2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Long-term outcomes comparison of mitral valve repair or replacement for secondary mitral valve regurgitation. An updated systematic review and reconstructed time-to-event study-level meta-analysis

BACKGROUND AND AIM

The ideal surgical intervention for secondary mitral regurgitation (SMR), a disease of the left ventricle not the mitral valve itself, is still debated. We performed an updated systematic review and study-level meta-analysis investigating mitral valve repair (MVr) versus mitral valve replacement (MVR) for adult patients with SMR, with or without coronary artery disease (CAD).

METHODS

PubMed, CENTRAL and EMBASE were searched for studies comparing MVr versus MVR. Randomized trial or observational studies were considered eligible. Primary endpoint was long-term mortality for any cause. Kaplan-Meier survival curves were reconstructed and compared with Cox linear regression. Landmark analysis and time-varying hazard ratio (HR) were analyzed. Sensitivity analyses included meta-regression and separate sub-analysis. A random effects model was used.

RESULTS

Twenty-three studies (MVr=3,727 and MVR=2,839) were included. One study was a randomized trial, and 19 studies were adjusted. The mean weighted follow-up was 3.7±2.8 years. MVR was associated with significative greater late mortality (HR=1.26; 95 % CI, 1.14-1.39; P<0.0001) at 10-year follow-up. There was a time-varying trend showing an increased risk of mortality in the first 2 years after MVR (HR=1.38; 95 % CI, 1.21-1.56; P<0.0001), after which this difference dissipated (HR=0.94; 95 % CI, 0.81-1.09; P=0.41). Separate sub-analyses showed comparable long-term mortality in patients with concomitant coronary surgery ≥90 %, left ventricle ejection fraction ≤40 %, and sub-valvular apparatus preservation rate of 100 %.

CONCLUSIONS

Compared to repair, MVR is associated with higher probability of mortality in the first 2 years following surgery, after which the two procedures showed comparable late mortality rate.

Genetic aortopathies: a case-based approach to multidisciplinary program development

PURPOSE OF REVIEW

The incorporation of genetic counseling and testing is essential to evaluation and management of thoracic aortic disease in patients under 60 years of age and those with family histories suspicious for heritable thoracic aortic disease and disorders associated with increased risk for acute type-A aortic dissection.

RECENT FINDINGS

As many as 20% of individuals with thoracic aortic disease under the age of 60 years have autosomal dominant patterns of inheritance. A considerable number of heritability factors remain undefined for these families.

SUMMARY

Genetic aortopathy programs require a collaborative approach including cardiovascular specialists and surgeons, medical geneticists, genetic counselors, and allied healthcare professionals. Comprehensive evaluation and management of these patients includes collection of detailed phenotypic data to inform the broader community and identify new associated and causative genes of interest, genetic modifiers, and other risk factors. These programs optimize outcomes and reduce the overall burden in the population of acute aortic dissection and related comorbidities.

Thoracic Stent Grafts Induce Persistent Aortic Remodeling in Aortic Coarctation

OBJECTIVE

This study's objective is to describe outcomes of adult patients who underwent thoracic stent graft placement treatment for primary or recurrent aortic coarctation.

METHODS

This is a retrospective study of 30 adult patients who underwent thoracic stent graft placement for aortic coarctation at our institution. Average age was 46.5 years, with 53.3% of patients presented with no prior treatment or repair for coarctation. Indications for repair included gradient ≥20 mm Hg with anatomic evidence of coarctation on imaging with left ventricular hypertrophy, pseudoaneurysm, aneurysm, refractory hypertension, or claudication. Stent grafts used for repair included MDT (Medtronic, Santa Rosa, CA) and GORE TAG (W. L. Gore & Associates, Flagstaff, AZ).

RESULTS

Patients were observed for a median of 979 days, with one death during the study. All patients had complete resolution of symptoms with no recurrences. TEVAR significantly reduced the gradient across the coarctation (p <0.0001). Aortic coarctation diameter significantly increased at 30-days postoperatively and continued to increase up to 5 years post-treatment. At 3+ years, aortic remodeling was observed at the coarctation site and surrounding regions. At 30 days, systolic, diastolic, and mean arterial pressure were all reduced. Systolic and diastolic blood pressure as well as MAP continued to significantly improve 1-year post-treatment.

CONCLUSIONS

Stent grafts are a safe and effective treatment for aortic coarctation. We observed a clinically significant improvement in blood pressure, and longitudinal aortic remodeling of the coarctation segment and the entire aorta that persisted over more than 3 years.

Multicentric clinical evaluation of a computed tomography-based fully automated deep neural network for aortic maximum diameter and volumetric measurements

OBJECTIVE

This study aims to evaluate a fully automatic deep learning-based method (augmented radiology for vascular aneurysm [ARVA]) for aortic segmentation and simultaneous diameter and volume measurements.

METHODS

A clinical validation dataset was constructed from preoperative and postoperative aortic computed tomography angiography (CTA) scans for assessing these functions. The dataset totaled 350 computed tomography angiography scans from 216 patients treated at two different hospitals. ARVA's ability to segment the aorta into seven morphologically based aortic segments and measure maximum outer-to-outer wall transverse diameters and compute volumes for each was compared with the measurements of six experts (ground truth) and thirteen clinicians.

RESULTS

Ground truth (experts') measurements of diameters and volumes were manually performed for all aortic segments. The median absolute diameter difference between ground truth and ARVA was 1.6 mm (95% confidence interval [CI], 1.5-1.7; and 1.6 mm [95% CI, 1.6-1.7]) between ground truth and clinicians. ARVA produced measurements within the clinical acceptable range with a proportion of 85.5% (95% CI, 83.5-86.3) compared with the clinicians' 86.0% (95% CI, 83.9-86.0). The median volume similarity error ranged from 0.93 to 0.95 in the main trunk and achieved 0.88 in the iliac arteries.

CONCLUSIONS

This study demonstrates the reliability of a fully automated artificial intelligence-driven solution capable of quick aortic segmentation and analysis of both diameter and volume for each segment.

Practice Patterns and Barriers to Vascular Genetic Testing Among Vascular Surgeons

INTRODUCTION

Engaging patients living with or at risk of aortic dissection via the Aortic Dissection Collaborative, physician education in vascular genetics was identified as a research priority. We surveyed vascular surgeons to characterize practice patterns, motivations, and barriers regarding aortopathy genetic testing.

METHODS

An anonymous 27-question survey was distributed on social media platforms between November and December 2022. Domains included demographics, vascular genetic education, testing attitudes and utilization, and experience in treating patients with genetic vascular aortopathies. The analysis included summary statistics and unpaired t-test to compare responses by interest in incorporating testing and practice type.

RESULTS

A total of 171 vascular surgeons from 15 countries responded to the survey (23% trainees). Over half received vascular genetics education during training (59%), and most (86%) were interested in incorporating genetic testing into their practice. Academic surgeons were more likely to have cared for a patient with a known genetic aortopathy over the past year than surgeons in hospital-based and private practices (83% vs. 56% vs. 27%; P < 0.01), to have ever made a referral to a medical geneticist (78% vs. 51% vs. 9%; P < 0.01), and have access to genetic counselors or geneticists (66% vs. 46% vs. 0%; P < 0.01). Barriers to genetic testing were rated as more significant by surgeons in nonacademic practices, with top barriers being insurance coverage of testing, cost of genetic testing, and access to genetic counselors. Evidence-based professional society guidelines were the strongest rated motivating factor for testing incorporation among respondents.

CONCLUSIONS

Vascular surgeon attitudes are not major barriers to incorporating genetic testing for patients with aortopathies; however, practical challenges regarding genetic testing and counseling are barriers to implementation especially for vascular surgeons in nonacademic practices. Future efforts should focus on evidence-based society guidelines, continuing medical education to increase adoption, and facilitating access to genetic counseling.

Pediatric Chest Pain: A Review of Diagnostic Tools in the Pediatric Emergency Department

Pediatric chest pain is a common chief complaint in the emergency department. Not surprisingly, children with chest pain are usually brought to the emergency department by their parents out of fear of heart disease. However, chest pain in the pediatric population is generally a benign disease. In this review, we have identified musculoskeletal pain as the most prevalent etiology of chest pain in the pediatric population, accounting for 38.7-86.3% of cases, followed by pulmonary (1.8-12.8%), gastrointestinal (0.3-9.3%), psychogenic (5.1-83.6%), and cardiac chest pain (0.3-8.0%). Various diagnostic procedures are commonly used in the emergency department for cardiac chest pain, including electrocardiogram (ECG), chest radiography, cardiac troponin examination, and echocardiography. However, these examinations demonstrate limited sensitivity in identifying cardiac etiologies, with sensitivities ranging from 0 to 17.8% for ECG and 11.0 to 17.2% for chest radiography. To avoid the overuse of these diagnostic tools, a well-designed standardized algorithm for pediatric chest pain could decrease unnecessary examination without missing severe diseases.

Multiple Cardiac Diseases Involving the Aortic Arch: Beating Heart Debranching, and Normothermic Arch Replacement: A Case Series

(1) Background: Conventional open surgery is still the gold standard for aortic arch disease, and despite recent developments in optimizing strategies for neuroprotection, distal organ perfusion, and myocardial protection, aortic arch replacement is still associated with high morbidity and mortality rates. (2) Methods: We present our case series of 12 patients undergoing surgical management of multiple cardiac diseases involving the aortic arch. In this single-center study, we report our initial experience over a five-year period (from December 2018 to October 2023) with the use of a "debranching first" technique for the supra-aortic vessels of a beating heart, followed by the cardiac step addressing proximal diseases, and a final distal step treating the aortic arch. This strategy aims to minimize cardiac, cerebral, and peripheral ischemia. (3) Results: Six patients underwent aortic root replacement with either Bentall (n = 4) or valve-sparing aortic root (David procedure) (n = 2). The mean nasopharyngeal temperature was 34 °C and the mean cardiocirculatory arrest was 14.3 min. The early mortality was 8.3% (1 patient); no patient experienced a permanent neurologic event. (4) Conclusions: In patients with complex aortic disease and concomitant cardiac disease, this approach reduces the need for hypothermia and decreases cardiopulmonary bypass time and myocardial arrest time and therefore could represent a valid surgical option, even in high-risk patients.

Case Report: Transcatheter treatment of aortic coarctation in a 58-year-old patient with LACHT syndrome and left lung agenesis

LACHT (Lung Agenesis, Congenital Heart, and Thumb anomalies) syndrome is an extremely rare congenital anomaly and presents significant challenges in adults due to its poor survival rates. Herein, we report a case of late diagnosis and successful transcatheter treatment of aortic coarctation in a 58-year-old male patient with LACHT syndrome, medically resistant arterial hypertension, and left lung agenesis. Baseline CT angiography showed isthmic aortic coarctation and left lung agenesis, with compensatory right pulmonary artery and vein thickenings. The patient underwent balloon dilation and subsequent implantation of a covered NuMED 45 mm 8-ZIG CP stent with satisfactory outcomes. The pressure gradient decreased from 43 to 23 mmHg. The arterial pressures normalized during the follow-up with fewer medications. Genetic testing identified a heterozygous mutation (c.6583C > T) in the FBN2, supporting the diagnosis of variant Marfan syndrome.