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Fu Y, Huang S, Zhao D, Qiu P, Hu J, Liu X, Lu X, Feng L, Hu M, Cheng Y. Establishing and Validating a Morphological Prediction Model Based on CTA to Evaluate the Incidence of Type-B Dissection. Diagnostics (Basel) 2023; 13:3130. [PMID: 37835873 PMCID: PMC10572133 DOI: 10.3390/diagnostics13193130] [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: 08/21/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
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.
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Affiliation(s)
- Yan Fu
- Department of Nursing, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200011, China; (Y.F.)
| | - Siyi Huang
- Department of Nursing, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200011, China; (Y.F.)
| | - Deyin Zhao
- Second Ward of General Surgery, Suzhou Hospital of Anhui Medical University (Suzhou Municipal Hospital of Anhui Province), Suzhou 234000, China;
| | - Peng Qiu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Jiateng Hu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Xiaobing Liu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Lvfan Feng
- Shanghai Health Development Research Center (Shanghai Medical Information Center), Shanghai 200031, China
| | - Min Hu
- Department of Nursing, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200011, China; (Y.F.)
| | - Yong Cheng
- Department of Nursing, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200011, China; (Y.F.)
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Sapalo AT. The moment has arrived to consider the combination of echocardiography and transabdominal ultrasound for accurate diagnosis in cases of aortic dissection. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1318-1320. [PMID: 37665270 DOI: 10.1002/jcu.23552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 09/05/2023]
Affiliation(s)
- André Timóteo Sapalo
- Laboratory of Echocardiography at the Cardiology Center, Department of Clinical Medicine at the Ribeirão Preto Medical School, Ribeirão Preto Clinic Hospital, University of São Paulo, São Paulo, Brazil
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Al-Tawil M, Geragotellis A, Jubouri M, Tan SZ, Mohammed I, Williams I, Bashir M. Population risk profile analysis of acute uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair. Asian Cardiovasc Thorac Ann 2023; 31:549-556. [PMID: 35532028 DOI: 10.1177/02184923221099771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Uncomplicated type B aortic dissection (unTBAD) comprises the estimated majority of type B aortic dissection (TBAD), presenting without any of the complications associated with complicated TBAD (coTBAD). Although first-line treatment for coTBAD is thoracic endovascular aortic repair (TEVAR), and despite the fact that TEVAR has proven its safety and effectiveness in the treatment of unTBAD, unTBAD is still being predominantly managed conservatively with medical therapy, with a small proportion of patients being offered TEVAR. AIMS The main scope of this review is to highlight the evidence in the literature of the demographic characteristics and associated co-morbidities of unTBAD patients undergoing TEVAR in order to produce a risk stratification system to achieve favourable outcomes. METHODS A comprehensive literature search was conducted using multiple electronic databases including PubMed, Ovid, Scopus, and EMBASE. RESULTS Multiple demographic characteristics and associated co-morbidities of unTBAD patients affecting TEVAR outcomes were identified, assessed, and investigated, including age, gender, race, genetics, medical conditions, such as hypertension and diabetes, and lifestyle factors such as smoking. Most factors were associated with increased risks of mortality and morbidity, while others, such as race, were identified as being protective against those when it comes to TEVAR. CONCLUSION Despite the favourable results yielded by TEVAR in unTBAD, there remains a grey area concerning its management. Thus, it is important to incorporate the demographics and co-morbidities of unTBAD patients' when into clinical judgement when assessing indications for TEVAR intervention to ensure optimum results can be achieved.
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Affiliation(s)
| | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, UK
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Galian-Gay L, Pijuan-Domenech A, Cantalapiedra-Romero J, Serrano B, Goya M, Maiz N, Casellas M, Manrique S, Suàrez-Edo E, Miranda-Barrio B, Gordon Ramirez B, Teixidó-Turà G, Gutierrez-Moreno L, González-Fernández V, Dux-Santoy L, Guala A, Evangelista A, Dos-Subirà L, Rodriguez-Palomares JF, Ferreira-Gonzalez I. Pregnancy-related aortic complications in women with bicuspid aortic valve. Heart 2023:heartjnl-2022-322328. [PMID: 37147129 DOI: 10.1136/heartjnl-2022-322328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/05/2023] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES To describe the aortic-related risks associated with pregnancy in women with bicuspid aortic valve (BAV) and to evaluate changes in aortic diameter in pregnancy. METHODS Prospective observational study of patients with BAV from a single-site registry of pregnant women with structural heart disease between 2013 and 2020. Cardiac, obstetric and neonatal outcomes were studied. An assessment of aortic dimensions was performed during pregnancy by two-dimensional echocardiography. Aortic diameters were measured at the annulus, root, sinotubular junction and maximum ascending aorta diameter, and the largest diameter was used. Measurements of the aorta were made using the end-diastolic leading edge-to-leading edge convention. RESULTS Forty-three women (32.9 years, IQR 29.6-35.3) with BAV were included: 9 (20.9%) had repaired aortic coarctation; 23 (53.5%) had moderate or severe aortic valve disease; 5 (11.6%) had a bioprosthetic aortic valve; and 2 (4.7%) had a mechanical prosthetic aortic valve. Twenty (47.0%) were nulliparous. The mean aortic diameter in the first trimester was 38.5 (SD 4.9) mm, and that in the third trimester was 38.4 (SD 4.8) mm. Forty (93.0%) women had an aortic diameter of <45 mm; 3 (7.0%) had 45-50 mm; and none had >50 mm. Three women (6.9%) with BAV presented cardiovascular complications during pregnancy or the postpartum period (two prosthetic thrombosis and one heart failure). No aortic complications were reported. There was a small but significant increase in aortic diameter during pregnancy (third trimester vs first trimester, 0.52 (SD 1.08) mm; p=0.03). Obstetric complications appeared in seven (16.3%) of pregnancies, and there were no maternal deaths. Vaginal non-instrumental delivery was performed in 21 (51.2%) out of 41 cases. There were no neonatal deaths, and the mean newborn weight was 3130 g (95% CI 2652 to 3380). CONCLUSIONS Pregnancy in BAV women had a low rate of cardiac complications with no aortic complications observed in a small study group. Neither aortic dissection nor need for aortic surgery was reported. A low but significant aortic growth was observed during pregnancy. Although requiring follow-up, the risk of aortic complications in pregnant women with BAV and aortic diameters of <45 mm at baseline is low.
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Affiliation(s)
- Laura Galian-Gay
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Javier Cantalapiedra-Romero
- Integrated Vall d'Hebron - Sant Pau Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Berta Serrano
- Department of Obstetrics and Gynaecology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Maria Goya
- Obstetrics, Maternal Fetal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Nerea Maiz
- Department of Obstetrics and Gynaecology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Manel Casellas
- Department of Obstetrics and Gynaecology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Susana Manrique
- Department of Anesthesiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Elena Suàrez-Edo
- Department of Anesthesiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Blanca Gordon Ramirez
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Integrated Vall d'Hebron - Sant Pau Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gisela Teixidó-Turà
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | - Lydia Dux-Santoy
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Andrea Guala
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Laura Dos-Subirà
- Adult Congenital Heart Disease Unit, Hospital Vall d'Hebron, Barcelona, Spain
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Sawyer JM, Moridzadeh N, Bavolek RA. Cardiovascular Complications of Pregnancy. Emerg Med Clin North Am 2023; 41:247-258. [PMID: 37024161 DOI: 10.1016/j.emc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The physiologic changes in pregnancy predispose the pregnant patient to a variety of potential cardiovascular complications. In this article, we discuss the major cardiovascular disorders of pregnancy and their management, highlight specific diagnostic challenges, and discuss new developments in the field. Topics covered in this article include venous thromboembolism, acute myocardial infarction, peripartum cardiomyopathy, and aortic dissection.
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Affiliation(s)
- John Mark Sawyer
- UCLA Ronald Reagan, Olive View Emergency Medicine Residency, 1100 Glendon Avenue, Suite 1200, Los Angeles, CA 90024, USA.
| | | | - Rebecca A Bavolek
- UCLA Ronald Reagan, Olive View Emergency Medicine Residency, 1100 Glendon Avenue, Suite 1200, Los Angeles, CA 90024, USA
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Dong J, Ma X. Uncommon Female-Predominant Etiologies of Cryptogenic Stroke. Front Neurol 2022; 13:900991. [PMID: 35812089 PMCID: PMC9263352 DOI: 10.3389/fneur.2022.900991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
The etiologies of cryptogenic stroke are complex and heterogeneous. A number of uncommon etiologies are not fully recognized, some of which predominantly affect females. Most of these etiologies are closely related to the hormonal level, reproductive factors, coagulation function, and medications of females. Moreover, once cryptogenic stroke is diagnosed, females tend to have worse outcomes. Therefore, prompt etiological recognition and treatment are crucial for good recovery. The aim of this article is to review advances in exploring uncommon female-predominant etiologies of cryptogenic stroke. These etiologies are categorized into arterial, cardiac, and venous sources. Arterial vasoconstrictive narrowing, intimal injury, and intimal developmental abnormality can cause brain ischemia or artery-to-artery cerebral embolism. Myocardial contraction dysfunction, cardiac wall injury, and developmental abnormality can induce intracardiac thrombosis and lead to cardiac embolism. In addition, cortical venous thrombosis and occult venous thromboembolism via intracardiac or extracardiac channels also account for cryptogenic stroke in females. Due to the lack of knowledge, in clinical practice, the above etiologies are seldom assessed. The low incidence rate of these etiologies can lead to missed diagnosis. This review will provide novel clinical clues for the etiological diagnosis of cryptogenic stroke and will help to improve the management and secondary prevention of stroke in the female population. In the future, more studies are needed to explore the etiology and prevention strategies of cryptogenic stroke.
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Affiliation(s)
- Jing Dong
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Geriatric Disorders, Beijing, China
- Clinical Center for Cardio-Cerebrovascular Disease of Capital Medical University, Beijing, China
- *Correspondence: Xin Ma
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Ayati A, Sarraf S, Asl Fallah S, Bagheri J, Ahmadi Tafti H, Same K, Hosseini K. Aortic dissection in the first trimester; is it a dead end? A narrative review of recent articles. J Card Surg 2022; 37:1705-1711. [PMID: 35352396 DOI: 10.1111/jocs.16451] [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: 12/29/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Acute-type aortic dissection (AD) during pregnancy is considered a rare and potentially fatal complication for both mother and fetus. Although the definite treatment for an acute-type AD is considered to be open-heart surgery, the decision to perform such a surgery during pregnancy requires a multidisciplinary approach and carries significant risks. METHODS In the present review of the literature, we have discussed various challenges in the management of acute-type AD during pregnancy, including therapeutic approaches, choosing the preferred imaging modalities, surgical techniques, and medication challenges. We have also reported an 8-week pregnant woman with Marfan syndrome who presented with chest pain and was diagnosed with acute AD. RESULTS The patient underwent a Bentall operation and was discharged in good condition with her fetus alive. The medical team's various decisions during preoperative, operative, and postoperative treatments were discussed. CONCLUSIONS Type A AD is considered infrequent in the second and third trimester of pregnancy and rare in the first trimester. Performing a CMR study without contrast in stable patients can help evaluate the extension of the flap. Urgent surgery in the hands of a skilled surgeon may prove lifesaving for the mother while maximizing the likelihood of preserving the fetus.
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Affiliation(s)
- Aryan Ayati
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Syna Sarraf
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Asl Fallah
- Rajaie Cardiovascular Medical And Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jamshid Bagheri
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi Tafti
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Advanced Technologies in Cardiovascular Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Same
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Russo M, Boehler-Tatman M, Albright C, David C, Kennedy L, Roberts AW, Shalhub S, Afifi R. Aortic dissection in pregnancy and the postpartum period. Semin Vasc Surg 2022; 35:60-68. [PMID: 35501042 DOI: 10.1053/j.semvascsurg.2022.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 01/18/2023]
Abstract
Pregnancy-associated aortic dissection (AD) is a rare event, with an incidence of 0.0004% per pregnancy. The work of the Aortic Dissection Collaborative identified pregnancy-associated AD as a high-priority topic, despite its rarity. The Pregnancy Working Group, which included physicians and patient stakeholders, performed a systematic literature review of pregnancy-associated AD from 1960 to 2021 and identified 6,333 articles through PubMed, OVID MEDLINE, Cochrane, Embase, CINAHL and Web of Science. The inclusion criterion was AD in pregnant populations and exclusion criteria were case reports, conference abstracts, and languages other than English. Assessment of full-text articles for eligibility after removal of duplicates from all databases yielded 68 articles to be included in the final review. Topics included were timing of AD in pregnancy, type of AD, and management considerations of pregnancy-associated AD. The Pregnancy Working Group identified gaps in knowledge and future areas of research for pregnancy-associated AD, including clinical management, mental health outcomes post AD, reproductive and genetic counseling, and contraception after AD. Future collaborative projects could be a multicenter, international registry for all pregnancy-associated AD to refine the risk factors, best practice and management of AD in pregnancy. In addition, future mixed methodology studies may be useful to explore social, mental, and emotional factors related to pregnancy-associated AD and to determine support groups' effect on anxiety and depression related to these events in the pregnancy and postpartum period.
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Affiliation(s)
- Melissa Russo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, Warren Alpert Medical School of Brown University, Providence, RI
| | | | - Catherine Albright
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, WA
| | - Carmen David
- Aortic Dissection Collaborative Patient Stakeholder Group, Bedford, TX
| | | | - Aaron W Roberts
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Rana Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), 6400 Fannin Street, Suite #2850, Houston, TX 77030.
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Ascione G, Morello F, Bonaccorsi L, Ranaldi F, Santosuosso U, Nazerian P. History taking for suspected acute aortic syndrome: other predictors outside the aortic dissection detection risk score bundle? Intern Emerg Med 2021; 16:2307-2308. [PMID: 34115288 DOI: 10.1007/s11739-021-02785-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Giovanni Ascione
- Department of Emergency Medicine, Careggi University Hospital, largo Brambilla 3, 50134, Firenze, Italy
| | - Fulvio Morello
- S.C. Medicina d'Urgenza, Ospedale Molinette, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Lorella Bonaccorsi
- Department of Clinical and Experimental Medicine, University of Firenze, Firenze, Italy
| | - Francesco Ranaldi
- Department of Clinical and Experimental Medicine, University of Firenze, Firenze, Italy
| | - Ugo Santosuosso
- Department of Clinical and Experimental Medicine, University of Firenze, Firenze, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, largo Brambilla 3, 50134, Firenze, Italy.
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Beyer SE, Dicks AB, Shainker SA, Feinberg L, Schermerhorn ML, Secemsky EA, Carroll BJ. Pregnancy-associated arterial dissections: a nationwide cohort study. Eur Heart J 2021; 41:4234-4242. [PMID: 32728725 DOI: 10.1093/eurheartj/ehaa497] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/08/2020] [Accepted: 05/28/2020] [Indexed: 12/27/2022] Open
Abstract
AIMS Pregnancy is a known risk factor for arterial dissection, which can result in significant morbidity and mortality in the peripartum period. However, little is known about the risk factors, timing, distribution, and outcomes of arterial dissections associated with pregnancy. METHODS AND RESULTS We included all women ≥12 years of age with hospitalizations associated with pregnancy and/or delivery in the Nationwide Readmissions Database between 2010 and 2015. The primary outcome was any dissection during pregnancy, delivery, or the postpartum period (42-days post-delivery). Secondary outcomes included timing of dissection, location of dissection, and in-hospital mortality. Among 18 151 897 pregnant patients, 993 (0.005%) patients were diagnosed with a pregnancy-related dissection. Risk factors included older age (32.8 vs. 28.0 years), multiple gestation (3.6% vs. 1.9%), gestational diabetes (14.3% vs. 0.2%), gestational hypertension (6.0% vs. 0.6%), and pre-eclampsia/eclampsia (2.7% vs. 0.4%), in addition to traditional cardiovascular risk factors. Of the 993 patients with dissection, 150 (15.1%) dissections occurred in the antepartum period, 232 (23.4%) were diagnosed during the admission for delivery, and 611 (61.5%) were diagnosed in the postpartum period. The most common locations for dissections were coronary (38.2%), vertebral (22.9%), aortic (19.8%), and carotid (19.5%). In-hospital mortality was 3.7% among pregnant patients with a dissection vs. <0.001% in patients without a dissection. Deaths were isolated to patients with an aortic (8.6%), coronary (4.2%), or supra-aortic (<2.5%) dissection. CONCLUSION Arterial dissections occurred in 5.5/100 000 hospitalized pregnant or postpartum women, most frequently in the postpartum period, and were associated with high mortality risk. The coronary arteries were most commonly involved. Pregnancy-related dissections were associated with traditional risk factors, as well as pregnancy-specific conditions.
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Affiliation(s)
- Sebastian E Beyer
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Andrew B Dicks
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Loryn Feinberg
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA.,Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
| | - Brett J Carroll
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA
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12
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Liu L, Li L, Luo L, Jin M. Combined cesarean delivery and repair of acute type A aortic dissection at advanced pregnancy. J Card Surg 2021; 36:1576-1579. [PMID: 33625759 DOI: 10.1111/jocs.15300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Liwei Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lu Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lan Luo
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Mu Jin
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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13
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De Martino A, Blasi S, Bortolotti U. Understanding pregnancy-related aortic dissection-still a long way to go? J Card Surg 2021; 36:1580. [PMID: 33625766 DOI: 10.1111/jocs.15302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Andrea De Martino
- Section of Cardiac Surgery, Department of Surgical, Medical, and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Stefania Blasi
- Division of Cardiac Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Uberto Bortolotti
- Section of Cardiac Surgery, Department of Surgical, Medical, and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
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Groth KA, Nielsen BB, Sheyanth IN, Gravholt CH, Andersen NH, Stochholm K. Maternal health and pregnancy outcome in diagnosed and undiagnosed Marfan syndrome: A registry-based study. Am J Med Genet A 2021; 185:1414-1420. [PMID: 33590700 DOI: 10.1002/ajmg.a.62122] [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: 11/13/2020] [Revised: 01/15/2021] [Accepted: 01/30/2021] [Indexed: 11/09/2022]
Abstract
In Marfan syndrome (MFS), pregnancy is considered as high risk due to the deficiency of fibrillin in the connective tissue and increased risk of aortic dissection. The objective was to demonstrate the consequences on maternal health, in women with diagnosed and undiagnosed MFS at the time of pregnancy and childbirth. By using national health care registries, we identified all pregnancy related outcomes, from women with MFS (n = 183) and an age-matched background population (n = 18,300). We found 91 pregnancies during follow-up. Significantly fewer women with MFS gave birth, compared to the background population. No women with known MFS had a pregnancy related aortic dissection but complications related to the cervix were increased (HR:19.8 [95% CI:2.2-177.5]). Fifty women with MFS were undiagnosed at the time of their first pregnancy and/or childbirth. Among these, there were more birth canal related complications HR:27.2 (95% CI: 2.3-315.0), preeclampsia (HR:2.25 [95% CI: 1.11-4.60]), fetal deaths (HR:12.3 [95% CI: 1.51-99.8]), and all delivery-related dissections came from this subgroup. In conclusion, undiagnosed women with MFS experienced more pregnancy and childbirth related complications including fetal death, birth canal issues, preeclampsia, and aortic disease, which emphasizes the need for an early MFS diagnosis and special care during pregnancy and childbirth.
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Affiliation(s)
- Kristian A Groth
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Birgitte B Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Inger N Sheyanth
- Department of Clinical Genetics, Aalborg University Hospital, Aalborg, Denmark
| | - Claus H Gravholt
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Kirstine Stochholm
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark
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15
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Abstract
Aortic dissection remains a highly morbid diagnosis. The treatment of aortic dissection has undergone several paradigm shifts since it was first understood. However, despite the robust research in treatment, the epidemiology of aortic dissection is limited. In this review, we discuss the historical perspectives of aortic dissection with a review of risk factors and presentation. We review the trends in incidence during the past 40 years, with consideration for sex, race, and ethnicity in admission. We further focus our discussion of the classically described Type B aortic dissection treatment. Lastly, we review the impact of long-term events, readmissions, cost assessments, and quality of life studies of patients with aortic dissection. Care for those with aortic dissection remains a long-term challenge for providers and a multispecialty approach is needed for complete patient management.
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Affiliation(s)
- Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 2(nd) Street SW, Rochester, MN 55902
| | - Young M Erben
- Department of Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 2(nd) Street SW, Rochester, MN 55902.
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16
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Rimmer L, Mellor S, Harky A, Gouda M, Bashir M. Pernicious pregnancy: Type B aortic dissection in pregnant women. J Card Surg 2021; 36:1232-1240. [PMID: 33533078 DOI: 10.1111/jocs.15354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Type B aortic dissection (TBAD) occurs seldomly, particularly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of type A aortic dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. This article collates knowledge so far on this rare event during pregnancy. METHODS A comprehensive literature search was performed in PubMed, Scopus, Google Scholar, Embase, and Medline. Key search terms included "type B aortic dissection," "pregnancy," and corresponding synonyms. Non-English papers were excluded. RESULTS Risk factors for TBAD include aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a cesarean section before intervention is carried out unless certain indications are present. CONCLUSIONS Due to a scarce number of cases across the decades, it is difficult to determine which management is optimal. The gold-standard management of TBAD has traditionally been the medical treatment for uncomplicated cases and open surgery for those needing urgent intervention, but with the advent of techniques, such as thoracic endovascular aortic repair, the management of these group of patients continues to develop.
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Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Sophie Mellor
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Amer Harky
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Mohamed Gouda
- Vascular & Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
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17
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Abstract
The number of reproductive age women with valvular heart disease is rising and accounts for one third of all heart disease among pregnant women. Severe, symptomatic left-sided cardiac lesions, particularly mitral and aortic stenosis, and mechanical heart valves, are associated with adverse maternal and fetal outcomes. Decreasing maternal and fetal risk requires shared decision-making among patients and the heart team, consisting of obstetricians, maternal-fetal medicine subspecialists, and cardiologists.
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18
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Rimmer L, Heyward-Chaplin J, South M, Gouda M, Bashir M. Acute aortic dissection during pregnancy: Trials and tribulations. J Card Surg 2020; 36:1799-1805. [PMID: 32996191 DOI: 10.1111/jocs.15068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and the unborn baby. Pregnancy has been recognized as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. This review seeks to outline the current controversies around this unique group. METHODS A comprehensive literature search was carried out across large databases to assimilate relevant papers regarding acute aortic dissection in pregnant women. RESULTS The presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via the quickest form of imaging, whether computed tomography, magnetic resonance imaging, or transesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the fetus concomitantly or to perform the aortic repair with the fetus in utero. CONCLUSIONS Management of this group includes rapid and dynamic assessment without delay. From conception to postpartum, there are multiple stages in which to manage these women. Challenges in carrying out management in the form of operative techniques and cardiopulmonary bypass place the fetus at risk and must be approached with caution, particularly as there is little evidence-base for many of these decisions. Further research into reducing maternal and fetal mortality is necessary.
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Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Jessica Heyward-Chaplin
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Matthew South
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Mohamed Gouda
- Department of Vascular and Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
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19
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Bogaert K, Christensen K, Cagliostro M, Ferrara L. Contained aortic rupture in a term pregnant patient during the COVID-19 pandemic. BMJ Case Rep 2020; 13:13/9/e238370. [PMID: 32933917 PMCID: PMC7493124 DOI: 10.1136/bcr-2020-238370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Aortic dissection and rupture is a rare occurrence in pregnant and postpartum patients. This case discusses the presentation and diagnosis of a patient with an acute contained thoracic aortic aneurysm rupture at 38 weeks of gestation, after presenting with throat pain and syncope during the COVID-19 pandemic. The patient underwent emergent caesarean delivery for non-reassuring fetal heart tracing, following which continued syncope workup revealed an aortic aneurysm and pericardial effusion. Diagnosis in this case was finalised with multimodality imaging, including transthoracic echocardiogram, and the patient underwent surgical aortic repair.
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Affiliation(s)
- Kelly Bogaert
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kyrstin Christensen
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew Cagliostro
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lauren Ferrara
- Department of Maternal Fetal Medicine, Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Obstetrics and Gynecology, NYC Health and Hospitals Elmhurst, Elmhurst, New York, USA
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20
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Abstract
Aortic dilatation is common in patients with congenital heart disease and is seen in patients with bicuspid aortic valve and those with conotruncal congenital heart defects. It is important to identify patients with bicuspid aortic valve at high risk for aortic dissection. High-risk patients include those with the aortic root phenotype and those with syndromic or familial aortopathies including Marfan syndrome, Loeys-Dietz syndrome, and Turner syndrome. Aortic dilatation is common in patients with conotruncal congenital heart defects and rarely results in aortic dissection.
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21
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Pilato E, Pinna GB, Grande L, Cirillo V, Izzo R, Tufano A, Guida M, Sarno L, Browning R, Comentale G. Challenging report of cardiopulmonary bypass in 16th week pregnant patient with endoventricular mass. Heart Lung 2020; 50:174-176. [PMID: 32473746 DOI: 10.1016/j.hrtlng.2020.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pregnancy usually represents a risk factor for aortic dissection or thrombotic events, but therapeutic options are very scarce because the foetus limits the common approaches especially in the early stages of pregnancy. CASE PRESENTATION We present a challenging case of a young woman in her 16th week of gestation with an history of multiple abortions associated with autoimmune thrombophilia. A strictly designed perioperative management protocol was required to remove a huge right endoventricular mass, due to her decision to not terminate the pregnancy. CONCLUSIONS Nowadays the mother, completely healthy, gived birth to her baby so it demonstrates how cardiac surgery, even in complicated circumstances, can be feasible during pregnancy through a multidisciplinary approach.
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Affiliation(s)
- Emanuele Pilato
- Division of Cardiovascular Emergencies, University of Napoli "Federico II", Italy
| | | | - Loredana Grande
- Division of Cardiovascular Emergencies, University of Napoli "Federico II", Italy
| | - Vera Cirillo
- Division of Cardiovascular Emergencies, University of Napoli "Federico II", Italy
| | - Raffaele Izzo
- Division of Cardiovascular Emergencies, University of Napoli "Federico II", Italy
| | - Antonella Tufano
- Division of Cardiovascular Emergencies, University of Napoli "Federico II", Italy
| | - Maurizio Guida
- Division of Obstetrics and Gynaecology, University of Napoli "Federico II", Italy
| | - Laura Sarno
- Division of Obstetrics and Gynaecology, University of Napoli "Federico II", Italy
| | - Rosie Browning
- Division of Cardiovascular Perfusion, The Royal Brompton, London, UK
| | - Giuseppe Comentale
- Division of Cardiovascular Emergencies, University of Napoli "Federico II", Italy.
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