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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [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] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
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Kalogerakos PD, Zafar MA, Li Y, Ellauzi H, Mukherjee SK, Ziganshin BA, Rizzo JA, Elefteriades JA. Patient-specific ascending aortic intervention criteria. Eur J Cardiothorac Surg 2024; 65:ezae162. [PMID: 38632077 DOI: 10.1093/ejcts/ezae162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/26/2024] [Accepted: 04/16/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES Ascending aortic aneurysms pose a different risk to each patient. We aim to provide personalized risk stratification for such patients based on sex, age, body surface area and aneurysm location (root versus ascending). METHODS Root and ascending diameters, and adverse aortic events (dissection, rupture, death) of ascending thoracic aortic aneurysm patients were analysed. Aortic diameter was placed in context vis-a-vis the normal distribution in the general population with similar sex, age and body surface area, by conversion to z scores. These were correlated of major adverse aortic events, producing risk curves with 'hinge points' of steep risk, constructed separately for the aortic root and mid-ascending aorta. RESULTS A total of 1162 patients were included. Risk curves unveiled generalized thresholds of z = 4 for the aortic root and z = 5 for the mid-ascending aorta. These correspond to individualized thresholds of less than the standard criterion of 5.5 cm in the vast majority of patients. Indicative results include a 75-year-old typical male with 2.1 m2 body surface area, who was found to be at increased risk of adverse events if root diameter exceeds 5.15 cm, or mid ascending exceeds 5.27 cm. An automated calculator is presented, which identifies patients at high risk of adverse events based on sex, age, height, weight, and root and ascending size. CONCLUSIONS This analysis exploits a large sample of aneurysmal patients, demographic features of the general population, pre-dissection diameter, discrimination of root and supracoronary segments, and statistical tools to extract thresholds of increased risk tailor-made for each patient.
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Affiliation(s)
- Paris D Kalogerakos
- Department of Surgery, Division of Cardiac Surgery, Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad A Zafar
- Department of Surgery, Division of Cardiac Surgery, Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, NJ, USA
| | - Hesham Ellauzi
- Department of Surgery, Division of Cardiac Surgery, Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Sandip K Mukherjee
- Department of Surgery, Division of Cardiac Surgery, Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Bulat A Ziganshin
- Department of Surgery, Division of Cardiac Surgery, Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - John A Rizzo
- Department of Economics, Stony Brook University, Stony Brook, NY, USA
- Department of Preventive Medicine, Stony Brook University, Stony Brook, NY, USA
| | - John A Elefteriades
- Department of Surgery, Division of Cardiac Surgery, Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
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3
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Li B, Meng X, Fu C, Yang Z, Zhao X. The correlation study between the length and angle of ascending aortic and the incidence risk of acute type A aortic dissection. Front Cardiovasc Med 2024; 11:1375601. [PMID: 38590696 PMCID: PMC10999610 DOI: 10.3389/fcvm.2024.1375601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/14/2024] [Indexed: 04/10/2024] Open
Abstract
Objective This study utilized computed tomography angiography (CTA) to assess the risk of acute type A aortic dissection (ATAAD) by analyzing the imaging morphology indicators of the ascending aorta, along with the relevant risk factors associated with aortic dissection. Methods The study utilized a retrospective observational research design. The population consisted of 172 patients who received treatment in the Department of Cardiothoracic Surgery at Qilu Hospital, Shandong University, from January 2018 to December 2022. The patients were divided into two groups: the ATAAD group (n = 97) and the thoracic aortic aneurysm group (TAA, n = 75). Demographic data and ascending aorta CTA measurements were collected from all patients. Single factor and multivariate logistic regression were employed to analyze the statistical differences in clinical data and ascending aorta CTA imaging morphology indicators between the two groups. Results The variables were included in logistic multivariate analysis for further screening, indicating that the length of the ascending aorta (LAA) before ATAAD (OR = 3.365; 95% CI :1.742-6.500, P<0.001), ascending arch angle (asc-arch angle, OR = 0.902; 95% CI: 0.816-0.996, P = 0.042) and the maximum aortic diameter (MAD) before ATAAD, (OR = 0.614; 95% CI: 0.507-0.743, P<0.001) showed statistically significant differences. Conclusions This study suggests that increased LAA and MAD, as well as a smaller asc-arch angle may be high-risk factors for the onset of ATAAD.
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Affiliation(s)
| | | | | | | | - Xin Zhao
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan, China
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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [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: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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Sun L, Li H, Feng X, Li X, Wang G, Sun J, Zhang X, Zhang W, Wang J, Niu Z, Liu G. Morphological risk of acute type A aortic dissection in the mildly to moderately dilated aorta. Eur J Cardiothorac Surg 2024; 65:ezae016. [PMID: 38218720 DOI: 10.1093/ejcts/ezae016] [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: 09/27/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/15/2024] Open
Abstract
OBJECTIVES This study aimed to analyse and determine the role of aortic length and curvature in the pathogenesis of acute type A aortic dissection (ATAAD) with ascending aortic diameters (AADs) <5 cm. METHODS We reviewed the clinical and imaging data of patients with ATAAD (n = 201) and ascending aortic dilation (n = 83). Thoracic aortic bending index (TABI) was used to quantify aortic curvature and analyse its role in ATAAD below the diameter risk threshold. RESULTS The AAD was <5.0 and <4.0 cm in 78% and 37% of patients with ATAAD, respectively. The median ascending aortic length (AAL) was 104.6 mm (Q1-Q3, 96.5-113.6 mm), and in 62.7% of patients, it was <11 cm. The median TABI was 14.99 mm/cm (Q1-Q3, 14.18-15.86 mm/cm). Patients with ATAAD and those with aortic dilation were matched for AAD, age, sex, height and other clinical factors. After matched, the dissection group had higher AALs (median, 102.9 mm; Q1-Q3, 96.0-112.5 mm vs median, 88.2 mm; Q1-Q3, 83.7-95.9 mm; P < 0.001) and TABI (median, 14.84 mm/cm; Q1-Q3, 14.06-15.83 mm/cm vs median, 13.55 mm/cm; Q1-Q3, 13.03-14.28 mm/cm; P < 0.001). According to the regression analysis, the area under the curve required to distinguish patients with ATAAD from those with aortic dilation was 0.831 in AAL, 0.837 in TABI and 0.907 when AAL was combined with TABI. CONCLUSIONS The patients with ATAAD had higher AAL and TABI than those with aortic dilation. The combination of TABI and AAL might be a potential morphological marker for determining ATAAD risk below the current aortic diameter risk threshold.
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Affiliation(s)
- Lianjie Sun
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Qingdao, China
| | - Haoyou Li
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Qingdao, China
| | - Xiangzhen Feng
- Department of Cardiovascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiao Li
- Department of Ultrasound, Institute of Ultrasound in Medicine and Engineering, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guoqing Wang
- Department of Cardiovascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianchao Sun
- Department of Cardiovascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoming Zhang
- Department of Cardiovascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wenfeng Zhang
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Qingdao, China
| | - Jianxun Wang
- Department of Cardiovascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhaozhuo Niu
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Qingdao, China
| | - Gaoli Liu
- Department of Cardiovascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Meccanici F, Bom A, Knol W, Gökalp A, Thijssen C, Bekkers J, Geuzebroek G, Mokhles M, van Kimmenade R, Budde R, Takkenberg J, Roos-Hesselink J. Male-female differences in thoracic aortic diameters at presentation of acute type A aortic dissection. IJC HEART & VASCULATURE 2023; 49:101290. [PMID: 37942298 PMCID: PMC10628350 DOI: 10.1016/j.ijcha.2023.101290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023]
Abstract
Background Acute type A aortic dissection (ATAAD) is a highly lethal event, associated with aortic dilatation. It is not well known if patient height, weight or sex impact the thoracic aortic diameter (TAA) at ATAAD. The study aim was to identify male-female differences in TAA at ATAAD presentation. Methods This retrospective cross-sectional study analysed all adult patients who presented with ATAAD between 2007 and 2017 in two tertiary care centres and underwent contrast enhanced computed tomography (CTA) before surgery. Absolute aortic diameters were measured at the sinus of Valsalva (SoV), ascending (AA) and descending thoracic aorta (DA) using double oblique reconstruction, and indexed for body surface area (ASI) and height (AHI). Z-scores were calculated using the Campens formula. Results In total, 59 % (181/308) of ATAAD patients had CT-scans eligible for measurements, with 82 female and 99 male patients. Females were significantly older than males (65.5 ± 12.4 years versus 60.3 ± 2.3, p = 0.024). Female patients had larger absolute AA diameters than male patients (51.0 mm [47.0-57.0] versus 49.0 mm [45.0-53.0], p = 0.023), and larger ASI and AHI at all three levels. Z-scores for the SoV and AA were significantly higher for female patients (2.99 ± 1.66 versus 1.34 ± 1.77, p < 0.001 and 5.27 [4.38-6.26] versus 4.06 [3.14-5.02], p < 0.001). After adjustment for important clinical factors, female sex remained associated with greater maximal TAA (p = 0.019). Conclusion Female ATAAD patients had larger absolute ascending aortic diameters than males, implying a distinct timing in disease presentation or selection bias. Translational studies on the aortic wall and studies on growth patterns should further elucidate these sex differences.
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Affiliation(s)
- F. Meccanici
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - A.W. Bom
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - W.G. Knol
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - A.L. Gökalp
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - C.G.E. Thijssen
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - J.A. Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - G.S.C. Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - M.M. Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
- Department of Cardiothoracic Surgery, Utrecht University Medical Centre, Utrecht, Netherlands
| | - R.R.J. van Kimmenade
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - R.P.J. Budde
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - J.J.M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - J.W. Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
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7
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Wu J, Zafar MA, Liu Y, Chen JF, Li Y, Ziganshin BA, Ellauzi H, Mukherjee SK, Rizzo JA, Elefteriades JA. Fate of the unoperated ascending thoracic aortic aneurysm: three-decade experience from the Aortic Institute at Yale University. Eur Heart J 2023; 44:4579-4588. [PMID: 36994934 DOI: 10.1093/eurheartj/ehad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/31/2023] [Accepted: 03/01/2023] [Indexed: 03/31/2023] Open
Abstract
AIMS This study aims to outline the 'true' natural history of ascending thoracic aortic aneurysm (ATAA) based on a cohort of patients not undergoing surgical intervention. METHODS AND RESULTS The outcomes, risk factors, and growth rates of 964 unoperated ATAA patients were investigated, over a median follow-up of 7.9 (maximum of 34) years. The primary endpoint was adverse aortic events (AAE), including dissection, rupture, and aortic death. At aortic sizes of 3.5-3.9, 4.0-4.4, 4.5-4.9, 5.0-5.4, 5.5-5.9, and ≥6.0 cm, the average yearly risk of AAE was 0.2%, 0.2%, 0.3%, 1.4%, 2.0%, and 3.5%, respectively (P < 0.001), and the 10-year survival free from AAE was 97.8%, 98.2%, 97.3%, 84.6%, 80.4%, and 70.9%, respectively (P < 0.001). The risk of AAE was relatively flat until 5 cm of aortic size, at which it began to increase rapidly (P for non-linearity <0.001). The mean annual growth rate was estimated to be 0.10 ± 0.01 cm/year. Ascending thoracic aortic aneurysms grew in a very slow manner, and aortic growth over 0.2 cm/year was rarely seen. Multivariable Cox regression identified aortic size [hazard ratio (HR): 1.78, 95% confidence interval (CI): 1.50-2.11, P < 0.001] and age (HR: 1.02, 95% CI: 1.00-1.05, P = 0.015) as significant independent risk factors for AAE. Interestingly, hyperlipidemia (HR: 0.46, 95% CI: 0.23-0.91, P = 0.025) was found to be a significant protective factor for AAE in univariable Cox regression. CONCLUSION An aortic size of 5 cm, rather than 5.5 cm, may be a more appropriate intervention criterion for prophylactic ATAA repair. Aortic growth may not be an applicable indicator for intervention.
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Affiliation(s)
- Jinlin Wu
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
- Department of Cardiac Surgery, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, 106 Zhongshan Er Road, Yuexiu District, Guangzhou, Guangdong 510060, China
| | - Mohammad A Zafar
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Yiwei Liu
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 101 Tangqiao Beiyuan Road, Pudong New Area District, Shanghai 200127, China
| | - Julia Fayanne Chen
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Toronto, 27 King's College Cir, Toronto, ON M5S, Canada
| | - Yupeng Li
- Department of Political Sciences and Economics, Rowan University, 201 Mullica Hill Rd, Glassboro, NJ 08028, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Hesham Ellauzi
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Sandip K Mukherjee
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - John A Rizzo
- Department of Economics and Department of Preventive Medicine, Stony Brook University, 100 Nicolls Rd, Stony Brook, NY 11794, USA
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
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8
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Kalogerakos PD, Pirentis A, Papaharilaou Y, Skiadas C, Karantanas A, Mojibian H, Marketou M, Kochiadakis G, Elefteriades JA, Lazopoulos G. Significant unfavorable geometrical changes in ascending aorta despite stable diameter at follow-up. Hellenic J Cardiol 2023:S1109-9666(23)00198-7. [PMID: 37931701 DOI: 10.1016/j.hjc.2023.10.007] [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: 05/25/2023] [Revised: 08/25/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND The clinical importance of following-up the ascending aortic diameter lies on the fundamental presumption that wall pathology eventually manifests as change in shape. However, the diameter describes the vessel locally, and the 55mm criterion fails to prevent most dissections. We hypothesized that geometric changes across the ascending aorta are not necessarily imprinted on its diameter; i.e. the maximum diameter correlates weakly and insignificantly with elongation, surface stretching, engorgement, and tortuosity. METHODS Two databases were interrogated for patients who had undergone at least 2 ECG-gated CT scans. The absence of motion artifacts permitted the generation of exact copies of the ascending aorta which then underwent three-dimensional analysis producing objective and accurate measurements of the centreline length, surface, volume, and tortuosity. The correlations of these global variables with the diameter were explored. RESULTS Twenty-two patients, 13 male and 9 females, were included. The mean age at the first and last scan was 63.7 and 67.1y, respectively. The mean diameter increase was approximately 1mm/y. There were no dissections, while 7 patients underwent preemptive surgery. The yearly change rate of the global variables, normalized to height if applicable, showed statistically insignificant, weak or negligible correlation with diameter increments at follow-up. Most characteristically, a patient's aorta maintained its diameter, while undergoing 1mm/y elongation, 151mm2/(y∙m) stretching, 2366mm3/(y∙m) engorgement, and 0.02/y tortuosity. CONCLUSIONS Maximum diameter provides a local description for the ascending aorta and cannot fully portray the pathological process across this vessel. Following-up the diameter is not suggestive of length, surface, volume and tortuosity changes.
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Affiliation(s)
- Paris Dimitrios Kalogerakos
- Cardiac Surgery Division, General University Hospital of Heraklion, Crete, Greece; Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.
| | | | | | - Christos Skiadas
- Department of Radiology, General University Hospital of Heraklion, Crete, Greece
| | - Apostolos Karantanas
- Department of Radiology, General University Hospital of Heraklion, Crete, Greece
| | - Hamid Mojibian
- Department of Diagnostic Imaging, Yale University School of Medicine, New Haven, CT, USA; Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Maria Marketou
- Department of Cardiology, General University Hospital of Heraklion, Crete, Greece
| | - George Kochiadakis
- Department of Cardiology, General University Hospital of Heraklion, Crete, Greece
| | - John Alex Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - George Lazopoulos
- Cardiac Surgery Division, General University Hospital of Heraklion, Crete, Greece
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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: 12] [Impact Index Per Article: 12.0] [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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10
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Lopez Perez N, Reymond P, Cikirikcioglu M, van Steenberghe M, Sologashvili T, Murith N, Perneger T, Huber C. Aortic Dilatation on the Edge of Dissection-Do We Operate Too Late? The Ratio between Ascending and Descending Aorta DiameteR (RADAR). J Clin Med 2023; 12:4400. [PMID: 37445435 DOI: 10.3390/jcm12134400] [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: 05/22/2023] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
(1) Background: There is a need for a novel surrogate marker to ease decision making when facing ascending aortic dilatation. In this article, we study the ratio between ascending and descending aorta diameters as a potential one. (2) Methods: Retrospective observational cohort study, including all the patients who underwent surgery for acute type A aorta dissection (aTAAD) between January 2014 and September 2020 at our center. A total of 50 patients were included. Clinical and demographic data were collected. The anatomical measurements were made including orthogonal maximal diameters of the ascending and descending aorta, post-dissection whole circumference length (post-wCL), post-dissection true lumen circumference length (post-tCL), and surface and sphericity indices of the ascending and descending aorta. Pre-dissection ascending aorta diameter (pre-AAD) and pre-dissection descending aorta diameter (pre-DAD) were calculated as well as the ratio between them and compared with reference values. (3) Results: Of the pre-AAD patients, 96% had smaller than the recommended 55 mm. The ratio between the descending and ascending aorta pre-dissection diameters was significantly smaller compared to the reference value (0.657 ± 0.125 versus 0.745 ± 0.016 with a mean difference of -0.088 and a p < 0.001). (4) Conclusions: The 55 mm threshold for aorta maximal diameter is an insufficient criterion when assessing the risk of dissection. The ratio between DAD and AAD is a parameter worthy of analysis as a tool to stratify the risk of dissection.
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Affiliation(s)
- Nerea Lopez Perez
- Cardiovascular Surgery Department, University Hospitals of Geneva (HUG), 1205 Geneva, Switzerland
| | - Philippe Reymond
- Cardiovascular Surgery Department, University Hospitals of Geneva (HUG), 1205 Geneva, Switzerland
| | - Mustafa Cikirikcioglu
- Cardiovascular Surgery Department, University Hospitals of Geneva (HUG), 1205 Geneva, Switzerland
| | - Mathieu van Steenberghe
- Cardiovascular Surgery Department, University Hospitals of Geneva (HUG), 1205 Geneva, Switzerland
| | - Tornike Sologashvili
- Cardiovascular Surgery Department, University Hospitals of Geneva (HUG), 1205 Geneva, Switzerland
| | - Nicolas Murith
- Cardiovascular Surgery Department, University Hospitals of Geneva (HUG), 1205 Geneva, Switzerland
| | - Thomas Perneger
- Clinical Research Center, University Hospitals of Geneva (HUG), 1205 Geneva, Switzerland
| | - Christoph Huber
- Cardiovascular Surgery Department, University Hospitals of Geneva (HUG), 1205 Geneva, Switzerland
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11
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Xiao M, Wu J, Chen D, Wang C, Wu Y, Sun T, Chen J. Ascending Aortic Volume: A Feasible Indicator for Ascending Aortic Aneurysm Elective Surgery? Acta Biomater 2023:S1742-7061(23)00353-7. [PMID: 37356784 DOI: 10.1016/j.actbio.2023.06.026] [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: 03/01/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
Diameter-based criterion have been widely adopted for preventive surgery of ascending thoracic aortic aneurysm (ATAA). However, recent and growing evidence has shown that diameter-based methods may not be sufficient for identifying patients who are at risk of an ATAA. In this study, fluid-structure interaction (FSI) analysis was performed on one-hundred ATAA geometries reconstructed from clinical data to examine the relationship between hemodynamic conditions, ascending aortic volume (AAV), ascending aortic curvature, and aortic ratios measured from the reconstructed 3D models. The simulated hemodynamic and biomechanical parameters were compared among different groups of ATAA geometries classified based on AAV. The ATAAs with enlarged AAV showed significantly compromised hemodynamic conditions and higher mechanical wall stress. The maximum oscillatory shear index (OSI), particle residence time (PRT) and wall stress (WS) were significantly higher in enlarged ATAAs compared with controls (0.498 [0.497, 0.499] vs 0.499 [0.498, 0.499], p = 0.002, 312.847 [207.445, 519.391] vs 996.047 [640.644, 1573.140], p < 0.001, 769.680 [668.745, 879.795] vs 1072.000 [873.060, 1280.000] kPa, p < 0.001, respectively). Values were reported as median with interquartile range (IQR). AAV was also found to be more strongly correlated with these parameters compared to maximum diameter. The correlation coefficient between AAV and average WS was as high as 0.92 (p < 0.004), suggesting that AAV might be a feasible risk identifier for ATAAs. STATEMENT OF SIGNIFICANCE: Ascending thoracic aortic aneurysm is associated with the risk of dissection or rupture, creating life-threatening conditions. Current surgical intervention guidelines are purely diameter based. Recently, many studies proposed to incorporate other morphological parameters into the current clinical guidelines to better prevent severe adverse aortic events like rupture or dissection. The purpose of this study is to gain a better understanding of the relationship between morphological parameters and hemodynamic parameters in ascending aortic aneurysms using fluid-solid-interaction analysis on patient-specific geometries. Our results suggest that ascending aortic volume may be a better indicator for surgical intervention as it shows a stronger association with pathogenic hemodynamic conditions.
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Affiliation(s)
- Meng Xiao
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Guangzhou, China, 510000.; Department of Electrical and Computer Engineering, University of Alberta, 116 St & 85 Ave, Edmonton, AB, Canada, T6G 2R3..
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Guangzhou, China, 510000..
| | - Duanduan Chen
- Department of Biomedical Engineering, Beijing Institute of Technology, No. 5, South Street, Zhongguancun, Beijing, China..
| | - Chenghu Wang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Guangzhou, China, 510000..
| | - Yanfen Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Guangzhou, China, 510000..
| | - Tucheng Sun
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Guangzhou, China, 510000..
| | - Jie Chen
- Department of Electrical and Computer Engineering, University of Alberta, 116 St & 85 Ave, Edmonton, AB, Canada, T6G 2R3..
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12
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Papakonstantinou NA, Rorris FP, Antonopoulos CN, Theodosis A, Argiriou M, Charitos C. Ascending Aorta Dissection Before 5.5 cm Diameter; "It Wasn't Raining When Noah Built the Ark". Heart Lung Circ 2023; 32:379-386. [PMID: 36476395 DOI: 10.1016/j.hlc.2022.10.020] [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: 04/22/2022] [Revised: 08/01/2022] [Accepted: 10/28/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The aim of this study was to compare mean maximum ascending aortic diameter at the time of acute aortic dissection with the current surgical threshold for elective ascending aortic operations on non-syndromic thoracic aortic aneurysms. MATERIAL AND METHODS All consecutive non-syndromic adult patients admitted for acute type A aortic dissection in a single tertiary centre were prospectively enrolled from April 2020 to March 2021. The primary endpoint was the difference between mean maximum aortic diameter at the time of dissection and the 5.5 cm threshold for elective repair. Secondary endpoints included 30-day/in-hospital mortality, aortic length and comparison with normal controls, length/height ratio index, "actual" preoperative Euroscore II and "predicted" Euroscore II if electively operated. RESULTS Among 31 patients ageing 67.3±12.03 years on average, mean maximum aortic diameter at the time of dissection was 5.13±0.66 cm, significantly lower than the guidelines-derived surgical threshold of 5.5 cm (p=0.004). Mean aortic length was 11±1.47 cm, also significantly longer compared normal controls reported in the literature (p<0.001). The 30-day/in-hospital mortality was 35.5%. Mean length/height ratio index was 6.18±0.76 cm/m. Finally, mean "actual" preoperative Euroscore II was 10.43±4.07 which was significantly higher than the 1.47±0.57 "predicted" Euroscore II (p<0.05). CONCLUSIONS The maximum aortic diameter at the time of acute type A aortic dissection of non-syndromic cases was significantly lower than the current recommendation for elective repair. Lowering of the current diameter-based surgical threshold of 5.5 cm may be profitable in terms of prevention, but further investigations should be undertaken. Length-based thresholds could also add to timely aortic dissection prevention.
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Affiliation(s)
- Nikolaos A Papakonstantinou
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network and University of Toronto, Toronto, Ontario, Canada.
| | - Filippos-Paschalis Rorris
- Cardiovascular and Thoracic Surgery Department. General Hospital of Athens "Evangelismos'', Athens, Greece
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Antonios Theodosis
- 2(nd) Department of Radiology, 'Attikon' General University Hospital, Athens, Greece
| | - Mihalis Argiriou
- Cardiovascular and Thoracic Surgery Department. General Hospital of Athens "Evangelismos'', Athens, Greece
| | - Christos Charitos
- Cardiovascular and Thoracic Surgery Department. General Hospital of Athens "Evangelismos'', Athens, Greece
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13
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Meccanici F, de Bruijn JWC, Dommisse JS, Takkenberg JJM, van den Bosch AE, Roos-Hesselink JW. Prevalence and development of aortic dilation and dissection in women with Turner syndrome: a systematic review and meta-analysis. Expert Rev Cardiovasc Ther 2023; 21:133-144. [PMID: 36688313 DOI: 10.1080/14779072.2023.2172403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Women with Turner syndrome (TS) have an increased risk of aortic disease, reducing life-expectancy. This study aimed to systematically review the prevalence of thoracic aortic dilatation, aortic dimensions and growth, and the incidence of aortic dissection. METHODS A systematic literature search was conducted up to July 2022. Observational studies with an adult TS population were included, and studies including children aged <15 years old or specific TS populations were excluded. RESULTS In total 21 studies were included. The pooled prevalence of ascending aortic dilatation was 23% (95% CI 19-26) at a mean pooled age of 29 years (95% CI 26-32), while the incidence of aortic dissection was 164 per 100.000 patient-years (95% CI 95-284). Three reporting studies showed aortic growth over time to be limited. Risk factors for aortic dilation or dissection were older age, bicuspid aortic valve, aortic coarctation, and hypertension. CONCLUSION In adult TS women, ascending aortic dilatation is common and the hazard of aortic dissection increased compared to the general population, whereas aortic growth is limited. Conventional risk markers do not explain all aortic dissection cases; therefore, new imaging parameters and blood biomarkers are needed to improve prediction, allowing for patient-tailored follow-up and surgical decision-making.
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Affiliation(s)
- F Meccanici
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J W C de Bruijn
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J S Dommisse
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A E van den Bosch
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J W Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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14
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Regional and directional delamination properties of healthy human ascending aorta and sinotubular junction. J Mech Behav Biomed Mater 2023; 138:105603. [PMID: 36512974 DOI: 10.1016/j.jmbbm.2022.105603] [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: 11/15/2021] [Revised: 07/23/2022] [Accepted: 11/20/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE Acute type A aortic dissection (AD) is a catastrophic event associated with high mortality. Biomechanics can provide an understanding of the forces that lead the initial intimal tear to propagate, resulting in aortic dissection. We previously studied the material properties of normal human aortic roots. In this study, our objective was to determine the regional and directional delamination properties of healthy human ascending aorta (AscAo) and sinotubular junction (STJ). RESULTS From 19 healthy donor hearts, total 107 samples from the AscAo and STJ were collected and tested along the circumferential and longitudinal directions. Specimens were subjected to uniaxial peeling testing with a manually created tear in the medial layer. The lateral AscAo subregion (greater curvature) had significantly lower delamination strength and dissection energy than anterior, medial, and posterior subregions in the longitudinal direction. Regionally, the delamination strength at AscAo was significantly lower than at STJ overall (p = 0.02) and in circumferential direction (p = 0.02) only. Directionally, the delamination strength at AscAo overall and in the anterior AscAo was significant lower in circumferential direction than longitudinal direction. Dissection energy demonstrated similar regional and directional trend as delamination strength. In addition, both dissection energy and delamination strength were correlated positively with thickness and negatively with age in the AscAo. In addition, the dissection energy was negatively related to stiffness at physiologic mean blood pressure. CONCLUSIONS The greater curvature of the AscAo had the lowest delamination strength and dissection energy suggesting that region was most vulnerable to dissection propagation distally. Increased thickness of AscAo would be protective of dissection propagation while propagation would be more likely with increased AscAo stiffness.
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15
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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: 368] [Impact Index Per Article: 184.0] [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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16
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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: 129] [Impact Index Per Article: 64.5] [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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17
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Solomon MD, Leong T, Sung SH, Lee C, Allen JG, Huh J, LaPunzina P, Lee H, Mason D, Melikian V, Pellegrini D, Scoville D, Sheikh AY, Mendoza D, Naderi S, Sheridan A, Hu X, Cirimele W, Gisslow A, Leung S, Padilla K, Bloom M, Chung J, Topic A, Vafaei P, Chang R, Miller DC, Liang DH, Go AS. Association of Thoracic Aortic Aneurysm Size With Long-term Patient Outcomes: The KP-TAA Study. JAMA Cardiol 2022; 7:1160-1169. [PMID: 36197675 PMCID: PMC9535537 DOI: 10.1001/jamacardio.2022.3305] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
Abstract
Importance The risk of adverse events from ascending thoracic aorta aneurysm (TAA) is poorly understood but drives clinical decision-making. Objective To evaluate the association of TAA size with outcomes in nonsyndromic patients in a large non-referral-based health care delivery system. Design, Setting, and Participants The Kaiser Permanente Thoracic Aortic Aneurysm (KP-TAA) cohort study was a retrospective cohort study at Kaiser Permanente Northern California, a fully integrated health care delivery system insuring and providing care for more than 4.5 million persons. Nonsyndromic patients from a regional TAA safety net tracking system were included. Imaging data including maximum TAA size were merged with electronic health record (EHR) and comprehensive death data to obtain demographic characteristics, comorbidities, medications, laboratory values, vital signs, and subsequent outcomes. Unadjusted rates were calculated and the association of TAA size with outcomes was evaluated in multivariable competing risk models that categorized TAA size as a baseline and time-updated variable and accounted for potential confounders. Data were analyzed from January 2018 to August 2021. Exposures TAA size. Main Outcomes and Measures Aortic dissection (AD), all-cause death, and elective aortic surgery. Results Of 6372 patients with TAA identified between 2000 and 2016 (mean [SD] age, 68.6 [13.0] years; 2050 female individuals [32.2%] and 4322 male individuals [67.8%]), mean (SD) initial TAA size was 4.4 (0.5) cm (828 individuals [13.0% of cohort] had initial TAA size 5.0 cm or larger and 280 [4.4%] 5.5 cm or larger). Rates of AD were low across a mean (SD) 3.7 (2.5) years of follow-up (44 individuals [0.7% of cohort]; incidence 0.22 events per 100 person-years). Larger initial aortic size was associated with higher risk of AD and all-cause death in multivariable models, with an inflection point in risk at 6.0 cm. Estimated adjusted risks of AD within 5 years were 0.3% (95% CI, 0.3-0.7), 0.6% (95% CI, 0.4-1.3), 1.5% (95% CI, 1.2-3.9), 3.6% (95% CI, 1.8-12.8), and 10.5% (95% CI, 2.7-44.3) in patients with TAA size of 4.0 to 4.4 cm, 4.5 to 4.9 cm, 5.0 to 5.4 cm, 5.5 to 5.9 cm, and 6.0 cm or larger, respectively, in time-updated models. Rates of the composite outcome of AD and all-cause death were higher than for AD alone, but a similar inflection point for increased risk was observed at 6.0 cm. Conclusions and Relevance In a large sociodemographically diverse cohort of patients with TAA, absolute risk of aortic dissection was low but increased with larger aortic sizes after adjustment for potential confounders and competing risks. Our data support current consensus guidelines recommending prophylactic surgery in nonsyndromic individuals with TAA at a 5.5-cm threshold.
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Affiliation(s)
- Matthew D. Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Thomas Leong
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - J. Geoff Allen
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Joseph Huh
- Department of Cardiothoracic Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Paul LaPunzina
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Hon Lee
- Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Duncan Mason
- Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Vicken Melikian
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Daniel Pellegrini
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - David Scoville
- Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Ahmad Y. Sheikh
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Dorinna Mendoza
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Sahar Naderi
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Ann Sheridan
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Xinge Hu
- Department of Cardiology, Kaiser Permanente Fremont Medical Center, Fremont, California
| | - Wendy Cirimele
- Department of Cardiothoracic Surgery, Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Anne Gisslow
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Sandy Leung
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Kristine Padilla
- Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Michael Bloom
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Josh Chung
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Adrienne Topic
- Department of Cardiology, WellSpan Health Good Samaritan Hospital, Lebanon, Pennsylvania
| | - Paniz Vafaei
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Robert Chang
- Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - D. Craig Miller
- Department of Cardiovascular Surgery, Stanford University School of Medicine, Stanford, California
| | - David H. Liang
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Department of Epidemiology, University of California, San Francisco
- Department of Biostatistics, University of California, San Francisco
- Department of Medicine, University of California, San Francisco
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18
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Anfinogenova ND, Sinitsyn VE, Kozlov BN, Panfilov DS, Popov SV, Vrublevsky AV, Chernyavsky A, Bergen T, Khovrin VV, Ussov WY. Existing and Emerging Approaches to Risk Assessment in Patients with Ascending Thoracic Aortic Dilatation. J Imaging 2022; 8:jimaging8100280. [PMID: 36286374 PMCID: PMC9605541 DOI: 10.3390/jimaging8100280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/20/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Ascending thoracic aortic aneurysm is a life-threatening disease, which is difficult to detect prior to the occurrence of a catastrophe. Epidemiology patterns of ascending thoracic aortic dilations/aneurysms remain understudied, whereas the risk assessment of it may be improved. The electronic databases PubMed/Medline 1966–2022, Web of Science 1975–2022, Scopus 1975–2022, and RSCI 1994–2022 were searched. The current guidelines recommend a purely aortic diameter-based assessment of the thoracic aortic aneurysm risk, but over 80% of the ascending aorta dissections occur at a size that is lower than the recommended threshold of 55 mm. Moreover, a 55 mm diameter criterion could exclude a vast majority (up to 99%) of the patients from preventive surgery. The authors review several visualization-based and alternative approaches which are proposed to better predict the risk of dissection in patients with borderline dilated thoracic aorta. The imaging-based assessments of the biomechanical aortic properties, the Young’s elastic modulus, the Windkessel function, compliance, distensibility, wall shear stress, pulse wave velocity, and some other parameters have been proposed to improve the risk assessment in patients with ascending thoracic aortic aneurysm. While the authors do not argue for shifting the diameter threshold to the left, they emphasize the need for more personalized solutions that integrate the imaging data with the patient’s genotypes and phenotypes in this heterogeneous pathology.
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Affiliation(s)
- Nina D. Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk 634012, Russia
- Correspondence: ; Tel.: +7-9095390220
| | | | - Boris N. Kozlov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk 634012, Russia
| | - Dmitry S. Panfilov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk 634012, Russia
| | - Sergey V. Popov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk 634012, Russia
| | - Alexander V. Vrublevsky
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk 634012, Russia
| | | | - Tatyana Bergen
- E. Meshalkin National Medical Research Center, Novosibirsk 630055, Russia
| | - Valery V. Khovrin
- Petrovsky National Research Centre of Surgery, Moscow 119991, Russia
| | - Wladimir Yu. Ussov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk 634012, Russia
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19
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Pradella M, Achermann R, Sperl JI, Kärgel R, Rapaka S, Cyriac J, Yang S, Sommer G, Stieltjes B, Bremerich J, Brantner P, Sauter AW. Performance of a deep learning tool to detect missed aortic dilatation in a large chest CT cohort. Front Cardiovasc Med 2022; 9:972512. [PMID: 36072871 PMCID: PMC9441594 DOI: 10.3389/fcvm.2022.972512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeThoracic aortic (TA) dilatation (TAD) is a risk factor for acute aortic syndrome and must therefore be reported in every CT report. However, the complex anatomy of the thoracic aorta impedes TAD detection. We investigated the performance of a deep learning (DL) prototype as a secondary reading tool built to measure TA diameters in a large-scale cohort.Material and methodsConsecutive contrast-enhanced (CE) and non-CE chest CT exams with “normal” TA diameters according to their radiology reports were included. The DL-prototype (AIRad, Siemens Healthineers, Germany) measured the TA at nine locations according to AHA guidelines. Dilatation was defined as >45 mm at aortic sinus, sinotubular junction (STJ), ascending aorta (AA) and proximal arch and >40 mm from mid arch to abdominal aorta. A cardiovascular radiologist reviewed all cases with TAD according to AIRad. Multivariable logistic regression (MLR) was used to identify factors (demographics and scan parameters) associated with TAD classification by AIRad.Results18,243 CT scans (45.7% female) were successfully analyzed by AIRad. Mean age was 62.3 ± 15.9 years and 12,092 (66.3%) were CE scans. AIRad confirmed normal diameters in 17,239 exams (94.5%) and reported TAD in 1,004/18,243 exams (5.5%). Review confirmed TAD classification in 452/1,004 exams (45.0%, 2.5% total), 552 cases were false-positive but identification was easily possible using visual outputs by AIRad. MLR revealed that the following factors were significantly associated with correct TAD classification by AIRad: TAD reported at AA [odds ratio (OR): 1.12, p < 0.001] and STJ (OR: 1.09, p = 0.002), TAD found at >1 location (OR: 1.42, p = 0.008), in CE exams (OR: 2.1–3.1, p < 0.05), men (OR: 2.4, p = 0.003) and patients presenting with higher BMI (OR: 1.05, p = 0.01). Overall, 17,691/18,243 (97.0%) exams were correctly classified.ConclusionsAIRad correctly assessed the presence or absence of TAD in 17,691 exams (97%), including 452 cases with previously missed TAD independent from contrast protocol. These findings suggest its usefulness as a secondary reading tool by improving report quality and efficiency.
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Affiliation(s)
- Maurice Pradella
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- *Correspondence: Maurice Pradella
| | - Rita Achermann
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | | | | | - Joshy Cyriac
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Shan Yang
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gregor Sommer
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Hirslanden Klinik St. Anna, Luzern, Switzerland
| | - Bram Stieltjes
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jens Bremerich
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philipp Brantner
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Regional Hospitals Rheinfelden and Laufenburg, Rheinfelden, Switzerland
| | - Alexander W. Sauter
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Radiology, University Hospital Tuebingen, University of Tuebingen, Tuebingen, Germany
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20
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Schena S. Ascending Aortic Aneurysms: Is it Time for a Radical Change of the Current Surveillance and Treatment Guidelines? Eur J Cardiothorac Surg 2022; 62:6655728. [PMID: 35925008 DOI: 10.1093/ejcts/ezac406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/02/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stefano Schena
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, HUB-5 Fl, Milwaukee, WI, 53226, United States
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21
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Elefteriades JA, Rizzo JA, Zafar MA, Ziganshin BA. Ascending Aneurysmectomy: Should we Shift to the Left? J Thorac Cardiovasc Surg 2022:S0022-5223(22)00833-9. [DOI: 10.1016/j.jtcvs.2022.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/13/2022] [Accepted: 07/14/2022] [Indexed: 11/24/2022]
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22
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Syed MBJ, Fletcher AJ, Debono S, Forsythe RO, Williams MC, Dweck MR, Shah ASV, Macaskill MG, Tavares A, Denvir MA, Lim K, Wallace WA, Kaczynski J, Clark T, Sellers SL, Masson N, Falah O, Chalmers RTA, Tambyraja AL, van Beek EJR, Newby DE. 18F-Sodium Fluoride Positron Emission Tomography and Computed Tomography in Acute Aortic Syndrome. JACC Cardiovasc Imaging 2022; 15:1291-1304. [PMID: 35798405 DOI: 10.1016/j.jcmg.2022.01.003] [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: 08/24/2021] [Revised: 01/01/2022] [Accepted: 01/07/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute aortic syndrome is associated with aortic medial degeneration. 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) detects microscopic tissue calcification as a marker of disease activity. OBJECTIVES In a proof-of-concept study, this investigation aimed to establish whether 18F-NaF PET combined with computed tomography (CT) angiography could identify aortic medial disease activity in patients with acute aortic syndrome. METHODS Patients with aortic dissection or intramural hematomas and control subjects underwent 18F-NaF PET/CT angiography of the aorta. Aortic 18F-NaF uptake was measured at the most diseased segment, and the maximum value was corrected for background blood pool activity (maximum tissue-to-background ratio [TBRmax]). Radiotracer uptake was compared with change in aortic size and major adverse aortic events (aortic rupture, aorta-related death, or aortic repair) over 45 ± 13 months. RESULTS Aortic 18F-NaF uptake co-localized with histologically defined regions of microcalcification and elastin disruption. Compared with control subjects, patients with acute aortic syndrome had increased 18F-NaF uptake (TBRmax: 1.36 ± 0.39 [n = 20] vs 2.02 ± 0.42 [n = 47] respectively; P < 0.001) with enhanced uptake at the site of intimal disruption (+27.5%; P < 0.001). 18F-NaF uptake in the false lumen was associated with aortic growth (+7.1 mm/year; P = 0.011), and uptake in the outer aortic wall was associated with major adverse aortic events (HR: 8.5 [95% CI: 1.4-50.4]; P = 0.019). CONCLUSIONS In patients with acute aortic syndrome, 18F-NaF uptake was enhanced at sites of disease activity and was associated with aortic growth and clinical events. 18F-NaF PET/CT holds promise as a noninvasive marker of disease severity and future risk in patients with acute aortic syndrome. (18F Sodium Fluoride PET/CT in Acute Aortic Syndrome [FAASt]; NCT03647566).
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Affiliation(s)
- Maaz B J Syed
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
| | - Alexander J Fletcher
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Samuel Debono
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rachel O Forsythe
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Mark G Macaskill
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Adriana Tavares
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Martin A Denvir
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Kelvin Lim
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - William A Wallace
- Department of Pathology, University of Edinburgh, Edinburgh, United Kingdom
| | - Jakub Kaczynski
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Tim Clark
- Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh. Edinburgh, United Kingdom
| | - Stephanie L Sellers
- Centre for Heart Lung Innovation, St Paul's Hospital and University of British Columbia, Vancouver, British Colombia, Canada
| | - Neil Masson
- Department of Radiology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - Orwa Falah
- The Edinburgh Vascular Service, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - Roderick T A Chalmers
- The Edinburgh Vascular Service, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - Andrew L Tambyraja
- The Edinburgh Vascular Service, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - Edwin J R van Beek
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queens Medical Research Institute, University of Edinburgh. Edinburgh, United Kingdom
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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23
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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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24
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Perez ZG, Zafar MA, Ziganshin BA, Elefteriades JA. Toward standard abbreviations and acronyms for use in articles on aortic disease. JTCVS OPEN 2022; 10:34-38. [PMID: 36004246 PMCID: PMC9390674 DOI: 10.1016/j.xjon.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 11/08/2022]
Abstract
Objectives Academic medical literature is fraught with complex article-specific acronyms and abbreviations that can impair communication and make reading arduous. Our goal is to ease frustration with bespoke, inconsistent, and variable sets of abbreviations that currently exist for common aorta-related terminology (eg, anatomy, imaging, disease, and therapy). We hope to ease reading and improve communication in the aortic sphere of cardiovascular literature. Methods We reviewed a total of 205 published references related to aortic disease, including a systematic review of aorta-related articles in the Journal of Thoracic and Cardiovascular Surgery from the years 2020 and 2021. The array of variable definitions, abbreviations, and acronyms encountered in different papers that refer to the same terminology was striking, revealing that there were few standardized abbreviations in the aortic literature. We cataloged these terms, their associated abbreviations, and their frequency of use, and compiled a list of proposed standard abbreviations for commonly used terms that could be implemented uniformly in articles written about aortic diseases. Results We present suggested acronyms and abbreviations for common terminology related to the aorta. It is anticipated that this standard list will evolve over time as the literature and technology of the field grows and develops. Conclusions A proposed standard set of acronyms and abbreviations for aorta-related terminology is provided that, if found useful, could be implemented broadly in the aortic literature.
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Affiliation(s)
- Zachary G. Perez
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
- Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
- Address for reprints: John A. Elefteriades, MD, PhD (hon), Aortic Institute at Yale-New Haven, Yale University School of Medicine, Clinic Building CB 317, 789 Howard Ave, New Haven, CT 06519.
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25
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Jahangiri M, Mani K, Acharya M, Bilkhu R, Quinton P, Schroeder F, Morgan R, Edsell M. Early and long-term outcomes of conventional and valve-sparing aortic root replacement. Heart 2022; 108:1858-1863. [PMID: 35580978 DOI: 10.1136/heartjnl-2022-320870] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/19/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To determine the early and long-term outcomes of conventional aortic root (ARR) and valve-sparing root replacement (VSRR) using a standard perioperative and operative approach. METHODS We present prospectively collected data of 609 consecutive patients undergoing elective and urgent aortic root surgery (470 ARR, 139 VSRR) between 2006 and 2020. Primary outcomes were operative mortality and incidence of postoperative complications. Secondary outcomes were long-term survival and requirement for reintervention. Median follow-up was 7.6 years (range 0.5-14.5). RESULTS 189 patients (31%) had bicuspid aortic valves and 17 (6.9%) underwent redo procedures. Median cross-clamp time was 88 (range 54-208) min with cardiopulmonary bypass of 108 (range 75-296) min. In-hospital mortality was 10 (1.6%), with transient ischaemic attacks/strokes occurring in 1.1%. In-hospital mortality for VSRR was 0.7%. 12 patients (2.0%) required a resternotomy for bleeding and 14 (2.3%) received haemofiltration. Intensive care unit and hospital stay were 1.7 and 7.0 days, respectively. During follow-up, redo surgery for native aortic valve replacement was required in 1.4% of the VSRR group. Overall survival was 95.1% at 3 years, 93.1% at 5 years, 91.2% at 7 years and 88.6% at 10 years. CONCLUSIONS ARR and VSRR can be performed with low mortality and morbidity as well as a low rate of reintervention during the period of long-term follow-up, if performed by an experienced team with a consistent perioperative approach. This series provides contemporary evidence to balance the risks of aortic aneurysms and their rupture at diameters of <5.5 cm against the risks and benefits of surgery.
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Affiliation(s)
| | - Krishna Mani
- Cardiac Surgery, St George's Hospital, London, UK
| | | | | | - Paul Quinton
- Cardiac Anaesthesia, St George's Hospital, London, UK
| | | | | | - Mark Edsell
- Cardiac Anaesthesia, St George's Hospital, London, UK
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26
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Samanidis G, Kanakis M, Georgiou C, Perreas K. Association of dissected ascending aorta diameter with preoperative adverse events in patients with acute type A aortic dissection. World J Cardiol 2022; 14:231-238. [PMID: 35582464 PMCID: PMC9048272 DOI: 10.4330/wjc.v14.i4.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/02/2022] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) is a life-threatening disease associated with high morbidity and mortality.
AIM To evaluate the diameter of dissected ascending aorta in patients diagnosed with ATAAD and whether the aortic diameter is associated with preoperative adverse events.
METHODS A total of 108 patients diagnosed with ATAAD who underwent emergency operation under hypothermic circulatory arrest were enrolled in this study. Demographic characteristics and perioperative data were recorded. In all patients, preoperative chest and abdomen computed tomography (CT) scans were performed.
RESULTS Median age of the patients was 61.5 (52.5-70.5) years and median body mass index (BMI) was 28.2 (25.1-32.6) cm2. The number of female patients was 37 (25%). Median diameter of the ascending aorta was 5.0 (4.5-6) cm and 53.8% of the patients had an aortic diameter < 5.0 cm, while 32.3% of the patients had an aortic diameter of 4.5cm and 72.0% had an ascending aorta diameter < 5.5 cm. The diameter of the ascending aorta did not differ in patients with vs without preoperative adverse events: Preoperative neurological dysfunction (P = 0.53) and hemodynamic instability (P = 0.43). Median age of patients with preoperative hemodynamic instability was 65 (57.5-74) years, while it was 60 (51-68) years in patients without (P = 0.04)
CONCLUSION Although current guidelines suggest replacing the ascending aorta with a diameter > 5.5 cm, most of the patients with ATAAD had an aortic diameter of less than 5.5 cm. The diameter of the ascending aorta in patients diagnose with ATAAD is not associated with preoperative adverse events.
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Affiliation(s)
- George Samanidis
- Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Charalampos Georgiou
- Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Konstantinos Perreas
- Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens 17674, Greece
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Diletta L, Enrico R, Germano M. Thoracoabdominal aortic aneurysm in connective tissue disorder patients. Indian J Thorac Cardiovasc Surg 2022; 38:146-156. [PMID: 35463710 PMCID: PMC8980973 DOI: 10.1007/s12055-021-01324-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022] Open
Abstract
Connective tissue disorders (CTDs) are a group of genetically triggered diseases in which the primary defect involves collagen and elastin protein assembly with potential vascular degenerations such as thoracoabdominal aortic aneurysm (TAAA) and dissection. These most commonly include Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, and familial thoracic aortic aneurysm and dissection. Open surgical repair represents the standard approach in this specific group of patients. Extensive aortic replacements are generally performed in order to reduce long-term complications caused by the progressive dilatation of the remnant aortic segments. In the last decades, endovascular interventions have emerged as a valid alternative in patients affected by degenerative TAAA. However, in patients with CTD, this approach presents higher rates of reinterventions and postoperative complications with a disputable long-term durability, and it is nowadays performed for very selective indications such as severe comorbidities and urgent/emergent settings. Despite a deeper knowledge of the pathophysiological mechanisms involved in CTD, improvements in medical therapy, and a multidisciplinary approach fully involved in the management of these usually frailer patients, this specific group still represents a challenge. Further dedicated studies addressing mid-term and long-term outcomes in this selected population are needed.
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Affiliation(s)
- Loschi Diletta
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy
| | - Rinaldi Enrico
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy
| | - Melissano Germano
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy
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Johnson DY, Cavalcante J, Schmidt C, Thomas K, Garberich R, Pavlovec M, Mudy K, Bradley SM, Harris KM. Aortic Size and Clinical Care Pathways Before Type A Aortic Dissection. Am J Cardiol 2022; 163:104-108. [PMID: 34862003 DOI: 10.1016/j.amjcard.2021.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 11/26/2022]
Abstract
Patients with aortic enlargement are recommended to undergo serial imaging and clinical follow-up until they reach surgical thresholds. This study aimed to identify aortic diameter and care of patients with aortic imaging before aortic dissection (AD). In a retrospective cohort of AD patients, we evaluated previous imaging results in addition to ordering providers and indications. Imaging was stratified as >1 or <1 year: 62 patients (53% men) had aortic imaging before AD (most recent test: 82% echo, 11% computed tomography, 6% magnetic resonance imaging). Imaging was ordered most frequently by primary care physicians (35%) and cardiologists (39%). The most frequent imaging indications were arrhythmia (11%), dyspnea (10%), before or after aortic valve surgery (8%), chest pain (6%), and aneurysm surveillance in 13%. Of all patients, 94% had aortic diameters below the surgical threshold before the AD. Imaging was performed <1 year before AD in 47% and aortic size was 4.4 ± 0.8 cm in ascending aorta and 4.0 ± 0.8 cm in sinus. In patients whose most recent imaging was >1 year before AD (1,317 ± 1,017 days), the mean ascending aortic diameter was 4.2 ± 0.4 cm. In conclusion, in a series of patients with aortic imaging before AD, the aortic size was far short of surgical thresholds in 94% of the group. In >50%, imaging was last performed >1 year before dissection.
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Einfluss der bikuspiden und trikuspiden Aortenklappe bei Typ-A-Aortendissektion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-021-00468-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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30
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Elefteriades JA, Ziganshin BA. A new 'angle' towards prediction of type A aortic dissection. Eur J Cardiothorac Surg 2021; 60:987-988. [PMID: 34165530 DOI: 10.1093/ejcts/ezab270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John A Elefteriades
- Aortic Institute at Yale New Haven, Yale University School of Medicine, New Haven, CT, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale New Haven, Yale University School of Medicine, New Haven, CT, USA
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Peterss S, Buech J, Hagl C, Pichlmaier M. What do we know? The dilemma of modelling risk for aortic dissection. Eur J Cardiothorac Surg 2021; 61:731. [PMID: 34347075 DOI: 10.1093/ejcts/ezab361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
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Kalogerakos PD, Zafar MA, Li Y, Mukherjee SK, Ziganshin BA, Rizzo JA, Elefteriades JA. Root Dilatation Is More Malignant Than Ascending Aortic Dilation. J Am Heart Assoc 2021; 10:e020645. [PMID: 34238012 PMCID: PMC8483477 DOI: 10.1161/jaha.120.020645] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Data from the International Registry of Acute Aortic Dissection indicate that the guideline criterion of 5.5 cm for ascending aortic intervention misses many dissections occurring at smaller dimensions. Furthermore, studies of natural behavior have generally treated the aortic root and the ascending aorta as 1 unit despite embryological, anatomical, and functional differences. This study aims to disentangle the natural histories of the aforementioned aortic segments, allowing natural behavior to define specific intervention criteria for root and ascending segments of the aorta. Methods and Results Diameters of the aortic root and mid‐ascending segment were measured separately. Long‐term complications (dissection, rupture, and death) were analyzed retrospectively for 1162 patients with ascending thoracic aortic aneurysm. Cox regression analysis suggested that aortic root dilatation (P=0.017) is more significant in predicting adverse events than mid‐ascending aortic dilatation (P=0.087). Short stature posed as a serious risk factor. The dedicated risk curves for the aortic root and the mid‐ascending aorta revealed hinge points at 5.0 and 5.25 cm, respectively. Conclusions The natural histories of the aortic root and mid‐ascending aorta are uniquely different. Dilation of the aortic root imparts a significant higher risk of adverse events. A diameter shift for intervention to 5.0 cm for the aortic root and to 5.25 cm for the mid‐ascending aorta should be considered at expert centers.
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Affiliation(s)
- Paris D Kalogerakos
- Aortic Institute at Yale-New Haven Hospital Yale University School of Medicine New Haven CT
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital Yale University School of Medicine New Haven CT
| | - Yupeng Li
- Department of Political Science and Economics Rowan University Glassboro NJ
| | - Sandip K Mukherjee
- Aortic Institute at Yale-New Haven Hospital Yale University School of Medicine New Haven CT
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital Yale University School of Medicine New Haven CT
| | - John A Rizzo
- Department of Economics and Department of Preventive Medicine Stony Brook University Stony Brook NY
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital Yale University School of Medicine New Haven CT
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Tozzi P, Gunga Z, Niclauss L, Delay D, Roumy A, Pfister R, Colombier S, Patella F, Qanadli SD, Kirsch M. Type A aortic dissection in aneurysms having modelled pre-dissection maximum diameter below 45 mm: should we implement current guidelines to improve the survival benefit of prophylactic surgery? Eur J Cardiothorac Surg 2021; 59:473-478. [PMID: 33006606 PMCID: PMC7850065 DOI: 10.1093/ejcts/ezaa351] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Current guidelines recommend prophylactic replacement of the ascending aorta at an aneurysmal diameter of >55 mm to prevent acute Type A aortic dissection (TAAD) in non-Marfan patients. Several publications have challenged this threshold, suggesting that surgery should be performed in smaller aneurysms to prevent this devastating disease. We reviewed our experience with measuring aortic size at the time of TAAD to validate the existing recommendation for prophylactic ascending aorta replacement. METHODS All patients who had been admitted for TAAD to our emergency department from 2014 to 2019 and underwent ascending aorta replacement were included. Marfan patients were excluded. The maximum diameter of the dissected aorta was measured preoperatively using CT scan. We estimated the aortic diameter at the time of dissection to be 7 mm smaller than the measured maximum diameter of the dissected aorta (modelled pre-dissection diameter). RESULTS Overall, 102 patients were included. Of these, 67 were male (65.6%) and 35 were female (34.4%), and the cohort’s mean age was 65 ± 12.1 years. In addition, 66% were treated for arterial hypertension. The mean maximum modelled pre-dissection diameter was 39.6 ± 4.8 mm: 39.1 ± 5.1 mm in men and 40.7 ± 2.8 mm in women (P = 0.1). The cumulative 30-day mortality rate was 19.6% (20/102). CONCLUSIONS TAAD occurred at a modelled aortic diameter below 45 mm in 87.7% of our patients. Therefore, the current aortic diameter threshold of 55 mm excludes ∼99% of patients with TAAD from prophylactic replacement of the ascending aorta. The maximum diameter of the ascending aorta warrants reappraisal and this parameter should be a distinct part of a personalized decision-making process that also takes into account age, gender and body surface area to establish the surgical indication for preventive aorta replacement aimed to improve the survival benefit of this procedure.
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Affiliation(s)
- Piergiorgio Tozzi
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Ziyad Gunga
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Lars Niclauss
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Dominique Delay
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Aurelian Roumy
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Raymond Pfister
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Sebastien Colombier
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | | | - Salah Dine Qanadli
- Radiology Department, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
| | - Matthias Kirsch
- Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland
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Eliathamby D, Gutierrez M, Liu A, Ouzounian M, Forbes TL, Tan KT, Chung J. Ascending Aortic Length and Its Association With Type A Aortic Dissection. J Am Heart Assoc 2021; 10:e020140. [PMID: 34121418 PMCID: PMC8403277 DOI: 10.1161/jaha.120.020140] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background The aim of this study was to determine the role of ascending aortic length and diameter in type A aortic dissection. Methods and Results Computed tomography scans from patients with acute type A dissections (n=51), patients with proximal thoracic aortic aneurysms (n=121), and controls with normal aortas (n=200) were analyzed from aortic annulus to the innominate artery using multiplanar reconstruction. In the control group, ascending aortic length correlated with diameter (r2=0.35, P<0.001), age (r2=0.17, P<0.001), and sex (P<0.001). As a result of immediate changes in aortic morphology at the time of acute dissection, predissection lengths and diameters were estimated based on models from published literature. Ascending aortic length was longer in patients immediately following acute dissection (median, 109.7 mm; interquartile range [IQR], 101.0–115.1 mm), patients in the estimated predissection group (median, 104.2 mm; IQR, 96.0–109.3 mm), and patients in the aneurysm group (median, 107.0 mm; IQR, 99.6–118.7 mm) in comparison to controls (median, 83.2 mm; IQR, 74.5–90.7 mm) (P<0.001 all comparisons). The diameter of the ascending aorta was largest in the aneurysm group (median, 52.0 mm; IQR, 45.9–58.0 mm), followed by the dissection group (median, 50.3 mm; IQR, 46.6–57.5 mm), and not significantly different between controls and the estimated predissection group (median, 33.4 mm [IQR, 30.7–36.7 mm] versus 35.2 mm [IQR, 32.6–40.3 mm], P=0.09). After adjustment for diameter, age, and sex, the estimated predissection aortic lengths were 16 mm longer than those in the controls and 12 mm longer than in patients with nondissected thoracic aneurysms. Conclusions The length of the ascending aorta, after adjustment for age, sex, and aortic diameter, may be useful in discriminating patients with type A dissection from normal controls and patients with nondissected thoracic aneurysms.
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Affiliation(s)
| | - Mariana Gutierrez
- Division of Cardiovascular Surgery University Health Network Toronto Canada
| | - Aileen Liu
- Division of Cardiovascular Surgery University Health Network Toronto Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery University Health Network Toronto Canada
| | - Thomas L Forbes
- Division of Vascular Surgery University Health Network Toronto Canada
| | - Kong Teng Tan
- Division of Vascular/Interventional Radiology University Health Network Toronto Canada
| | - Jennifer Chung
- Division of Cardiovascular Surgery University Health Network Toronto Canada
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Saade W, Vinciguerra M, Romiti S, Macrina F, Frati G, Miraldi F, Greco E. 3D morphometric analysis of ascending aorta as an adjunctive tool to predict type A acute aortic dissection. J Thorac Dis 2021; 13:3443-3457. [PMID: 34277040 PMCID: PMC8264695 DOI: 10.21037/jtd-21-119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/09/2021] [Indexed: 12/14/2022]
Abstract
Background Acute type A aortic dissection (AAAD) is a pathological process that implicates the ascending aorta and represents a surgical emergency burdened by high mortality if not promptly treated in the first hours of onset. Despite best efforts, the annual incidence rates of aortic dissection has remained stable over the past decades. We measured aortic dimensions (aortic diameters, area, length and volume) using 3D multiplanar reconstruction imaging with the purpose of refining the risk- morphology for AAAD. Methods Computerized tomography angiography studies of three groups were compared retrospectively: patients affected by AAAD (AAAD group; n=71), patients affected by aortic aneurysm and subsequently subjected to ascending aorta replacement (Aneurysm, n=77) and a healthy aorta’s group (Control, n=75). Results Mean diameters of AAAD (4.9 cm) and Aneurysm (5.1 cm) aortas were significantly larger than those of the control group (3.4 cm). In AAAD patients, an ascending aorta diameter greater than 5.5 cm was observed in 18% of patients. Multiple comparisons showed statistically significant differences among mean of the ratio of aortic root area to height between the three groups (P<0.001). In frontal and sagittal planes, the length of the ascending aorta was significantly greater in patients affected by aortic pathology (AAAD and aneurysm) than in the control group (P<0.001). Significant differences were confirmed when indexing the aortic length to patient’s height and BSA, and the aortic volume to patient’s BSA. Conclusions Maximum transverse diameter, considered separately, is not the best predictor of aortic dissection. In our opinion, the introduction into clinical practice of measurements of the area, length, and volume of the aorta, as absolute or indexed values, could improve the selection of patients who would benefit from preventive surgical aortic replacement.
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Affiliation(s)
- Wael Saade
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Mattia Vinciguerra
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Romiti
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Macrina
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Rome, Italy.,IRCCS NEUROMED, Pozzilli, Italy
| | - Fabio Miraldi
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Ernesto Greco
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Guo MH, Appoo JJ, Wells GA, Chu M, Ouzounian M, Fortier J, Boodhwani M. Protocol for a randomised controlled trial for Treatment in Thoracic Aortic Aneurysm: Surgery versus Surveillance (TITAN: SvS). BMJ Open 2021; 11:e052070. [PMID: 34039580 PMCID: PMC8160193 DOI: 10.1136/bmjopen-2021-052070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Ascending thoracic aortic aneurysm (ATAA) is an asymptomatic condition that can lead to catastrophic events of rupture or dissection. Current guidelines are based on limited retrospective data and recommend surgical intervention for ATAA with a diameter of greater or equal to 5.5 cm. Treatment in Thoracic Aortic Aneurysm: Surgery versus Surveillance is the first prospective, multicentre, randomised controlled trial that compares outcomes of patients undergoing early elective ascending aortic surgery to patients undergoing medical surveillance. METHODS AND ANALYSIS Patients between the ages of 18 and 80 with an asymptomatic ATAA between 5.0 cm and 5.4 cm in diameter are eligible for randomisation to early surgery or surveillance. Patients in the surgery group will be followed at 1 month after discharge, then annually for a minimum of 2 years and up to 5 years. Patients in the surveillance group will be followed annually from their index clinic visit for a minimum of 2 years and up to 5 years. The primary outcome is all-cause mortality at follow-up. A sample size of 618 subjects (309 in each group) will achieve an 80% power at a 0.047 significance level. ETHICS AND DISSEMINATION This study has received Ottawa Health Science Network Research Ethics Board approval (Protocol 20180007-01H), which was most recently updated on 25 November 2020. The Research Ethics Board have granted approval to the study at 14 participating institutions, including the Ottawa Health Science Network Research Ethics Board. On completion of data analysis, the result of the trial will be presented at national and international conferences, and published in relevant journals, regardless of the finding of the trial. TRIAL REGISTRATION NUMBER NCT03536312.
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Affiliation(s)
- Ming Hao Guo
- Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jehangir J Appoo
- Cardiac Surgery, University of Calgary, Calgary, Alberta, Canada
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael Chu
- Cardiac Surgery, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Maral Ouzounian
- Cardiac Surgery, University Health Network, Toronto, Ontario, Canada
| | - Jacqueline Fortier
- Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Munir Boodhwani
- Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Della Corte A, Rubino AS, Montella AP, Bancone C, Lo Presti F, Galbiati D, Dialetto G, De Feo M. Implications of abnormal ascending aorta geometry for risk prediction of acute type A aortic dissection. Eur J Cardiothorac Surg 2021; 60:978-986. [PMID: 34021321 DOI: 10.1093/ejcts/ezab218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/07/2021] [Accepted: 03/09/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Recently, increased length of the ascending aorta has been suggested as a possible risk factor for acute type A aortic dissection (ATAAD). Our goal was to identify measurable aortic geometrical characteristics associated with elongation that could differentiate ATAAD from uncomplicated aortic dilation (>45 mm). METHODS In angiographic computed tomography scans performed in 180 patients having cardiac surgery, aortic diameters, root length, length of the ascending aorta at both the centreline and the greater curvature (convexity) and the root-ascending (root-asc) angle (that between the root axis and the axis of the ascending tract) and the ascending-arch (asc-arch) angle (that between the axis of the ascending aorta and the arch axis) were measured and compared among 3 patient groups: normal aorta (diameter < 45 mm), dilation/aneurysm (>45 mm) and ATAAD. Correlations between diameters and angles, diameters and lengths and lengths and angles were analysed; multivariable analysis including geometrical factors was performed to identify independent predictors of ATAAD. RESULTS Both patients with aneurysms and patients with ATAAD showed significantly elongated ascending aortas (P < 0.001 vs normal). However, in the aneurysms, the root-asc angle (136° ± 20° vs 147° ± 17°; P < 0.001) and in ATAAD the asc-arch angle were uniquely narrower than that in the normal aorta (116° ± 11° vs 132° ± 19°; P < 0.001). All patients with an ATAAD had an asc-arch angle ≤130°. Both in patients with ATAAD and in those without ATAAD, narrowing of the asc-arch angle was associated with elongation of the root segment (P < 0.001). In multivariable analysis, the asc-arch angle and the total length of the ascending aorta (root + tubular) were significant predictors of ATAAD. CONCLUSIONS The asc-arch angle is a promising measurement that could help predict aortic dissection along with aortic diameter and length: further verification is warranted.
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Affiliation(s)
- Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Unit of Cardiac Surgery, V. Monaldi Hospital, Naples, Italy
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Saha S, Peterss S, Mueller C, Deseive S, Sadoni S, Hausleiter J, Massberg S, Hagl C, Joskowiak D. Cardiac surgery following transcatheter aortic valve replacement. Eur J Cardiothorac Surg 2021; 60:1149-1155. [PMID: 34021322 DOI: 10.1093/ejcts/ezab217] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/12/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The objective of this study was to retrospectively analyse surgical outcomes of patients undergoing secondary cardiac surgery after initial transcatheter aortic valve replacement (TAVR). METHODS Between December 2012 and February 2020, a total of 41 consecutive patients underwent cardiac surgery after a TAVR procedure at our institution. Patients who underwent emergency operations due to periprocedural complications such as ventricular rupture and TAVR dislocation were excluded from this study (n = 12). Thus, 29 patients were included in the analysis. Data are presented as medians (25th-75th quartiles) or as absolute numbers (percentages). RESULTS The median age was 76 years (68-80); 58.6% were men. The median time to a secondary conventional procedure was 23 months (8-40), with 8 patients requiring surgical intervention within the first year post TAVR. The indications for secondary conventional procedures were prosthesis endocarditis (n = 15), prosthesis degeneration or dysfunction (n = 7) and progression of valvular, aortic or coronary artery disease (n = 7). Surgical redo aortic valve replacement was performed in 24 patients (82.8%). No complications involving the aortic root or the aortomitral continuity were observed. The operative mortality was 10.3%. Extracorporeal life support was required in 3 patients (10.3%) for a median duration of 3 days (3-3 days). No adverse cerebrovascular events were observed postoperatively. Postoperatively, 4 patients (13.8%) required a pacemaker and 7 patients (24.1%) required renal replacement therapy. Overall survival at 1 year was 83.0%. CONCLUSIONS Conventional cardiac surgical procedures following TAVR are feasible with reasonable results and a low complication rate.
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Affiliation(s)
- Shekhar Saha
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Christoph Mueller
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Simon Deseive
- Department of Cardiology, LMU University Hospital, Munich, Germany
| | - Sebastian Sadoni
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Jörg Hausleiter
- Department of Cardiology, LMU University Hospital, Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, LMU University Hospital, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
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Papakonstantinou NA, Rorris FP. Elective replacement of the ascending aorta: is the 5.5-cm threshold appropriate? The insidious, small aorta. Eur J Cardiothorac Surg 2021; 59:554-561. [PMID: 33226084 DOI: 10.1093/ejcts/ezaa387] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/24/2020] [Accepted: 08/29/2020] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES As thoracic aortic aneurysm disease continues to cause significant morbidity and mortality in the general population, the cardiovascular community continues the search for the golden threshold of elective surgical replacement of the ascending aorta. METHODS Thoracic aortic aneurysm is a common disease, classified within the 20 most common causes of death in patients over 65 years old. Once aortic complications like dissection or rupture occur, they can prove fatal. Prophylactic surgical replacement of the ascending aorta remains the mainstay of treatment to prevent these complications. Current American and European guidelines agree that the threshold for the diameter for elective replacement of the ascending aorta in non-syndromic, asymptomatic aneurysmal disease is 5.5 cm. Overall, aortic dissection is related to poor prognosis, thus making early intervention paramount. RESULTS There is a critical size above which the risk of dissection or rupture becomes extremely high. However, a significant post-dissection increase in diameter is reported, thus rendering the predissection aortic diameter well below the current threshold for elective surgical replacement of the ascending aorta. Moreover, it is widely reported that the majority of acute aortic dissections would not meet the criteria for prophylactic surgery prior to dissection. Additionally, elective surgical ascending aortic replacement in the current era shows a significantly improved risk-benefit ratio, which justifies a more aggressive approach in the management of aortic aneurysmal disease. CONCLUSIONS As a result, there is a lot of discussion in the literature about the requirement of a leftward shifting of the surgical threshold for elective aortic replacement.
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Affiliation(s)
| | - Filippos-Paschalis Rorris
- Cardiovascular and Thoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece
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Czerny M, Rylski B, Della Corte A, Krüger T. Decision-making to perform elective surgery for patients with proximal thoracic aortic pathology: A European perspective. J Thorac Cardiovasc Surg 2021; 163:2025-2030. [PMID: 33781591 DOI: 10.1016/j.jtcvs.2021.01.141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/13/2021] [Accepted: 01/22/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli," Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center, Tübingen, Germany
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Commentary: Preventing the virulent lethality of ascending aortic aneurysm. J Thorac Cardiovasc Surg 2021; 163:2031-2033. [PMID: 33744012 DOI: 10.1016/j.jtcvs.2021.02.046] [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: 02/08/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/23/2022]
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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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Wu Y, Gong M, Fan R, Gu T, Qian X, Zhang H. Analysis of ascending aortic diameter and long-term prognosis in patients with ascending aortic dissection. Echocardiography 2021; 38:531-539. [PMID: 33528062 DOI: 10.1111/echo.14980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/22/2020] [Accepted: 01/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES This study was designed to review the ascending aortic diameter of patients undergoing surgery for AAD in China and its influence on prognosis. METHODS In the period between January 2018 and January 2020, 265 patients eligible for analysis of ascending aorta were included in this study. The maximum diameter of the ascending aorta was assessed using preoperative computed tomography (CT) scan for patients. RESULTS The mean diameter of the ascending aorta of the reference population was 48.16 ± 9.37 mm, and the percentage of subjects with an aorta <55 mm was 80.38%. In this study, we found that BMI, hypertension, and bicuspid aortic valve are the main factors affecting the widening of the ascending aorta, and the diameter of the ascending aorta in patients with AAD is negatively correlated with the patient's long-term prognosis. However, there is no significant difference in survival rates among patients with different ascending aortic diameter. CONCLUSIONS Ascending aortas with smaller diameter are also prone to dissection, most of which occur at a lower surgical threshold than recommended by current guidelines. Therefore, the diameter of ascending aorta cannot be used as an independent risk factor for high-risk patients with aortic dissection, but it can be used as an important indicator to evaluate the long-term prognosis of patients.
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Affiliation(s)
- Yuduo Wu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ming Gong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ruixin Fan
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong, China
| | - Tianxiang Gu
- Department of Cardiac Surgery, The First Affiliated Hospital of the China Medical University, Shenyang, China
| | - Ximing Qian
- Department of Cardiac Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Luan J, Mao L, Zhu Z, Fu W, Zhu T. New indicators for systematic assessment of aortic morphology: a narrative review. J Thorac Dis 2021; 13:372-383. [PMID: 33569218 PMCID: PMC7867839 DOI: 10.21037/jtd-20-2728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In order to prevent the occurrence of aortic adverse events in ascending thoracic aortic aneurysm patients, preventive surgery is the sole option in case of large aneurysm. Identifying high-risk patients timely and accurately requires effective predictive indicators of aortic adverse events and accurate risk stratification thresholds. Absolute diameter measured after a single imaging examination, which has been used as the predictive indicator for decades, has been proved to be ineffective for risk stratification in moderately dilated aorta. Previously, new indicators combining absolute diameters with personalized parameters have been reported to show better predictive power of aortic adverse events than absolute diameters by correcting the effect of these parameters on the diameters. Meanwhile, combining three-dimensional parameters to formulate risk stratification thresholds not only may characterize the aortic risk morphology more precisely, but also predict aortic adverse events more accurately. These new indicators may provide more systematic assessment methods of patients’ risk, formulate more personalized intervention strategies for ascending thoracic aortic aneurysm patients, and also provide a basis for researchers to develop more accurate and effective risk thresholds. We also highlight that the algorithm obtained by combining multiple indicators may be a better choice compared with single indicator, but this still requires the support of more evidence. Due to the particularity of syndromic aortic disease, whether these new indicators can be used for its risk stratification is still uncertain. Therefore, the scope of this manuscript does not include this kind of disease.
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Affiliation(s)
- Jingyang Luan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Le Mao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ziqing Zhu
- Department of Psychology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ting Zhu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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45
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Elefteriades JA, Ziganshin BA. Commentary: The elusive perfect criterion for aortic intervention. J Thorac Cardiovasc Surg 2020; 161:1198-1201. [PMID: 33160614 DOI: 10.1016/j.jtcvs.2020.07.071] [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: 07/22/2020] [Revised: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Affiliation(s)
- John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
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46
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Krüger T. Diameter under pressure. Eur J Cardiothorac Surg 2020; 59:ezaa396. [PMID: 33111139 DOI: 10.1093/ejcts/ezaa396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
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Saleh QW, Diederichsen ACP, Lindholt JS. Ascending Aortic Diameter after Dissection Does Not Reflect Size before Dissection. EJVES Vasc Forum 2020; 49:20-22. [PMID: 33089224 PMCID: PMC7567910 DOI: 10.1016/j.ejvsvf.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/24/2020] [Accepted: 09/21/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction Current guidelines for prophylactic resection of ascending aortic aneurysms are based on post-dissection aortic diameter. However, this may not reflect the diameter prior to dissection. Report Pre- and post-dissection aortic diameters were compared in 34 patients with available computerised tomography scans. The median time interval between these scans was 536 days (interquartile range 354 – 1237). Discussion There was a statistically significant difference in diameters from the sinotubular junction to the proximal abdominal aorta, the largest was in the ascending aorta with a mean of 7.6 mm (standard deviation 4.5). This suggests that the ascending aortic diameter is a poor predictor of dissection in most patients. Ascending aortic diameter expands due to acute dissection. Post-dissection aortic diameters probably overestimate pre-dissection diameters. Following ascending dissection, diameter expansion is not limited to aorta ascendens. In this sample, estimated pre-dissection ascending aortic diameters were below 60 mm in 91% of patients and below 50 mm in 85%.
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Affiliation(s)
- Qais W Saleh
- Department of Thoracic-, Cardiac- and Vascular Surgery, Odense University Hospital, Odense, Denmark.,Centre for Individualised Medicine in Arterial Diseases (CIMA), Odense University Hospital, Denmark.,Centre of Clinical Excellence in Southern Denmark (CAVAC), Odense University Hospital, Denmark
| | - Axel C P Diederichsen
- Centre for Individualised Medicine in Arterial Diseases (CIMA), Odense University Hospital, Denmark.,Centre of Clinical Excellence in Southern Denmark (CAVAC), Odense University Hospital, Denmark.,Department of Cardiology, Odense University Hospital, Denmark
| | - Jes S Lindholt
- Department of Thoracic-, Cardiac- and Vascular Surgery, Odense University Hospital, Odense, Denmark.,Centre for Individualised Medicine in Arterial Diseases (CIMA), Odense University Hospital, Denmark.,Centre of Clinical Excellence in Southern Denmark (CAVAC), Odense University Hospital, Denmark
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Mullan CW, Mori M, Bin Mahmood SU, Yousef S, Mangi AA, Elefteriades JA, Geirsson A. Incidence and characteristics of hospitalization for proximal aortic surgery for acute syndromes and for aneurysms in the USA from 2005 to 2014. Eur J Cardiothorac Surg 2020; 58:583-589. [PMID: 32163136 DOI: 10.1093/ejcts/ezaa067] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/21/2020] [Accepted: 02/05/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES The effectiveness of proximal thoracic aortic aneurysm (TAA) surgery in preventing acute aortic syndromes, such as dissection and rupture, is unknown at the populational level. This study evaluated trends in acute aortic syndrome operation incidence relative to proximal aortic surgical volume in the USA. METHODS A retrospective analysis of the National Inpatient Sample in 2005-2014 was performed. Acute aortic syndrome and TAA were identified with International Classification of Diseases, 9th edition diagnosis codes. Proximal aortic surgery was defined as the diagnosis of acute aortic syndrome or TAA with an aortic procedure and either cardioplegia, cardiopulmonary bypass or other cardiac operation. Annual rates of acute aortic syndrome surgery and proximal thoracic aneurysm surgery were adjusted for US population. Trends were evaluated using linear regression. RESULTS We identified 38 442 operations for acute aortic diagnoses and 74 953 operations for TAAs. Case volume for acute aortic syndromes increased from 0.93 to 1.63 per 100 000 (P = 0.001), and aneurysm surgery increased from 1.75 to 3.19 per 100 000 (P < 0.001). Patient and hospital characteristics differed between acute aortic and aneurysm operations, with black patients being most notably underrepresented in the aneurysm population (4.9% vs 17.0%, P < 0.001). CONCLUSIONS Acute aortic syndrome operative volume increased from 2005 to 2014 despite increasing rates of proximal aortic aneurysm surgery. Patient characteristic discrepancies were observed between the 2 groups of hospitalizations, highlighting the need for continued efforts to minimize sociodemographic disparities.
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Affiliation(s)
- Clancy William Mullan
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Makoto Mori
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Syed Usman Bin Mahmood
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sameh Yousef
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Abeel A Mangi
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - John A Elefteriades
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Kreibich M, Rylski B, Czerny M, Pingpoh C, Siepe M, Beyersdorf F, Khurshan F, Vallabhajosyula P, Szeto WY, Bavaria JE, Desai ND, Branchetti E. Type A Aortic Dissection in Patients With Bicuspid Aortic Valve Aortopathy. Ann Thorac Surg 2020; 109:94-100. [DOI: 10.1016/j.athoracsur.2019.05.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 04/03/2019] [Accepted: 05/02/2019] [Indexed: 01/16/2023]
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50
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Zafar MA, Chen JF, Wu J, Li Y, Papanikolaou D, Abdelbaky M, Faggion Vinholo T, Rizzo JA, Ziganshin BA, Mukherjee SK, Elefteriades JA. Natural history of descending thoracic and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2019; 161:498-511.e1. [PMID: 31982126 DOI: 10.1016/j.jtcvs.2019.10.125] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Elucidating critical aortic diameters at which natural complications (rupture, dissection, and death) occur is of paramount importance to guide timely surgical intervention. Natural history knowledge for descending thoracic and thoracoabdominal aortic aneurysms is sparse. Our small early studies recommended repairing descending thoracic and thoracoabdominal aortic aneurysms before a critical diameter of 7.0 cm. We focus exclusively on a large number of descending thoracic and thoracoabdominal aortic aneurysms followed over time, enabling a more detailed analysis with greater granularity across aortic sizes. METHODS Aortic diameters and long-term complications of 907 patients with descending thoracic and thoracoabdominal aortic aneurysms were reviewed. Growth rates (instrumental variables approach), yearly complication rates, 5-year event-free survival (Kaplan-Meier), and risk of complications as a function of aortic height index (aortic diameter [centimeters]/height [meters]) (competing-risks regression) were calculated. RESULTS Estimated mean growth rate of descending thoracic and thoracoabdominal aortic aneurysms was 0.19 cm/year, increasing with increasing aortic size. Median size at acute type B dissection was 4.1 cm. Some 80% of dissections occurred below 5 cm, whereas 93% of ruptures occurred above 5 cm. Descending thoracic and thoracoabdominal aortic aneurysm diameter 6 cm or greater was associated with a 19% yearly rate of rupture, dissection, or death. Five-year complication-free survival progressively decreased with increasing aortic height index. Hazard of complications showed a 6-fold increase at an aortic height index of 4.2 or greater compared with an aortic height index of 3.0 to 3.5 (P < .05). The probability of fatal complications (aortic rupture or death) increased sharply at 2 hinge points: 6.0 and 6.5 cm. CONCLUSIONS Acute type B dissections occur frequently at small aortic sizes; thus, prophylactic size-based surgery may not afford a means for dissection protection. However, fatal complications increase dramatically at 6.0 cm, suggesting that preemptive intervention before that criterion can save lives.
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Affiliation(s)
- Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Julia Fayanne Chen
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Jinlin Wu
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College, Beijing, China
| | - Yupeng Li
- Department of Political Sciences and Economics, Rowan University, Glassboro, NJ
| | - Dimitra Papanikolaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Mohamed Abdelbaky
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Thais Faggion Vinholo
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - John A Rizzo
- Department of Economics and Department of Preventive Medicine, Stony Brook University, Stony Brook, NY
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn; Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - Sandip K Mukherjee
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.
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