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Rosnel C, Sivera R, Cervi E, Danton M, Schievano S, Capelli C, Aggarwal A. Are aortic biomechanical properties early markers of dilatation in patients with Marfan syndrome? A systematic review and meta-analysis. Biomech Model Mechanobiol 2024:10.1007/s10237-024-01881-z. [PMID: 39073692 DOI: 10.1007/s10237-024-01881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 07/13/2024] [Indexed: 07/30/2024]
Abstract
Although tissue stiffness is known to play an important role in aortic dilatation, the current guidelines for offering preventative surgery in patients with Marfan syndrome rely solely on the aortic diameter. In this systematic review and meta-analysis, we analyze and compare literature on in vivo aortic stiffness measures in Marfan patients. Our aim is to assess the potential of these measurements as early indicators of aortic dilatation. Following the PRISMA guidelines, we collected literature on diameter and three in vivo stiffness measures: Pulse wave velocity (PWV), β -stiffness index (SI) and distensibility, at five different aortic locations in patients with Marfan syndrome. Results were reviewed and compared against each other. For meta-analysis, an augmented dataset was created by combining data from the literature. Regression with respect to age and statistical comparisons were performed. Thirty articles reporting data from 1925 patients with Marfan and 836 patients without Marfan were reviewed. PWV was found to be higher in Marfan, but only in dilated aortas. Distensibility was found to be lower even in non-dilated aortas, and its decrease was associated with higher chances of developing aortic dilatation. β -SI was higher in Marfan patients and was positively correlated with the rate of aortic dilatation, emphasizing its role as a valuable indicator. In our meta-analysis, all stiffness measures showed a significant variation with age. Distensibility and β -stiffness index were different in Marfan patients at all locations, and the difference was more pronounced after accounting for age-related variation. From the literature, β -SI and distensibility emerge as the best predictors of future aortic dilatation. Our meta-analysis quantifies age-related changes in aortic stiffness and highlights the importance of accounting for age in comparing these measurements. Missing diameter values in the literature limited our analysis. Further investigation of criteria combining stiffness and diameter is recommended to better assist clinical decisions for prophylactic surgery.
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Affiliation(s)
- Claire Rosnel
- Glasgow Computational Engineering Centre, James Watt School of Engineering, University of Glasgow, Glasgow, Scotland, UK
| | - Raphael Sivera
- Institute of Cardiovascular Science, University College London, London, England, UK
| | - Elena Cervi
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, England, UK
| | - Mark Danton
- Department of Paediatric Cardiac Services, Royal Hospital for Children, Glasgow, Scotland, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, UK
| | - Silvia Schievano
- Institute of Cardiovascular Science, University College London, London, England, UK
| | - Claudio Capelli
- Institute of Cardiovascular Science, University College London, London, England, UK
| | - Ankush Aggarwal
- Glasgow Computational Engineering Centre, James Watt School of Engineering, University of Glasgow, Glasgow, Scotland, UK.
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2
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Thompson MA, Kramer B, Tarraf SA, Vianna E, Gillespie C, Germano E, Gentle B, Cikach F, Lowry AM, Pande A, Blackstone E, Hargrave J, Colbrunn R, Bellini C, Roselli EE. Age is superior to aortopathy phenotype as a predictor of aortic mechanics in patients with bicuspid valve. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01206-0. [PMID: 38154501 DOI: 10.1016/j.jtcvs.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Bicuspid aortic valve (BAV) aortopathy is defined by 3 phenotypes-root, ascending, and diffuse-based on region of maximal aortic dilation. We sought to determine the association between aortic mechanical behavior and aortopathy phenotype versus other clinical variables. METHODS From August 1, 2016, to March 1, 2023, 375 aortic specimens were collected from 105 patients undergoing elective ascending aortic aneurysm repair for BAV aortopathy. Planar biaxial data (191 specimens) informed constitutive descriptors of the arterial wall that were combined with in vivo geometry and hemodynamics to predict stiffness, stress, and energy density under physiologic loads. Uniaxial testing (184 specimens) evaluated failure stretch and failure Cauchy stress. Boosting regression was implemented to model the association between clinical variables and mechanical metrics. RESULTS There were no significant differences in mechanical metrics between the root phenotype (N = 33, 31%) and ascending/diffuse phenotypes (N = 72, 69%). Biaxial testing demonstrated older age was associated with increased circumferential stiffness, decreased stress, and decreased energy density. On uniaxial testing, longitudinally versus circumferentially oriented specimens failed at significantly lower Cauchy stress (50th [15th, 85th percentiles]: 1.0 [0.7, 1.6] MPa vs 1.9 [1.3, 3.1] MPa; P < .001). Age was associated with decreased failure stretch and stress. Elongated ascending aortas were also associated with decreased failure stress. CONCLUSIONS Aortic mechanical function under physiologic and failure conditions in BAV aortopathy is robustly associated with age and poorly associated with aortopathy phenotype. Data suggesting that the root phenotype of BAV aortopathy portends worse outcomes are unlikely to be related to aberrant, phenotype-specific tissue mechanics.
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Affiliation(s)
- Matthew A Thompson
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin Kramer
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samar A Tarraf
- Department of Bioengineering, College of Engineering, Northeastern University, Boston, Mass
| | - Emily Vianna
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Callan Gillespie
- Department of Biomedical Engineering, BioRobotics and Mechanical Testing Core, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emidio Germano
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brett Gentle
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Frank Cikach
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amol Pande
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene Blackstone
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer Hargrave
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Robb Colbrunn
- Department of Biomedical Engineering, BioRobotics and Mechanical Testing Core, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chiara Bellini
- Department of Bioengineering, College of Engineering, Northeastern University, Boston, Mass
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
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3
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Iskandar Z, Dodd M, Huang J, Chin CWL, Stuart G, Caputo M, Clayton T, Child A, Jin XY, Aragon-Martin JA, Gibb J, Flather M, Choy AM. Exaggerated elastin turnover in young individuals with Marfan syndrome: new insights from the AIMS trial. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead095. [PMID: 37829559 PMCID: PMC10567063 DOI: 10.1093/ehjopen/oead095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 10/14/2023]
Abstract
Aims The fragmentation and loss of elastic fibre in the tunica media of the aorta are pathological hallmarks of Marfan syndrome (MFS) but the dynamics of elastin degradation and its relationship to aortic size and physiological growth remain poorly understood. Methods and results In this post hoc analysis of the AIMS randomized controlled trial, the association of plasma desmosine (pDES)-a specific biomarker of mature elastin degradation-with age and aortic size was analysed in 113 patients with MFS and compared to 109 healthy controls. There was a strong association between age and pDES in both groups, with higher pDES levels in the lower age groups compared to adults. During childhood, pDES increased and peaked during early adolescence, and thereafter decreased to lower adult levels. This trend was exaggerated in young individuals with MFS but in those above 25 years of age, pDES levels were comparable to controls despite the presence of aortic root dilation. In MFS children, increased aortic diameter relative to controls was seen at an early age and although the increase in diameter was less after adolescence, aortic root size continued to increase steadily with age. In MFS participants, there was an indication of a positive association between baseline pDES levels and aortic root dilatation during up to 5 years of follow-up. Conclusion This study has shown that developmental age has a significant effect on levels of elastin turnover as measured by pDES in MFS individuals as well as healthy controls. This effect is exaggerated in those with MFS with increased levels seen during the period of physiologic development that plateaus towards adulthood. This suggests an early onset of pathophysiology that may present an important opportunity for disease-modifying intervention.
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Affiliation(s)
| | - Matthew Dodd
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Calvin W L Chin
- National Heart Center Singapore, Cardiovascular ACP, Duke-NUS Medical School, Singapore
| | - Graham Stuart
- University Hospitals Bristol NHS Foundation Trust/Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Royal Hospital for Children/Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Tim Clayton
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Anne Child
- Royal Brompton and Harefield Clinical Group, Guy’s and St Thomas’ Trust, King’s College, London, UK
| | - Xu Yu Jin
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK
| | | | - Jack Gibb
- Bristol Royal Hospital for Children/Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
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Kim T, Tjahjadi NS, He X, van Herwaarden JA, Patel HJ, Burris NS, Figueroa CA. Three-Dimensional Characterization of Aortic Root Motion by Vascular Deformation Mapping. J Clin Med 2023; 12:4471. [PMID: 37445507 DOI: 10.3390/jcm12134471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
The aorta is in constant motion due to the combination of cyclic loading and unloading with its mechanical coupling to the contractile left ventricle (LV) myocardium. This aortic root motion has been proposed as a marker for aortic disease progression. Aortic root motion extraction techniques have been mostly based on 2D image analysis and have thus lacked a rigorous description of the different components of aortic root motion (e.g., axial versus in-plane). In this study, we utilized a novel technique termed vascular deformation mapping (VDM(D)) to extract 3D aortic root motion from dynamic computed tomography angiography images. Aortic root displacement (axial and in-plane), area ratio and distensibility, axial tilt, aortic rotation, and LV/Ao angles were extracted and compared for four different subject groups: non-aneurysmal, TAA, Marfan, and repair. The repair group showed smaller aortic root displacement, aortic rotation, and distensibility than the other groups. The repair group was also the only group that showed a larger relative in-plane displacement than relative axial displacement. The Marfan group showed the largest heterogeneity in aortic root displacement, distensibility, and age. The non-aneurysmal group showed a negative correlation between age and distensibility, consistent with previous studies. Our results revealed a strong positive correlation between LV/Ao angle and relative axial displacement and a strong negative correlation between LV/Ao angle and relative in-plane displacement. VDM(D)-derived 3D aortic root motion can be used in future studies to define improved boundary conditions for aortic wall stress analysis.
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Affiliation(s)
- Taeouk Kim
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nic S Tjahjadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Xuehuan He
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - J A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nicholas S Burris
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - C Alberto Figueroa
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
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Chen M, Cavinato C, Hansen J, Tanaka K, Ren P, Hassab A, Li DS, Youshao E, Tellides G, Iyengar R, Humphrey JD, Schwartz MA. FN (Fibronectin)-Integrin α5 Signaling Promotes Thoracic Aortic Aneurysm in a Mouse Model of Marfan Syndrome. Arterioscler Thromb Vasc Biol 2023; 43:e132-e150. [PMID: 36994727 PMCID: PMC10133209 DOI: 10.1161/atvbaha.123.319120] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/20/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Marfan syndrome, caused by mutations in the gene for fibrillin-1, leads to thoracic aortic aneurysms (TAAs). Phenotypic modulation of vascular smooth muscle cells (SMCs) and ECM (extracellular matrix) remodeling are characteristic of both nonsyndromic and Marfan aneurysms. The ECM protein FN (fibronectin) is elevated in the tunica media of TAAs and amplifies inflammatory signaling in endothelial and SMCs through its main receptor, integrin α5β1. We investigated the role of integrin α5-specific signals in Marfan mice in which the cytoplasmic domain of integrin α5 was replaced with that of integrin α2 (denoted α5/2 chimera). METHODS We crossed α5/2 chimeric mice with Fbn1mgR/mgR mice (mgR model of Marfan syndrome) to evaluate the survival rate and pathogenesis of TAAs among wild-type, α5/2, mgR, and α5/2 mgR mice. Further biochemical and microscopic analysis of porcine and mouse aortic SMCs investigated molecular mechanisms by which FN affects SMCs and subsequent development of TAAs. RESULTS FN was elevated in the thoracic aortas from Marfan patients, in nonsyndromic aneurysms, and in mgR mice. The α5/2 mutation greatly prolonged survival of Marfan mice, with improved elastic fiber integrity, mechanical properties, SMC density, and SMC contractile gene expression. Furthermore, plating of wild-type SMCs on FN decreased contractile gene expression and activated inflammatory pathways whereas α5/2 SMCs were resistant. These effects correlated with increased NF-kB activation in cultured SMCs and mgR aortas, which was alleviated by the α5/2 mutation or NF-kB inhibition. CONCLUSIONS FN-integrin α5 signaling is a significant driver of TAA in the mgR mouse model. This pathway thus warrants further investigation as a therapeutic target.
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Affiliation(s)
- Minghao Chen
- Cardiovascular Research Center (M.C., K.T., M.A.S.), Yale School of Medicine, New Haven, CT
| | - Cristina Cavinato
- Department of Biomedical Engineering, Yale University, New Haven, CT (C.C., D.S.L., E.Y., J.D.H., M.A.S.)
| | - Jens Hansen
- Department of Pharmacological Sciences and Institute for Systems Biomedicine, Icahn School of Medicine at Mount Sinai, New York (J.H., R.I.)
| | - Keiichiro Tanaka
- Cardiovascular Research Center (M.C., K.T., M.A.S.), Yale School of Medicine, New Haven, CT
| | - Pengwei Ren
- Department of Surgery (P.R., A.H., G.T., M.A.S.), Yale School of Medicine, New Haven, CT
| | - Abdulrahman Hassab
- Department of Surgery (P.R., A.H., G.T., M.A.S.), Yale School of Medicine, New Haven, CT
| | - David S Li
- Department of Biomedical Engineering, Yale University, New Haven, CT (C.C., D.S.L., E.Y., J.D.H., M.A.S.)
| | - Eric Youshao
- Department of Biomedical Engineering, Yale University, New Haven, CT (C.C., D.S.L., E.Y., J.D.H., M.A.S.)
| | - George Tellides
- Department of Surgery (P.R., A.H., G.T., M.A.S.), Yale School of Medicine, New Haven, CT
- Vascular Biology and Therapeutics Program (G.T., J.D.H.), Yale School of Medicine, New Haven, CT
| | - Ravi Iyengar
- Department of Pharmacological Sciences and Institute for Systems Biomedicine, Icahn School of Medicine at Mount Sinai, New York (J.H., R.I.)
| | - Jay D Humphrey
- Vascular Biology and Therapeutics Program (G.T., J.D.H.), Yale School of Medicine, New Haven, CT
- Department of Biomedical Engineering, Yale University, New Haven, CT (C.C., D.S.L., E.Y., J.D.H., M.A.S.)
| | - Martin A Schwartz
- Cardiovascular Research Center (M.C., K.T., M.A.S.), Yale School of Medicine, New Haven, CT
- Department of Surgery (P.R., A.H., G.T., M.A.S.), Yale School of Medicine, New Haven, CT
- Departments of Medicine (Cardiology) and Cell Biology (M.A.S.), Yale School of Medicine, New Haven, CT
- Department of Biomedical Engineering, Yale University, New Haven, CT (C.C., D.S.L., E.Y., J.D.H., M.A.S.)
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6
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Abstract
PURPOSE OF REVIEW Bicuspid aortic valve (BAV) disease is observed in 1-2% of the general population. In addition to valve-related complications (such as aortic stenosis and aortic regurgitation), individuals with BAV often develop dilatation of the proximal aorta (aortic root and ascending aorta), a condition termed BAV aortopathy. The development of BAV aortopathy can occur independent of valvular alterations and can lead to aneurysm formation, aortic dissection or aortic rupture. This review aims to update the clinician with an approach to BAV aortopathy decision making in keeping with the 2022 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline recommendations. RECENT FINDINGS The ACC/AHA 2022 guidelines provide a contemporary and comprehensive approach to the diagnosis and treatment of aortic pathologies. We review the thresholds for replacement of the aortic root and/or ascending aorta along with the strength and level of evidence recommendations. We also review the various Class 2A and 2B recommendations for earlier intervention, which emphasize the importance of experienced surgeons, and multidisciplinary aortic teams (MATs). SUMMARY BAV aortopathy is a common and heterogenous clinical problem. The decision making around timing of intervention requires a personalized approach that is based on the aortic dimensions, valve function, rate of growth, family history, patient factors, and surgical experience within MATs.
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Affiliation(s)
- Raj Verma
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gideon Cohen
- Division of Cardiac Surgery, Sunnybrook Hospital, Toronto, Canada
| | - Jillian Colbert
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Paul W M Fedak
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
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7
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Genome-wide associations of aortic distensibility suggest causality for aortic aneurysms and brain white matter hyperintensities. Nat Commun 2022; 13:4505. [PMID: 35922433 PMCID: PMC9349177 DOI: 10.1038/s41467-022-32219-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 07/20/2022] [Indexed: 12/13/2022] Open
Abstract
Aortic dimensions and distensibility are key risk factors for aortic aneurysms and dissections, as well as for other cardiovascular and cerebrovascular diseases. We present genome-wide associations of ascending and descending aortic distensibility and area derived from cardiac magnetic resonance imaging (MRI) data of up to 32,590 Caucasian individuals in UK Biobank. We identify 102 loci (including 27 novel associations) tagging genes related to cardiovascular development, extracellular matrix production, smooth muscle cell contraction and heritable aortic diseases. Functional analyses highlight four signalling pathways associated with aortic distensibility (TGF-β, IGF, VEGF and PDGF). We identify distinct sex-specific associations with aortic traits. We develop co-expression networks associated with aortic traits and apply phenome-wide Mendelian randomization (MR-PheWAS), generating evidence for a causal role for aortic distensibility in development of aortic aneurysms. Multivariable MR suggests a causal relationship between aortic distensibility and cerebral white matter hyperintensities, mechanistically linking aortic traits and brain small vessel disease.
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8
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Spronck B, Ramachandra AB, Moriyama L, Toczek J, Han J, Sadeghi MM, Humphrey JD. Deletion of matrix metalloproteinase-12 compromises mechanical homeostasis and leads to an aged aortic phenotype in young mice. J Biomech 2022; 141:111179. [PMID: 35759974 PMCID: PMC9585962 DOI: 10.1016/j.jbiomech.2022.111179] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
Mechanical homeostasis emerges following normal development of the arterial wall and requires thereafter a slow balanced degradation and deposition of extracellular matrix constituents within an unchanging mechanical state. Recent findings suggest that homeostasis is compromised in arterial aging, which contributes to the structural stiffening that is characteristic of aged central arteries. Matrix metalloproteinases (MMPs) have strong proteolytic activity and play fundamental roles in matrix turnover. Here, we use Mmp12-/- mice to examine effects of a potent metalloelastase, MMP-12, on the biomechanical phenotype of the thoracic and abdominal aorta in young and naturally aged mice. A key finding is that germline deletion of the gene (Mmp12) that encodes MMP-12 alters biomechanical properties from normal more in young adult than in older adult mice. Consequently, percent changes in biomechanical properties during aortic aging are greater in wild-type than in MMP-12 deficient mice, though with similar overall decreases in elastic energy storage and distensibility and increases in calculated pulse wave velocity. Reduced elastic energy storage compromises the ability of the aorta to augment antegrade and retrograde blood flow while an increased pulse wave velocity can adversely affect end organs, both conditions being characteristic of aortic aging in humans. In summary, MMP-12 is fundamental for establishing homeostatic values of biomechanical metrics in the aorta and its absence leads to a pre-aged aortic phenotype in young mice.
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Affiliation(s)
- Bart Spronck
- Department of Biomedical Engineering, School of Engineering and Applied Science, Yale University, New Haven, CT, USA; Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands.
| | - Abhay B Ramachandra
- Department of Biomedical Engineering, School of Engineering and Applied Science, Yale University, New Haven, CT, USA
| | - Lauren Moriyama
- Department of Biomedical Engineering, School of Engineering and Applied Science, Yale University, New Haven, CT, USA
| | - Jakub Toczek
- Cardiovascular Medicine and Cardiovascular Research Center, Yale School of Medicine, New Haven, CT, USA; Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Jinah Han
- Cardiovascular Medicine and Cardiovascular Research Center, Yale School of Medicine, New Haven, CT, USA; Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Mehran M Sadeghi
- Cardiovascular Medicine and Cardiovascular Research Center, Yale School of Medicine, New Haven, CT, USA; Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA; Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, School of Engineering and Applied Science, Yale University, New Haven, CT, USA; Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
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9
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Ascending aorta curvature and flow displacement are associated with accelerated aortic growth at long-term follow-up: A MRI study in Marfan and thoracic aortic aneurysm patients. IJC HEART & VASCULATURE 2022; 38:100926. [PMID: 34977327 PMCID: PMC8683588 DOI: 10.1016/j.ijcha.2021.100926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/05/2021] [Indexed: 01/16/2023]
Abstract
Background Aortic aneurysm formation is associated with increased risk of aortic dissection. Current diagnostic strategies are focused on diameter growth, the predictive value of aortic morphology and function remains underinvestigated. We aimed to assess the long-term prognostic value of ascending aorta (AA) curvature radius, regional pulse wave velocity (PWV) and flow displacement (FD) on aortic dilatation/elongation and evaluated adverse outcomes (proximal aortic surgery, dissection/rupture, death) in Marfan and non-syndromic thoracic aortic aneurysm (NTAA) patients. Methods Long-term magnetic resonance imaging (MRI) and clinical follow-up of two previous studies consisting of 21 Marfan and 40 NTAA patients were collected. Baseline regional PWV, AA curvature radius and normalized FD were assessed as well as diameter and length growth rate at follow-up. Multivariate linear regression was performed to evaluate whether baseline predictors were associated with aortic growth.=. Results Of the 61 patients, 49 patients were included with MRI follow-up (n = 44) and/or adverse aortic events (n = 7). Six had undergone aortic surgery, no dissection/rupture occurred and one patient died during follow-up. During 8.0 [7.3-10.7] years of follow-up, AA growth rate was 0.40 ± 0.31 mm/year. After correction for confounders, AA curvature radius (p = 0.01), but not FD or PWV, was a predictor of AA dilatation. Only FD was associated with AA elongation (p = 0.01). Conclusion In Marfan and non-syndromic thoracic aortic aneurysm patients, ascending aorta curvature radius and flow displacement are associated with accelerated aortic growth at long-term follow-up. These markers may aid in the risk stratification of ascending aorta elongation and aneurysm formation.
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10
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Perez-Casares A, Dionne A, Gauvreau K, Prakash A. Rapid ascending aorta stiffening in bicuspid aortic valve on serial cardiovascular magnetic resonance evaluation: comparison with connective tissue disorders. J Cardiovasc Magn Reson 2021; 23:11. [PMID: 33618720 PMCID: PMC7898767 DOI: 10.1186/s12968-021-00716-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aortic stiffness has been shown to be abnormal in patients with bicuspid aortic valve (BAV), and is considered a component of the aortopathy associated with this condition. Progressive aortic stiffening associated with aging has been previously described in normal adults. However, it is not known if aging related aortic stiffening occurs at the same rate in BAV patients. We determined the longitudinal rate of decline in segmental distensibility in BAV patients using serial cardiovascular magnetic resonance (CMR) studies, and compared to previously published results from a group of patients with connective tissue disorders (CTD). METHODS A retrospective review of CMR and clinical data on children and adults with BAV (n = 49, 73% male; 23 ± 11 years) with at least two CMRs (total 98 examinations) over a median follow-up of 4.1 years (range 1-9 years) was performed to measure aortic distensibility at the ascending (AAo) and descending aorta (DAo). Longitudinal changes in aortic stiffness were assessed using linear mixed-effects modeling. The comparison group of CTD patients had a similar age and gender profile (n = 50, 64% male; 20.6 ± 12 years). RESULTS Compared to CTD patients, BAV patients had a more distensible AAo early in life but showed a steeper decline in distensibility on serial examinations [mean 10-year decline in AAo distensibility (× 10-3 mmHg-1) 2.4 in BAV vs 1.3 in CTD, p = 0.005]. In contrast, the DAo was more distensible in BAV patients throughout the age spectrum, and DAo distensibility declined with aging at a rate similar to CTD patients [mean 10 year decline in DAo distensibility (× 10-3 mmHg-1) 0.3 in BAV vs 0.4 in CTD, p = 0.58]. CONCLUSIONS On serial CMR measurements, AAo distensibility declined at significantly steeper rate in BAV patients compared to a comparison group with CTDs, while DAo distensibility declined at similar rates in both groups. These findings offer new mechanistic insights into the differing pathogenesis of the aortopathy seen in BAV and CTD patients.
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Affiliation(s)
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Ashwin Prakash
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
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11
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Creamer TJ, Bramel EE, MacFarlane EG. Insights on the Pathogenesis of Aneurysm through the Study of Hereditary Aortopathies. Genes (Basel) 2021; 12:183. [PMID: 33514025 PMCID: PMC7912671 DOI: 10.3390/genes12020183] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 12/15/2022] Open
Abstract
Thoracic aortic aneurysms (TAA) are permanent and localized dilations of the aorta that predispose patients to a life-threatening risk of aortic dissection or rupture. The identification of pathogenic variants that cause hereditary forms of TAA has delineated fundamental molecular processes required to maintain aortic homeostasis. Vascular smooth muscle cells (VSMCs) elaborate and remodel the extracellular matrix (ECM) in response to mechanical and biochemical cues from their environment. Causal variants for hereditary forms of aneurysm compromise the function of gene products involved in the transmission or interpretation of these signals, initiating processes that eventually lead to degeneration and mechanical failure of the vessel. These include mutations that interfere with transduction of stimuli from the matrix to the actin-myosin cytoskeleton through integrins, and those that impair signaling pathways activated by transforming growth factor-β (TGF-β). In this review, we summarize the features of the healthy aortic wall, the major pathways involved in the modulation of VSMC phenotypes, and the basic molecular functions impaired by TAA-associated mutations. We also discuss how the heterogeneity and balance of adaptive and maladaptive responses to the initial genetic insult might contribute to disease.
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Affiliation(s)
- Tyler J. Creamer
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Emily E. Bramel
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Predoctoral Training in Human Genetics and Molecular Biology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Elena Gallo MacFarlane
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (T.J.C.); (E.E.B.)
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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12
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Boczar KE, Boodhwani M, Beauchesne L, Dennie C, Chan KL, Wells GA, Coutinho T. Aortic Stiffness, Central Blood Pressure, and Pulsatile Arterial Load Predict Future Thoracic Aortic Aneurysm Expansion. Hypertension 2020; 77:126-134. [PMID: 33249858 DOI: 10.1161/hypertensionaha.120.16249] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Thoracic aortic aneurysm is a disease associated with high morbidity and mortality. Clinically useful strategies for medical management of thoracic aortic aneurysm are critically needed. To address this need, we sought to determine the role of aortic stiffness and pulsatile arterial load on future aneurysm expansion. One hundred five consecutive, unoperated subjects with thoracic aortic aneurysm were recruited and prospectively followed. By combining arterial tonometry with echocardiography, we estimated measures of aortic stiffness, central blood pressure, steady, and pulsatile arterial load at baseline. Aneurysm size was measured at baseline and follow-up with imaging; growth was calculated in mm/y. Stepwise multivariable linear regression assessed associations of arterial stiffness and load measures with aneurysm growth after adjusting for potential confounders. Mean±SD age, baseline aneurysm size, and follow-up time were 62.6±11.4 years, 46.24±3.84 mm, and 2.92±1.01 years, respectively. Aneurysm growth rate was 0.43±0.37 mm/y. After correcting for multiple comparisons, higher central systolic (β±SE: 0.026±0.009, P=0.007), and pulse pressures (β±SE: 0.032±0.009, P=0.0002), carotid-femoral pulse wave velocity (β±SE: 0.032±0.011, P=0.005), amplitudes of the forward (β±SE: 0.044±0.012, P=0.0003) and reflected (β±SE: 0.060±0.020, P=0.003) pressure waves, and lower total arterial compliance (β±SE: -0.086±0.032, P=0.009) were independently associated with future aneurysm growth. Measures of aortic stiffness and pulsatile hemodynamics are independently associated with future thoracic aortic aneurysm growth and provide novel insights into disease activity. Our findings highlight the role of central hemodynamic assessment to tailor novel risk assessment and therapeutic strategies to patients with thoracic aortic aneurysm.
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Affiliation(s)
- Kevin E Boczar
- From the Division of Cardiology (K.E.B., L.B., K.C., T.C.), University of Ottawa Heart Institute, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, ON, Canada (K.E.B., G.A.W, T.C.)
| | - Munir Boodhwani
- Division of Cardiac Surgery (M.B.), University of Ottawa Heart Institute, ON, Canada
| | - Luc Beauchesne
- From the Division of Cardiology (K.E.B., L.B., K.C., T.C.), University of Ottawa Heart Institute, ON, Canada
| | - Carole Dennie
- Department of Radiology (C.D.), The Ottawa Hospital, ON, Canada
| | | | - George A Wells
- Research Methods Centre (G.A.W.), University of Ottawa Heart Institute, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, ON, Canada (K.E.B., G.A.W, T.C.)
| | - Thais Coutinho
- From the Division of Cardiology (K.E.B., L.B., K.C., T.C.), University of Ottawa Heart Institute, ON, Canada.,Division of Cardiac Prevention and Rehabilitation (T.C.), University of Ottawa Heart Institute, ON, Canada.,Canadian Women's Heart Health Centre (T.C.), University of Ottawa Heart Institute, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, ON, Canada (K.E.B., G.A.W, T.C.)
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13
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Pascaner AF, Houriez-Gombaud-Saintonge S, Craiem D, Gencer U, Casciaro ME, Charpentier E, Bouaou K, Cesare AD, Dietenbeck T, Chenoune Y, Kachenoura N, Mousseaux E, Soulat G, Bollache E. Comprehensive assessment of local and regional aortic stiffness in patients with tricuspid or bicuspid aortic valve aortopathy using magnetic resonance imaging. Int J Cardiol 2020; 326:206-212. [PMID: 33259874 DOI: 10.1016/j.ijcard.2020.11.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/27/2020] [Accepted: 11/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND We aimed to provide a comprehensive aortic stiffness description using magnetic resonance imaging (MRI) in patients with ascending thoracic aorta aneurysm and tricuspid (TAV-ATAA) or bicuspid (BAV) aortic valve. METHODS This case-control study included 18 TAV-ATAA and 19 BAV patients, with no aortic valve stenosis/severe regurgitation, who were 1:1 age-, gender- and central blood pressures (BP)-matched to healthy volunteers. Each underwent simultaneous aortic MRI and BP measurements. 3D anatomical MRI provided aortic diameters. Stiffness indices included: regional ascending (AA) and descending (DA) aorta pulse wave velocity (PWV) from 4D flow MRI; local AA and DA strain, distensibility and theoretical Bramwell-Hill (BH) model-based PWV, as well as regional arch PWV from 2D flow MRI. RESULTS Patient groups had significantly higher maximal AA diameter (median[interquartile range], TAV-ATAA: 47.5[42.0-51.3]mm, BAV: 45.0[41.0-47.0]mm) than their respective controls (29.1[26.8-31.8] and 28.1[26.0-32.0]mm, p < 0.0001), while BP were similar (p ≥ 0.25). Stiffness indices were significantly associated with age (ρ ≥ 0.33), mean BP (arch PWV: ρ = 0.25, p = 0.05; DA distensibility: ρ = -0.30, p = 0.02) or AA diameter (arch PWV: ρ = 0.28, p = 0.03; DA PWV: ρ = 0.32, p = 0.009). None of them, however, was significantly different between TAV-ATAA or BAV patients and their matched controls. Finally, while direct PWV measures were significantly correlated to BH-PWV estimates in controls (ρ ≥ 0.40), associations were non-significant in TAV-ATAA and BAV groups (p ≥ 0.18). CONCLUSIONS The overlap of MRI-derived aortic stiffness indices between patients with TAV or BAV aortopathy and matched controls highlights another heterogeneous feature of aortopathy, and suggests the urgent need for more sensitive indices which might help better discriminate such diseases.
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Affiliation(s)
- Ariel F Pascaner
- Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMETTyB), Universidad Favaloro - CONICET, Buenos Aires, Argentina
| | - Sophia Houriez-Gombaud-Saintonge
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; ESME Sudria Research Lab, Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Damian Craiem
- Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMETTyB), Universidad Favaloro - CONICET, Buenos Aires, Argentina
| | - Umit Gencer
- Département de Radiologie Cardiovasculaire, Hôpital Européen Georges Pompidou - INSERM U970, PARCC, Paris, France
| | - Mariano E Casciaro
- Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMETTyB), Universidad Favaloro - CONICET, Buenos Aires, Argentina
| | - Etienne Charpentier
- Département de Radiologie Cardiovasculaire, Hôpital Européen Georges Pompidou - INSERM U970, PARCC, Paris, France
| | - Kevin Bouaou
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Alain De Cesare
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Thomas Dietenbeck
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | | | - Nadjia Kachenoura
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Elie Mousseaux
- Département de Radiologie Cardiovasculaire, Hôpital Européen Georges Pompidou - INSERM U970, PARCC, Paris, France
| | - Gilles Soulat
- Département de Radiologie Cardiovasculaire, Hôpital Européen Georges Pompidou - INSERM U970, PARCC, Paris, France
| | - Emilie Bollache
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.
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Davaapil H, Shetty DK, Sinha S. Aortic "Disease-in-a-Dish": Mechanistic Insights and Drug Development Using iPSC-Based Disease Modeling. Front Cell Dev Biol 2020; 8:550504. [PMID: 33195187 PMCID: PMC7655792 DOI: 10.3389/fcell.2020.550504] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/08/2020] [Indexed: 12/24/2022] Open
Abstract
Thoracic aortic diseases, whether sporadic or due to a genetic disorder such as Marfan syndrome, lack effective medical therapies, with limited translation of treatments that are highly successful in mouse models into the clinic. Patient-derived induced pluripotent stem cells (iPSCs) offer the opportunity to establish new human models of aortic diseases. Here we review the power and potential of these systems to identify cellular and molecular mechanisms underlying disease and discuss recent advances, such as gene editing, and smooth muscle cell embryonic lineage. In particular, we discuss the practical aspects of vascular smooth muscle cell derivation and characterization, and provide our personal insights into the challenges and limitations of this approach. Future applications, such as genotype-phenotype association, drug screening, and precision medicine are discussed. We propose that iPSC-derived aortic disease models could guide future clinical trials via “clinical-trials-in-a-dish”, thus paving the way for new and improved therapies for patients.
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Affiliation(s)
- Hongorzul Davaapil
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, Cambridge, United Kingdom
| | - Deeti K Shetty
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, Cambridge, United Kingdom
| | - Sanjay Sinha
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, Cambridge, United Kingdom
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15
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Latorre M, Humphrey JD. Numerical knockouts-In silico assessment of factors predisposing to thoracic aortic aneurysms. PLoS Comput Biol 2020; 16:e1008273. [PMID: 33079926 PMCID: PMC7598929 DOI: 10.1371/journal.pcbi.1008273] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 10/30/2020] [Accepted: 08/19/2020] [Indexed: 02/06/2023] Open
Abstract
Myriad risk factors–including uncontrolled hypertension, aging, and diverse genetic mutations–contribute to the development and enlargement of thoracic aortic aneurysms. Detailed analyses of clinical data and longitudinal studies of murine models continue to provide insight into the natural history of these potentially lethal conditions. Yet, because of the co-existence of multiple risk factors in most cases, it has been difficult to isolate individual effects of the many different factors or to understand how they act in combination. In this paper, we use a data-informed computational model of the initiation and progression of thoracic aortic aneurysms to contrast key predisposing risk factors both in isolation and in combination; these factors include localized losses of elastic fiber integrity, aberrant collagen remodeling, reduced smooth muscle contractility, and dysfunctional mechanosensing or mechanoregulation of extracellular matrix along with superimposed hypertension and aortic aging. In most cases, mild-to-severe localized losses in cellular function or matrix integrity give rise to varying degrees of local dilatations of the thoracic aorta, with enlargement typically exacerbated in cases wherein predisposing risk factors co-exist. The simulations suggest, for the first time, that effects of compromised smooth muscle contractility are more important in terms of dysfunctional mechanosensing and mechanoregulation of matrix than in vessel-level control of diameter and, furthermore, that dysfunctional mechanobiological control can yield lesions comparable to those in cases of compromised elastic fiber integrity. Particularly concerning, therefore, is that loss of constituents such as fibrillin-1, as in Marfan syndrome, can compromise both elastic fiber integrity and mechanosensing. Aneurysms are local dilatations of the arterial wall that are responsible for significant disability and death. Detailed analyses of clinical data continue to provide insight into the natural history of these potentially lethal conditions, with myriad risk factors–including uncontrolled hypertension, aging, and diverse genetic mutations–contributing to their development and enlargement. Yet, because of the co-existence of these risk factors in most cases, it has been difficult to isolate individual effects or to understand how they act in combination. In this paper, we use a computational model of the initiation and progression of thoracic aortic aneurysms to contrast key predisposing factors both in isolation and in combination as well as with superimposed hypertension and aging. The present study recovers many findings from mouse models but with new and important observations that promise to guide in vivo and ex vivo studies as we seek to understand and eventually better treat these complex, multi-factorial lesions, with data-informed patient-specific computations eventually the way forward.
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Affiliation(s)
- M. Latorre
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States of America
| | - J. D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States of America
- * E-mail:
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16
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Impact of simultaneous measurement of central blood pressure with the SphygmoCor Xcel during MRI acquisition to better estimate aortic distensibility. J Hypertens 2020; 37:1448-1454. [PMID: 31145713 DOI: 10.1097/hjh.0000000000002061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Aortic distensibility estimation of local aortic stiffness is based on local aortic strains and central pulse pressure (cPP) measurements. Most MRI studies used either brachial PP (bPP) despite differences with cPP, or direct cPP estimates obtained after MRI examination, assuming no major pressure variations. We evaluated the feasibility of assessment of cPP with a specific device fitted with a 6 m long hose (study1) and looked at the influence of using such cPP within the magnet instead of bPP on aortic distensibility in a control population (study 2). METHODS Brachial and central pressures values were recorded with the SphygmoCor XCEL system fitted with 2 and 6 m long tubing randomly assigned on arms. A 6 m long tubing was used in the second study to measure aortic distensibility with MRI. Aortic distensibility was calculated using either bPP (bAD) or cPP (cAD). RESULTS Study1, performed on 38 patients (mean age: 43 ± 17 years), showed no statistical difference between bPP and cPP measured with 2 or 6 m long tubing (0.41 ± 4.45 and 0.78 ± 3.18 mmHg, respectively, both P = ns). In study 2, cAD provided statistically higher values than bAD (1.87 ± 1.43 10 · mmHg, P < 0.001) especially in younger individuals (3.28 ± 0.86 10 · mmHg). The correlation between age and aortic distensibility was stronger with cAD (r = -0.92; P < 0,001) than with bAD (r = -0.88; P < 0.001). CONCLUSION cPP can be estimated with reasonable accuracy during MRI acquisition using a 6 m long tube. Using either cPP or bPP greatly influences aortic distensibility values, especially in young individuals in whom an accurate detection of early or accelerated vascular aging can be of major importance.
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Abstract
Aortic dilatation is common in patients with congenital heart disease and is seen in patients with bicuspid aortic valve and those with conotruncal congenital heart defects. It is important to identify patients with bicuspid aortic valve at high risk for aortic dissection. High-risk patients include those with the aortic root phenotype and those with syndromic or familial aortopathies including Marfan syndrome, Loeys-Dietz syndrome, and Turner syndrome. Aortic dilatation is common in patients with conotruncal congenital heart defects and rarely results in aortic dissection.
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18
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Spronck B, Ferruzzi J, Bellini C, Caulk AW, Murtada SI, Humphrey JD. Aortic remodeling is modest and sex-independent in mice when hypertension is superimposed on aging. J Hypertens 2020; 38:1312-1321. [PMID: 32068640 PMCID: PMC7611466 DOI: 10.1097/hjh.0000000000002400] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Increased central artery stiffness associates with cardiovascular disease. Among other factors, hypertension and aging are strong contributors to central artery stiffening, yet it has been difficult to separate their effects. Herein, we study isolated and combined effects of hypertension and aging on central artery remodeling in multiple mouse models as a function of sex. METHODS We biomechanically phenotyped the aorta as a function of two different methods of inducing hypertension [infusion of angiotensin II (AngII) or combining a high salt diet with inhibition of endothelial-derived nitric oxide synthase using L-NAME] in male and female wild-type and fibulin-5 null mice, the latter of which models aspects of aortic aging. RESULTS Despite increasing blood pressure similarly, salt + L-NAME led to adaptive and maladaptive remodeling in the abdominal and thoracic aorta, respectively, whereas AngII caused luminal dilatation but little remodeling of the wall. Importantly, effects of aging were more dramatic than those resulting from induced hypertension and, consequently, superimposing hypertension on aging led to modest additional changes in luminal radius and wall thickness, though wall stress and stiffness increased mainly because of the elevated pressure. CONCLUSION Our results suggest that effects of hypertension on aortic remodeling are modest when superimposed on aging in mice, largely independent of sex. These findings are consistent with general observations in humans and in spontaneously hypertensive rats, though separated here for the first time in a rodent model characterized by a severe loss of elastic fiber integrity similar to that found in the aged human aorta.
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Affiliation(s)
- Bart Spronck
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
- Department of Biomedical Engineering, Maastricht University, Maastricht, The Netherlands
| | - Jacopo Ferruzzi
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
| | - Chiara Bellini
- Department of Bioengineering, Northeastern University, Boston, Massachusetts
| | - Alexander W Caulk
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
| | - Sae-Il Murtada
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, USA
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Abstract
Inherited thoracic aortopathies denote a group of congenital conditions that predispose to disease of the thoracic aorta. Aortic wall weakness and abnormal aortic hemodynamic profiles predispose these patients to dilatation of the thoracic aorta, which is generally silent but can precipitate aortic dissection or rupture with devastating and often fatal consequences. Current strategies to assess the future risk of aortic dissection or rupture are based primarily on monitoring aortic diameter. However, diameter alone is a poor predictor of risk, with many patients experiencing dissection or rupture below current intervention thresholds. Developing tools that improve the risk assessment of those with aortopathy is internationally regarded as a research priority. A robust understanding of the molecular pathways that lead to aortic wall weakness is required to identify biomarkers and therapeutic targets that could improve patient management. Here, we summarize the current understanding of the genetically determined mechanisms underlying inherited aortopathies and critically appraise the available blood biomarkers, imaging techniques, and therapeutic targets that have shown promise for improving the management of patients with these important and potentially fatal conditions.
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Affiliation(s)
- Alexander J. Fletcher
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Maaz B.J. Syed
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Timothy J. Aitman
- Centre for Genomics and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, United Kingdom (T.J.A.)
| | - David E. Newby
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Niki L. Walker
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
- Scottish Adult Congenital Heart Disease Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (N.L.W.)
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20
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Familial Aortopathies - State of the Art Review. Heart Lung Circ 2019; 29:607-618. [PMID: 32067919 DOI: 10.1016/j.hlc.2019.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/18/2019] [Accepted: 12/03/2019] [Indexed: 02/06/2023]
Abstract
Aortopathies are conditions that result in aortic dilatation, aneurysm formation and dissection. Familial aortopathies (perhaps better known as heritable thoracic aortic aneurysm and dissection, h-TAAD, as not all have a positive family history) are recognised to have an underlying genetic cause and affect the aorta, predisposing it to the above pathologies. These conditions can also affect the extra-aortic vasculature, particularly large elastic arteries and other body systems. Mutations in a number of genes have been associated with h-TAAD. However, not all affected families have a pathogenic gene variant identified-highlighting the importance of a three-generational family history and the likely role of both environmental factors and future gene discoveries in furthering knowledge. Survival has improved over the last few decades, essentially due to surgical intervention. The benefit of identifying affected individuals depends upon a regular surveillance program and timely referral for surgery before complications such as dissection. Further research is required to appreciate fully the effects of individual gene variants and improve evidence for prophylactic medical therapy, as well as to understand the effect of h-TAAD on quality of life and life choices, particularly around exercise and pregnancy, for affected individuals. This will be complemented by laboratory-based research that seeks to understand the tissue pathways that underlie development of arterial pathology, ideally providing targets for novel medical therapies and a means of non-invasively identifying individuals at increased vascular risk to reduce dissection, which remains a devastating life-threatening event.
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Róg B, Okólska M, Dziedzic-Oleksy H, Sałapa K, Rubiś P, Kopeć G, Podolec P, Tomkiewicz-Pająk L. Arterial stiffness in adult patients after coarctation of aorta repair and with bicuspid aortic valve. Acta Cardiol 2019; 74:517-524. [PMID: 30507296 DOI: 10.1080/00015385.2018.1530084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: The coarctation of aorta is commonly related to bicuspid aortic valve. The aim of the study was to assess arterial stiffness in adults after aortic coarctation repair and to evaluate an impact of bicuspid aortic valve concomitance on arterial stiffness results.Methods: Fifty-eight patients after coarctation of aorta repair, 36 male, median age of 27.46 ± 10.57, were compared to 30 with bicuspid aortic valve and to 30 healthy, sex, age and BMI matched volunteers. Physical examination, laboratory analysis and non-invasive assessment of arterial stiffness were performed.Results: CoA patients and BAV patients have higher central arterial stiffness parameters in comparison to healthy controls: AP (7.86 ± 6.56 vs 7.68 ± 5.96 vs 1.41 ± 3.82 mmHg, p < 0.001, p = 0.011, respectively) and AIx (18.81 ± 14.94 vs 18.06 ± 13.38 vs 4.41 ± 10.82%, p < 0.001, p = 0.006, respectively). There were no differences of PWV between CoA patients, BAV patients and healthy controls (6.07 ± 1.20 vs 5.95 ± 1.20 vs 5.67 ± 0.73 m/s, p = 0.099, p = 0.278, respectively). In CoA group, there was correlation of PWV with age (r = 0.55 p < 0.001), BMI (r = 0.29, p = 0.025), fibrinogen (r = 0.31, p = 0.039), glucose (r = 0.58, p < 0.001), ascending aorta diameter (r = 0.29, p = 0.026) and age at operation (r = 0.27, p = 0.041). Among group of BAV, there was a correlation of PWV with age (r = 0.58, p < 0.001), central AP with total cholesterol (r = 0.38, p = 0.036) and fibrinogen (r = 0.41, p = 0.024).Conclusions: The increased arterial stiffness occurs in both groups: patients after aortic coarctation repair and patients with bicuspid aortic valve. Concomitance of coarctation of the aorta and bicuspid aortic valve has no influence on arterial stiffness augmentation.
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Affiliation(s)
- Beata Róg
- Department of Cardiovascular Diseases, Cardiological Outpatient Clinic, John Paul II Hospital, Krakow, Poland
| | - Magdalena Okólska
- Department of Cardiovascular Diseases, Cardiological Outpatient Clinic, John Paul II Hospital, Krakow, Poland
| | - Hanna Dziedzic-Oleksy
- Department of Cardiovascular Diseases, Cardiological Outpatient Clinic, John Paul II Hospital, Krakow, Poland
| | - Kinga Sałapa
- Department of Bioinformatics and Telemedicine, Jagiellonian University, Krakow, Poland
| | - Paweł Rubiś
- Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Grzegorz Kopeć
- Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Piotr Podolec
- Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Lidia Tomkiewicz-Pająk
- Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
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Goudot G, Mirault T, Bruneval P, Soulat G, Pernot M, Messas E. Aortic Wall Elastic Properties in Case of Bicuspid Aortic Valve. Front Physiol 2019; 10:299. [PMID: 31024329 PMCID: PMC6467952 DOI: 10.3389/fphys.2019.00299] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/06/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose of the Review Bicuspid aortic valve (BAV) is associated with a significant risk of development of aneurysm and dissection of the ascending thoracic aorta. Development of what is called BAV associated aortopathy is particularly heterogeneous with an uncertain prognosis and with no prognostic biomarkers except for the aortic diameter. This situation leads to an important variability of the therapeutic strategy of this aortopathy. By reviewing the literature on aortic stiffness in the case of BAV, we aimed at evaluating its potential prognostic role in the development of aortic dilatation. Recent Findings Studies evaluating aortic stiffness, with ultrasound or magnetic resonance imaging, converge toward the description of an increased segmental aortic stiffness in BAV patients regardless of age, diameter or aortic level, from the root to the arch. Even though there is a lack of longitudinal studies evaluating the progression of aortic dilatation, new data have recently shown the potential prognostic role of the maximal rate of systolic distension of the aortic wall with magnetic resonance imaging. Summary Although the use of aortic distensibility calculation is a simple evaluation of stiffness that could be easily transposed in daily practice, its interpretation remains uncertain. New arterial stiffening indicators seem more promising but need a stronger validation.
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Affiliation(s)
- Guillaume Goudot
- INSERM U1273, ESPCI Paris, CNRS FRE 2031, Physics for Medicine Paris, PSL Research University, Paris, France
| | - Tristan Mirault
- Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.,INSERM U970 PARCC, Paris Descartes University - Sorbonne Paris Cité University, Paris, France
| | - Patrick Bruneval
- Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.,Service d'Anatomie Pathologique, Hôpital Européen Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Gilles Soulat
- Service de Radiologie Cardiovasculaire, Hôpital Européen Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Mathieu Pernot
- INSERM U1273, ESPCI Paris, CNRS FRE 2031, Physics for Medicine Paris, PSL Research University, Paris, France
| | - Emmanuel Messas
- Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.,INSERM U970 PARCC, Paris Descartes University - Sorbonne Paris Cité University, Paris, France
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23
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Humphrey JD, Tellides G. Central artery stiffness and thoracic aortopathy. Am J Physiol Heart Circ Physiol 2019; 316:H169-H182. [PMID: 30412443 PMCID: PMC6880196 DOI: 10.1152/ajpheart.00205.2018] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/22/2018] [Accepted: 10/31/2018] [Indexed: 12/20/2022]
Abstract
Thoracic aortopathy, especially aneurysm, dissection, and rupture, is responsible for significant morbidity and mortality. Uncontrolled hypertension and aging are primary risk factors for such conditions, and they contribute to an increase in the mechanical stress on the wall and an increase in its structural vulnerability, respectively. Select genetic mutations also predispose to these lethal conditions, and the collection of known mutations suggests that dysfunctional mechanosensing and mechanoregulation of the extracellular matrix may contribute to pathogenesis and disease progression. In the absence of a well-accepted pharmacotherapy, nonsurgical treatments tend to focus on reducing the mechanical loading on the aorta, particularly via the use of antihypertensive medications and recommendations to avoid strenuous exercises such as weight lifting. In this brief review, we discuss the important effects of central artery stiffening on global hemodynamics and, in particular, on the increase in pulse pressure that acts on the proximal thoracic aorta. We consider Marfan syndrome as an illustrative aortopathy but discuss other conditions leading to thoracic aortic aneurysm and dissection. We highlight the importance of phenotyping the aorta biomechanically, not just clinically, and emphasize the utility of mouse models in elucidating molecular and mechanical mechanisms of disease. Notwithstanding the widely recognized role of central artery stiffening in driving end-organ disease, we suggest that there is similarly a need to consider its key role in thoracic aortopathy.
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Affiliation(s)
- J. D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics Program, Yale University, New Haven, Connecticut
| | - G. Tellides
- Department of Surgery, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics Program, Yale University, New Haven, Connecticut
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24
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Local variations in material and structural properties characterize murine thoracic aortic aneurysm mechanics. Biomech Model Mechanobiol 2018; 18:203-218. [PMID: 30251206 DOI: 10.1007/s10237-018-1077-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 09/14/2018] [Indexed: 12/18/2022]
Abstract
We recently developed an approach to characterize local nonlinear, anisotropic mechanical properties of murine arteries by combining biaxial extension-distension testing, panoramic digital image correlation, and an inverse method based on the principle of virtual power. This experimental-computational approach was illustrated for the normal murine abdominal aorta assuming uniform wall thickness. Here, however, we extend our prior approach by adding an optical coherence tomography (OCT) imaging system that permits local reconstructions of wall thickness. This multimodality approach is then used to characterize spatial variations of material and structural properties in ascending thoracic aortic aneurysms (aTAA) from two genetically modified mouse models (fibrillin-1 and fibulin-4 deficient) and to compare them with those from angiotensin II-infused apolipoprotein E-deficient and wild-type control ascending aortas. Local values of stored elastic energy and biaxial material stiffness, computed from spatial distributions of the best fit material parameters, varied significantly with circumferential position (inner vs. outer curvature, ventral vs. dorsal sides) across genotypes and treatments. Importantly, these data reveal an inverse relationship between material stiffness and wall thickness that underlies a general linear relationship between stiffness and wall stress across aTAAs. OCT images also revealed sites of advanced medial degeneration, which were captured by the inverse material characterization. Quantification of histological data further provided high-resolution local correlations among multiple mechanical metrics and wall microstructure. This is the first time that such structural defects and local properties have been characterized mechanically, which can better inform computational models of aortopathy that seek to predict where dissection or rupture may initiate.
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25
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Bhave NM, Nienaber CA, Clough RE, Eagle KA. Multimodality Imaging of Thoracic Aortic Diseases in Adults. JACC Cardiovasc Imaging 2018; 11:902-919. [DOI: 10.1016/j.jcmg.2018.03.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/28/2022]
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26
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Loeper F, Oosterhof J, van den Dorpel M, van der Linde D, Lu Y, Robertson E, Hambly B, Jeremy R. Ventricular-Vascular Coupling in Marfan and Non-Marfan Aortopathies. J Am Heart Assoc 2016; 5:JAHA.116.003705. [PMID: 27852591 PMCID: PMC5210366 DOI: 10.1161/jaha.116.003705] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Marfan syndrome (MFS) and familial non–syndromal thoracic aortic aneurysm and dissection (ns‐TAAD) are genetic aortopathies causing aortic dilatation with increased aortic stiffness. Left ventricular (LV) contractility and ventricular‐vascular coupling index (VVI) were compared between MFS and ns‐TAAD and determinants of VVI were investigated. Methods and Results Patients with MFS (M 57, F 47) and ns‐TAAD (M 72, F 39) were studied by echocardiography and compared with controls (M 77, F 71). Aortic geometry, hemodynamics, LV work, LV contractility (end‐systolic elastance [Ees]), and VVI were documented. Aortic sinuses were equally dilated in MFS (19.7±2.4) and ns‐TAAD (19.8±1.8) compared to controls (16.2±1.4 mm·m−2, P<0.001). Aortic stiffness index was increased in MFS (9.7±5.1) and ns‐TAAD (10.8±4.7) versus controls (5.4±2.0, P<0.01); LV stroke work was unchanged in MFS (436±74) compared to controls (435±60) but increased in ns‐TAAD (492±109 mJ·m−2P<0.01). The LV Ees was reduced in MFS (1.32±0.19) compared to controls (1.65±0.29 mm Hg·mL−1, P<0.01) but increased in ns‐TAAD (1.83±0.30, P<0.01) and VVI was abnormal in MFS (0.71±0.11) compared to controls (0.62±0.07, P<0.01) and ns‐TAAD (0.62±0.09). Treatment with β‐blockers was associated with partial normalization of VVI in MFS. A VVI ≥0.8 was associated with increased risk of death and heart failure in MFS. Conclusions Left ventricular contractility and ventricular‐vascular coupling are abnormal in MFS but preserved in ns‐TAAD, and are independent of aortic stiffness, consistent with intrinsic impairment of myocardial contractility in MFS.
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Affiliation(s)
| | | | | | | | - Yaxin Lu
- Sydney Medical School, University of Sydney, Australia
| | | | - Brett Hambly
- Sydney Medical School, University of Sydney, Australia
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27
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Andelfinger G, Loeys B, Dietz H. A Decade of Discovery in the Genetic Understanding of Thoracic Aortic Disease. Can J Cardiol 2015; 32:13-25. [PMID: 26724507 DOI: 10.1016/j.cjca.2015.10.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/14/2015] [Accepted: 10/18/2015] [Indexed: 12/23/2022] Open
Abstract
Aortic aneurysms are responsible for a significant number of all deaths in Western countries. In this review we provide a perspective on the important progress made over the past decade in the understanding of the genetics of this condition, with an emphasis on the more frequent forms of vascular smooth muscle and transforming growth factor β (TGF-β) signalling alterations. For several nonsyndromic and syndromic forms of thoracic aortic disease, a genetic basis has now been identified, with 3 main pathomechanisms that have emerged: perturbation of the TGF-β signalling pathway, disruption of the vascular smooth muscle cell (VSMC) contractile apparatus, and impairment of extracellular matrix synthesis. Because smooth muscle cells and proteins of the extracellular matrix directly regulate TGF-β signalling, this latter pathway emerges as a key component of thoracic aortic disease initiation and progression. These discoveries have revolutionized our understanding of thoracic aortic disease and provided inroads toward gene-specific stratification of treatment. Last, we outline how these genetic findings are translated into novel pharmaceutical approaches for thoracic aortic disease.
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Affiliation(s)
- Gregor Andelfinger
- Cardiovascular Genetics, Department of Pediatrics, Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada.
| | - Bart Loeys
- Centre for Medical Genetics, University Hospital of Antwerp/University of Antwerp, Antwerp, Belgium; Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hal Dietz
- Howard Hughes Medical Institute and Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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28
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Padang R, Ganigara M, O'Meagher S, Grieve SM, Bannon PG, Celermajer DS, Jeremy R, Semsarian C, Puranik R. Feasibility of using real-time CMR imaging to evaluate acute thoracic aortic response to exercise. Int J Cardiol 2015; 197:306-8. [PMID: 26148771 DOI: 10.1016/j.ijcard.2015.05.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Ratnasari Padang
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia
| | - Madhusudan Ganigara
- Sydney Medical School, University of Sydney, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia
| | - Shamus O'Meagher
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia
| | - Stuart M Grieve
- Sydney Medical School, University of Sydney, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia; Department of Radiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul G Bannon
- Sydney Medical School, University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Richmond Jeremy
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Rajesh Puranik
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia.
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29
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Attenhofer Jost CH, Greutmann M, Connolly HM, Weber R, Rohrbach M, Oxenius A, Kretschmar O, Luscher TF, Matyas G. Medical treatment of aortic aneurysms in Marfan syndrome and other heritable conditions. Curr Cardiol Rev 2015; 10:161-71. [PMID: 24527681 PMCID: PMC4021286 DOI: 10.2174/1573403x1002140506124902] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 12/22/2013] [Accepted: 02/06/2014] [Indexed: 01/15/2023] Open
Abstract
Thoracic aortic
aneurysms can be triggered by genetic disorders such as Marfan syndrome (MFS)
and related aortic diseases as well as by inflammatory disorders such as giant
cell arteritis or atherosclerosis. In all these conditions, cardiovascular risk
factors, such as systemic arterial hypertension, may contribute to faster rate
of aneurysm progression. Optimal medical management to prevent progressive
aortic dilatation and aortic dissection is unknown. β-blockers have been the
mainstay of medical treatment for many years despite limited evidence of
beneficial effects. Recently, losartan, an angiotensin II type I receptor
antagonist (ARB), has shown promising results in a mouse model of MFS and
subsequently in humans with MFS and hence is increasingly used. Several ongoing
trials comparing losartan to β-blockers and/or placebo will better define the
role of ARBs in the near future. In addition, other medications, such as statins
and tetracyclines have demonstrated potential benefit in experimental aortic
aneurysm studies. Given the advances in our understanding of molecular
mechanisms triggering aortic dilatation and dissection, individualized
management tailored to the underlying genetic defect may be on the horizon of
individualized medicine. We anticipate that ongoing research will address the
question whether such genotype/pathogenesis-driven
treatments can replace current phenotype/syndrome-driven strategies and whether
other forms of aortopathies should be treated similarly. In this work, we review
currently used and promising medical treatment options for patients with
heritable aortic aneurysmal disorders.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gabor Matyas
- Cardiovascular Center Zurich, Klinik Im Park, Seestr. 220, CH-8027 Zurich, Switzerland.
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30
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Prakash A, Adlakha H, Rabideau N, Hass CJ, Morris SA, Geva T, Gauvreau K, Singh MN, Lacro RV. Segmental Aortic Stiffness in Children and Young Adults With Connective Tissue Disorders: Relationships With Age, Aortic Size, Rate of Dilation, and Surgical Root Replacement. Circulation 2015; 132:595-602. [PMID: 26115544 DOI: 10.1161/circulationaha.114.014934] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 06/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic diameter is an imperfect predictor of aortic complications in connective tissue disorders (CTDs). Novel indicators of vascular phenotype severity such as aortic stiffness and vertebral tortuosity index have been proposed. We assessed the relation between aortic stiffness by cardiac MRI, surgical root replacement, and rates of aortic root dilation in children and young adults with CTDs. METHODS AND RESULTS Retrospective analysis of cardiac MRI data on children and young adults with a CTD was performed to derive aortic stiffness measures (strain, distensibility, and β-stiffness index) at the aortic root, ascending aorta, and descending aorta. Vertebral tortuosity index was calculated as previously described. Rate of aortic root dilation before cardiac MRI was calculated as change in echocardiographic aortic root diameter z score per year. In 83 CTD patients (median age, 24 years; range, 1-55; 17% <18 years of age; 60% male), ascending aorta distensibility was reduced in comparison with published normative values: median z score, -1.93 (range, -8.7 to 1.3; P<0.0001 versus normals). Over a median follow-up period of 2.7 years, there were no aortic dissections or deaths, but 16 of 83 (19%) patients underwent surgical aortic root replacement. In multivariable analysis, lower aortic root strain (P=0.05) and higher vertebral tortuosity index (P=0.01) were independently associated with aortic root replacement. Lower ascending aorta strain (P=0.02) was associated with a higher rate of aortic root dilation. CONCLUSIONS Higher aortic stiffness is associated with higher rates of surgical aortic replacement and aortic root dilation in children and young adults with CTDs.
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Affiliation(s)
- Ashwin Prakash
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.).
| | - Himanshu Adlakha
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.)
| | - Nicole Rabideau
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.)
| | - Cara J Hass
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.)
| | - Shaine A Morris
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.)
| | - Tal Geva
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.)
| | - Kimberlee Gauvreau
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.)
| | - Michael N Singh
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.)
| | - Ronald V Lacro
- From Department of Cardiology, Boston Children's Hospital, MA (A.P., H.A., N.R., C.J.H., S.A.M., T.G., K.G., M.N.S., R.V.L); and Department of Pediatrics, Harvard Medical School, Boston, MA (A.P., T.G., M.N.S., R.V.L.)
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31
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Busnadiego O, Gorbenko Del Blanco D, González-Santamaría J, Habashi JP, Calderon JF, Sandoval P, Bedja D, Guinea-Viniegra J, Lopez-Cabrera M, Rosell-Garcia T, Snabel JM, Hanemaaijer R, Forteza A, Dietz HC, Egea G, Rodriguez-Pascual F. Elevated expression levels of lysyl oxidases protect against aortic aneurysm progression in Marfan syndrome. J Mol Cell Cardiol 2015; 85:48-57. [PMID: 25988230 DOI: 10.1016/j.yjmcc.2015.05.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 04/28/2015] [Accepted: 05/11/2015] [Indexed: 01/02/2023]
Abstract
Patients with Marfan syndrome (MFS) are at high risk of life-threatening aortic dissections. The condition is caused by mutations in the gene encoding fibrillin-1, an essential component in the formation of elastic fibers. While experimental findings in animal models of the disease have shown the involvement of transforming growth factor-β (TGF-β)- and angiotensin II-dependent pathways, alterations in the vascular extracellular matrix (ECM) may also play a role in the onset and progression of the aortic disease. Lysyl oxidases (LOX) are extracellular enzymes, which initiates the formation of covalent cross-linking of collagens and elastin, thereby contributing to the maturation of the ECM. Here we have explored the role of LOX in the formation of aortic aneurysms in MFS. We show that aortic tissue from MFS patients and MFS mouse model (Fbn1(C1039G/+)) displayed enhanced expression of the members of the LOX family, LOX and LOX-like 1 (LOXL1), and this is associated with the formation of mature collagen fibers. Administration of a LOX inhibitor for 8weeks blocked collagen accumulation and aggravated elastic fiber impairment, and these effects correlated with the induction of a strong and rapidly progressing aortic dilatation, and with premature death in the more severe MFS mouse model, Fbn1(mgR/mgR), without any significant effect on wild type animals. This detrimental effect occurred preferentially in the ascending portion of the aorta, with little or no involvement of the aortic root, and was associated to an overactivation of both canonical and non-canonical TGF-β signaling pathways. The blockade of angiotensin II type I receptor with losartan restored TGF-β signaling activation, normalized elastic fiber impairment and prevented the aortic dilatation induced by LOX inhibition in Fbn1(C1039G/+) mice. Our data indicate that LOX enzymes and LOX-mediated collagen accumulation play a critical protective role in aneurysm formation in MFS.
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Affiliation(s)
- O Busnadiego
- Centro de Biología Molecular "Severo Ochoa" Consejo Superior de Investigaciones Científicas (C.S.I.C.)/Universidad Autónoma de Madrid (Madrid), Madrid, Spain
| | - D Gorbenko Del Blanco
- Departamento de Biología Celular, Inmunología y Neurociencias, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - J González-Santamaría
- Centro de Biología Molecular "Severo Ochoa" Consejo Superior de Investigaciones Científicas (C.S.I.C.)/Universidad Autónoma de Madrid (Madrid), Madrid, Spain
| | - J P Habashi
- Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J F Calderon
- Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P Sandoval
- Centro de Biología Molecular "Severo Ochoa" Consejo Superior de Investigaciones Científicas (C.S.I.C.)/Universidad Autónoma de Madrid (Madrid), Madrid, Spain
| | - D Bedja
- Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Guinea-Viniegra
- Fundación Banco Bilbao Vizcaya-CNIO Cancer Cell Biology Program, Centro Nacional de Investigaciones Oncológicas, Madrid, Spain
| | - M Lopez-Cabrera
- Centro de Biología Molecular "Severo Ochoa" Consejo Superior de Investigaciones Científicas (C.S.I.C.)/Universidad Autónoma de Madrid (Madrid), Madrid, Spain
| | - T Rosell-Garcia
- Centro de Biología Molecular "Severo Ochoa" Consejo Superior de Investigaciones Científicas (C.S.I.C.)/Universidad Autónoma de Madrid (Madrid), Madrid, Spain
| | - J M Snabel
- TNO Metabolic Health Research, Leiden, The Netherlands
| | - R Hanemaaijer
- TNO Metabolic Health Research, Leiden, The Netherlands
| | - A Forteza
- Hospital Universitario 12 de Octubre, Unidad de Marfan, Madrid, Spain
| | - H C Dietz
- Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G Egea
- Departamento de Biología Celular, Inmunología y Neurociencias, Facultad de Medicina, Universidad de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - F Rodriguez-Pascual
- Centro de Biología Molecular "Severo Ochoa" Consejo Superior de Investigaciones Científicas (C.S.I.C.)/Universidad Autónoma de Madrid (Madrid), Madrid, Spain.
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32
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Crosas-Molist E, Meirelles T, López-Luque J, Serra-Peinado C, Selva J, Caja L, Gorbenko Del Blanco D, Uriarte JJ, Bertran E, Mendizábal Y, Hernández V, García-Calero C, Busnadiego O, Condom E, Toral D, Castellà M, Forteza A, Navajas D, Sarri E, Rodríguez-Pascual F, Dietz HC, Fabregat I, Egea G. Vascular smooth muscle cell phenotypic changes in patients with Marfan syndrome. Arterioscler Thromb Vasc Biol 2015; 35:960-72. [PMID: 25593132 DOI: 10.1161/atvbaha.114.304412] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Marfan's syndrome is characterized by the formation of ascending aortic aneurysms resulting from altered assembly of extracellular matrix microfibrils and chronic tissue growth factor (TGF)-β signaling. TGF-β is a potent regulator of the vascular smooth muscle cell (VSMC) phenotype. We hypothesized that as a result of the chronic TGF-β signaling, VSMC would alter their basal differentiation phenotype, which could facilitate the formation of aneurysms. This study explores whether Marfan's syndrome entails phenotypic alterations of VSMC and possible mechanisms at the subcellular level. APPROACH AND RESULTS Immunohistochemical and Western blotting analyses of dilated aortas from Marfan patients showed overexpression of contractile protein markers (α-smooth muscle actin, smoothelin, smooth muscle protein 22 alpha, and calponin-1) and collagen I in comparison with healthy aortas. VSMC explanted from Marfan aortic aneurysms showed increased in vitro expression of these phenotypic markers and also of myocardin, a transcription factor essential for VSMC-specific differentiation. These alterations were generally reduced after pharmacological inhibition of the TGF-β pathway. Marfan VSMC in culture showed more robust actin stress fibers and enhanced RhoA-GTP levels, which was accompanied by increased focal adhesion components and higher nuclear localization of myosin-related transcription factor A. Marfan VSMC and extracellular matrix measured by atomic force microscopy were both stiffer than their respective controls. CONCLUSIONS In Marfan VSMC, both in tissue and in culture, there are variable TGF-β-dependent phenotypic changes affecting contractile proteins and collagen I, leading to greater cellular and extracellular matrix stiffness. Altogether, these alterations may contribute to the known aortic rigidity that precedes or accompanies Marfan's syndrome aneurysm formation.
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Affiliation(s)
- Eva Crosas-Molist
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Thayna Meirelles
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Judit López-Luque
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Carla Serra-Peinado
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Javier Selva
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Laia Caja
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Darya Gorbenko Del Blanco
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Juan José Uriarte
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Esther Bertran
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Yolanda Mendizábal
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Vanessa Hernández
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Carolina García-Calero
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Oscar Busnadiego
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Enric Condom
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - David Toral
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Manel Castellà
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Alberto Forteza
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Daniel Navajas
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Elisabet Sarri
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Fernando Rodríguez-Pascual
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Harry C Dietz
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Isabel Fabregat
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.)
| | - Gustavo Egea
- From the Department of Cell Biology, Immunology and Neurosciences (E.C.-M., T.M., C.S.-P, J.S., D.G, Y.M., V.H., E.S., G.E.), Departments of Physiological Sciences I (J.J.U., D.N.) and Physiological Sciences II (I.F.), Department of Pathology and Experimental Therapeutics (E.C.), University of Barcelona School of Medicine, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (M.C., G.E.); Institut de Nanociència i Nanotecnologia (IN2UB), Barcelona, Spain (G.E.); Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain and CIBER de Enfermedades Respiratorias (CIBERES) (D.N.); Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil (T.M.); Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain (E.C.-M., J.L.-L. L.C., E.B., I.F.); Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain (O.B., F.R.-P.); Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain (C.G.-C., E.C., D.T.); Cardiovascular Surgery Department, Hospital Clínic i Provincial, Barcelona, Spain (M.C.); Cardiac Surgery Department, Marfan Syndrome Unit, Hospital Universitario 12 de Octubre, Madrid, Spain (A.F.); and William S. Smilow Center for Marfan Syndrome Research, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD (H.C.D.).
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Rabkin SW, Chan KK, Chow B, Janusz MT. Pulse wave velocity involving proximal portions of the aorta correlates with the degree of aortic dilatation at the sinuses of valsalva in ascending thoracic aortic aneurysms. Ann Vasc Dis 2015; 7:404-9. [PMID: 25593626 DOI: 10.3400/avd.oa.14-00063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 10/06/2014] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To determine the relationship between arterial stiffness measured in different aortic segments and the presence and extent of ascending thoracic aortic aneurysm (ATAA). METHODS Patients at a Thoracic Aortic Diseases clinic at a University teaching hospital were compared to patients attending a Cardiology outpatient Clinic at the same institution. A non-invasive measure of vascular stiffness was performed using pulse wave velocity (PWV) measurement of several vascular segments-carotid-femoral pulse wave velocity (cfPWV), heart-femoral pulse wave velocity (hfPWV) and brachial-ankle pulse wave velocity (baPWV). Aortic dimensions were measured on echocardiogram. RESULTS Patients with ATAA (N = 32) were 66 years and the same age as those without ATAA (N = 46). There was no significant difference between those with or without aortic aneurysm with respect to cfPWV, hfPWV or baPWV. In ATAA, there was a significant (p <0.05) inverse correlation between aortic diameter at the sinuses of Valsalva and cfPWV, as well as hfPWV, but not with baPWV. This relationship was not evident in persons without ATAA. CONCLUSION Reduced aortic stiffness (increased compliance), assessed by cfPWV or hfPWV, correlates with larger aortic size of ATAA at the level of the sinuses of Valsalva but not at the ascending aorta, suggesting cfPWV may be a useful method to assess the size of ATAA at the level of the sinuses of Valsalva. Overall aortic stiffness assessed by PWV did not differentiate persons with or without an ATAA, in individuals who do not have a genetic or inheritable cause of their ATAA.
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Affiliation(s)
- Simon W Rabkin
- Department of Medicine, University of British Columbia , Vancouver, Canada
| | - Kenneth K Chan
- Department of Medicine, University of British Columbia , Vancouver, Canada
| | - Bryan Chow
- Department of Medicine, University of British Columbia , Vancouver, Canada
| | - Michael T Janusz
- Department of Surgery, University of British Columbia , Vancouver, Canada
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Bellini C, Wang S, Milewicz DM, Humphrey JD. Myh11(R247C/R247C) mutations increase thoracic aorta vulnerability to intramural damage despite a general biomechanical adaptivity. J Biomech 2014; 48:113-21. [PMID: 25433566 DOI: 10.1016/j.jbiomech.2014.10.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/21/2014] [Accepted: 10/24/2014] [Indexed: 01/03/2023]
Abstract
Genetic studies in patients reveal that mutations to genes that encode contractile proteins in medial smooth muscle cells can cause thoracic aortic aneurysms and dissections. Mouse models of such mutations, including Acta2(-/-) and Myh11(R247C/R247C), surprisingly do not present with any severe vascular phenotype under normal conditions. This observation raises the question whether these mutations nevertheless render the thoracic aorta increasingly vulnerable to aneurysms or dissections in the presence of additional, epigenetic, factors such as hypertension, a known risk factor for thoracic aortic disease. Accordingly, we compared the structure and biaxial mechanical properties of the ascending and descending thoracic aorta from male wild-type and Myh11(R247C/R247C) mice under normotension and induced hypertension. On average, the mutant aortas exhibited near normal biomechanics under normotensive hemodynamics and near normal adaptations to hypertensive hemodynamics, yet the latter led to intramural delaminations or premature deaths in over 20% of these mice. Moreover, the delaminated vessels exhibited localized pools of mucoid material, similar to the common histopathologic characteristic observed in aortas from humans affected by thoracic aortic aneurysms and dissections. The present findings suggest, therefore, that mutations to smooth muscle cell contractile proteins may place the thoracic aorta at increased risk to epigenetic factors and that there is a need to focus on focal, not global, changes in aortic structure and properties, including the pooling of glycosaminoglycans/proteoglycans that may lead to thoracic aortic dissection.
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Affiliation(s)
- Chiara Bellini
- Department of Biomedical Engineering, Yale University, New Haven, CT, 06511, USA.
| | - Shanzhi Wang
- Department of Internal Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Dianna M Milewicz
- Department of Internal Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, 06511, USA
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Affiliation(s)
- Subodh Verma
- From the Division of Cardiac Surgery, St. Michael's Hospital, Department of Surgery, University of Toronto, Toronto (S.V.), and the Division of Cardiology, Department of Medicine, Lawson Research Institute, London Health Sciences Centre, Western University, London, ON (S.C.S.) - both in Canada
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Roccabianca S, Figueroa C, Tellides G, Humphrey J. Quantification of regional differences in aortic stiffness in the aging human. J Mech Behav Biomed Mater 2014; 29:618-34. [PMID: 23499251 PMCID: PMC3842391 DOI: 10.1016/j.jmbbm.2013.01.026] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/28/2013] [Accepted: 01/30/2013] [Indexed: 01/29/2023]
Abstract
There has been a growing awareness over the past decade that stiffening of the aorta, and its attendant effects on hemodynamics, is both an indicator and initiator of diverse cardiovascular, neurovascular, and renovascular diseases. Although different clinical metrics of arterial stiffness have been proposed and found useful in particular situations, there remains a need to understand better the complex interactions between evolving aortic stiffness and the hemodynamics. Computational fluid-solid-interaction (FSI) models are amongst the most promising means to understand such interactions for one can parametrically examine effects of regional variations in material properties and arterial geometry on local and systemic blood pressure and flow. Such models will not only increase our understanding, they will also serve as important steps towards the development of fluid-solid-growth (FSG) models that can further examine interactions between the evolving wall mechanics and hemodynamics that lead to arterial adaptations or disease progression over long periods. In this paper, we present a consistent quantification and comparison of regional nonlinear biaxial mechanical properties of the human aorta based on 19 data sets available in the literature and we calculate associated values of linearized stiffness over the cardiac cycle that are useful for initial large-scale FSI and FSG simulations. It is shown, however, that there is considerable variability amongst the available data and consequently that there is a pressing need for more standardized biaxial testing of the human aorta to collect data as a function of both location and age, particularly for young healthy individuals who serve as essential controls.
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Affiliation(s)
- S. Roccabianca
- Department of Biomedical Engineering, Yale University, New Haven, CT 06520-8260, USA
| | - C.A. Figueroa
- Department of Bioengineering, King’s College London, England, SE1 8WA, UK
| | - G. Tellides
- Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT 06510, USA
| | - J.D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT 06520-8260, USA
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT 06510, USA
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Kallenbach K, Sundt TM, Marwick TH. Aortic Surgery for Ascending Aortic Aneurysms Under 5.0 cm in Diameter in the Presence of Bicuspid Aortic Valve. JACC Cardiovasc Imaging 2013; 6:1321-6. [DOI: 10.1016/j.jcmg.2013.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 08/27/2013] [Indexed: 11/15/2022]
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Della Corte A, Bancone C, Buonocore M, Dialetto G, Covino FE, Manduca S, Scognamiglio G, D'Oria V, De Feo M. Pattern of Ascending Aortic Dimensions Predicts the Growth Rate of the Aorta in Patients With Bicuspid Aortic Valve. JACC Cardiovasc Imaging 2013; 6:1301-10. [DOI: 10.1016/j.jcmg.2013.07.009] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 07/18/2013] [Indexed: 11/29/2022]
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Jeremy RW, Robertson E, Lu Y, Hambly BD. Perturbations of mechanotransduction and aneurysm formation in heritable aortopathies. Int J Cardiol 2013; 169:7-16. [PMID: 24016541 DOI: 10.1016/j.ijcard.2013.08.056] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 08/18/2013] [Indexed: 12/20/2022]
Abstract
Thoracic aortic aneurysm and dissection in young and middle aged patients is increasingly recognised as due to genetic aortopathy. Mutations in multiple genes affecting proteins in the extracellular matrix, microfibrillar structure, the endothelium and cell signalling pathways have been associated with thoracic aortic disease. The TGFß signalling pathway appears to play a key role in mediating abnormal aortic growth and aneurysm formation. A challenge remains in understanding how the many different gene mutations can result in deranged TGFß signalling. This review examines the functional relationships between key structural and signalling proteins, with reference to the need for maintenance of homeostasis in mechanotransduction within the aortic wall. A mechanism, through which perturbations in mechanotransduction, arising from different gene mutations, results in altered TGFß signalling is described.
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Verma S, Yanagawa B, Kalra S, Ruel M, Peterson MD, Yamashita MH, Fagan A, Currie ME, White CW, Wai Sang SL, Rosu C, Singh S, Mewhort H, Gupta N, Fedak PWM. Knowledge, attitudes, and practice patterns in surgical management of bicuspid aortopathy: a survey of 100 cardiac surgeons. J Thorac Cardiovasc Surg 2013; 146:1033-1040.e4. [PMID: 23988289 DOI: 10.1016/j.jtcvs.2013.06.037] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 06/10/2013] [Accepted: 06/27/2013] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Clinical practice guidelines have been established for surgical management of the aorta in bicuspid aortic valve disease. We hypothesized that surgeons' knowledge of and attitudes toward bicuspid aortic valve aortopathy influence their surgical approaches. METHODS We surveyed cardiac surgeons to probe the knowledge of, attitudes toward, and surgical management of bicuspid aortopathy. A total of 100 Canadian adult cardiac surgeons participated. RESULTS Fifty-two percent of surgeons believed that the mechanism underlying aortic dilation in those with bicuspid aortic valve was due to an inherent genetic abnormality of the aorta, whereas only 2% believed that altered valve-related processes were involved in this process. Only a minority (15%) believed that bicuspid valve leaflet fusion type is associated with a unique pattern of aortic dilatation aortic phenotype. Sixty-five percent of surgeons recommended echocardiographic screening of first-degree relatives of patients with bicuspid aortic valve. Most surgeons (61%) elected to replace the aorta when the diameter is 45 mm or greater at the time of valve surgery. Fifty-five percent of surgeons surveyed suggested that in the absence of concomitant valvular disease, they would recommend ascending aortic replacement at a threshold of 50 mm or greater. Approximately one third of surgeons suggested that they would elect to replace a mildly dilated ascending aorta (40 mm) at the time of valve surgery. The most common surgical approach (61%) for combined valve and aortic surgery was aortic valve replacement and supracoronary replacement of the ascending aorta, and only a minority suggested the use of deep hypothermic circulatory arrest and open distal anastomosis. More aggressive approaches were favored with greater surgeon experience, and when circulatory arrest was chosen, the majority (68%) suggested they would use antegrade cerebral perfusion. In the setting of aortic insufficiency and a dilated aorta, 42% of surgeons suggested that they would perform valve-sparing surgery. Of note, 40% of respondents used an index measure of aortic size to body surface area in addition to absolute aortic diameter in assessing the threshold for intervention. CONCLUSIONS This large survey uncovered significant gaps in the knowledge and attitudes of surgeons toward the diagnosis and management of bicuspid aortopathy, many of which were at odds with current guideline recommendations. Efforts to promote knowledge translation in this area are strongly encouraged.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Predicting increased risk of aortic dissection. Heart Lung Circ 2012; 22:1-2. [PMID: 23219313 DOI: 10.1016/j.hlc.2012.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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