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Yagyu T, Noguchi T. Diagnosis and treatment of cardiovascular disease in patients with heritable connective tissue disorders or heritable thoracic aortic diseases. Cardiovasc Interv Ther 2024; 39:126-136. [PMID: 38182694 DOI: 10.1007/s12928-023-00977-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 01/07/2024]
Abstract
Patients with heritable connective tissue disorders (HCTDs), represented by Marfan syndrome, can develop fatal aortic and/or arterial complications before age 50. Therefore, accurate diagnosis, appropriate medical treatment, and early prophylactic surgical treatment of aortic and arterial lesions are essential to improve prognosis. Patients with HCTDs generally present with specific physical features due to connective tissue abnormalities, while some patients with heritable thoracic aortic diseases (HTADs) have few distinctive physical characteristics. The development of genetic testing has made it possible to provide accurate diagnoses for patients with HCTDs/HTADs. This review provides an overview of the diagnosis and treatment of HCTDs/HTADs, including current evidence on cardiovascular interventions for this population.
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Affiliation(s)
- Takeshi Yagyu
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
- Department of Genomic Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
- Department of Genomic Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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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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Elefteriades JA, Ziganshin BA, Zafar MA. Nonsize Criteria for Surgical Intervention on the Ascending Thoracic Aorta. AORTA (STAMFORD, CONN.) 2023; 11:71-86. [PMID: 37172942 PMCID: PMC10232037 DOI: 10.1055/s-0043-1766114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/02/2023] [Indexed: 05/15/2023]
Abstract
For decades, aortic surgery has relied on size criteria for intervention on the ascending aorta. While diameter has served well, diameter alone falls short of an ideal criterion. Herein, we examine the potential application of other, nondiameter criteria in aortic decision-making. These findings are summarized in this review. We have conducted multiple investigations of specific alternate nonsize criteria by leveraging our extensive database, which includes complete, verified anatomic, clinical, and mortality data on 2,501 patients with thoracic aortic aneurysm (TAA) and dissections (198 Type A, 201 Type B, and 2102 TAAs). We examined 14 potential intervention criteria. Each substudy had its own specific methodology, reported individually in the literature. The overall findings of these studies are presented here, with a special emphasis on how the findings can be incorporated into enhanced aortic decision-making-above and beyond sheer diameter. The following nondiameter criteria have been found useful in decision-making regarding surgical intervention. (1) Pain: In the absence of other specific cause, substernal chest pain mandates surgery. Well-developed afferent neural pathways carry warning signals to the brain. (2) Aortic length/tortuosity: Length is emerging as a mildly better predictor of impending events than diameter. (3) Genes: Specific genetic aberrations provide a powerful predictor of aortic behavior; malignant genetic variants obligate earlier surgery. (4) Family history: Aortic events closely follow those in relatives with a threefold increase in likelihood of aortic dissection for other family members once an index family dissection has occurred. (5) Bicuspid aortic valve: Previously thought to increase aortic risk (as a "Marfan light" situation), current data show that bicuspid valve is not a predictor of higher risk. (6) Diabetes actually protects against aortic events, via mural thickening and fibrosis. (7) Biomarkers: A specialized "RNA signature test" identifies aneurysm-bearing patients in the general population and promises to predict impending dissection. (8) Aortic stress: Blood pressure (BP) elevation from anxiety/exertion precipitates dissection, especially with high-intensity weightlifting. (9) Root dilatation imposes higher dissection risk than supracoronary ascending aneurysm. (10) Inflammation on positron emission tomography (PET) imaging implies high rupture risk and merits surgical intervention. (11) A KIF6 p.Trp719Arg variant elevates aortic dissection risk nearly two-fold. (12) Female sex confers some increased risk, which can be largely accommodated by using body-size-based nomograms (especially height nomograms). (13) Fluoroquinolones predispose to catastrophic dissection events and should be avoided rigorously in aneurysm patients. (14) Advancing age makes the aorta more vulnerable, increasing likelihood of dissection. In conclusion, nondiameter criteria can beneficially be brought to bear on the decision to observe or operate on specific TAA.
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Affiliation(s)
- John A. Elefteriades
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
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4
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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: 376] [Impact Index Per Article: 188.0] [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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5
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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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6
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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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7
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Tijmes FS, Karur GR. Imaging of Heritable Thoracic Aortic Disease. Semin Roentgenol 2022; 57:364-379. [DOI: 10.1053/j.ro.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 11/11/2022]
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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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Abbasciano RG, Mariscalco G, Barwell J, Owens G, Zakkar M, Joel-David L, Pathak S, Adebayo A, Shannon N, Haines RL, Aujla H, Eagle-Hemming B, Kumar T, Lai F, Wozniak M, Murphy G. Evaluating the Feasibility of Screening Relatives of Patients Affected by Nonsyndromic Thoracic Aortic Diseases: The REST Study. J Am Heart Assoc 2022; 11:e023741. [PMID: 35383466 PMCID: PMC9238461 DOI: 10.1161/jaha.121.023741] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Diseases of the thoracic aorta are characterized by a familial etiology in up to 30% of the cases. Nonsyndromic thoracic aorta diseases (NS‐TADs) lack overt clinical signs and systemic features, which hinder early detection and prompt surgical intervention. We hypothesize that tailored genetic testing and imaging of first‐degree and second‐degree relatives of patients affected by NS‐TADs may enable early diagnosis and allow appropriate surveillance or intervention. Methods and Results We conducted a feasibility study involving probands affected by familial or sporadic NS‐TADs who had undergone surgery, which also offered screening to their relatives. Each participant underwent a combined imaging (echocardiogram and magnetic resonance imaging) and genetic (whole exome sequencing) evaluation, together with physical examination and psychological assessment. The study population included 16 probands (8 sporadic, 8 familial) and 54 relatives (41 first‐degree and 13 second‐degree relatives) with median age 48 years (range: 18–85 years). No syndromic physical features were observed. Imaging revealed mild‐to‐moderate aortic dilation in 24% of relatives. A genetic variant of uncertain significance was identified in 3 families. Imaging, further phenotyping, or a form of secondary prevention was indicated in 68% of the relatives in the familial group and 54% in the sporadic group. No participants fulfilled criteria for aortic surgery. No differences between baseline and 3‐month follow‐up scores for depression, anxiety, and self‐reported quality of life were observed. Conclusions In NS‐TADs, imaging tests, genetic counseling, and family screening yielded positive results in up to 1 out of 4 screened relatives, including those in the sporadic NS‐TAD group. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03861741.
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Affiliation(s)
| | - Giovanni Mariscalco
- Department of Cardiac Surgery University Hospitals of Leicester NHS Trust Leicester UK
| | - Julian Barwell
- Department of Genetics and Genome Biology University of Leicester UK
| | - Gareth Owens
- Aortic Dissection Awareness UK & Ireland York UK
| | - Mustafa Zakkar
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Lathishia Joel-David
- Department of Cardiac Surgery University Hospitals of Leicester NHS Trust Leicester UK
| | - Suraj Pathak
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Adewale Adebayo
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Nora Shannon
- Department of Clinical Genetics Nottingham University Hospitals Nottingham UK
| | | | - Hardeep Aujla
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Bryony Eagle-Hemming
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit University of Leicester Leicester UK
| | - Florence Lai
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Marcin Wozniak
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Gavin Murphy
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
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Acharya M, Maselli D, Mariscalco G. Genetic screening in heritable thoracic aortic disease—rationale, potentials and pitfalls. Indian J Thorac Cardiovasc Surg 2022; 38:24-35. [PMID: 35463717 PMCID: PMC8980988 DOI: 10.1007/s12055-020-01124-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022] Open
Abstract
Thoracic aortic aneurysms are silent yet deadly clinical entities which may elude detection until an acutely life-threatening aortic dissection or rupture occurs. Approximately 20% of patients with thoracic aortic aneurysms or dissection have a positive family history, indicating a strong genetic component to the aetiology. Genetic screening in such hereditary thoracic aortic disease (HTAD) may thus be beneficial in detecting causative genetic mutations in affected patients, identifying asymptomatic family members who may be at risk, and in guiding the optimal timing of preventative surgery in those with confirmed genetic aortopathy. Genetic screening can facilitate personalised aortic care tailored to an individual's specific genetic abnormality, with the aim of mitigating the significant morbidity burden and premature mortality associated with HTAD. This review examines the rationale for genetic screening in HTAD, its potential applications, current limitations and potential future directions.
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Affiliation(s)
- Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Daniele Maselli
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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11
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Papanikolaou D, Zafar MA, Ziganshin BA, Elefteriades JA. Aortic gene dictionary in the precision medicine era—update from the Aortic Institute at Yale New Haven. Indian J Thorac Cardiovasc Surg 2022; 38:14-23. [PMID: 35463698 PMCID: PMC8980985 DOI: 10.1007/s12055-021-01308-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/20/2021] [Accepted: 12/01/2021] [Indexed: 11/30/2022] Open
Abstract
This paper reviews the current understanding of the inherited, genetic nature of thoracic aortic aneurysm and dissection (TAAD), as well as the practice of genetic testing for thoracic aortic disease at the Aortic Institute at Yale-New Haven Hospital.
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Affiliation(s)
- Dimitra Papanikolaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, Clinic Building CB 317, 789 Howard Avenue, New Haven, CT 06519 USA
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, Clinic Building CB 317, 789 Howard Avenue, New Haven, CT 06519 USA
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, Clinic Building CB 317, 789 Howard Avenue, New Haven, CT 06519 USA
- 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, Clinic Building CB 317, 789 Howard Avenue, New Haven, CT 06519 USA
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12
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Kalyanasundaram A, Elefteriades J. The Genetics of Inheritable Aortic Diseases. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00687-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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13
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Cecchi AC, Drake M, Campos C, Howitt J, Medina J, Damrauer SM, Shalhub S, Milewicz DM. Current state and future directions of genomic medicine in aortic dissection: A path to prevention and personalized care. Semin Vasc Surg 2022; 35:51-59. [PMID: 35501041 PMCID: PMC9258522 DOI: 10.1053/j.semvascsurg.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 12/03/2022]
Abstract
Aortic dissection confers high mortality and morbidity rates despite advances in treatment, impacts quality of life, and contributes immense burden to the healthcare system globally. Efforts to prevent aortic dissection through screening and management of modifiable risk factors and early detection of aneurysms should incorporate genomic information, as it is integral to stratifying risk. However, effective integration of genomic-guided risk assessment into clinical practice will require addressing implementation barriers that currently permeate our healthcare systems. The Aortic Dissection Collaborative was established to define aortic dissection research priorities through patient engagement. Using a collaborative patient-centered feedback model, our Genomic Medicine Working Group identified related research priorities that could be investigated by pragmatic interventional studies aimed at aortic dissection prevention, utilization of genomic information to improve patient outcomes, and access to genomic medicine services. Further research is also needed to identify the genomic, lifestyle, and environmental risk factors that contribute to aortic dissection so these data can be incorporated into future comparative effectiveness studies to prevent aortic dissection.
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14
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Benjamins JW, Yeung MW, van de Vegte YJ, Said MA, van der Linden T, Ties D, Juarez-Orozco LE, Verweij N, van der Harst P. Genomic insights in ascending aortic size and distensibility. EBioMedicine 2021; 75:103783. [PMID: 34968759 PMCID: PMC8718733 DOI: 10.1016/j.ebiom.2021.103783] [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] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/17/2021] [Accepted: 12/13/2021] [Indexed: 02/06/2023] Open
Abstract
Background Alterations in the anatomic and biomechanical properties of the ascending aorta (AAo) can give rise to various vascular pathologies. The aim of the current study is to gain additional insights in the biology of the AAo size and function. Methods We developed an AI based analysis pipeline for the segmentation of the AAo, and the extraction of AAO parameters. We then performed genome-wide association studies of AAo maximum area, AAo minimum area and AAo distensibility in up to 37,910 individuals from the UK Biobank. Variants that were significantly associated with AAo phenotypes were used as instrumental variables in Mendelian randomization analyses to investigate potential causal relationships with coronary artery disease, myocardial infarction, stroke and aneurysms. Findings Genome-wide association studies revealed a total of 107 SNPs in 78 loci. We annotated 101 candidate genes involved in various biological processes, including connective tissue development (THSD4 and COL6A3). Mendelian randomization analyses showed a causal association with aneurysm development, but not with other vascular diseases. Interpretation We identified 78 loci that provide insights into mechanisms underlying AAo size and function in the general population and provide genetic evidence for their role in aortic aneurysm development.
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Affiliation(s)
- Jan Walter Benjamins
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands.
| | - Ming Wai Yeung
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands; Department of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherland
| | - Yordi J van de Vegte
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - M Abdullah Said
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Thijs van der Linden
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Daan Ties
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Luis E Juarez-Orozco
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands; Department of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherland
| | - Niek Verweij
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands; Department of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherland
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Chesneau B, Plancke A, Rolland G, Marcheix B, Dulac Y, Edouard T, Plaisancié J, Aubert-Mucca M, Julia S, Langeois M, Lavabre-Bertrand T, Khau Van Kien P. A +3 variant at a donor splice site leads to a skipping of the MYH11 exon 32, a recurrent RNA defect causing Heritable Thoracic Aortic Aneurysm and Dissection and/or Patent Ductus Arteriosus. Mol Genet Genomic Med 2021; 9:e1814. [PMID: 34672437 PMCID: PMC8606209 DOI: 10.1002/mgg3.1814] [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] [Received: 04/20/2021] [Revised: 08/11/2021] [Accepted: 09/03/2021] [Indexed: 12/29/2022] Open
Abstract
Background Pathogenic variants in MYH11 are associated with either heritable thoracic aortic aneurysm and dissection (HTAAD), patent ductus arteriosus (PDA) syndrome, or megacystis‐microcolon‐intestinal hypoperistalsis syndrome (MMIHS). Methods and Results We report a family referred for molecular diagnosis with HTAAD/PDA phenotype in which we found a variant at a non‐conserved position of the 5’ donor splice site of intron 32 of MYH11 potentially altering splicing (NM_002474.3:c.4578+3A>C). Although its cosegregation with disease was observed, it remained of unknown significance. Later, aortic surgery in the proband gave us the opportunity to perform a transcript analysis. This showed a skipping of the exon 32, an RNA defect previously reported to be translated to an in‐frame loss of 71 amino acids and a dominant‐negative effect in the smooth muscle myosin rod. This RNA defect is also reported in 3 other HTAAD/PDA pedigrees. Conclusion This report confirms that among rare variants in MYH11, skipping of exon 32 is recurrent. This finding is of particular interest to establish complex genotype–phenotype correlations where some alleles are associated with autosomal dominant HTAAD/PDA, while others result in recessive or dominant visceral myopathies.
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Affiliation(s)
- Bertrand Chesneau
- UF de Génétique Médicale et Cytogénétique, Centre Hospitalier Régional Universitaire de Nîmes, Nîmes, France.,Centre de Référence du syndrome de Marfan et des syndromes apparentés, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - Aurélie Plancke
- UF de Génétique Médicale et Cytogénétique, Centre Hospitalier Régional Universitaire de Nîmes, Nîmes, France
| | - Guillaume Rolland
- UF de Génétique Médicale et Cytogénétique, Centre Hospitalier Régional Universitaire de Nîmes, Nîmes, France
| | - Bertrand Marcheix
- Département de Chirurgie Cardiaque, Hôpital Universitaire de Rangueil, Toulouse, France
| | - Yves Dulac
- Centre de Référence du syndrome de Marfan et des syndromes apparentés, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - Thomas Edouard
- Centre de Référence du syndrome de Marfan et des syndromes apparentés, Hôpital des Enfants, CHU de Toulouse, Toulouse, France
| | - Julie Plaisancié
- Service de Génétique Médicale, Hôpital Universitaire de Purpan, Toulouse, France
| | - Marion Aubert-Mucca
- Centre de Référence du syndrome de Marfan et des syndromes apparentés, Hôpital des Enfants, CHU de Toulouse, Toulouse, France.,Service de Génétique Médicale, Hôpital Universitaire de Purpan, Toulouse, France
| | - Sophie Julia
- Service de Génétique Médicale, Hôpital Universitaire de Purpan, Toulouse, France
| | - Maud Langeois
- Centre de Référence du syndrome de Marfan et des syndromes apparentés, Hôpital des Enfants, CHU de Toulouse, Toulouse, France.,Service de Génétique Médicale, Hôpital Universitaire de Purpan, Toulouse, France
| | - Thierry Lavabre-Bertrand
- UF de Génétique Médicale et Cytogénétique, Centre Hospitalier Régional Universitaire de Nîmes, Nîmes, France.,Institut des Biomolécules Max Mousseron (IBMM), CNRS UMR5247, Université de Montpellier, Montpellier, France.,Faculté de Médecine Montpellier-Nîmes, Laboratoire d'Histologie-Embryologie-Cytogénétique, Institut des Biomolécules Max Mousseron (IBMM), CNRS UMR5247, Nîmes, France
| | - Philippe Khau Van Kien
- UF de Génétique Médicale et Cytogénétique, Centre Hospitalier Régional Universitaire de Nîmes, Nîmes, France.,Institut des Biomolécules Max Mousseron (IBMM), CNRS UMR5247, Université de Montpellier, Montpellier, France.,Faculté de Médecine Montpellier-Nîmes, Laboratoire d'Histologie-Embryologie-Cytogénétique, Institut des Biomolécules Max Mousseron (IBMM), CNRS UMR5247, Nîmes, France
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16
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Won EJ, Stein LH. Commentary: Measure twice, but cut early? JTCVS OPEN 2021; 7:10-11. [PMID: 36003747 PMCID: PMC9390630 DOI: 10.1016/j.xjon.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 06/15/2023]
Affiliation(s)
| | - Louis H. Stein
- Address for reprints: Louis H. Stein, MD, PhD, Department of Cardiothoracic Surgery, RWJBarnabas Health at Newark Beth Israel Medical Center, 201 Lyons Ave, Suite G5, Newark, NJ 07112.
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The impact of genetic factors and testing on operative indications and extent of surgery for aortopathy. JTCVS OPEN 2021; 6:15-23. [PMID: 36003569 PMCID: PMC9390368 DOI: 10.1016/j.xjon.2021.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/22/2022]
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18
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Commentary: Thoracic aortic disease: One step closer to precision medicine. J Thorac Cardiovasc Surg 2021; 163:47-49. [PMID: 33894998 DOI: 10.1016/j.jtcvs.2021.03.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/20/2022]
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19
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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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20
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Shalhub S, Wallace S, Okunbor O, Newhall K. Genetic aortic disease epidemiology, management principles, and disparities in care. Semin Vasc Surg 2021; 34:79-88. [PMID: 33757640 DOI: 10.1053/j.semvascsurg.2021.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Patients with syndromic and nonsyndromic heritable aortopathies (also known as genetic aortic disease) are a heterogeneous group of patients who present at younger ages with more rapid growth of aortic aneurysms and/or increased frequency of dissections compared with patients with atherosclerotic aortopathies. In this review, we describe the etiology, epidemiology, and appropriate care delivery for these conditions at each stage of management. Within each section, we discuss sex, gender, and race differences and highlight disparities in care and knowledge. We then discuss the role of the vascular team throughout the cycle of care and the evolving inclusion of patient input in research. This understanding is essential to the creation of effective health care policies that support equitable, appropriate, and patient-centered clinical practices.
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Affiliation(s)
- Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195.
| | - Stephanie Wallace
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
| | - Osa Okunbor
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
| | - Karina Newhall
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
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21
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Two-Dimensional Aortic Size Normalcy: A Novelty Detection Approach. Diagnostics (Basel) 2021; 11:diagnostics11020220. [PMID: 33540834 PMCID: PMC7912952 DOI: 10.3390/diagnostics11020220] [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] [Received: 12/20/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 01/16/2023] Open
Abstract
Background: To develop a tool for assessing normalcy of the thoracic aorta (TA) by echocardiography, based on either a linear regression model (Z-score), or a machine learning technique, namely one-class support vector machine (OC-SVM) (Q-score). Methods: TA diameters were measured in 1112 prospectively enrolled healthy subjects, aging 5 to 89 years. Considering sex, age and body surface area we developed two calculators based on the traditional Z-score and the novel Q-score. The calculators were compared in 198 adults with TA > 40 mm, and in 466 patients affected by either Marfan syndrome or bicuspid aortic valve (BAV). Results: Q-score attained a better Area Under the Curve (0.989; 95% CI 0.984–0.993, sensitivity = 97.5%, specificity = 95.4%) than Z-score (0.955; 95% CI 0.942–0.967, sensitivity = 81.3%, specificity = 93.3%; p < 0.0001) in patients with TA > 40 mm. The prevalence of TA dilatation in Marfan and BAV patients was higher as Z-score > 2 than as Q-score < 4% (73.4% vs. 50.09%, p < 0.00001). Conclusions: Q-score is a novel tool for assessing TA normalcy based on a model requiring less assumptions about the distribution of the relevant variables. Notably, diameters do not need to depend linearly on anthropometric measurements. Additionally, Q-score can capture the joint distribution of these variables with all four diameters simultaneously, thus accounting for the overall aortic shape. This approach results in a lower rate of predicted TA abnormalcy in patients at risk of TA aneurysm. Further prognostic studies will be necessary for assessing the relative effectiveness of Q-score versus Z-score.
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22
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Dawson A, LeMaire SA. Building on a genetic framework: Can we personalize the timing of surgical repair for patients with heritable thoracic aortic disease? J Thorac Cardiovasc Surg 2020; 160:901-905. [DOI: 10.1016/j.jtcvs.2020.01.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/13/2022]
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23
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Abbasciano RG, Barwell J, Sayers R, Bown M, Milewicz D, Cooper G, Mariscalco G, Wheeldon N, Fowler C, Owens G, Murphy GJ. Report of a Delphi exercise to inform the design of a research programme on screening for thoracic aortic disease. Trials 2020; 21:656. [PMID: 32678053 PMCID: PMC7367380 DOI: 10.1186/s13063-020-04562-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/26/2020] [Indexed: 01/16/2023] Open
Abstract
Objectives To inform the design of a clinical trial of a targeted screening programme for relatives of individuals affected by thoracic aortic disease, we performed a consensus exercise as to the acceptability of screening, the optimal sequence and choice of tests, long-term patient management, and choice of trial design. Methods Working with the Aortic Dissection Awareness UK & Ireland patient association, we performed a Delphi exercise with clinical experts, patients, and carers, consisting of three rounds of consultation followed by a final multi-stakeholder face-to-face workshop. Results Thirty-five experts and 84 members of the public took part in the surveys, with 164 patients and clinicians attending the final workshop. There was substantial agreement on the need for a targeted screening pathway that would employ a combined approach (imaging + genetic testing). The target population would include the first- and second-degree adult (> 15 years) relatives, with no upper age limit of affected patients. Disagreement persisted about the screening process, sequence, personnel, the imaging method to adopt, computed tomography (CT) scan vs magnetic resonance imaging (MRI), and the specifics of a potential trial, including willingness to undergo randomisation, and measures of effectiveness and acceptability. Conclusion A Delphi process, initiated by patients, identified areas of uncertainty with respect to behaviour, process, and the design of a targeted screening programme for thoracic aortic disease that requires further research prior to any future trial.
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Affiliation(s)
- R G Abbasciano
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK.
| | - J Barwell
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - R Sayers
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - M Bown
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - D Milewicz
- Division of Medical Genetics, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - G Cooper
- Northern General Hospital, Herries Road, Sheffield, UK
| | - G Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
| | - N Wheeldon
- Northern General Hospital, Herries Road, Sheffield, UK
| | | | | | - G J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, LE3 9QP, UK
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Abstract
Inherited thoracic aortopathies denote a group of congenital conditions that predispose to disease of the thoracic aorta. Aortic wall weakness and abnormal aortic hemodynamic profiles predispose these patients to dilatation of the thoracic aorta, which is generally silent but can precipitate aortic dissection or rupture with devastating and often fatal consequences. Current strategies to assess the future risk of aortic dissection or rupture are based primarily on monitoring aortic diameter. However, diameter alone is a poor predictor of risk, with many patients experiencing dissection or rupture below current intervention thresholds. Developing tools that improve the risk assessment of those with aortopathy is internationally regarded as a research priority. A robust understanding of the molecular pathways that lead to aortic wall weakness is required to identify biomarkers and therapeutic targets that could improve patient management. Here, we summarize the current understanding of the genetically determined mechanisms underlying inherited aortopathies and critically appraise the available blood biomarkers, imaging techniques, and therapeutic targets that have shown promise for improving the management of patients with these important and potentially fatal conditions.
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Affiliation(s)
- Alexander J. Fletcher
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Maaz B.J. Syed
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Timothy J. Aitman
- Centre for Genomics and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, United Kingdom (T.J.A.)
| | - David E. Newby
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Niki L. Walker
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
- Scottish Adult Congenital Heart Disease Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (N.L.W.)
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25
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The Genetics of Thoracic Aortic Aneurysms and Dissection: A Clinical Perspective. Biomolecules 2020; 10:biom10020182. [PMID: 31991693 PMCID: PMC7072177 DOI: 10.3390/biom10020182] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 12/13/2022] Open
Abstract
Thoracic aortic aneurysm and dissection (TAAD) affects many patients globally and has high mortality rates if undetected. Once thought to be solely a degenerative disease that afflicted the aorta due to high pressure and biomechanical stress, extensive investigation of the heritability and natural history of TAAD has shown a clear genetic basis for the disease. Here, we review both the cellular mechanisms and clinical manifestations of syndromic and non-syndromic TAAD. We particularly focus on genes that have been linked to dissection at diameters <5.0 cm, the current lower bound for surgical intervention. Genetic screening tests to identify patients with TAAD associated mutations that place them at high risk for dissection are also discussed.
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26
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Faggion Vinholo T, Zafar MA, Ziganshin BA, Elefteriades JA. Nonsyndromic Thoracic Aortic Aneurysms and Dissections-Is Screening Possible? Semin Thorac Cardiovasc Surg 2019; 31:628-634. [PMID: 31212014 DOI: 10.1053/j.semtcvs.2019.05.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/02/2019] [Indexed: 01/14/2023]
Abstract
Nonsyndromic thoracic aortic aneurysm and dissection (TAAD) account for 95% of all TAAD cases and comprise a subset in which the lack of obvious clinical signs makes diagnosis a challenge. Despite the potentially fatal natural history, timely diagnosis and prophylactic surgical intervention allow restoration of near-normal life expectancy in TAAD patients, underlining the critical importance of screening tests. To date, more than 30 TAAD disease-causing genes have been identified, and over 30% of nonsyndromic TAAD patients have a genetic mutation in 1 or more of these genes. Whole exome sequencing allows routine genetic testing in a clinical setting by screening for all TAAD-related genes, thus facilitating personalized aortic care. Additionally, increased vigilance upon diagnosis of certain TAAD-related diseases ("guilty associates") and the emergence of modern radiologic and novel serologic screening tests will further bolster efforts to detect undiagnosed asymptomatic nonsyndromic TAAD.
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Affiliation(s)
- Thais Faggion Vinholo
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut; 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, Connecticut.
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27
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Silvestri V, Mazzesi G, Mele R. Postpartum aortic dissection. A case report and review of literature. Int J Surg Case Rep 2019; 56:101-106. [PMID: 30870737 PMCID: PMC6425083 DOI: 10.1016/j.ijscr.2019.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/05/2019] [Accepted: 02/08/2019] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular comorbidities may complicate pregnancy. Pregnancy carries a 25-fold relative risk for aortic dissection. Dissection may occur in pregnancies without known genetic or anatomical risk factors (non syndromic sporadic aortic dissection). Dissection may occur in the postpartum period. Given the high mortality for both mother and foetus, a high clinical suspicion for aortic dissection is needed in an emergency setting in postpartum.
Introduction Aortic dissection is a rare cardiovascular complication in pregnancy. Most of the cases occur during the third trimester of pregnancy, whilst 33% of cases are reported during the postpartum period. Presentation of case We report the case of a multiparous 35-year-old patient with gestational hypertension treated for a type A aortic dissection on the second postpartum day. A review of literature on non-syndromic sporadic aortic dissection during the postpartum period is presented. Discussion Aortic complications in pregnancy have been described in genetic syndromes or congenital aortic malformations but may also be non -syndromic and occur in the absence of any other risk factor. Pregnancy carries a 25-fold increase in relative risk for dissection. A review of the 16 cases published in literature from 1995 to December 2016 of non-syndromic, sporadic aortic dissections in pregnancy showed that the event may occur more frequently in the first week post-partum, be symptomatic for thoracic pain or dyspnoea. Type A aortic dissection accounts to 75% of cases. Mortality, despite surgical treatment, has been reported in 4 cases. Conclusions Even though rarely reported, given the increasing incidence and the high mortality of aortic dissection in pregnancy, along with the potential challenge for two lives, clinician must consider aortic dissection in post-partum while dealing with differential diagnosis in post-partum patients in the emergency setting.
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Affiliation(s)
- Valeria Silvestri
- Surgical Science Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy; Cardiac Surgery Unit, Cardiovascular, Respiratory, Nefrologic and Geriatric Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy.
| | - Giuseppe Mazzesi
- Surgical Science Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy; Cardiac Surgery Unit, Cardiovascular, Respiratory, Nefrologic and Geriatric Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy
| | - Rita Mele
- Surgical Science Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy; Cardiac Surgery Unit, Cardiovascular, Respiratory, Nefrologic and Geriatric Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy
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