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Coselli JS, Roselli EE, Preventza O, Malaisrie SC, Stewart A, Stelzer P, Takayama H, Chen EP, Estrera AL, Gleason TG, Fischbein MP, Girardi LN, Patel HJ, Bavaria JE, LeMaire SA. Total aortic arch replacement using a frozen elephant trunk device: Results of a 1-year US multicenter trial. J Thorac Cardiovasc Surg 2024; 167:1680-1692.e2. [PMID: 36253292 DOI: 10.1016/j.jtcvs.2022.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/01/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In this prospective US investigational device exemption trial, we assessed the safety and 1-year clinical outcomes of the Thoraflex Hybrid device (Terumo Aortic) for the frozen elephant trunk technique to repair the ascending aorta, aortic arch, and descending thoracic aorta. METHODS For the trial, which involved 12 US sites, 65 patients without rupture were recruited into the primary study group, and 9 patients were recruited into the rupture group. All patients underwent open surgical repair of the ascending aorta, aortic arch, and descending thoracic aorta in cases of aneurysm and/or dissection. The primary end point was freedom from major adverse events (MAE), defined as permanent stroke, permanent paraplegia/paraparesis, unanticipated aortic-related reoperation (excluding reoperation for bleeding), or all-cause mortality. RESULTS In the primary study group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 81% (51/63). Seven patients (11%) died (including 2 before 30 days or discharge), 3 patients (5%) suffered permanent stroke, and 3 (5%) developed permanent paraplegia/paraparesis. Twenty-six patients (41%) underwent planned extension procedures, including 22 endovascular procedures within a median of 122 (interquartile range, 64-156) days. In the aortic rupture group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 71% (5/7). One patient (14%) died, 2 patients (29%) had permanent stroke, and none had permanent paraplegia/paraparesis. No extension procedures were performed in the rupture group. CONCLUSIONS One-year results with the Thoraflex Hybrid device are acceptable. Long-term data are necessary to assess the durability of these repairs.
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Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Eric E Roselli
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - S Chris Malaisrie
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Allan Stewart
- East Florida Division, HCA Florida Healthcare, Fort Lauderdale, Fla
| | - Paul Stelzer
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, NY
| | - Hiroo Takayama
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Edward P Chen
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas, McGovern Medical Center, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Joseph E Bavaria
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
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Chou EL, Lu E, Dake MD, Fischbein MP, Bavaria JE, Oderich G, Makaroun MS, Charlton-Ouw KM, Naslund T, Suckow BD, Matsumura JS, Patel HJ, Azizzadeh A. Initial Outcomes of the Gore TAG Thoracic Branch Endoprosthesis for Endovascular Repair of Blunt Thoracic Aortic Injury. Ann Vasc Surg 2024:S0890-5096(24)00097-9. [PMID: 38492730 DOI: 10.1016/j.avsg.2023.12.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 03/18/2024]
Abstract
OBJECTIVE Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation. METHODS Across 34 investigative sites, 9 patients with BTAI requiring left subclavian artery coverage were enrolled in a nonrandomized, prospective study of a single branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion. RESULTS This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up is planned. All participants had grade 3 BTAI. All procedures took place between 2018-2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 minutes (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection or thrombosis) through 12 months of follow-up. CONCLUSIONS Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for definitive assessment of the device safety and durability in traumatic aortic injuries.
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Affiliation(s)
- Elizabeth L Chou
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Eileen Lu
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, Tucson, AZ
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University Hospitals, Palo Alto, CA
| | - Joseph E Bavaria
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PE
| | | | - Michel S Makaroun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PE
| | - Kristofer M Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Thomas Naslund
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Bjoern D Suckow
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jon S Matsumura
- Department of Surgery, University of Colorado School of Medicine, Department of Surgery, Division of Vascular Surgery, Aurora, CO
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI
| | - Ali Azizzadeh
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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3
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Sharma D, Worssam MD, Pedroza AJ, Dalal AR, Alemany H, Kim HJ, Kundu R, Fischbein MP, Cheng P, Wirka R, Quertermous T. Comprehensive Integration of Multiple Single-Cell Transcriptomic Data Sets Defines Distinct Cell Populations and Their Phenotypic Changes in Murine Atherosclerosis. Arterioscler Thromb Vasc Biol 2024; 44:391-408. [PMID: 38152886 DOI: 10.1161/atvbaha.123.320030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND The application of single-cell transcriptomic (single-cell RNA sequencing) analysis to the study of atherosclerosis has provided unique insights into the molecular and genetic mechanisms that mediate disease risk and pathophysiology. However, nonstandardized methodologies and relatively high costs associated with the technique have limited the size and replication of existing data sets and created disparate or contradictory findings that have fostered misunderstanding and controversy. METHODS To address these uncertainties, we have performed a conservative integration of multiple published single-cell RNA sequencing data sets into a single meta-analysis, performed extended analysis of native resident vascular cells, and used in situ hybridization to map the disease anatomic location of the identified cluster cells. To investigate the transdifferentiation of smooth muscle cells to macrophage phenotype, we have developed a classifying algorithm based on the quantification of reporter transgene expression. RESULTS The reporter gene expression tool indicates that within the experimental limits of the examined studies, transdifferentiation of smooth muscle cell to the macrophage lineage is extremely rare. Validated transition smooth muscle cell phenotypes were defined by clustering, and the location of these cells was mapped to lesion anatomy with in situ hybridization. We have also characterized 5 endothelial cell phenotypes and linked these cellular species to different vascular structures and functions. Finally, we have identified a transcriptomically unique cellular phenotype that constitutes the aortic valve. CONCLUSIONS Taken together, these analyses resolve a number of outstanding issues related to differing results reported with vascular disease single-cell RNA sequencing studies, and significantly extend our understanding of the role of resident vascular cells in anatomy and disease.
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Affiliation(s)
- Disha Sharma
- Division of Cardiovascular Medicine (D.S., M.D.W., H.A., H.-J.K., R.K., P.C., T.Q.), Stanford University School of Medicine, CA
| | - Matthew D Worssam
- Division of Cardiovascular Medicine (D.S., M.D.W., H.A., H.-J.K., R.K., P.C., T.Q.), Stanford University School of Medicine, CA
| | - Albert J Pedroza
- Division of Cardiothoracic Surgery (A.J.P., A.R.D., M.P.F.), Stanford University School of Medicine, CA
| | - Alex R Dalal
- Division of Cardiothoracic Surgery (A.J.P., A.R.D., M.P.F.), Stanford University School of Medicine, CA
| | - Haizea Alemany
- Division of Cardiovascular Medicine (D.S., M.D.W., H.A., H.-J.K., R.K., P.C., T.Q.), Stanford University School of Medicine, CA
| | - Hyun-Jung Kim
- Division of Cardiovascular Medicine (D.S., M.D.W., H.A., H.-J.K., R.K., P.C., T.Q.), Stanford University School of Medicine, CA
| | - Ramendra Kundu
- Division of Cardiovascular Medicine (D.S., M.D.W., H.A., H.-J.K., R.K., P.C., T.Q.), Stanford University School of Medicine, CA
| | - Michael P Fischbein
- Division of Cardiothoracic Surgery (A.J.P., A.R.D., M.P.F.), Stanford University School of Medicine, CA
| | - Paul Cheng
- Division of Cardiovascular Medicine (D.S., M.D.W., H.A., H.-J.K., R.K., P.C., T.Q.), Stanford University School of Medicine, CA
| | - Robert Wirka
- Division of Cardiology, McAllister Heart Institute, UNC School of Medicine, Chapel Hill, NC (R.W.)
| | - Thomas Quertermous
- Division of Cardiovascular Medicine (D.S., M.D.W., H.A., H.-J.K., R.K., P.C., T.Q.), Stanford University School of Medicine, CA
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4
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Min Y, Dalal AR, Pedroza AJ, Pham TD, Panigrahi AK, Goldstone AB, MacArthur JW, Woo YJ, Baiocchi M, Fischbein MP. Blood transfusion in cardiac surgeries - Toward a personalized protocol. Am J Surg 2024; 227:237-238. [PMID: 37558518 DOI: 10.1016/j.amjsurg.2023.07.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Yan Min
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford CA, USA
| | - Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford CA, USA
| | - Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford CA, USA
| | - Tho D Pham
- Department of Pathology, Stanford University School of Medicine, Stanford CA, USA
| | - Anil K Panigrahi
- Department of Pathology, Stanford University School of Medicine, Stanford CA, USA; Department of Anesthesiology, Stanford University School of Medicine, Stanford CA, USA
| | - Andrew B Goldstone
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - John W MacArthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford CA, USA
| | - Michael Baiocchi
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford CA, USA
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford CA, USA.
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Turner V, Maret E, Kim JB, Codari M, Hinostroza V, Mastrodicasa D, Watkins AC, Fearon WF, Fischbein MP, Haddad F, Willemink MJ, Fleischmann D. Reduced Pulmonary Artery Distensibility Predicts Persistent Pulmonary Hypertension and 2-Year Mortality in Patients with Severe Aortic Stenosis Undergoing TAVR. Acad Radiol 2023; 30:2825-2833. [PMID: 37147161 DOI: 10.1016/j.acra.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 05/07/2023]
Abstract
RATIONALE AND OBJECTIVES Post-TAVR persistent pulmonary hypertension (PH) is a better predictor of poor outcome than pre-TAVR PH. In this longitudinal study we sought to evaluate whether pulmonary artery (distensibility (DPA) measured on preprocedural ECG-gated CTA is associated with persistent-PH and 2-year mortality after TAVR. MATERIALS AND METHODS Three hundred and thirty-six patients undergoing TAVR between July 2012 and March 2016 were retrospectively included and followed for all-cause mortality until November 2017. All patients underwent retrospectively ECG-gated CTA prior to TAVR. Main pulmonary artery (MPA) area was measured in systole and in diastole. DPA was calculated as: [(area-MPAmax-area-MPAmin)/area-MPAmax]%. ROC analysis was performed to assess the AUC for persistent-PH. Youden Index was used to determine the optimal threshold of DPA for persistent-PH. Two groups were compared based on a DPA threshold of 8% (specificity of 70% for persistent-PH). Kaplan-Meier, Cox proportional-hazard, and logistic regression analyses were performed. The primary clinical endpoint was defined as persistent-PH post-TAVR. The secondary endpoint was defined as all-cause mortality 2 years after TAVR. RESULTS Median follow-up time was 413 (interquartiles 339-757) days. A total of 183 (54%) had persistent-PH and 68 (20%) patients died within 2-years after TAVR. Patients with DPA<8% had significantly more persistent-PH (67% vs 47%, p<0.001) and 2-year deaths (28% vs 15%, p=0.006), compared to patients with DPA>8%. Adjusted multivariable regression analyses showed that DPA<8% was independently associated with persistent-PH (OR 2.10 [95%-CI 1.3-4.5], p=0.007) and 2-year mortality (HR 2.91 [95%-CI 1.5-5.8], p=0.002). Kaplan-Meier analysis showed that 2-year mortality of patients with DPA<8% was significantly higher compared to patients with DPA≥8% (mortality 28% vs 15%; log-rank p=0.003). CONCLUSION DPA on preprocedural CTA is independently associated with persistent-PH and two-year mortality in patients who undergo TAVR.
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Affiliation(s)
- Valery Turner
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304.
| | - Eva Maret
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Juyong B Kim
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Marina Codari
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Virginia Hinostroza
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - A Claire Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - William F Fearon
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Francois Haddad
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
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Pedroza AJ, Cheng P, Dalal AR, Baeumler K, Kino A, Tognozzi E, Shad R, Yokoyama N, Nakamura K, Mitchel O, Hiesinger W, MacFarlane EG, Fleischmann D, Woo YJ, Quertermous T, Fischbein MP. Early clinical outcomes and molecular smooth muscle cell phenotyping using a prophylactic aortic arch replacement strategy in Loeys-Dietz syndrome. J Thorac Cardiovasc Surg 2023; 166:e332-e376. [PMID: 37500053 DOI: 10.1016/j.jtcvs.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/12/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES Patients with Loeys-Dietz syndrome demonstrate a heightened risk of distal thoracic aortic events after valve-sparing aortic root replacement. This study assesses the clinical risks and hemodynamic consequences of a prophylactic aortic arch replacement strategy in Loeys-Dietz syndrome and characterizes smooth muscle cell phenotype in Loeys-Dietz syndrome aneurysmal and normal-sized downstream aorta. METHODS Patients with genetically confirmed Loeys-Dietz syndrome (n = 8) underwent prophylactic aortic arch replacement during valve-sparing aortic root replacement. Four-dimensional flow magnetic resonance imaging studies were performed in 4 patients with Loeys-Dietz syndrome (valve-sparing aortic root replacement + arch) and compared with patients with contemporary Marfan syndrome (valve-sparing aortic root replacement only, n = 5) and control patients (without aortopathy, n = 5). Aortic tissues from 4 patients with Loeys-Dietz syndrome and 2 organ donors were processed for anatomically segmented single-cell RNA sequencing and histologic assessment. RESULTS Patients with Loeys-Dietz syndrome valve-sparing aortic root replacement + arch had no deaths, major morbidity, or aortic events in a median of 2 years follow-up. Four-dimensional magnetic resonance imaging demonstrated altered flow parameters in patients with postoperative aortopathy relative to controls, but no clear deleterious changes due to arch replacement. Integrated analysis of aortic single-cell RNA sequencing data (>49,000 cells) identified a continuum of abnormal smooth muscle cell phenotypic modulation in Loeys-Dietz syndrome defined by reduced contractility and enriched extracellular matrix synthesis, adhesion receptors, and transforming growth factor-beta signaling. These modulated smooth muscle cells populated the Loeys-Dietz syndrome tunica media with gradually reduced density from the overtly aneurysmal root to the nondilated arch. CONCLUSIONS Patients with Loeys-Dietz syndrome demonstrated excellent surgical outcomes without overt downstream flow or shear stress disturbances after concomitant valve-sparing aortic root replacement + arch operations. Abnormal smooth muscle cell-mediated aortic remodeling occurs within the normal diameter, clinically at-risk Loeys-Dietz syndrome arch segment. These initial clinical and pathophysiologic findings support concomitant arch replacement in Loeys-Dietz syndrome.
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Affiliation(s)
- Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Paul Cheng
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Kathrin Baeumler
- Department of Radiology, Stanford University School of Medicine, Stanford, Calif
| | - Aya Kino
- Department of Radiology, Stanford University School of Medicine, Stanford, Calif
| | - Emily Tognozzi
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Rohan Shad
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Olivia Mitchel
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Elena Gallo MacFarlane
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Thomas Quertermous
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
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7
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Ruel M, Fischbein MP, de Lemos JA. Introduction to the 2023 Cardiovascular Surgery Issue. Circulation 2023; 148:1287-1288. [PMID: 37871236 DOI: 10.1161/circulationaha.123.067002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Marc Ruel
- University of Ottawa Heart Institute, Canada (M.R.)
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA (M.P.F.)
| | - James A de Lemos
- Cardiology, University of Texas Southwestern Medical Center, Cardiology, Dallas (J.A.d.L.)
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8
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Kaw A, Wu T, Starosolski Z, Zhou Z, Pedroza AJ, Majumder S, Duan X, Kaw K, Pinelo JEE, Fischbein MP, Lorenzi PL, Tan L, Martinez SA, Mahmud I, Devkota L, Taegtmeyer H, Ghaghada KB, Marrelli SP, Kwartler CS, Milewicz DM. Augmenting Mitochondrial Respiration in Immature Smooth Muscle Cells with an ACTA2 Pathogenic Variant Mitigates Moyamoya-like Cerebrovascular Disease. Res Sq 2023:rs.3.rs-3304679. [PMID: 37886459 PMCID: PMC10602100 DOI: 10.21203/rs.3.rs-3304679/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
ACTA2 pathogenic variants altering arginine 179 cause childhood-onset strokes due to moyamoya disease (MMD)-like occlusion of the distal internal carotid arteries. A smooth muscle cell (SMC)-specific knock-in mouse model (Acta2SMC-R179C/+) inserted the mutation into 67% of aortic SMCs, whereas explanted SMCs were uniformly heterozygous. Acta2R179C/+ SMCs fail to fully differentiate and maintain stem cell-like features, including high glycolytic flux, and increasing oxidative respiration (OXPHOS) with nicotinamide riboside (NR) drives the mutant SMCs to differentiate and decreases migration. Acta2SMC-R179C/+ mice have intraluminal MMD-like occlusive lesions and strokes after carotid artery injury, whereas the similarly treated WT mice have no strokes and patent lumens. Treatment with NR prior to the carotid artery injury attenuates the strokes, MMD-like lumen occlusions, and aberrant vascular remodeling in the Acta2SMC-R179C/+ mice. These data highlight the role of immature SMCs in MMD-associated occlusive disease and demonstrate that altering SMC metabolism to drive quiescence of Acta2R179C/+ SMCs attenuates strokes and aberrant vascular remodeling in the Acta2SMC-R179C/+ mice.
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Affiliation(s)
- Anita Kaw
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
| | - Ting Wu
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, McGovern Medical School, 6431 Fannin Street, Houston, TX 77030, USA
| | - Zbigniew Starosolski
- Department of Radiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Zhen Zhou
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
| | - Albert J. Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Suravi Majumder
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
| | - Xueyan Duan
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
| | - Kaveeta Kaw
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
| | - Jose E. E. Pinelo
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Philip L. Lorenzi
- Metabolomics Core Facility, Department of Bioinformatics & Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lin Tan
- Metabolomics Core Facility, Department of Bioinformatics & Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sara A. Martinez
- Metabolomics Core Facility, Department of Bioinformatics & Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Iqbal Mahmud
- Metabolomics Core Facility, Department of Bioinformatics & Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laxman Devkota
- Department of Radiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Heinrich Taegtmeyer
- Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
| | - Ketan B. Ghaghada
- Department of Radiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Sean P. Marrelli
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, McGovern Medical School, 6431 Fannin Street, Houston, TX 77030, USA
| | - Callie S. Kwartler
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
| | - Dianna M. Milewicz
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, TX 77030, USA
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9
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Nakamura K, Dalal AR, Yokoyama N, Pedroza AJ, Kusadokoro S, Mitchel O, Gilles C, Masoudian B, Leipzig M, Casey KM, Hiesinger W, Uchida T, Fischbein MP. Lineage-Specific Induced Pluripotent Stem Cell-Derived Smooth Muscle Cell Modeling Predicts Integrin Alpha-V Antagonism Reduces Aortic Root Aneurysm Formation in Marfan Syndrome Mice. Arterioscler Thromb Vasc Biol 2023; 43:1134-1153. [PMID: 37078287 PMCID: PMC10330156 DOI: 10.1161/atvbaha.122.318448] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 04/05/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND The role of increased smooth muscle cell (SMC) integrin αv signaling in Marfan syndrome (MFS) aortic aneurysm remains unclear. Herein, we examine the mechanism and potential efficacy of integrin αv blockade as a therapeutic strategy to reduce aneurysm progression in MFS. METHODS Induced pluripotent stem cells (iPSCs) were differentiated into aortic SMCs of the second heart field (SHF) and neural crest (NC) lineages, enabling in vitro modeling of MFS thoracic aortic aneurysms. The pathological role of integrin αv during aneurysm formation was confirmed by blockade of integrin αv with GLPG0187 in Fbn1C1039G/+ MFS mice. RESULTS iPSC-derived MFS SHF SMCs overexpress integrin αv relative to MFS NC and healthy control SHF cells. Furthermore, integrin αv downstream targets (FAK [focal adhesion kinase]/AktThr308/mTORC1 [mechanistic target of rapamycin complex 1]) were activated, especially in MFS SHF. Treatment of MFS SHF SMCs with GLPG0187 reduced p-FAK/p-AktThr308/mTORC1 activity back to control SHF levels. Functionally, MFS SHF SMCs had increased proliferation and migration compared to MFS NC SMCs and control SMCs, which normalized with GLPG0187 treatment. In the Fbn1C1039G/+ MFS mouse model, integrin αv, p-AktThr308, and downstream targets of mTORC1 proteins were elevated in the aortic root/ascending segment compared to littermate wild-type control. Mice treated with GLPG0187 (age 6-14 weeks) had reduced aneurysm growth, elastin fragmentation, and reduction of the FAK/AktThr308/mTORC1 pathway. GLPG0187 treatment reduced the amount and severity of SMC modulation assessed by single-cell RNA sequencing. CONCLUSIONS The integrin αv-FAK-AktThr308 signaling pathway is activated in iPSC SMCs from MFS patients, specifically from the SHF lineage. Mechanistically, this signaling pathway promotes SMC proliferation and migration in vitro. As biological proof of concept, GLPG0187 treatment slowed aneurysm growth and p-AktThr308 signaling in Fbn1C1039G/+ mice. Integrin αv blockade via GLPG0187 may be a promising therapeutic approach to inhibit MFS aneurysmal growth.
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Affiliation(s)
- Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Alex R. Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Albert J. Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Sho Kusadokoro
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Olivia Mitchel
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Casey Gilles
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Bahar Masoudian
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Matthew Leipzig
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Kerriann M. Casey
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford CA, USA
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Tetsuro Uchida
- Second Department of Surgery, Yamagata University Faculty of Medicine. Yamagata, Japan
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
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10
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Pedroza AJ, Dalal AR, Shad R, Yokoyama N, Nakamura K, Mitchel O, Gilles C, Hiesinger W, Fischbein MP. Smooth Muscle Cell Klf4 Expression Is Not Required for Phenotype Modulation or Aneurysm Formation in Marfan Syndrome Mice-Brief Report. Arterioscler Thromb Vasc Biol 2023; 43:971-978. [PMID: 37128911 PMCID: PMC10434826 DOI: 10.1161/atvbaha.122.318509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 04/13/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Smooth muscle cell (SMC) phenotypic reprogramming toward a mixed synthetic-proteolytic state is a central feature of aortic root aneurysm in Marfan syndrome (MFS). Previous work identified Klf4 as a potential mediator of SMC plasticity in MFS. METHODS MFS (Fbn1C1041G/+) mouse strains with an inducible vascular SMC fluorescent reporter (MFSSMC) with or without SMC-specific deletion of Klf4 exons 2 to 3 (MFSSMC-Klf4Δ) were generated. Simultaneous SMC tracing and Klf4 loss-of-function (Klf4Δ mice) was induced at 6 weeks of age. Aneurysm growth was assessed via serial echocardiography (4-24 weeks). Twenty-four-week-old mice were assessed via histology, RNA in situ hybridization, and aortic single-cell RNA sequencing. RESULTS MFS mice demonstrated progressive aortic root dilatation compared with control (WTSMC) mice regardless of Klf4 genotype (P<0.001), but there was no difference in aneurysm growth in MFSSMC-Klf4Δ versus MFSSMC (P=0.884). Efficient SMC Klf4 deletion was confirmed via lineage-stratified genotyping, RNA in situ hybridization, and immunohistochemistry. Single-cell RNA sequencing of traced SMCs revealed a highly similar pattern of phenotype modulation marked by loss of contractile markers (eg, Myh11, Cnn1) and heightened expression of matrix genes (eg, Col1a1, Fn1) between Klf4 genotypes. Pseudotemporal quantitation of SMC dedifferentiation confirmed that Klf4 deletion did not alter the global extent of phenotype modulation, but reduced expression of 23 genes during this phenotype transition in MFSSMC-Klf4Δmice, including multiple chondrogenic genes expressed by only the most severely dedifferentiated SMCs (eg, Cytl1, Tnfrsf11b). CONCLUSIONS Klf4 is not required to initiate SMC phenotype modulation in MFS aneurysm but may exert regulatory control over chondrogenic genes expressed in highly dedifferentiated SMCs.
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Affiliation(s)
- Albert J. Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Alex R. Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Rohan Shad
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Olivia Mitchel
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Casey Gilles
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
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11
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Dalal AR, Pedroza AJ, Krishnan A, Min Y, Tognozzi E, Yokoyama N, Nakamura K, Mitchel OR, Baiocchi M, Woo YJ, MacArthur JW, Fischbein MP. Blood transfusion in aortic root surgery impairs midterm survival. JTCVS Open 2023; 13:9-19. [PMID: 37063152 PMCID: PMC10091283 DOI: 10.1016/j.xjon.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 12/14/2022] [Accepted: 01/05/2023] [Indexed: 01/18/2023]
Abstract
Objective To evaluate the effect of perioperative allogeneic packed red blood cell (RBC) transfusion during aortic root replacement. Method We reviewed patients undergoing aortic root replacement at our institution between March 2014 and April 2020. In total, 760 patients underwent aortic root replacement, of whom 442 (58%) received a perioperative RBC transfusion. Propensity score matching was used to account for baseline and operative differences resulting in 159 matched pairs. All-cause mortality was assessed with Kaplan-Meier curves. Data were obtained from our institutional Society of Thoracic Surgeons database and chart review. Results After propensity score matching, the RBC-transfused and -nontransfused groups were similar for all preoperative characteristics. Cardiopulmonary bypass time, crossclamp time, and lowest operative temperature were similar between the transfused and nontransfused groups (standardized mean difference <0.05). RBC transfusion was associated with more frequent postoperative ventilation greater than 24 hours (36/159 [23%] vs 19/159 [12%]; P = .01), postoperative hemodialysis (9/159 [5.7%] vs 0/159 [0%]; P = .003), reoperation for mediastinal hemorrhage (9/159 [5.7%] vs 0/159 [0%]; P = .003), and longer intensive care unit and hospital length of stay (3 vs 2 days and 8 vs 6 days respectively; P < .001). Thirty-day operative mortality after propensity score matching was similar between the cohorts (1.9%; 3/159 vs 0%; P = .2), and 5-year survival was reduced in the RBC transfusion cohort (90.2% [95% confidence interval, 84.1%-96.7%] vs 97.1% [95% confidence interval, 92.3%-100%] P = .035). Conclusions Aortic root replacement frequently requires RBC transfusion during and after the operation, but even after matching for observed preoperative and operative characteristics, RBC transfusion is associated with more frequent postoperative complications and reduced midterm survival.
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Affiliation(s)
- Alex R. Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Albert J. Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Yan Min
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, Calif
| | - Emily Tognozzi
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Olivia R. Mitchel
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Michael Baiocchi
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, Calif
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - John W. MacArthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
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12
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Kwartler CS, Pedroza AJ, Kaw A, Guan P, Ma S, Duan XY, Kernell C, Wang C, Pinelo JEE, Borthwick MS, Chen J, Zhong Y, Sinha S, Shen X, Fischbein MP, Milewicz DM. Nuclear Smooth Muscle α-actin in Vascular Smooth Muscle Cell Differentiation. Res Sq 2023:rs.3.rs-1623114. [PMID: 36909460 PMCID: PMC10002808 DOI: 10.21203/rs.3.rs-1623114/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Missense variants throughout ACTA2, encoding smooth muscle α-actin (αSMA), predispose to adult onset thoracic aortic disease, but variants disrupting arginine 179 (R179) lead to Smooth Muscle Dysfunction Syndrome (SMDS) characterized by childhood-onset diverse vascular diseases. Our data indicate that αSMA localizes to the nucleus in wildtype (WT) smooth muscle cells (SMCs), enriches in the nucleus with SMC differentiation, and associates with chromatin remodeling complexes and SMC contractile gene promotors, and the ACTA2 p.R179 variant decreases nuclear localization of αSMA. SMCs explanted from a SMC-specific conditional knockin mouse model, Acta2SMC-R179/+, are less differentiated than WT SMCs, both in vitro and in vivo, and have global changes in chromatin accessibility. Induced pluripotent stem cells from patients with ACTA2 p.R179 variants fail to fully differentiate from neural crest cells to SMCs, and single cell transcriptomic analyses of an ACTA2 p.R179H patient's aortic tissue shows increased SMC plasticity. Thus, nuclear αSMA participates in SMC differentiation and loss of this nuclear activity occurs with ACTA2 p.R179 pathogenic variants.
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Affiliation(s)
- Callie S. Kwartler
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Albert J. Pedroza
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305
| | - Anita Kaw
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Pujun Guan
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Shuangtao Ma
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
- Current address: Department Medicine, Michigan State University, East Lansing, MI 48824
| | - Xue-yan Duan
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Caroline Kernell
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Charis Wang
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Jose Emiliano Esparza Pinelo
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Mikayla S. Borthwick
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Jiyuan Chen
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Yuan Zhong
- Department of Epigenetics and Molecular Carcinogenesis, The University of Texas MD Anderson Cancer Center, Smithville, TX 78957
| | - Sanjay Sinha
- Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, United Kingdom
| | - Xuetong Shen
- Institute of Cancer Research, Shenzhen Bay Laboratory, Shenzhen, China
| | | | - Dianna M. Milewicz
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
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13
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Pedroza AJ, Dalal AR, Krishnan A, Yokoyama N, Nakamura K, Tognozzi E, Woo YJ, Macarthur JW, Fischbein MP. Outcomes of Reoperative Aortic Root Replacement After Previous Acute Type A Dissection Repair. Semin Thorac Cardiovasc Surg 2023:S1043-0679(23)00016-3. [PMID: 36758660 DOI: 10.1053/j.semtcvs.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
Limited aortic root repair for acute type A dissection is associated with greater risk of proximal reoperations compared to full aortic root replacement. Surgical outcomes for patients undergoing reoperative root replacement after previous dissection repair are unknown. This study seeks to determine outcomes for these patients to further inform the debate surrounding optimal upfront management of the aortic root in acute dissection. Retrospective record review of all patients who underwent full aortic root replacement after a previous type A dissection repair operation at a tertiary academic referral center from 2004-2020 was performed. Among 57 cases of reoperative root replacement after type A repair, 35 cases included concomitant aortic arch replacements, and 21 cases involved coronary reconstruction (unilateral or bilateral modified Cabrol grafts). There were 3 acute postoperative strokes and 4 operative mortalities (composite 30-day and in-hospital deaths, 7.0%). Mid-term outcomes were equivalent for patients who required arch replacement compared to isolated proximal repairs (81.8% vs 80.6% estimated 5-year survival, median follow-up 5.53 years. Reoperative root replacement after index type A dissection repairs, including those with concomitant aortic arch replacement and/or coronary reconstruction is achievable with acceptable outcomes at an experienced aortic center.
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Affiliation(s)
- Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Emily Tognozzi
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - John W Macarthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California..
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14
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Dalal AR, Dossabhoy S, Heng E, Yasin A, Leipzig MM, Bonham SA, Fischbein MP, Lee JT, Woo YJ, Watkins AC. Midterm Outcomes in Type A Aortic Dissection Repair With and Without Malperfusion in a Hybrid Operating Room. Semin Thorac Cardiovasc Surg 2022:S1043-0679(22)00280-5. [PMID: 36567047 DOI: 10.1053/j.semtcvs.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Treatment approach to type A aortic dissection with malperfusion, immediate open aortic repair vs upfront endovascular treatment, remains controversial. From January 2017 to July 2021, 301 consecutive type A repairs were evaluated at our institution. Starting in 2019, all type A aortic dissections were performed in a fixed-fluoroscopy, hybrid operating room. Propensity score matching was used to control baseline patient characteristics between traditional and hybrid operating room approaches. There were 144 patients in the traditional group and 157 in the hybrid group. In the hybrid group, 41% (64/157) underwent intraoperative angiograms, and of those, 58% (37/64) received at least 1 endovascular intervention. Following propensity matching, 125 patients remained in each the traditional and hybrid groups. Thirty-day survival was significantly improved in the hybrid cohort at 96.7% (122/125) as compared to the traditional cohort at 87.2% (109/125) (P = 0.002). There were no significant differences in perioperative paralysis (1.6% vs 1.6%, P > 0.9), new hemodialysis (12% vs 9.6%, P = 0.5), fasciotomy (2.4% vs 5.6%, P = 0.20, and exploratory laparotomy (1.6% vs 4.8%, P = 0.3). The hybrid operating room approach to type A aortic dissection, provides the ability to immediately assess distal malperfusion and perform endovascular interventions at the time of open aortic repair, and is associated with significantly higher 30-day and 2-year survival when compared to a stepwise repair approach in a traditional operating room.
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Affiliation(s)
- Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Shernaz Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Elbert Heng
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Aleena Yasin
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Matthew M Leipzig
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Spencer A Bonham
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - A Claire Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
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15
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Mastrodicasa D, Willemink MJ, Turner VL, Hinostroza V, Codari M, Hanneman K, Ouzounian M, Ocazionez Trujillo D, Afifi RO, Hedgire S, Burris NS, Yang B, Lacomis JM, Gleason TG, Pacini D, Folesani G, Lovato L, Hinzpeter R, Alkadhi H, Stillman AE, Chen EP, van Kuijk SMJ, Schurink GWH, Sailer AM, Bäumler K, Miller DC, Fischbein MP, Fleischmann D. Registry of Aortic Diseases to Model Adverse Events and Progression (ROADMAP) in Uncomplicated Type B Aortic Dissection: Study Design and Rationale. Radiol Cardiothorac Imaging 2022; 4:e220039. [PMID: 36601455 PMCID: PMC9806732 DOI: 10.1148/ryct.220039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 09/01/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
Purpose To describe the design and methodological approach of a multicenter, retrospective study to externally validate a clinical and imaging-based model for predicting the risk of late adverse events in patients with initially uncomplicated type B aortic dissection (uTBAD). Materials and Methods The Registry of Aortic Diseases to Model Adverse Events and Progression (ROADMAP) is a collaboration between 10 academic aortic centers in North America and Europe. Two centers have previously developed and internally validated a recently developed risk prediction model. Clinical and imaging data from eight ROADMAP centers will be used for external validation. Patients with uTBAD who survived the initial hospitalization between January 1, 2001, and December 31, 2013, with follow-up until 2020, will be retrospectively identified. Clinical and imaging data from the index hospitalization and all follow-up encounters will be collected at each center and transferred to the coordinating center for analysis. Baseline and follow-up CT scans will be evaluated by cardiovascular imaging experts using a standardized technique. Results The primary end point is the occurrence of late adverse events, defined as aneurysm formation (≥6 cm), rapid expansion of the aorta (≥1 cm/y), fatal or nonfatal aortic rupture, new refractory pain, uncontrollable hypertension, and organ or limb malperfusion. The previously derived multivariable model will be externally validated by using Cox proportional hazards regression modeling. Conclusion This study will show whether a recent clinical and imaging-based risk prediction model for patients with uTBAD can be generalized to a larger population, which is an important step toward individualized risk stratification and therapy.Keywords: CT Angiography, Vascular, Aorta, Dissection, Outcomes Analysis, Aortic Dissection, MRI, TEVAR© RSNA, 2022See also the commentary by Rajiah in this issue.
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16
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Liang NL, Dake MD, Fischbein MP, Bavaria JE, Desai ND, Oderich GS, Singh MJ, Fillinger M, Suckow BD, Matsumura JS, Patel HJ, Makaroun MS. Midterm Outcomes of Endovascular Repair of Aortic Arch Aneurysms with the Gore Thoracic Branch Endoprosthesis. Eur J Vasc Endovasc Surg 2022; 64:639-645. [PMID: 35970335 DOI: 10.1016/j.ejvs.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 07/17/2022] [Accepted: 08/05/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Aortic aneurysms involving aortic arch vessels are anatomically unsuitable for standard thoracic endovascular repair (TEVAR) without cervical debranching of the arch vessels. Three year outcomes of a single branched thoracic endograft following previous publication of peri-operative and one year outcomes are reported. METHODS This was a multicentre feasibility trial of the GORE TAG Thoracic Branch Endoprosthesis (TBE), a thoracic endovascular graft incorporating a single retrograde branch for aortic arch vessel perfusion. The first study arm enrolled patients with an intact descending thoracic aortic aneurysm extending to the distal arch with left subclavian artery (LSA) incorporation (zone 2). The second arm enrolled patients with arch aneurysms requiring incorporation of the left carotid or innominate artery (zone 0/1) and extra-anatomic surgical revascularisation of the remaining aortic arch vessels. Outcomes at three years are reported. RESULTS The cohort comprised 40 patients (31 zone 2, nine zone 0/1). The majority were male (52%). Mean follow up was 1 408 ± 552 days in the zone 2 and 1 187 ± 766 days in the zone 0/1 cohort. During three year follow up there was no device migration, fracture, or aortic rupture in either arm. In the zone 2 arm, freedom from re-intervention was 97% at one and three years but there were two side branch occlusions. Two patients had aneurysm enlargement > 5 mm without documented endoleak or re-intervention. Freedom from death at one and three years was 90% and 84%. In the zone 0/1 arm there were no re-interventions, loss of branch patency, or aneurysm enlargement at three years. Cerebrovascular events occurred in three patients during follow up: two unrelated to the device or procedure, and one of unknown relationship. Two patients in this arm died during the follow up period, both unrelated to the procedure or the aneurysm. CONCLUSION Initial three year results of the TBE device for endovascular repair of arch aneurysms show favourable patency and durability with low rates of graft related complications.
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Affiliation(s)
- Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA.
| | - Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, Tucson, AZ, USA
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University Hospitals, Palo Alto, CA, USA
| | - Joseph E Bavaria
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh D Desai
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Mark Fillinger
- Section of Vascular of Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Bjoern D Suckow
- Section of Vascular of Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison WI, USA
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Centre, Ann Arbor, MI, USA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
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17
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Shin HS, Thakore A, Tada Y, Pedroza AJ, Ikeda G, Chen IY, Chan D, Jaatinen KJ, Yajima S, Pfrender EM, Kawamura M, Yang PC, Wu JC, Appel EA, Fischbein MP, Woo YJ, Shudo Y. Angiogenic stem cell delivery platform to augment post-infarction neovasculature and reverse ventricular remodeling. Sci Rep 2022; 12:17605. [PMID: 36266453 PMCID: PMC9584918 DOI: 10.1038/s41598-022-21510-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 09/28/2022] [Indexed: 01/13/2023] Open
Abstract
Many cell-based therapies are challenged by the poor localization of introduced cells and the use of biomaterial scaffolds with questionable biocompatibility or bio-functionality. Endothelial progenitor cells (EPCs), a popular cell type used in cell-based therapies due to their robust angiogenic potential, are limited in their therapeutic capacity to develop into mature vasculature. Here, we demonstrate a joint delivery of human-derived endothelial progenitor cells (EPC) and smooth muscle cells (SMC) as a scaffold-free, bi-level cell sheet platform to improve ventricular remodeling and function in an athymic rat model of myocardial infarction. The transplanted bi-level cell sheet on the ischemic heart provides a biomimetic microenvironment and improved cell-cell communication, enhancing cell engraftment and angiogenesis, thereby improving ventricular remodeling. Notably, the increased density of vessel-like structures and upregulation of biological adhesion and vasculature developmental genes, such as Cxcl12 and Notch3, particularly in the ischemic border zone myocardium, were observed following cell sheet transplantation. We provide compelling evidence that this SMC-EPC bi-level cell sheet construct can be a promising therapy to repair ischemic cardiomyopathy.
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Affiliation(s)
- Hye Sook Shin
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Akshara Thakore
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Yuko Tada
- grid.168010.e0000000419368956Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Albert J. Pedroza
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Gentaro Ikeda
- grid.168010.e0000000419368956Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Ian Y. Chen
- grid.168010.e0000000419368956Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Doreen Chan
- grid.168010.e0000000419368956Department of Chemistry, Department of Materials Science & Engineering, Stanford University, Stanford University, Stanford, USA
| | - Kevin J. Jaatinen
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA
| | - Shin Yajima
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Eric M. Pfrender
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Masashi Kawamura
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA
| | - Phillip C. Yang
- grid.168010.e0000000419368956Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Joseph C. Wu
- grid.168010.e0000000419368956Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Eric A. Appel
- grid.168010.e0000000419368956Department of Materials Science & Engineering, Department of Bioengineering, Department of Pediatric (Endocrinology), Stanford University, Stanford, USA
| | - Michael P. Fischbein
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - YJoseph Woo
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
| | - Yasuhiro Shudo
- grid.168010.e0000000419368956Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305 USA ,grid.168010.e0000000419368956Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, USA
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18
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Kaw A, Pedroza AJ, Chattopadhyay A, Pinard A, Guo D, Kaw K, Zhou Z, Shad R, Fischbein MP, Kwartler CS, Milewicz DM. Mosaicism for the smooth muscle cell (SMC)-specific knock-in of the Acta2 R179C pathogenic variant: Implications for gene editing therapies. J Mol Cell Cardiol 2022; 171:102-104. [PMID: 35878552 PMCID: PMC11027732 DOI: 10.1016/j.yjmcc.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/20/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Anita Kaw
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Abhijnan Chattopadhyay
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Amelie Pinard
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Dongchuan Guo
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Kaveeta Kaw
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Zhen Zhou
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Rohan Shad
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Callie S Kwartler
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, TX 77030, USA
| | - Dianna M Milewicz
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, TX 77030, USA.
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19
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Pedroza AJ, Dalal AR, Shad R, Yokoyama N, Nakamura K, Cheng P, Wirka RC, Mitchel O, Baiocchi M, Hiesinger W, Quertermous T, Fischbein MP. Embryologic Origin Influences Smooth Muscle Cell Phenotypic Modulation Signatures in Murine Marfan Syndrome Aortic Aneurysm. Arterioscler Thromb Vasc Biol 2022; 42:1154-1168. [PMID: 35861960 PMCID: PMC9420801 DOI: 10.1161/atvbaha.122.317381] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic root smooth muscle cells (SMC) develop from both the second heart field (SHF) and neural crest. Disparate responses to disease-causing Fbn1 variants by these lineages are proposed to promote focal aortic root aneurysm formation in Marfan syndrome (MFS), but lineage-stratified SMC analysis in vivo is lacking. METHODS We generated SHF lineage-traced MFS mice and performed integrated multiomic (single-cell RNA and assay for transposase-accessible chromatin sequencing) analysis stratified by embryological origin. SMC subtypes were spatially identified via RNA in situ hybridization. Response to TWIST1 overexpression was determined via lentiviral transduction in human aortic SMCs. RESULTS Lineage stratification enabled nuanced characterization of aortic root cells. We identified heightened SHF-derived SMC heterogeneity including a subset of Tnnt2 (cardiac troponin T)-expressing cells distinguished by altered proteoglycan expression. MFS aneurysm-associated SMC phenotypic modulation was identified in both SHF-traced and nontraced (neural crest-derived) SMCs; however, transcriptomic responses were distinct between lineages. SHF-derived modulated SMCs overexpressed collagen synthetic genes and small leucine-rich proteoglycans while nontraced SMCs activated chondrogenic genes. These modulated SMCs clustered focally in the aneurysmal aortic root at the region of SHF/neural crest lineage overlap. Integrated RNA-assay for transposase-accessible chromatin analysis identified enriched Twist1 and Smad2/3/4 complex binding motifs in SHF-derived modulated SMCs. TWIST1 overexpression promoted collagen and SLRP gene expression in vitro, suggesting TWIST1 may drive SHF-enriched collagen synthesis in MFS aneurysm. CONCLUSIONS SMCs derived from both SHF and neural crest lineages undergo phenotypic modulation in MFS aneurysm but are defined by subtly distinct transcriptional responses. Enhanced TWIST1 transcription factor activity may contribute to enriched collagen synthetic pathways SHF-derived SMCs in MFS.
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Affiliation(s)
- Albert J. Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Alex R. Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Rohan Shad
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Paul Cheng
- Division of Cardiovascular Medicine, Stanford University School of Medicine. Stanford CA, USA
| | - Robert C. Wirka
- Division of Cardiology, UNC School of Medicine, Chapel Hill NC, USA
| | | | - Michael Baiocchi
- Department of Epidemiology and Population Health, Stanford Unviersity School of Medicine. Stanford CA, USA
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Thomas Quertermous
- Division of Cardiovascular Medicine, Stanford University School of Medicine. Stanford CA, USA
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
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20
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Cheng P, Pedroza AJ, Sharma D, Weldy CS, Nguyen T, Dalal AR, Shad R, Kim JB, Fischbein MP, Wirka R, Quertermous T. Abstract P3006: A Human Arterial Cell Atlas. Circ Res 2022. [DOI: 10.1161/res.131.suppl_1.p3006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Human vascular diseases are the worldwide leading causes of morbidity and mortality. Nearly all human vascular diseases have arterial segment-specific tropisms despite identical exposures to genetic and environmental risk factors. Understanding the cellular and transcriptomic determinants of arterial identities may hold the key to identifying novel pathophysiology and potential therapies.
Methods:
To specifically determine arterial site-specific differences independent of inter-individual variation, we have generated a human arterial cellular atlas by simultaneously collecting and analyzing up to 8 arterial sites from multiple healthy transplant donors. We performed single cell transcriptomic analysis on arterial segments to determine the differences in cellular composition and transcriptomic programs. We subsequently integrated human genetic data with cell-type specific transcriptomic differences across vascular beds to identify probable causal cells and causal genes associated with human vascular phenotypes.
Results/Conclusions:
Single cell transcriptomic analysis of >150,000 cells sequenced at >50,000 reads per cell revealed that the dominant cellular drivers of transcriptomic differences between distinct arterial segments, i.e. determinants of arterial identity, are fibroblasts and smooth muscle cells, not endothelial cells or macrophages. Adult vascular cells transcriptomes from different segments are most influenced by their embryonic origins but not by anatomical proximity. Differentially regulated genes in fibroblast across different vascular beds were particularly enriched for vascular disease associated genetic signals, suggesting a prominent role for these cells in human disease. While the majority of endothelial cells were transcriptionally similar across vascular beds, a rare, previously undescribed, cluster of endothelial cells were identified who expressed segment-specific transcriptomic signatures. Differentially expressed genes in these cells were enriched for vascular disease signals, suggesting a possible role of these rare cells in human disease.
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21
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Vaikunth SS, Chan JL, Woo JP, Bykhovsky MR, Lui GK, Ma M, Romfh AW, Lamberti J, Mastrodicasa D, Fleischmann D, Fischbein MP. Tetralogy of Fallot and Aortic Dissection: Implications in Management. JACC Case Rep 2022; 4:581-586. [PMID: 35615213 PMCID: PMC9125517 DOI: 10.1016/j.jaccas.2022.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 02/10/2022] [Accepted: 02/27/2022] [Indexed: 11/29/2022]
Abstract
We present the case of a 61-year-old man with tetralogy of Fallot postrepair and mechanical aortic valve replacement with an aortic root/ascending/arch aneurysm with chronic type A aortic dissection. He underwent uncomplicated aortic root and total arch replacement. Continued surveillance for aortic aneurysm is necessary in the tetralogy of Fallot population. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Sumeet S. Vaikunth
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joshua L. Chan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer P. Woo
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael R. Bykhovsky
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - George K. Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Anitra W. Romfh
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - John Lamberti
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA,Address for correspondence: Dr Michael P. Fischbein, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Falk CVRB, 300 Pasteur Drive, Falk CVRB ULN MC5407, Stanford, California 94305, USA.
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22
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Kwartler C, Pedroza AJ, Kaw A, Ma S, Duan XY, Kernell C, Waters M, Chen J, Fischbein MP, Milewicz DM. Abstract 144: Nuclear Smooth Muscle α-actin Is Critical For Smooth Muscle Cell Differentiation And To Prevent Cerebrovascular Disease. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Missense pathogenic variants in
ACTA2,
encoding α-smooth muscle actin (SMA), predispose to thoracic aortic aneurysms. A subset of these
ACTA2
pathogenic variants also predispose to childhood onset cerebrovascular disease characterized by occlusion of the distal internal carotid arteries and small vessel disease. In our studies to identify how specific
ACTA2
pathogenic variants predispose to cerebrovascular disease, we confirmed that SMA is localized to the nucleus in wildtype (WT) smooth muscle cells (SMCs), is enriched in the nucleus over β-actin with differentiation of SMCs, associates with the INO80 chromatin remodeling complex, and selectively binds to the promoters of SMC contractile genes. Pluripotent stem cell-derived SMCs from patients with
ACTA2
-associated cerebrovascular disease (
ACTA2
R179C) as well as SMCs explanted from a knockin mouse model (
Acta2
SMC-R179C/+
) confirm that R179 variants disrupt SMA nuclear localization. Both mouse and human cells harboring the R179C pathogenic variant proliferate and migrate more than WT SMCs, are less differentiated than WT SMCs, and have increased expression of pluripotency-associated genes. Although the variant is heterozygous, these cells show a dominant negative impact on nuclear SMA function through dramatically reduced levels of SMA in the nucleus, in the INO80 chromatin remodeling complex, and on the promoters of SMC-specific genes. Finally, single cell RNA sequencing analysis of aortic tissue from an
ACTA2
R179H patient confirms dedifferentiation of SMCs as a key phenotype associated with this mutation. Taken together, we have identified a novel role for α-SMA in driving differentiation of SMCs, and our data supports that defects in this nuclear role drive cellular phenotypes consistent with the cerebrovascular disease seen in patients with
ACTA2
R179 pathogenic variants.
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23
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Pedroza AJ, Dalal AR, Shad R, Yokoyama N, Nakamura K, Cheng P, Mitchel O, Hiesinger W, Quertermous T, Fischbein MP. Abstract 360: Epigenomic Changes Govern Smooth Muscle Cell Phenotype Shift In Marfan Syndrome Aortic Root Aneurysm. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background:
Vascular smooth muscle cell (SMC) phenotype modulation produces a mixed proteolytic/collagen synthetic state in Marfan syndrome (MFS) aortic root aneurysm. While the transcriptomic changes associated with this process are established, upstream regulators governing this plasticity are poorly characterized.
Methods/Results:
We performed concurrent single-cell RNA sequencing (scRNAseq) and assay for transposase-accessible chromatin using sequencing (scATACseq) on aortic root aneurysm tissue from adult
Fbn1
C1041G/+
(MFS) mice and littermate controls. MFS/control scRNAseq data analysis identified four SMC subtypes including MFS-specific ‘modulated’ cells (modSMCs) which enriched for extracellular matrix organization and collagen synthesis pathway activation. These SMC clusters were projected onto the MFS/control scATAC dataset via integrative label transfer to study dynamic chromatin accessibility during SMC phenotype modulation. We compared DNA accessibility in modSMCs versus mature SMCs, finding 336 enriched and 29 suppressed peaks, suggesting increased open chromatin during modulation. Using chromVAR, we identified 242 enriched transcription factor motifs overrepresented in modSMCs. Motifs representing central but nonspecific transcription factor families including numerous AP-1 (FOS/JUN/ATF) heterodimers and TEAD family members showed highest enrichment, while enriched TWIST1, HAND2, and SMAD2:SMAD3:SMAD4 complex motifs suggested more specific functions. To functionally validate these findings, we examined
TWIST1
as a potential regulator of SMC modulation
in vitro
via lentiviral overexpression in MFS patient-derived aortic SMCs.In SMCs with forced TWIST1 overexpression, we found heightened promoter region DNA accessibility (via bulk ATACseq) and increased mRNA expression (via RT-PCR) for specific modSMC markers (e.g.,
COL1A1
and
LUM
confirming TWIST1 promotes collagen synthesis.
Conclusions:
Integrated single-cell transcriptomic/epigenomic analysis permits identification of critical upstream regulatory signals promoting disease-specific cell phenotype changes. TWIST1 is a potential driver of SMC modulation and a target for therapeutic agent design in MFS aortic aneurysm.
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24
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Cheng P, Wirka R, Kim JB, Nguyen T, Kundu RK, Zhao Q, Sharma D, Pedroza AJ, Nagao M, Iyer D, Fischbein MP, Quertermous T. Abstract 220:
Smad3
Regulates Smooth Muscle Cell Fate And Governs Adverse Remodeling And Calcification Of Atherosclerotic Plaque. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Atherosclerotic plaques consist mostly of smooth muscle cells (SMC), and genes that influence SMC phenotype can modulate coronary artery disease (CAD) risk. Allelic variation at 15q22.33 has been identified by genome-wide association studies to modify the risk of CAD, and is associated with expression of
SMAD3
in SMC
,
however the mechanism by which this gene modifies CAD risk remains poorly understood. SMC-specific deletion of
Smad3
in a murine atherosclerosis model resulted in greater plaque burden, more positive remodeling, and increased vascular calcification. Single-cell transcriptomic analyses revealed that loss of
Smad3
altered SMC transition cell state toward two fates: a novel SMC phenotype that governs both vascular remodeling and recruitment of inflammatory cells, as well as a chondromyocyte fate. The remodeling population was marked by uniquely high
Mmp3
and
Cxcl12
expression, and its appearance correlated with higher risk plaque features such as increased positive remodeling and macrophage content. Further, investigation of transcriptional mechanisms by which Smad3 alters SMC cell fate revealed novel roles for Hox and Sox transcription factors whose direct interaction with Smad3 regulate an extensive transcriptional program balancing remodeling and vascular extracellular matrix. These findings have significant implications for atherosclerotic and Mendelian aortic aneurysmal diseases. Together, these data suggest that
Smad3
expression in SMC inhibits the emergence of specific SMC phenotypic transition cells that mediate adverse plaque features, including positive remodeling, monocyte recruitment, and vascular calcification.
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25
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Cheng P, Pedroza AJ, Sharma D, Weldy C, Ryan Y, Nguyen T, sundaram L, Dalal A, Shad R, Kim HJ, Shi H, Kundu RK, Kundaje A, Kim JB, Fischbein MP, Wirka R, Quertermous T. Abstract 107: A Human Arterial Cell Atlas. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background:
Human vascular diseases are the worldwide leading causes of morbidity and mortality. Nearly all human vascular diseases have arterial segment-specific tropisms despite identical exposures to genetic and environmental risk factors. Understanding the cellular and transcriptomic determinants of arterial identities may hold the key to identifying novel pathophysiology and potential therapies.
Methods:
To specifically determine arterial site-specific differences independent of inter-individual variation, we have generated a human arterial cellular atlas by simultaneously collecting and analyzing up to 8 arterial sites from multiple healthy transplant donors. We performed single cell transcriptomic analysis on arterial segments to determine the differences in cellular composition and transcriptomic programs. We subsequently integrated human genetic data with cell-type specific transcriptomic differences across vascular beds to identify probable causal cells and causal genes associated with human vascular phenotypes.
Results/Conclusions:
Single cell transcriptomic analysis of > 150,000 cells sequenced at > 50,000 reads per cell revealed that the dominant cellular drivers of transcriptomic differences between distinct arterial segments, i.e. determinants of arterial identity, are fibroblasts and smooth muscle cells, not endothelial cells or macrophages. Adult vascular cells from different segments clustered not by anatomical proximity but by embryonic origin. Differentially regulated genes in fibroblast across different vascular beds were particularly enriched for vascular disease associated genetic signals, suggesting a prominent role for these cells in human disease. While the majority of endothelial cells were transcriptionally similar across vascular beds, a rare, previously undescribed, cluster of endothelial cells were identified who expressed segment-specific transcriptomic signatures. Differentially expressed genes in these cells were enriched for vascular disease signals, suggesting a possible role of these rare cells in human disease.
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26
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Pedroza AJ, Shad R, Dalal AR, Yokoyama N, Nakamura K, Hiesinger W, Fischbein MP. Acute Induced Pressure Overload Rapidly Incites Thoracic Aortic Aneurysmal Smooth Muscle Cell Phenotype. Hypertension 2022; 79:e86-e89. [PMID: 35124970 PMCID: PMC8916978 DOI: 10.1161/hypertensionaha.121.18640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Albert J. Pedroza
- Department of Cardiothoracic Surgery, Stanford University
School of Medicine. Stanford CA, USA
| | - Rohan Shad
- Department of Cardiothoracic Surgery, Stanford University
School of Medicine. Stanford CA, USA
| | - Alex R. Dalal
- Department of Cardiothoracic Surgery, Stanford University
School of Medicine. Stanford CA, USA
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University
School of Medicine. Stanford CA, USA
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University
School of Medicine. Stanford CA, USA
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University
School of Medicine. Stanford CA, USA
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University
School of Medicine. Stanford CA, USA
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27
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Cheng P, Wirka RC, Kim JB, Kim HJ, Nguyen T, Kundu R, Zhao Q, Sharma D, Pedroza A, Nagao M, Iyer D, Fischbein MP, Quertermous T. Smad3 regulates smooth muscle cell fate and mediates adverse remodeling and calcification of the atherosclerotic plaque. Nat Cardiovasc Res 2022; 1:322-333. [PMID: 36246779 PMCID: PMC9560061 DOI: 10.1038/s44161-022-00042-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 03/01/2022] [Indexed: 04/20/2023]
Abstract
Atherosclerotic plaques consist mostly of smooth muscle cells (SMC), and genes that influence SMC phenotype can modulate coronary artery disease (CAD) risk. Allelic variation at 15q22.33 has been identified by genome-wide association studies to modify the risk of CAD and is associated with the expression of SMAD3 in SMC. However, the mechanism by which this gene modifies CAD risk remains poorly understood. Here we show that SMC-specific deletion of Smad3 in a murine atherosclerosis model resulted in greater plaque burden, more outward remodelling and increased vascular calcification. Single-cell transcriptomic analyses revealed that loss of Smad3 altered SMC transition cell state toward two fates: a SMC phenotype that governs both vascular remodelling and recruitment of inflammatory cells, as well as a chondromyocyte fate. Together, the findings reveal that Smad3 expression in SMC inhibits the emergence of specific SMC phenotypic transition cells that mediate adverse plaque features, including outward remodelling, monocyte recruitment, and vascular calcification.
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Affiliation(s)
- Paul Cheng
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Robert C. Wirka
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Juyong Brian Kim
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Hyun-Jung Kim
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Trieu Nguyen
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Ramendra Kundu
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Quanyi Zhao
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Disha Sharma
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Albert Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305
| | - Manabu Nagao
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Dharini Iyer
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305
| | - Thomas Quertermous
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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29
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MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Fleischmann D, Afifi RO, Casanegra AI, Elefteriades JA, Gleason TG, Hanneman K, Roselli EE, Willemink MJ, Fischbein MP. Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2022; 15:e000075. [PMID: 35172599 DOI: 10.1161/hci.0000000000000075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.
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31
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Wobben LD, Codari M, Mistelbauer G, Pepe A, Higashigaito K, Hahn LD, Mastrodicasa D, Turner VL, Hinostroza V, Baumler K, Fischbein MP, Fleischmann D, Willemink MJ. Deep Learning-Based 3D Segmentation of True Lumen, False Lumen, and False Lumen Thrombosis in Type-B Aortic Dissection. Annu Int Conf IEEE Eng Med Biol Soc 2021; 2021:3912-3915. [PMID: 34892087 PMCID: PMC9261941 DOI: 10.1109/embc46164.2021.9631067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Patients with initially uncomplicated typeB aortic dissection (uTBAD) remain at high risk for developing late complications. Identification of morphologic features for improving risk stratification of these patients requires automated segmentation of computed tomography angiography (CTA) images. We developed three segmentation models utilizing a 3D residual U-Net for segmentation of the true lumen (TL), false lumen (FL), and false lumen thrombosis (FLT). Model 1 segments all labels at once, whereas model 2 segments them sequentially. Best results for TL and FL segmentation were achieved by model 2, with median (interquartiles) Dice similarity coefficients (DSC) of 0.85 (0.77-0.88) and 0.84 (0.82-0.87), respectively. For FLT segmentation, model 1 was superior to model 2, with median (interquartiles) DSCs of 0.63 (0.40-0.78). To purely test the performance of the network to segment FLT, a third model segmented FLT starting from the manually segmented FL, resulting in median (interquartiles) DSCs of 0.99 (0.98-0.99) and 0.85 (0.73-0.94) for patent FL and FLT, respectively. While the ambiguous appearance of FLT on imaging remains a significant limitation for accurate segmentation, our pipeline has the potential to help in segmentation of aortic lumina and thrombosis in uTBAD patients.Clinical relevance- Most predictors of aortic dissection (AD) degeneration are identified through anatomical modeling, which is currently prohibitive in clinical settings due to the timeintense human interaction. False lumen thrombosis, which often develops in patients with type B AD, has proven to show significant prognostic value for predicting late adverse events. Our automated segmentation algorithm offers the potential of personalized treatment for AD patients, leading to an increase in long-term survival.
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Chiu P, Lee HP, Dalal AR, Koyano T, Nguyen M, Connolly AJ, Chaudhuri O, Fischbein MP. Relative strain is a novel predictor of aneurysmal degeneration of the thoracic aorta: An ex vivo mechanical study. JVS Vasc Sci 2021; 2:235-246. [PMID: 34806052 PMCID: PMC8585654 DOI: 10.1016/j.jvssci.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/28/2021] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Current guidelines for prophylactic replacement of the thoracic aorta, primarily based on size alone, may not be adequate in identifying patients at risk for either progression of disease or aortic catastrophe. We undertook the current study to determine whether the mechanical properties of the aorta might be able to predict aneurysmal dilatation of the aorta using a clinical database and benchtop mechanical testing of human aortic tissue. METHODS Using over 400 samples from 31 patients, mechanical properties were studied in (a) normal aorta and then (b) between normal and diseased aorta using linear mixed-effects models. A machine learning technique was used to predict aortic growth rate over time using mechanical properties and baseline clinical characteristics. RESULTS Healthy aortic tissue under in vivo loading conditions, after accounting for aortic segment location, had lower longitudinal elastic modulus compared with circumferential elastic modulus: -166.8 kPa (95% confidence interval [CI]: -210.8 to -122.7, P < .001). Fracture toughness was also lower in the longitudinal vs circumferential direction: -201.2 J/m3 (95% CI: -272.9 to -129.5, P < .001). Finally, relative strain was lower in the longitudinal direction compared with the circumferential direction: -0.01 (95% CI: -0.02 to -0.004, P = .002). Patients with diseased aorta, after accounting for segment location and sample direction, had decreased toughness compared with normal aorta, -431.7 J/m3 (95% CI: -628.6 to -234.8, P < .001), and increased relative strain, 0.09 (95% CI: 0.04 to 0.14, P = .003). CONCLUSIONS Increasing relative strain was identified as a novel independent predictor of aneurysmal degeneration. Noninvasive measurement of relative strain may aid in the identification and monitoring of patients at risk for aneurysmal degeneration. (JVS-Vascular Science 2021;2:1-12.). CLINICAL RELEVANCE Aortic aneurysm surveillance and prophylactic surgical recommendations are based on computed tomographic angiogram aortic dimensions and growth rate measurements. However, aortic catastrophes may occur at small sizes, confounding current risk stratification models. Herein, we report that increasing aortic relative strain, that is, greater distensibility, is associated with growth over time, thus potentially identifying patients at risk for dissection/rupture.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif
| | - Hong-Pyo Lee
- Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Alex R. Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif
| | - Tiffany Koyano
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif
| | - Marie Nguyen
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif
| | - Andrew J. Connolly
- Department of Pathology, University of California San Francisco, San Francisco, Calif
| | - Ovijit Chaudhuri
- Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif
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33
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Turner VL, Jubran A, Kim JB, Maret E, Moneghetti KJ, Haddad F, Amsallem M, Codari M, Hinostroza V, Mastrodicasa D, Sailer AM, Kobayashi Y, Nishi T, Yeung AC, Watkins AC, Lee AM, Miller DC, Fischbein MP, Fearon WF, Willemink MJ, Fleischmann D. CTA pulmonary artery enlargement in patients with severe aortic stenosis: Prognostic impact after TAVR. J Cardiovasc Comput Tomogr 2021; 15:431-440. [PMID: 33795188 PMCID: PMC10017114 DOI: 10.1016/j.jcct.2021.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/09/2021] [Accepted: 03/13/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Identifying high-risk patients who will not derive substantial survival benefit from TAVR remains challenging. Pulmonary hypertension is a known predictor of poor outcome in patients undergoing TAVR and correlates strongly with pulmonary artery (PA) enlargement on CTA. We sought to evaluate whether PA enlargement, measured on pre-procedural computed tomography angiography (CTA), is associated with 1-year mortality in patients undergoing TAVR. METHODS We retrospectively included 402 patients undergoing TAVR between July 2012 and March 2016. Clinical parameters, including Society of Thoracic Surgeons (STS) score and right ventricular systolic pressure (RVSP) estimated by transthoracic echocardiography were reviewed. PA dimensions were measured on pre-procedural CTAs. Association between PA enlargement and 1-year mortality was analyzed. Kaplan-Meier and Cox proportional hazards regression analyses were performed. RESULTS The median follow-up time was 433 (interquartiles 339-797) days. A total of 56/402 (14%) patients died within 1 year after TAVR. Main PA area (area-MPA) was independently associated with 1-year mortality (hazard ratio per standard deviation equal to 2.04 [95%-confidence interval (CI) 1.48-2.76], p < 0.001). Area under the curve (95%-CI) of the clinical multivariable model including STS-score and RVSP increased slightly from 0.67 (0.59-0.75) to 0.72 (0.72-0.89), p = 0.346 by adding area-MPA. Although the AUC increased, differences were not significant (p = 0.346). Kaplan-Meier analysis showed that mortality was significantly higher in patients with a pre-procedural non-indexed area-MPA of ≥7.40 cm2 compared to patients with a smaller area-MPA (mortality 23% vs. 9%; p < 0.001). CONCLUSIONS Enlargement of MPA on pre-procedural CTA is independently associated with 1-year mortality after TAVR.
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Affiliation(s)
- Valery L Turner
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Ayman Jubran
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Juyong Brian Kim
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Eva Maret
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Department of Clinical Physiology, Karolinska University Hospital, Karolinska Institute, Stockholm.
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Marina Codari
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Virginia Hinostroza
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Anna M Sailer
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Takeshi Nishi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Alan C Yeung
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Amelia C Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Anson M Lee
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - D Craig Miller
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Michael P Fischbein
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
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Dake MD, Fischbein MP, Bavaria JE, Desai ND, Oderich G, Singh MJ, Fillinger M, Suckow BD, Matsumura JS, Patel HJ. Evaluation of the Gore TAG thoracic branch endoprosthesis in the treatment of proximal descending thoracic aortic aneurysms. J Vasc Surg 2021; 74:1483-1490.e2. [PMID: 33940079 DOI: 10.1016/j.jvs.2021.04.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/19/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair has radically transformed the treatment of descending thoracic aortic aneurysms. However, when aneurysms involve the aortic arch in the region of the left subclavian artery, branch vessel preservation must be considered. Branched aortic endografts have provided a new option to maintain branch patency. METHODS Six investigative sites enrolled 31 patients in a nonrandomized, prospective investigational device exemption feasibility trial of a single branched aortic endograft for the management of aneurysms that include the distal aortic arch. The Gore TAG thoracic branch endoprosthesis (W. L. Gore & Associates, Inc, Flagstaff, Ariz), an investigational device, allows for graft placement proximal to the left subclavian artery and incorporates a single side branch for left subclavian perfusion. RESULTS All 31 patients (100%) had undergone successful implantation of the investigational device in landing zone 2. Men slightly outnumbered women (51.6%). Their average age was 74.1 ± 10.4 years. The aneurysm morphology was fusiform in 12 and saccular in 19 patients, with a mean maximum aortic diameter of 54.8 ± 10.9 mm. The mean follow-up period for the cohort was 25.2 ± 11.1 months. We have reported the patient outcomes at 1 month and 1 year. At 1 month, the side branch patency was 100% and the freedom from core laboratory-reported device-related endoleak (types I and III) was 96.7%, without 30-day death or permanent paraplegia. One patient experienced a procedure-related stroke. Through 1 year, five patients had died; none of the deaths were related to the device or procedure (clinical endpoint committee adjudicated). One thoracic reintervention was required. No conversions were required, and no aneurysm growth (core laboratory) was reported. One case of the loss of side branch patency was diagnosed in the left subclavian artery in an asymptomatic individual from computed tomography at 6 months, with no reported subsequent adverse events due to loss of patency. Endoleaks were reported by the core laboratory in five patients at 12 months (two, type II; and three, indeterminate). CONCLUSIONS The present investigational device exemption feasibility study has reported the preliminary results of the use of a single side branch endograft to treat patients with proximal descending thoracic aortic aneurysms.
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Affiliation(s)
- Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, Tuscon, Ariz.
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University Hospitals, Palo Alto, Calif
| | - Joseph E Bavaria
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Nimesh D Desai
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | | | - Michael J Singh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Mark Fillinger
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Bjoern D Suckow
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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35
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Malaisrie SC, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt TM, Chen EP, Fischbein MP, Gleason TG, Okita Y, Ouzounian M, Patel HJ, Roselli EE, Shrestha ML, Svensson LG, Moon MR. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162:735-758.e2. [PMID: 34112502 DOI: 10.1016/j.jtcvs.2021.04.053] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 01/16/2023]
Affiliation(s)
- S Christopher Malaisrie
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa
| | - Monika Halas
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC
| | | | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Hospitals, Ann Arbor, Mich
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Malakh L Shrestha
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
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Higashigaito K, Sailer AM, van Kuijk SMJ, Willemink MJ, Hahn LD, Hastie TJ, Miller DC, Fischbein MP, Fleischmann D. Aortic growth and development of partial false lumen thrombosis are associated with late adverse events in type B aortic dissection. J Thorac Cardiovasc Surg 2021; 161:1184-1190.e2. [PMID: 31839226 PMCID: PMC10552621 DOI: 10.1016/j.jtcvs.2019.10.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 09/13/2019] [Accepted: 10/02/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with medically treated type B aortic dissection (TBAD) remain at significant risk for late adverse events (LAEs). We hypothesize that not only initial morphological features, but also their change over time at follow-up are associated with LAEs. MATERIALS AND METHODS Baseline and 188 follow-up computed tomography (CT) scans with a median follow-up time of 4 years (range, 10 days to 12.7 years) of 47 patients with acute uncomplicated TBAD were retrospectively reviewed. Morphological features (n = 8) were quantified at baseline and each follow-up. Medical records were reviewed for LAEs, which were defined according to current guidelines. To assess the effects of changes of morphological features over time, the linear mixed effects models were combined with Cox proportional hazards regression for the time-to-event outcome using a joint modeling approach. RESULTS LAEs occurred in 21 of 47 patients at a median of 6.6 years (95% confidence interval [CI], 5.1-11.2 years). Among the 8 investigated morphological features, the following 3 features showed strong association with LAEs: increase in partial false lumen thrombosis area (hazard ratio [HR], 1.39; 95% CI, 1.18-1.66 per cm2 increase; P < .001), increase of major aortic diameter (HR, 1.24; 95% CI, 1.13-1.37 per mm increase; P < .001), and increase in the circumferential extent of false lumen (HR, 1.05; 95% CI, 1.01-1.10 per degree increase; P < .001). CONCLUSIONS In medically treated TBAD, increases in aortic diameter, new or increased partial false lumen thrombosis area, and increases of circumferential extent of the false lumen are strongly associated with LAEs.
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Affiliation(s)
- Kai Higashigaito
- Stanford 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University School of Medicine, Stanford, Calif; Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, Calif
| | - Anna M Sailer
- Stanford 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University School of Medicine, Stanford, Calif; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, Calif
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martin J Willemink
- Stanford 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University School of Medicine, Stanford, Calif; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, Calif; Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lewis D Hahn
- Stanford 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University School of Medicine, Stanford, Calif
| | - Trevor J Hastie
- Department of Statistics, Stanford University, Stanford, Calif
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Dominik Fleischmann
- Stanford 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University School of Medicine, Stanford, Calif; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, Calif.
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Abstract
The developmental origin of vascular smooth muscle cells (VSMCs) has been increasingly recognized as a major determinant for regional susceptibility or resistance to vascular diseases. As a human material-based complement to animal models and human primary cultures, patient induced pluripotent stem cell iPSC-derived VSMCs have been leveraged to conduct basic research and develop therapeutic applications in vascular diseases. However, iPSC-VSMCs (induced pluripotent stem cell VSMCs) derived by most existing induction protocols are heterogeneous in developmental origins. In this review, we summarize signaling networks that govern in vivo cell fate decisions and in vitro derivation of distinct VSMC progenitors, as well as key regulators that terminally specify lineage-specific VSMCs. We then highlight the significance of leveraging patient-derived iPSC-VSMCs for vascular disease modeling, drug discovery, and vascular tissue engineering and discuss several obstacles that need to be circumvented to fully unleash the potential of induced pluripotent stem cells for precision vascular medicine.
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Affiliation(s)
- Mengcheng Shen
- Stanford Cardiovascular Institute
- Division of Cardiovascular Medicine, Department of Medicine
| | - Thomas Quertermous
- Stanford Cardiovascular Institute
- Division of Cardiovascular Medicine, Department of Medicine
| | | | - Joseph C. Wu
- Stanford Cardiovascular Institute
- Division of Cardiovascular Medicine, Department of Medicine
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
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Dake MD, Bavaria JE, Singh MJ, Oderich G, Filinger M, Fischbein MP, Matsumura JS, Patel HJ. Management of arch aneurysms with a single-branch thoracic endograft in zone 0. JTCVS Tech 2021; 7:1-6. [PMID: 34318189 PMCID: PMC8311452 DOI: 10.1016/j.xjtc.2021.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background We present preliminary data from a patient cohort undergoing thoracic endovascular aortic repair for Ishimaru zone 0 and 1 using a novel branched arch endograft. Methods This US multicenter early feasibility investigational device exemption clinical trial treated 9 patients with a mean age 72.8 ± 8.0 years (77.8% male). The endograft was designed with a single side branch designed to facilitate aortic coverage proximal to the innominate or left carotid artery while maintaining branch vessel patency. Pathology treated included fusiform (n = 2) or saccular (n = 7) aneurysm, with a maximum aortic diameter of 6.3 ± 0.7 cm. Treatment was into zone 0 in 8 patients, and zone 1 in 1 patient. Results All patients underwent initial successful first-stage supra-aortic trunk revascularization using a variety of techniques, without the occurrence of stroke. For the second thoracic endovascular aortic repair stage, median total treatment length was 20 cm. The primary end point of device delivery and branch vessel patency was achieved in 100% of patients, without 30-day mortality or spinal cord ischemia. Cerebrovascular events were observed in 2 patients through 30 days. No type I or III endoleaks were reported and all side branches were patent at 12-month imaging follow-up. Conclusions Endovascular repair of Ishimaru zone 0 or 1 arch aortic aneurysms can be achieved with a novel branched arch endograft. Future studies will evaluate the mid-term outcomes with this device in other pathologies and further define the occurrence of postoperative neurologic events.
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Affiliation(s)
- Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, Tucson, Ariz
| | - Joseph E Bavaria
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Michael J Singh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | - Mark Filinger
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University Hospitals, Palo Alto, Calif
| | - Jon S Matsumura
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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Wang H, Pargaonkar VS, Hironaka CE, Bajaj SS, Abbot CJ, O'Donnell CT, Miller SL, Honda Y, Rogers IS, Tremmel JA, Fischbein MP, Mitchell RS, Schnittger I, Boyd JH. Off-Pump Minithoracotomy Versus Sternotomy for Left Anterior Descending Myocardial Bridge Unroofing. Ann Thorac Surg 2020; 112:1474-1482. [PMID: 33333083 DOI: 10.1016/j.athoracsur.2020.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/01/2020] [Accepted: 11/30/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Myocardial bridge (MB) of the left anterior descending (LAD) coronary artery occurs in approximately 25% of the population. When medical therapy fails in patients with a symptomatic, hemodynamically significant MB, MB unroofing represents the optimal surgical management. Here, we evaluated minimally invasive MB unroofing in selected patients compared with sternotomy. METHODS MB unroofing was performed in 141 adult patients by sternotomy on-pump (ST-on, n = 40), sternotomy off-pump (ST-off, n = 62), or minithoracotomy off-pump (MT, n = 39). Angina symptoms were assessed preoperatively and 6 months postoperatively using the Seattle Angina Questionnaire. Matching included all MT patients and 31 ST-off patients with similar MB characteristics, no previous cardiac operations or coronary interventions, and no concomitant procedures. RESULTS MT patients tended to have a shorter MB length than ST-on and ST-off patients (2.57 vs 2.93 vs 3.09 cm, P = .166). ST-on patients had a longer hospital stay than ST-off and MT patients (5.0 vs 4.0 vs 3.0 days, P < .001), and more blood transfusions (15.2% vs 0.0% vs 2.6%, P = .002). After matching, MT patients had a shorter hospital stay than ST-off patients (3.0 vs 4.0 days, P = .005). No deaths or major complications occurred in any group. In all groups, MB unroofing yielded significant symptomatic improvement regarding physical limitation, angina stability, angina frequency, treatment satisfaction, and quality of life. CONCLUSIONS We report our single-center experience of off-pump minimally invasive MB unroofing, which may be safely performed in carefully selected patients, yielding dramatic improvements in angina symptoms at 6 months after the operation.
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Affiliation(s)
- Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Vedant S Pargaonkar
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Camille E Hironaka
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Simar S Bajaj
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Chad J Abbot
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | | | - Shari L Miller
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Yasuhiro Honda
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Ian S Rogers
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Jennifer A Tremmel
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - R Scott Mitchell
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Ingela Schnittger
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Jack H Boyd
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.
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Iosef C, Pedroza AJ, Cui JZ, Dalal AR, Arakawa M, Tashima Y, Koyano TK, Burdon G, Churovich SMP, Orrick JO, Pariani M, Fischbein MP. Quantitative proteomics reveal lineage-specific protein profiles in iPSC-derived Marfan syndrome smooth muscle cells. Sci Rep 2020; 10:20392. [PMID: 33230159 PMCID: PMC7683538 DOI: 10.1038/s41598-020-77274-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/09/2020] [Indexed: 12/27/2022] Open
Abstract
Marfan syndrome (MFS) is a connective tissue disorder caused by mutations in the FBN1 gene that produces wide disease phenotypic variability. The lack of ample genotype-phenotype correlation hinders translational study development aimed at improving disease prognosis. In response to this need, an induced pluripotent stem cell (iPSC) disease model has been used to test patient-specific cells by a proteomic approach. This model has the potential to risk stratify patients to make clinical decisions, including timing for surgical treatment. The regional propensity for aneurysm formation in MFS may be related to distinct smooth muscle cell (SMC) embryologic lineages. Thus, peripheral blood mononuclear cell (PBMC)-derived induced pluripotent stem cells (iPSC) were differentiated into lateral mesoderm (LM, aortic root) and neural crest (NC, ascending aorta/transverse arch) SMC lineages to model MFS aortic pathology. Isobaric Tags for Relative and Absolute Quantitation (iTRAQ) proteomic analysis by tandem mass spectrometry was applied to profile LM and NC iPSC SMCs from four MFS patients and two healthy controls. Analysis revealed 45 proteins with lineage-dependent expression in MFS patients, many of which were specific to diseased samples. Single protein-level data from both iPSC SMCs and primary MFS aortic root aneurysm tissue confirmed elevated integrin αV and reduced MRC2 in clinical disease specimens, validating the iPSC iTRAQ findings. Functionally, iPSC SMCs exhibited defective adhesion to a variety of extracellular matrix proteins, especially laminin-1 and fibronectin, suggesting altered cytoskeleton dynamics. This study defines the aortic embryologic origin-specific proteome in a validated iPSC SMC model to identify novel protein markers associated with MFS aneurysm phenotype. Translating iPSC findings into clinical aortic aneurysm tissue samples highlights the potential for iPSC-based methods to model MFS disease for mechanistic studies and therapeutic discovery in vitro.
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Affiliation(s)
- Cristiana Iosef
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Jason Z Cui
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Mamoru Arakawa
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Yasushi Tashima
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Tiffany K Koyano
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Grayson Burdon
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Samantha M P Churovich
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Joshua O Orrick
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Mitchel Pariani
- Department of Pediatrics-Genetics, Stanford University, Stanford, CA, USA
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA.
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Tashima Y, He H, Cui JZ, Pedroza AJ, Nakamura K, Yokoyama N, Iosef C, Burdon G, Koyano T, Yamaguchi A, Fischbein MP. Androgens Accentuate TGF-β Dependent Erk/Smad Activation During Thoracic Aortic Aneurysm Formation in Marfan Syndrome Male Mice. J Am Heart Assoc 2020; 9:e015773. [PMID: 33059492 PMCID: PMC7763370 DOI: 10.1161/jaha.119.015773] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 07/29/2020] [Indexed: 12/18/2022]
Abstract
Background Male patients with Marfan syndrome have a higher risk of aortic events and root dilatation compared with females. The role androgens play during Marfan syndrome aneurysm development in males remains unknown. We hypothesized that androgens potentiate transforming growth factor beta induced Erk (extracellular-signal-regulated kinase)/Smad activation, contributing to aneurysm progression in males. Methods and Results Aortic diameters in Fbn1C1039G/+ and littermate wild-type controls were measured at ages 6, 8, 12, and 16 weeks. Fbn1C1039G/+ males were treated with (1) flutamide (androgen receptor blocker) or (2) vehicle control from age 6 to 16 weeks and then euthanized. p-Erk1/2, p-Smad2, and matrix metalloproteinase (MMP) activity were measured in ascending/aortic root and descending aorta specimens. Fbn1C1039G/+ male and female ascending/aortic root-derived smooth muscle cells were utilized in vitro to measure Erk/Smad activation and MMP-2 activity following dihydrotestosterone, flutamide or transforming growth factor beta 1 treatment. Fbn1C1039G/+ males have increased aneurysm growth. p-Erk1/2 and p-Smad2 were elevated in ascending/aortic root specimens at age 16 weeks. Corresponding with enhanced Erk/Smad signaling, MMP-2 activity was higher in Fbn1C1039G/+ males. In vitro smooth muscle cell studies revealed that dihydrotestosterone potentiates transforming growth factor beta-induced Erk/Smad activation and MMP-2 activity, which is reversed by flutamide treatment. Finally, in vivo flutamide treatment reduced aneurysm growth via p-Erk1/2 and p-Smad2 reduction in Fbn1C1039G/+ males. Conclusions Fbn1C1039G/+ males have enhanced aneurysm growth compared with females associated with enhanced p-Erk1/2 and p-Smad2 activation. Mechanistically, in vitro smooth muscle cell studies suggested that dihydrotestosterone potentiates transforming growth factor beta induced Erk/Smad activation. As biological proof of concept, flutamide treatment attenuated aneurysm growth and p-Erk1/2 and p-Smad2 signaling in Fbn1C1039G/+ males.
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Affiliation(s)
- Yasushi Tashima
- Department of Cardiothoracic SurgeryStanford UniversityStanfordCA
- Department of Cardiovascular SurgeryJichi Medical UniversitySaitama Medical CenterSaitamaJapan
| | - Hao He
- Department of Cardiothoracic SurgeryStanford UniversityStanfordCA
| | - Jason Z. Cui
- Department of Cardiothoracic SurgeryStanford UniversityStanfordCA
| | | | - Ken Nakamura
- Department of Cardiothoracic SurgeryStanford UniversityStanfordCA
| | - Nobu Yokoyama
- Department of Cardiothoracic SurgeryStanford UniversityStanfordCA
| | - Cristiana Iosef
- Department of Cardiothoracic SurgeryStanford UniversityStanfordCA
| | - Grayson Burdon
- Department of Cardiothoracic SurgeryStanford UniversityStanfordCA
| | - Tiffany Koyano
- Department of Cardiothoracic SurgeryStanford UniversityStanfordCA
| | - Atsushi Yamaguchi
- Department of Cardiovascular SurgeryJichi Medical UniversitySaitama Medical CenterSaitamaJapan
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Pedroza AJ, Tashima Y, Shad R, Cheng P, Wirka R, Churovich S, Nakamura K, Yokoyama N, Cui JZ, Iosef C, Hiesinger W, Quertermous T, Fischbein MP. Single-Cell Transcriptomic Profiling of Vascular Smooth Muscle Cell Phenotype Modulation in Marfan Syndrome Aortic Aneurysm. Arterioscler Thromb Vasc Biol 2020; 40:2195-2211. [PMID: 32698686 PMCID: PMC7484233 DOI: 10.1161/atvbaha.120.314670] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To delineate temporal and spatial dynamics of vascular smooth muscle cell (SMC) transcriptomic changes during aortic aneurysm development in Marfan syndrome (MFS). Approach and Results: We performed single-cell RNA sequencing to study aortic root/ascending aneurysm tissue from Fbn1C1041G/+ (MFS) mice and healthy controls, identifying all aortic cell types. A distinct cluster of transcriptomically modulated SMCs (modSMCs) was identified in adult Fbn1C1041G/+ mouse aortic aneurysm tissue only. Comparison with atherosclerotic aortic data (ApoE-/- mice) revealed similar patterns of SMC modulation but identified an MFS-specific gene signature, including plasminogen activator inhibitor-1 (Serpine1) and Kruppel-like factor 4 (Klf4). We identified 481 differentially expressed genes between modSMC and SMC subsets; functional annotation highlighted extracellular matrix modulation, collagen synthesis, adhesion, and proliferation. Pseudotime trajectory analysis of Fbn1C1041G/+ SMC/modSMC transcriptomes identified genes activated differentially throughout the course of phenotype modulation. While modSMCs were not present in young Fbn1C1041G/+ mouse aortas despite small aortic aneurysm, multiple early modSMCs marker genes were enriched, suggesting activation of phenotype modulation. modSMCs were not found in nondilated adult Fbn1C1041G/+ descending thoracic aortas. Single-cell RNA sequencing from human MFS aortic root aneurysm tissue confirmed analogous SMC modulation in clinical disease. Enhanced expression of TGF-β (transforming growth factor beta)-responsive genes correlated with SMC modulation in mouse and human data sets. CONCLUSIONS Dynamic SMC phenotype modulation promotes extracellular matrix substrate modulation and aortic aneurysm progression in MFS. We characterize the disease-specific signature of modSMCs and provide temporal, transcriptomic context to the current understanding of the role TGF-β plays in MFS aortopathy. Collectively, single-cell RNA sequencing implicates TGF-β signaling and Klf4 overexpression as potential upstream drivers of SMC modulation.
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Affiliation(s)
- Albert J. Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Yasushi Tashima
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Rohan Shad
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Paul Cheng
- Division of Cardiovascular Medicine, Stanford University School of Medicine. Stanford CA, USA
| | - Robert Wirka
- Division of Cardiovascular Medicine, Stanford University School of Medicine. Stanford CA, USA
| | - Samantha Churovich
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Jason Z. Cui
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Cristiana Iosef
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
| | - Thomas Quertermous
- Division of Cardiovascular Medicine, Stanford University School of Medicine. Stanford CA, USA
| | - Michael P. Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine. Stanford CA, USA
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Pong T, Cyr K, Niesen J, Aparicio-Valenzuela J, Carlton C, Fischbein MP, Woo YJ, Boyd JH, Lee AM. Screening and Prophylactic Amiodarone Reduces Post-Operative Atrial Fibrillation in At-Risk Patients. J Am Coll Cardiol 2020; 75:1361-1363. [PMID: 32192666 DOI: 10.1016/j.jacc.2020.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/12/2019] [Accepted: 01/07/2020] [Indexed: 11/17/2022]
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Bäumler K, Vedula V, Sailer AM, Seo J, Chiu P, Mistelbauer G, Chan FP, Fischbein MP, Marsden AL, Fleischmann D. Fluid-structure interaction simulations of patient-specific aortic dissection. Biomech Model Mechanobiol 2020; 19:1607-1628. [PMID: 31993829 DOI: 10.1007/s10237-020-01294-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/14/2020] [Indexed: 12/01/2022]
Abstract
Credible computational fluid dynamic (CFD) simulations of aortic dissection are challenging, because the defining parallel flow channels-the true and the false lumen-are separated from each other by a more or less mobile dissection membrane, which is made up of a delaminated portion of the elastic aortic wall. We present a comprehensive numerical framework for CFD simulations of aortic dissection, which captures the complex interplay between physiologic deformation, flow, pressures, and time-averaged wall shear stress (TAWSS) in a patient-specific model. Our numerical model includes (1) two-way fluid-structure interaction (FSI) to describe the dynamic deformation of the vessel wall and dissection flap; (2) prestress and (3) external tissue support of the structural domain to avoid unphysiologic dilation of the aortic wall and stretching of the dissection flap; (4) tethering of the aorta by intercostal and lumbar arteries to restrict translatory motion of the aorta; and a (5) independently defined elastic modulus for the dissection flap and the outer vessel wall to account for their different material properties. The patient-specific aortic geometry is derived from computed tomography angiography (CTA). Three-dimensional phase contrast magnetic resonance imaging (4D flow MRI) and the patient's blood pressure are used to inform physiologically realistic, patient-specific boundary conditions. Our simulations closely capture the cyclical deformation of the dissection membrane, with flow simulations in good agreement with 4D flow MRI. We demonstrate that decreasing flap stiffness from [Formula: see text] to [Formula: see text] kPa (a) increases the displacement of the dissection flap from 1.4 to 13.4 mm, (b) decreases the surface area of TAWSS by a factor of 2.3, (c) decreases the mean pressure difference between true lumen and false lumen by a factor of 0.63, and (d) decreases the true lumen flow rate by up to 20% in the abdominal aorta. We conclude that the mobility of the dissection flap substantially influences local hemodynamics and therefore needs to be accounted for in patient-specific simulations of aortic dissection. Further research to accurately measure flap stiffness and its local variations could help advance future CFD applications.
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Affiliation(s)
- Kathrin Bäumler
- 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University, Stanford, CA, 94305, USA.
| | - Vijay Vedula
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, 94305, USA
| | - Anna M Sailer
- 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University, Stanford, CA, 94305, USA
| | - Jongmin Seo
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, 94305, USA
| | - Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, 94305, USA
| | - Gabriel Mistelbauer
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Frandics P Chan
- 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University, Stanford, CA, 94305, USA
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, 94305, USA
| | - Alison L Marsden
- Department of Bioengineering, Stanford University, Stanford, CA, 94305, USA
| | - Dominik Fleischmann
- 3D and Quantitative Imaging Laboratory, Department of Radiology, Stanford University, Stanford, CA, 94305, USA
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Pedroza AJ, Koyano T, Trojan J, Rubin A, Palmon I, Jaatinen K, Burdon G, Chang P, Tashima Y, Cui JZ, Berry G, Iosef C, Fischbein MP. Divergent effects of canonical and non-canonical TGF-β signalling on mixed contractile-synthetic smooth muscle cell phenotype in human Marfan syndrome aortic root aneurysms. J Cell Mol Med 2019; 24:2369-2383. [PMID: 31886938 PMCID: PMC7011150 DOI: 10.1111/jcmm.14921] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/04/2019] [Accepted: 12/10/2019] [Indexed: 01/27/2023] Open
Abstract
Aortic root aneurysm formation is a cardinal feature of Marfan syndrome (MFS) and likely TGF‐β driven via Smad (canonical) and ERK (non‐canonical) signalling. The current study assesses human MFS vascular smooth muscle cell (SMC) phenotype, focusing on individual contributions by Smad and ERK, with Notch3 signalling identified as a novel compensatory mechanism against TGF‐β‐driven pathology. Although significant ERK activation and mixed contractile gene expression patterns were observed by traditional analysis, this did not directly correlate with the anatomic site of the aneurysm. Smooth muscle cell phenotypic changes were TGF‐β‐dependent and opposed by ERK in vitro, implicating the canonical Smad pathway. Bulk SMC RNA sequencing after ERK inhibition showed that ERK modulates cell proliferation, apoptosis, inflammation, and Notch signalling via Notch3 in MFS. Reversing Notch3 overexpression with siRNA demonstrated that Notch3 promotes several protective remodelling pathways, including increased SMC proliferation, decreased apoptosis and reduced matrix metalloproteinase activity, in vitro. In conclusion, in human MFS aortic SMCs: (a) ERK activation is enhanced but not specific to the site of aneurysm formation; (b) ERK opposes TGF‐β‐dependent negative effects on SMC phenotype; (c) multiple distinct SMC subtypes contribute to a ‘mixed’ contractile‐synthetic phenotype in MFS aortic aneurysm; and (d) ERK drives Notch3 overexpression, a potential pathway for tissue remodelling in response to aneurysm formation.
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Affiliation(s)
- Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Tiffany Koyano
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Jeffrey Trojan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Adam Rubin
- Stanford University School of Medicine, Stanford, California
| | - Itai Palmon
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Kevin Jaatinen
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Grayson Burdon
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Paul Chang
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Yasushi Tashima
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason Z Cui
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Gerry Berry
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Cristiana Iosef
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
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Sato T, Arakawa M, Tashima Y, Tsuboi E, Burdon G, Trojan J, Koyano T, Youn YN, Penov K, Pedroza AJ, Shabazzi M, Palmon I, Nguyen MN, Connolly AJ, Yamaguchi A, Fischbein MP. Statins Reduce Thoracic Aortic Aneurysm Growth in Marfan Syndrome Mice via Inhibition of the Ras-Induced ERK (Extracellular Signal-Regulated Kinase) Signaling Pathway. J Am Heart Assoc 2019; 7:e008543. [PMID: 30571378 PMCID: PMC6404178 DOI: 10.1161/jaha.118.008543] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Statins reduce aneurysm growth in mouse models of Marfan syndrome, although the mechanism is unknown. In addition to reducing cholesterol, statins block farnesylation and geranylgeranylation, which participate in membrane‐bound G‐protein signaling, including Ras. We dissected the prenylation pathway to define the effect of statins on aneurysm reduction. Methods and Results Fbn1C1039G/+ mice were treated with (1) pravastatin (HMG‐CoA [3‐hydroxy‐3‐methylglutaryl coenzyme A] reductase inhibitor), (2) manumycin A (MA; FPT inhibitor), (3) perillyl alcohol (GGPT1 and ‐2 inhibitor), or (4) vehicle control from age 4 to 8 weeks and euthanized at 12 weeks. Histological characterization was performed. Protein analysis was completed on aortic specimens to measure ERK (extracellular signal‐regulated kinase) signaling. In vitro Fbn1C1039G/+ aortic smooth muscle cells were utilized to measure Ras‐dependent ERK signaling and MMP (matrix metalloproteinase) activity. Pravastatin and MA significantly reduced aneurysm growth compared with vehicle control (n=8 per group). In contrast, PA did not significantly decrease aneurysm size. Histology illustrated reduced elastin breakdown in MA‐treated mice compared with vehicle control (n=5 per group). Although elevated in control Marfan mice, both phosphorylated c‐Raf and phosphorylated ERK1/2 were significantly reduced in MA‐treated mice (4–5 per group). In vitro smooth muscle cell studies confirmed phosphorylated cRaf and phosphorylated ERK1/2 signaling was elevated in Fbn1C1039G/+ smooth muscle cells (n=5 per group). Fbn1C1039G/+ smooth muscle cell Ras‐dependent ERK signaling and MMP activity were reduced following MA treatment (n=5 per group). Corroborating in vitro findings, MMP activity was also decreased in pravastatin‐treated mice. Conclusions Aneurysm reduction in Fbn1C1039G/+ mice following pravastatin and MA treatment was associated with a decrease in Ras‐dependent ERK signaling. MMP activity can be reduced by diminishing Ras signaling.
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Affiliation(s)
- Tetsuya Sato
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA.,2 Department of Cardiovascular Surgery Jichi Medical University Saitama Medical Center Saitama Japan
| | - Mamoru Arakawa
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA.,2 Department of Cardiovascular Surgery Jichi Medical University Saitama Medical Center Saitama Japan
| | - Yasushi Tashima
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA.,2 Department of Cardiovascular Surgery Jichi Medical University Saitama Medical Center Saitama Japan
| | - Eitoshi Tsuboi
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA.,4 Department of Cardiovascular Surgery Iwaki Kyoritsu General Hospital Fukushima Japan
| | - Grayson Burdon
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA
| | - Jeffrey Trojan
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA
| | - Tiffany Koyano
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA
| | - Young-Nam Youn
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA.,3 Division of Cardiovascular Surgery Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Kiril Penov
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA.,5 Department of Cardiac Surgery Heart Center Leipzig University of Leipzig Germany
| | - Albert J Pedroza
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA
| | - Mohammad Shabazzi
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA
| | - Itai Palmon
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA
| | - Marie Noel Nguyen
- 1 Department of Cardiothoracic Surgery Stanford University Stanford CA
| | | | - Atsushi Yamaguchi
- 2 Department of Cardiovascular Surgery Jichi Medical University Saitama Medical Center Saitama Japan
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48
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Goldstone AB, Chiu P, Baiocchi M, Lingala B, Lee J, Rigdon J, Fischbein MP, Woo YJ. Interfacility Transfer of Medicare Beneficiaries With Acute Type A Aortic Dissection and Regionalization of Care in the United States. Circulation 2019; 140:1239-1250. [PMID: 31589488 PMCID: PMC9856243 DOI: 10.1161/circulationaha.118.038867] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The feasibility and effectiveness of delaying surgery to transfer patients with acute type A aortic dissection-a catastrophic disease that requires prompt intervention-to higher-volume aortic surgery hospitals is unknown. We investigated the hypothesis that regionalizing care at high-volume hospitals for acute type A aortic dissections will lower mortality. We further decomposed this hypothesis into subparts, investigating the isolated effect of transfer and the isolated effect of receiving care at a high-volume versus a low-volume facility. METHODS We compared the operative mortality and long-term survival between 16 886 Medicare beneficiaries diagnosed with an acute type A aortic dissection between 1999 and 2014 who (1) were transferred versus not transferred, (2) underwent surgery at high-volume versus low-volume hospitals, and (3) were rerouted versus not rerouted to a high-volume hospital for treatment. We used a preference-based instrumental variable design to address unmeasured confounding and matching to separate the effect of transfer from volume. RESULTS Between 1999 and 2014, 40.5% of patients with an acute type A aortic dissection were transferred, and 51.9% received surgery at a high-volume hospital. Interfacility transfer was not associated with a change in operative mortality (risk difference, -0.69%; 95% CI, -2.7% to 1.35%) or long-term mortality. Despite delaying surgery, a regionalization policy that transfers patients to high-volume hospitals was associated with a 7.2% (95% CI, 4.1%-10.3%) absolute risk reduction in operative mortality; this association persisted in the long term (hazard ratio, 0.81; 95% CI, 0.75-0.87). The median distance needed to reroute each patient to a high-volume hospital was 50.1 miles (interquartile range, 12.4-105.4 miles). CONCLUSIONS Operative and long-term mortality were substantially reduced in patients with acute type A aortic dissection who were rerouted to high-volume hospitals. Policy makers should evaluate the feasibility and benefits of regionalizing the surgical treatment of acute type A aortic dissection in the United States.
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Affiliation(s)
- Andrew B. Goldstone
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California,Department of Health Research and Policy, Stanford University, Stanford, California
| | - Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California,Department of Health Research and Policy, Stanford University, Stanford, California
| | - Michael Baiocchi
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California
| | - Bharathi Lingala
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Justin Lee
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California
| | - Joseph Rigdon
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California
| | | | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
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49
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Chin AS, Willemink MJ, Kino A, Hinostroza V, Sailer AM, Fischbein MP, Mitchell RS, Berry GJ, Miller DC, Fleischmann D. Acute Limited Intimal Tears of the Thoracic Aorta. J Am Coll Cardiol 2019; 71:2773-2785. [PMID: 29903350 DOI: 10.1016/j.jacc.2018.03.531] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/04/2018] [Accepted: 03/21/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Limited intimal tears (LITs) of the aorta (Class 3 dissection variant) are the least common form of aortic pathology in patients presenting with acute aortic syndrome (AAS). LITs are difficult to detect on imaging and may be underappreciated. OBJECTIVES This study sought to describe the frequency, pathology, treatment, and outcome of LITs compared with other AAS, and to demonstrate that LITs can be detected pre-operatively by contemporary imaging. METHODS The authors retrospectively reviewed 497 patients admitted for 513 AAS events at a single academic aortic center between 2003 and 2012. AAS were classified into classic dissection (AD), intramural hematoma, LIT, penetrating atherosclerotic ulcer, and rupturing thoracic aortic aneurysm. The prevalence, pertinent risk factors, and detailed imaging findings with surgical and pathological correlation of LITs are described. Management, early outcomes, and late mortality are reported. RESULTS Among 497 patients with AAS, the authors identified 24 LITs (4.8% of AAS) in 16 men and 8 women (17 type A, 7 type B). Patients with LITs were older than those with AD, and type A LITs had similarly dilated ascending aortas as type A AD. Three patients presented with rupture. Eleven patients underwent urgent surgical aortic replacement, and 2 patients underwent endovascular repair. Medial degeneration was present in all surgical specimens. In-hospital mortality was 4% (1 of 24), and in total, 5 patients with LIT died subsequently at 1.5 years (interquartile range [IQR]: 0.3 to 2.5 years). Computed tomography imaging detected all but 1 LIT, best visualized on volume-rendered images. CONCLUSIONS LITs are rare acute aortic lesions within the dissection spectrum, with similar presentation, complications, and outcomes compared with AD and intramural hematoma. Awareness of this lesion allows pre-operative diagnosis using high-quality computed tomography angiography.
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Affiliation(s)
- Anne S Chin
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Aya Kino
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Virginia Hinostroza
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Anna M Sailer
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - R Scott Mitchell
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Gerald J Berry
- Department of Pathology, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California.
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50
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Emrich F, Penov K, Arakawa M, Dhablania N, Burdon G, Pedroza AJ, Koyano TK, Kim YM, Raaz U, Connolly AJ, Iosef C, Fischbein MP. Anatomically specific reactive oxygen species production participates in Marfan syndrome aneurysm formation. J Cell Mol Med 2019; 23:7000-7009. [PMID: 31402541 PMCID: PMC6787454 DOI: 10.1111/jcmm.14587] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 12/20/2022] Open
Abstract
Marfan syndrome (MFS) is a connective tissue disorder that results in aortic root aneurysm formation. Reactive oxygen species (ROS) seem to play a role in aortic wall remodelling in MFS, although the mechanism remains unknown. MFS Fbn1C1039G/+ mouse root/ascending (AS) and descending (DES) aortic samples were examined using DHE staining, lucigenin‐enhanced chemiluminescence (LGCL), Verhoeff's elastin‐Van Gieson staining (elastin breakdown) and in situ zymography for protease activity. Fbn1C1039G/+ AS‐ or DES‐derived smooth muscle cells (SMC) were treated with anti‐TGF‐β antibody, angiotensin II (AngII), anti‐TGF‐β antibody + AngII, or isotype control. ROS were detected during early aneurysm formation in the Fbn1C1039G/+ AS aorta, but absent in normal‐sized DES aorta. Fbn1C1039G/+ mice treated with the unspecific NADPH oxidase inhibitor, apocynin reduced AS aneurysm formation, with attenuated elastin fragmentation. In situ zymography revealed apocynin treatment decreased protease activity. In vitro SMC studies showed Fbn1C1039G/+‐derived AS SMC had increased NADPH activity compared to DES‐derived SMC. AS SMC NADPH activity increased with AngII treatment and appeared TGF‐β dependent. In conclusion, ROS play a role in MFS aneurysm development and correspond anatomically with aneurysmal aortic segments. ROS inhibition via apocynin treatment attenuates MFS aneurysm progression. AngII enhances ROS production in MFS AS SMCs and is likely TGF‐β dependent.
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Affiliation(s)
- Fabian Emrich
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.,Department of Cardiothoracic Surgery, Leipzig University Heart Center, Leipzig, Germany
| | - Kiril Penov
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.,Department of Cardiothoracic Surgery, Leipzig University Heart Center, Leipzig, Germany
| | - Mamoru Arakawa
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.,Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
| | - Nathan Dhablania
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Grayson Burdon
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Tiffany K Koyano
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Young M Kim
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Uwe Raaz
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | | | - Cristiana Iosef
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
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