Porcelain aorta: a comprehensive review

Clinical implications of diverse calcification patterns in endovascular therapy for femoral-popliteal arterial occlusive disease

OBJECTIVE

The aim of this study was to investigate whether intimal arterial calcification (IAC) and medial arterial calcification (MAC) are correlated with the various clinical outcomes following endovascular therapy (EVT) for peripheral arterial disease (PAD).

METHODS

This single-center retrospective study comprised 154 consecutively hospitalized individuals with PAD who underwent EVT for de novo femoral-popliteal calcific lesions from January 2016 to July 2021. The predominant calcification patterns of IAC and MAC were assessed using a semi-quantitative computed tomography scoring system. The Kaplan-Meier method and Cox regression were conducted to evaluate the correlations between calcification patterns and medium- to long-term outcomes.

RESULTS

The distribution of calcification patterns was as follows: IAC in 111 patients (72%) and MAC in 43 patients (28%). No remarkable variation was noted between the IAC and MAC groups regarding age (P = .84) and gender (P = .23). The MAC group indicated lower rates of 4-year primary patency, assisted primary patency, secondary patency, and amputation-free survival (AFS) compared with the IAC group (24% ± 7% vs 40% ± 6%; P = .003; 30% ± 8% vs 51% ± 6%; P = .001; 51% ± 8% vs 65% ± 5%; P = .004; and 43% ± 9% vs 76% ± 5%; P < .001, respectively). There was no significant difference in the rate of freedom from clinically driven target lesion revascularization between the MAC and IAC groups (63% ± 10% vs 73% ± 5%; P = .26). Stepwise multivariable Cox regression analysis demonstrated that MAC was associated with poor patency (hazard ratio, 1.81; 95% confidence interval, 1.12-2.93; P = .016) and AFS (hazard ratio, 2.80; 95% confidence interval, 1.52-5.16; P = .001).

CONCLUSIONS

Compared with IAC, MAC is independently associated with lower medium- to long-term patency and AFS after EVT for de novo femoral-popliteal occlusive lesions.

Outcomes of transcatheter aortic valve replacement in patients with history of chest wall irradiation: Propensity matched analysis of five years data from national inpatient sample (2016-2020)

INTRODUCTION

Chest radiotherapy has been utilized to treat intra-thoracic and mediastinal tumors. Chest wall irradiation (C-XRT) survivors frequently develop valvular disease, including aortic stenosis, which eventually requires valve replacement. Previous trials have shown worse outcomes with surgical aortic valve replacement. However, transcatheter aortic valve replacement (TAVR) outcomes-related data in patients with C-XRT is limited.

METHODS

The national inpatient sample (NIS) database was queried from 2016 to 2020 to identify adult hospitalizations with TAVR, which were dichotomized based on a history of C-XRT using ICD-10-CM codes. Propensity score matching was performed to derive age, sex, hospital characteristics, and co-morbidities matched controls without a history of C-XRT. The outcomes studied were inpatient mortality and complications, mean length of stay (LOS), and total hospital charge (THC). Multivariate logistic and linear regression were used to analyze the outcomes.

RESULTS

Of 296,670 patients who underwent TAVR between 2016 and 2020, 515 had a history of C-XRT. Upon propensity score matching in patients undergoing TAVR, Patients with a history of C-XRT showed significantly lower adjusted odds of in-hospital mortality (adjusted odd ratio [aOR] 0.04, 95 % CI [0.003-0.57], p = 0.017), lower mean LOS by 1.6 days (-1.88 to -1.26 days, p < 0.001) and reduced mean THC (-$74,720, [-$88,784 to -$60,655], p < 0.001). Additionally, patients with C-XRT had significantly lower adjusted odds of inpatient complications, mainly acute myocardial infarction, cerebrovascular events, acute respiratory failure, acute kidney injury, need for vasopressors and cardiopulmonary resuscitation, whereas similar odds of complications, including a requirement of intubation, mechanical ventilation, hemodialysis, and cardiogenic shock.

CONCLUSION

Our analysis showed reduced adjusted odds of in-hospital mortality, length of stay, total hospital charges, and inpatient complications in patients undergoing TAVR with a history of C-XRT. TAVR appears to be a safe and viable alternative in this population subgroup.

Association of Oral Anticoagulant Therapy with the Prevalence and Severity of Vascular Calcification among Patients with Atrial Fibrillation: A Cohort Study

Many patients with atrial fibrillation (AF) requiring long-term use of oral anticoagulants (OACs) are at high risk for vascular calcification and anticoagulation therapy with warfarin exacerbate vascular calcification. However, the effect of nonvitamin K agonists on vascular calcification has not been clearly investigated. This study explored the effects of dabigatran etexilate, rivaroxaban, and warfarin on vascular calcification among 1527 patients with AF. Demographics, comorbidities, laboratory test data, medications, and the prevalence and severity of vascular calcification in different vascular beds were compared. After propensity score matching, the incidence of vascular calcification in the rivaroxaban and warfarin group was significantly higher than that in the nonanticoagulant group, while there was no difference between the dabigatran etexilate group and the nonanticoagulant group. Similarly, we found that the rivaroxaban group had more severe calcification in the overall vascular level (P < 0.001), thoracic aorta (P < 0.001), aortic arch (P = 0.001), and left common carotid artery (P = 0.005) than the nonanticoagulant group. In addition, in the left common carotid artery, there was more severe calcification in the rivaroxaban group than that in the dabigatran group (P = 0.005). Our results suggest that rivaroxaban can significantly increase both the incidence and severity of vascular calcification among patients with AF, while dabigatran etexilate has no such effect. Many patients with AF requiring long-term use of OACs are at high risk for vascular calcification. This is the first study to conduct a head-to-head comparison of the effects of dabigatran etexilate and rivaroxaban on vascular calcification. Rivaroxaban, rather than dabigatran etexilate, promotes vascular calcification in patients with AF, providing important implications to aid clinicians in their choice for OAC selection, especially those at high risk for vascular calcification.

Percutaneous transluminal coronary angioplasty in a 52-year-old patient with porcelain aorta and calcified coronaries: A case report

Porcelain aorta, characterized by extensive calcification of the aortic wall is often associated with coronary calcification. It can pose an increased risk of thromboembolic complications during interventional and surgical procedures. We present a case of a 52-year-old female, a chronic smoker with dyslipidemia with complaints of exertional chest pain for past 6 months. She was diagnosed as a case of non-ST elevation myocardial infarction (NSTEMI) with multivessel CAD, with porcelain aorta and calcified coronaries based on abnormal ECG, elevated troponin and coronary angiography findings. Percutaneous transluminal coronary angioplasty (PTCA) was the treatment modality chosen considering the risk of thromboembolism with aortic manipulation during coronary artery bypass grafting (CABG). Repeat ECG after the procedure showed resolution of ST segment depression. Her hospital stay was uneventful. She was discharged on dual antiplatelet therapy, statin and metoprolol. One-week follow-up revealed normal ECG and blood reports, with further outpatient department visits scheduled every 3 months. Porcelain aorta and coronary calcification is a challenging case for cardiologists. PTCA if done meticulously could be preferable to coronary-artery by-pass grafting (CABG) in such patients. Despite the risks like aortic rupture and thromboembolic complications, PTCA in a case of multivessel CAD with porcelain aorta and calcified coronaries could be a life-saving procedure.

Transaortic TAVR and Mitral Repair Under Deep Hypothermic Circulatory Arrest in a Porcelain Aorta Patient

Vascular and valvular calcifications, commonly seen in renal patients, increase operative mortality and can preclude conventional valvular management. We show a novel approach to treat aortic stenosis and degenerative mitral regurgitation under hypothermic circulatory arrest in a hemodialysis patient with aortic, mitral disease and porcelain aorta with surgical and transcatheter contraindications.

Shaggy aorta-An autopsy analysis

Aims

Shaggy aorta is defined as "very extensive atheromatous disease with diffuse ulcers associated with soft, loosely held debris and a paucity of actual thrombus" and often results in visceral or peripheral arterial embolization (shaggy aorta syndrome). Most of the studies are clinico-radiological with hardly any assessment of the pathological features. We present an autopsy analysis of shaggy aorta.

Materials and Methods

A retrospective study of autopsied cases of shaggy aorta over 15 years was conducted. The involvement of the various segments of the aorta (ascending, transverse, thoracic, and abdominal) was correlated with the clinical manifestations and cardiac/extra-cardiac findings at autopsy. The mortality was categorized as those related to shaggy aorta (Group I), related to cardiac diseases (Group II), and those unrelated to cardiovascular diseases (Group III).

Statistical Analysis

Nil.

Results

In a span of 15 years, there were 76 cases of shaggy aorta affecting predominantly males (85.5%) and patients in the sixth decades of life (mean age of 64.5 years). The important associated cardiovascular risk factors included hypertension, tobacco use, and diabetes mellitus. Predominant involvement of the entire aorta and arch + descending aorta was seen in 39.5% and 35.5% of the cases, respectively. Regardless of extreme severity, only half of the patients (37 cases, 48. 7%) had clinical presentation due to shaggy aorta.

Conclusions

The occurrence of shaggy aorta may be more common than expected, and it would be important to keep this possibility in mind even in asymptomatic elderly patients with cardiovascular risk factors since aorto-arterial manipulations and anti-coagulant therapy can prove detrimental in such patients.

Endothelial-to-mesenchymal transition: New insights into vascular calcification

With the continuous progress of atherosclerosis research, the significant pathological change of it--vascular calcification (VC), gains increasing attention. In recent years, numerous studies have demonstrated that it is an independent predictor of death risk of cardiovascular disease, and it has a strong correlation with poor clinical prognosis. As the world's population continues to age, the occurrence of VC is expected to reach its highest point in the near future. Therefore, it is essential to investigate ways to prevent or even reverse this process for clinical purposes. Endothelial-to-mesenchymal transition (EndMT) describes the progressive differentiation of endothelial cells into mesenchymal stem cells (MSCs) under various stimuli and acquisition of pluripotent cell characteristics. More and more studies show that EndMT plays a vital role in various cardiovascular diseases, including atherosclerosis, vascular calcification and heart valvular disease. EndMT is also involved in the formation and progression of VC. This review vividly describes the history, characteristics of EndMT and how it affects the endothelial cell process, then focuses on the relationship between vascular endothelium, EndMT, amino acid metabolism, and vascular calcification. Finally, it overviews the signal pathway of EndMT and drugs targeting EndMT, hoping to provide new ideas and a theoretical basis for studying potential therapeutic targets of VC.

Choosing transcatheter aortic valve replacement in porcelain aorta: outcomes versus surgical replacement

OBJECTIVES

Porcelain aorta complicates aortic valve replacement and is an indication for transcatheter approaches. No study has compared surgical and transcatheter valve replacement in the setting of porcelain aorta. We characterize porcelain aorta patients undergoing aortic valve replacement and the association of aortic calcification and outcomes.

METHODS

Patients undergoing aortic valve replacement with porcelain aorta were identified. Aortic calcium volume was determined using 3D computed tomography thresholding techniques. Propensity scoring was performed to assess the effect of surgical versus transcatheter approaches. Risk factors for composite major hospital complications (death, stroke and dialysis) were identified using random forest machine learning.

RESULTS

From January 2006 to January 2015, 164 patients with porcelain aorta underwent aortic valve replacement [105 (64%) surgical replacement, 59 (36%) transcatheter replacement]. Propensity scoring matched 29 pairs (49% of transcatheter patients). Before matching, 5-year survival was 41% [(43% surgical, 35% transcatheter, P(log-rank) = 0.9]. After matching, mortality for surgical versus transcatheter replacement was 3.4% (n = 1) vs 10% (n = 3), stroke 14% (n = 4) vs 3.4% (n = 1) and dialysis 6.9% (n = 2) versus 11% (n = 3). Matched 5-year survival was 40% after surgical replacement and 29% after transcatheter replacement [P(log-rank) = 0.4]. Total aortic calcium volume was greater in transcatheter than surgical patients [18 (8.0) vs 17 (7.7) ml] and was associated with more major hospital complications after either approach.

CONCLUSIONS

Surgical and transcatheter approaches are complementary options for aortic stenosis with porcelain aorta. Surgical valve replacement remains an effective treatment for patients requiring concomitant procedures. Quantifying aortic calcium volume is a helpful risk predictor in all patients with porcelain aorta.

Relationship between Muscle Mass, Bone Density and Vascular Calcifications in Elderly People with SARS-CoV-2 Pneumonia

BACKGROUND

Little is known about the changes in organs and tissues that may make elder patients more vulnerable to acute stressors such as SARS-CoV-2 infection.

METHODS

In 80 consecutive elderly patients with SARS-CoV-2 infection, we evaluated the association between the descending thoracic aorta calcium score, L1 bone density and T12 skeletal muscle density measured on the same scan by high-resolution computed tomography.

RESULTS

At median regression, the ln-transformed DTA calcium score was inversely associated with L1 bone density (-0.02, 95%CI -0.04 to -0.01 ln-Agatston units for an increase of 1 HU) and with T12 muscle density (-0.03, -0.06 to -0.001 ln-Agatston units for an increase of 1 HU). At penalized logistic regression, an increase of 1 ln-Agatston unit of DTA calcium score was associated with an OR of death of 1.480 (1.022 to 2.145), one of 1 HU of bone density with an OR of 0.981 (0.966 to 0.996) and one of 1 HU of muscle density with an OR of 0.973 (0.948 to 0.999). These relationships disappeared after correction for age and age was the stronger predictor of body composition and death.

CONCLUSIONS

Age has a big effect on the relationship between vascular calcifications, L1 bone density and T12 muscle density and on their relationship with the odds of dying.

Management of cardiovascular surgery in patients with systemic lupus erythematosus including thromboembolism and multiple organ failure prevention: A retrospective observational study

Systemic lupus erythematosus is a chronic autoimmune disease that affects most tissues. Cardiovascular events are critical, life-threatening, long-term complications of systemic lupus erythematosus (SLE). We report our single-center experience of performing cardiovascular surgery in patients with SLE while avoiding postoperative complications. We also suggest a new approach for cardiopulmonary bypass and perioperative management. We applied the antiphospholipid antibody syndrome (APS) severity classification published by the Japan Intractable Disease Information Center to patients with SLE for perioperative management. Patients with Grade III or higher severity are treated with a slightly relaxed version of catastrophic APS therapy. This treatment modality includes glucocorticoids, anticoagulation, intravenous immunoglobulin, and plasma exchange. Between April 2010 and January 2021, 26 patients (2 males, 24 females) with SLE underwent cardiovascular surgery. The mean age was 74.2 ± 13.0 years (38-84 years). The primary outcomes were in-hospital mortality and long-term results, and the secondary outcomes were related to bleeding/embolization and coagulation function/platelet count. A subset analysis was performed to examine treatment efficacy in the APS Grade III or higher group. Of the 26 patients, 17 underwent valve surgery, 4 underwent isolated coronary artery bypass grafting, and 5 underwent thoracic aortic aneurysm surgery. There were no in-hospital deaths or associated bleeding/embolic complications. Postoperative antithrombin III decreased in patients who underwent valvular and aortic surgery, and platelet counts recovered to preoperative levels within 7 to 10 days. The 5- and 10-year survival rates were 80.5% and 53.7%, respectively. In addition, there were 10 patients with APS Grade III or higher, but there was no significant difference in the frequency of complications other than platelet recovery after treatment. The surgical outcome of open-heart surgery in patients with SLE was good. Surgical treatment of cardiovascular disease in these patients is difficult and complex. We focused on blood coagulation abnormalities and treated each patient by selecting the best individual treatment protocol according to the severity of the disease, taking into account the risk of bleeding and thrombosis. Management of blood coagulation function in these patients is essential, and careful therapeutic management should be considered during open-heart surgery.

Radiation-Induced Aortic Stenosis: An Update on Treatment Modalities

The adverse effects of radiation therapy for cancer are well described and can include a wide array of cardiac complications. Radiation-induced aortic stenosis (AS) is an increasingly recognized entity that poses particular therapeutic challenges. Several retrospective studies comparing the outcomes after transcatheter aortic valve replacement (TAVR) vs those after surgical aortic valve replacement patients with radiation-induced AS have found a trend toward decreased mortality and fewer major complications with TAVR. Surgical aortic valve replacement is associated with increased mortality in patients with radiation-induced AS compared with patients without a history of prior radiation. TAVR has been shown to be a safe and effective alternative in patients with radiation-induced AS, with safety similar to that for patients who have not received prior radiation. However, rare and unexpected complications may occur after TAVR from the deleterious effects of radiation on mediastinal structures. More studies are needed to identify the optimal way of managing patients with radiation-induced AS, and algorithms are needed for planning these complex interventions.

Porcelain Aorta in a Young Person Living with HIV Who Presented with Angina

People living with human immunodeficiency virus have an increased cardiovascular risk due to higher prevalence of traditional risk factors, such as smoking, dyslipidemia, hypertension, diabetes, or obesity, and particular risk factors, such as inflammation, endothelial dysfunction, and antiretroviral therapy. Thus, people living with human immunodeficiency virus can develop accelerated atherosclerosis. The incidence of coronary artery disease in these patients may be twice as high compared with that of HIV-negative individuals with similar characteristics. "Porcelain aorta" is a term used to describe extensive circumferential calcification of the thoracic aorta. The pathophysiology of porcelain aorta is not fully understood. We present a case of a young man who was a smoker and living with HIV since childhood, without other traditional cardiovascular risk factors, who presented to the emergency room with a positive stress test for myocardial ischemia. Transthoracic echocardiography revealed normal regional and global myocardial wall motion, ascending aorta ectasia, and moderate aortic regurgitation. Coronary angiography showed a critical calcified proximal left anterior descending artery stenosis and an important calcification of the thoracic aorta. Therefore, the most important challenge was the management of coronary syndrome in a young person living with HIV, with associated porcelain aorta and aortic regurgitation.

Pediatric Porcelain Aorta Secondary to Gaucher Disease Type 3C With Successful Aortic Replacement Surgery

Gaucher type 3C disease with porcelain aorta can cause severe hemodynamic impairment. We report the first case, to our knowledge, of a 13-year-old Mexican girl with a GBA1 homozygous c.1342G>C [p.Asp448His] (commonly known as p.D409H) pathogenic variant who underwent extensive aortic replacement. She has been on enzyme replacement therapy and is alive 5 years after surgery. (Level of Difficulty: Intermediate.)

A CT-based pelvic calcification score in kidney transplant patients is a possible predictor of graft and overall survival

OBJECTIVES

Computerized tomography (CT) is the most accurate method for evaluating pelvic calcifications, which are of utmost importance for planning kidney transplantation (KT). The aim of our study was to evaluate the incidence and distribution of iliac artery calcifications and correlate the novel pelvic calcification score (PCS) with cardiovascular risk factors and graft and overall survival in KT patients.

METHODS

We retrospectively included 118 KT patients operated at our institution with pretransplant pelvic CT. Calcification morphology, circumference and length of both common and external iliac arteries were independently scored by two uroradiologists. PCS was calculated as the total score sum of all three calcification features in all vessels. PCS correlation with graft and patient survival was performed.

RESULTS

Calcification in at least one vascular segment was found in 79% of patients. PCS was significantly higher in male patients (p = 0.006), patients over 55 years (p < 0.001), and patients on haemodialysis (p = 0.016). Patients with a PCS >3 had significantly shorter graft and overall survival rates (p = 0.041 and p = 0.039, respectively).

CONCLUSIONS

The extent of iliac artery calcification in KT recipients quantified by PCS on pretransplant CT correlates with graft and overall patient survival. A PCS over three was associated with worse clinical outcomes and could become a possible prognostic factor.

ADVANCES IN KNOWLEDGE

Our novel PCS is a robust method for quantifying iliac artery calcification burden. Since higher a PCS correlates with worse patient and graft survival, PCS has the potential to become a prognostic factor in kidney transplant patients.

Concomitant anaortic OPCAB and transfemoral TAVR for high-risk patients: A case series

BACKGROUND

Combined on-pump coronary artery bypass (ONCAB) and surgical aortic valve replacement (SAVR) is the treatment of choice for concomitant severe aortic stenosis and coronary artery disease not amenable to percutaneous coronary intervention. Extensive aortic calcification and atheromatous disease may prohibit cardiopulmonary bypass and aortic cross-clamping. In these cases, anaortic off-pump coronary artery bypass (OPCAB) is a Class I (EACTS 2018) and Class IIA (AHA 2021) indication for surgical coronary revascularization. Transcatheter aortic valve replacement (TAVR) has similar benefits when compared with SAVR for this population (Partner 2 & 3). Herewith we describe a case series of concomitant Anaortic OPCAB and TAVR via the transfemoral approach for patients with coronary artery and valve disease considered too high risk for traditional coronary artery bypass grafting and SAVR due to severe aortic disease.

METHODS/RESULTS

Eight patients underwent anaortic OPCAB and transfemoral TAVR during the same anesthetic in a hybrid operating room. Seven patients with multivessel disease had anaortic OPCAB via a sternotomy using composite grafts, one patient with LAD disease had anaortic OPCAB using a Da Vinci-assisted MIDCAB approach. All patients then had an Edwards Sapien 3 TAVR placed percutaneously via the common femoral artery. There was no 30 mortality or CVA in the series and all patients were discharged to home or a rehabilitation facility on Day 4-13.

CONCLUSIONS

Combined anaortic OPCAB and transfemoral TAVR is a safe and feasible approach to treating concomitant extensive coronary artery disease and severe aortic stenosis. The aortic no-touch technique provides benefits in the elderly high-risk patients by reducing the risk of postoperative myocardial infarction and cerebrovascular stroke.

Porcelain aorta does not mean inoperability but needs special strategies

Porcelain aorta is not an absolute contraindication for aortic valve and/or coronary bypass grafting but it requires a special strategy and individualized approach to minimize the risk of embolic complications and technical problems during opening and/or closing the aortotomy.

Exercise echocardiography for a differential diagnosis in a patient with radiation-induced heart disease: A case report

Advances in radiation therapy (RT) have dramatically improved the survival rates of patients with cancer, but radiation-induced heart disease (RIHD) has become an emerging problem, which is complex and multifaceted.

A 65-year-old man with a medical history of chemoradiotherapy for esophageal cancer, who had multiple admissions for acute heart failure (AHF), was readmitted to our hospital. Transthoracic echocardiography at rest revealed left ventricular diastolic dysfunction, moderate aortic stenosis with mild aortic regurgitation, and mild mitral regurgitation (MR). A diagnosis of RIHD was obtained, however, the main cause of the AHF was not clearly understood. Exercise echocardiography (ExE) revealed an exacerbation of the MR and exercise-induced pulmonary hypertension (EIPH), and the severe dynamic MR was considered to be the main cause of the AHF. A transcatheter edge-to-edge repair (TEER) with a MitraClip (Abbott Vascular, Menlo Park, CA, USA) was performed, and the post-procedural ExE showed the mitigation of the dynamic MR and EIPH. He had no further heart failure admissions for more than one year.

Our case showed that ExE may be useful in the management of patients with RIHD, and a TEER with a MitraClip may be an effective treatment for RT-related dynamic MR.

Learning objective

Radiation therapy (RT) has improved the survival rates of patients with cancer, but which involves radiation-induced heart disease (RIHD). RIHD is complex and multifaceted, and RT-related valvular disease may be underestimated with transthoracic echocardiography at rest alone. Then exercise echocardiography may be useful in the management. It is important to perform an individualized approach including medical therapy, surgery, and percutaneous intervention by a heart team.

The Contribution of Extracellular Vesicles From Senescent Endothelial and Vascular Smooth Muscle Cells to Vascular Calcification

Vascular calcification is an irreversible pathological process associated with a loss of vascular wall function. This process occurs as a result of aging and age-related diseases, such as cardiovascular and chronic kidney diseases, and leads to comorbidities. During these age-related diseases, the endothelium accumulates senescent cells, which stimulate calcification in vascular smooth muscle cells. Currently, vascular calcification is a silent pathology, and there are no early diagnostic tools. Therefore, by the time vascular calcification is diagnosed, it is usually untreatable. Some mediators, such as oxidative stress, inflammation, and extracellular vesicles, are inducers and promoters of vascular calcification. They play a crucial role during vascular generation and the progression of vascular calcification. Extracellular vesicles, mainly derived from injured endothelial cells that have acquired a senescent phenotype, contribute to calcification in a manner mostly dependent on two factors: (1) the number of extracellular vesicles released, and (2) their cargo. In this review, we present state-of-the-art knowledge on the composition and functions of extracellular vesicles involved in the generation and progression of vascular calcification.

Effect of routine preoperative screening for aortic calcifications using noncontrast computed tomography on stroke rate in cardiac surgery: the randomized controlled CRICKET study

Objectives

To evaluate if routine screening for aortic calcification using unenhanced CT lowers the risk of stroke and alters the surgical approach in patients undergoing general cardiac surgery compared with standard of care (SoC).

Methods

In this prospective, multicenter, randomized controlled trial, adult patients scheduled for cardiac surgery from September 2014 to October 2019 were randomized 1:1 into two groups: SoC alone, including chest radiography, vs. SoC plus preoperative noncontrast CT. The primary endpoint was in-hospital perioperative stroke. Secondary endpoints were preoperative change of the surgical approach, in-hospital mortality, and postoperative delirium. The trial was halted halfway for expected futility, as the conditional power analysis showed a chance < 1% of finding the hypothesized effect.

Results

A total of 862 patients were evaluated (SoC-group: 433 patients (66 ± 11 years; 74.1% male) vs. SoC + CT-group: 429 patients (66 ± 10 years; 69.9% male)). The perioperative stroke rate (SoC + CT: 2.1%, 9/429 vs. SoC: 1.2%, 5/433, p = 0.27) and rate of changed surgical approach (SoC + CT: 4.0% (17/429) vs. SoC: 2.8% (12/433, p = 0.35) did not differ between groups. In-hospital mortality and postoperative delirium were comparable between groups. In the SoC + CT group, aortic calcification was observed on CT in the ascending aorta in 28% (108/380) and in the aortic arch in 70% (265/379).

Conclusions

Preoperative noncontrast CT in cardiac surgery candidates did not influence the surgical approach nor the incidence of perioperative stroke compared with standard of care. Aortic calcification is a frequent finding on the CT scan in these patients but results in major surgical alterations to prevent stroke in only few patients.

Key Points

• Aortic calcification is a frequent finding on noncontrast computed tomography prior to cardiac surgery.

• Routine use of noncontrast computed tomography does not often lead to a change of the surgical approach, when compared to standard of care.

• No effect was observed on perioperative stroke after cardiac surgery when using routine noncontrast computed tomography screening on top of standard of care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08360-4.

Porcelain aorta: A surgical dilemma in orthotopic heart transplantation

BACKGROUND

Circumferential calcification of the ascending aorta, known as porcelain aorta, in a patient candidate to a heart transplant, requires technically demanding and high-risk procedural adjustments.

AIMS

This case report showed successful replacement of ascending aorta due to extensive calcification at time of heart transplantation.

MATERIALS AND METHODS

In the operating theatre, after median sternotomy, cardiopulmonary bypass (CPB) was achieved via the right femoral artery and vein. Due to the impossibility of replacing the ascending aorta using safe aortic cross-clamping, a moderate hypothermia was established, and circulatory arrest was realized. According to Kazui protocol for selective anterograde cerebral perfusion via anonymous trunk and left carotid artery, ascending aorta was replaced with vascular prosthesis.

RESULTS

Thanks to accurate pre-surgical planning, which included hypothermic circulatory arrest, ascending aorta replacement, before orthotopic heart implantation, we were able to perform the procedure successfully and prevent neurological events.

DISCUSSION

Although different reports showed the feasibility of heart transplant combined to aortic replacement for aneurysmatic pathology, few cases were described for porcelain aorta, due to technically demanding procedure and prohibitive aortic cross-clamping. To avoid vascular embolization, dissection and mural laceration, aortic cross-clamping is not recommended. We performed aortic replacement at first, to reduce allograft ischemia.

CONCLUSION

The use of hypothermic circulatory arrest technique with selective cerebral perfusion for aortic replacement, followed by vascular graft clamping to favour cardiac allograft implantation, could be considered a winning combination to guarantee procedural success and to reduce perioperative complications.

Medial Arterial Calcification: JACC State-of-the-Art Review

Medial arterial calcification (MAC) is a chronic systemic vascular disorder distinct from atherosclerosis that is frequently but not always associated with diabetes mellitus, chronic kidney disease, and aging. MAC is also a part of more complex phenotypes in numerous less common diseases. The hallmarks of MAC include disseminated and progressive precipitation of calcium phosphate within the medial layer, a prolonged and clinically silent course, and compromise of hemodynamics associated with chronic limb-threatening ischemia. MAC increases the risk of complications during vascular interventions and mitigates their outcomes. With the exception of rare monogenetic defects affecting adenosine triphosphate metabolism, MAC pathogenesis remains unknown, and causal therapy is not available. Implementation of genetics and omics-based approaches in research recognizing the critical importance of calcium phosphate thermodynamics holds promise to unravel MAC molecular pathogenesis and to provide guidance for therapy. The current state of knowledge concerning MAC is reviewed, and future perspectives are outlined.

Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting

Porcelain aorta (PA) is an asymptomatic atherosclerotic disease, characterized by circumferential calcification throughout the whole perimeter of the aorta. It is seen in 2% to 9.3% of patients undergoing elective coronary artery bypass grafting (CABG) and makes manipulation of the ascending aorta impossible. It has been clearly shown that most emboli seen and detected during the CABG procedure occur during aortic cross-clamping and aortic side-clamping. Manipulation of porcelain or a severely atherosclerotic aorta increases the risk of perioperative stroke. The incidence of stroke after CABG is between 0.48% and 2.9%, and the risk is correlated with the extent and severity of the atherosclerotic disease. A conventional CABG procedure involves successive steps that include cannulation of the ascending aorta, application of a cross-clamp to the aorta, and partial clamping of the aorta to create the proximal anastomosis. Therefore in procedures that involve cannulation, clamping, or proximal anastomosis, and where aortic manipulation is inevitable, preassessment of the atherosclerotic aortic plaques is crucial. Although many surgeons still rely on intraoperative manual aortic palpation, this approach has very low sensitivity and underestimates the severity of the atherosclerotic illness. Imaging methods including preoperative computed tomography or intraoperative epiaortic ultrasonography enable modification of the surgical technique according to the severity of atherosclerosis. Various surgical techniques have been described to reduce the risk of atheroembolism that may lead to cerebrovascular events in patients with severely atherosclerotic ascending aorta. Anaortic or "no-touch" techniques that do not utilize aortic manipulation may significantly decrease the development of neurological complications by avoiding aortic maneuvers known to cause emboli. In cases where severe atherosclerotic disease or other factors preclude safe use of the ascending aorta, modifications in the surgical techniques, such as switching to different cannulation sites including the axillary/subclavian, femoral and innominate arteries, or using hypothermic ventricular fibrillation and in-situ pedicled arterial grafts, or performing proximal anastomoses at alternative anatomical locations will enable CABG operations to be performed safely with low morbidity and mortality rates in patients with porcelain aortas.

Comparison of Prognosis Between Hybrid Debranching Surgery and Total Open Arch Replacement With Frozen Elephant Trunk for Type A Acute Aortic Syndrome Patients

Background: It is unclear whether the total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation and hybrid debranching surgery have a difference in the prognosis of patients with type A acute aortic syndrome (AAS). We attempted to compare the short-term and long-term prognosis of total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation and hybrid debranching surgery in patients with type A acute aortic syndrome (AAS).

Methods: From January 2014 to September 2020, a total of 518 patients who underwent TAR with FET surgery and 31 patients who underwent hybrid surgery were included. We analyzed the post-operative mortality and morbidity of complications of the two surgical methods, and we determined 67 patients for subgroup analysis through a 1:2 propensity score match (PSM). We identified risk factors for patient mortality and post-operative neurological complications through multivariate regression analysis.

Results: Compared with the TAR with FET group, hybrid surgery could reduce aortic cross-clamp time, reduce intraoperative blood loss and prevent some patients from cardiopulmonary bypass. There was no significant difference in 30-day mortality between the TAR with FET group and the hybrid surgery group (10.6 vs. 9.7%). However, hybrid surgery had increased the incidence of permanent neurological complications in patients (95%CI: 4.7–35.7%, P = 0.001), especially post-operative cerebral infarction (P < 0.001). During the average follow-up period of 31.6 months, there was no significant difference in the 1-year survival rate and 3-year survival rate between the TAR with FET group and the hybrid surgery group (P = 0.811), but hybrid surgery increased the incidence of long-term neurological complications (P < 0.001). In multivariate regression analysis, surgical methods were not a risk factor for post-operative deaths, but hybrid surgery was a risk factor for post-operative neurological complications (P < 0.001).

Conclusions: Hybrid surgery is an acceptable treatment for AAS, and its post-operative mortality is similar to FET. But hybrid surgery may increase the risk of permanent neurological complications after surgery, and this risk must be carefully considered when choosing hybrid surgery.

3D printed ascending aortic simulators with physiological fidelity for surgical simulation

Introduction

Three-dimensional (3D) printed multimaterial ascending aortic simulators were created to evaluate the ability of polyjet technology to replicate the distensibility of human aortic tissue when perfused at physiological pressures.

Methods

Simulators were developed by computer-aided design and 3D printed with a Connex3 Objet500 printer. Two geometries were compared (straight tube and idealised aortic aneurysm) with two different material variants (TangoPlus pure elastic and TangoPlus with VeroWhite embedded fibres). Under physiological pressure, β Stiffness Index was calculated comparing stiffness between our simulators and human ascending aortas. The simulators’ material properties were verified by tensile testing to measure the stiffness and energy loss of the printed geometries and composition.

Results

The simulators’ geometry had no effect on measured β Stiffness Index (p>0.05); however, β Stiffness Index increased significantly in both geometries with the addition of embedded fibres (p<0.001). The simulators with rigid embedded fibres were significantly stiffer than average patient values (41.8±17.0, p<0.001); however, exhibited values that overlapped with the top quartile range of human tissue data suggesting embedding fibres can help replicate pathological human aortic tissue. Biaxial tensile testing showed that fiber-embedded models had significantly higher stiffness and energy loss as compared with models with only elastic material for both tubular and aneurysmal geometries (stiffness: p<0.001; energy loss: p<0.001). The geometry of the aortic simulator did not statistically affect the tensile tested stiffness or energy loss (stiffness: p=0.221; energy loss: p=0.713).

Conclusion

We developed dynamic ultrasound-compatible aortic simulators capable of reproducing distensibility of real aortas under physiological pressures. Using 3D printed composites, we are able to tune the stiffness of our simulators which allows us to better represent the stiffness variation seen in human tissue. These models are a step towards achieving better simulator fidelity and have the potential to be effective tools for surgical training.

Successful Transcatheter Aortic Valve Implantation in a Patient with Radiation-induced Aortic Stenosis for Mediastinal Hodgkin Lymphoma

Aortic stenosis (AS), a late complication of thoracic radiation therapy for chest lesions, is often coincident with porcelain aorta or hostile thorax. We herein report a 59-year-old man with a history of mediastinal Hodgkin lymphoma treated with radiation therapy but later presenting with heart failure caused by severe AS. Severe calcification in the mediastinum and around the ascending aorta made it difficult to perform surgical aortic valve replacement. The patient therefore underwent transcatheter aortic valve implantation (TAVI). It is important to recognize radiation-induced AS early, now that TAVI is a well-established treatment required by increasing numbers of successfully treated cancer patients.

Impact of standardized computed tomographic angiography for minimally invasive mitral and tricuspid valve surgery

Background

Femoral cannulation for extracorporeal circulation (ECC) is a standard procedure for minimally invasive cardiac surgery (MICS) of the atrio-ventricular valves. Vascular pathologies may cause serious complications. Preoperative computed tomography-angiography (CT-A) of the aorta, axillary and iliac arteries was implemented at our department.

Methods

Between July 2017 and December 2018 all MICS were retrospectively reviewed (n = 143), and divided into 3 groups.

Results

In patients without CT (n = 45, 31.5%) ECC was applied via femoral arteries (91.1% right, 8.9% left). Vascular related complications (dissection, stroke, coronary and visceral ischemia, related in-hospital death) occurred in 3 patients (6.7%). In patients with non-contrast CT (n = 35, 24.5%) only femoral cannulation was applied (94.3% right) with complications in 4 patients (11.4%). CT-angiography (n = 63, 44.1%) identified 12 patients (19.0%) with vulnerable plaques, 7 patients (11.1%) with kinking of iliac vessels, 41 patients (65.1%) with multiple calcified plaques and 5 patients (7.9%) with small femoral artery diameter (d ≤ 6 mm). In 7 patients (11.1%) pathologic findings led to alternative cannulation via right axillary artery, additional 4 patients (6.3%) were cannulated via left femoral artery. Only 2 patients (3.2%) suffered from complications.

Conclusions

CT-A identifies vascular pathologies otherwise undetectable in routine preoperative preparation. A standardized imaging protocol may help to customize the operative strategy.

Plaster pipes and crystalized graphite: Open transventricular transcatheter aortic valve replacement for failed mechanical aortic valve prostheses in the porcelain aorta

Patients with a true porcelain aorta and a failed mechanical aortic valve prosthesis have limited treatment options. Using a hybrid of an open trans-ventricular approach with peripheral cardiopulmonary bypass and integration of transcatheter techniques this challenge can be overcome. Trans-ventricular mechanical valve extraction (with transcatheter endovascular occlusion and cardioplegia) followed by direct ante-grade transcatheter heart valve implantation offers a potential solution to this conundrum. The procedure described is a novel technique that allows for the effective treatment of patients with failed mechanical surgical aortic valve prostheses in the setting of an inoperable porcelain aorta. In addition, a collaborative integrated multi-disciplinary heart team environment is required for the management of these complex patients.

Aortic Arch Replacement without Deep Hypothermic Circulatory Arrest

A 60-year-old man presented with a thoracic aortic aneurysm without rupture accompanied by severe nonrheumatic aortic valve insufficiency and unstable angina. Surgery was performed and included several steps: (1) resection and reconstruction of ascending aorta and aortic arch using a tube graft, (2) replacement of aortic valve using a biological prosthesis, and (3) coronary artery bypass grafting was performed with two distal anastomoses. All of these procedures were performed with total cardiopulmonary bypass without deep hypothermic circulatory arrest under conditions of moderate hypothermia using dual concurrent cannulation of the subclavian and femoral arteries.

Two Barricades in a Row Mixed Lesion of Dynamic Left Ventricular Outflow Tract Obstruction and Aortic Stenosis: Finding the Culprit for Decision Making

Concurrent lesions of dynamic left ventricular outflow tract obstruction (DLVOTO) with aortic stenosis pose a challenge in the measurement of the pressure gradient and severity of each lesion. Determining the true culprit lesion is difficult and challenging. The establishment of true culprit lesion is crucial in deciding the future course of action. We present two cases of concurrent DLVOTO and aortic stenosis. Although the composition of lesions is similar, the severity of each lesion was different and described a variety of technical problems. Finding the culprit through the shape of the stenotic jet from the continuous wave Doppler as well as other different technical approaches is the critical point of this case report. The first patient showed nonsignificant DLVOTO with severe aortic stenosis in which transthoracic echocardiography (TTE) alone was sufficient to find the culprit. Meanwhile, the second patient concluded to have significant DLVOTO with moderate aortic stenosis based on TTE and transesophageal echocardiography examination data. Jet morphology from Doppler examination is a crucial finding to differentiate DLVOTO with aortic stenosis, along with other parameters that might help find the dominant lesion. Multiple modalities with several tailor-made technical considerations might be needed to establish a culprit lesion.

Time-Dependent Changes in Porcelain Aorta and Aortic Stenosis in a Patient with Systemic Lupus Erythematosus

Porcelain aorta, defined as extensive calcification of the ascending aorta or aortic arch, is a reported risk factor for embolic stroke during cardiac surgery. However, the time course of the progression of aortic calcification leading to porcelain aorta has not been elucidated. We herein describe a 70-year-old woman who was followed up for systemic lupus erythematosus and antiphospholipid syndrome for approximately 20 years. A routine computed tomography scan revealed progression of ascending aortic calcification to porcelain aorta. The calcification was absent during the preceding 12 years, partial 6 years later, and total after another 3 years. Computed tomography also demonstrated aortic and mitral valve calcification in the development of porcelain aorta. During the 3 years prior to the last admission, annual echocardiography examinations showed progression of calcific aortic stenosis with symptoms. The patient was admitted to our institution for aortic valve replacement. Considering the high risk of perioperative stroke associated with porcelain aorta, transcatheter aortic valve implantation was performed. Postoperative transthoracic echocardiography revealed improvement of the aortic stenosis with no symptoms. The present case revealed aortic calcific progression to porcelain aorta during an approximately 10-year period with deterioration of aortic stenosis within a short time. The aortic and valvular calcification could be attributed to the inflammatory process of systemic lupus erythematosus and antiphospholipid syndrome. The presence of aortic and mitral annular calcification in the serial imaging can provide information on aortic and valvular atherosclerotic progression, which may be modifiable by early steroid-lowering therapy.

A hybrid clampless technique for aortic anastomoses

Background and Purpose

In various circumstances of aortic repairs (heavy circumferential calcifications or shaggy aorta with extensive thrombus), open and endovascular techniques are at high risk. In addition to a likelihood of emboli, aortic clamping can be complicated by rupture and endovascular techniques may not be successful. We here describe a simple and reproducible hybrid technique that allows performing an aortic anastomosis without clamping in these situations.

Methods

After a limited exposure of the anterior aortic wall in a healthy segment, a prosthetic graft is sutured without any arteriotomy or clamping (adventitial suture), mimicking the final aspect of an end-to-side anastomosis. The graft and the anastomosis site are punctured using a long needle, allowing a guidewire to be positioned in the aorta under fluoroscopic guidance. Protected covered stenting of the anastomosis site opens the anastomosis without aortic clamping. After tunneling the graft to the target artery, the distal anastomosis is performed in a usual fashion.

Results

This technique was successfully used in 10 challenging consecutive cases with a sustained patency.

Conclusions

This hybrid clampless technique for aortic anastomosis represents a useful alternative for challenging lesions unsuitable for a simple open or endovascular treatment.

Non-coronary cardiac calcifications and outcomes in patients with heart failure

BACKGROUND

Calcium deposits on heart valves are considered a local manifestation of atherosclerosis and are associated with poor cardiovascular outcomes. The clinical significance of cardiac calcifications among heart failure (HF) patients, as assessed by echocardiography, is unknown. This study evaluated associations of cardiac calcifications with mortality and hospital admissions in this specific population.

METHODS

Medical records of all patients who initiated ambulatory surveillance at our HF clinic during 2011-2018 were reviewed. Calcifications in the aortic valve, aortic root, or the mitral valve were evaluated. Patients with moderate to severe regurgitation or stenosis of the aortic or mitral valves were excluded. The primary endpoint was the composite of long-term all-cause mortality and HF hospitalizations. Secondary endpoints were long-term all-cause mortality and more than one hospitalization due to HF.

RESULTS

This retrospective study included 814 patients (mean age 70.9 ± 13 years, 63.2% male). Of the total cohort, 350 (43%) had no cardiac calcifications and 464 (57%) had at least 1 calcified site. Considering the patients with no calcification as the reference group yielded a higher adjusted odds ratios for the composite endpoint, all-cause death, and recurrent HF hospitalizations, among patients with any cardiac calcification (OR = 1.68, 95%CI = 1.1-2.5, p = 0.01, OR=1.61, 95%CI = 1.1-2.3, p < 0.01, and OR = 1.50, 95%CI = 1.1-2.2, p < 0.01, respectively).

CONCLUSIONS

We found an independent association between cardiac calcifications and the risk of death and HF hospitalizations among ambulatory HF patients. Cardiac calcifications evaluated during routine echocardiography may contribute to the risk stratification of patients with HF.

State of the Art Management of Aortic Valve Disease in Ankylosing Spondylitis

PURPOSE OF REVIEW

Cardiac involvement in patients with ankylosing spondylitis (AS) generally manifests itself as aortic insufficiency, aortitis, disturbance in cardiac conduction, and myocardial dysfunction. We have used a case-based approach to review the current state of the art knowledge regarding the diagnosis and management of aortic valve disease and aortitis in patients with AS.

RECENT FINDINGS

The risk for aortic valve disease and aortic valve replacement or repair is significantly higher than in people without AS, and this risk increases with age. Echocardiography, cardiac MRI, and CT can serve as effective tools for screening and follow-up. Surgical repair/replacement remains the mainstay of therapy for aortic insufficiency and aortic dilation, whereas transcatheter-based techniques may be favorable in the setting of aortic stenosis. Aortic valve and atrioventricular conduction abnormalities contribute to overall cardiovascular burden in AS. Optimal timing and therapeutic technique are dependent on assessment of overall risk and serial follow-up.

Targeting Vascular Calcification in Chronic Kidney Disease

Cardiovascular (CV) disease remains an important cause of morbidity and mortality for patients with chronic kidney disease (CKD). Although clustering of traditional risk factors with CKD is well recognized, kidney-specific mechanisms are believed to drive the disproportionate burden of CV disease. One perturbation that is frequently observed at high rates in patients with CKD is vascular calcification, which may be a central mediator for an array of CV sequelae. This review summarizes the pathophysiological bases of intimal and medial vascular calcification in CKD, current strategies for diagnosis and management, and posits vascular calcification as a risk marker and therapeutic target.

When the Complex Meets the High-Risk: Mechanical Cardiac Support Devices and Percutaneous Coronary Interventions in Severe Coronary Artery Disease

Coronary artery disease (CAD) remains a leading cause of mortality and morbidity worldwide. Few practice guidelines directly address the issue of revascularization in patients with CAD at higher risk of periprocedural complications. It remains a challenge to appropriately identify the subset of patients with CAD who will require short-term use of mechanical cardiocirculatory support devices (MCSDs) when high-risk (HR) percutaneous coronary intervention (PCI) is required. Issues of the complexity (coronary anatomy and high burden of comorbidities) and risk status (hemodynamic precarity or compromise) need to be considered when considering revascularization in patients. This review will focus on the evolving concept of protected PCI in patients with CAD, and how a balanced, integrated heart-team approach remains the path to optimal patient-centred care in the setting of HR-PCI supported with MCSD.

Relation of Thoracic Aortic and Coronary Artery Calcium to Cardiovascular Risk Factors (from The Brazilian Longitudinal Study of Adult Health [ELSA-Brazil])

Thoracic aortic calcium (TAC) and coronary artery calcium (CAC) are associated with an increased risk of cardiovascular disease (CVD) and death. However, risk factors associated with arterial calcium may vary across vascular beds. We verified whether TAC is associated with the same risk factors as is CAC in adults without established CVD. Cross-sectional analysis including 2,433 participants (aged 38 to 78 years) of ELSA-Brasil cohort in Minas Gerais, Brazil. Nonenhanced ECG-gated multislice computed tomography were performed to detect calcium in the thoracic aorta and the coronaries (2015 to 2016). Multivariate logistic regression evaluated the associations of both TAC and CAC with CVD risk factors (smoking, body mass index, physical activity, alcohol intake, family history of CVD, low-density lipoprotein- and high-density lipoprotein-cholesterol, HbA1c, blood pressure, antidiabetic, antihypertensive, and lipid lowering medications). Overall prevalence of TAC and CAC were 69% and 43%, respectively. CAC prevalence was lower among women (31%) than men (56%) (Adjusted odds ratio [OR] 0.30; 0.24 to 0.38). After adjustments, black individuals were less likely to have any CAC as compared with whites (OR 0.63; 0.47 to 0.86). Neither sex, nor race/skin color were statistically associated with TAC. Use of antidiabetic medications remained associated with CAC (OR 1.80; 1.23 to 2.631.01), but not with TAC. All other risk factors, except education, alcohol, physical activity and HbA1c, persisted statistically associated with both TAC and CAC in the final analysis, with small differences in the magnitudes of the ORs. In conclusion, the only disagreements seen in the risk factors associated with CAC and TAC were sex, race/skin color, and use of antidiabetic medications.

Simultaneous transapical aortic and mitral valve implantation in a patient with porcelain aorta

Left-sided double valve disease in the setting of extensive mitral annular calcifications and porcelain aorta raises multiple surgical challenges when considering an open surgical repair. We herein present the case of a 67-year-old patient with severe symptomatic aortic and mitral stenosis associated with extensive mitral annular calcifications and porcelain aorta, successfully treated by simultaneous transapical transcatheter aortic and mitral valve implantation.

Bilateral versus single internal thoracic artery grafting in hemodialysis patients

BACKGROUND

The use of the bilateral internal thoracic arteries (BITAs) during myocardial revascularization reportedly provides a survival benefit over using a single internal thoracic artery (SITA). However, the advantages in chronic hemodialysis patients, who generally have multiple comorbidities, is unclear.

METHODS

Outcomes of chronic hemodialysis patients who underwent isolated coronary artery bypass grafting (CABG) using a SITA with additional saphenous vein grafts (SVGs) (n = 33) or BITAs (n = 30) for left-side revascularization were retrospectively reviewed.

RESULTS

With the exception of the rate of diabetes mellitus (SITA vs. BITA: 84.8% vs. 50.0%; p = 0.003), the two groups showed similar patient characteristics. Using the off-pump technique, revascularization was completed without manipulation of the ascending aorta in 45.7% of patients in the BITA group, whereas all patients in the SITA group required aortic manipulation (p < 0.001). Of note, the incidence of extensive aortic calcification (>50% of ascending aorta circumference) was not uncommon (14.3%). The in-hospital mortality (3.0% vs. 0%, p = 0.336) and complication rates (including deep wound infection, re-exploration and stroke) were similar in both groups. The 5-year estimated survival rates for freedom from overall death in the SITA and BITA groups were 42.4% and. 57.4%, respectively (p = 0.202).

CONCLUSIONS

BITA grafting was able to achieve revascularization with minimal manipulation of the diseased ascending aorta without increasing the complication rate. The long-term survival benefit of BITA grafting, however, was unclear in dialysis patients, especially because such patients have a relatively short life expectancy.

Thoracic Aortic Calcification: Diagnostic, Prognostic, and Management Considerations

Thoracic aortic calcification (TAC) is associated with adverse cardiovascular outcomes, and for the cardiovascular imager, is predominantly encountered in 4 settings: 1) incidentally, for example, during a coronary artery calcium scan; 2) as part of dedicated screening; 3) in the evaluation of an embolic event; or 4) in procedural planning. This review focuses on TAC in these contexts. Within atherosclerosis, TAC is common, variable in extent, and begins in the intima with a patchy distribution. In metabolic disorders, aortitis, and radiation-associated cardiovascular disease, calcification preferentially involves the media and is often more concentric. As an incidental finding, atherosclerotic TAC provides limited incremental discriminative value, and current data do not support screening. After an embolic event, the demonstration of thoracic atheroma provides diagnostic clarity, but has limited treatment implications. Before any procedure, the plan often changes if the most severe form of TAC, a porcelain aorta, is discovered.

HMGB1-modified mesenchymal stem cells attenuate radiation-induced vascular injury possibly via their high motility and facilitation of endothelial differentiation

Background

Vascular injury is one of the most common detrimental effects of cancer radiotherapy on healthy tissues. Since the efficacy of current preventive and therapeutic strategies remains limited, the exploration of new approaches to treat radiation-induced vascular injury (RIV) is on high demands. The use of mesenchymal stem cells (MSCs) to treat RIV holds great promise thanks to their well-documented function of mediating tissue regeneration after injury. Recently, we genetically modified MSCs with high mobility group box 1 (HMGB1) and demonstrated the high efficacy of these cells in treating graft atherosclerosis. The current study was to investigate the protective effect of HMGB1-modified MSCs (MSC-H) on RIV by using a rat model.

Methods

Female F344 rats received an intravenous injection of male F344 MSC-H cells or vehicle control at four doses of 2 × 10⁶ cells with a 15-day interval starting from 30 days after irradiation to the abdominal aorta. The aortas were procured for histological and biomedical analysis at 90 days after irradiation. Cell migration to irradiated aortas was traced by green fluorescent protein and sex determination region on the Y chromosome. In vitro cell migration and endothelial differentiation of MSC-H cells were analyzed by stromal-derived factor 1-induced transwell assay and RNA microarray, respectively. The contribution of extracellular HMGB1 to the bioactivity of MSC-H cells was investigated by inhibition experiments with HMGB1 antibody.

Result

MSC-H cell infusion alleviated neointimal formation, vascular inflammation, and fibrosis in irradiated aortas, which was associated with local migration and endothelial differentiation of MSC-H cells. The MSC-H cells showed high motility and potential of endothelial differentiation in vitro. Microarray analysis suggested multiple pathways like MAPK and p53 signaling were activated during endothelial differentiation. MSC-H cells highly expressed CXC chemokine receptor 4 and migrated progressively after stromal-derived factor 1 stimulation, which was blocked by the antagonist of CXC chemokine receptor 4. Finally, the migration and endothelial differentiation of MSC-H cells were inhibited by HMGB1 antibody.

Conclusion

MSC-H cell infusion significantly attenuated RIV, which was associated with their high motility and endothelial differentiation potential. Multiple pathways that possibly contributed to the efficacy of MSC-H cells were suggested and deserved further investigation.

Electronic supplementary material

The online version of this article (10.1186/s13287-019-1197-x) contains supplementary material, which is available to authorized users.

An autopsy case of aortic root rupture with thin porcelain aorta during balloon-expandable transcatheter aortic valve implantation

A 92-year-old woman was transferred to our institute due to drug-resistant heart failure from severe aortic stenosis. She seemed to be a candidate for transcatheter aortic valve implantation (TAVI) because of her frailty and porcelain aorta. There were no severe calcified nodules in the left-ventricular outflow tract area. Because three-dimensional computed tomography analysis showed that her basal annulus area was 419 mm², a 26-mm SAPIEN XT (Edwards Lifesciences, Irvine, CA, USA) was selected for implantation. After deployment of the valve with 10% reduced volume, aortic root rupture occurred and her blood pressure fell due to acute cardiac tamponade. Emergent cardiac pericardial fenestration was done and drained blood was continuously returned to the circulation through percutaneous cardiopulmonary bypass. Despite strenuous efforts to save her life, she died 13 h after the event. An autopsy revealed a thin porcelain aorta and aortic root rupture with a fragile aortic wall. <Learning objective: Porcelain aorta is known to be a risk factor for perioperative stroke during surgical aortic valve replacement, and TAVI could be chosen for a treatment strategy in those cases. We present a case of aortic root rupture caused by unusually fragile aortic wall during TAVI and the lesson from the autopsy results.>.