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Silva NP, Amin B, Dunne E, Hynes N, O’Halloran M, Elahi A. Implantable Pressure-Sensing Devices for Monitoring Abdominal Aortic Aneurysms in Post-Endovascular Aneurysm Repair. SENSORS (BASEL, SWITZERLAND) 2024; 24:3526. [PMID: 38894317 PMCID: PMC11175030 DOI: 10.3390/s24113526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Over the past two decades, there has been extensive research into surveillance methods for the post-endovascular repair of abdominal aortic aneurysms, highlighting the importance of these technologies in supplementing or even replacing conventional image-screening modalities. This review aims to provide an overview of the current status of alternative surveillance solutions for endovascular aneurysm repair, while also identifying potential aneurysm features that could be used to develop novel monitoring technologies. It offers a comprehensive review of these recent clinical advances, comparing new and standard clinical practices. After introducing the clinical understanding of abdominal aortic aneurysms and exploring current treatment procedures, the paper discusses the current surveillance methods for endovascular repair, contrasting them with recent pressure-sensing technologies. The literature on three commercial pressure-sensing devices for post-endovascular repair surveillance is analyzed. Various pre-clinical and clinical studies assessing the safety and efficacy of these devices are reviewed, providing a comparative summary of their outcomes. The review of the results from pre-clinical and clinical studies suggests a consistent trend of decreased blood pressure in the excluded aneurysm sac post-repair. However, despite successful pressure readings from the aneurysm sac, no strong link has been established to translate these measurements into the presence or absence of endoleaks. Furthermore, the results do not allow for a conclusive determination of ongoing aneurysm sac growth. Consequently, a strong clinical need persists for monitoring endoleaks and aneurysm growth following endovascular repair.
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Affiliation(s)
- Nuno P. Silva
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
| | - Bilal Amin
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Eoghan Dunne
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Niamh Hynes
- Western Vascular Institute, Galway Clinic, Doughiska Road, H91 HHT0 Galway, Ireland;
| | - Martin O’Halloran
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Adnan Elahi
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
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Zamirpour S, Xuan Y, Wang Z, Gomez A, Leach JR, Mitsouras D, Saloner DA, Guccione JM, Ge L, Tseng EE. Height and body surface area versus wall stress for stratification of mid-term outcomes in ascending aortic aneurysm. IJC HEART & VASCULATURE 2024; 51:101375. [PMID: 38435381 PMCID: PMC10909604 DOI: 10.1016/j.ijcha.2024.101375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/13/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
Objectives Current diameter-based guidelines for ascending thoracic aortic aneurysms (aTAA) do not consistently predict risk of dissection/rupture. ATAA wall stresses may enhance risk stratification independent of diameter. The relation of wall stresses and diameter indexed to height and body surface area (BSA) is unknown. Our objective was to compare aTAA wall stresses with indexed diameters in relation to all-cause mortality at 3.75 years follow-up. Methods Finite element analyses were performed in a veteran population with aortas ≥ 4.0 cm. Three-dimensional geometries were reconstructed from computed tomography with models accounting for pre-stress geometries. A fiber-embedded hyperelastic material model was applied to obtain wall stress distributions under systolic pressure. Peak wall stresses were compared across guideline thresholds for diameter/BSA and diameter/height. Hazard ratios for all-cause mortality and surgical aneurysm repair were estimated using cause-specific Cox proportional hazards models. Results Of 253 veterans, 54 (21 %) had aneurysm repair at 3.75 years. Indexed diameter alone would have prompted repair at baseline in 17/253 (6.7 %) patients, including only 4/230 (1.7 %) with diameter < 5.5 cm. Peak wall stresses did not significantly differ across guideline thresholds for diameter/BSA (circumferential: p = 0.15; longitudinal: p = 0.18), but did differ for diameter/height (circumferential: p = 0.003; longitudinal: p = 0.048). All-cause mortality was independently associated with peak longitudinal stresses (p = 0.04). Peak longitudinal stresses were best predicted by diameter (c-statistic = 0.66), followed by diameter/height (c-statistic = 0.59), and diameter/BSA (c-statistic = 0.55). Conclusions Diameter/height improved stratification of peak wall stresses compared to diameter/BSA. Peak longitudinal stresses predicted all-cause mortality independent of age and indexed diameter and may aid risk stratification for aTAA adverse events.
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Affiliation(s)
- Siavash Zamirpour
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
- School of Medicine, University of California, San Francisco, USA
| | - Yue Xuan
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Zhongjie Wang
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Axel Gomez
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Joseph R. Leach
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Dimitrios Mitsouras
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - David A. Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Julius M. Guccione
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Liang Ge
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Elaine E. Tseng
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
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Manopoulos C, Seferlis K, Raptis A, Kouerinis I, Mathioulakis D. Mechanics of ascending aortic aneurysms based on a modulus of elasticity dependent on aneurysm diameter and pressure. Comput Methods Biomech Biomed Engin 2023:1-16. [PMID: 38008970 DOI: 10.1080/10255842.2023.2285722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/15/2023] [Indexed: 11/28/2023]
Abstract
The mechanical stresses and strains are examined, in ascending thoracic aortic aneurysm (aTAA) models, in a patient-specific aTAA as well as in healthy thoracic aortic models, via Finite Element Analysis. The aneurysms are assumed spherical, 1.5 mm thick, with diameters between 47 mm and 80 mm, eccentrically positioned. The geometry and wall thickness distribution of the aorta along its length are based on open literature data for an average patient age of 66.25 years, accounting for the Body Surface Area (BSA) parameter. The vessel wall material is assumed isotropic and incompressible, with its Young's modulus varying with the aneurysm diameter and the applied intraluminal pressure (120 mmHg to 240 mmHg). In the aTAAs, peak stresses were found to increase nonlinearly with aneurysm diameter (for a given pressure) tending to reach a plateau, appearing at the proximal area of the aneurysm, whereas lower stresses were found at its distal part and even smaller at the aneurysm maximum diameter. Regarding the patient-specific aTAA model, the peak stresses appeared at the distal part of the aneurysm where a tear of the intima layer was detected during surgical intervention. Peak strains exhibited for each pressure a maximum at a certain aneurysm diameter beyond which they dropped so that essentially the vessel wall's distensibility was thus reduced. Examining more than 100 geometry cases and employing a failure stress criterion, the rupture diameter thresholds were estimated to be 65, 52.5, 50 and 47.5 mm for a pressure of 120, 160, 200 and 240 mmHg respectively.
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Affiliation(s)
- Christos Manopoulos
- Laboratory of Biofluid Mechanics and Biomedical Technology, School of Mechanical Engineering, National Technical University of Athens, Athens, Greece
| | - Konstantinos Seferlis
- Laboratory of Biofluid Mechanics and Biomedical Technology, School of Mechanical Engineering, National Technical University of Athens, Athens, Greece
| | - Anastasios Raptis
- Laboratory of Biofluid Mechanics and Biomedical Technology, School of Mechanical Engineering, National Technical University of Athens, Athens, Greece
| | - Ilias Kouerinis
- 1st Department of Cardiothoracic Surgery, 'Hippocration' Hospital; National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Mathioulakis
- Laboratory of Biofluid Mechanics and Biomedical Technology, School of Mechanical Engineering, National Technical University of Athens, Athens, Greece
- School of Engineering, Bahrain Polytechnic, Isa Town, Kingdom of Bahrain
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 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. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
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.
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Ban E, Kalogerakos PD, Khosravi R, Ziganshin BA, Ellauzi H, Ramachandra AB, Zafar MA, Humphrey JD, Elefteriades JA. Extended law of laplace for measurement of the cloverleaf anatomy of the aortic root. Int J Cardiovasc Imaging 2023; 39:1345-1356. [PMID: 37046157 PMCID: PMC10250276 DOI: 10.1007/s10554-023-02847-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/27/2023] [Indexed: 04/14/2023]
Abstract
The cross-sectional shape of the aortic root is cloverleaf, not circular, raising controversy regarding how best to measure its radiographic "diameter" for aortic event prediction. We mathematically extended the law of Laplace to estimate aortic wall stress within this cloverleaf region, simultaneously identifying a new metric of aortic root dimension that can be applied to clinical measurement of the aortic root and sinuses of Valsalva on clinical computerized tomographic scans. Enforcing equilibrium between blood pressure and wall stress, finite element computations were performed to evaluate the mathematical derivation. The resulting Laplace diameter was compared with existing methods of aortic root measurement across four patient groups: non-syndromic aneurysm, bicuspid aortic valve, Marfan syndrome, and non-dilated root patients (total 106 patients, 62 M, 44 F). (1) Wall stress: Mean wall stress at the depth of the sinuses followed this equation: Wall stress = BP × Circumscribing circle diameter/(2 × Aortic wall thickness). Therefore, the diameter of the circle enclosing the root cloverleaf, that is, twice the distance between the center, where the sinus-to-commissure lines coincide, and the depth of the sinuses, may replace diameter in the Laplace relation for a cloverleaf cross-section (or any shaped cross-section with two or more planes of symmetry). This mathematically derived result was verified by computational finite element analyses. (2) Diameters: CT scan measurements showed a significant difference between this new metric, the Laplace diameter, and the sinus-to-commissure, mid-sinus-to-mid-sinus, and coronal measurements in all four groups (p-value < 0.05). The average Laplace diameter measurements differed significantly from the other measurements in all patient groups. Among the various possible measurements within the aortic root, the diameter of the circumscribing circle, enclosing the cloverleaf, represents the diameter most closely related to wall stress. This diameter is larger than the other measurements, indicating an underestimation of wall stress by prior measurements, and otherwise provides an unbiased, convenient, consistent, physics-based measurement for clinical use. "Diameter" applies to circles. Our mathematical derivation of an extension of the law of Laplace, from circular to cloverleaf cross-sectional geometries of the aortic root, has implications for measurement of aortic root "diameter." The suggested method is as follows: (1) the "center" of the aortic root is identified by drawing three sinus-to-commissure lines. The intersection of these three lines identifies the "center" of the cloverleaf. (2) The largest radius from this center point to any of the sinuses is identified as the "radius" of the aortic root. (3) This radius is doubled to give the "diameter" of the aortic root. We find that this diameter best corresponds to maximal wall stress in the aortic root. Please note that this diameter defines the smallest circle that completely encloses the cloverleaf shape, touching the depths of all three sinuses.
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Affiliation(s)
- Ehsan Ban
- Department of Biomedical Engineering, Yale University, New Haven, USA
| | | | - Ramak Khosravi
- Department of Biomedical Engineering, Yale University, New Haven, USA
| | - Bulat A Ziganshin
- Aortic Institute, Yale School of Medicine, CB-3, 789 Howard Ave., New Haven, CT, 06510, USA
| | - Hesham Ellauzi
- Aortic Institute, Yale School of Medicine, CB-3, 789 Howard Ave., New Haven, CT, 06510, USA
| | | | - Mohammad A Zafar
- Aortic Institute, Yale School of Medicine, CB-3, 789 Howard Ave., New Haven, CT, 06510, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, USA
| | - John A Elefteriades
- Aortic Institute, Yale School of Medicine, CB-3, 789 Howard Ave., New Haven, CT, 06510, USA.
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6
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Silva MLFDA, Gonçalves SDEF, Haniel J, Lucas TC, Huebner R. Comparative study between 1-way and 2-way coupled fluid-structure interaction in numerical simulation of aortic arch aneurysms. AN ACAD BRAS CIENC 2023; 95:e20210859. [PMID: 37255166 DOI: 10.1590/0001-3765202320210859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/19/2022] [Indexed: 06/01/2023] Open
Abstract
Hemodynamic forces are related to pathological variations of the cardiovascular system, and numerical simulations for fluid-structure interaction have been systematically used to analyze the behavior of blood flow and the arterial wall in aortic aneurysms. This paper proposes a comparative analysis of 1-way and 2-way coupled fluid-structure interaction for aortic arch aneurysm. The coupling models of fluid-structure interaction were conducted using 3D geometry of the thoracic aorta from computed tomography. Hyperelastic anisotropic properties were estimated for the Holzapfel arterial wall model. The rheological behavior of the blood was modeled by the Carreau-Yasuda model. The results showed that the 1-way approach tends to underestimate von Mises stress, displacement, and strain over the entire cardiac cycle, compared to the 2-way approach. In contrast, the behavior of the variables of flow field, velocity, wall shear stress, and Reynolds number when coupled by the 1-way model was overestimated at the systolic moment and tends to be equal at the diastolic moment. The quantitative differences found, especially during the systole, suggest the use of 2-way coupling in numerical simulations of aortic arch aneurysms due to the hyperelastic nature of the arterial wall, which leads to a strong iteration between the fluid and the arterial wall.
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Affiliation(s)
- Mário Luis F DA Silva
- Programa de Pós-Graduação em Engenharia Mecânica, Universidade Federal de Minas Gerais, Departamento de Engenharia Mecânica, Avenida Presidente Antônio Carlos, 6627, Pampulha, 31270-901 Belo Horizonte, MG, Brazil
| | - Saulo DE Freitas Gonçalves
- Programa de Pós-Graduação em Engenharia Mecânica, Universidade Federal de Minas Gerais, Departamento de Engenharia Mecânica, Avenida Presidente Antônio Carlos, 6627, Pampulha, 31270-901 Belo Horizonte, MG, Brazil
| | - Jonathas Haniel
- Programa de Pós-Graduação em Engenharia Mecânica, Universidade Federal de Minas Gerais, Departamento de Engenharia Mecânica, Avenida Presidente Antônio Carlos, 6627, Pampulha, 31270-901 Belo Horizonte, MG, Brazil
| | - Thabata C Lucas
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Departamento de Enfermagem, MGC 367, km 583, 5000, Alto da Jacuba, 39100-000 Diamantina, MG, Brazil
| | - Rudolf Huebner
- Universidade Federal de Minas Gerais, Departamento de Engenharia Mecânica, Avenida Presidente Antônio Carlos, 6627, Pampulha, 31270-901 Belo Horizonte, MG, Brazil
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7
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 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. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 346] [Impact Index Per Article: 173.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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8
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 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. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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9
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Gomez A, Wang Z, Xuan Y, Hope MD, Saloner DA, Guccione JM, Ge L, Tseng EE. Association of diameter and wall stresses of tricuspid aortic valve ascending thoracic aortic aneurysms. J Thorac Cardiovasc Surg 2022; 164:1365-1375. [PMID: 34275618 PMCID: PMC8716675 DOI: 10.1016/j.jtcvs.2021.05.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Ascending thoracic aortic aneurysms carry a risk of acute type A dissection. Elective repair guidelines are designed around size thresholds, but the 1-dimensional parameter of maximum diameter cannot predict acute events in small aneurysms. Biomechanically, dissection can occur when wall stress exceeds strength. Patient-specific ascending thoracic aortic aneurysm wall stresses may be a better predictor of dissection. Our aim was to compare wall stresses in tricuspid aortic valve-associated ascending thoracic aortic aneurysms based on diameter. METHODS Patients with tricuspid aortic valve-associated ascending thoracic aortic aneurysm and diameter 4.0 cm or greater (n = 221) were divided into groups by 0.5-cm diameter increments. Three-dimensional geometries were reconstructed from computed tomography images, and finite element models were developed taking into account prestress geometries. A fiber-embedded hyperelastic material model was applied to obtain longitudinal and circumferential wall stress distributions under systolic pressure. Median stresses with interquartile ranges were determined. The Kruskal-Wallis test was used for comparisons between size groups. RESULTS Peak longitudinal wall stresses for tricuspid aortic valve-associated ascending thoracic aortic aneurysm were 290 (265-323) kPa for size 4.0 to 4.4 cm versus 330 (296-359) kPa for 4.5 to 4.9 cm versus 339 (320-373) kPa for 5.0 to 5.4 cm versus 318 (293-351) kPa for 5.5 to 5.9 cm versus 373 (363-449) kPa for 6.0 cm or greater (P = 8.7e-8). Peak circumferential wall stresses were 460 (421-543) kPa for size 4.0 to 4.4 cm versus 503 (453-569) kPa for 4.5 to 4.9 cm versus 549 (430-588) kPa for 5.0 to 5.4 cm versus 540 (471-608) kPa for 5.5 to 5.9 cm versus 596 (506-649) kPa for 6.0 cm or greater (P = .0007). CONCLUSIONS Circumferential and longitudinal wall stresses are higher as diameter increases, but size groups had large overlap of stress ranges. Wall stress thresholds based on aneurysm wall strength may be a better predictor of patient-specific risk of dissection than diameter in small ascending thoracic aortic aneurysms.
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Affiliation(s)
- Axel Gomez
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, Calif
| | - Zhongjie Wang
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, Calif
| | - Yue Xuan
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, Calif
| | - Michael D Hope
- Department of Radiology & Biomedical Imaging, University of California San Francisco and San Francisco VA Medical Center, San Francisco, Calif
| | - David A Saloner
- Department of Radiology & Biomedical Imaging, University of California San Francisco and San Francisco VA Medical Center, San Francisco, Calif
| | - Julius M Guccione
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, Calif
| | - Liang Ge
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, Calif
| | - Elaine E Tseng
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, Calif.
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10
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Zamirpour S, Xuan Y, Wang Z, Gomez A, Hope MD, Leach J, Mitsouras D, Saloner DA, Guccione JM, Ge L, Tseng EE. Association of 3-Year All-Cause Mortality and Peak Wall Stresses of Ascending Thoracic Aortic Aneurysms in Veterans. Semin Thorac Cardiovasc Surg 2022; 35:447-456. [PMID: 35690227 DOI: 10.1053/j.semtcvs.2022.06.002] [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: 05/12/2022] [Accepted: 06/02/2022] [Indexed: 11/11/2022]
Abstract
Risk of aortic dissection in ascending thoracic aortic aneurysms is not sufficiently captured by size-based metrics. From a biomechanical perspective, dissection may be initiated when wall stress exceeds wall strength. Our objective was to assess the association between aneurysm peak wall stresses and 3-year all-cause mortality. Finite element analysis was performed in 273 veterans with chest computed tomography for surveillance of ascending thoracic aortic aneurysms. Three-dimensional geometries were reconstructed and models developed accounting for prestress geometries. A fiber-embedded hyperelastic material model was applied to obtain circumferential and longitudinal wall stresses under systolic pressure. Patients were followed up to 3 years following the scan to assess aneurysm repair and all-cause mortality. Fine-Gray subdistribution hazards were estimated for all-cause mortality based on age, aortic diameter, and peak wall stresses, treating aneurysm repair as a competing risk. When accounting for age, subdistribution hazard of mortality was not significantly increased by peak circumferential stresses (p = 0.30) but was significantly increased by peak longitudinal stresses (p = 0.008). Aortic diameter did not significantly increase subdistribution hazard of mortality in either model (circumferential model: p = 0.38; longitudinal model: p = 0.30). The effect of peak longitudinal stresses on subdistribution hazard of mortality was maximized at a binary threshold of 355kPa, which captured 34 of 212(16%) patients with diameter <5 cm, 11 of 36(31%) at 5.0-5.4 cm, and 11 of 25(44%) at ≥5.5 cm. Aneurysm peak longitudinal stresses stratified by age and diameter were associated with increased hazard of 3-year all-cause mortality in a veteran cohort. Risk prediction may be enhanced by considering peak longitudinal stresses.
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Affiliation(s)
- Siavash Zamirpour
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA; Joint Medical Program, School of Public Health, University of California, Berkeley, and School of Medicine, University of California, San Francisco, CA, USA
| | - Yue Xuan
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Zhongjie Wang
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Axel Gomez
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Michael D Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Joseph Leach
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Dimitrios Mitsouras
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - David A Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Julius M Guccione
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Liang Ge
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Elaine E Tseng
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA.
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11
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Gulati A, Leach J, Wang Z, Xuan Y, Hope MD, Saloner DA, Ge L, Tseng EE. Ascending thoracic aortic aneurysm growth is minimal at sizes that do not meet criteria for surgical repair. Quant Imaging Med Surg 2022; 12:333-340. [PMID: 34993082 DOI: 10.21037/qims-21-55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/17/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Historic studies of nonsyndromic ascending thoracic aortic aneurysms (aTAAs) reported that the typical aTAA growth rate was approximately 0.6 mm/year, but data were limited due to relatively few studies using computed tomography (CT) imaging. Our purpose was to reevaluate the annual growth rate of nonsyndromic aTAAs that do not meet criteria for surgical repair in veterans in the contemporary era, using modern CT imaging suitable for highly accurate and reproducible aneurysm measurement. METHODS Nonsurgical patients (diameter <5.5 cm) undergoing aneurysm surveillance at a Veterans Affairs Medical Center with repeat CT imaging performed 3 to 5 years apart were identified. Maximum diameter was determined by a single radiologist using multiplanar reformat-based measurements. Average rate of aneurysm growth was evaluated based on longest available follow-up. RESULTS Sixty-seven patients were included. Average follow-up time was 4.06±0.83 years. Patients were exclusively male, with average age of 68.1±6.0 years, and the majority had a history of smoking (n=52, 78%), hypertension (n=52, 78%), and dyslipidemia (n=48, 72%). Average baseline aneurysm diameter was 44.0±3.2 mm and average growth rate was 0.11±0.31 mm/year, with no difference in growth rate between patients with initial diameter ≤45 vs. >45 mm. Only 3 patients experienced clinically significant changes in diameter with magnitude greater than 5% of baseline. CONCLUSIONS In this veteran population, most patients did not experience significant annual aneurysm growth over up to 5 years of follow-up, regardless of initial diameter. Thus, in the modern era, aTAAs may not grow as quickly as previously described, which will be important in determining appropriate intervals for aneurysm surveillance based upon risk-benefit ratio.
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Affiliation(s)
- Arushi Gulati
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Joseph Leach
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Zhongjie Wang
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Yue Xuan
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Michael D Hope
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - David A Saloner
- Department of Radiology, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Liang Ge
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Elaine E Tseng
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco Medical Center and San Francisco VA Medical Center, San Francisco, CA, USA
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12
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Atlas-Based Evaluation of Hemodynamic in Ascending Thoracic Aortic Aneurysms. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app12010394] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Atlas-based analyses of patients with cardiovascular diseases have recently been explored to understand the mechanistic link between shape and pathophysiology. The construction of probabilistic atlases is based on statistical shape modeling (SSM) to assess key anatomic features for a given patient population. Such an approach is relevant to study the complex nature of the ascending thoracic aortic aneurysm (ATAA) as characterized by different patterns of aortic shapes and valve phenotypes. This study was carried out to develop an SSM of the dilated aorta with both bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV), and then assess the computational hemodynamic of virtual models obtained by the deformation of the mean template for specific shape boundaries (i.e., ±1.5 standard deviation, σ). Simulations demonstrated remarkable changes in the velocity streamlines, blood pressure, and fluid shear stress with the principal shape modes such as the aortic size (Mode 1), vessel tortuosity (Mode 2), and aortic valve morphologies (Mode 3). The atlas-based disease assessment can represent a powerful tool to reveal important insights on ATAA-derived hemodynamic, especially for aneurysms which are considered to have borderline anatomies, and thus challenging decision-making. The utilization of SSMs for creating probabilistic patient cohorts can facilitate the understanding of the heterogenous nature of the dilated ascending aorta.
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13
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Patient-Specific Analysis of Ascending Thoracic Aortic Aneurysm with the Living Heart Human Model. Bioengineering (Basel) 2021; 8:bioengineering8110175. [PMID: 34821741 PMCID: PMC8615119 DOI: 10.3390/bioengineering8110175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 01/11/2023] Open
Abstract
In ascending thoracic aortic aneurysms (ATAAs), aneurysm kinematics are driven by ventricular traction occurring every heartbeat, increasing the stress level of dilated aortic wall. Aortic elongation due to heart motion and aortic length are emerging as potential indicators of adverse events in ATAAs; however, simulation of ATAA that takes into account the cardiac mechanics is technically challenging. The objective of this study was to adapt the realistic Living Heart Human Model (LHHM) to the anatomy and physiology of a patient with ATAA to assess the role of cardiac motion on aortic wall stress distribution. Patient-specific segmentation and material parameter estimation were done using preoperative computed tomography angiography (CTA) and ex vivo biaxial testing of the harvested tissue collected during surgery. The lumped-parameter model of systemic circulation implemented in the LHHM was refined using clinical and echocardiographic data. The results showed that the longitudinal stress was highest in the major curvature of the aneurysm, with specific aortic quadrants having stress levels change from tensile to compressive in a transmural direction. This study revealed the key role of heart motion that stretches the aortic root and increases ATAA wall tension. The ATAA LHHM is a realistic cardiovascular platform where patient-specific information can be easily integrated to assess the aneurysm biomechanics and potentially support the clinical management of patients with ATAAs.
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14
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Xuan Y, D'Souza SN, Wang Z, Pierre AS, Lawton JS, Ge L, Tseng EE. Patient-Specific Biomechanics in Marfan Ascending Thoracic Aortic Aneurysms. Ann Thorac Surg 2021; 114:1367-1375. [PMID: 34416226 DOI: 10.1016/j.athoracsur.2021.07.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/11/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Guidelines for Sinus of Valsalva-thoracic aortic aneurysms (SOV-TAA) in Marfan syndrome recommend size-based criteria for elective surgical repair. Biomechanics may provide a better prediction of dissection risk than diameter. Our aim was to determine magnitudes of wall stress in the aortic root of Marfan patients using finite element analyses. METHODS Forty-six Marfan patients underwent patient-specific 3D SOV-TAA geometry reconstruction using imaging data. Finite element analyses were performed to determine wall stress distributions at SOV, sinotubular junction (STJ), and ascending aorta (AscAo) at systole. RESULTS Peak circumferential stresses were 432.8±111kPa, 408.1±88.3kPa, and 321.9±83.8kPa at the SOV, STJ, and AscAo, respectively with significant differences between SOV and AscAo (p<3.08E-07), and STJ and AscAo (p<2.26E-06). Peak longitudinal wall stresses were 352±73.9kPa, 277.5±89.5kPa, and 200.6±81kPa at SOV, STJ, and AscAo, respectively with significant differences between SOV and STJ (p< 6.01E-06), SOV and AscAo (p< 9.79E-13), and STJ and AscAo (p< 3.34E-07). Diameter was not correlated to wall stresses. Comparison of wall stresses in aneurysm <5cm vs ≥5cm and <4.5cm vs ≥4.5 showed no significant differences in wall stresses in the circumferential or longitudinal direction. CONCLUSIONS Peak wall stresses in Marfan SOV-TAA were greatest in SOV than STJ than AscAo. Diameter was poorly correlated to peak stresses such that current guidelines with 5cm cutoff had significant overlap in peak stresses in patients with <5cm vs ≥5cm. Use of patient-specific Marfan aneurysm models may identify patients with high wall stresses and small aneurysms who could benefit from earlier surgical repair to prevent aortic dissection.
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Affiliation(s)
- Yue Xuan
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California
| | - Sara N D'Souza
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California
| | - Zhongjie Wang
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California
| | - Alejandro Suarez Pierre
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Liang Ge
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California
| | - Elaine E Tseng
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California.
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15
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DeAnda A, Rajagopal K, Griffith BE. Commentary: Diameter and wall stress-Wrong Laplace, wrong time? J Thorac Cardiovasc Surg 2021; 164:1376-1377. [PMID: 34217538 DOI: 10.1016/j.jtcvs.2021.06.020] [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: 06/14/2021] [Revised: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Abe DeAnda
- Division of Cardiovascular and Thoracic Surgery, UTMB-Galveston, Galveston, Tex.
| | - Keshava Rajagopal
- Department of Clinical Sciences, University of Houston College of Medicine, Houston, Tex; Houston Heart, HCA Houston Healthcare, Houston, Tex
| | - Boyce E Griffith
- Carolina Center for Interdisciplinary Applied Mathematics, University of North Carolina, Chapel Hill, NC; Computational Medicine Program, University of North Carolina, Chapel Hill, NC; McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
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16
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Wang Y, Zhang Y, Wen Z, Tian B, Kao E, Liu X, Xuan W, Ordovas K, Saloner D, Liu J. Deep learning based fully automatic segmentation of the left ventricular endocardium and epicardium from cardiac cine MRI. Quant Imaging Med Surg 2021; 11:1600-1612. [PMID: 33816194 DOI: 10.21037/qims-20-169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background The segmentation of cardiac medical images is a crucial step for calculating clinical indices such as wall thickness, ventricular volume, and ejection fraction. Methods In this study, we introduce a method named LsUnet that combines multi-channel, fully convolutional neural network, and annular shape level-set methods for efficiently segmenting cardiac cine magnetic resonance (MR) images. In this method, the multi-channel deep learning algorithm is applied to train the segmentation task to extract the left ventricle (LV) endocardial and epicardial contours. Next, the segmentation contours from the multi-channel deep learning method are incorporated into a level-set formulation, which is dedicated explicitly to detecting annular shapes to assure the segmentation's accuracy and robustness. Results The proposed automatic approach was evaluated on 95 volumes (total 1,076 slices, ~80% as for training datasets, ~20% 2D as for testing datasets). This combined multi-channel deep learning and annular shape level-set segmentation method achieved high accuracy with average Dice values reaching 92.15% and 95.42% for LV endocardium and epicardium delineation, respectively, in comparison to the reference standard (the manual segmentation). Conclusions A novel method for fully automatic segmentation of the LV endocardium and epicardium from different MRI datasets is presented. The proposed workflow is accurate and robust compared to the reference and other state-of-the-art methods.
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Affiliation(s)
- Yan Wang
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Yue Zhang
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA.,Department of Radiology, Veterans Affairs Medical Center, San Francisco, USA
| | - Zhaoying Wen
- Department of Radiology, Anzhen Hospital, Beijing, China
| | - Bing Tian
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Evan Kao
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Xinke Liu
- Department of Interventional Neuroradiology, Capital Medical University, Beijing Tiantan Hospital, Beijing, China
| | - Wanling Xuan
- Medical College of Georgia at Augusta University, Augusta, USA
| | - Karen Ordovas
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA.,Department of Radiology, Veterans Affairs Medical Center, San Francisco, USA
| | - Jing Liu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
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17
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Estimating aortic thoracic aneurysm rupture risk using tension-strain data in physiological pressure range: an in vitro study. Biomech Model Mechanobiol 2021; 20:683-699. [PMID: 33389275 DOI: 10.1007/s10237-020-01410-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/02/2020] [Indexed: 12/17/2022]
Abstract
Previous studies have shown that the rupture properties of an ascending thoracic aortic aneurysm (ATAA) are strongly correlated with the pre-rupture response features. In this work, we present a two-step machine learning method to predict where the rupture is likely to occur in ATAA and what safety reserve the structure may have. The study was carried out using ATAA specimens from 15 patients who underwent surgical intervention. Through inflation test, full-field deformation data and post-rupture images were collected, from which the wall tension and surface strain distributions were computed. The tension-strain data in the pressure range of 9-18 kPa were fitted to a third-order polynomial to characterize the response properties. It is hypothesized that the region where rupture is prone to initiate is associated with a high level of tension buildup. A machine learning method is devised to predict the peak risk region. The predicted regions were found to match the actual rupture sites in 13 samples out of the total 15. In the second step, another machine learning model is utilized to predict the tissue's rupture strength in the peak risk region. Results suggest that the ATAA rupture risk can be reasonably predicted using tension-strain response in the physiological range. This may open a pathway for evaluating the ATAA rupture propensity using information of in vivo response.
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18
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Tseng EE, Wang Z, Ge L. Reply from authors: Aortic aneurysm biomechanics: Perfect is the enemy of good. J Thorac Cardiovasc Surg 2020; 160:e105-e106. [PMID: 32595031 PMCID: PMC8505005 DOI: 10.1016/j.jtcvs.2020.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Elaine E Tseng
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, Calif
| | - Zhongjie Wang
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, Calif
| | - Liang Ge
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, Calif
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19
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Ma W, Liang Y, Wang C. Assessment of wall stress distribution in thoracic ascending aortic aneurysm: Simulation, prediction, and prevention. J Thorac Cardiovasc Surg 2020; 160:e101. [PMID: 32653279 DOI: 10.1016/j.jtcvs.2020.04.178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Wenrui Ma
- Department of Cardiac Surgery, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yulin Liang
- Division of Mechanics, Dalian Jiao Tong University, Dalian, China
| | - Chunsheng Wang
- Department of Cardiac Surgery, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
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20
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Reply: Accurate evaluation of the risk of acute aortic events: Still room for improvement. J Thorac Cardiovasc Surg 2020; 160:e102-e103. [PMID: 32620400 DOI: 10.1016/j.jtcvs.2020.04.146] [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: 04/24/2020] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 11/23/2022]
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21
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Etz CD, Haunschild J, Girdauskas E, Della Corte A, Fedak PWM, Schäfers HJ, Sundt TM, Borger MA. Surgical management of the aorta in BAV patients. Prog Cardiovasc Dis 2020; 63:475-481. [PMID: 32640281 DOI: 10.1016/j.pcad.2020.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 12/12/2022]
Abstract
Patients with a bicuspid aortic valve (BAV) frequently develop aneurysms of the aortic root and tubular ascending aorta. Aneurysms of the aortic arch, in the absence of concomitant aortopathies, are much less common. According to the 2018 American Association of Thoracic Surgery consensus guidelines on BAV-related aortopathy, prophylactic surgical aortic repair / replacement is recommended starting at a maximum aortic diameter of 50 mm in patients with risk factors. Concomitant aortic surgery is also recommended at an aortic diameter of 45 mm in those patients with other indications for cardiac surgery (most commonly aortic valve procedures). The ultimate goal of prophylactic aortic surgery is the prevention of aortic catastrophes, e.g. aortic rupture or acute aortic dissection, which are associated with high morbidity and mortality. The surgical technique used - in elective and emergency cases - depends on the involvement and nature of the aortic valve disease, as well as the extent of aortic aneurysm formation. The current review focusses on the surgical management of the aortic root, tubular ascending aorta, and proximal aortic arch in BAV patients. Despite the abovementioned recommendations, many BAV patients develop acute aortic syndromes below the recommended aortic diameter thresholds. Further research is therefore required in order to identify high-risk BAV subgroups that would benefit from earlier surgical repair.
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Affiliation(s)
- Christian D Etz
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Paul W M Fedak
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Canada
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Michael A Borger
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
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22
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Bakaeen FG, Roselli EE, Svensson LG. Reply: Novel aortic imaging modalities: Mine detectors or just metal detectors. J Thorac Cardiovasc Surg 2020; 160:e102. [PMID: 32482402 DOI: 10.1016/j.jtcvs.2020.04.109] [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: 04/20/2020] [Revised: 04/20/2020] [Accepted: 04/20/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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23
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Commentary: Do not "futz" with Laplace. J Thorac Cardiovasc Surg 2020; 162:1463-1466. [PMID: 32448689 DOI: 10.1016/j.jtcvs.2020.03.008] [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: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/20/2022]
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Carrel T, Schoenhoff F. Commentary: Diameter alone is not precise enough but wall stress analysis may facilitate decision-making for indications for prophylactic aortic repair. J Thorac Cardiovasc Surg 2020; 162:1461-1462. [PMID: 32345463 DOI: 10.1016/j.jtcvs.2020.02.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Thierry Carrel
- Department for Cardiovascular Surgery, University Hospital and University of Bern, Bern, Switzerland.
| | - Florian Schoenhoff
- Department for Cardiovascular Surgery, University Hospital and University of Bern, Bern, Switzerland
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25
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Bakaeen FG, Roselli EE, Svensson LG. Commentary: Thoracic aortas: More to stress about than just size. J Thorac Cardiovasc Surg 2020; 162:1460-1461. [PMID: 32171484 DOI: 10.1016/j.jtcvs.2020.02.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Faisal G Bakaeen
- Aorta Center, Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Eric E Roselli
- Aorta Center, Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Aorta Center, Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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