Aortic Cellular Heterogeneity in Health and Disease: Novel Insights Into Aortic Diseases From Single-Cell RNA Transcriptomic Data Sets

Aortic diseases such as atherosclerosis, aortic aneurysms, and aortic stiffening are significant complications that can have significant impact on end-stage cardiovascular disease. With limited pharmacological therapeutic strategies that target the structural changes in the aorta, surgical intervention remains the only option for some patients with these diseases. Although there have been significant contributions to our understanding of the cellular architecture of the diseased aorta, particularly in the context of atherosclerosis, furthering our insight into the cellular drivers of disease is required. The major cell types of the aorta are well defined; however, the advent of single-cell RNA sequencing provides unrivaled insights into the cellular heterogeneity of each aortic cell type and the inferred biological processes associated with each cell in health and disease. This review discusses previous concepts that have now been enhanced with recent advances made by single-cell RNA sequencing with a focus on aortic cellular heterogeneity.

Identifying Predictors for Hypoplastic Aortic Arch (HAA) in Pediatric Patients with Complex Coarctation of the Aorta (CoA)

OBJECTIVE

HAA is a significant risk factor in complex CoA patients. We conducted a retrospective study to explore the relationship between HAA and other cardiovascular factors.

METHODS

We analyzed 103 patients diagnosed with complex CoA using CT angiography and echocardiography. Aortic diameter was measured at six levels, and severe coarctation was defined as coarctation site to diaphragmatic level ratio (CDR) < 50%. Correlations between non-HAA and HAA groups were assessed. Univariate and multivariate logistic regression identified HAA risk factors.

RESULTS

Among 103 children with complex CoA, 55 were in the non-HAA group and 48 in the HAA group. The incidence of PDA (56.3% vs. 32.7%, p < 0.05), severe coarctation (CDR < 50%, 81.3% vs. 34.5%, p < 0.01), and collateral arteries (39.6% vs. 0, p < 0.01) were higher in the HAA group than one in the non-HAA group. The aortic arch size was positively correlated with age and negatively correlated with severe coarctation, VSD, collateral arteries, and left heart dysfunction. Logistic regression results showed that collateral arteries were risk factors for the whole aortic arch (proximal arch OR = 11.458; p < 0.01, distal arch OR = 4.211; p < 0.05, and isthmus OR = 11.744; p < 0.01), severe coarctation (OR = 6.653; p < 0.01), and left heart dysfunction (OR = 5.149; p < 0.01) associated with isthmus hypoplasia.

CONCLUSION

This study highlights the prevalence of HAA in complex CoA patients and its associations with various cardiovascular factors. These insights improve diagnosis and treatment approaches.

Image quality, contrast enhancement and radiation dose of electrocardiograph- versus non-electrocardiograph-triggered computed tomography angiography of the aorta

INTRODUCTION

Computed tomography angiography of the aorta (CTAA) is the modality of choice for investigating aortic disease. Our aim was to evaluate the image quality, contrast enhancement and radiation dose of electrocardiograph (ECG)-triggered and non-ECG-triggered CTAA on a 256-slice single-source CT scanner. This allows the requesting clinician and the radiologist to balance radiation risk and image quality.

METHODS

We retrospectively assessed the data of 126 patients who had undergone CTAA on a single-source CT scanner using ECG-triggered (group 1, n = 77) or non-ECG-triggered (group 2, n = 49) protocols. Radiation doses were compared. Qualitative (4-point scale) and quantitative image quality assessments were performed.

RESULTS

The mean volume CT dose index, dose length product and effective dose in group 1 were 12.4 ± 1.9 mGy, 765.8 ± 112.4 mGy cm and 13.0 ± 1.9 mSv, respectively. These were significantly higher compared to group 2 values (9.1 ± 2.6 mGy, 624.1 ± 174.8 mGy cm and 10.6 ± 3.0 mSv, respectively) ( P < 0.001). Qualitative assessment showed the image quality at the aortic root-proximal ascending aorta was significantly higher in group 1 (median 3) than in group 2 (median 2, P < 0.001). Quantitative assessment showed significantly better mean arterial attenuation, signal-to-noise ratio and contrast-to-noise ratio in ECG-triggered CTAA compared to non-ECG-triggered CTAA.

CONCLUSION

ECG-triggered CTAA in a single-source scanner has superior image quality and vessel attenuation of aortic root/ascending aorta, but a higher radiation dose of approximately 23%. Its use should be considered specifically when assessing aortic root/ascending aorta pathology.

Aortic calcification correlates with pseudoaneurysm or penetrating aortic ulcer of different etiologies

Chronic risk factors for pseudoaneurysm (PSA) or penetrating aortic ulcer (PAU) have not been fully clarified. This study aims to evaluate the association of aortic calcification with PSA or PAU of different etiologies. Totally 77 pseudoaneurysms, 80 PAU, and 160 healthy controls (HCs) were retrospectively included, of which 30 were infected, 34 were immunological, and 93 were atherosclerotic etiologies. The aortic calcification status, position of aortic tears/ulcers, and risk factors for disease or acute aortic syndrome (AAS) were identified. Atherosclerotic patients aged more than 65 and infective patients aged more than 60 had significantly higher calcification scores. The immunological group had a lower level of calcification in the infrarenal aorta. For patients of infective or atherosclerotic etiology, 60% (18/30) and 60.22% (56/93) of the tears/ulcers occurred at the aortic parts with the highest level of calcification. Patients with longitudinal calcification exceeding 1/3 of the aortic arch had an increased risk of acquiring diseases (OR = 13.231). The presence of longitudinal calcification of the descending aorta or cross-sectional calcification of the infrarenal aorta increased the risks of acquiring diseases (OR = 8.484 and 8.804). After adjusting for age, longitudinal calcification of the descending aorta exceeding 1/3 length was found to be associated with AAS (OR = 4.662). Tears/ulcers of pseudoaneurysm and PAU were both generally found at the part of the aorta with most calcification. Distinct aorta calcification characteristics were observed for lesions of different etiologies. Longitudinal thoracic and cross-sectional infrarenal abdominal aortic calcification increased the risk of acquiring diseases, and descending aortic calcification was associated with symptomatic patients.

Hemodynamic effects of entry and exit tear size in aortic dissection evaluated with in vitro magnetic resonance imaging and fluid-structure interaction simulation

Understanding the complex interplay between morphologic and hemodynamic features in aortic dissection is critical for risk stratification and for the development of individualized therapy. This work evaluates the effects of entry and exit tear size on the hemodynamics in type B aortic dissection by comparing fluid-structure interaction (FSI) simulations with in vitro 4D-flow magnetic resonance imaging (MRI). A baseline patient-specific 3D-printed model and two variants with modified tear size (smaller entry tear, smaller exit tear) were embedded into a flow- and pressure-controlled setup to perform MRI as well as 12-point catheter-based pressure measurements. The same models defined the wall and fluid domains for FSI simulations, for which boundary conditions were matched with measured data. Results showed exceptionally well matched complex flow patterns between 4D-flow MRI and FSI simulations. Compared to the baseline model, false lumen flow volume decreased with either a smaller entry tear (- 17.8 and - 18.5%, for FSI simulation and 4D-flow MRI, respectively) or smaller exit tear (- 16.0 and - 17.3%). True to false lumen pressure difference (initially 11.0 and 7.9 mmHg, for FSI simulation and catheter-based pressure measurements, respectively) increased with a smaller entry tear (28.9 and 14.6 mmHg), and became negative with a smaller exit tear (- 20.6 and - 13.2 mmHg). This work establishes quantitative and qualitative effects of entry or exit tear size on hemodynamics in aortic dissection, with particularly notable impact observed on FL pressurization. FSI simulations demonstrate acceptable qualitative and quantitative agreement with flow imaging, supporting its deployment in clinical studies.

Sex-specific effects of a high fat diet on aortic inflammation and dysfunction

Obesity and vascular dysfunction are independent and sexually dimorphic risk factors for cardiovascular disease. A high fat diet (HFD) is often used to model obesity in mice, but the sex-specific effects of this diet on aortic inflammation and function are unclear. Therefore, we characterized the aortic immune cell profile and function in 6-week-old male and female C57BL/6 mice fed a normal chow diet (NCD) or HFD for 10 weeks. Metabolic parameters were measured weekly and fortnightly. At end point, aortic immune cell populations and endothelial function were characterized using flow cytometry and wire myography. HFD-male mice had higher bodyweight, blood cholesterol, fasting blood glucose and plasma insulin levels than NCD mice (P < 0.05). HFD did not alter systolic blood pressure (SBP), glycated hemoglobin or blood triglycerides in either sex. HFD-females had delayed increases in bodyweight with a transient increase in fasting blood glucose at week 8 (P < 0.05). Flow cytometry revealed fewer proinflammatory aortic monocytes in females fed a HFD compared to NCD. HFD did not affect aortic leukocyte populations in males. Conversely, HFD impaired endothelium-dependent vasorelaxation, but only in males. Overall, this highlights biological sex as a key factor determining vascular disease severity in HFD-fed mice.

Challenging Diagnosis and Management: A Complex Case Following an Urgent Caeserean Section

Hemodynamic changes during pregnancy are physiological adaptations to fulfill new demands. Although these adaptations are often well-tolerated, they may unmask or exacerbate underlying cardiovascular conditions, posing unique challenges for medical professionals. We present a case that outlines the evaluation and treatment of a 38-year-old woman who experienced health complications shortly after undergoing a Caesarean section.  A 38-year-old woman who had a previous caeserean section presented for an urgent caeserean section at 39 weeks of gestational age due to non-reassuring cardiotocography. Shortly after spinal anesthesia and misoprostol administration, she developed cyanosis, confusion, mottling skin, tachycardia, tachypnea, and hypotension. The patient's clinical presentation led to a broad differential diagnosis, including cardiovascular complications, infection, medication reactions, and hemorrhage, being the ultimate diagnosis of a case of severe aortic stenosis. Successful management involved a multidisciplinary approach and coordinated effort, particularly involving the anesthesiology team, which was pivotal in timely diagnosis and intervention. The ultimate diagnosis of severe aortic stenosis emphasized the significance of accurate and coordinated healthcare. Successful management involves collaboration between obstetric, intensive care, and cardiac care teams, highlighting the potential for improved outcomes when healthcare professionals work together in complex clinical scenarios.

CD73 deficiency does not aggravate angiotensin II-induced aortic inflammation in mice

Vascular inflammation plays a key role in the development of aortic diseases. A potential novel target for treatment might be CD73, an ecto-5'-nucleotidase that generates anti-inflammatory adenosine in the extracellular space. Here, we investigated whether a lack of CD73 results in enhanced aortic inflammation. To this end, angiotensin II was infused into wildtype and CD73-/- mice over 10 days. Before and after infusion, mice were analyzed using magnetic resonance imaging, ultrasound, flow cytometry, and histology. The impact of age and gender was investigated using female and male mice of three and six months of age, respectively. Angiotensin II infusion led to increased immune cell infiltration in both genotypes' aortae, but depletion of CD73 had no impact on immune cell recruitment. These findings were not modified by age or sex. No substantial difference in morphological or functional characteristics could be detected between wildtype and CD73-/- mice. Interestingly, the expression of CD73 on neutrophils decreased significantly in wildtype mice during treatment. In summary, we have found no evidence that CD73 deficiency affects the onset of aortic inflammation. However, as CD73 expression decreased during disease induction, an increase in CD73 by pharmaceutical intervention might result in lower vascular inflammation and less vascular disease.

A Devastating Floating Aortic Thrombus and Ketosis-Prone Diabetes

This article reports a case study of a middle-aged patient diagnosed with Ketosis-Prone Diabetes (KPD) and diabetic ketoacidosis who had a mobile thrombus in the distal aortic arch with catastrophic complications from thrombus embolization. The pathogenesis of the mobile aortic thrombus is currently under investigation, with many risk factors having been found. Based on the patient's limited manifestation of atherosclerosis and the absence of any indications of thrombophilia, KPD and inflammation from uncontrolled hyperglycemia likely played a significant role in the formation of the thrombus. KPD is a subtype of diabetes characterized by the abrupt onset of severe hyperglycemia and ketoacidosis. The inflammation caused by uncontrolled hyperglycemia in KPD patients can lead to endothelial dysfunction and the activation of prothrombotic pathways. There is a lack of consensus regarding the optimal approach for managing a mobile aortic thrombus. The main strategies under consideration are conservative care, including anticoagulation alone, invasive removal of the thrombus, or endovascular intervention.

The impact of circulatory arrest with selective antegrade cerebral perfusion on brain functional connectivity and postoperative cognitive function

Aortic surgery is one of the most challenging types of surgeries, which is possibly related to cognitive sequelae. We aimed to investigate the changes in resting-state functional connectivity (rsFC) associated with intraoperative circulatory arrest (CA) in aortic surgery, exploring the relationship between the altered connectivity and postoperative cognitive functions. Thirty-eight patients participated in this study (14 with CA, 24 without). Functional magnetic resonance imaging was scanned on the fifth day after surgery or after the resolution of delirium if it was developed. We assessed the differences in the development of postoperative cognitive changes and rsFC between patients with and without CA. The occurrence of postoperative delirium and postoperative cognitive dysfunction was not significantly different between the patients with and without the application of CA. However, patients with CA showed increased in posterior cingulate cortex-based connectivity with the right superior temporal gyrus, right precuneus, and right hippocampus, and medial prefrontal cortex-based connectivity with the dorsolateral prefrontal cortex. The application of moderate hypothermic CA with unilateral antegrade cerebral perfusion is unlikely to affect aspects of postoperative cognitive changes, whereas it may lead to increased rsFC of the default mode network at a subclinical level following acute brain insults.

Haemodynamic changes in visceral hybrid repairs of type III and type V thoracoabdominal aortic aneurysms

The visceral hybrid procedure combining retrograde visceral bypass grafting and completion endovascular stent grafting is a feasible alternative to conventional open surgical or wholly endovascular repairs of thoracoabdominal aneurysms (TAAA). However, the wide variability in visceral hybrid configurations means that a priori prediction of surgical outcome based on haemodynamic flow profiles such as velocity pattern and wall shear stress post repair remain challenging. We sought to appraise the clinical relevance of computational fluid dynamics (CFD) analyses in the setting of visceral hybrid TAAA repairs. Two patients, one with a type III and the other with a type V TAAA, underwent successful elective and emergency visceral hybrid repairs, respectively. Flow patterns and haemodynamic parameters were analysed using reconstructed pre- and post-operative CT scans. Both type III and type V TAAAs showed highly disturbed flow patterns with varying helicity values preoperatively within their respective aneurysms. Low time-averaged wall shear stress (TAWSS) and high endothelial cell action potential (ECAP) and relative residence time (RRT) associated with thrombogenic susceptibility was observed in the posterior aspect of both TAAAs preoperatively. Despite differing bypass configurations in the elective and emergency repairs, both treatment options appear to improve haemodynamic performance compared to preoperative study. However, we observed reduced TAWSS in the right iliac artery (portending a theoretical risk of future graft and possibly limb thrombosis), after the elective type III visceral hybrid repair, but not the emergency type V repair. We surmise that this difference may be attributed to the higher neo-bifurcation of the aortic stent graft in the type III as compared to the type V repair. Our results demonstrate that CFD can be used in complicated visceral hybrid repair to yield potentially actionable predictive insights with implications on surveillance and enhanced post-operative management, even in patients with complicated geometrical bypass configurations.

LINC02015 modulates the cell proliferation and apoptosis of aortic vascular smooth muscle cells by transcriptional regulation and protein interaction network

Long intergenic nonprotein coding RNA 2015 (LINC02015) is a long non-coding RNA that has been found elevated in various cell proliferation-related diseases. However, the functions and interactive mechanism of LINC02015 remain unknown. This study aimed to explore the role of LINC02015 in the cell proliferation and apoptosis of vascular smooth muscle cells (VSMCs) to explain the pathogenesis of aortic diseases. Ascending aorta samples and angiotensin-II (AT-II) treated primary human aortic VSMCs (HAVSMCs) were used to evaluate the LINC02015 expression. RNA sequencing, chromatin isolation by RNA purification sequencing, RNA pull-down, and mass spectrometry (MS) were applied to explore the potential interacting mechanisms. LINC02015 expression was found elevated in aortic dissection and AT-II-treated HAVSMCs. Cell proliferation and cell cycle were activated in HAVSMCs with LINC02015 knockdown. The cyclins family and caspase family were found to participate in regulating the cell cycle and apoptosis via the NF-κB signaling pathway. RXRA was discovered as a possible hub gene for LINC02015 transcriptional regulating networks. Besides, the protein interaction network of LINC02015 was revealed with candidate regulating molecules. It was concluded that the knockdown of LINC02015 could promote cell proliferation and inhibit the apoptosis of HAVSMCs through an RXRA-related transcriptional regulation network, which could provide a potential therapeutic target for aortic diseases.

Aortic Dissection Associated With Seizures

We present a case of an extensive aortic dissection identified in a young male patient with atypical symptoms. The patient presented to the Emergency Department with severe sudden onset chest pain and seizure. In the Emergency Department, bedside Transthoracic Echocardiography (TTE) identified moderate pericardial effusion which correlated with a widened mediastinum on chest radiograph. The presence of aortic dissection was confirmed by an urgent CT angiogram of the thorax and abdomen. Our case highlights the importance of critical thinking in the atypical presentation of aortic dissection in which this diagnosis may not be considered, leading to negative and possibly deadly outcomes.

Diagnosis and management of vascular Ehlers-Danlos syndrome: Experience of the UK national diagnostic service, Sheffield

The UK National Diagnostic Service for Ehlers-Danlos Syndromes (EDS) was established in 2009 for the rare types of EDS. Vascular EDS (vEDS) is an inherited connective tissue disorder caused by pathogenic variants in the COL3A1 gene. Associated tissue fragility affects multiple organ systems, increasing the risk of blood vessel dissection and rupture, with potentially fatal consequences. The diagnosis of vEDS has improved with advances in genetic testing, however this is most often suspected following an acute event. We provide data on the clinical features of vEDS for 180 patients (full cohort) seen in our service with confirmed molecular diagnoses. Increased awareness of this rare condition will prompt genetic testing essential to confirm the diagnosis. Outcomes are improved by early diagnosis followed by appropriate management. Fragile connective tissues make invasive procedures potentially dangerous, particularly in an emergency setting. Lifestyle advice from a young age can help acceptance and understanding of the diagnosis and inform choices. There is currently limited evidence for the use of drug therapy to reduce vascular events. We report on the incidence of vascular events in 126 patients (statistical analysis cohort) in our care and the use of medication. Our retrospective data showed that those patients on a long-term angiotensin II receptor blocker and/or beta-blocker had fewer vascular events than those not on cardiac medication who received the same lifestyle and emergency care advice.

A Devastating Tear: Atypical Presentation of Aortic Dissection Discovered on Echocardiography

Acute aortic dissection (AAD) is a serious medical problem that requires prompt recognition in order to prevent deadly complications. Nevertheless, making the diagnosis can often be challenging. The clinical signs and symptoms of AAD may vary depending on the location of the dissection, leading to subtle differences in the initial patient presentation. Moreover, the classically described signs of blood pressure disparity, pulse deficit, or the presence of a diastolic murmur are often absent. Here, we report a challenging case of AAD in which the patient presented with acute substernal chest pain that resolved after a short period and was associated with hypotension. His bilateral upper and lower extremities were well perfused with symmetrical, palpable pulses. The initial point-of-care ultrasound (POCUS) showed a small pericardial effusion, and a follow-up echocardiogram revealed an ascending aortic flap with aortic root dilation diagnostic of AAD. Our aim is to shed light on the challenge of diagnosing AAD.

Risk Factors for Mortality From Aortic Aneurysm and Dissection: Results From a 26-Year Follow-Up of a Community-Based Population

Background Aortic aneurysm rupture and acute aortic dissection are life-threatening conditions and represent an ever-growing public health challenge. Comprehensive epidemiologic investigations for their risk factors are scant. We aimed to investigate risk factors associated with mortality from aortic diseases through analysis of a community-based Japanese cohort. Methods and Results IPHS (Ibaraki Prefectural Health Study) comprises 95 723 participants who took part in municipal health checkups in 1993. Factors considered for analysis included age, sex, body mass index, blood pressure, serum lipids (high-density lipoprotein [HDL] cholesterol, non-HDL cholesterol, and triglycerides), diabetes, antihypertensive and lipid-lowering drug use, and smoking and drinking habits. Cox proportional hazards models were applied to evaluate the associations between these variables and mortality from aortic diseases. During the median 26-year follow-up, 190 participants died of aortic aneurysm rupture, and 188 died of aortic dissection. An increased multivariable hazard ratio (HR) for mortality from total aortic diseases was observed for high systolic blood pressure (1.61 [1.00-2.59]), diastolic blood pressure (2.95 [1.95-4.48]), high non-HDL cholesterol (1.63 [1.19-2.24]), low HDL cholesterol (1.86 [1.29-2.68]), and heavy (>20 cigarettes/day) smoking habit (2.46 [1.66-3.63]). A lower multivariable HR was observed for diabetes (0.50 [0.28-0.89]). Conclusions Smoking habit, higher systolic blood pressure and diastolic blood pressure levels, higher non-HDL, and lower HDL cholesterol levels were positively associated with mortality from total aortic diseases, whereas diabetes was inversely associated.

Challenges of Managing Non-rheumatic Aortic Valve Disorder in a Genetically Susceptible Woman

In this case report, we investigated the potential link between SMAD3/transforming growth factor β (TGF-β) pathway dysregulation and aortic valvular disease. We report a middle-aged female, heterozygous for the R18W novel variant of the SMAD3 gene, with a history of an aortic valve disorder and three aortic valve replacements in a span of 15 years. The patient neither has a history of congenital connective tissue disorders nor any known congenital valvular defects. The patient had genetic testing for thoracic aortic aneurysm and dissection (TAAD)/Marfan syndrome/related disorders. She was found to be heterozygous for the p.Arg18Trp (R18W) protein variant of the SMAD3 gene (chromosome position 15:67430416), coding DNA c.52 C>T. Members of the transforming growth factor β (TGF-β) family and their downstream signaling proteins, including SMAD, are important for establishing proper embryogenic development and maintaining adult tissue homeostasis. Investigating the disturbances within the TGF-β signaling pathways may provide insightful knowledge of how genetic factors can cause structural and functional valvular defects.

A Novel Endovascular Treatment for Recurrent Secondary Aorto-Enteric Fistula in a Patient With Prior Infra-Renal Aortic Ligation

This report highlights the use of novel endovascular techniques in a 68-year-old male patient with massive hematemesis from a recurrent secondary aorto-enteric fistula (SAEF). With a prior history of infrarenal aortic ligation and the location of the SAEF being at the aortic sac, we explain the considerations for the techniques used and how we were able to stop the bleeding using percutaneous transarterial embolotherapy.

Imaging surveillance for complications after primary surgery for type A aortic dissection

Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergency surgery to avert fatal outcome. Conventional surgical procedures comprise excision of the entry tear and replacement of the proximal aorta with a synthetic vascular graft. In patients with DeBakey type I dissection, this approach leaves a chronically dissected distal aorta, putting them at risk for progressive dilatation, dissection propagation and aortic rupture. Therefore, ATAAD survivors should undergo serial imaging for evaluation of the aortic valve, proximal and distal anastomoses, and the aortic segments beyond the distal anastomosis. The current narrative review aims to describe potential complications in the early and late phases after ATAAD surgery, with focus on their specific imaging findings.

Applications of Three-Dimensional Printing in the Management of Complex Aortic Diseases

The use of three-dimensional (3D) printing is gaining considerable success in many medical fields, including surgery; however, the spread of this innovation in cardiac and vascular surgery is still limited. This article reports our pilot experience with this technology, applied as an additional tool for 20 patients treated for complex vascular or cardiac surgical diseases. We have analyzed the feasibility of a "3D printing and aortic diseases project," which helps to obtain a more complete approach to these conditions. 3D models have been used as a resource to improve preoperative planning and simulation, both for open and endovascular procedures; furthermore, real 3D aortic models were used to develop doctor-patients communication, allowing better knowledge and awareness of their disease and of the planned surgical procedure. A 3D printing project seems feasible and applicable as an adjunctive tool in the diagnostic-therapeutic path of complex aortic diseases, with the need for future studies to verify the results.

Detection of acute thoracic aortic dissection based on plain chest radiography and a residual neural network (Resnet)

Acute thoracic aortic dissection is a life-threatening disease, in which blood leaking from the damaged inner layer of the aorta causes dissection between the intimal and adventitial layers. The diagnosis of this disease is challenging. Chest x-rays are usually performed for initial screening or diagnosis, but the diagnostic accuracy of this method is not high. Recently, deep learning has been successfully applied in multiple medical image analysis tasks. In this paper, we attempt to increase the accuracy of diagnosis of acute thoracic aortic dissection based on chest x-rays by applying deep learning techniques. In aggregate, 3,331 images, comprising 716 positive images and 2615 negative images, were collected from 3,331 patients. Residual neural network 18 was used to detect acute thoracic aortic dissection. The diagnostic accuracy of the ResNet18 was observed to be 90.20% with a precision of 75.00%, recall of 94.44%, and F1-score of 83.61%. Further research is required to improve diagnostic accuracy based on aorta segmentation.

Long-term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta-analysis of Kaplan-Meier-derived individual patient data

OBJECTIVES

To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD).

METHODS

We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD.

RESULTS

Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025).

CONCLUSION

The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.

Effects of non-Newtonian viscosity on arterial and venous flow and transport

It is well known that blood exhibits non-Newtonian viscosity, but it is generally modeled as a Newtonian fluid. However, in situations of low shear rate, the validity of the Newtonian assumption is questionable. In this study, we investigated differences between Newtonian and non-Newtonian hemodynamic metrics such as velocity, vorticity, and wall shear stress. In addition, we investigated cardiovascular transport using two different approaches, Eulerian mass transport and Lagrangian particle tracking. Non-Newtonian solutions revealed important differences in both hemodynamic and transport metrics relative to the Newtonian model. Most notably for the hemodynamic metrics, in-plane velocity and vorticity were consistently larger in the Newtonian approximation for both arterial and venous flows. Conversely, wall shear stresses were larger for the non-Newtonian case for both the arterial and venous models. Our results also indicate that for the Lagrangian metrics, the history of accumulated shear was consistently larger for both arterial and venous flows in the Newtonian approximation. Lastly, our results also suggest that the Newtonian model produces larger near wall and luminal mass transport values compared to the non-Newtonian model, likely due to the increased vorticity and recirculation. These findings demonstrate the importance of accounting for non-Newtonian behavior in cardiovascular flows exhibiting significant regions of low shear rate and recirculation.

Cross-sectional association of equol producing status with aortic calcification in Japanese men aged 40-79 years

Equol is an isoflavone (ISF)-derived metabolite by the gut microbiome in certain individuals termed equol-producers (EP). Equol might be the critical anti-atherogenic component of ISFs. In a population-based study of 979 Japanese men aged 40-79 without cardiovascular (CVD) or chronic kidney disease, we measured the urinary levels of equol and ISFs. Aortic calcification (AC) in the entire aorta was assessed by electron-beam or multi-detector-row computed tomography. Subjects with log10 (urinary equol to daidzein concentration) > - 1.5 were classified as EP. EP was further classified as person with low- and high-equol. We analyzed the association between equol-producing status and AC presence, defined as AC score > 0, by the logistic regressions. We found that EP (50% of the sample) had significantly lower odds of AC presence (odds ratio (OR): 0.62, 95% confidence interval (CI): 0.39, 0.98) compared to non-EP. This association was independent of CVD risk factors. For the dose-response association, compared to non-EP, subjects with low and high levels of equol had ORs of 0.51 (95% CI 0.30, 0.84) and 0.67 (95% CI 0.39, 1.14) after adjusting for major CVD risk factors (p for trend = 0.06). ISFs concentrations were not significantly associated with AC presence (OR: 1.18, 95% CI: 0.82, 1.69). In conclusion, EP had a significantly lower burden of AC than non-EP, while ISFs were not associated with AC presence in Japanese men aged 40-79 years.

Prognostic model for survival of patients with abdominal aortic aneurysms treated with endovascular aneurysm repair

The role of endovascular aneurysm repair (EVAR) in patients with asymptomatic abdominal aortic aneurysm (AAA) who are unfit for open surgical repair has been questioned. The impending risk of aneurysm rupture, the risk of elective repair, and the life expectancy must be balanced when considering elective AAA repair. This retrospective observational cohort study included all consecutive patients treated with standard EVAR for AAA at a referral centre between 2001 and 2020. A previously published predictive model for survival after EVAR in patients treated between 2001 and 2012 was temporally validated using patients treated at the same institution between 2013 and 2020 and updated using the overall cohort. 558 patients (91.2% males, mean age 74.9 years) were included. Older age, lower eGFR, and COPD were independent predictors for impaired survival. A risk score showed good discrimination between four risk groups (Harrel's C = 0.70). The 5-years survival probabilities were only 40% in "high-risk" patients, 68% in "moderate-to-high-risk" patients, 83% in "low-to-moderate-risk", and 89% in "low-risk" patients. Low-risk patients with a favourable life expectancy are likely to benefit from EVAR, while high-risk patients with a short life expectancy may not benefit from EVAR at the current diameter threshold.

Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Aortitis Presenting With Acute Dissection: Case Report and Comprehensive Literature Review

Description Vasculitides are a group of diseases that produces vasculitis, which is characterized by inflammatory infiltrates within blood vessel walls and results in intimal injury as well as progressive mural destruction. Infiltrates are characterized per the Chapel Hill classification, into large, medium, and small-vessel vasculitides. ANCA-associated vasculitis (AAV) is a disease that has been described as involving small-sized vessels. However, some cases of large vessel disease involvement have been documented. ANCA-associated aortitis is a rare entity poorly described in the literature. Due to the rarity of this pathology, there is no Level I evidence available regarding diagnosis and treatment. We present the rare case of an 80-year-old male presenting with ANCA-associated aortitis complicated by acute dissection of the left common iliac artery. His case was successfully managed by corticosteroid therapy and endovascular stenting of the involved iliac artery. ANCA-associated aortitis is a rare entity that has not been described well in the current literature. We believe this case to be the first involving ANCA-associated aortitis presenting with an acute dissection.

Pinocembrin suppresses oxidized low-density lipoprotein-triggered NLRP3 inflammasome/GSDMD-mediated endothelial cell pyroptosis through an Nrf2-dependent signaling pathway

Pinocembrin (Pin) has been confirmed to exert anti-inflammatory and antiatherosclerotic effects. Here we have explored whether and how Pin would protect vascular endothelial cells against pyroptosis elicited by the exposure to oxidized low density lipoprotein (oxLDL). Our results showed that Pin preconditioning dose-dependently suppressed oxLDL-stimulated HUVEC injury and pyroptosis, which were manifested by improved cell viability, lower lactate dehydrogenase (LDH) levels and DNA damage as well as decreased expression of pyroptosis-related markers, such as NOD-like receptor pyrin domain-containing 3 (NLRP3), apoptosis-associated speck-like protein containing a caspase activation and recruitment domain (ASC), pro-Caspase-1, cleaved Caspase-1, N-terminus of Gasdermin D-N (GSDMD-N), pro-interleukins-1β (pro-IL-1β), IL-1β and inflammatory cytokines (IL-18 and IL-1β). All of the effects were similar to those of MCC950 (an NLRP3 inhibitor). As expected, Pin distinctly activated the Nuclear factor erythroid 2-related factor 2 (Nrf2) antioxidative signaling pathway assessed through increased expressions of Nrf2, heme oxygenase-1 (HO-1) and NAD(P)H quinone oxidoreductase 1 (NQO1). Furthermore, after transfection with small interfering RNA of Nrf2, the inhibitory effects of Pin on oxLDL-triggered NLRP3 inflammasome/GSDMD-mediated pyroptosis and oxidative stress in HUVECs were weakened. Additionally, Pin up-regulated Nrf2/HO-1 axis and down-regulated NLRP3 inflammasome/GSDMD-mediated pyroptosis signals in Apoe^-/- mice fed with high fat diet. These results contribute to the understanding of the anti-pyroptosis mechanisms of Pin and provide a reference for future research on the anti-atherosclerotic effect of Pin.

An Myh11 single lysine deletion causes aortic dissection by reducing aortic structural integrity and contractility

Pathogenic variants in myosin heavy chain (Myh11) cause familial thoracic aortic aneurysms and dissections (FTAAD). However, the underlying pathological mechanisms remain unclear because of a lack of animal models. In this study, we established a mouse model with Myh11 K1256del, the pathogenic variant we found previously in two FTAAD families. The Myh11∆K/∆K aorta showed increased wall thickness and ultrastructural abnormalities, including weakened cell adhesion. Notably, the Myh11∆K/+ mice developed aortic dissections and intramural haematomas when stimulated with angiotensin II. Mechanistically, integrin subunit alpha2 (Itga2) was downregulated in the Myh11∆K/∆K aortas, and the smooth muscle cell lineage cells that differentiated from Myh11∆K/∆K induced pluripotent stem cells. The contractility of the Myh11∆K/∆K aortas in response to phenylephrine was also reduced. These results imply that the suboptimal cell adhesion indicated by Itga2 downregulation causes a defect in the contraction of the aorta. Consequently, the defective contraction may increase the haemodynamic stress underlying the aortic dissections.

Management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

OBJECTIVES

The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies.

METHODS

PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'.

RESULTS

Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I2 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I2 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I2 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I2 77%).

CONCLUSION

This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention.

PROSPERO REGISTRATION NUMBER

CRD42022301037.

Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association

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.

Imaging Techniques for Aortic Aneurysms and Dissections in Mice: Comparisons of Ex Vivo, In Situ, and Ultrasound Approaches

Aortic aneurysms and dissections are life-threatening conditions that have a high risk for lethal bleeding and organ malperfusion. Many studies have investigated the molecular basis of these diseases using mouse models. In mice, ex vivo, in situ, and ultrasound imaging are major approaches to evaluate aortic diameters, a common parameter to determine the severity of aortic aneurysms. However, accurate evaluations of aortic dimensions by these imaging approaches could be challenging due to pathological features of aortic aneurysms. Currently, there is no standardized mode to assess aortic dissections in mice. It is important to understand the characteristics of each approach for reliable evaluation of aortic dilatations. In this review, we summarize imaging techniques used for aortic visualization in recent mouse studies and discuss their pros and cons. We also provide suggestions to facilitate the visualization of mouse aortas.

Morphometric predictors of aortic remodeling after frozen elephant trunk repair of type A dissection

OBJECTIVES

We analyzed the predictors of postoperative aortic remodeling after the frozen elephant trunk technique for type A dissection.

METHODS

This retrospective study cohort comprised 20 patients who underwent the frozen elephant trunk technique for type A dissection. The incidence of aortic remodeling was evaluated at four levels: middle of the frozen elephant trunk, distal end of the frozen elephant trunk, 10th thoracic vertebra, and proximal to the celiac artery. Several parameters of the residual dissected aorta were analyzed at these four levels, and the predictors of aortic remodeling were investigated.

RESULTS

The incidence of aortic remodeling was 85% at the middle of the frozen elephant trunk, 70% at the distal end of the frozen elephant trunk, 50% at the 10th thoracic vertebra, and 35% proximal to the celiac artery. In a total of 80 computed tomography images, there were significant differences between the aortic remodeling and non-remodeling groups in the true lumen diameter, false lumen diameter, true lumen/aortic diameter ratio, true lumen area, true lumen/aortic area ratio, and two parameters explaining the shape of the true lumen (created using elliptic Fourier analysis). Multivariate analysis revealed that the independent predictors of aortic remodeling were the true lumen/aortic area ratio and principal component 1.

CONCLUSIONS

There were high incidences of aortic remodeling at the middle and distal end of the frozen elephant trunk. Multivariate analysis showed that the true lumen/aorta area ratio and the shape of the true lumen may be important predictors of aortic remodeling.

The effect of vitamin K1 on arterial calcification activity in subjects with diabetes mellitus: a post hoc analysis of a double-blind, randomized, placebo-controlled trial

BACKGROUND

Coronary and aortic artery calcifications are generally slow to develop, and their burden predicts cardiovascular disease events. In patients with diabetes mellitus, arterial calcification is accelerated and calcification activity can be detected using 18F-sodium fluoride positron emission tomography (18F-NaF PET).

OBJECTIVES

We aimed to determine whether vitamin K1 supplementation inhibits arterial calcification activity in individuals with diabetes mellitus.

METHODS

This was a post hoc analysis of the ViKCoVaC (effect of Vitamin-K1 and Colchicine on Vascular Calcification activity in subjects with Diabetes Mellitus) double-blind randomized controlled trial conducted in Perth, Western Australia. Individuals with diabetes mellitus and established coronary calcification (coronary calcium score > 10), but without clinical coronary artery disease, underwent baseline 18F-NaF PET imaging, followed by oral vitamin K1 supplementation (10 mg/d) or placebo for 3 mo, after which 18F-NaF PET imaging was repeated. We tested whether individuals randomly assigned to vitamin K1 supplementation had reduced development of new 18F-NaF PET positive lesions within the coronary arteries and aorta.

RESULTS

In total, 149 individuals completed baseline and follow-up imaging studies. Vitamin K1 supplementation independently decreased the odds of developing new 18F-NaF PET positive lesions in the coronary arteries (OR: 0.35; 95% CI: 0.16, 0.78; P = 0.010), aorta (OR: 0.27; 95% CI: 0.08, 0.94; P = 0.040), and in both aortic and coronary arteries (OR: 0.28; 95% CI: 0.13, 0.63; P = 0.002).

CONCLUSIONS

In individuals with diabetes mellitus, supplementation with 10 mg vitamin K1/d may prevent the development of newly calcifying lesions within the aorta and the coronary arteries as detected using 18F-NaF PET. Further long-term studies are needed to test this hypothesis.This trial was registered at anzctr.org.au as ACTRN12616000024448.

Environmental tobacco smoke and carotid intima-media thickness in healthy children and adolescents: a systematic review

Thicker carotid intima-media thickness (CIMT) has been a valid predictor for atherosclerosis development. A significant association between environmental tobacco smoke (ETS) and thickening of CIMT has been demonstrated in adults, whereas such association has scarcely been reviewed in paediatric population. The dominate electronic databases, including MEDLINE (Ovid), PubMed, Embase, CINAHL, Web of Science, Scopus, were searched from inception. Reference lists of retrieved articles were further scanned as to avoid any missing literatures. Newcastle-Ottawa scale was used to assess the quality of the included studies. Qualitative synthesis analyses were performed on the selected studies. 331 articles were retrieved, and 4 were finally selected. All four studies investigated the association between postnatal ETS and CIMT in children, and three of them reported a statistically significant positive association. Three studies investigated the association between prenatal maternal ETS and CIMT, and one of the three found a positive association. Two studies explored the association between postnatal maternal ETS and CIMT, one reported a positive association. Two studies used serum cotinine measurement to quantify ETS and demonstrated potential dose-response relationship with CIMT. ETS exposure may play an independent role in the development of cardiovascular risks in healthy children and adolescents. In the consideration of the great burden of respiratory and cardiovascular diseases, there is an urgent need of effective surveillance for paediatric population's ETS exposure to reduce smoke exposure.

Congenital Abdominal Aortic Aneurysm: A Case Report and Literature Review

Congenital abdominal aortic aneurysm is a rare disease with unknown etiology, and the common symptoms are abdominal pulsatile mass and pain caused by aneurysm rupture. The disease has a high mortality rate and fewer reports of surgical treatment. Here, we present a case of an idiopathic congenital abdominal aortic aneurysm. A 4-year-old boy had an abdominal pulsatile mass, and computed tomography angiography revealed an isolated infrarenal abdominal aortic aneurysm. To prevent rupture of the aneurysm, we repaired the aneurysm with artificial graft transplantation. No genetic mutation of the known congenital aneurysmal diseases was found in the whole-exome sequencing of the patient and his parents. There was no graft obstruction, and the patient grew well 40 months after surgery. Open surgery is the best treatment for idiopathic congenital abdominal aortic aneurysms. Surgical details such as timing and graft selection need to be further explored.

Single-cell analysis of salt-induced hypertensive mouse aortae reveals cellular heterogeneity and state changes

Elevated blood pressure caused by excessive salt intake is common and associated with cardiovascular diseases in most countries. However, the composition and responses of vascular cells in the progression of hypertension have not been systematically described. We performed single-cell RNA sequencing on the aortic arch from C57BL/6J mice fed a chow/high-salt diet. We identified 19 distinct cell populations representing 12 lineages, including smooth muscle cells (SMCs), fibroblasts, endothelial cells (ECs), B cells, and T cells. During the progression of hypertension, the proportion of three SMC subpopulations, two EC subpopulations, and T cells increased. In two EC clusters, the expression of reactive oxygen species-related enzymes, collagen and contractility genes was upregulated. Gene set enrichment analysis showed that three SMC subsets underwent endothelial-to-mesenchymal transition. We also constructed intercellular networks and found more frequent cell communication among aortic cells in hypertension and that some signaling pathways were activated during hypertension. Finally, joint public genome-wide association study data and our single-cell RNA-sequencing data showed the expression of hypertension susceptibility genes in ECs, SMCs, and fibroblasts and revealed 21 genes involved in the initiation and development of high-salt-induced hypertension. In conclusion, our data illustrate the transcriptional landscape of vascular cells in the aorta associated with hypertension and reveal dramatic changes in cell composition and intercellular communication during the progression of hypertension.

Quality of life after transcatheter or surgical aortic valve replacement using the Toronto Aortic Stenosis Quality of Life Questionnaire

BACKGROUND

The Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) is a validated instrument for assessing quality of life (QoL) in patients with severe aortic stenosis (AS). In this study, we evaluated health status outcomes, based on the TASQ, in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

METHODS

The TASQ registry was a prospective observational registry. Patients with severe AS from nine centres in Europe and one in Canada underwent either SAVR or transfemoral TAVR. Patients completed the TASQ, Kansas City Cardiomyopathy Questionnaire and Short Form-12 V.2 prior to the intervention, predischarge, and at 30-day and 3-month follow-ups. Primary end point was the TASQ score.

RESULTS

In both the TAVR (n=137) and SAVR (n=137) cohorts, significant increases were observed in all three scores. The overall TASQ score improved as did all but one of the individual domains at 3 months after the intervention (p<0.001). TASQ health expectations were the only domain which worsened (p<0.001). Across TASQ subscores, significant changes were evident from the time of discharge in the TAVR and 30-day follow-up in the SAVR cohort. In a categorical analysis of the TASQ, 39.7% of the TAVR group and 35.0% of the SAVR group had a substantially improved health status at 3 months compared with baseline.

CONCLUSIONS

The TASQ captured changes in QoL among patients with severe AS who were treated with TAVR or SAVR. QoL improved substantially after either intervention, as indicated by changes in the TASQ overall score at 3 months.

TRIAL REGISTRATION NUMBER

NCT03186339.

Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review

The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.