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Morris MF, Henry TS, Raptis CA, Amin AN, Auffermann WF, Hatten BW, Kelly AM, Lai AR, Martin MD, Sandler KL, Sirajuddin A, Surasi DS, Chung JH. ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease. J Am Coll Radiol 2024; 21:S343-S352. [PMID: 38823955 DOI: 10.1016/j.jacr.2024.02.013] [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: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Pleural effusions are categorized as transudative or exudative, with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders. This document summarizes appropriateness guidelines for imaging in four common clinical scenarios in patients with known or suspected pleural effusion or pleural disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Michael F Morris
- University of Arizona College of Medicine, Phoenix, Tucson, Arizona.
| | | | | | - Alpesh N Amin
- University of California, Irvine, Irvine, California; American College of Physicians
| | | | - Benjamin W Hatten
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado; American College of Emergency Physicians
| | | | - Andrew R Lai
- University of California San Francisco, San Francisco, California, Hospitalist
| | - Maria D Martin
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kim L Sandler
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Devaki Shilpa Surasi
- The University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging
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Yang L, Wang Y, He X, Liu X, Sui H, Wang X, Wang M. Develop ment and validation of a prognostic dynamic nomogram for in-hospital mortality in patients with Stanford type B aortic dissection. Front Cardiovasc Med 2023; 9:1099055. [PMID: 36698955 PMCID: PMC9868166 DOI: 10.3389/fcvm.2022.1099055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/16/2022] [Indexed: 01/11/2023] Open
Abstract
Background This study aimed to identify the risk factors for in-hospital mortality in patients with Stanford type B aortic dissection (TBAD) and develop and validate a prognostic dynamic nomogram for in-hospital mortality in these patients. Methods This retrospective study involved patients with TBAD treated from April 2002 to December 2020 at the General Hospital of Northern Theater Command. The patients with TBAD were divided into survival and non-survival groups. The data were analyzed by univariate and multivariate logistic regression analyses. To identify independent risk factors for in-hospital mortality, multivariate logistic regression analysis, least absolute shrinkage, and selection operator regression were used. A prediction model was constructed using a nomogram based on these factors and validated using the original data set. To assess its discriminative ability, the area under the receiver operating characteristic curve (AUC) was calculated, and the calibration ability was tested using a calibration curve and the Hosmer-Lemeshow test. Clinical utility was evaluated using decision curve analysis (DCA) and clinical impact curves (CIC). Results Of the 978 included patients, 52 (5.3%) died in hospital. The following variables helped predict in-hospital mortality: pleural effusion, systolic blood pressure ≥160 mmHg, heart rate >100 bpm, anemia, ischemic cerebrovascular disease, abnormal cTnT level, and estimated glomerular filtration rate <60 ml/min. The prediction model demonstrated good discrimination [AUC = 0.894; 95% confidence interval (CI), 0.850-0.938]. The predicted probabilities of in-hospital death corresponded well to the actual prevalence rate [calibration curve: via 1,000 bootstrap resamples, a bootstrap-corrected Harrell's concordance index of 0.905 (95% CI, 0.865-0.945), and the Hosmer-Lemeshow test (χ2 = 8.3334, P = 0.4016)]. DCA indicated that when the risk threshold was set between 0.04 and 0.88, the predictive model could achieve larger clinical net benefits than "no intervention" or "intervention for all" options. Moreover, CIC showed good predictive ability and clinical utility for the model. Conclusion We developed and validated prediction nomograms, including a simple bed nomogram and online dynamic nomogram, that could be used to identify patients with TBAD at higher risk of in-hospital mortality, thereby better enabling clinicians to provide individualized patient management and timely and effective interventions.
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Affiliation(s)
- Lin Yang
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, Liaoning, China,Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Yasong Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Xiaofeng He
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Xuanze Liu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Honggang Sui
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Xiaozeng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China,*Correspondence: Xiaozeng Wang,
| | - Mengmeng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China,Mengmeng Wang,
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Heuts S, Schalla S, Ramaekers MJFG, Bidar E, Mihl C, Wildberger JE, Adriaans BP. Imaging surveillance for complications after primary surgery for type A aortic dissection. HEART (BRITISH CARDIAC SOCIETY) 2022; 109:96-101. [PMID: 35321890 DOI: 10.1136/heartjnl-2022-320881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergency surgery to avert fatal outcome. Conventional surgical procedures comprise excision of the entry tear and replacement of the proximal aorta with a synthetic vascular graft. In patients with DeBakey type I dissection, this approach leaves a chronically dissected distal aorta, putting them at risk for progressive dilatation, dissection propagation and aortic rupture. Therefore, ATAAD survivors should undergo serial imaging for evaluation of the aortic valve, proximal and distal anastomoses, and the aortic segments beyond the distal anastomosis. The current narrative review aims to describe potential complications in the early and late phases after ATAAD surgery, with focus on their specific imaging findings.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht Universitair Medisch Centrum+, Maastricht, Limburg, The Netherlands
| | - Simon Schalla
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Mitch J F G Ramaekers
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht Universitair Medisch Centrum+, Maastricht, Limburg, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Casper Mihl
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Bouke P Adriaans
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Limburg, The Netherlands
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Reutersberg B, Trimarchi S, Gilon D, Kaiser C, Harris K, Shalhub S, Reece TB, Nienaber C, Ehrlich M, Isselbacher E, De Oliveira N, Montgomery D, Eagle K, Tolva V, Chen EP, Eckstein HH. Pleural effusion: a potential surrogate marker for higher-risk patients with acute type B aortic dissections. Eur J Cardiothorac Surg 2021; 61:816-825. [PMID: 34966915 DOI: 10.1093/ejcts/ezab540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/31/2021] [Accepted: 11/21/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pleural effusions (PEffs) are known to occur in type B acute aortic dissection (TBAAD). We investigated the relationship between pleural effusion and the development of early or late complications following TBAAD. METHODS The incidence of PEff (defined as at least an obliteration of the costophrenic angle in a frontal projection) diagnosed on their initial chest X-ray in patients with TBAAD enrolled in the International Registry of Acute Aortic Dissection was examined. We analysed in-hospital outcomes and long-term survival separately for patients with and without PEffs (PEff+ versus PEff-, respectively). RESULTS Included were 1252 patients with TBAAD, of whom 224 (17.9%) had PEff. Compared with patients without PEff in the initial chest X-ray, these were significantly older [mean age 67 (SD: 14.7) vs 63.4 (SD: 14.2) years, P = 0.001] and more often female (42.4% vs 34.2%, P = 0.021) and had more comorbidities (known aortic aneurysm, chronic obstructive pulmonary disease, chronic renal failure, diabetes, congestive heart failure or mitral valve disease). PEff was associated with higher in-hospital mortality (16.1% vs 9.1%, P = 0.002) and increased rates of neurological complications (16.6% vs 11.1%, P = 0.029), acute renal failure (27.2% vs 19.7%, P = 0.017) and hypotension (17.4% vs 9.6%, P = 0.001). In addition, patients with PEff underwent aortic repair more frequently (44.6% vs 32.5%, P < 0.001). In the long-term patients with PEff showed lower 5-year post-discharge survival (67.6% vs 77.6%, P = 0.004). Multivariable analysis with propensity-matched data showed that PEff was not an independent risk factor for in-hospital mortality (odds ratio 1.9, 95% CI 0.8-4.4, P = 0.141). CONCLUSIONS Patients with TBAAD and evidence of PEff showed a higher in-hospital mortality, are more likely to develop additional in-hospital complications and have a decreased likelihood of survival during follow-up. However, according to propensity-matched analysis, PEff remained not as an independent predictor of worse outcome but might serve as an early surrogate marker to identify higher-risk patients.
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Affiliation(s)
- Benedikt Reutersberg
- Department for Vascular and Endovascular Surgery, Munich Aortic Center (MAC), Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Santi Trimarchi
- Department of Clinical and Community Sciences-University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dan Gilon
- Department of Noninvasive Cardiology and Echocardiography, Heart Institute, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Jerusalem, Israel
| | - Clayton Kaiser
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin Harris
- Department of Cardiology, Minneapolis Heart Institute, Abbott, Northwestern Hospital, Minneapolis, MN, USA
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - T Brett Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christoph Nienaber
- Department of Cardiology, The Royal Brompton & Harefield NHS Trust, Cardiology and Aortic Centre, Imperial College, London, UK
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | - Eric Isselbacher
- Division of Cardiac Surgery, Thoracic Aortic Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nilto De Oliveira
- Division of Cardiac Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Daniel Montgomery
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.,Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Kim Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.,Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Valerio Tolva
- Department of Vascular Surgery, Policlinico di Monza Hospital, Centro Cuore. Policlinico di Monza, Monza, Italy
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Munich Aortic Center (MAC), Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
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Murillo H, Molvin L, Chin AS, Fleischmann D. Aortic Dissection and Other Acute Aortic Syndromes: Diagnostic Imaging Findings from Acute to Chronic Longitudinal Progression. Radiographics 2021; 41:425-446. [PMID: 33646901 DOI: 10.1148/rg.2021200138] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Acute aortic dissection is the prototype of acute aortic syndromes (AASs), which include intramural hematoma, limited intimal tear, penetrating atherosclerotic ulcer, traumatic or iatrogenic aortic dissection, and leaking or ruptured aortic aneurysm. The manifestation is usually sudden and catastrophic with acutely severe tearing chest or back pain. However, clinical symptoms do not allow distinction between AAS types and other acute pathologic conditions. Diagnostic imaging is essential to rapidly confirm and accurately diagnose the type, magnitude, and complications of AASs. CT fast acquisition of volumetric datasets has become instrumental in diagnosis, surveillance, and intervention planning. Most critical findings affecting initial intervention and prognosis are obtained at CT, including involvement of the ascending aorta, primary intimal tear location, rupture, malperfusion, size and patency of the false lumen, complexity and extent of the dissection, maximum caliber of the aorta, and progression or postintervention complications. Involvement of the ascending aorta-Stanford type A-has the most rapid lethal complications and requires surgical intervention to affect its morbidity and mortality. Lesions not involving the ascending aorta-Stanford type B-have a lesser rate of complications in the acute phase. During the acute to longitudinal progression, various specific and nonspecific imaging findings are encountered, including pleural and pericardial effusions, fluid collections, progression including aortic enlargement, and postoperative changes that can be discerned at CT. A systematic analysis algorithm is proposed for CT of the entire aorta throughout the continuum of AASs into the chronic and posttreated disease state, which synthesizes and communicates salient findings to all care providers. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Horacio Murillo
- From the Department of Radiology, Enloe Medical Center, 1531 Esplanade, Chico, CA 95926 (H.M.); Department of Radiology, Stanford University School of Medicine, Stanford, Calif (L.M., D.F.); and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada (A.S.C.)
| | - Lior Molvin
- From the Department of Radiology, Enloe Medical Center, 1531 Esplanade, Chico, CA 95926 (H.M.); Department of Radiology, Stanford University School of Medicine, Stanford, Calif (L.M., D.F.); and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada (A.S.C.)
| | - Anne S Chin
- From the Department of Radiology, Enloe Medical Center, 1531 Esplanade, Chico, CA 95926 (H.M.); Department of Radiology, Stanford University School of Medicine, Stanford, Calif (L.M., D.F.); and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada (A.S.C.)
| | - Dominik Fleischmann
- From the Department of Radiology, Enloe Medical Center, 1531 Esplanade, Chico, CA 95926 (H.M.); Department of Radiology, Stanford University School of Medicine, Stanford, Calif (L.M., D.F.); and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada (A.S.C.)
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Morello F, Santoro M, Fargion AT, Grifoni S, Nazerian P. Diagnosis and management of acute aortic syndromes in the emergency department. Intern Emerg Med 2021; 16:171-181. [PMID: 32358680 DOI: 10.1007/s11739-020-02354-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 12/12/2022]
Abstract
Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.
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Affiliation(s)
- Fulvio Morello
- S.C.U. Medicina d'Urgenza, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
- Dipartimento di Scienze Mediche, Università degli Studi di Torino, Torino, Italy
| | - Marco Santoro
- S.C.U. Medicina d'Urgenza, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
| | | | - Stefano Grifoni
- Department of Emergency Medicine, Careggi University Hospital, Largo Brambilla, 3, 50134, Firenze, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Largo Brambilla, 3, 50134, Firenze, Italy.
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Hysa L, Khor S, Starnes BW, Chow WB, Sweet MP, Nguyen J, Shalhub S. Cause-specific mortality of type B aortic dissection and assessment of competing risks of mortality. J Vasc Surg 2020; 73:48-60.e1. [PMID: 32437949 DOI: 10.1016/j.jvs.2020.04.499] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 04/03/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Natural history studies of type B aortic dissection (TBAD) commonly report all-cause mortality. Our aim was to determine cause-specific mortality in TBAD and to evaluate the clinical characteristics associated with aorta-related and nonaorta-related mortality. METHODS Clinical and administrative records were reviewed for patients with acute TBAD between 1995 and 2017. Demographics, comorbidities, presentation, and initial imaging findings were abstracted. Cause of death was ascertained through a multimodality approach using electronic health records, obituaries, social media, Social Security Death Index, and state mortality records. Causes of death were classified as aorta related, nonaorta related, or unknown. A Fine-Gray multivariate competing risk regression model for subdistribution hazard ratio was employed to analyze the association of clinical characteristics with aorta-related and nonaorta-related mortality. RESULTS A total of 275 individuals met inclusion criteria (61.1 ± 13.7 years, 70.9% male, 68% white). Mean survival after discharge was 6.3 ± 4.7 years. Completeness of follow-up Clark C index was 0.87. All-cause mortality was 50.2% (n = 138; mean age, 70.1 ± 14.6 years) including an in-hospital mortality of 8.4%. Cause-specific mortality was aorta related, nonaorta related, and unknown in 51%, 43%, and 6%, respectively. Compared with patients with nonaorta-related mortality, patients with aorta-related mortality were younger at acute TBAD (69.5 ± 11.2 years vs 61.6 ± 15.5 years; P = .001), underwent more descending thoracic aortic repairs (19.4% vs 45.8%; P = .002), and had a shorter survival duration (5.7 ± 3.9 vs 3.4 ± 4.5 years; P = .002). There was clear variation in cause of death by each decade of life, with higher aorta-related mortality among those younger than 50 years and older than 70 years and a stepwise increase in nonaorta-related mortality with each increasing decade (P < .001). All-cause mortality at 1 year, 3 years, and 10 years was 15%, 24%, and 57%, respectively. After accounting for competing risks, the cumulative incidence of aorta-related mortality at 1 year, 3 years, and 10 years was 8.9%, 16.5%, and 27.2%, respectively, and that of nonaorta-related mortality was 2.7%, 7.2%, and 29%, respectively. A maximum descending thoracic aortic diameter >4 cm was associated with an increase in hazard of aorta-related mortality by 84% (subdistribution hazard ratio, 1.84; 95% confidence interval, 1.03-3.28) on multivariate competing risk regression analysis. CONCLUSIONS TBAD is associated with high 10-year mortality. Those at risk for aorta-related mortality have a clinical phenotype different from that of individuals at risk for nonaorta-related mortality. This information is important for building risk prediction models that account for competing mortality risks and to direct optimal and individualized surgical and medical management of TBAD.
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Affiliation(s)
- Lisa Hysa
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Sara Khor
- Department of Surgery, University of Washington, Seattle, Wash
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Warren B Chow
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Jimmy Nguyen
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash.
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Liu H, Xiao T, Zhang L, Huang Y, Shi Y, Ji Q, Shi L, Zeng T, Lin Y, Liu L. Effects of circulating levels of Th17 cells on the outcomes of acute Stanford B aortic dissection patients after thoracic endovascular aortic repair: A 36-month follow-up study a cohort study. Medicine (Baltimore) 2019; 98:e18241. [PMID: 31852089 PMCID: PMC6922440 DOI: 10.1097/md.0000000000018241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
T helper 17 (Th17) cells are related to the progression of aortic dissection. This study aimed to determine whether circulating Th17 levels are associated with the prognosis of acute Stanford type B aortic dissection (STBAD) after thoracic endovascular aortic repair (TEVAR).A cohort study was performed and STBAD patients (n = 140) received TEVAR were enrolled, the circulating Th17 levels were measured and the patients were divided into low and high Th17 groups, and 36 months of follow-up was performed. The data for mortality, survival outcomes, heart structure and function changes, aortic regurgitation prevalence, and aortic remodeling outcomes were recorded.Lower mortality and fewer complications were observed in the low Th17 group than in the high Th17 group in the third year of follow-up. In addition, the low Th17 group exhibited better cardiac remodeling and cardiac function when compared with that in the high Th17 group in the second to third year after TEVAR. Aortic reflux was improved in both groups but was more pronounced in the low Th17 group. During follow-up, the true lumen of the proximal thoracic aorta at the level of the celiac trunk in both the low and high Th17 groups continuously enlarged and was more pronounced in the low Th17 group.Circulating Th17 cells were related to cardiac and aortic remodeling and prognosis during STBAD after TEVAR. Anti-inflammatory therapy may be useful for STBAD patients who have undergone TEVAR.
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Affiliation(s)
- Hongtao Liu
- Department of Cardiovascular medicine, Shenzhen Longhua District Central Longhua Central Hospital Affiliated Guangdong Medical University, Shenzhen, Guangdong Province
| | - Ting Xiao
- Department of Cardiovascular medicine, Shenzhen Longhua District Central Longhua Central Hospital Affiliated Guangdong Medical University, Shenzhen, Guangdong Province
| | - Le Zhang
- Department of Cardiovascular medicine, Shenzhen Longhua District Central Longhua Central Hospital Affiliated Guangdong Medical University, Shenzhen, Guangdong Province
| | - Ying Huang
- Department of Cardiology, the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Ying Shi
- Department of Cardiology, the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Qingwei Ji
- Emergency & Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Lei Shi
- Department of Cardiology, the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Tao Zeng
- Department of Cardiology, the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Yingzhong Lin
- Department of Cardiology, the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Ling Liu
- Department of Cardiology, the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
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Retrospective Comparative Analysis of Computed Tomography Findings of Acute and Chronic Aortic Dissections and Intramural Hematomas. J Thorac Imaging 2019; 34:400-403. [PMID: 30817503 DOI: 10.1097/rti.0000000000000401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The objective of this study was to assess the reliability of ancillary imaging findings in distinguishing acute from chronic aortic dissection (AD) and intramural hematoma (IMH) using computed tomography angiography (CTA). MATERIALS AND METHODS Two radiologists specializing in cardiothoracic and vascular imaging reviewed paired CTAs of patients with AD or IMH who underwent CTA in the acute (within 24 h of presentation) and chronic settings. The radiologists were blinded to the temporal order of the CTAs. Minimum and maximum flap thicknesses and presence or absence of pleural effusion, pericardial effusion, mediastinal hematoma or fat standing, and mediastinal lymphadenopathy were recorded. RESULTS Patients included 25 male individuals and 13 female individuals with a mean age of 59 years (range: 34 to 87 y). The group included 29 AD and 9 IMH cases. The median interval between the paired CTs was 542 days (range: 100 to 2533 d). Respectively, the mean minimum flap thicknesses in the acute and chronic AD were 1.3 and 1.4 mm (P=0.3), and the mean maximum flap thicknesses were 2.7 and 2.9 mm (P=0.29). The incidences of ancillary findings in acute and chronic AD and IMH were as follows: pleural effusion (55% vs. 37%, P=0.143), pericardial effusion (8% vs. 11%, P=1.0), lymphadenopathy (47% vs. 47%, P=1.0), and periaortic fat stranding (87% vs. 76%, P=0.344). CONCLUSIONS Ancillary CT imaging findings traditionally ascribed to acute AD and IMH are also often found in the chronic setting and are not reliable indicators of acuity. Flap thickness in AD may not be a reliable imaging indicator of acuity of AD.
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Early postoperative hypoalbuminaemia is associated with pleural effusion after donor hepatectomy: A propensity score analysis of 2316 donors. Sci Rep 2019; 9:2790. [PMID: 30808903 PMCID: PMC6391412 DOI: 10.1038/s41598-019-39126-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 01/18/2019] [Indexed: 11/08/2022] Open
Abstract
Pleural effusion and hypoalbuminaemia frequently occur after hepatectomy. Despite the emphasis on the safety of donors, little is known about the impact of postoperative albumin level on pleural effusion in liver donors. We retrospectively assessed 2316 consecutive liver donors from 2004 to 2014. The analysis of donors from 2004 to 2012 showed that postoperative pleural effusion occurred in 47.4% (970/2046), and serum albumin levels decreased until postoperative day 2 (POD2) and increased thereafter. In multivariable analysis, the lowest albumin level within POD2 (POD2ALB) was inversely associated with pleural effusion (OR 0.28, 95% CI 0.20-0.38; P < 0.001). POD2ALB ≤3.0 g/dL, the cutoff value at the 75th percentile, was associated with increased incidence of pleural effusion after propensity score (PS) matching (431 pairs; OR 1.69, 95% CI 1.30-2.21; P < 0.001). When we further analysed data from 2010 to 2014, intraoperative albumin infusion was associated with higher POD2ALB (P < 0.001) and lower incidence of pleural effusion (P = 0.024), compared with synthetic colloid infusion after PS matching (193 pairs). In conclusion, our data showed that POD2ALB is inversely associated with pleural effusion, and that intraoperative albumin infusion is associated with a lower incidence of pleural effusion when compared to synthetic colloid infusion in liver donors.
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Hiraoka A, Suzuki K, Chikazawa G, Nogami S, Sakaguchi T, Yoshitaka H. Adaptive servo-ventilation suppresses elevation of C-reactive protein and sympathetic activity in acute uncomplicated type B aortic dissection. Interact Cardiovasc Thorac Surg 2016; 24:27-33. [PMID: 27605569 DOI: 10.1093/icvts/ivw286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 07/13/2016] [Accepted: 07/28/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this prospective, randomized study was to investigate the effects of adaptive servo-ventilation (ASV), based on haemodynamic parameters, sympathetic status and respiratory conditions in patients with acute uncomplicated type B aortic dissection. METHODS We enrolled 28 patients with acute uncomplicated type B aortic dissection requiring antihypertensive therapies, who had been admitted within 24 h from onset. Study subjects were randomly assigned either to the ASV group (n = 14) or to the non-ASV group (n = 14). RESULTS Antihypertensive therapy at an acute phase led to significant reduction in blood pressure in both groups. Heart rate significantly dropped in the ASV group. In the non-ASV group, noradrenaline (746 ± 343 to 912 ± 402 pg/ml, P = 0.033) and dopamine (30 ± 21 to 42 ± 28 pg/ml, P = 0.015) significantly increased at 1 h after admission. Low frequency/high frequency ratios significantly decreased in the ASV group (2.1 ± 1.6 to 1.7 ± 1.1, P = 0.045). During follow-up at the subacute period, pleural effusion significantly increased in the non-ASV group (649 ± 611 vs 190 ± 292%, P = 0.033). Peak C-reactive protein (CRP) had a significant positive correlation with pleural effusion volume (P = 0.039) and was significantly greater in the non-ASV group (15.5 ± 6.3 vs 8.5 ± 6.1 mg/dl, P= 0.009). CONCLUSIONS In acute type B aortic dissection, ASV was considered to have suppressed the development of sympathetic nervous activity, pleural effusion and elevation of peak CRP.
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Affiliation(s)
- Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Kota Suzuki
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Shinsaku Nogami
- Department of Nursing, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
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