2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine

Aortic events and relative survival in patients with moderately dilated proximal thoracic aorta

Objectives. This study describes growth, local and remote aortic events, and survival in patients with proximal (root, ascending) aortic diameters just below threshold for operation. Methods. Patients with proximal aortic diameter of 4.5 to 5.4 cm at baseline, were followed with serial computed tomography studies and data collected retrospectively. Aortic growth rate was estimated using mixed effects modelling. Clinical and radiological features associated with outcomes (all-cause death, aortic death, local or remote aortic events (dissection, rupture, intramural hematoma, or intervention)) were assessed with Cox analysis. Survival and freedom from events were estimated using Kaplan-Meier methods. Results. 80 patients underwent 274 CT scans during 265 patient-years. Median proximal aortic growth was 0.2 cm in 3 years. 32 events occurred in 28 patients (35%). Eleven events were local, all elective proximal aortic surgery. Nine events were remote: 5 type B aortic dissections, 3 descending aneurysms undergoing elective repair, and one infrarenal aortic rupture. Twelve patients died, half of type B aortic dissection. Relative survival compared to a matched normal population was 82% (95% confidence limits 55-98%) at 10 years. In Cox analysis, increased descending aortic diameter was an independent predictor of all-cause death (hazard ratio [HR], 1.39) and aortic death (HR 1.96). Conclusions. Descending, but not proximal, aortic growth was predictive of lethal events. The decreased relative survival, the substantial number of remote aortic events and aortic deaths strongly suggest continuous serial CT surveillance of the entire aorta. Other indicators than proximal aortic diameter appear needed to improve management of this patient group.

Effect of stress-induced hyperglycemia on long-term mortality in non-diabetic patients with acute type A aortic dissection: a retrospective analysis

BACKGROUND

Acute Type A Aortic Dissection (AAAD) is one of the most life-threatening diseases, often associated with transient hyperglycemia induced by acute physiological stress. The impact of stress-induced hyperglycemia on the prognosis of ST-segment elevation myocardial infarction has been reported. However, the relationship between stress-induced hyperglycemia and the prognosis of AAAD patients remains uncertain.

METHODS

The clinical data of 456 patients with acute type A aortic dissection were retrospectively reviewed. Patients were divided into two groups based on their admission blood glucose. Cox model regression analysis was performed to assess the relationship between stress-induced hyperglycemia and the 30-day and 1-year mortality rates of these patients.

RESULTS

Among the 456 patients, 149 cases (32.7%) had AAAD combined with stress-induced hyperglycemia (SIH). The results of the multifactor regression analysis of the Cox model indicated that hyperglycemia (RR = 1.505, 95% CI: 1.046-2.165, p = 0.028), aortic coarctation involving renal arteries (RR = 3.330, 95% CI: 2.237-4.957, p < 0.001), aortic coarctation involving superior mesenteric arteries (RR = 1.611, 95% CI: 1.056-2.455, p = 0.027), and aortic coarctation involving iliac arteries (RR = 2.034, 95% CI: 1.364-3.035, p = 0.001) were independent influences on 1-year postoperative mortality in AAAD patients.

CONCLUSION

The current findings indicate that stress-induced hyperglycemia measured on admission is strongly associated with 1-year mortality in patients with AAAD. Furthermore, stress-induced hyperglycemia may be related to the severity of the condition in patients with AAAD.

Intra- and Early Post-Operative Factors Affecting Spinal Cord Ischemia in Patients Undergoing Fenestrated and Branched Endovascular Aortic Repair

Background: Spinal cord ischemia (SCI) is a severe complication after fenestrated/branched endovascular repair (f/bEVAR). The underlying causes of SCI are still under investigation. This study aimed to evaluate intra- and early post-operative parameters that may affect SCI evolution. Methods: A single-center retrospective analysis was conducted including SCI patients with complete anesthesiologic records (1 January 2011 to 31 December 2023). Values of intra-operative glucose, hemoglobin, lactate, activated clotting time (ACT), and the need for transfusion were collected. The cohort was compared to a matched cohort of non-SCI patients. Results: Fifty-one patients with SCI and complete anesthesiologic records were included (mean age: 69.8 ± 6.2 years; 39.2% male). Intra-operative glucose value < 110 mg/dL (AUC: 0.73; sensitivity 91%, specificity of 83%) and hemoglobin value > 8.5 mg/dL (AUC: 0.61; sensitivity 83%, specificity 78%) were protective for Grade 3 SCI. Twenty-three patients with SCI were matched to 23 patients without SCI. SCI patients presented significantly higher glucose levels intra-operatively (glucose mean value: SCI 150 ± 46 mg/dL vs. non-SCI: 122 ± 30 mg/dL, p = 0.005). ACT (SCI 259 ± 31 svs. non-SCI 288 ± 28 s, p = 0.001), volume input (SCI 4030 ± 1430 mL vs. non-SCI 3020 ± 113 mL, p = 0.009), and need for transfusion (SCI: 52.5% vs. 4.3%, p < 0.001) were related to SCI. Higher glucose levels were detected among patients with SCI, at 24 (SCI: 142 ± 30 mg/dL vs. non-SCI: 118 ± 26 mg/dL, p=0.004) and 48 h (SCI: 140 ± 29 mg/dL vs. non-SCI: 112 ± 20 mg/dL, p < 0.001) post-operatively. Conclusions: SCI is a multifactorial complication after f/bEVAR. Intra-operative and early post-operative glucose levels may be related to SCI evolution. Targeted glucose < 110 mg/dL may be protective for Grade 3 SCI.

Losing, regaining, and continuing to build self-confidence - a qualitative, phenomenological study of being physically active with a type B aortic dissection

PURPOSE

To gain a comprehensive understanding of experiences related to being physically active in participants with an uncomplicated type B aortic dissection.

MATERIALS AND METHODS

We performed a qualitative, phenomenological study. First-person accounts of adults, who at least one year ago had an uncomplicated type B aortic dissection, were collected using semi-structured interviews. The audio recordings of the interviews were transcribed verbatim and analyzed with interpretative phenomenological analysis.

RESULTS

We collected, in total, 644 min interview data from 14 participants. Three patterns were interpreted: losing self-confidence, regaining self-confidence, and continuing to build self-confidence. Experiencing symptoms when pushing limits, challenges with energy management, and side effects of medication caused loss of self-confidence. Changes in identity, reaching milestones that reflect improvement, and support from others and tools helped participants regain self-confidence. To continuing to build self-confidence, participants indicated they needed success experiences and activities make life worth living.

CONCLUSIONS

Self-confidence in adults with an uncomplicated type B aortic dissection changes immediately after the diagnosis of the aortic dissection. Rehabilitation professionals can support adults regaining and continuing to build self-confidence, aiming for the perfect balance between blood pressure regulation, quality of life, and being physically active.Implications for rehabilitationRehabilitation professionals should support regaining and continuing to build self-confidence related to being physically active in adults with type B aortic dissection in the early stages of recovery and beyond.Adults with an uncomplicated type B aortic dissection want rehabilitation professionals to tell them primarily what is possible (recommendations) rather than what is not allowed (rules).Rehabilitation professionals should help adults with an uncomplicated type B aortic dissection to explore, push and, ultimately, accept limits related to exercise tolerance.

Cardiovascular pathology, inheritance and prognosis in a familial cohort of Loeys-Dietz type III

INTRODUCTION

Loeys-Dietz syndrome (LDS) is a heritable disease that is the result of dysregulation of the transforming growth factor beta (TGFβ) pathway. The pathogenic variants associated with the condition are linked to aortic aneurysms and dissections along with other cardiovascular and non-cardiovascular abnormalities. LDS type III is associated with pathogenic variants in the SMAD3 gene responsible for signally in the TGFβ pathway. Most of the current knowledge of LDS stems from studies of LDS I and II patient with limited data on large cohorts of LDS III patients. We sought to identify the prevalence and course of cardiovascular diseases in a large familial cohort of LDS III patients and also to compare these findings with a previously described cohort of similar size with the identical pathogenic variant.

METHODS

The cohort was identified by systematic genetic screening of a familial cohort identified through a single proband. Data was collected from retrospective chart review of patients identified to be affected by the syndrome.

RESULTS

Screening of 97 patients identified 19 patients (16 through genetic testing and 3 through phenotypic screening of untested direct descendants of genetically positive individuals). The prevalence of cardiovascular abnormalities was 84%. There was significant intrafamilial phenotypic variability within the cohort with the predominant cardiovascular abnormality being mitral valve disease followed by aortic disease. 92% of patients >18 years of age had osteoarthritis which is a further hallmark of LDS III.

CONCLUSION

LDS III sets itself apart from the more widely studied LDS types I and II cardiovascular phenotypes by presenting later in life and tending to be more strongly associated with mitral valve disease.

Optimal antiplatelet therapy after revascularization of left subclavian artery during TEVAR

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is required when treating patients with involvement of LSA. The best antiplatelet therapy after LSA reconstruction is presently uncertain.

METHODS

This study retrospectively analyzed 245 type B aortic dissection patients who underwent left subclavian artery revascularization during TEVAR. Out of 245 patients, 159 (64.9%) were in the single antiplatelet therapy (SAPT) group, receiving only aspirin, and 86 (35.1%) were in the dual antiplatelet therapy (DAPT) group, receiving aspirin combined with clopidogrel. During the 6-month follow-up, primary endpoints included hemorrhagic events (general bleeding and hemorrhagic strokes), while secondary endpoints comprised ischemic events (left upper limb ischemia, ischemic stroke, and thrombotic events), as well as death and leakage events. Both univariate and multivariate Cox regression analyses were performed on hemorrhagic and ischemic events, with the Kaplan-Meier method used to generate the survival curve.

RESULTS

During the six-month follow-up, the incidence of hemorrhagic events in the DAPT group was higher (8.2% vs. 30.2%, P < 0.001). No significant differences were observed in ischemic events, death, or leakage events among the different antiplatelet treatment schemes. Multivariate Cox regression analysis showed that DAPT (HR: 2.22, 95% CI: 1.07-4.60, P = 0.032) and previous chronic conditions (HR:3.88, 95% CI: 1.24-12.14, P = 0.020) significantly affected the occurrence of hemorrhagic events. Chronic conditions in this study encompassed depression, vitiligo, and cholecystolithiasis. Carotid subclavian bypass (CSB) group (HR:0.29, 95% CI: 0.12-0.68, P = 0.004) and single-branched stent graft (SBSG) group (HR:0.26, 95% CI: 0.13-0.50, P < 0.001) had a lower rate of ischemic events than fenestration TEVAR (F-TEVAR). Survival analysis over 6 months revealed a lower risk of bleeding associated with SAPT during hemorrhagic events (P = 0.043).

CONCLUSIONS

In type B aortic dissection patients undergoing LSA blood flow reconstruction after synchronous TEVAR, the bleeding risk significantly decreases with the SAPT regimen, and there is no apparent ischemic compensation within 6 months. Patients with previous chronic conditions have a higher risk of bleeding. The CSB group and SBSG group have less ischemic risk compared to F-TEVAR group.

Differential impacts of clinical, anatomical, and procedural factors on early and late mortality following open thoracoabdominal aortic repair: a retrospective observational study

BACKGROUND

The operative outcomes of thoracoabdominal aortic aneurysms (TAAAs) are challenged by high operative mortality and disabling complications. This study aimed to explore the baseline clinical, anatomical, and procedural risk factors that impact early and late outcomes following open repair of TAAAs.

METHODS

We reviewed the medical records of 290 patients who underwent open repair of TAAAs between 1992 and 2020 at a tertiary referral center. Determinants of early mortality (within 30 days or in hospital) were analyzed using multivariable logistic regression models, while those of overall follow-up mortality were explored using multivariable Cox proportional hazards models and landmark analyses.

RESULTS

The rates of early mortality and spinal cord deficits were 13.1% and 11.0%, respectively, with Crawford extent II showing the highest rates. In the logistic regression models, older age (P < 0.001), high cardiopulmonary bypass (CPB) time (P < 0.001), and low surgical volume of the surgeon (P < 0.001) emerged as independent factors significantly associated with early mortality. During follow-up (median, 5.0 years; interquartile range, 1.1-7.6 years), 82 late deaths occurred (5.7%/patient-year). Cox proportional hazards models demonstrated that older age (P < 0.001) and low hemoglobin level (P = 0.032) were significant risk factors of overall mortality, while the landmark analyses revealed that the significant impacts of low surgical volume (P = 0.017), high CPB time (P = 0.002), and Crawford extent II (P = 0.017) on mortality only remained in the early postoperative period, without significant late impacts (all P > 0.05).

CONCLUSION

There were differential temporal impacts of perioperative risk variables on mortality in open repair of TAAAs, with older age and low hemoglobin level having significant impacts throughout the postoperative period, and low surgical volume, high CPB time, and Crawford extent II having impacts in the early postoperative phase.

CT angiography prior to endovascular procedures: can artificial intelligence improve reporting?

CT angiography prior to endovascular aortic surgery is the standard non-invasive imaging method for evaluation of aortic dimensions and access sites. A detailed report is crucial to a proper planning. We assessed Artificial Intelligence (AI)-algorithm accuracy to measure vessels diameters at CT prior to transcatheter aortic valve implantation (TAVI). CT scans of 50 patients were included. Two Radiologists with experience in vascular imaging together manually assessed diameters at nine landmark positions according to the American Heart Association guidelines: 450 values were obtained. We implemented TOST (Two One-Sided Test) to determine whether the measurements were equivalent to the values obtained from the AI algorithm. When the equivalence bound was a range of ± 2 mm the test showed equivalence for every point; if the range was equal to ± 1 mm the two measurements were not equivalent in 6 points out of 9 (p-value > 0.05), close to the aortic valve. The time for automatic evaluation (average 1 min 47 s) was significantly lower compared with manual measurements (5 min 41 s) (p < 0.01). In conclusion, our results indicate that AI-algorithms can measure aortic diameters at CT prior to endovascular surgery with high accuracy. AI-assisted reporting promises high efficiency, reduced inter-reader variabilities and time saving. In order to perform optimal TAVI procedure planning aortic root analysis could be improved, including annulus dimensions.

Incidence, Predictors, and Implications of Secondary Aortic Intervention Following Thoracic Endovascular Aortic Repair for Type B Dissection

BACKGROUND

Secondary aortic intervention (SAI) following thoracic endovascular aortic repair (TEVAR) is not uncommon. However, a satisfactory management system has not been established for these patients. We aimed to report our single-center experience with SAI after prior TEVAR for type B aortic dissection (TBAD).

METHODS

From January 2010 to May 2017, 860 eligible patients with TBAD underwent TEVAR. One hundred seven (12.4%) patients required SAI, either endovascularly (n=76) or surgically (n=31). The main indications for SAI were entry flow (n=58 [54.2%]), aneurysm expansion of the proximal or remote aorta (n=26 [24.3%]), retrograde type A aortic dissection (n=11 [10.3%]), distal stent-graft-induced new entry tear (n=6 [5.6%]), and stent migration (n=4 [3.7%]). The Kaplan-Meier curves were generated to determine the degree of freedom from SAI and the prognosis. Cox proportional hazards were used to screen for risk factors for SAI and poor prognosis.

RESULTS

The overall 30-day mortality rate after SAI was 4.7% (n=5): endovascular (n=2 [2.6%]) vs open surgery (n=3 [9.7%]; p=0.145). The cumulative survival rates with or without SAI were 86.3%±3.6% vs 95.7%±0.8% at 3 years and 82.0%±4.2% vs 92.2%±1.1% at 5 years, respectively (log-rank p<0.001). Although no significant difference in survival was observed, the incidence of SAI was significantly greater in patients who underwent TEVAR during the chronic phase (acute [11.6%] vs subacute [9.6%] vs chronic [27.8]; p<0.001). Multivariate regression analysis revealed that prior TEVAR in the chronic phase (hazard ratio [HR]=1.73, 95% confidence interval [CI]=1.03-2.90; p=0.039), maximum aortic diameter (HR=1.05, 95% CI=1.04-1.07; p<0.001), and arch involvement (HR=1.48, 95% CI=1.01-2.18; p=0.048) were predictors of the incidence of SAI. In addition, the maximum aortic diameter was demonstrated to be the only risk factor for prognosis after adjusting for confounding factors.

CONCLUSIONS

Thoracic endovascular aortic repair for chronic TBAD patients should be reconsidered. Open surgery is preferable for those with proximal progression, whereas endovascular treatment is more suitable for distal lesions. Close surveillance and timely reintervention after TEVAR, whether via endovascular techniques or open surgery, are necessary to prevent devastating complications.

CLINICAL IMPACT

The management of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR) is challenging. We summarized our single-center experience regarding secondary aortic intervention after TEVAR for TBAD. We found that TEVAR for chronic TBAD patients should be carefully evaulated, and open surgery is recommended for those with proximal progession, while endovascular treatment is more preferable for distal lesions.

Combined blood pressure and heart rate trajectories are associated with prognosis in critically ill patients with acute aortic dissection: A group-based multi-trajectory analysis

Background

Managing systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) is pivotal in acute aortic dissection (AAD) care. However, no prior studies have jointly analyzed the trajectories of these parameters. This research aimed to characterize their joint longitudinal trajectories and investigate the influence on AAD prognosis.

Methods

We included AAD patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Using group-based multi-trajectory modeling (GBMTM), we identified combined trajectories of SBP, DBP, and HR within the initial 24 h of intensive care unit (ICU) admission. Cox proportional hazard regression, log-binomial regression, and logistic regression were employed to assess the association between trajectory groups and mortality outcomes.

Results

Data from 337 patients were analyzed. GBMTM identified five combined trajectory groups. Group 1 featured rapidly declining SBP and DBP with high pulse pressure and low HR; Group 2 showed high to moderate SBP with slight rebound and persistently low HR; Group 3 displayed persistently moderate BP and HR; Group 4 was characterized by moderate blood pressure with persistently high HR; and Group 5 had high to moderate SBP with slight rebound, high but gradually declining DBP, and slightly high HR. Group 3 demonstrated a lower risk of mortality, with an adjusted hazard ratio of 0.32 (95 % CI, 0.14-0.74), and the adjusted relative risks for in-hospital, 30-day, and 1-year mortalities were 0.37 (95 % CI, 0.15-0.87), 0.25 (95 % CI, 0.10-0.62), and 0.41 (95 % CI, 0.22-0.79), respectively. The time-independent C-index curve demonstrated that the multi-trajectory groups had higher C-index values than any univariate trajectory groups or admission values of SBP, DBP, and HR.

Conclusions

Utilization of GBMTM can yield data-driven insights to identify distinct subphenotypes in AAD patients. The combined trajectories of SBP, DBP, and HR within 24 h of ICU admission significantly influenced the mortality rate.

Clinical Interpretation of Genetic Variants in the Evaluation and Management of Thoracic Aortic Aneurysm and Dissection

BACKGROUND

We aimed to elucidate clinical implications of genetic variant interpretation in assessing disease severity and progression in thoracic aortic aneurysm and dissection (TAAD) patients.

METHODS

Consecutive TAAD patients with aortic root and/or ascending aortic aneurysms seen between 2011 and 2020 were included. Serial echocardiography, family history of TAAD, and management information were retrospectively collected and analyzed. Patients were classified into gene-positive (Gen-P), variants of uncertain significance, and gene-negative (Gen-N) groups.

RESULTS

A total of 407 patients were included: mean age 53.7 ± 15.4 years, 64.4% men, and 38% with reported family history of TAAD. Thirty-seven (9.1%) were Gen-P; 147 (36.1%) had a variant of uncertain significance. The maximal aneurysm diameter was 4.78 mm larger in Gen-P than the other groups (P < .001). In 162 unoperated TAAD patients with serial echocardiographic measurements, aneurysms enlarged at a significantly higher rate in the Gen-P (1.36 mm/year, 95% CI: 0.77-1.95) than variants of uncertain significance and Gen-N groups (0.83 mm/year vs 0.89 mm/year, respectively; P < .001). Aneurysms were 20% more likely to require surgical intervention for every millimeter increase in diameter. When considered on an individual basis, the highest growth rates were found in the variants of uncertain significance group.

CONCLUSIONS

While aneurysms linked to variants of uncertain significance demonstrate average growth rates comparable to those in Gen-N, close follow-up and genetic counseling in the variants of uncertain significance group are recommended for assessment of pathogenicity on a case-by-case basis. Early familial gene testing in TAAD is important to develop individualized preventive and therapeutic criteria.

Recapturing the Team Approach to Vascular Care

BACKGROUND

The care of the vascular patient remains decentralized rather than coordinated.

METHODS

We reviewed the current state of practice and published competency and care documents created by vascular professional societies.

RESULTS

Vascular professional societies routinely and repeatedly endorse both a team approach and the competency of specialists from disparate training backgrounds. The care of the vascular patient does not always reflect these public endorsements.

CONCLUSIONS

Centering the vascular patient as the mode of organization of care should improve care processes, expertise brought to bear, and outcomes.

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

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

Improvement of Early Outcomes in Type A Acute Aortic Syndrome After an Aorta Code Implementation

BACKGROUND

Reduction of variability through process reengineering can improve surgical results for patients with type A acute aortic syndrome. We compare short-term results before and after implementation of an Aorta Code for patients with type A acute aortic syndrome who underwent surgery.

METHODS

The Aorta Code was implemented in a 5-hospital healthcare network in 2019. This critical pathway was based on a simple diagnostic algorithm, ongoing training, immediate patient transfer, and treatment by an expert multidisciplinary team. We retrospectively compared all patients operated on in our center before (2005-2018) and after (January 2019 to February 2023) its implementation.

RESULTS

One hundred two and 70 patients underwent surgery in the precode and code periods, respectively. In the code period the number of patients operated on per year increased (from 7.3 to 16.8), and the median elapsed time until diagnosis (6.5 hours vs 4.2 hours), transfer (4 hours vs 2.2 hours), and operating room (2.7 hours vs 1.8 hours) were significantly shorter (P < .05). Aortic root repair and total arch replacement were more frequent (66.7% vs 82.9% [P = .003] and 20.6% vs 40% [P = .001]). Cardiopulmonary bypass and ischemia times were also shorter (179.7 minutes vs 148.2 minutes [P = .001] and 105 minutes vs 91.2 minutes [P = .022]). Incidence of prolonged mechanical ventilation (53.9% vs 34.3%, P = .011), major stroke (17.7% vs 7.1%, P = .047), and 30-day mortality (27.5% vs 7.1%, P = .001) decreased significantly.

CONCLUSIONS

An Aorta Code can be successfully implemented by using a standardized protocol within a hospital network. The number of cases increased; time to diagnosis, transfer, and operating room were reduced; and 30- day mortality significantly decreased.

Research Concepts and Opportunities for Early-Career Investigators in Cardiac Surgery

Basic, translational or clinic, research is a key component of cardiac surgery. Understanding basic cellular and molecular mechanisms is key to improving patient outcomes, and cardiac surgical procedures must be compared with nonsurgical alternatives. However, guidance for early-career investigators interested in cardiac surgery research is limited. This opinion piece aims at providing basic guidance and principles based on the authors' experience.

Flow patterns in ascending aortic aneurysms: Determining the role of hypertension using phase contrast magnetic resonance and computational fluid dynamics

Thoracic aortic aneurysm (TAA) is a local dilation of the thoracic aorta. Although universally used, aneurysm diameter alone is a poor predictor of major complications such as rupture. There is a need for better biomarkers for risk assessment that also reflect the aberrant flow patterns found in TAAs. Furthermore, hypertension is often present in TAA patients and may play a role in progression of aneurysm. The exact relation between TAAs and hypertension is poorly understood. This study aims to create a numerical model of hypertension in the aorta by using computational fluid dynamics. First, a normotensive state was simulated in which flow and resistance were kept unaltered. Second, a hypertensive state was modeled in which blood inflow was increased by 30%. Third, a hypertensive state was modeled in which the proximal and peripheral resistances and capacitance parameters from the three-element Windkessel boundary condition were adjusted to mimic an increase in resistance of the rest of the cardiovascular system. One patient with degenerative TAA and one healthy control were successfully simulated at hypertensive states and were extensively analyzed. Furthermore, three additional TAA patients and controls were simulated to validate our method. Hemodynamic variables such as wall shear stress, oscillatory shear index, endothelial cell activation potential (ECAP), vorticity and helicity were studied to gain more insight on the effects of hypertension on flow patterns in TAAs. By comparing a TAA patient and a control at normotensive state at peak-systole, helicity and vorticity were found to be lower in the TAA patient throughout the entire domain. No major changes in flow and flow derived quantities were observed for the TAA patient and control when resistance was increased. When flow rate was increased, regions with high ECAP values were found to reduce in TAA patients in the aneurysm region which could reduce the risk of thrombogenesis. Thus, it may be important to assess cardiac output in patients with TAA.

The diagnostic approach and management of hypertension in the emergency department

Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.

Outcomes of emergency surgery for acute type A aortic dissection complicated by malperfusion syndrome

OBJECTIVE

The study objective was to determine the impact of malperfusion syndrome on in-hospital mortality and midterm survival after emergency aortic arch reconstruction for acute type A aortic dissection.

METHODS

This was an observational study of aortic surgeries from 2010 to 2018. All patients with acute type A aortic dissection undergoing open aortic arch reconstruction were included. Patients were dichotomized by the presence or absence of malperfusion syndrome and were analyzed for differences in short-term postoperative outcomes, including morbidity and in-hospital mortality. Kaplan-Meier survival estimation and multivariable Cox analysis were performed to identify variables associated with survival.

RESULTS

A total of 467 patients undergoing aortic arch reconstruction for acute type A aortic dissection were identified, of whom 332 (71.1%) presented without malperfusion syndrome and 135 (28.9%) presented with malperfusion syndrome. Patients with malperfusion syndrome had higher in-hospital mortality (21.5% vs 5.7%) than patients without malperfusion syndrome. After multivariable adjustment, malperfusion syndrome was associated with worse survival (hazard ratio, 2.43, 95% confidence interval, 1.61-3.66, P < .001) compared with patients without malperfusion syndrome. The predicted risk of mortality increased as the number of malperfused vascular beds increased. Patients with coronary malperfusion syndrome and neuro-malperfusion syndrome had reduced survival compared with the rest of the cohort (P < .05).

CONCLUSIONS

Malperfusion syndrome is associated with higher in-hospital mortality and reduced survival for patients with acute type A aortic dissection, with the risk of mortality increasing as the number of malperfused vascular beds increases. Coronary malperfusion syndrome and neuro-malperfusion syndrome may represent a high-risk subgroup of patients presenting with acute type A aortic dissection complicated by malperfusion syndrome. Finally, malperfusion syndrome may benefit from immediate surgical intervention to restore true lumen perfusion, as opposed to operative delay.

HSPB6 Deficiency Promotes the Development of Aortic Dissection and Rupture

To better understand the pathogenesis of acute type A aortic dissection, high-sensitivity liquid chromatography-tandem mass spectrometry/mass spectrometry (LC-MS/MS)-based proteomics and phosphoproteomics approaches were used to identify differential proteins. Heat shock protein family B (small) member 6 (HSPB6) in aortic dissection was significantly reduced in human and mouse aortic dissection samples by real-time PCR, western blotting, and immunohistochemical staining techniques. Using an HSPB6-knockout mouse, we investigated the potential role of HSPB6 in β-aminopropionitrile monofumarate-induced aortic dissection. We found increased mortality and increased probability of ascending aortic dissection after HSPB6 knockout compared with wild-type mice. Mechanistically, our data suggest that HSPB6 deletion promoted vascular smooth muscle cell apoptosis. More importantly, HSPB6 deletion attenuated cofilin activity, leading to excessive smooth muscle cell stiffness and eventually resulting in the development of aortic dissection and rupture. Our data suggest that excessive stiffness of vascular smooth muscle cells caused by HSPB6 deficiency is a new pathogenetic mechanism leading to aortic dissection.

Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome

BACKGROUND

The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. We describe characteristics of ED attendances with symptoms potentially associated with AAS, diagnostic performance of clinical decision tools (CDTs) and physicians and yield of CT aorta angiogram (CTA).

METHODS

This was a multicentre observational cohort study of adults attending 27 UK EDs between 26 September 2022 and 30 November 2022, with potential AAS symptoms: chest, back or abdominal pain, syncope or symptoms related to malperfusion. Patients were preferably identified prospectively, but retrospective recruitment was also permitted. Anonymised, routinely collected patient data including components of CDTs, was abstracted. Clinicians treating prospectively identified patients were asked to record their perceived likelihood of AAS, prior to any confirmatory testing. Reference standard was radiological or operative confirmation of AAS. 30-day electronic patient record follow-up evaluated whether a subsequent diagnosis of AAS had been made and mortality.

RESULTS

5548 patients presented, with a median age of 55 years (IQR 37-72; n=5539). 14 (0.3%; n=5353) had confirmed AAS. 10/1046 (1.0%) patients in whom the ED clinician thought AAS was possible had AAS. 5/147 (3.4%) patients in whom AAS was considered the most likely diagnosis had AAS. 2/3319 (0.06%) patients in whom AAS was considered not possible did have AAS. 540 (10%; n=5446) patients underwent CT, of which 407 were CTA (7%). 30-day follow-up did not reveal any missed AAS diagnoses. AUROC (area under the receiver operating characteristic) curve for ED clinician AAS likelihood rating was 0.958 (95% CI 0.933 to 0.983, n=4006) and for individual CDTs were: Aortic Dissection Detection Risk Score (ADD-RS) 0.674 (95% CI 0.508 to 0.839, n=4989), AORTAs 0.689 (95% CI 0.527 to 0.852, n=5132), Canadian 0.818 (95% CI 0.686 to 0.951, n=5180) and Sheffield 0.628 (95% CI 0.467 to 0.788, n=5092).

CONCLUSION

Only 0.3% of patients presenting with potential AAS symptoms had AAS but 7% underwent CTA. CDTs incorporating clinician gestalt appear to be most promising, but further prospective work is needed, including evaluation of the role of D-dimer.

TRIAL REGISTRATION NUMBER

NCT05582967; NCT05582967.

Utility of structured follow-up imaging after aortic surgery

BACKGROUND

Although postoperative follow-up after aortic surgery is recommended by guidelines, its clinical utility is not well documented. We hypothesized that structured follow-up imaging by an aortic program would improve outcomes. We then documented radiologic findings on asymptomatic postoperative imaging.

METHODS

All patients who survived to discharge after open thoracic aortic surgery between January 2017 and July 2021 were included, excluding endocarditis. Patients who followed at our center and received scheduled imaging were compared with patients who did not. Survival was analyzed by the method of Kaplan-Meier, and reintervention was assessed using the Fine-Gray subhazard function. Routine imaging was reviewed for aortic growth, pseudoaneurysm, and perigraft density.

RESULTS

After aortic surgery, the cumulative incidence of follow-up was 38.6% at 3 years postoperatively. Patients with follow-up were more likely to have a dissection and fewer comorbidities but were similar in regards to socioeconomic factors and distance to hospital. After matching and accounting for immortal time bias, patients with follow-up had a greater reintervention rate (26.0% vs 9.0%) with similar survival (98.7% vs 95.2%, P = .110) at 4 years. The cumulative incidence of pseudoaneurysm, significant perigraft density, and growth ≥3 mm/year on routine imaging was 49.7% at 3 years.

CONCLUSIONS

Implementation of structured follow-up imaging by an aortic program resulted in low clinical compliance. Follow-up was associated with increased rates of aortic reintervention. Clinically relevant radiologic findings were common on asymptomatic imaging and increased throughout 5-year follow-up rather than plateauing in the early postoperative period.

Relationship between false lumen morphology and entry tear in acute type A aortic dissection

OBJECTIVES

This study aimed to investigate the relationship between false lumen morphology and the size, aortic segment and position of the entry tear for acute type A aortic dissection.

METHODS

The records of patients who underwent emergency operation for acute type A aortic dissection in our institution between April 2011 and May 2022 were examined. Data regarding size, location and position of the entry tear and preoperative computed tomography findings were reviewed. The relationship of these variables with false lumen morphology was examined and retrospectively compared according to tear size.

RESULTS

Of 243 cases, characteristics of the entry tear, visualized during surgery, were confirmed in 134 cases (age = 70.9 ± 12.6 years, male = 45.5%). Tear sizes at different aortic segments were not significantly different (P = 0.376). Tears posterior to the lesser curvature were significantly smaller than those anterior to the greater curvature (P = 0.004). A thrombosed false lumen was associated with a significantly smaller tear size and position on the posterior to the lesser curvature side in aortic cross-section (all P < 0.001). Multivariate analysis showed that tear size, the presence of re-entry and tear position anterior to the greater curvature were independent predictors of a patent false lumen.

CONCLUSIONS

In acute type A aortic dissection, larger tear size, the presence of re-entry and tear position anterior to the greater curvature are risk factors for a patent false lumen. Although the results of this study are valid only for patients in whom intimal tears were detected during aortic surgery, this trend may provide information for pathophysiology of the disease.

[Acute aortic syndrome]

Acute aortic syndrome embraces a group of heterogenous pathological entities involving the aortic wall with a common clinical profile. The current epidemiology, clinical presentation, diagnosis and treatment strategy are discussed in this review. Besides, the importance of multidisciplinary aortic teams, aortic centers and the implementation of an aortic code are emphasized.

Aortic regurgitation provokes phenotypic modulation of smooth muscle cells in the normal ascending aorta

BACKGROUND

Aortic complications are more likely to occur in patients with ascending aortic aneurysms and concomitant aortic regurgitation (AR). AR may have a negative influence on the aortic wall structure even in patients with tricuspid aortic valves and absence of aortic dilatation. It is unknown whether smooth muscle cell (SMC) changes are a feature of AR-associated aortic remodeling.

METHODS

Nondilated aortic samples were harvested intraoperatively from individuals with normal aortic valves (n = 10) or those with either predominant aortic stenosis (AS) (n = 20) or AR (n = 35). Tissue from each patient was processed for immunohistochemistry or used for the extraction of medial SMCs. Tissue and cells were stained for markers of SMC contraction (alpha-smooth muscle actin), synthesis (vimentin) and senescence (p16INK4A and p21Cip1 [p16/p21]). Replicative capacity was analyzed in cultured SMCs from AS- and AR-associated aortas. A subanalysis compared SMCs from individuals with either tricuspid aortic valves or bicuspid aortic valves to evaluate the effect of aortic valve morphology.

RESULTS

In aortic tissue samples, AR was associated with decreased alpha-smooth muscle actin and increased vimentin, p16 and p21 compared with normal aortic valves and AS. In cell culture, SMCs from AR-aortas had decreased alpha-smooth muscle actin and increased vimentin compared with SMCs from AS-aortas. AR-associated SMCs had increased p16 and p21 expression, and they reached senescence earlier than SMCs from AS-aortas. In AR, SMC changes were more pronounced with the presence of a bicuspid aortic valve.

CONCLUSIONS

AR itself negatively influences SMC phenotype in the ascending aortic wall. This AR-specific effect is independent of aortic diameter and aortic valve morphology, although it is more pronounced with bicuspid aortic valves. These findings provide insight into the mechanisms of AR-related aortic remodeling, and they provide a model for studying SMC-specific therapies in culture.

Midterm outcomes of open repair versus endovascular descending thoracic aortic aneurysm repair

Objective

The study objective was to evaluate the midterm outcome of thoracic endovascular aortic repair compared with open repair in patients with descending thoracic aortic aneurysm.

Methods

From August 1993 to February 2023, 499 patients with descending thoracic aortic aneurysms underwent open repair (n = 221) or thoracic endovascular aortic repair (n = 278). Of these, 120 matched pairs were identified using propensity score matching based on age, sex, chronic lung disease, stroke, coronary artery disease, diabetes, ejection fraction, dialysis, peripheral vascular disease, prior cardiac surgery, connective tissue disease, and chronic dissection. Primary outcomes were postoperative paralysis, operative mortality, reoperation, and midterm survival.

Results

After matching, the preoperative demographics and comorbidities were balanced in both groups. Intraoperatively, open repair had a lower temperature (18 °C vs 36 °C) and more patients required blood products (66% vs 8%), P < .001. Postoperatively, patients undergoing thoracic endovascular aortic repair had fewer strokes (2.5% vs 9.2%; P = .03), less dialysis (0% vs 3.3%; P = .04), and shorter length of stay (5 days vs 12 days, P < .001), but similar lower-extremity paralysis (2.5% vs 2.5%, P = 1.00) compared with open repair. Furthermore, thoracic endovascular aortic repair had higher 7-year incidence of first reoperation (16.1% vs 3.6%, P < .001) but similar operative mortality (0.8% vs 4.2%; P = .10) and 10-year survival outcome (56%; 95% CI, 43-72 vs 58%; 95% CI, 49-68; P = .55) compared with open aortic repair. The hazard ratio was 0.93 (P = .78) for thoracic endovascular aortic repair for midterm mortality and 6.87 (P < .001) for reoperation.

Conclusions

Open repair could be the first option for patients with descending thoracic aortic aneurysms who were surgical candidates.

Molecular characterization and clinical investigation of patients with heritable thoracic aortic aneurysm and dissection

OBJECTIVES

Thoracic aortic aneurysm and dissection has a genetic predisposition and a variety of clinical manifestations. This study aimed to investigate the clinical and molecular characterizations of patients with thoracic aortic aneurysm and dissection and further explore the relationship between the genotype and phenotype, as well as their postoperative outcomes.

METHODS

A total of 1095 individuals with thoracic aortic aneurysm and dissection admitted to our hospital between 2013 and 2022 were included. Next-generation sequencing and multiplex ligation-dependent probe amplification were performed, and mosaicism analysis was additionally implemented to identify the genetic causes.

RESULTS

A total of 376 causative variants were identified in 83.5% of patients with syndromic thoracic aortic aneurysm and dissection and 18.7% of patients with nonsyndromic thoracic aortic aneurysm and dissection, including 8 copy number variations and 2 mosaic variants. Patients in the "pathogenic" and "variant of uncertain significance" groups had younger ages of aortic events and higher aortic reintervention risks compared with genetically negative cases. In addition, patients with FBN1 haploinsufficiency variants had shorter reintervention-free survival than those with FBN1 dominant negative variants.

CONCLUSIONS

Our data expanded the genetic spectrum of heritable thoracic aortic aneurysm and dissection and indicated that copy number variations and mosaic variants contributed to a small proportion of the disease-causing alterations. Moreover, positive genetic results might have a possible predictive value for aortic event severity and postoperative risk stratification.

Characteristics and outcomes of the Spanish registry for pediatric patients with bicuspid aortic valve (REVAB)

INTRODUCTION AND OBJECTIVES

Bicuspid aortic valve (BAV) disorder is the most common congenital heart disease. The aim of this study was to describe the characteristics of 0- to 18-year olds with BAV in a population-based registry.

METHODS

Data from all pediatric patients were obtained from the Spanish registry for pediatric patients with bicuspid aortic valve (REVAB) (< 18 years). For data analysis, patients with BAV were divided into 2 groups by their features: isolated BAV and BAV with associated congenital heart disease.

RESULTS

We included 1681 patients from 33 hospitals. Males accounted for 69.6% (n = 1158). Valve morphology was horizontal in 63.4% (n = 1012) and pure (Sievers type 0) in 28.4% (n=469). Isolated BAV was present in 63.7% (n=1060), and concomitant left-sided obstructive lesions in 23.4% (n=390). Interventions were required in 8.6% (n=145).

CONCLUSION

These data represent the first large, population-based description of the clinical presentations and outcomes of patients enrolled in the Spanish registry for pediatric patients with bicuspid aortic valve.

Can you accurately rule out acute aortic syndrome by restricting imaging of the aorta to the area of the patient's pain?

BACKGROUND

Acute aortic syndrome (AAS) is a life-threatening condition necessitating timely and accurate diagnosis for appropriate treatment. Currently, the only way to rule out the diagnosis is advanced imaging. The most accessible is computed tomography of the entire aorta. Most scans are negative, exposing patients to radiation, increased time in the emergency department (ED), and non-significant incidental findings. This study investigated whether restricting imaging to the area of aortic-related pain accurately rules out AAS.

METHODS

A health records review was conducted on consecutive cases from three academic EDs between 2015 and 2020. Data were extracted and verified from multiple sources. Participants included adults diagnosed with AAS based on radiological evidence. The diagnostic performance of the restricted imaging strategy was assessed; sensitivity and likelihood ratios with 95% confidence intervals were calculated.

RESULTS

Data from 149 cases of AAS were collected, with the majority presenting with chest pain (46%) or abdominal pain (24%). The restricted imaging strategy demonstrated a sensitivity of 96% (95% CI 91.4-98.5%) in ruling out AAS. In a subset of patients with systolic blood pressure > 90 mmHg and without aortic aneurysm/repair (n = 86), the sensitivity was 100% (95% CI 96-100%).

CONCLUSION

Restricting imaging to the area of pain in hemodynamically stable patients without known aortic aneurysm provides a highly sensitive approach to ruling out AAS.

Improved Maximal Workload and Systolic Blood Pressure After Cardiac Rehabilitation Following Thoracic Aortic Repair: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

It is of clinical importance to gain more knowledge about the risks and benefits of exercise in patients recovering from thoracic aortic repair. Therefore, the aim of this review was to perform a meta-analysis on changes in cardiorespiratory fitness, blood pressure, and the incidence of adverse events during cardiac rehabilitation (CR) in patients recovering from thoracic aortic repair.

REVIEW METHODS

We performed a systematic review and random-effects meta-analysis of outcomes before versus after outpatient CR in patients recovering from thoracic aortic repair. The study protocol was registered (PROSPERO CRD42022301204) and published. MEDLINE, EMBASE, and CINAHL were systematically searched for eligible studies. Overall certainty of evidence was scored with Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

SUMMARY

We included five studies with data from in total 241 patients. Data from one study could not be used in our meta-analysis because they were provided in a different unit of measure. Four studies with data of 146 patients were included in the meta-analysis. The mean maximal workload increased with 28.7 W (95% CI: 21.8-35.6 W, n = 146, low certainty of evidence). The mean systolic blood pressure during exercise testing increased with 25.4 mm Hg (95% CI: 16.6-34.3, n = 133, low certainty of evidence). No exercise-induced adverse events were reported. These outcomes indicate that CR seems beneficial and safe to improve exercise tolerance in patients recovering from thoracic aortic repair, although outcomes were based on data from a small, heterogeneous group of patients.

Tailored treatment modality in acute type A intramural hematoma

OBJECTIVES

Intramural hematoma may be generated by a minimal intimal tear. Most surgeries for acute type A intramural hematoma are performed on the proximal aorta alone regardless of the intimal tear site. Under the assumption that major adverse aortic events (MAAEs) would be related to the location of primary intimal tear, we reviewed preoperative computed tomography scan findings.

METHODS

Sixty patients with acute type A intramural hematoma who underwent surgery from January 2008 to December 2019 were retrospectively analyzed. The maximal diameter, maximal thickness of the intramural hematoma, and hematoma thickness ratio of the ascending and descending aortae were measured. MAAEs were defined as newly developed aortic dissection, rupture, newly developed penetrating aortic ulcer (PAU), enlargement of the PAU, and aortic death.

RESULTS

The number of patients with PAU in the descending aorta (dPAU) was significantly higher in the MAAE (+) group. The MAAE (+) group showed lower measurements of the ascending aorta and higher measurements of the descending aorta than the MAAE (-) group. In the univariate analysis, dPAU, hematoma thickness ratio of the ascending and descending aortae, and descending aorta hematoma thickness >8.58 mm were risk factors of MAAE. Intimal tear noted intraoperatively and ascending aorta hematoma thickness >10.25 mm were protective factors of MAAE.

CONCLUSIONS

Aortopathies (ie, PAU, ulcer-like projections, and the hematoma thickness ratio) are important clues to determine the location of intimal tear. Occurrence of MAAEs seems to be highly related to the pathology of the descending aorta. The modalities of treatment for stable acute type A intramural hematoma that do not meet the existing guidelines should be tailored to the location of the intimal tear.

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

AIM

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

METHODS

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

STRUCTURE

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

Educational value of mixed reality combined with a three-dimensional printed model of aortic disease for vascular surgery in the standardized residency training of surgical residents in China: a case control study

BACKGROUND

The simulated three-dimensional (3D) printed anatomical model of the aorta, which has become the norm in medical education, has poor authenticity, tactility, feasibility, and interactivity. Therefore, this study explored the educational value and effect of mixed reality (MR) combined with a 3D printed model of aortic disease in training surgical residents.

METHOD

Fifty-one resident physicians who rotated in vascular surgery were selected and divided into traditional (27) and experimental (24) teaching groups using the random number table method. After undergoing the experimental and traditional training routines on aortic disease, both the groups took a theoretical test on aortic disease and an assessment of the simulation based on the Michigan Standard Simulation Experience Scale (MiSSES) template. Their scores and assessment results were compared. The study was conducted at the Department of Vascular Surgery of Peking University People's Hospital, Beijing, China.

RESULTS

In the theoretical test on aortic disease, the experimental teaching group obtained higher mean total scores (79.0 ± 9.1 vs. 72.6 ± 7.5, P = 0.013) and higher scores in anatomy/ pathophysiology (30.8 ± 5.4 vs. 24.8 ± 5.8; P < 0.001) than the traditional teaching group. The differences in their scores in the differential diagnosis (25.8 ± 3.0 vs. 23.3 ± 4.9; P = 0.078) and treatment (22.5 ± 11.8 vs. 24.5 ± 8.2; P = 0.603) sessions were insignificant. The MR-assisted teaching stratified the vascular residents through the MiSSES survey. Overall, 95.8% residents (23/24) strongly or somewhat agreed that the MR was adequately realistic and the curriculum helped improve the ability to understanding aortic diseases. Further, 91.7% residents (22/24) strongly or somewhat agreed that the MR-assisted teaching was a good training tool for knowledge on aortic diseases. All residents responded with "Good" or "Outstanding" on the overall rating of the MR experience.

CONCLUSIONS

MR combined with the 3D printed model helped residents understand and master aortic disease, particularly regarding anatomy and pathophysiology. Additionally, the realistic 3D printing and MR models improved the self-efficacy of residents in studying aortic diseases, thus greatly stimulating their enthusiasm and initiative to study.

Establishing and Validating a Morphological Prediction Model Based on CTA to Evaluate the Incidence of Type-B Dissection

Background: Many patients with Type B aortic dissection (TBAD) may not show noticeable symptoms until they become intervention and help prevent critically ill, which can result in fatal outcomes. Thus, it is crucial to screen people at high risk of TBAD and initiate the necessary preventive and therapeutic measures before irreversible harm occurs. By developing a prediction model for aortic arch morphology, it is possible to accurately identify those at high risk and take prompt action to prevent the adverse consequences of TBAD. This approach can facilitate timely the development of serious illnesses. Method: The predictive model was established in a primary population consisting of 173 patients diagnosed with acute Stanford TBAD, with data collected from January 2017 and December 2018, as well as 534 patients with healthy aortas, with data collected from April 2018 and December 2018. Explicitly, the data were randomly separated into the derivation set and validation set in a 7:3 ratio. Geometric and anatomical features were extracted from a three-dimensional multiplanar reconstruction of the aortic arch. The LASSO regression model was utilized to minimize the data dimension and choose relevant features. Multivariable logistic regression analysis and backward stepwise selection were employed for predictive model generation, combining demographic and clinical features as well as geometric and anatomical features. The predictive model's performance was evaluated by examining its calibration, discrimination, and clinical benefit. Finally, we also conducted internal verification. Results: After applying LASSO logistic regression and backward stepwise selection, 12 features were entered into the prediction model. Age, aortic arch angle, total thoracic aorta distance, ascending aorta tortuosity, aortic arch tortuosity, distal descending aorta tortuosity, and type III arch were protective factors, while male sex, hypertension, aortic arch height, and aortic arch distance were risk factors. The model exhibited satisfactory discrimination (AUC, 0.917 [95% CI, 0.890-0.945]) and good calibration in the derivation set. Applying the predictive model to the validation set also provided satisfactory discrimination (AUC, 0.909 [95% CI, 0.864-0.953]) and good calibration. The TBAD nomogram for clinical use was established. Conclusions: This study demonstrates that a multivariable logistic regression model can be used to predict TBAD patients.

Outcomes of open repair for descending thoracic and thoracoabdominal aortic aneurysm in recent 10 years: experience of a high-volume centre in Korea

OBJECTIVES

Although recent studies and guidelines suggest the preferred outcomes after surgical repair of thoracic aortic aneurysm (TAA) and thoracoabdominal aortic aneurysm (TAAA), published results are limited to those from high-volume hospitals and based on old data gathered before optimal management was established. Here, we analysed our outcomes over the previous 10 years from cases of open TAA and TAAA repair to offer updated and real-world results of those complex procedures performed in a high-volume centre.

METHODS

From November 2013 to April 2022, 212 consecutive adult patients who underwent open TAA and TAAA repair were enrolled. We analysed early and late outcomes after surgery, including postoperative complications and mortality.

RESULTS

There were 154 (73%) men, and the median age at surgery was 61 years. Intraoperative death occurred in 1 patient due to uncontrolled bleeding. Nine patients (4%) died during follow-up, and the survival estimates at 5 years were 94 ± 3% and 95 ± 3% after descending TAA and TAAA repair, respectively. Ten patients (4%) suffered from spinal cord ischaemic injury (9 with paraplegia and 1 with paresthesia), but permanent paraplegia persisted in only 1 case.

CONCLUSIONS

We report very low postoperative complication rates and excellent early and late survival rates after open TAA and TAAA repair from our recent 10-year data analysis. These findings may assist when choosing treatment options for these complicated diseases.

Simultaneous Highly Efficient Contrast-Free Lumen and Vessel Wall MR Imaging for Anatomical Assessment of Aortic Disease

BACKGROUND

Bright-blood lumen and black-blood vessel wall imaging are required for the comprehensive assessment of aortic disease. These images are usually acquired separately, resulting in long examinations and potential misregistration between images.

PURPOSE

To characterize the performance of an accelerated and respiratory motion-compensated three-dimensional (3D) cardiac MRI technique for simultaneous contrast-free aortic lumen and vessel wall imaging with an interleaved T2 and inversion recovery prepared sequence (iT2Prep-BOOST).

STUDY TYPE

Prospective.

POPULATION

A total of 30 consecutive patients with aortopathy referred for a clinically indicated cardiac MRI examination (9 females, mean age ± standard deviation: 32 ± 12 years).

FIELD STRENGTH/SEQUENCE

1.5-T; bright-blood MR angiography (diaphragmatic navigator-gated T2-prepared 3D balanced steady-state free precession [bSSFP], T2Prep-bSSFP), breath-held black-blood two-dimensional (2D) half acquisition single-shot turbo spin echo (HASTE), and 3D bSSFP iT2Prep-BOOST.

ASSESSMENT

iT2Prep-BOOST bright-blood images were compared to T2prep-bSSFP images in terms of aortic vessel dimensions, lumen-to-myocardium contrast ratio (CR), and image quality (diagnostic confidence, vessel sharpness and presence of artifacts, assessed by three cardiologists on a 4-point scale, 1: nondiagnostic to 4: excellent). The iT2Prep-BOOST black-blood images were compared to 2D HASTE images for quantification of wall thickness. A visual comparison between computed tomography (CT) and iT2Prep-BOOST was performed in a patient with chronic aortic dissection.

STATISTICAL TESTS

Paired t-tests, Wilcoxon signed-rank tests, intraclass correlation coefficient (ICC), Bland-Altman analysis. A P value < 0.05 was considered statistically significant.

RESULTS

Bright-blood iT2Prep-BOOST resulted in significantly improved image quality (mean ± standard deviation 3.8 ± 0.5 vs. 3.3 ± 0.8) and CR (2.9 ± 0.8 vs. 1.8 ± 0.5) compared with T2Prep-bSSFP, with a shorter scan time (7.8 ± 1.7 minutes vs. 12.9 ± 3.4 minutes) while providing a complementary 3D black-blood image. Aortic lumen diameter and vessel wall thickness measurements in bright-blood and black-blood images were in good agreement with T2Prep-bSSFP and HASTE images (<0.02 cm and <0.005 cm bias, respectively) and good intrareader (ICC > 0.96) and interreader (ICC > 0.94) agreement was observed for all measurements.

DATA CONCLUSION

iT2Prep-BOOST might enable time-efficient simultaneous bright- and black-blood aortic imaging, with improved image quality compared to T2Prep-bSSFP and HASTE imaging, and comparable measurements for aortic wall and lumen dimensions.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 2.

Cannulation Strategies in Type A Aortic Dissection: Overlooked Details and Novel Approaches

Aortic dissection type A is a life-threatening condition that frequently necessitates surgical intervention. This review focuses on central aortic cannulation, arch branch vessel (ABV) cannulation, and proximal arch cannulation as key techniques during aortic surgery. It discusses innovative solutions for addressing these challenges. The review synthesizes findings from recent studies and emphasizes the significance of meticulous planning and execution of cannulation in aortic dissection repair. This review aims to contribute to the advancement of surgical practices and the enhancement of patient outcomes in the management of type A aortic dissection (AAD) by addressing these frequently overlooked details.

Women With Acute Aortic Dissection Have Higher Prehospital Mortality Than Men

Background

Acute aortic dissection (AAD) often leads to out-of-hospital cardiac arrest (OHCA) and death before hospital arrival.

Objectives

The purpose of this study was to investigate differences in AAD incidence by sex.

Methods

A population-based study in a city with 121,180 residents was conducted using postmortem computed tomography data to identify patients with AAD who died before hospital arrival in 2008-2020. The incidence rate ratio and odds ratio were estimated using Poisson regression and univariable logistic regression, respectively.

Results

A total of 266 patients with incident AAD were enrolled: 84 patients with OHCA, 137 women [n = 137], and 164 patients with type A AAD. The crude and age-adjusted incidence of AAD was 16.2 and 14.3/100,000 person-years, respectively. The incidence of AAD was comparable by sex (men, 16.7/100,000 person-years; women, 15.7/100,000 person-years; incidence rate ratio: 0.94; 95% CI: 0.74-1.20; P = 0.64). Compared with men with AAD, women with AAD were older (77 ± 11 years vs 70 ± 14 years; P < 0.001), and a higher proportion had type A AAD (76% vs 47%; P < 0.001). Women with AAD had higher prehospital mortality than men with AAD (37% vs 21%; P = 0.004; OR: 2.24; 95% CI: 1.30-3.87; P = 0.004). Among 1,373 patients with OHCA, the proportion of women with AAD was significantly higher than the proportion of men with AAD (11% vs 3.9%; P < 0.001; OR: 2.90; 95% CI: 1.86-4.53; P < 0.001). AAD was most common in women aged 60 to 69 years (16.4%).

Conclusions

Women had a higher incidence of AAD presenting as prehospital death than men.

Thoracic Aortic Aneurysm Risk Assessment: A Machine Learning Approach

Background

Traditional methods of risk assessment for thoracic aortic aneurysm (TAA) based on aneurysm size alone have been called into question as being unreliable in predicting complications. Biomechanical function of aortic tissue may be a better predictor of risk, but it is difficult to determine in vivo.

Objectives

This study investigates using a machine learning (ML) model as a correlative measure of energy loss, a measure of TAA biomechanical function.

Methods

Biaxial tensile testing was performed on resected TAA tissue collected from patients undergoing surgery. The energy loss of the tissue was calculated and used as the representative output. Input parameters were collected from clinical assessments including observations from medical scans and genetic paneling. Four ML algorithms including Gaussian process regression were trained in Matlab.

Results

A total of 158 patients were considered (mean age 62 years, range 22-89 years, 78% male), including 11 healthy controls. The mean ascending aortic diameter was 47 ± 10 mm, with 46% having a bicuspid aortic valve. The best-performing model was found to give a greater correlative measure to energy loss (R2 = 0.63) than the surprisingly poor performance of aortic diameter (R2 = 0.26) and indexed aortic size (R2 = 0.32). An echocardiogram-derived stiffness metric was investigated on a smaller subcohort of 67 patients as an additional input, improving the correlative performance from R2 = 0.46 to R2 = 0.62.

Conclusions

A preliminary set of models demonstrated the ability of a ML algorithm to improve prediction of the mechanical function of TAA tissue. This model can use clinical data to provide additional information for risk stratification.

Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study

Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes.

METHODS

All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient.

RESULTS

A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L.

CONCLUSION

The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.

17 β-Estradiol Impedes Aortic Root Dilation and Rupture in Male Marfan Mice

Marfan syndrome causes a hereditary form of thoracic aortic aneurysms with worse outcomes in male compared to female patients. In this study, we examine the effects of 17 β-estradiol on aortic dilation and rupture in a Marfan mouse model. Marfan male mice were administered 17 β-estradiol, and the growth in the aortic root, along with the risk of aortic rupture, was measured. Transcriptomic profiling was used to identify enriched pathways from 17 β-estradiol treatments. Aortic smooth muscle cells were then treated with cytokines to validate functional mechanisms. We show that 17 β-estradiol decreased the size and rate of aortic root dilation and improved survival from rupture. The Marfan transcriptome was enriched in inflammatory genes, and the addition of 17 β-estradiol modulated a set of genes that function through TNFα mediated NF-κB signaling. In addition, 17 β-estradiol suppressed the induction of these TNFα induced genes in aortic smooth muscle cells in vitro in an NF-κB dependent manner, and 17 β-estradiol decreased the formation of adventitial inflammatory foci in aortic roots in vivo. In conclusion, 17 β-estradiol protects against the dilation and rupture of aortic roots in Marfan male mice through the inhibition of TNFα-NF-κB signaling.

Fully automated pipeline for measurement of the thoracic aorta using joint segmentation and localization neural network

Purpose

Diagnosis and surveillance of thoracic aortic aneurysm (TAA) involves measuring the aortic diameter at various locations along the length of the aorta, often using computed tomography angiography (CTA). Currently, measurements are performed by human raters using specialized software for three-dimensional analysis, a time-consuming process, requiring 15 to 45 min of focused effort. Thus, we aimed to develop a convolutional neural network (CNN)-based algorithm for fully automated and accurate aortic measurements.

Approach

Using 212 CTA scans, we trained a CNN to perform segmentation and localization of key landmarks jointly. Segmentation mask and landmarks are subsequently used to obtain the centerline and cross-sectional diameters of the aorta. Subsequently, a cubic spline is fit to the aortic boundary at the sinuses of Valsalva to avoid errors related inclusions of coronary artery origins. Performance was evaluated on a test set of 60 scans with automated measurements compared against expert manual raters.

Result

Compared to training separate networks for each task, joint training yielded higher accuracy for segmentation, especially at the boundary (p < 0.001 ), but a marginally worse (0.2 to 0.5 mm) accuracy for landmark localization (p < 0.001 ). Mean absolute error between human and automated was ≤ 1    mm at six of nine standard clinical measurement locations. However, higher errors were noted in the aortic root and arch regions, ranging between 1.4 and 2.2 mm, although agreement of manual raters was also lower in these regions.

Conclusion

Fully automated aortic diameter measurements in TAA are feasible using a CNN-based algorithm. Automated measurements demonstrated low errors that are comparable in magnitude to those with manual raters; however, measurement error was highest in the aortic root and arch.

1821-2021: Contributions of physicians and researchers of Greek descent in the advancement of clinical and experimental cardiology and cardiac surgery

While the role of Greeks in the development of early western medicine is well-known and appreciated, the contributions of modern Greek medical practitioners are less known and often overlooked. On the occasion of the 200-year anniversary of the Greek War of Independence, this review article sheds light onto the achievements of modern scientists of Greek descent in the development of cardiology, cardiac surgery, and cardiovascular research, through a short history of the development of these fields and of the related institutions in Greece. In the last decades, the Greek cardiology and Cardiac Surgery communities have been active inside and outside Greece and have a remarkable presence internationally, particularly in the United States. This article highlights the ways in which Greek cardiology and cardiovascular research has been enriched by absorbing knowledge produced in international medical centers, academic institutes and pharmaceutical industries in which generations of Greek doctors and researchers trained prior to their return to the homeland; it also highlights the achievements of medical practitioners and researchers of Greek descent who excelled abroad, producing ground-breaking work that has left a permanent imprint on global medicine.

Evidence in Clinical Studies for the Role of Wall Thickness in Ascending Thoracic Aortic Aneurysms: A Scoping Review

BACKGROUND

Ascending thoracic aortic aneurysm is a chronic degenerative pathology characterized by dilatation of this segment of the aorta. Clinical guidelines use aortic diameter and growth rate as predictors of rupture and dissection. However, these guidelines neglect the effects of tissue remodeling, which may affect wall thickness. The present study aims to systematically review observational studies to examine to what extent wall thickness is considered and measured in clinical practice.

METHODS

Using PubMed and Web of Science, studies were identified with data on ascending aortic wall thickness, morphology, aortic diameter, and measurement techniques.

RESULTS

15 included studies report several methods by which wall thickness is measured. No association was observed between wall thickness and aortic diameter across included studies. Wall thickness values appear not materially different between aneurysmatic aortas and non-aneurysmal aortas.

CONCLUSIONS

The effects on and consequences of wall thickness changes during ATAA formation are ill-defined. Wall thickness values for aneurysmatic aortas can be similar to aortas with normal diameters. Given the existing notion that wall thickness is a determinant of mechanical stress homeostasis, our review exposes a clear need for consistent as well as clinically applicable methods and studies to quantify wall thickness in ascending aortic aneurysm research.

An Evidenced-Based Review of Emergency Target Blood Pressure Management for Acute Aortic Dissection

Objective

To summarize the best evidence of emergency target blood pressure management for acute aortic dissection and provide guidance for evidence-based practice of emergency target blood pressure management.

Methods

According to the "6S" evidence pyramid model, the evidence of emergency target blood pressure management of acute aortic dissection in various foreign databases and websites of professional associations from January 1, 2010, to August 1, 2022, was retrieved, including clinical decision-making, guidelines, expert consensus, systematic reviews, randomized controlled trials, cohort studies, and case series. Two researchers used the corresponding document quality evaluation tools to evaluate the documents and extracted and summarized the evidence of documents above grade B.

Results

A total of 17 articles were included, including 6 clinical decision-making articles, 5 guidelines, 2 expert consensus articles, 1 systematic review article, 1 randomized controlled trial article, 1 cohort study article, and 1 case series article, forming 36 best evidences, including 9 topics, which are target value setting, management strategy, disease observation, medical history collection, monitoring methods, vasoactive drugs, nonvasoactive drugs, related examinations, and patient education.

Conclusion

The best evidence summarized provides a reference for doctors and nurses in the emergency department to manage the emergency target blood pressure of patients with acute aortic dissection. It is recommended that doctors and nurses in the emergency department follow the best evidence summarized to develop individualized target blood pressure management plan for patients.

The prognosis of patients with postoperative hyperglycemia after Stanford type A aortic dissection surgery and construction of prediction model for postoperative hyperglycemia

Objective

The mortality of type A aortic dissection (TAAD) is extremely high. The effect of postoperative hyperglycemia (PHG) on the prognosis of TAAD surgery is unclear. This study aims to investigate the prognosis of patients with PHG after TAAD surgery and construct prediction model for PHG.

Methods

Patients underwent TAAD surgery from January 2016 to December 2020 in Xiangya Hospital were collected. A total of 203 patients were included and patients were divided into non PHG group and PHG group. The occurrence of postoperative delirium, cardiac complications, spinal cord complication, cerebral complications, acute kidney injury (AKI), hepatic dysfunction, hypoxemia, and in-hospital mortality were compared between two groups. Data from MIMIC-IV database were further applied to validate the relationship between PHG and clinical outcomes. The prediction model for PHG was then constructed using Extreme Gradient Boosting (XGBoost) analysis. The predictive value of selected features was further validated using patient data from MIMIC-IV database. Finally, the 28-days survival rate of patient with PHG was analyzed using data from MIMIC-IV database.

Results

There were 86 patients developed PHG. The incidences of postoperative AKI, hepatic dysfunction, and in-hospital mortality were significant higher in PHG group. The ventilation time after surgery was significant longer in PHG group. Data from MIMIC-IV database validated these results. Neutrophil, platelet, lactic acid, weight, and lymphocyte were selected as features for prediction model. The values of AUC in training and testing set were 0.8697 and 0.8286 respectively. Then, five features were applied to construct another prediction model using data from MIMIC-IV database and the value of AUC in the new model was 0.8185. Finally, 28-days survival rate of patients with PHG was significantly lower and PHG was an independent risk factor for 28-days mortality after TAAD surgery.

Conclusion

PHG was significantly associated with the occurrence of AKI, hepatic dysfunction, increased ventilation time, and in-hospital mortality after TAAD surgery. The feature combination of neutrophil, platelet, lactic acid, weight, and lymphocyte could effectively predict PHG. The 28-days survival rate of patients with PHG was significantly lower. Moreover, PHG was an independent risk factor for 28-days mortality after TAAD surgery.