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Thakker PD, Braverman AC. Cardiogenetics: genetic testing in the diagnosis and management of patients with aortic disease. Heart 2020; 107:619-626. [PMID: 33334864 DOI: 10.1136/heartjnl-2020-317036] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/01/2020] [Accepted: 11/12/2020] [Indexed: 12/30/2022] Open
Abstract
Thoracic aortic aneurysm and aortic dissection have a potent genetic underpinning with 20% of individuals having an affected relative. Heritable thoracic aortic diseases (HTAD) may be classified as syndromic (including Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome and others) or non-syndromic (without recognisable phenotypes) and relate to pathogenic variants in multiple genes affecting extracellular matrix proteins, transforming growth factor-beta (TGF-β) signalling and smooth muscle contractile function. Clinical and imaging characteristics may heighten likelihood of an underlying HTAD. HTAD should be investigated in individuals with thoracic aortic aneurysm or aortic dissection, especially when occurring in younger individuals, in those with phenotypic features and in those with a family history of aneurysm disease. Screening family members for aneurysm disease is important. Consultation with a medical geneticist and genetic testing of individuals at increased risk for HTAD is recommended. Medical management and prophylactic aortic surgical thresholds are informed by an accurate clinical and molecular diagnosis.
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Affiliation(s)
- Prashanth D Thakker
- Cardiovascular Division, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Alan C Braverman
- Cardiovascular Division, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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Herrman NWC, Hatton C, Fung C. Postpartum aortic dissection diagnosed by point-of-care ultrasound in the emergency department: A case study. Australas Emerg Care 2020; 23:193-195. [PMID: 32546393 DOI: 10.1016/j.auec.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/05/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
Aortic dissection is a rare but clinically significant cause of chest pain in the emergency department (ED). While classic risk factors include advanced age, male sex, and tobacco use, pregnancy is also an independent and easily overlooked risk factor. Aortic dissection carries both high maternal and fetal morbidity and mortality. Point-of-care ultrasound is increasingly employed in the ED and has been shown to be useful in the evaluation of abdominal aortic pathologies. We present a case in which abdominal aortic ultrasound was utilized in the diagnosis of an acute Stanford type B aortic dissection in a recently postpartum patient.
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Affiliation(s)
| | - Colman Hatton
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Christopher Fung
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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Kostadinovska B, Nikolic A, Slaveski D, Milojevic M. Acute aortic dissection in a patient with Marfan syndrome during advanced pregnancy. J Card Surg 2019; 35:499-502. [DOI: 10.1111/jocs.14408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Beti Kostadinovska
- Department of Cardiac SurgeryAcibadem Sistina Hospital Skopje North Macedonia
| | - Aleksandar Nikolic
- Department of Cardiac SurgeryAcibadem Sistina Hospital Skopje North Macedonia
| | - Dimche Slaveski
- Department of Cardiac SurgeryAcibadem Sistina Hospital Skopje North Macedonia
| | - Milan Milojevic
- Department of Cardiac SurgeryAcibadem Sistina Hospital Skopje North Macedonia
- Department of Cardiothoracic SurgeryErasmus University Medical Center Rotterdam The Netherlands
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Zhu JM, Ma WG, Peterss S, Wang LF, Qiao ZY, Ziganshin BA, Zheng J, Liu YM, Elefteriades JA, Sun LZ. Aortic Dissection in Pregnancy: Management Strategy and Outcomes. Ann Thorac Surg 2016; 103:1199-1206. [PMID: 27825688 DOI: 10.1016/j.athoracsur.2016.08.089] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Aortic dissection in pregnancy is a rare but lethal catastrophe. Clinical experiences are limited. We report our experience in 25 patients focusing on etiology, management strategies, and outcomes. METHODS Between June 1998 and February 2015, we treated 25 pregnant women (mean age, 31.6 ± 4.7 years) in whom aortic dissection developed at a mean of 28 ± 10 gestational weeks (GWs). Type A aortic dissection (TAAD) was present in 20 (80%) and type B (TBAD) in 5 (20%). Marfan syndrome was seen in 17 (68%). Management strategy was based on dissection type and GWs. RESULTS TAADs were managed surgically in 19 (95.0%) and medically in 1 (5.0%). Maternal and fetal mortalities were, respectively, 14.3% (1 of 7) and 0 (0 of 7) in the "delivery first" group (7 of 20), 16.7% (1 of 6) and 33.3% (2 of 6) in "single-stage delivery and aortic repair" group (6 of 20), 16.7% (1 of 6) and 66.7% (4 of 6) in "aortic repair first" group (6 of 20), and 100% (1 of 1) and 100% (1 of 1) in the "medical management" group (1 of 20). TBADs were managed surgically in 60% (3 of 5) and endovascularly and medically in 20% each (1 of 5). No maternal deaths occurred. Fetal mortality was 100% in the surgical group and 0% in the other groups. During late follow-up, which was complete in 95.2% (20 of 21), 3 maternal and 2 fetal deaths occurred in the TAAD group. Overall maternal survival was 68.6% at 5 years. CONCLUSIONS Marfan syndrome predominates among women with aortic dissection in pregnancy. For TAADs, after 28 GWs, delivery followed by surgical repair can achieve maternal and fetal survival adequately; before 28 GWs, maternal survival should be prioritized given the high risk of fetal death. For TBADs in pregnancy, nonsurgical management is preferred.
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Affiliation(s)
- Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China; Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
| | - Sven Peterss
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
| | - Long-Fei Wang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Zhi-Yu Qiao
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China.
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Ji J, Posenau JT, Lindley KJ, Braverman AC. Dissecting the Dilemma: Uncontrolled Hypertension in a Pregnant Patient. Am J Med 2016; 129:e1-3. [PMID: 26551983 DOI: 10.1016/j.amjmed.2015.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Joyce Ji
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Mo.
| | - J Trevor Posenau
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Mo; Cardiovascular Division, Washington University School of Medicine, St. Louis, Mo
| | - Kathryn J Lindley
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Mo; Cardiovascular Division, Washington University School of Medicine, St. Louis, Mo
| | - Alan C Braverman
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Mo; Cardiovascular Division, Washington University School of Medicine, St. Louis, Mo
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