Early Mortality in Type A Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection

Importance

Early data revealed a mortality rate of 1% to 2% per hour for type A acute aortic dissection (TAAAD) during the initial 48 hours. Despite advances in diagnostic testing and treatment, this mortality rate continues to be cited because of a lack of contemporary data characterizing early mortality and the effect of timely surgery.

Objective

To examine early mortality rates for patients with TAAAD in the contemporary era.

Design, Setting, and Participants

This cohort study examined data for patients with TAAAD in the International Registry of Acute Aortic Dissection between 1996 and 2018. Patients were grouped according to the mode of their intended treatment, surgical or medical.

Exposure

Surgical treatment.

Main Outcomes and Measures

Mortality was assessed in the initial 48 hours after hospital arrival using Kaplan-Meier curves. In-hospital complications were also evaluated.

Results

A total of 5611 patients with TAAAD were identified based on intended treatment: 5131 (91.4%) in the surgical group (3442 [67.1%] male; mean [SD] age, 60.4 [14.1] years) and 480 (8.6%) in the medical group (480 [52.5%] male; mean [SD] age, 70.9 [14.7] years). Reasons for medical management included advanced age (n = 141), comorbidities (n = 281), and patient preference (n = 81). Over the first 48 hours, the mortality for all patients in the study was 5.8%. Among patients who were medically managed, mortality was 0.5% per hour (23.7% at 48 hours). For those whose intended treatment was surgical, 48-hour mortality was 4.4%. In the surgical group, 51 patients (1%) died before the operation.

Conclusions and Relevance

In this study, the overall mortality rate for TAAAD was 5.8% at 48 hours. For patients in the medical group, TAAAD had a mortality rate of 0.5% per hour (23.7% at 48 hours). However, among those in the surgical group, 48-hour mortality decreased to 4.4%.

Carnival: A Graph-Based Data Integration and Query Tool to Support Patient Cohort Generation for Clinical Research

Clinical research studies often leverage various heterogeneous data sources including patient electronic health record, online survey, and genomic data. We introduce a graph-based, data integration and query tool called Carnival. We demonstrate its powerful ability to unify data from these disparate data sources to create datasets for two studies: prevalence and incidence case/control matches for coronary artery disease and controls for Marfan syndrome. We conclude with future directions for Carnival development.

Lack of Growth of Small (≤2 mm Feeding Artery) Untreated Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia

PURPOSE

To assess pulmonary arteriovenous malformation (PAVM) growth among patients with untreated PAVMs using imaging from long-term follow-up per hereditary hemorrhagic telangiectasia international guidelines.

MATERIALS AND METHODS

Analysis included 88 untreated PAVMs from 21 patients (6 male;15 female; mean age at presentation 47 y; range, 12-68 y). Two CT studies with the longest interval between were evaluated (mean 8.4 y; median 8.8 y; range, 3.1-14.1 y). Measurement of feeding artery diameter and anteroposterior (AP) and mediolateral (ML) sac dimensions for each PAVM was performed separately by 2 radiologists blinded to patient and CT order. Statistical analysis was performed to determine change in size between earliest and follow-up imaging.

RESULTS

Mean feeding artery diameter, AP sac dimension, and ML sac dimension were 1.4 mm (range, 0.8-3.7 mm), 4.3 mm (range, 2.1-11.1 mm), and 4.1 mm (range, 1.8-9.2 mm) on earliest imaging and 1.4 mm (range, 0.9-2.6 mm), 4.5 mm (range, 2.2-12.2 mm), and 4.3 mm (range, 2.0-9.6 mm) on follow-up. Model-based mean analysis showed no statistically significant change in dimension of any variable between earliest and follow-up imaging. Secondary analysis including age also found no statistically significant difference (feeding diameter, P = .09; AP sac dimension, P = .9; ML sac dimension, P = .1). Analysis including time between measurements found no significant relationship between change in variables and time (feeding artery diameter, P = .4; AP sac dimension, P = .3; ML sac dimension, P = .06).

CONCLUSIONS

Untreated PAVMs grew slowly, if at all, in a near-decade span, and any demonstrated growth was minimal. These findings challenge the current recommendation of 3- to 5-year CT follow-up.

Fragile X Associated Primary Ovarian Insufficiency (FXPOI): Case Report and Literature Review

Abnormalities in the X-linked FMR1 gene are associated with a constellation of disorders, which have broad and profound implications for the person first diagnosed, and extended family members of all ages. The rare and pleiotropic nature of the associated disorders, both common and not, place great burdens on (1) the affected families, (2) their care providers and clinicians, and (3) investigators striving to conduct research on the conditions. Fragile X syndrome, occurring more severely in males, is the leading genetic cause of intellectual disability. Fragile X associated tremor and ataxia syndrome (FXTAS) is a neurodegenerative disorder seen more often in older men. Fragile X associated primary ovarian insufficiency (FXPOI) is a chronic disorder characterized by oligo/amenorrhea and hypergonadotropic hypogonadism before age 40 years. There may be significant morbidity due to: (1) depression and anxiety related to the loss of reproductive hormones and infertility; (2) reduced bone mineral density; and (3) increased risk of cardiovascular disease related to estrogen deficiency. Here we report the case of a young woman who never established regular menses and yet experienced a 5-year diagnostic odyssey before establishing a diagnosis of FXPOI despite a known family history of fragile X syndrome and early menopause. Also, despite having clearly documented FXPOI the woman conceived spontaneously and delivered two healthy children. We review the pathophysiology and management of FXPOI. As a rare disease, the diagnosis of FXPOI presents special challenges. Connecting patients and community health providers with investigators who have the requisite knowledge and expertise about the FMR1 gene and FXPOI would facilitate both patient care and research. There is a need for an international natural history study on FXPOI. The effort should be coordinated by a global virtual center, which takes full advantage of mobile device communication systems.

Clinical history and management recommendations of the smooth muscle dysfunction syndrome due to ACTA2 arginine 179 alterations

PURPOSE

Smooth muscle dysfunction syndrome (SMDS) due to heterozygous ACTA2 arginine 179 alterations is characterized by patent ductus arteriosus, vasculopathy (aneurysm and occlusive lesions), pulmonary arterial hypertension, and other complications in smooth muscle-dependent organs. We sought to define the clinical history of SMDS to develop recommendations for evaluation and management.

METHODS

Medical records of 33 patients with SMDS (median age 12 years) were abstracted and analyzed.

RESULTS

All patients had congenital mydriasis and related pupillary abnormalities at birth and presented in infancy with a patent ductus arteriosus or aortopulmonary window. Patients had cerebrovascular disease characterized by small vessel disease (hyperintense periventricular white matter lesions; 95%), intracranial artery stenosis (77%), ischemic strokes (27%), and seizures (18%). Twelve (36%) patients had thoracic aortic aneurysm repair or dissection at median age of 14 years and aortic disease was fully penetrant by the age of 25 years. Three (9%) patients had axillary artery aneurysms complicated by thromboembolic episodes. Nine patients died between the ages of 0.5 and 32 years due to aortic, pulmonary, or stroke complications, or unknown causes.

CONCLUSION

Based on these data, recommendations are provided for the surveillance and management of SMDS to help prevent early-onset life-threatening complications.

Managing cell and human identity

Will powerful new technologies affect our perception of self-identity?

International Registry of Patients Carrying TGFBR1 or TGFBR2 Mutations: Results of the MAC (Montalcino Aortic Consortium)

BACKGROUND

The natural history of aortic diseases in patients with TGFBR1 or TGFBR2 mutations reported by different investigators has varied greatly. In particular, the current recommendations for the timing of surgical repair of the aortic root aneurysms may be overly aggressive.

METHODS AND RESULTS

The Montalcino Aortic Consortium, which includes 15 centers worldwide that specialize in heritable thoracic aortic diseases, was used to gather data on 441 patients from 228 families, with 176 cases harboring a mutation in TGBR1 and 265 in TGFBR2. Patients harboring a TGFBR1 mutation have similar survival rates (80% survival at 60 years), aortic risk (23% aortic dissection and 18% preventive aortic surgery), and prevalence of extra-aortic features (29% hypertelorism, 53% cervical arterial tortuosity, and 27% wide scars) when compared with patients harboring a TGFBR2 mutation. However, TGFBR1 males had a greater aortic risk than females, whereas TGFBR2 males and females had a similar aortic risk. Additionally, aortic root diameter prior to or at the time of type A aortic dissection tended to be smaller in patients carrying a TGFBR2 mutation and was ≤45 mm in 6 women with TGFBR2 mutations, presenting with marked systemic features and low body surface area. Aortic dissection was observed in 1.6% of pregnancies.

CONCLUSIONS

Patients with TGFBR1 or TGFBR2 mutations show the same prevalence of systemic features and the same global survival. Preventive aortic surgery at a diameter of 45 mm, lowered toward 40 in females with low body surface area, TGFBR2 mutation, and severe extra-aortic features may be considered.

Recurrent Aortic Dissection

Background:

Improved medical care after initial aortic dissection (AD) has led to increased survivorship and a population of individuals at risk for further cardiovascular events, including recurrent AD. Reports describing recurrent ADs have been restricted to small numbers of patients from single institutions. We used the IRAD (International Registry of Acute Aortic Dissection) database to examine the clinical profiles and outcomes of patients with recurrent AD.

Methods:

We identified 204 patients enrolled in IRAD with recurrent AD. For the primary analysis, patient characteristics, interventions, and outcomes were analyzed and compared with 3624 patients with initial AD. Iterative logistic modeling was performed to investigate variables associated with recurrent AD. Cox regression analyses were used to determine variables associated with 5-year survival. A subset of recurrent AD patients was analyzed for anatomic and demographic details of initial and recurrent ADs.

Results:

Patients with recurrent AD were more likely to have Marfan syndrome (21.5% versus 3.1%; P <0.001) but not bicuspid aortic valve (3.6% versus 3.2%; P =0.77). Descending aortic dimensions were greater in patients with recurrent AD than in patients with initial AD independently of sentinel dissection type (type A: 4.3 cm [3.5–5.6 cm] versus 3.3 cm [2.9–3.7 cm], P <0.001; type B: 5.0 cm [3.9–6.0 cm] versus 4.0 cm [3.5–4.8 cm], P <0.001), and this observation was accentuated among patients with Marfan syndrome. In multivariate analysis, the diagnosis of Marfan syndrome independently predicted recurrent AD (hazard ratio, 8.6; 95% confidence interval, 5.8–12.8; P <0.001). Patients with recurrent AD who presented with proximal followed by distal AD were younger than patients who experienced distal followed by proximal dissection AD (42.1±16.1 versus 54.3±14.8 years; P =0.004).

Conclusions:

Among those suffering acute aortic dissection, 5% have a history of a prior aortic dissection. Recurrent AD is strongly associated with Marfan syndrome.

The IGNITE network: a model for genomic medicine implementation and research

BACKGROUND

Patients, clinicians, researchers and payers are seeking to understand the value of using genomic information (as reflected by genotyping, sequencing, family history or other data) to inform clinical decision-making. However, challenges exist to widespread clinical implementation of genomic medicine, a prerequisite for developing evidence of its real-world utility.

METHODS

To address these challenges, the National Institutes of Health-funded IGNITE (Implementing GeNomics In pracTicE; www.ignite-genomics.org ) Network, comprised of six projects and a coordinating center, was established in 2013 to support the development, investigation and dissemination of genomic medicine practice models that seamlessly integrate genomic data into the electronic health record and that deploy tools for point of care decision making. IGNITE site projects are aligned in their purpose of testing these models, but individual projects vary in scope and design, including exploring genetic markers for disease risk prediction and prevention, developing tools for using family history data, incorporating pharmacogenomic data into clinical care, refining disease diagnosis using sequence-based mutation discovery, and creating novel educational approaches.

RESULTS

This paper describes the IGNITE Network and member projects, including network structure, collaborative initiatives, clinical decision support strategies, methods for return of genomic test results, and educational initiatives for patients and providers. Clinical and outcomes data from individual sites and network-wide projects are anticipated to begin being published over the next few years.

CONCLUSIONS

The IGNITE Network is an innovative series of projects and pilot demonstrations aiming to enhance translation of validated actionable genomic information into clinical settings and develop and use measures of outcome in response to genome-based clinical interventions using a pragmatic framework to provide early data and proofs of concept on the utility of these interventions. Through these efforts and collaboration with other stakeholders, IGNITE is poised to have a significant impact on the acceleration of genomic information into medical practice.

Aortic Disease Presentation and Outcome Associated With ACTA2 Mutations

BACKGROUND

ACTA2 mutations are the major cause of familial thoracic aortic aneurysms and dissections. We sought to characterize these aortic diseases in a large case series of individuals with ACTA2 mutations.

METHODS AND RESULTS

Aortic disease, management, and outcome associated with the first aortic event (aortic dissection or aneurysm repair) were abstracted from the medical records of 277 individuals with 41 various ACTA2 mutations. Aortic events occurred in 48% of these individuals, with the vast majority presenting with thoracic aortic dissections (88%) associated with 25% mortality. Type A dissections were more common than type B dissections (54% versus 21%), but the median age of onset of type B dissections was significantly younger than type A dissections (27 years versus 36 years). Only 12% of aortic events were repair of ascending aortic aneurysms, which variably involved the aortic root, ascending aorta, and aortic arch. Overall, cumulative risk of an aortic event at age 85 years was 0.76 (95% confidence interval, 0.64-0.86). After adjustment for intrafamilial correlation, sex and race, mutations disrupting p.R179 and p.R258 were associated with significantly increased risk for aortic events, whereas p.R185Q and p.R118Q mutations showed significantly lower risk of aortic events compared with other mutations.

CONCLUSIONS

ACTA2 mutations are associated with high risk of presentation with an acute aortic dissection. The lifetime risk for an aortic event is only 76%, suggesting that additional environmental or genetic factors play a role in expression of aortic disease in individuals with ACTA2 mutations.

The translational potential of research on the ethical, legal, and social implications of genomics

Federally funded research on the ethical, legal, and social implications (ELSI) of genomics includes a programmatic charge to consider policy-relevant questions and to communicate findings in venues that help inform the policy-making process. In addressing this goal, investigators must consider the range of policies that are relevant to human genetics; how foundational research in bioethics, law, and the social sciences might inform those policies; and the potential professional issues that this translational imperative raises for ELSI investigators. We review these questions in light of experiences from a consortium of federally funded Centers of Excellence in ELSI Research, and offer a set of policy recommendations for program design and evaluation of ELSI research. We conclude that it would be a mistake to require that ELSI research programs demonstrate a direct impact on science or health policy; however, ELSI researchers can take steps to increase the relevance of their work to policy makers. Similarly, funders of ELSI research who are concerned with facilitating policy development can help by building cross-disciplinary translational research capacities, and universities can take steps to make policy-relevant research more rewarding for scholars in the humanities, social sciences, and law.

Community pharmacists' attitudes towards clinical utility and ethical implications of pharmacogenetic testing

AIM

To examine community pharmacists' attitudes towards pharmacogenetic (PGx) testing, including their views of the clinical utility of PGx and the ethical, social, legal and practical implications of PGx testing.

METHODS

A web-based survey administered to 5600 licensed community pharmacists in the states of Ohio and Pennsylvania (USA).

RESULTS

Of 580 respondents, 78% had a Bachelor of Science degree in pharmacy and 58% worked in a chain drug store. Doctors of pharmacy-trained pharmacists had a significantly higher knowledge score than those with a Bachelor of Science in pharmacy (3.2 ± 0.9 vs 2.6 ± 0.6; p < 0.0001). All pharmacists had positive attitudes towards PGx and most (87%) felt it would decrease the number of adverse events, and optimize drug dosing. More than half (57%) of pharmacists felt that it was their role to counsel patients regarding PGx information. Many (65%) were concerned that PGx test results may be used to deny health insurance.

CONCLUSION

Regardless of the type of education, all pharmacists had positive attitudes towards PGx. There is still a concern among pharmacists that PGx test results may be used to deny health insurance and, thus, there is a need to educate pharmacists about legal protections prohibiting certain forms of unfair discrimination based on genotype.

Abstract 277: The Relationship Between Aortic And PA Diameter Among Individuals With Genetic Conditions Of The Thoracic Aorta: A Report From The NIH Gentac Registry

Background The aorta and pulmonary artery (PA) share structural similarities, and thus genetic conditions affecting the thoracic aorta may also affect the PA. We evaluated the relationship between aortic and pulmonary artery dimensions on chest CT among a subset of participants in the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions Registry (GenTAC).

Methods Data Adults in GenTAC without a history of aortic surgery or aortic dissection (N = 144) and with computed tomography of the chest were included. Standardized double oblique measurements of the pulmonary artery, and thoracic aortic dimensions at 8 sites (sinus of Valsalva through the suprarenal aorta) were measured in a core laboratory. The relationship between the PA and aortic dimensions were analyzed using bivariate correlations, and multivariable linear regression controlling for age and body size.

Results Mean age was 45±13 years. The mean maximum ascending aortic dimension was 3.8±0.9 cm (range 2.4-7.9 cm); mean PA dimension was 3.1±0.5 cm (1.8-4.8 cm). Using a cutoff of 2.8 cm defining the 90 th percentile value for PA diameter, 65% of the study population had dilated PA. Correlations between the aortic and pulmonary artery diameter were higher for the descending aorta than the ascending aorta. The highest observed correlation between PA and aortic diameter was observed for the thoracoabdominal aorta at the level of the diaphragm (r = 0.40; P <0.001). In a linear regression model evaluating relationships between PA diameter and various aortic segments, after controlling for age and body size, the PA and descending thoracic aorta were independently related (partial correlation r = 0.28; P<0.001). Similar relationships were not observed for the ascending aorta.

Conclusions A dilated PA is common among individuals with genetically-associate thoracic aortic dilatation. The diameter of the PA relates modestly to aortic dimensions, most strongly with the descending thoracic aorta.

A new syndrome of myelinated nerve fibers, vitreoretinopathy, and skeletal malformations

OBJECTIVE

To report a new vitreoretinopathy with high myopia, myelinated nerve fibers, and skeletal abnormalities.

PATIENTS

A mother and daughter with a previously undescribed constellation of severe vitreoretinal degeneration with high myopia and extensive myelination of the retinal nerve fiber layer, and in addition, the daughter has limb reduction deformities. Vision was severely impaired in both patients and results of electroretinography indicated the presence of cone and rod dysfunction.

CONCLUSION

This is a previously undescribed autosomal dominant vitreoretinopathy with congenital poor vision, vitreoretinal degeneration, myelinated nerve fibers, and skeletal deformities.