Depressed Ejection Fraction Does Not Affect Perioperative Mortality After Thoracic Endovascular Aortic Repair for Type B Aortic Dissection

BACKGROUND

Despite the expanded application of thoracic endovascular aortic repair (TEVAR) in patients with significant cardiac comorbidities, the effect of decreased left ventricular ejection fraction (EF) on outcomes remains unknown. The aim of this study was to compare outcomes in patients with normal and abnormal EFs undergoing TEVAR for type-B aortic dissection (TBAD).

METHODS

The Vascular Quality Initiative database was reviewed from 2012 to 2020. Patients were categorized into severely reduced (EF ≤ 30%), reduced (EF 30-50%) and normal EF (EF>50%). Baseline characteristics, procedural details and 18-month outcomes were compared. Multivariable logistic regression identified factors associated with mortality, major adverse cardiac events (MACEs), and aortic-related reintervention.

RESULTS

Of 1,993 patients, 38 (2%) and 208 (10%) patients had severely reduced ejection fraction (SREF) and reduced ejection fraction (REF). Patients with abnormal EF were more likely to have cardiac comorbidities and be prescribed angiotensin-converting enzyme inhibitors and anticoagulants. Perioperatively, patients with SREF were more likely to experience mortality (13.2% vs. 6.7% vs. 4.4%, P = 0.018), MACE (26.3% vs. 11.5% vs. 8%, P < 0.001), hemodialysis (13.5% vs. 5% vs. 2.9%, P = 0.001) and aortic related reintervention (21.1% vs. 13% vs. 10%, P = 0.041), compared to REF and normal ejection fraction (NEF) patients. However, these associations were not present on multivariable analysis. At 18 months, mortality was significantly higher in patients with SREF, which was confirmed on multivariable analysis, but depressed EF was not associated with increased aortic reintervention compared to NEF.

CONCLUSIONS

SREF was not independently associated with perioperative mortality or MACE compared to NEF. REF had similar risk of morbidity and mortality compared to NEF in both the perioperative and early postoperative periods. TEVAR-related complications were similar among the cohorts. As such, TEVAR may be offered to appropriately selected patients regardless of EF.

Postendovascular Aneurysmal Repair Increase in Local Energy Loss for Fusiform Abdominal Aortic Aneurysm: Assessments With 4D flow MRI

BACKGROUND

Although endovascular aneurysmal repair (EVAR) is a preferred treatment for abdominal aortic aneurysm (AAA) owing to its low invasiveness, its impact on the local hemodynamics has not been fully assessed.

PURPOSE

To elucidate how EVAR affects the local hemodynamics in terms of energy loss (EL).

STUDY TYPE

Prospective single-arm study.

FIELD STRENGTH/SEQUENCE

A 3.0 T/4D flow MRI using a phase-contrast three-dimensional cine-gradient-echo sequence.

POPULATION

A total of 13 consecutive patients (median [interquartile range] age: 77.0 [73.0, 78.8] years, 11 male) scheduled for EVAR as an initial treatment for fusiform AAA.

ASSESSMENT

4D flow MRI covering the abdominal aorta and bilateral common iliac arteries and the corresponding stent-graft (SG) lumen was performed before and after EVAR. Plasma brain natriuretic peptide (BNP) was measured within 1 week before and 1 month after EVAR. The hemodynamic data, including mean velocity and the local EL, were compared pre-/post-EVAR. EL was correlated with AAA neck angle and with BNP. Patients were subdivided into deformed (N = 5) and undeformed SG subgroups (N = 8) and pre-/post-EVAR BNP compared in each.

STATISTICS

Parametric or nonparametric methods. Spearman's rank correlation coefficients (r). The interobserver/intraobserver variabilities with Bland-Altman plots. A P value < 0.05 is considered significant.

RESULTS

The mean velocity (cm/sec) at the AAA was five times greater after EVAR: 4.79 ± 0.32 vs. 0.91 ± 0.02. The total EL (mW) increased by 1.7 times after EVAR: 0.487 (0.420, 0.706) vs. 0.292 (0.192, 0.420). The total EL was proportional to the AAA neck angle pre-EVAR (r = 0.691) and post-EVAR (r = 0.718). BNP (pg/mL) was proportional to the total EL post-EVAR (r = 0.773). In the deformed SG group, EL (0.349 [0.261, 0.416]) increased 2.4-fold to 0.848 (0.597, 1.13), and the BNP 90.3 (53.6, 105) to 100 (67.2, 123) post-EVAR.

CONCLUSION

The local EL showed a 1.7-fold increase after EVAR. The larger increase in the EL in the deformed SG group might be a potential concern for frail patients.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 2.

Reflected wave intensity increases based on aortic diameter after endovascular aortic therapy in a goat model

Reflected wave increases after endovascular aortic repair (EVAR) in patients with aortic aneurysm. This affects the left ventricular (LV) diastolic function and leads to a poor prognosis. This study aimed to evaluate the relationship between increased reflected wave amplitude and aortic diameter after EVAR. EVAR was performed in seven healthy goats. We assessed wave intensity (WI), aortic diameter, and stiffness parameter β. Moreover, we evaluated the relationship between negative reflected wave (NW, reflected waves toward the heart from the periphery by WI) and other parameters after EVAR. Results showed an increase in stiffness parameter β (3.5 ± 0.3 vs 15.9 ± 4.7, p = 0.018) and a decrease in the change of aortic diameter (6.9 ± 0.7 vs 2.7 ± 0.4%, p = 0.018) after EVAR. The NW was significantly amplified after EVAR from baseline (−589.8 ± 143.4 to  − 1192.3 ± 303.7 mmHg-m/sec³, p = 0.043). The NW showed a significant correlation with maximum aortic diameter (R = 0.707, p = 0.038) and minimum aortic diameter (R = 0.724, p = 0.033). The reflected wave was enhanced after EVAR and was correlated to the aortic diameter at the stent-graft site. It is important to consider that patients with smaller aortic diameters in landing zone who undergo EVAR may develop LV dysfunction.

Determinants of Changes in Arterial Stiffness after Thoracic Endovascular Aortic Repair

BACKGROUND

Aortic stent grafting can cause aortic stiffening and increase pulse wave velocity (PWV), which can potentially affect long-term cardiovascular outcomes. The aim of this study was to clarify the factors contributing to increases in PWV after thoracic endovascular aortic repair (TEVAR).

METHODS

We included 64 patients with thoracic aortic pathology (51 men; mean age, 73 years) who underwent elective TEVAR, in this study. TEVAR was performed for degenerative aortic aneurysm (n = 43) or aortic dissection (n = 21), and the treatment length was 175 ± 52 mm. Brachial-ankle PWV (baPWV) was obtained before and 1 week after TEVAR. Univariable and multivariable logistic regression analyses were used to determine the predictors of increases in baPWV of ≥100 cm/sec after TEVAR.

RESULTS

baPWV increased from 1,851 ± 392 cm/sec to 2,047 ± 479 cm/sec, and the change in baPWV (ΔbaPWV) was 195 ± 339 cm/sec (95% confidence interval, 111-280). Thirty-seven patients (58%) had ΔbaPWV ≥100 cm/sec after TEVAR. In the multivariable analysis, in addition to Δheart rate and Δsystolic blood pressure, age (odds ratio, 1.21/year; 95% confidence interval, 1.05-1.40) and coronary artery disease (odds ratio, 12.0; 95% confidence interval, 1.20-121) were independent determinants of ΔbaPWV ≥100 cm/sec after TEVAR, whereas ΔbaPWV ≥100 cm/sec was not associated with treatment length or device type.

CONCLUSIONS

TEVAR was associated with PWV progression, especially in older patients with coronary artery disease, whereas treatment length or device type was not a predictor of PWV progression after TEVAR.