021 with chest pain and a suspected diagnosis of CAD were reviewed retrospectively for the presence of extracardiac findings. Consensus review of CTCA studies was performed by two experienced thoracic radiologists. The presence and severity of extracardiac findings, together with the likelihood that chest pain might be attributed to these, was recorded. Patient records were reviewed to ascertain the recording of extracardiac findings on initial CTCA reports and, where applicable, the nature of the follow-up.

RESULTS

Extracardiac findings (n=210) were present in 110/180 patients (61%) with a mean of 1.9 findings per patient. Extracardiac findings were more prevalent in patients aged ≥65 years compared to those <65 years (p<0.001). At least one extracardiac finding with the potential to cause chest pain was present in 40 patients (22%): degenerative disc disease (n=23 [13%]) and hiatus hernia (n=6 [3.3%]) were the most common extracardiac findings. Only 37.6% (79) of all retrospectively identified findings had been initially reported and, of these, 12.7% (10) required further follow-up.

CONCLUSION

Extracardiac findings are common in patients with no evidence of CAD on CTCA. The entire dataset should be evaluated for the presence of extracardiac findings that could explain chest pain symptoms on wide field of view reconstructions.

Infected Takayasu's arteritis presenting with aortic perforation

We want to remind Physicians that unusual conditions can present in unusual ways and to keep an open mind always.

Thoracic Aortic Aneurysmal Disease: Comprehensive Recommendations for the Primary Care Physician

Thoracic aortic aneurysm (TAA) is a commonly encountered disease that is defined as aortic dilation with an increase in diameter of at least 50% greater than the expected age- and sex-adjusted size. Thoracic aortic aneurysms are described by their size, location, morphology, and cause. Primary care clinicians and other noncardiologists are often the first point of contact for patients with TAA. This review is intended to provide them with basic information on the differential diagnosis, diagnostic evaluation, and medical and surgical management of TAAs. Management decisions depend on having as precise a diagnosis as possible. Fortunately, this can often be achieved with a stepwise diagnostic approach that incorporates imaging and targeted genetic testing. Our review includes recommendations. In this review, we discuss these issues at a basic level and include recommendations for patients considering pregnancy.

The current and future role of imaging of thoracic aortic disease: a North American society for cardiovascular imaging commentary on the 2022 AHA/ACC guidelines for the diagnosis and management of aortic disease

The 2022 AHA/ACC Guidelines for the Diagnosis and Management of Aortic Disease introduced important updates for managing thoracic aorta aortic disease (TAD). In particular, the Guidelines underscore multimodality imaging's role in diagnosis, risk assessment, and monitoring of patients with TAD. This commentary aims to distill key imaging aspects from the Guidelines to provide a concise reference for the cardiovascular imaging community. Primary areas of focus include: (1) The importance of imagers in the multidisciplinary TAD care team, (2) Appropriate imaging techniques along with their strengths and weaknesses, (3) Aortic measurement methods and how aortic size and growth should contribute to TAD risk assessment, (4) Imaging evaluation of acute aortic syndrome. We have also highlighted several areas of ongoing uncertainty and confusion, specifically related to aortic measurement techniques and descriptive terminology. Finally, a perspective on the future of TAD imaging is discussed with a focus on advanced imaging tools and techniques as well as the potential role of artificial intelligence.

Non-A Non-B Acute Aortic Dissection: Is There Some Confusion in the Radiologist's Mind?

BACKGROUND

The aim of this study is to define and determine the rate of acute non-A-non-B aortic dissections, and to evaluate CT angiography findings and possible complications, as well as to discuss management strategies and currently available therapy. Non-A non-B type of aortic dissection is still a grey area in the radiologist's mind, such that it is not entirely clear what should be reported and completed in terms of this disease.

METHODS

A retrospective single-center study including 36 pre-treatment CT angiograms of consecutive patients (mean age: 61 years) between January 2012 and December 2022 with aortic dissection involving the aortic arch with/without the thoracic descending/abdominal aorta (type non-A non-B).

RESULTS

According to the dissection anatomy, we identified three modalities of spontaneous acute non-A-non-B anatomical configurations. Configuration 1 (n = 25) with descending-entry tear and retrograde arch extension (DTA entry). Configuration 2 (n = 4) with Arch entry tear and isolated arch involvement (Arch alone). Configuration 3 (n = 7) with Arch entry and anterograde descending (±abdominal) aorta involvement (Arch entry). CT angiogram findings, management, and treatment options are described.

CONCLUSIONS

Acute non-A non-B dissection represents an infrequent occurrence of aortic arch dissection (with or without involvement of the descending aorta) that does not extend to the ascending aorta. The complete understanding of its natural progression, distinct CT angiography subtypes, optimal management, and treatment strategies remains incomplete. Within our series, patients frequently exhibit a complex clinical course, often necessitating a more assertive approach to treatment compared to type B dissections.

Structural and Functional Disturbances of the Thoracic Aorta in Atherosclerosis of Various Gradations

Aim      To study global aortic circumferential strain in normal conditions and in atherosclerosis of various grades and to determine its role in prediction of structural and functional disorders of the thoracic aorta (TA) and coronary atherosclerosis using 2D speckle-tracking transesophageal echocardiography.Material and methods  182 patients with typical or probable angina were examined. The control group consisted of 11 healthy volunteers. TA was visualized along its entire length. The height of each atheroma was measured, and the total number of plaques in the TA was determined. Five stages of TA atherosclerosis were identified. In the descending TA, the global peak systolic circumferential strain (GCS, %) and the global peak systolic circumferential strain normalized to pulse arterial pressure (PAP) (GCS / PAP∙100) were calculated. All patients underwent coronary angiography. The number of coronary arteries (CAs) with >50 % stenosis was determined, and the SYNTAX Score was calculated.Results TA atherosclerosis was not detected in the control group. Among 182 patients, stage 1-5 TA atherosclerosis was found in 23 (12.6 %), 103 (56.6 %), 43 (23.6 %), 7 (3.8 %), and 6 (3.4 %) cases respectively. GCS and GCS / PAD decreased as the ultrasound stage of TA atherosclerosis increased as compared with the control group: 9.2 % and 15.3 for the control group; stage 1, 5.6 % and 8.9 (p<0.001); stage 2, 4.1 % and 5.9 (p<0.001); stage 3, 4 % and 5.8 (p<0.001); stage 4, 3.7 % and 4.9 (p<0.01); and stage 5, 2.6 % and 3.3 (p<0.01), respectively. ROC analysis showed that GCS ≥5.9 % (area under the curve, AUC, 0.94±0.03; p<0.001) and GCS / PAD ≥11.4 (AUC, 0.97±0.02; p <0.001) were predictors of intact TA. Also, GCS ≤4.85 % (AUC, 0.82±0.04; p<0.001) and GCS / PAD ≤8.06 (AUC, 0.87±0.03; p<0.001) were predictors of hemodynamically significant TA atherosclerosis (stages 3-5). GCS ≤4.05 % (AUC, 0.62±0.04; p=0.007) and GCS / PAD ≤5.95 (AUC, 0.61±0.04; p=0.018) were predictors of hemodynamically significant (>50 %) stenosing atherosclerosis of at least one CA. Furthermore, GCS ≤3.75 % (AUC, 0.67±0.07; p=0.039) and GCS / PAD ≤5.15 (AUC, 0.64±0.07; p=0.045) were predictors of severe and advanced coronary atherosclerosis (SYNTAX Score ≥22).Conclusion      GCS and GCS / PAD are new diagnostic markers of structural and functional disorders of TA in atherosclerosis of various grades. GCS and GCS / PAD are independent predictors of high-grade TA atherosclerosis (stages 3-5) with GCS / PAD demonstrating the highest level of significance. GCS and GCS / PAD are non-invasive predictors of severe and advanced CA atherosclerosis.

Aortic growth after arch reconstruction with patch augmentation: a 2-decade experience

OBJECTIVES

Optimal aortic sizing during aortic arch reconstruction remains unknown. Negative effects of arch under- or oversizing are well-published. We aimed to characterize longitudinal aortic growth after patch-augmented arch reconstruction to identify the initial reconstructed arch size that results in normal mid-term arch dimensions.

METHODS

Single-centre, retrospective review of infants undergoing Damus-Kaye-Stansel (DKS) or non-DKS patch-augmented aortic arch reconstruction between 2000 and 2021. Ascending aorta, proximal and distal transverse arch, aortic isthmus (AIsth) and descending aorta dimensions were measured in postoperative echocardiograms (<3 months from index operation) and cross-sectional imaging (>12 months). Longitudinal changes to aortic dimensions and z-scores were analysed. Secondary outcomes included reintervention, valve and ventricular function, mortality and transplantation.

RESULTS

Fifty-four patients (16 DKS, 38 non-DKS) were included. At 6.3 [2.2, 12.0]-year follow-up, all aortic segments grew significantly in both groups, while z-scores remained unchanged except for non-DKS proximal and distal transverse arch z-scores, which significantly increased (P < 0.05 each). When stratified by initial postoperative z-score (z < -1, -1 ≤ z ≤ 1, z > 1), non-DKS patients with initial AIsth z-score <-1 had a final z-score significantly smaller than both the targeted z-score zero (P = 0.014) and final z-score in a group with initial postoperative z-score ±1 (P = 0.009). Valve and ventricular function remained stable. Eighteen patients required reintervention, 1 died and 1 underwent transplant.

CONCLUSIONS

Over mid-term follow-up, aortic growth after arch reconstruction with patch augmentation was proportional when repaired to normal z-score dimensions, aside from proximal transverse arch, which disproportionately dilated. AIsth undersizing prevailed mid-term and trended towards a higher reintervention rate. Initial reconstruction between z-score 0 and +1 resulted in maintenance of that z-score size at mid-term follow-up. Overall, it is crucial to achieve targeted aortic sizing at index operation to maintain appropriate aortic dimensions over time and reduce reintervention risk with specific focus on the AIsth.

Ascending thoracic aortic aneurysm size at presentation and growth by diameter

AIM

To investigate the hypothesis that lung cancer screening allows for earlier identification of ascending thoracic aortic aneurysms (aTAAs) and that growth rates for aTAAs are greatest at larger sizes.

MATERIALS AND METHODS

This single referral centre retrospective study manually gathered computed tomography (CT) data from 732 patients presenting from July 2002 to August 2022. Five hundred and seventeen patients with aTAA >39 mm were identified to compare presenting diameter by year of presentation. Four hundred and thirty-two patients had CT examinations >3 months apart, allowing for growth analysis. Patients were separated by initial examination date (before or after 12/31/2013) for presenting size comparison. Patients were then divided into five groups based on aTAA diameter for growth rate analysis.

RESULTS

At identification, patients had a median aTAA diameter of 44 mm (IQR 41-47 mm). Patients with aTAAs identified prior to December 2013 (n=129) had an average aTAA diameter 1.7 mm larger than those identified later (n=388; p=0.003). The growth analysis showed an average growth rate of 0.1 mm/year (p<0.001) across the entire cohort. Patients with an aTAA diameter of ≥55 mm (n=12) grew the fastest at 1.9 mm/year (p<0.001). In the <40 mm group (n=43), the aTAAs expanded at 0.2 mm/year, faster than the 0.1 mm/year of the slowest expanding 45-49 mm group (n=130; p=0.04).

CONCLUSION

aTAA size at discovery was larger before lung cancer screening guidelines took effect in December 2013. The largest aTAAs expanded fastest, but growth rates were slowest in the medium-sized 45-49 mm diameter group.

Imaging Methods for Evaluation of Chronic Aortic Regurgitation in Adults: JACC State-of-the-Art Review

A global multidisciplinary workshop was convened to discuss the multimodality diagnostic evaluation of aortic regurgitation (AR). Specifically, the focus was on assessment tools for AR severity and analyzing evolving data on the optimal timing of aortic valve intervention. The key concepts from this expert panel are summarized as: 1) echocardiography is the primary imaging modality for assessment of AR severity; however, when data is incongruent or incomplete, cardiac magnetic resonance may be helpful; 2) assessment of left ventricular size and function is crucial in determining the timing of intervention; 3) recent evidence suggests current cutpoints for intervention in asymptomatic severe AR patients requires further scrutiny; 4) left ventricular end-systolic volume index has emerged as an additional parameter that has promise in guiding timing of intervention; and 5) the role of additional factors (including global longitudinal strain, regurgitant fraction, and myocardial extracellular volume) is worthy of future investigation.

Normalization of ascending aorta dimension for body size influences pathophysiologic correlation in hypertensive patients: the Campania Salute Network

AIMS

In the present study, we assessed correlates and their consistency of ascending aorta (AscAo) measurement in treated hypertensive patients.

METHODS AND RESULTS

A total of 1634 patients ≥ 18 years old with available AscAo ultrasound were included. Ascending aorta was measured at end-diastole with leading edge to leading edge method, perpendicular to the long axis of the aorta in parasternal long-axis view at its maximal identifiable dimension. Correlations of AscAo and AscAo normalized for height (AscAo/HT) or body surface area (AscAo/BSA) with demographics and metabolic profile were explored. Multi-variable regression was also used to identify potential confounders influencing univariate correlations. Sensitivity analysis was performed using cardiovascular (CV) outcome. Correlations with age, estimated glomerular filtration rate, systolic blood pressure (BP), and heart rate (HR) were similar among the three aortic measures. Women exhibited smaller AscAo but larger AscAo/BSA than men with AscAo/HT offsetting the sex difference. Obesity and diabetes were associated with greater AscAo and AscAo/HT but with smaller AscAo/BSA (all P < 0.001). In multi-variable regression model, all aortic measure confirmed the sign of their relations with sex and metabolic profile independently of age, BP, and HR. In Kaplan-Mayer analysis, only dilated AscAo and AscAo/HT were significantly associated with increased risk of CV events (both P < 0.008).

CONCLUSIONS

Among patients with long-standing controlled systemic hypertension, magnitude of aortic remodelling is influenced by the type of the measure adopted, with physiological consistency only for AscAo and AscAo/HT, but not for AscAo/BSA.

Clinical Usefulness of Echocardiographic Measurement of Proximal Aortic Diameter in Early Differentiation Between Type A Acute Aortic Dissection and ST-Segment-Elevation Myocardial Infarction

Background Contradictions between management modalities of type A acute aortic dissection (TAAAD) and ST-elevation-myocardial infarction (STEMI) may result in clinical catastrophe. Therefore, we aimed to explore which 2-dimensional echocardiography (2DE) findings are optimal for differentiating TAAAD from STEMI. Methods and Results This study included 340 patients with STEMI and 340 patients with TAAAD who underwent 2DE in the emergency department between 2012 and 2021. The proximal ascending aorta (PAA) diameter and other echocardiographic parameters were analyzed. PAA diameters were measured at 4 levels in the parasternal view: Valsalva, the sinotubular junction (STJ), the PAA at 1 cm above the STJ, and the PAA at 2 cm above the STJ. Receiver-operating characteristic curve analysis showed that Valsalva, STJ, PAA at 1 cm above the STJ, and PAA at 2 cm above the STJ were significant predictors of TAAAD (areas under the curve: 0.777, 0.924, 0.965, and 0.975, respectively; P<0.001) with the respective cutoff values of 39.4, 38.5, 39.8, and 41.2 mm. Multivariable analysis suggested that all 2DE parameters were significant predictors of TAAAD. Among the 2DE parameters examined, the incorporation of PAA at 2 cm above the STJ to clinical indicators exhibited the most significant diagnostic capability (C-statistics, 0.97; net reclassification improvement, 1.81; integrated discrimination improvement, 0.61). When only TAAAD with coronary malperfusion and STEMI were analyzed, the diagnostic utility of PAA at 1 cm above the STJ was evident (C-statistics, 0.99; net reclassification improvement, 1.79; integrated discrimination improvement, 0.67), with PAA at 2 cm above the STJ ranking second in diagnostic significance (C-statistics, 0.99; net reclassification improvement, 1.12; integrated discrimination improvement, 0.66). Conclusions PAA measurements were the most beneficial for diagnosing TAAAD in all 2DE findings and TAAAD from STEMI.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

ACR Appropriateness Criteria® Pulsatile Abdominal Mass, Suspected Abdominal Aortic Aneurysm: 2023 Update

Abdominal aortic aneurysm (AAA) is defined as abnormal dilation of the infrarenal abdominal aortic diameter to 3.0 cm or greater. The natural history of AAA consists of progressive expansion and potential rupture. Although most AAAs are clinically silent, a pulsatile abdominal mass identified on physical examination may indicate the presence of an AAA. When an AAA is suspected, an imaging study is essential to confirm the diagnosis. This document reviews the relative appropriateness of various imaging procedures for the initial evaluation of suspected AAA. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Thoracic aorta diameters in Marfan patients: Intraindividual comparison of 3D modified relaxation-enhanced angiography without contrast and triggering (REACT) with transthoracic echocardiography

OBJECTIVE

To compare the measurement of aortic diameters using a novel flow-independent MR-Angiography (3D modified Relaxation-Enhanced Angiography without Contrast and Triggering (modified REACT)) and transthoracic echocardiography (TTE) in Marfan syndrome (MFS) patients.

MATERIAL AND METHODS

This retrospective, single-center analysis included 46 examinations of 32 MFS patients (mean age 37.5 ± 11.3 years, 17 women, no prior aortic surgery) who received TTE and 3D modified REACT (ECG- and respiratory-triggering, Compressed SENSE factor 9 for acceleration of image acquisition) of the thoracic aorta. Aortic diameters (sinus of Valsalva (SV), sinotubular junction (STJ), and ascending aorta (AoA)) were independently measured by two cardiologists in TTE (leading-edge) and two radiologists in modified REACT (inner-edge, using multiplanar reconstruction). Intraclass correlation coefficient, Bland-Altman analyses, and Pearson's correlation (r) were used to assess agreement between observers and methods.

RESULTS

Interobserver correlation at the SV, STJ, and AoA were excellent for both, TTE (ICC = 0.95-0.98) and modified REACT (ICC = 0.99-1.00). There was no significant difference between TTE and modified REACT for diameters measured at the SV (39.24 ± 3.24 mm vs. 39.63 ± 3.76 mm; p = 0.26; r = 0.78) and the STJ (35.16 ± 4.47 mm vs. 35.37 ± 4.74 mm; p = 0.552; r = 0.87). AoA diameters determined by TTE were larger than in modified REACT (34.29 ± 5.31 mm vs. 30.65 ± 5.64 mm; p < 0.01; r = 0.74). The mean scan time of modified REACT was 05:06 min ± 02:47 min, depending on the patient's breathing frequency and heart rate.

CONCLUSIONS

Both TTE and modified REACT showed a strong correlation for all aortic levels; however, at the AoA, diameters were larger using TTE, mostly due to the limited field of view of the latter with measurements being closer to the aortic valve. Given the excellent interobserver correlation and the strong agreement with TTE, modified REACT represents an attractive method to depict the thoracic aorta in MFS patients.

Prevalence of dilated mid-ascending aorta in individuals 15 years and older: In search of optimal diagnostic criteria and their effect on the burden of disease

BACKGROUND

Controversy regarding the definition of the upper limit of normal (ULN) for dilated mid-ascending aorta (mAA) stems from variation in criteria, based on several small-sized studies with small datasets of normal subjects (DONS). The present study was carried out to demonstrate this variation in the prevalence of mAA dilation and to identify the optimal definition by creating the largest DONS.

METHODS

Echocardiographic studies of patients ≥ 15 years of age performed at a large tertiary care center over 4 years (n = 49,330) were retrospectively evaluated. The leading-edge-to-leading-edge technique was used to measure the mAA in diastole. The largest-to-date DONS (n = 2334) was created, including those who were normal on medical record review, did not have any of the 28 causes of dilated aorta, and had normal echocardiograms. Because age had the strongest correlation with mAA (multivariate adjusted R2 = 0.26), as compared with sex, height, and weight, we created a new ULN based on the DONS with narrow age stratification (10-year intervals).

RESULTS

The prevalence of dilated mAA varied between 17% and 23% when absolute criteria were used with sex stratification, and it varied between 6% and 11% when relative criteria (relative to age, body surface area, and sex) were used. Based on new criteria from the DONS, it was 7.6%, with a ULN of 3.07-3.64 cm in women and 3.3-3.91 cm in men.

CONCLUSIONS

These data demonstrate the undesirable variation in the prevalence of dilated mAA based on prior criteria and propose a new ULN for dilated mAA.

Clinical Outcomes in Patients With Bicuspid Aortic Valves and Ascending Aorta ≥50 mm Under Surveillance

Background

Clinical outcomes of bicuspid aortic valve (BAV) patients with ascending aortic diameters ≥50 mm who are under surveillance are poorly defined.

Objectives

The purpose of this study was to assess clinical outcomes in BAV patients with ascending aorta ≥50 mm.

Methods

Multicenter retrospective cohort study of BAV adults with ascending aorta diameters ≥50 mm by transthoracic echocardiography (TTE). Patients were categorized into 50 to 54 mm and ≥55 mm groups. Clinical outcomes were aortic dissection (AoD), aorta surgery, surgical mortality, and all-cause death.

Results

Of 875 consecutive BAV patients (age 60 ± 13 years, 86% men, aortic diameter 51 mm [interquartile range (IQR): 50-53 mm]), 328 (37%) underwent early surgery ≤3 months from index TTE. Of the remaining 547 patients under surveillance, 496 had diameters 50 to 54 mm and 51 had diameters ≥55 mm and were collectively followed for 7.51 (IQR: 3.98-12.20) years. Of 496 patients with diameters 50 to 54 mm under surveillance, 266 (54%) underwent surgery 2.0 (IQR: 0.77-4.16) years from index TTE. AoD occurred in 9/496 (1.8%) patients for an incidence of 0.4 cases per 100 person-years, surgical mortality was 5/266 (1.9%); and ≥moderate aortic stenosis (but not aorta size) was associated with all-cause death, hazard ratio: 2.05 (95% CI: 1.32-3.20), P = 0.001. Conversely, in 547 total patients under surveillance (including 50-54 mm and ≥55 mm), both aorta size and ≥moderate aortic stenosis were associated with all-cause death (both P ≤ 0.027). AoD rate in patients ≥55 mm under surveillance was 5.9%.

Conclusions

In BAV patients with ascending aorta 50 to 54 mm under surveillance, AoD incidence is low and the overall rates of AoD and surgical mortality are similar, suggesting clinical equivalence between surgical and surveillance strategies. Conversely, patients with aortas ≥55 mm should undergo surgery. Aortic stenosis is associated with all-cause death in these patients.

Proximal aorta dilatation in hypertension

Dilation of the proximal aorta is a common clinical manifestation in hypertensive patients. Although it is straightforward to link hypertension with proximal aortic dilation, previous studies on their interrelation have yielded controversial results. Cross-sectional design, methodology of blood pressure assessment, confounding factors like medications, and inconsistent reference values may lead to the paradoxical conclusions. Recently, advances have been made in the exploration of determinants and clinical value of proximal aortic dilatation. Thus, we reviewed these findings and summarized that aortic dilatation may be the consequence of hemodynamic and nonhemodynamic co-factors' combined action. Moreover, proximal aortic dilatation tends to be a predictor for aortic aneurysm dissection or rupture, hypertensive target organ damage as well as cardiovascular events. The present review contributes to a comprehensive understanding of the pathological process of proximal aortic dilatation in hypertension.

Review article: Accuracy of emergency physician performed point-of-care ultrasound of the thoracic aorta: A systematic review and narrative synthesis of the literature

Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta can also be assessed by POCUS for dissection and aneurysm and transthoracic echocardiography is endorsed by international guidelines as an initial test for thoracic aortic pathologies. A systematic search of Ovid Medline, PubMed, EMBASE, SCOPUS and Web of Science from January 2000 to August 2022 identified four studies evaluating diagnostic accuracy of emergency physician POCUS for thoracic aortic dissection (TAD) and five studies for thoracic aortic aneurysm (TAA). Study designs were heterogeneous including differing diagnostic criteria for aortic pathology. Convenience recruitment was frequent in prospective studies. Sensitivity and specificity ranges for studies of TAD were 41-91% and 94-100%, respectively when an intimal flap was seen. Sensitivity and specificity ranges for studies of thoracic aorta dilation >40 mm were 50-100% and 93-100%, respectively; for >45 mm ranges were 64-65% and 95-99%. Literature review identified that POCUS is specific for TAD and TAA. POCUS reduces the time to diagnosis of thoracic aortic pathology; however, it remains insensitive and cannot be recommended as a stand-alone rule-out test. We suggest that detection of thoracic aorta dilation >40 mm by POCUS at any site increases the suspicion of serious aortic pathology. Studies incorporating algorithmic use of POCUS, Aortic Dissection Detection Risk Score and D-dimer as decision tools are promising and may improve current ED practices. Further research is warranted in this rapidly evolving field.

Sex Differences in Thoracic Aortic Disease and Dissection: JACC Review Topic of the Week

Despite its higher prevalence among men, women with thoracic aortic aneurysm and dissection (TAAD) have lower rates of treatment and surgical intervention and often have worse outcomes. A growing number of women with TAAD also desire pregnancy, which can be associated with an increased risk of aortic complications. Understanding sex-specific differences in TAAD has the potential to improve care delivery, reduce disparities in treatment, and optimize outcomes for women with TAAD.

Genetic Basis, New Diagnostic Approaches, and Updated Therapeutic Strategies of the Syndromic Aortic Diseases: Marfan, Loeys-Dietz, and Vascular Ehlers-Danlos Syndrome

Syndromic aortic diseases (SADs) encompass various pathological manifestations affecting the aorta caused by known genetic factors, such as aneurysms, dissections, and ruptures. However, the genetic mutation underlying aortic pathology also gives rise to clinical manifestations affecting other vessels and systems. As a consequence, the main syndromes currently identified as Marfan, Loeys-Dietz, and vascular Ehlers-Danlos are characterized by a complex clinical picture. In this contribution, we provide an overview of the genetic mutations currently identified in order to have a better understanding of the pathogenic mechanisms. Moreover, an update is presented on the basis of the most recent diagnostic criteria, which enable an early diagnosis. Finally, therapeutic strategies are proposed with the goal of improving the rates of patient survival and the quality of life of those affected by these SADs.

Arterial Age and Early Vascular Aging, But Not Chronological Age, Are Associated With Faster Thoracic Aortic Aneurysm Growth

Background Aneurysm size is an imperfect risk assessment tool for those with thoracic aortic aneurysm (TAA). Assessing arterial age may help TAA risk stratification, as it better reflects aortic health. We sought to evaluate arterial age as a predictor of faster TAA growth, independently of chronological age. Methods and Results We examined 137 patients with TAA. Arterial age was estimated according to validated equations, using patients' blood pressure and carotid-femoral pulse wave velocity. Aneurysm growth was determined prospectively from available imaging studies. Multivariable linear regression assessed the association of chronological age and arterial age with TAA growth, and multivariable logistic regression assessed associations of chronological and arterial age with the presence of accelerated aneurysm growth (defined as growth>median in the sample). Mean±SD chronological and arterial ages were 62.2±11.3 and 54.2±24.5 years, respectively. Mean baseline TAA size and follow-up time were 45.9±4.0 mm and 4.5±1.9 years, respectively. Median (interquartile range) TAA growth was 0.31 (0.14-0.52) mm/year. Older arterial age (ß±SE for 1 year: 0.004±0.001, P<0.0001) was independently associated with faster TAA growth, while chronological age was not (P=0.083). In logistic regression, each 5-year increase in arterial age was associated with a 23% increase in the odds of accelerated TAA growth (95% CI, 1.085-1.394; P=0.001). Conclusions Arterial age is independently associated with accelerated aneurysm expansion, while chronological age is not. Our results highlight that a noninvasive and inexpensive assessment of arterial age can potentially be useful for TAA risk stratification and disease monitoring as compared with the current clinical standard (chronological age).

MR Angiography for Aortic Diseases

Aortic pathologic conditions represent diverse disorders, including aortic aneurysm, acute aortic syndrome, traumatic aortic injury, and atherosclerosis. Given the nonspecific clinical features, noninvasive imaging is critical in screening, diagnosis, management, and posttherapeutic surveillance. Of the commonly used imaging modalities, including ultrasound, computed tomography, and MR imaging, the final choice often depends on a combination of factors: acuity of clinical presentation, suspected underlying diagnosis, and institutional practice. Further research is needed to identify the potential clinical role and define appropriate use criteria for advanced MR applications such as four-dimenional flow to manage patients with aortic pathologic conditions.

Mechanisms of Aortic Dilation in Patients With Bicuspid Aortic Valve: JACC State-of-the-Art Review

Bicuspid aortic valve is the most common congenital heart disease and exposes patients to an increased risk of aortic dilation and dissection. Aortic dilation is a slow, silent process, leading to a greater risk of aortic dissection. The prevention of adverse events together with optimization of the frequency of the required lifelong imaging surveillance are important for both clinicians and patients and motivated extensive research to shed light on the physiopathologic processes involved in bicuspid aortic valve aortopathy. Two main research hypotheses have been consolidated in the last decade: one supports a genetic basis for the increased prevalence of dilation, in particular for the aortic root, and the second supports the damaging impact on the aortic wall of altered flow dynamics associated with these structurally abnormal valves, particularly significant in the ascending aorta. Current opinion tends to rule out mutually excluding causative mechanisms, recognizing both as important and potentially clinically relevant.

Marfan Syndrome: Enhanced Diagnostic Tools and Follow-up Management Strategies

Marfan syndrome (MFS) is a rare inherited autosomic disorder, which encompasses a variety of systemic manifestations caused by mutations in the Fibrillin-1 encoding gene (FBN1). Cardinal clinical phenotypes of MFS are highly variable in terms of severity, and commonly involve cardiovascular, ocular, and musculoskeletal systems with a wide range of manifestations, such as ascending aorta aneurysms and dissection, mitral valve prolapse, ectopia lentis and long bone overgrowth, respectively. Of note, an accurate and prompt diagnosis is pivotal in order to provide the best treatment to the patients as early as possible. To date, the diagnosis of the syndrome has relied upon a systemic score calculation as well as DNA mutation identification. The aim of this review is to summarize the latest MFS evidence regarding the definition, differences and similarities with other connective tissue pathologies with severe systemic phenotypes (e.g., Autosomal dominant Weill-Marchesani syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome) and clinical assessment. In this regard, the management of MFS requires a multidisciplinary team in order to accurately control the evolution of the most severe and potentially life-threatening complications. Based on recent findings in the literature and our clinical experience, we propose a multidisciplinary approach involving specialists in different clinical fields (i.e., cardiologists, surgeons, ophthalmologists, orthopedics, pneumologists, neurologists, endocrinologists, geneticists, and psychologists) to comprehensively characterize, treat, and manage MFS patients with a personalized medicine approach.

Aortic Root Diameter in Highly-Trained Competitive Athletes: Reference Values According to Sport and Prevalence of Aortic Enlargement

BACKGROUND

Studies exploring the extent of aortic root dilation across the different types of sport are limited. We aimed to define the physiological limits of aortic remodelling in a large population of healthy elite athletes in comparison with nonathletic controls.

METHODS

A total of 1995 consecutive athletes evaluated at the Institute of Sports Medicine (Rome, Italy) and 515 healthy controls underwent a comprehensive cardiovascular screening. The aortic diameter was measured at the level of the sinuses of Valsalva. The 99th percentile from the mean of the aortic diameter in the control population was used to define an abnormally enlarged aortic root dimension.

RESULTS

Athletes showed a larger aortic root diameter (30.6 [± 3.3] vs 28.1 [± 3.1] mm, P value < 0.001) than controls. The difference was evident in male and female athletes, regardless of sport- predominant component and level of intensity. The 99th percentile value for aortic root diameter in control male and female subjects was 37 mm and 32 mm, respectively. Based on these values, 50 (4.2%) male and 21 (2.6%) female athletes would have been diagnosed with an enlarged aortic root. However, aortic root diameter of clinical relevance-ie, ≥ 40 mm-was observed in only 17 male athletes (0.85%) and did not exceed > 44 mm.

CONCLUSIONS

Athletes show a mild, although significant, increased aortic dimension in comparison with healthy controls. The degree of aortic enlargement varies in relation to type of sports and sex. Eventually, only a small minority of athletes exhibited a markedly enlarged aortic diameter (ie, ≥ 40 mm) in a range of clinical relevance.

Recognizing blind spots on echocardiography: Incremental benefit of cardiac CT in investigating the source of systemic embolism

Transesophageal echocardiography is the gold-standard for evaluating potential central sources of thromboembolism. Despite its routine use and excellent safety profile, limitations exist in the ability to effectively assess the aortic arch and proximal descending aorta with this imaging modality. We herein present a case of a 59 year-old patient presenting with renal and splenic infarcts, without obvious cardioembolic source on echocardiography, who was found to have a large, mobile aortic thrombus on gated cardiac computed tomography.

Deep learning-aided extraction of outer aortic surface from CT angiography scans of patients with Stanford type B aortic dissection

BACKGROUND

Guidelines recommend that aortic dimension measurements in aortic dissection should include the aortic wall. This study aimed to evaluate two-dimensional (2D)- and three-dimensional (3D)-based deep learning approaches for extraction of outer aortic surface in computed tomography angiography (CTA) scans of Stanford type B aortic dissection (TBAD) patients and assess the speed of different whole aorta (WA) segmentation approaches.

METHODS

A total of 240 patients diagnosed with TBAD between January 2007 and December 2019 were retrospectively reviewed for this study; 206 CTA scans from 206 patients with acute, subacute, or chronic TBAD acquired with various scanners in multiple different hospital units were included. Ground truth (GT) WAs for 80 scans were segmented by a radiologist using an open-source software. The remaining 126 GT WAs were generated via semi-automatic segmentation process in which an ensemble of 3D convolutional neural networks (CNNs) aided the radiologist. Using 136 scans for training, 30 for validation, and 40 for testing, 2D and 3D CNNs were trained to automatically segment WA. Main evaluation metrics for outer surface extraction and segmentation accuracy were normalized surface Dice (NSD) and Dice coefficient score (DCS), respectively.

RESULTS

2D CNN outperformed 3D CNN in NSD score (0.92 versus 0.90, p = 0.009), and both CNNs had equal DCS (0.96 versus 0.96, p = 0.110). Manual and semi-automatic segmentation times of one CTA scan were approximately 1 and 0.5 h, respectively.

CONCLUSIONS

Both CNNs segmented WA with high DCS, but based on NSD, better accuracy may be required before clinical application. CNN-based semi-automatic segmentation methods can expedite the generation of GTs.

RELEVANCE STATEMENT

Deep learning can speeds up the creation of ground truth segmentations. CNNs can extract the outer aortic surface in patients with type B aortic dissection.

KEY POINTS

• 2D and 3D convolutional neural networks (CNNs) can extract the outer aortic surface accurately. • Equal Dice coefficient score (0.96) was reached with 2D and 3D CNNs. • Deep learning can expedite the creation of ground truth segmentations.

Impact of arterial stiffness on echocardiographic myocardial work indices in patients with isolated bicuspid aortic valve

OBJECTIVE

Data related to the existence of left ventricular (LV) abnormalities in normal functional bicuspid aortic valve (BAV) disease is scarce. In addition, the impact of afterload and the involved mechanisms are unclear. In this work, we study the relationship between LV function assessed with myocardial work index (MWI) and arterial stiffness in a cohort of normal functioning BAV patients.

METHODS

In this study, we included a total of 38 consecutive patients with isolated BAV and 44 age- and gender-matched control subjects with tricuspid aortic valve. All participants underwent transthoracic echocardiography to assess conventional parameters and global longitudinal strain (GLS). In addition, MWI was measured by the noninvasive LV pressure-strain cycle method. Aortic pulse wave velocity (PWV) and wave reflection were evaluated by applanation tonometry.

RESULTS

The mean aortic PWV was significantly higher in BAV patients (6.4 ± 0.80, 7.02 ± 0.1.2, p = .01, respectively). LV-MWI related parameters such as global work efficiency (GWE) (96.261.69 and 97.051.27, p = .02) and global wasted work (GWW) (78.232.1 and 61.824.4, p = .01) were found significantly different between the BAV and control groups. However, global working index and global constructive working were not different between groups (1969 ± 259 and 2014 ± 278, p = .45; 2299 ± 290 and 2359 ± 345, p = .39, respectively). Multivariable ordinary least squares regression analysis revealed that BAV (ß = 8.4; 95% CI: 1.5-15.3; p = .04) and PVW (ß = 5.6; 95% CI: 0.7-10.5; p = .01) were significant predictors of GWV.

CONCLUSION

GWW is increased and GWE is decreased in patients with BAV compared with controls, and these changes are related to arterial stiffness. The relationship between aortic PWV and GWW may help to explain the exact mechanism of subclinical myocardial dysfunction in patients with isolated BAV.

ACR Appropriateness Criteria® Thoracoabdominal Aortic Aneurysm or Dissection: Treatment Planning and Follow-Up

As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

4D-Flow Cardiovascular Magnetic Resonance Sequence for Aortic Assessment: Multi-Vendor and Multi-Magnetic Field Reproducibility in Healthy Volunteers

OBJECTIVES

Four-dimensional (4D) flow cardiac magnetic resonance (CMR) represents an emerging technique for non-invasive evaluation of the aortic flow. The aim of this study was to investigate a 4D-flow CMR sequence for the assessment of thoracic aorta comparing different vendors and different magnetic fields of MR scanner in fifteen healthy volunteers.

METHODS

CMR was performed on three different MRI scanners: one at 1.5 T and two at 3 T. Flow parameters and planar wall shear stress (WSS) were extracted from six transversal planes along the full thoracic aorta by three operators. Inter-vendor comparability as well as scan-rescan, intra- and interobserver reproducibility were examined.

RESULTS

A high heterogeneity was found in the comparisons for each operator and for each scanner in the six transversal planes analysis (Friedman rank-sum test; p-value ≤ 0.05). Among all, the most reproducible measures were extracted for the sinotubular junction plane and for the flow parameters.

CONCLUSIONS

Our results suggest that standardized procedures have to be defined to make more comparable and reproducible 4D-flow parameters and mainly, clinical impactfulness. Further studies on sequences development are needed to validate 4D-flow MRI assessment across vendors and magnetic fields also compared to a missing gold standard.

Echocardiographic changes and impact on clinical management in pregnant women with heart disease

BACKGROUND

While guidelines recommend echocardiography for pregnant women with heart disease, there are limited data on its effect on clinical practice. In this study, we investigated pregnancy-associated echocardiographic changes and their impact on management.

METHODS

This was a retrospective study of pregnant women with heart disease followed at an academic medical centre from 2016 to 2020. Data on maternal intrapartum and postpartum echocardiograms were collected and the impact on management analysed.

RESULTS

421 echocardiograms in 232 pregnancies were included in the study. The most common cardiac diagnosis was CHD (60.8% of pregnancies), followed by cardiomyopathy (9.9%). The frequency of baseline echocardiographic abnormalities varied by diagnosis, with abnormal right ventricular systolic pressure being the most common (15.0% of pregnancies in CHD and 23.1% of pregnancies with cardiomyopathy). 39.2% of the 189 follow-up echocardiograms had a significant change from the prior study, with the most common changes being declines in right ventricular function (4.2%) or left ventricular function (3.7%), and increases in right ventricular systolic pressure (5.3%) and aortic size (21.2%). 17.8% of echocardiograms resulted in a clinical management change, with the most common change being shorter interval follow-up.

CONCLUSIONS

Echocardiographic changes in pregnant women with heart disease are common, in particular increases in aortic size. Echocardiography results in changes in management in a small but significant proportion of patients. Further studies are needed to determine how other factors, including patient access and resource allocation, factor into the use of echocardiography during pregnancy.

Agreement of Proximal Thoracic Aorta Size by Two-Dimensional Transthoracic Echocardiography and Magnetic Resonance Angiography

There is currently a lack of uniformity in methods of aortic diameter measurements across different imaging modalities. In this study, we sought to evaluate the accuracy of transthoracic echocardiography (TTE) in comparison with magnetic resonance angiography (MRA) for the measurement of proximal thoracic aorta diameters. This is a retrospective analysis of 121 adult patients at our institution who had TTE and electrocardiogram  (ECG)-gated MRA performed within 90 days of each other between 2013 and 2020. Measurements were made at the level of sinuses of Valsalva (SoV), sinotubular junction (STJ), and ascending aorta (AA) using leading edge-to-leading edge (LE) convention for TTE and inner-edge-to-inner-edge (IE) convention for MRA. Agreement was assessed using Bland-Altman methods. Intra- and interobserver variability were assessed by intraclass correlation. The average age of patients in the cohort was 62 years, and 69% of patients were male. The prevalence of hypertension, obstructive coronary artery disease, and diabetes was 66%, 20%, and 11%, respectively. The mean aortic diameter by TTE was SoV 3.8 ± 0.5 cm, STJ 3.5 ± 0.4 cm, and AA 4.1 ± 0.6 cm. The TTE-derived measurements were larger than the MRA ones by 0.2 ± 2 mm, 0.8 ± 2 mm, and 0.4 ± 3 mm at the level of SoV, STJ, and AA, respectively, but the differences were not statistically significant. There were no significant differences in the aorta measurements by TTE compared with MRA, when stratified by gender. In conclusion, transthoracic echocardiogram-derived proximal aorta measurements are comparable to MRA measurements. Our study validates current recommendations that TTE is an acceptable modality for screening and serial imaging of the proximal aorta.

The Role of Multimodality Imaging Approach in Acute Aortic Syndromes: Diagnosis, Complications, and Clinical Management

Acute aortic syndromes are life-threatening conditions with high morbidity and mortality. The principal pathological feature is acute wall damage with possible evolution towards aortic rupture. Accurate and timely diagnosis is mandatory to avoid catastrophic consequences. Indeed, misdiagnosis with other conditions mimicking acute aortic syndromes is associated with premature death. In this view, cardiovascular imaging is necessary for the correct diagnosis and management. Echocardiography, computed tomography, magnetic resonance imaging, and aortography allow for diagnosis, guarantee immediate treatment, and detect associated complications. Multimodality imaging is essential in the diagnostic work-up to confirm or rule out acute aortic syndromes. The aim of this review is to highlight the contemporary evidence on the role of single cardiovascular imaging techniques and multimodality imaging in the diagnosis and management of acute aortic syndromes.

Hypertrophic cardiomyopathy is associated with dilated sinus of Valsalva: A case-control study

Background

We aimed to test the hypothesis that there is an association between hypertrophic cardiomyopathy and dilated aorta in a case-control, matched-design fashion.

Methods

Of 65,843 studies done from November 2011 to December 2015, we found, after detailed evaluation by a single author, 153 cases of hypertrophic cardiomyopathy and 3,213 controls who were classified as normal clinically and echocardiographically. Controls were defined as normal patients referred to the echocardiography laboratory with no diagnoses and no known risk factors for dilated aorta (e.g., aortic stenosis, hypertension, aortic regurgitation). Clinical chart review showed none of the risk factors for dilated aorta, and echocardiography did not reveal any abnormalities. Of these 3,213 patients, 153 controls were matched to cases by age and sex by propensity score. Dilated aorta was defined according to clinical, Goldstein, and Lang's criteria.

Results

The prevalence of a dilated sinus of Valsalva was 9 times higher in hypertrophic cardiomyopathy patients than controls (OR = 9.4, P = 0.003). The 9-fold higher prevalence in hypertrophic cardiomyopathy patients persisted after adjusting for height, weight, and aortic pathology. Association of dilated mid-ascending aorta with hypertrophic cardiomyopathy was significant after adjustment for height and body surface area but became borderline insignificant after adjusting for weight and aortic valve pathology.

Conclusion

Hypertrophic cardiomyopathy appears to be associated with a dilated sinus of Valsalva, even after adjusting for height, weight, and aortic valve pathology.

CT characteristics and clinical implications of acute type A aortic intramural hematoma

Objectives

Computed tomography (CT) has been increasingly used in the diagnosis of acute aortic syndrome, and a number of high-risk CT imaging features have been reported. We aimed to identify CT imaging findings suggesting high-risk for acute aortic syndrome by examining clinical outcomes of patients with acute type A aortic intramural hematoma (TAIMH).

Methods

This retrospective study analyzed the relationship of clinical patient characteristics and imaging features with mortality and aortic events in 63 patients receiving initial medical treatment for TAIMH. Multivariate regression analysis was used to determine the predictors of aortic events, and the Kaplan-Meier method was used to analyze survival and aortic events.

Results

During a median follow-up of 4.2 years, 25 patients experienced aortic events and 40% of these occurred within 7 days of admission. In total, 12 patients experienced aortic death and 12 patients underwent open aortic surgery or endovascular stenting for aortic disease. In multivariate regression analysis, penetrating atherosclerotic ulcers (PAUs) or ulcer-like projections (ULPs) (P = 0.04) and pericardial effusion (P = 0.03) were independent predictors of aortic events. In the Cox regression model, PAUs/ULPs (P = 0.04) and pericardial effusion (P = 0.04) were independently associated with lower aortic event-free survival.

Conclusion

Identification of high-risk CT features is important for clinical decision-making during TAIMH treatment. Early and frequent CT imaging follow-up is required in patients receiving medical treatment. PAUs/ULP and pericardial effusion were the strongest predictors of adverse aortic events.

Outcomes of reoperation for total arch replacement combined with frozen elephant trunk after previous cardiovascular surgery

BACKGROUND

Aortic arch replacement(TAR) combined with frozen elephant trunk (FET) technique is a high-risk operation after previous cardiovascular surgery. The aim of the study was to review our strategy and outcomes in this cohort.

METHOD

Data were reviewed for patients who underwent TAR combined with FET after previous cardiovascular surgery from January 2010 to December 2020. The patients were divided into elective group and non-selective group.

RESULTS

63 eligible patients were divided into elective(n = 44) and non-elective(n = 19) groups. The interval between two operations was shorter in non-elective group than elective groups (P = 0.001). The indication for reoperation was different in two groups (P = 0.000), however, the type of reoperations has no differences. Cardiopulmonary bypass time was shorter in elective group than non-elective group (P = 0.000). The over-all 30-day mortality rate was 17.5%, and it was higher in non-elective group (P = 0.013). The 24h drainage increased in non-elective group (P = 0.001) as well as re-explore rate for bleeding (P = 0.022). Postoperative hospital stay prolonged in non-elective group (P = 0.002). However, rates of survival without further aortic events were 72.3 ± 7.1% in elective group, 72.9 ± 13.5% in non-elective group at 5 years, respectively (P = 0. 955).

CONCLUSION

Reduced 30-day mortality and shortened post-operative hospital stay was observed in elective group, however, long-term survival rate without reintervention were not affected.