Incidence and characteristics of hospitalization for proximal aortic surgery for acute syndromes and for aneurysms in the USA from 2005 to 2014

Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

Temporal trends in mortality of aortic dissection and rupture in the UK, Japan, the USA and Canada

OBJECTIVE

Aortic dissection and aortic aneurysm rupture are aortic emergencies and their clinical outcomes have improved over the past two decades; however, whether this has translated into lower mortality across countries remains an open question. The purpose of this study was to compare mortality trends from aortic dissection and rupture between the UK, Japan, the USA and Canada.

METHODS

We analysed the WHO mortality database to determine trends in mortality from aortic dissection and rupture in four countries from 2000 to 2019. Age-standardised mortality rates per 100 000 persons were calculated, and annual percentage change was estimated using joinpoint regression.

RESULTS

Age-standardised mortality rates per 100 000 persons from aortic dissection and rupture in 2019 were 1.04 and 1.80 in the UK, 2.66 and 1.16 in Japan, 0.76 and 0.52 in the USA, and 0.67 and 0.81 in Canada, respectively. There was significantly decreasing trends in age-standardised mortality from aortic rupture in all four countries and decreasing trends in age-standardised mortality from aortic dissection in the UK over the study period. There was significantly increasing trends in mortality from aortic dissection in Japan over the study period. Joinpoint regression identified significant changes in the aortic dissection trends from decreasing to increasing in the USA from 2010 and Canada from 2012. In sensitivity analyses stratified by sex, similar trends were observed.

CONCLUSIONS

Trends in mortality from aortic rupture are decreasing; however, mortality from aortic dissection is increasing in Japan, the USA and Canada. Further study to explain these trends is warranted.

Ascending thoracic aortic aneurysm size at presentation and growth by diameter

AIM

To investigate the hypothesis that lung cancer screening allows for earlier identification of ascending thoracic aortic aneurysms (aTAAs) and that growth rates for aTAAs are greatest at larger sizes.

MATERIALS AND METHODS

This single referral centre retrospective study manually gathered computed tomography (CT) data from 732 patients presenting from July 2002 to August 2022. Five hundred and seventeen patients with aTAA >39 mm were identified to compare presenting diameter by year of presentation. Four hundred and thirty-two patients had CT examinations >3 months apart, allowing for growth analysis. Patients were separated by initial examination date (before or after 12/31/2013) for presenting size comparison. Patients were then divided into five groups based on aTAA diameter for growth rate analysis.

RESULTS

At identification, patients had a median aTAA diameter of 44 mm (IQR 41-47 mm). Patients with aTAAs identified prior to December 2013 (n=129) had an average aTAA diameter 1.7 mm larger than those identified later (n=388; p=0.003). The growth analysis showed an average growth rate of 0.1 mm/year (p<0.001) across the entire cohort. Patients with an aTAA diameter of ≥55 mm (n=12) grew the fastest at 1.9 mm/year (p<0.001). In the <40 mm group (n=43), the aTAAs expanded at 0.2 mm/year, faster than the 0.1 mm/year of the slowest expanding 45-49 mm group (n=130; p=0.04).

CONCLUSION

aTAA size at discovery was larger before lung cancer screening guidelines took effect in December 2013. The largest aTAAs expanded fastest, but growth rates were slowest in the medium-sized 45-49 mm diameter group.

Genetic evidence for the causal linkage between telomere length and aortic aneurysm risk: A Mendelian randomisation study

BACKGROUND

Evidence of a clear causal relationship between telomere length and aortic aneurysms is limited by the potential for confounding or reverse causation effects. In this study, we used a Mendelian randomisation (MR) approach to investigate this putative causal association.

METHODS

In total, 118 telomere length-associated single-nucleotide polymorphisms, identified in 472,174 individuals of European ancestry, were used as the instrumental variables. Summary statistics for genome-wide association studies of aortic aneurysms were obtained from the FinnGen consortium. For the primary MR analyses, the inverse-variance weighted random-effects method was used and was supplemented with multivariable MR, weighted median and MR-Egger approaches. The MR-Egger intercept test, Cochran's Q test and 'leave-one-out' sensitivity analysis were performed to evaluate the horizontal pleiotropy, heterogeneity and stability of the genetic variants. Forward and reverse MR analyses were performed.

RESULTS

All forward univariable MR analyses showed that longer telomere lengths decreased aortic aneurysm risks (total aortic aneurysms: OR = 0.80, 95% CI 0.67-0.96, p = .015; thoracic aortic aneurysms: OR = 0.82, 95% CI 0.68-0.98, p = .026; abdominal aortic aneurysms: OR = 0.525, 95% CI 0.398-0.69, p < .001), whereas all reverse MR analyses suggested the absence of aortic aneurysm liability on telomere length. The sensitivity analysis results were robust, and no evidence of horizontal pleiotropy was observed.

CONCLUSIONS

Our results support a possible causal association between telomere length and aortic aneurysms, providing new insights into the involvement of telomere biology in this condition and offering a potential avenue for targeted therapeutic interventions.

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

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Elective ascending aortic aneurysm repair outcomes in a nationwide US cohort

OBJECTIVE

To quantify contemporary outcomes following elective ascending aortic aneurysm repair, to determine risk factors for adverse events and to evaluate difference by institutional surgical volume.

METHODS

We included all elective hospitalisations of adult patients with an ascending aortic aneurysm who underwent aneurysm repair in the Nationwide Readmissions Database between 2016 and 2019. The primary outcome was a composite of in-hospital mortality, stroke (ischaemic and non-ischaemic) and myocardial infarction (MI). We identified independent predictor of adverse events and investigated outcomes by institutional volume.

RESULTS

Among 12 043 patients (mean 62.8 years of age, 28.0% female), MI, stroke or in-hospital death occurred in 598 (4.9%) patients during the index admission (acute stroke: 2.7%, MI: 0.7%, in-hospital death: 2.0%). The strongest predictors of in-hospital death, stroke or MI were chronic weight loss, pulmonary circulation disorder and concomitant descending aortic surgery. Higher procedural volume was associated with a lower incidence of in-hospital death, stroke or MI (OR comparing the highest with the lowest tertile 0.71, 95% CI 0.57 to 0.87; p=0.001) and in-hospital death (OR 0.51, 95% CI 0.37 to 0.72; p<0.001), but no difference in 30-day readmissions.

CONCLUSIONS

The overall rate of in-hospital death, stroke and MI is nearly 5% in patients undergoing elective ascending aortic aneurysm repair. Among several predictors, chronic weight loss is associated with the largest increase in the risk of poor outcomes. Higher hospital volume is associated with a lower in-hospital mortality, highlighting the importance to refer patients to high-volume centres while discussing the risks and benefits of proceeding with repair.

Increased aortic repair in Germany correlates with reduction of death caused by aortic aneurysms but not aortic dissections

INTRODUCTION

We asked if there is a significant correlation between the increasing trend in aortic repair (AR) and decreasing aortic aneurysm (AA) and aortic dissection (AD) mortality? Therefore, we retrospectively analyzed all aortic repairs in patients with AA and AD and its correlation with disease-specific death rates and hospitalizations for ruptured AA and AD in Germany.

METHODS

We retrieved the number of cases hospitalized for AA and AD as well as the procedures in these cases from the Federal Bureau of Statistics (DRG statistics) and death rates from the national mortality statistic published by the Federal Statistical Office in Germany for the years 2006-2017.

RESULTS

From 2006 to 2017, the total number of hospitalized cases admitted with principal diagnosis of AA increased by 25.8% and that of AD by 56.7%. That of cases with the principal diagnosis of ruptured AA (rAA) remained unchanged (-2.5%) and that with rAD increased by 54.6%. The number of (open and endovascular) procedures in cases hospitalized for AA increased by 39.4% and for AD by 126.4%. The age-adjusted death rates in Germany for AA decreased from 4.0 to 2.9 per 100,000 inhabitants and that for AD increased from 1.0 to 1.4. The decrease in death attributed to AA cases can be described by linear regression as y = -0.0003*y + 6.7076 (p < 0.0001). Accepting this association between increased elective procedures and reduced AA mortality, each/all 1000 procedures save 0.3 lives per 100,000 inhabitants.

CONCLUSION

Despite increasing numbers of AR for AA and AD, only the mortality rate for all AAs decreased, while we did not observe a decrease in overall mortality of AD in Germany.

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

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

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

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Sex Differences in Trends in Incidence of Thoracic Aortic Aneurysm Repair and Aortic Dissection: 2005-2015

Background

The purpose of this study was to examine trends in the incidence of thoracic aortic aneurysm (TAA) repair and aortic dissection.

Methods

A retrospective study was conducted of patients from the period 2005-2015 with thoracic aortic disease. Unadjusted mortality was compared in women vs men. Rates of scheduled TAA repair, dissection events, acute type A aortic dissection (TAAD) repair, and aorta-related mortality were obtained from our institution's clinical registry and administrative data sources and used to calculate the age-adjusted incidence for each sex, adjusted to the Canadian standard population. Weighted linear regression was performed to analyze trends over time.

Results

A total of 382 scheduled TAA repair operations, 345 dissection events, 85 TAAD repairs, and 182 aorta-related mortalities were identified. Women accounted for 23% of TAA repairs, 39% of dissection events, 22% of TAAD repairs, and 45% of aorta-related mortalities. The incidence of TAA repair was 3.5 per 100,000 person-years (95% confidence interval [CI]: 3.2-3.9), and increased in men (P = 0.02) but not women (P = 0.10) over time. The incidence of aortic dissection was 3.4 per 100,000 (95% CI: 3.1-3.8) and was stable over time (P = 0.43). The average annual age-adjusted incidence of TAAD repair was 0.8 per 100,000 (95% CI: 0.6-1.0) and increased over time (P = 0.001). The overall incidence of aorta-related mortality was 1.8 per 100,000 (95% CI: 1.5-2.0) and decreased over time (P = 0.02).

Conclusion

The incidence of TAA repair is increasing in men but not women. Although aorta-related mortality is decreasing overall, disparities exist between the male and female population.

Extent of aortic replacement and operative outcome in open proximal thoracic aortic aneurysm repair

Objectives

There are few data to delineate the risk differences among open aortic procedures. We aimed to investigate the influence of the procedural types on the outcomes of proximal thoracic aortic aneurysm repair.

Methods

Among 1900 patients who underwent aortic replacement in our institution between 2005 and 2019, 1132 patients with aortic aneurysm who underwent a graft replacement of proximal thoracic aorta were retrospectively reviewed. Patients were divided into 4 groups based on the extent of the aortic replacement: isolated ascending aortic replacement (n = 52); ascending aortic replacement with distal extension with hemiarch, partial arch, or total arch replacement (n = 126); ascending aortic replacement with proximal extension with aortic valve or root replacement (n = 620); and ascending aortic replacement with distal and proximal extension (n = 334). "Eventful recovery," defined as occurrence of any key complications, was used as the primary end point. Odds ratios for inability to achieve uneventful recovery in each procedure were calculated using ascending aortic replacement as a reference.

Results

Overall, in-hospital mortality and stroke occurred in 16 patients (1.4%) and 24 patients (2.1%). Eventful recovery was observed in 19.7% of patients: 11.5% in those with ascending aortic replacement, 36.5% in those with partial arch or total arch replacement, 16.6% in those with proximal extension with aortic valve or root replacement, and 20.4% in those with distal and proximal extension (P < .001). With ascending aortic replacement as the reference, a multivariable logistic regression revealed partial arch or total arch replacement (odds ratio, 10.0; 95% confidence interval, 1.8-189.5) was an independent risk factor of inability to achieve uneventful recovery.

Conclusions

Open proximal aneurysm repair in the contemporary era resulted in satisfactory in-hospital outcomes. Distal extension was associated with a higher risk for postoperative complications.

Toward standard abbreviations and acronyms for use in articles on aortic disease

Objectives

Academic medical literature is fraught with complex article-specific acronyms and abbreviations that can impair communication and make reading arduous. Our goal is to ease frustration with bespoke, inconsistent, and variable sets of abbreviations that currently exist for common aorta-related terminology (eg, anatomy, imaging, disease, and therapy). We hope to ease reading and improve communication in the aortic sphere of cardiovascular literature.

Methods

We reviewed a total of 205 published references related to aortic disease, including a systematic review of aorta-related articles in the Journal of Thoracic and Cardiovascular Surgery from the years 2020 and 2021. The array of variable definitions, abbreviations, and acronyms encountered in different papers that refer to the same terminology was striking, revealing that there were few standardized abbreviations in the aortic literature. We cataloged these terms, their associated abbreviations, and their frequency of use, and compiled a list of proposed standard abbreviations for commonly used terms that could be implemented uniformly in articles written about aortic diseases.

Results

We present suggested acronyms and abbreviations for common terminology related to the aorta. It is anticipated that this standard list will evolve over time as the literature and technology of the field grows and develops.

Conclusions

A proposed standard set of acronyms and abbreviations for aorta-related terminology is provided that, if found useful, could be implemented broadly in the aortic literature.

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.

Development and Validation of a Predictive Model to Identify Patients With an Ascending Thoracic Aortic Aneurysm

Background

Screening protocols do not exist for ascending thoracic aortic aneurysms (ATAAs). A risk prediction algorithm may aid targeted screening of patients with an undiagnosed ATAA to prevent aortic dissection. We aimed to develop and validate a risk model to identify those at increased risk of having an ATAA, based on readily available clinical information.

Methods and Results

This is a cross‐sectional study of computed tomography scans involving the chest at a tertiary care center on unique patients aged 50 to 85 years between 2013 and 2016. These criteria yielded 21 325 computed tomography scans. The double‐oblique technique was used to measure the ascending thoracic aorta, and an ATAA was defined as >40 mm in diameter. A logistic regression model was fitted for the risk of ATAA, with readily available demographics and comorbidity variables. Model performance was characterized by discrimination and calibration metrics via split‐sample testing. Among the 21 325 patients, there were 560 (2.6%) patients with an ATAA. The multivariable model demonstrated that older age, higher body surface area, history of arrhythmia, aortic valve disease, hypertension, and family history of aortic aneurysm were associated with increased risk of an ATAA, whereas female sex and diabetes were associated with a lower risk of an ATAA. The C statistic of the model was 0.723±0.016. The regression coefficients were transformed to scores that allow for point‐of‐care calculation of patients' risk.

Conclusions

We developed and internally validated a model to predict patients' risk of having an ATAA based on demographic and clinical characteristics. This algorithm may guide the targeted screening of an undiagnosed ATAA.

Proximal aortic repair in asymptomatic patients

Objective

Current guidelines for elective proximal aortic repair are applicable to elective first-time procedures in asymptomatic patients without other primary indications or connective tissue disorders and with specified aortic diameter or growth rate. The objective was to characterize the surgical outcomes in this narrowly defined patient-population.

Methods

Guideline-compliant patients were identified from a recent (2014-2019) single unit consecutive surgical cohort (n = 935) by excluding total arch replacements, redos, acute and symptomatic patients, and genetic syndromes. Remaining patients were included regardless of surgical procedure performed. Early (30-day or in-hospital) and 1-year mortality were primary outcome measures. Major complications (stroke, severe renal or respiratory insufficiency, postcardiotomy shock, deep sternal wound infection, permanent pacemaker, and re-exploration) up to 1 year postoperatively were secondary outcome measures.

Results

In the resulting study population (n = 262), median age was 63 (interquartile range, 52-71) years, and median surgical risk (European System for Cardiac Operative Risk Evaluation II) was 3.2% (2.0%-4.4%). Early mortality was 2 of 262 (0.76%) without additional deaths up to 1-year postoperatively. The occurrence of major complications was low: stroke, 2 (0.76%); renal insufficiency, 2 (0.76%); respiratory insufficiency, 1 (0.38%); postcardiotomy shock, 1 (0.38%); deep sternal wound infection, 0; permanent pacemaker, 3 (1.1%); and re-exploration, 20 (7.6%), all occurring in the immediate (30-day) postoperative period and without additional events up to 1 year postoperatively.

Conclusions

In this recent cohort including the target population referred to by and managed in accordance with current guidelines, mortality and major complications were exceptionally infrequent. Guidelines should adequately weigh risks of conservative management against current surgical outcomes.