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

Demographics and outcomes of acute type A aortic dissection in young adults in southeastern China: impact of syndromic heritable thoracic aortic disease

BACKGROUND

This study aimed to investigate the demographics and to evaluate long-term outcomes of acute type A aortic dissection (ATAAD) in surgically treated patients ≤40 years in China.

METHODS

This study included patients aged ≤40 with ATAAD who underwent surgical treatment at our institution between 2015 and 2019. The patients were categorized into groups according to heritable thoracic aortic disease (HTAD) presence or absence. The primary outcomes were in-hospital and late mortality, and aortic-related re-intervention.

RESULTS

Our cohort included 141 patients aged ≤ 40, representing 14.6% of all patients with ATAAD treated during the same period. 35.5% (50 of 141) of these cases were associated with HTAD. Among them, only 16.0% were aware of their condition prior to the occurrence of ATAAD. Most patients underwent extensive arch procedures and in-hospital mortality rate of patients was 14.2%, which was higher in the HTAD group than in the non-HTAD group (20.0% vs. 11.0%, p = .142). The overall 7-year survival was 80.0%. Twenty patients required late aortic reoperations, with emergency surgeries accounting for 45% of the cases. The incidence of reoperation was significantly higher in the HTAD group than that in the non-HTAD group (p = .03). In addition, the late aortic reoperation remained a risk factor for long-term survival after adjusting for clinical factors.

CONCLUSIONS

The prevalence of HTAD is high in the cohort of younger patients with ATAAD. HTAD is associated with high rates of in-hospital mortality and late reoperation. Extensive primary aortic repair is safe and has long-term benefits in young patients with ATAAD. Regular imaging assessment of the thoracoabdominal aorta after surgery is imperative for improving the long-term prognosis.

Successful open three-stage repair of multifocal aortic aneurysms in a 34-year-old

Open replacement of multifocal aortic aneurysms is an operative and clinical challenge. Thoughtful consideration of both surgical technique and timing is important to reduce risk of major cardiovascular and neurologic complications. We discuss the management of a 34-year-old male with suspected connective tissue disease admitted with multifocal, giant aneurysms of his right subclavian artery, ascending and aortic arch, descending and abdominal aorta, and right iliac artery. A complex, open three-stage repair was undertaken. Genetic testing revealed a missense MYH11 mutation. We describe our approach and patient outcome.

Giant ascending aortic aneurysm: A rare case report

A giant ascending aortic aneurysm (AscAA), defined as an aneurysm larger than 10 cm, is a rare and potentially life-threatening condition that often remains asymptomatic until it reaches a critical size. Atherosclerosis is the most common cause in elderly patients, and imaging plays a crucial role in diagnosis and management. In this case, a 72-year-old man presented with intermittent sharp chest pain radiating to the back, progressive hoarseness over 5 years, and shortness of breath. Imaging revealed a 12.51 cm × 11.27 cm × 10.0 cm saccular aneurysm with calcified plaques, consistent with a Stanford Type A aortic aneurysm and underlying atherosclerosis. Surgical intervention remains the only definitive treatment, although it carries significant risks. Early diagnosis, timely surgical intervention, and postoperative surveillance are critical in improving patient outcomes for this high-risk condition.

Imaging for Thoracic Aortic Dissections and Other Acute Aortic Syndromes

Imaging for aortic dissections and other acute aortic syndromes relies heavily on computed tomography (CT) scans. There is an ongoing need to educate providers and imaging specialists regarding the different protocols for CT scans and the heightened value of aortic protocol scans for acute aortic syndromes. Current dissection guidelines recommend the treatment for patients with acute aortic syndromes be performed at a high-volume center by a multidisciplinary team that includes an imaging specialist. MRI and echocardiography can provide additional information and possibly at lower radiation exposure compared to CT scans. All imaging modalities are evolving with new and future uses and capabilities.

The effect of aneurysm diameter on perioperative outcomes following complex endovascular repair

OBJECTIVES

Endovascular aneurysm repair (EVAR) for large infrarenal abdominal aortic aneurysms (AAAs) has been associated with worse outcomes compared with EVAR for smaller AAAs. Whether these findings apply to complex AAAs (cAAA) remains uncertain.

METHODS

We identified all intact complex EVAR (cEVAR) from 2012 to 2024 in the Vascular Quality Initiative. cEVAR was defined as having a proximal extent between zones 6 and 9 and at least one side branch/fenestration/chimney/parallel grafting. Aneurysm size was defined as follows: large: >65 mm (males), >60 mm (females); medium: 55 to 65 mm (males), 50 to 60 mm (females); and small: <55 mm (males), <50 mm (females). We assessed perioperative death, any complication, and in-hospital reintervention using logistic regression and midterm mortality using adjusted Kaplan-Meier methods and Cox regression analyses. Medium-sized aneurysms were compared with large and small aneurysms.

RESULTS

Of the 3426 patients, 22.6% had large, 60.4% medium, and 17.0% had small aneurysms. As compared with medium and small aneurysms, large aneurysms demonstrated higher rates of perioperative death (4.8% vs 2.6% vs 0.5%), any complication (33.3% vs 23.6% vs 19.4%), and in-hospital reintervention (6.2% vs 4.0% vs 2.6%) (all P < .05). The median follow-up was 445 days. One-year mortality rates were higher in large aneurysms (12.3% vs 7.8% vs 3.8%; P < .001). After adjustment, when compared with medium-sized aneurysms, large aneurysms were associated with a significantly higher risk of perioperative death (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.09-2.72), any complication (aOR, 1.44; 95% CI, 1.18-1.76), and midterm mortality (adjusted hazard ratio, 1.50; 95% CI, 1.19-1.88), but not in-hospital reintervention (aOR, 1.46; 95% CI, 0.99-2.13). Although small aneurysms, as compared with medium-sized aneurysms, did not demonstrate a difference in any complication (aOR, 0.87; 95% CI, 0.68-1.10), in-hospital reintervention (aOR, 0.77; 95% CI, 0.42-1.33), and midterm mortality (adjusted hazard ratio, 0.78; 95% CI, 0.57-1.08], they did demonstrate a lower risk of perioperative death (aOR, 0.26; 95% CI, 0.06-0.71).

CONCLUSIONS

In cEVAR for cAAA, large aneurysms, compared with medium-sized aneurysms, were associated with higher rates of perioperative death, any complication, and midterm mortality, with in-hospital reinterventions trending toward a statistically significant higher risk. Although these results align with expectations, they emphasize the importance of effectively managing patients with large cAAAs and highlight the need for future research to determine whether patients might benefit more from medical therapy or open repair.

Association between brominated flame retardants and heart failure in U.S. adults: A cross-sectional analysis of national health and nutrition examination survey 2005-2016

BACKGROUND

Brominated flame retardants (BFRs) are environmental pollutants widely used in consumer products, which accumulate in human tissues. Despite their prevalence, the potential impact of BFRs on cardiovascular health, particularly heart failure (HF), remains insufficiently explored.

OBJECTIVES

This study aims to investigate the association between BFR exposure and the prevalence of HF in U.S. adults.

METHODS

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2005-2016. To assess the relationship between BFR exposure and HF prevalence, weighted generalized linear regressions (GLMs) were applied. Restricted cubic splines (RCS) were used to examine potential nonlinear associations. Additionally, quantile-weighted quantile sum (WQS) regression and quantile g-computation (QGC) analysis were performed to evaluate the overall effect of BFR mixtures on HF.

RESULTS

A total of 6,931 individuals participated, with 219 diagnosed with HF. In the adjusted Model 3, BFRs including PBDE28, PBDE47, PBDE85, PBDE99, PBDE100, PBDE154, and PBB153 were significantly associated with increased odds of HF (all p < 0.05). RCS analysis revealed a significant nonlinear relationship between serum BFRs and HF. The WQS analysis showed a positive association between combined BFR exposure and HF (OR: 1.694; 95 % CI: 1.264, 2.270; p < 0.001), and QGC analysis similarly showed a significant positive association (OR: 1.365; 95 % CI: 1.094, 1.705; p = 0.006).

CONCLUSION

This study suggests a link between BFR exposure and an increased risk of HF. Further research is needed to explore the causal relationship and underlying mechanisms.

Management of Acute Type A Aortic Dissection

This article reviews the management of acute type A aortic dissection (ATAAD), from initial temporizing medical therapy to the technical aspects of urgent surgical repair, which is the definitive treatment for ATAAD. Surgical repair and the extent of aortic resection and replacement are dictated by the location and extent of intimal tears, as well as aneurysmal dilation of the aorta. Cardiopulmonary bypass, hypothermic circulatory arrest, and cerebral perfusion are major considerations in management of this acute process. Several techniques pertinent to each portion of the involved aorta and relevant intraoperative management points are also discussed.

Elective Aortic Surgery for Prevention of Aortic Dissection in Turner Syndrome: The Potential Impact of Updated European Society of Cardiology and International Turner Syndrome Consensus Group Guidelines on Referrals to the Heart Team

OBJECTIVE

The risk of aortic dissection is increased in Turner Syndrome (TS). Aortic dilation is thought to contribute to this risk and may be managed with elective aortic surgery. New TS guidance has lowered the aortic size thresholds for consideration of aortic surgery. We investigated the impact of new guidance on potential heart team referrals in a UK cohort of TS individuals.

METHODS

A cross-sectional study of 156 individuals with TS was performed. Up to date transthoracic echocardiography or cardiac MRI derived aortic dimensions, anthropometric data and the presence of aortic dissection risk factors were analysed.

RESULTS

Twenty-one individuals (13%) met updated guideline criteria for consideration of aortic surgery, 15 more than met 2016 TS guideline criteria. Use of aortic size index (ASI) and aortic height index (AHI) together identified additional individuals meeting criteria for surgical consideration compared with the use of ASI or AHI alone. Z-score identified no additional individuals for surgical consideration, nor did it reclassify any individuals into moderate or severe aortic dilation groups. Twelve of 13 individuals with moderate aortic dilation met criteria for surgical consideration due to the presence of additional risk factors for aortic dissection. There was no positive correlation between height or body surface area and ascending aorta diameter in this cohort.

CONCLUSIONS

New TS guidelines are likely to significantly increase the number of individuals with TS who might be considered for elective aortic surgery. Centres caring for individuals with TS should re-evaluate their TS cohorts for aortic dissection risk considering these new guidelines.

Aortic Dissections-Postoperative Care and Considerations

Postoperative care following aortic dissection is a multidisciplinary effort, which is enhanced by the presence of an experienced team. Overall outcomes, including survival, are correlated with the early postoperative course and presence of complications such as malperfusion. Despite improvements, in-hospital mortality remains high. Patients who do survive to hospital discharge have a positive prognosis; however, additional interventions for progression of aortic disease may be required. Discharge recommendations for patient care are largely institution and provider dependent due to limited data driven guidelines. Further study is warranted into these areas as well as health related quality of life following aortic dissection.

Thoracic Aorta Measurements Using Intraoperative Transesophageal Echocardiography: Validation via Cardiac Magnetic Resonance

OBJECTIVES

To examine the association and magnitude of agreement between intraoperative transesophageal echocardiography (TEE) and cardiac magnetic resonance imaging (CMR) on aortic diameter measurements, to guide perioperative decision making for ascending aortic aneurysms.

DESIGN

This prospective study included patients with an ascending aortic aneurysm undergoing surgical ascending aortic repair using a prosthetic graft between February 2018 and December 2019. Intraoperative TEE in 2-dimensional (2D) and 3-dimensional (3D) views were obtained and assessed relative to preoperative cine-CMR and contrast-enhanced 3D magnetic resonance angiography.

SETTING

Weill Cornell Medicine, a single large academic medical center.

PARTICIPANTS

Thirty patients undergoing ascending aortic repair using a prosthetic graft (polyethylene terephthalate [Dacron]) without severe aortic valve disease (stenosis or regurgitation).

INTERVENTIONS

CMR, TEE, and ascending aortic repair using prosthetic grafts.

MEASUREMENTS AND MAIN RESULTS

TEE-derived measurements correlated significantly with CMR at all aortic segments: root (r = 0.94-0.97; p < 0.001 for all), ascending (r = 0.95-0.98; p < 0.001 for all), arch (r = 0.88; p < 0.001), and descending (r = 0.91; p < 0.001). Bland-Altman analyses showed small mean differences between 2D and 3D TEE versus CMR (range, 0.05-0.22 cm and 0.04-0.18 cm, respectively), with narrow limits of agreement at all segments, although TEE underestimated CMR-derived measurements.

CONCLUSIONS

This study demonstrates the feasibility of intraoperative TEE to accurately measure aortic diameters in patients with ascending aortic aneurysms. The excellent correlations with CMR and small mean differences with narrow limits of agreement support intraoperative TEE to guide surgical decision making for possible aortic replacement.

Recommendations for Design, Execution, and Reporting of Studies on Experimental Thoracic Aortopathy in Preclinical Models

There is a recent dramatic increase in research on thoracic aortic diseases that includes aneurysms, dissections, and rupture. Experimental studies predominantly use mice in which aortopathy is induced by chemical interventions, genetic manipulations, or both. Many parameters should be deliberated in experimental design in concert with multiple considerations when providing dimensional data and characterization of aortic tissues. The purpose of this review is to provide recommendations on guidance in (1) the selection of a mouse model and experimental conditions for the study, (2) parameters for standardizing detection and measurements of aortic diseases, (3) meaningful interpretation of characteristics of diseased aortic tissue, and (4) reporting standards that include rigor and transparency.

Aortic valve-sparing operation at concomitant aortic root and total aortic arch replacement

OBJECTIVE

Sparing aortic valve during combined aortic root replacement (ARR) and total aortic arch replacement (TAR) adds surgical complexity; however, the long-term outcomes are unknown. We examine the safety of aortic valve-sparing during these operations.

METHODS

To include patients who were potentially eligible for valve-sparing procedures, aortic stenosis, endocarditis, and previous aortic valve surgery were excluded, leaving 81 patients who underwent ARR and TAR between 2004 and 2021 at 2 major aortic centers. Overall, 34 underwent valve-sparing aortic root replacement (VSRR) and 47 underwent composite valve graft root replacement (CVG). The primary endpoint was uneventful recovery: a composite endpoint describing any patient discharged from the hospital without mortality or any postoperative complications including stroke, re-operation for bleeding, prolonged ventilation, or acute renal failure. Secondary endpoints were long-term survival and cardiovascular reintervention at 12 years.

RESULTS

VSRR was more frequently performed in younger patients with connective tissue disorder (P = 0.006) and less than moderate aortic insufficiency (P = 0.002). VSRR had longer cross-clamp time (243, [200-286] vs. 216, [181-250] minutes, P = 0.032). In-hospital mortality (VSRR: 5.9% vs CVG: 10.6%, P = 0.693) and uneventful recovery (VSRR: 47.1% vs CVG: 44.7%, P = 1.000) were not different. Multivariable Logistic regression showed that VSRR was not associated with the uneventful recovery (OR 1.165, 95% CI [0.356-3.814], P = 0.801). Twelve-year survival (VSRR: 80.8% [63.1-100.0%] vs. CVG: 66.3% [47.9-91.7%]; P = 0.320) and the incidence of reintervention (VSRR: 39.0% [19.0-59.0%] vs. CVG: 39.0% [16.0-61.0%], P = 0.820) were similar between groups.

CONCLUSION

In appropriately selected patients requiring concomitant ARR and TAR, aortic valve-sparing operation may be performed safely.

Height Index and Diameter as Predictors of Outcomes in Males With Abdominal Aortic Aneurysms

INTRODUCTION

Abdominal aortic aneurysms (AAAs) affect over 1 million adults in the United States, with current guidelines recommending elective repair for males at diameters greater than 5.5 cm. While aneurysm diameter (AD) remains the primary predictor of rupture in men, indexed measurements such as the aortic size index (ASI) and aortic height index (AHI) may improve risk stratification. This study aims to evaluate the association between AD, ASI, and AHI with aortic-related complications in male patients following elective AAA repair.

METHODS

We conducted a single-center retrospective cohort study between 2014 and 2024 in male patients who underwent open or endovascular (endovascular aneurysm repair or fenestrated-endovascular aneurysm repair) AAA repair. Ruptured and saccular aneurysms were excluded. The primary outcome was 30-d and mid-term follow-up aortic-related complications and reintervention. Bivariate analysis was performed between the outcomes and stratified ASI (>2, >2.5, >3, and >3.5), AHI (>2.5, >3, >3.5, and >4), and AD in cm (>5, >5.5, >6, and >6.5 cm). Cox regression analysis was performed between each index as a continuous variable and each outcome. Area under the receiver operating characteristic curve analysis was conducted, and cumulative proportions were calculated.

RESULTS

Two hundred male patients were included with a mean age of 74.3 ± 8.5 y. Bivariate analysis demonstrated no significant association between ASI, AHI, or AD categories and 30-d aortic-related complications. During follow-up (mean: 2.6 ± 2.8 y), larger AD at the time of repair was significantly associated with an increased rate of aortic-related complications (AD > 5.5 cm: P = 0.01; >6 cm: P = 0.02; >6.5 cm: P = 0.02) and reinterventions at mid-term (AD > 5.5 cm: P = 0.02; >6 cm: P = 0.02; >6.5 cm: P = 0.01). In Cox regression analysis, AD (hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.41-3.2) and AHI (HR: 3.26, 95% CI: 1.47-7.22) were independently associated with mid-term aortic-related complications. Similarly, AD (HR: 1.72, 95% CI: 1.20-2.47) and AHI (HR: 2.21 95% CI: 1.13-4.32) were independently related to reinterventions at mid-term. Cumulative proportions for 30-d complications were 66.7%, 38.5% for mid-term complications, and 39.1% for reinterventions at a 5.5 cm AD, which was equivalent to ASI of 3.2 cm/m2 and AHI of 2.9 cm/m for 30-d complications and ASI of 2.35 cm/m2 and AHI of 2.9 cm/m for both mid-term complications and reinterventions.

CONCLUSIONS

Larger AD at the time of repair was associated with increased rates of mid-term aortic-related complications and reinterventions for diameters exceeding 5.5 cm. Cox regression analysis identified AD and AHI as independent predictors of mid-term complications and reinterventions. Indexed metrics for risk stratification promote personalized management approaches for AAA repair.

Lp(a): A clinical review

Elevated lipoprotein(a) (Lp[a]) is a genetically determined cardiovascular risk factor, linked to both atherosclerotic cardiovascular disease and aortic stenosis. Elevated Lp(a) is widely prevalent, and consequently, several cardiovascular societies now recommend performing Lp(a) screening at least once in all adults. While there are presently no approved drugs specifically aimed at lowering Lp(a), several promising candidates are currently in the drug development pipeline, and many of these are now undergoing late phase clinical trials. In this comprehensive review, we outline Lp(a) biology and genetics, describe Lp(a)'s relationship to various cardiovascular clinical phenotypes of interest, highlight novel Lp(a)-lowering therapies, and outline what role these may have in future clinical practice.

Circumferential Stanford Type A Acute Aortic Dissection with Proximal Intimo-Intimal Intussusception: A Case Report and Literature Review

BACKGROUND Circumferential acute aortic dissection is a rare and fatal condition. We present a surgical case of a 76-year-old woman presenting with Stanford type A acute aortic dissection with intimo-intimal intussusception. CASE REPORT A 76-year-old woman living on a remote island with no significant medical history visited a local general hospital because of sudden anterior thoracic strangulation. Contrast-enhanced computed tomography revealed Stanford type A acute aortic dissection, and the patient requested helicopter transport to our hospital for surgery. During preparation for transport, the patient's level of consciousness decreased, shock vitals were observed, and she was intubated at the hospital. The patient arrived at the hospital approximately 5 h after the request for transportation, and surgery was started immediately. Following anesthesia induction, transesophageal echocardiography showed that the intima was in a to and fro state. Inspection of the ascending aorta revealed that the intima was completely circumferentially dissected and that the inverted intima was entrapped in the left ventricle. The dissection extended into the sinus of Valsalva; however, because the intima of the bilateral coronary arteries was normal, Bio-Glue was applied to the false lumen of the sinus of Valsalva for adequate repair, and ascending aortic replacement was performed using a 26-mm graft. CONCLUSIONS In this case, the dissection progressed during transport, and the patient experienced intimo-intimal intussusception, leading to shock. In such cases, swift transportation should be prioritized, and immediate surgical intervention is necessary.

Using Genomics to Develop Personalized Cardiovascular Treatments

Advances in genomic technologies have significantly enhanced our understanding of both monogenic and polygenic etiologies of cardiovascular disease. In this review, we explore how the utilization of genomic information is bringing personalized medicine approaches to the forefront of cardiovascular disease management. We discuss how genomic data can resolve diagnostic uncertainty, support cascade screening, and inform treatment strategies. The role that genome-wide association studies have had in identifying thousands of risk variants for polygenic cardiovascular diseases, and how these insights, harnessed through the development of polygenic risk scores, could advance personalized risk prediction beyond traditional clinical algorithms. We detail how pharmacogenomics approaches leverage genotype information to guide drug selection and mitigate adverse events. Finally, we present the paradigm-shifting approach of gene therapy, which holds the promise of being a curative intervention for cardiovascular conditions.

Performance and costs of rule-out protocols for acute aortic syndromes: analysis of pooled prospective cohorts

BACKGROUND

Acute aortic syndromes (AAS) are deadly conditions causing unspecific symptoms, such as chest/abdominal/back pain, syncope and neurological deficit. They are diagnosed with computed tomography angiography (CTA), but the patient selection is challenging. To support physicians and standardize management, protocols combining a clinical score with D-dimer (DD) have been developed. However, direct comparison of their diagnostic performance and cost-effectiveness is lacking.

METHODS

We used individual patient data from 3 prospective diagnostic studies of patients with suspected AAS, enrolled in 12 centers from 5 countries. Diagnostic accuracy, failure rate and costs were calculated for 5 protocols, applying 3 scores (aortic dissection detection [ADD], AORTAs and Canadian) and 2 DD thresholds (500 ng/mL [DD500], age-adjusted [DDage]). Costs were estimated using Italian and German reimbursements.

RESULTS

Among 4907 patients, 506 (10.3 %) had an AAS. The sensitivity of the diagnostic protocols ranged from 97.6 % for Canadian/DD500 to 99.4 % for AORTAs/DD500 or DDage (P = 0.022). The specificity was lowest for AORTAs/DD500 (46.8 %; P < 0.001 vs AORTAs/DD500) and highest for ADD/DDage (61.5 %; P < 0.001). The number of potential AAS misses was 4-fold higher with Canadian/DD500 vs AORTAs/DD500 or DDage. The net clinical benefit was highest for ADD/DDage. All protocols reduced CTA exams and costs over a CTA-to-all strategy. Numbers of predicted CTA exams and costs per 100 patients were lowest for ADD/DDage (447 CTAs, 34,366 EUR) and highest (579 CTAs, 43,628 EUR) for AORTAs/DD500.

CONCLUSIONS

Guideline-compliant clinical score/DD based protocols are highly sensitive. Differences in specificity and efficiency are present. Data may guide decision-making based on policies and resources.

Optimal Management of Spontaneous Aortic Thrombus Floating in the Ascending Aorta, from a Single Case Experience to a Literature Review

As spontaneous ascending aortic thrombi (AATs) are uncommon in modern clinical practice, despite the application of new technology and the widespread use of contrast-enhanced computer tomography during primary assessments in patients without underlying predisposing conditions, a thrombus floating in the ascending aorta is rarely discovered in a timely manner; moreover, the ascending tract represents an unusual site for thrombus formation. The clinical presentation of AATs is also often in the form of peripheral arterial embolization, which can cause a wide variety of symptoms, from stroke to limb ischemia, and thus delay correct diagnosis. Medical management is a risky strategy, while surgical treatment is usually challenging due to the risk of thrombus dislodgement and difficulties related to prior embolization complication management. In this study, faced with a peculiar case of embolic stroke in an otherwise healthy 71-year-old woman, we analyzed the status of knowledge on spontaneous ascending aortic thrombus treatments and outcomes. A multidisciplinary approach represents the best choice for defining a patient's timing of surgery and ensuring the management of complications. Sequential multistage treatment minimizes further complications and prevents worsening patient outcomes, leading to the best management for every possible clinical presentation. A less invasive surgical approach could lead to complete resolution of the pathology, avoiding further potentially lethal complications, facilitating postoperative management, avoiding delayed treatments, and resulting in better outcomes.

Pregnancy-Related Heart Disease in the Emergency Department

Pregnancy induces significant physiologic changes that impact the cardiovascular system, potentially exacerbating pre-existing cardiac conditions or precipitating new illnesses. Pregnant patients with cardiac emergencies pose unique challenges, as standard interventions may pose risks to the developing fetus. This article aims to enhance emergency physicians' confidence in managing pregnancy-related cardiac emergencies by providing a structured approach to initial evaluation and stabilization. We review eight common categories of pregnancy-associated cardiac illness: gestational hypertension and pre-eclampsia, cardiomyopathy, arrhythmias, valvular disease, aortopathies, congenital heart disease and pulmonary hypertension, coronary disease, and anticoagulation-related complications. For each condition, we summarize relevant pregnancy-specific pathophysiology and outline evidence-based, personalized emergency management strategies.

Sex Differences in Peripheral Vascular Disease: A Scientific Statement From the American Heart Association

Sex differences in the risk factors, diagnosis, treatment, and outcomes of patients with cardiovascular disease have been well described; however, the bulk of the literature has focused on heart disease in women. Data on sex differences in peripheral vascular disease are ill defined, and there is a need to report and understand those sex-related differences to mitigate adverse outcomes related to those disparities. Although peripheral vascular disease is a highly diverse group of disorders affecting the arteries, veins, and lymphatics, this scientific statement focuses on disorders affecting the peripheral arteries to include the aorta and its branch vessels. The purpose of this scientific statement is to report the current status of sex-based differences and disparities in peripheral vascular disease and to provide research priorities to achieve health equity for women with peripheral vascular disease.

Aorta Wall Stress during Exercise in Patients with an Ascending Thoracic Aortic Aneurysm: Insights from a Case Series

Individuals with ascending thoracic aortic aneurysm (ATAA) are recommended to avoid intense exercise for fear of marked increases in aortic wall stress (AWS). However, no study has measured AWS during exercise. The aim of this case series was to examine AWS during "light-to-moderate" aerobic exercise in individuals with ATAA and healthy control (CON) participants.Three clinically stable patients with ATAA (2 male, mean age: 74 ± 1 years) and 3 CON (2 male, mean age: 69 ± 7 years) were studied on 2 separate days. Day 1: a maximal cardiopulmonary exercise test was performed to measure peak aerobic power (VO2peak), maximal heart rate, and blood pressure (BP). Day 2: cardiac and aortic magnetic resonance imaging were performed at rest and during submaximal (3-5 metabolic equivalents) "stepper" exercise during which cardiac output (Qc), aorta diameters, wall thickness, and BP were measured. Circumferential ascending and descending AWS were calculated in accord with LaPlace Law, whereas aorta mechanical efficiency was derived as the AWS/Qc slope.Patients with ATAA demonstrated lower median VO2peak (18.2 vs. 24.1 mL/kg/min). During exercise, the absolute ascending (ATAA: 257 vs. CON: 269 kPa) and descending AWS increased (ATAA: 224 vs. CON: 207 kPa), and ∆AWS during exercise was similar between ATAA and CON (Ascending, ATAA: 79 vs. CON: 62 kPa; Descending, ATAA: 64 vs. CON: 55 kPa). During exercise, ascending and descending AWS were 76 to 83% below ATAA rupture thresholds (i.e., 800-1,200 kPa) in all patients. Finally, exercise Qc was 17% lower and the ascending AWS/Qc slope was 30% higher in ATAA (16 kPa/L/min) versus CON (12 kPa/L/min).Our findings demonstrate "light-to-moderate" aerobic exercise produces similar AWS responses between ATAA and CON and is well below aneurysmal rupture thresholds. The higher AWS/Qc slope in ATAA suggests decreased aortic mechanical efficiency and may be a useful measure for exercise prescription for these patients.

Spinal cord protection by normothermic artery bypass and visceral-anastomosis-first strategy in thoracoabdominal aortic aneurysm repair

BACKGROUND

Spinal Cord Injury is a disastrous complication of thoracoabdominal aortic aneurysm surgery. This study is to assess the effectiveness and safety normothermic artery bypass and visceral-anastomosis-first strategy for thoracoabdominal aortic aneurysm repair.

METHODS

Normothermic artery bypass and visceral-anastomosis-first strategy prioritizes the reconstruction of visceral and other distal vessels, with intercostal arteries serving as the physiological blood supply at high pressure during this period. Reconstruction of intercostal arteries and proximal anastomosis is then performed, ensuring the longest possible physiological blood supply to the spinal cord. From July 2019 to December 2023, we retrospectively analyzed early postoperative complications in two groups of patients undergoing thoracoabdominal aortic aneurysm repair using the new strategy compared to normothermic iliac artery perfusion, clarifying the protective effects of the new strategy on visceral organs, especially the spinal cord.

RESULTS

The incidence of paraplegia was significantly lower in the NABP group than in the normothermic iliac perfusion (NIP) group (0.00% vs. 9.72%, p = 0.047), and the duration of postoperative mechanical ventilation was significantly lower in the NABP group than in the NIP group (p = 0.004). In addition, we found that the incidence of gastrointestinal adverse events was significantly lower in the NABP group than in the NIP group (7.32% vs. 45.83%, p < 0.001). Typically, patients' lactate levels returned to normal within approximately 48 h postoperatively. Although not statistically significant, lactate fell to normal more quickly in the NABP group after surgery.

CONCLUSIONS

The treatment of thoracoabdominal aortic aneurysm through open surgery is still an important method and remains difficult. The data we have suggests that our approach of normothermic artery bypass and visceral-anastomosis-first strategy can lower the risk of spinal cord injury complications.

Increased risk for thoracic aneurysms in female and familial abdominal aortic aneurysm patients

INTRODUCTION

Aneurysms of the thoracic aorta (TAA) occur more frequently in abdominal aortic aneurysm (AAA) patients than in the general population. The aim of the study was to investigate which AAA patients have an increased risk of developing TAA or thoraco-abdominal aortic aneurysm (TAAA), and if sex, genetic susceptibility for aneurysms, or conventional cardiovascular risk factors affect this risk.

METHODS

Repeated CT scans from consecutively diagnosed abdominal aortic aneurysm patients were evaluated retrospectively to determine the prevalence, sequence and location of multiple aortic aneurysms. Effects of sex, genetic predisposition for aneurysms (familial aneurysm, the presence of (likely) pathogenic variants in known aneurysm genes) and cardiovascular risk factors (age, smoking, hypertension, diabetes mellitus and hypercholesterolemia) on risk for TAA were analyzed. Five-year survival was used to evaluate the impact of having thoracic aneurysms on survival of AAA patients.

RESULTS

On the first CT scan 10.8% of AAA patients had a TAA. During follow-up an additional 5.1% of the AAA patients developed TAA and 2.4% developed TAAA. Female patients had a twofold increase in risk for TAA, in particular for aneurysms of the descending aorta. A twofold increase in risk for ascending TAA was observed in AAA patients reporting familial aneurysms. The 5-year survival of female TAAA patients was lower than that of AAA patients, independent of having a TAA.

CONCLUSIONS

Female AAA patients had a two-fold increase in risk for TAA, particularly in the descending aorta. Familial AAA patients had a two-fold increase in aneurysm risk for ascending aortic aneurysms. TAAA patients had a lower survival compared to TAA or AAA patients, specifically among female TAAA patients. TAA and TAAA developed during follow-up. Therefore, follow-up imaging of both the ascending and descending aorta after diagnosis of AAA may improve early detection of multiple aneurysms.

Case Report: Unlocking arteria Lusoria challenges: sternotomy's role in a single-stage aneurysm repair and artery realignment

Arteria lusoria (AL), an anomaly of the right subclavian artery, occurs in 2% of individuals and can cause symptoms such as dysphagia due to its retroesophageal course. Often associated with Kommerell's diverticulum (KD), a dilation at the artery's origin, this condition poses risks of rupture or dissection. Symptomatic cases and aneurysms necessitate surgical intervention, while asymptomatic cases may warrant observation. We present a case of a 44-year-old woman with dysphagia lusoria due to AL and KD, confirmed by imaging. Given anatomical complexities, a one-stage open surgical repair via sternotomy was performed. This involved resecting the KD and creating a neo-trajectory for the right subclavian artery using a Dacron tube graft. Cardiopulmonary bypass ensured safe manipulation, and post-operative imaging confirmed excellent outcomes, with complete symptom resolution. Surgical approaches for AL and KD vary depending on anatomy and symptomatology, ranging from open repairs to hybrid and endovascular techniques. Open thoracotomy remains the gold standard for young patients without comorbidities. Hybrid approaches are reserved for emergencies or high-risk patients, offering reduced morbidity but potentially higher complication rates. Advances in imaging and surgical techniques, including hybrid methods, have improved outcomes, with mortality rates significantly lower than historical benchmarks. The 2024 EACTS/STS guidelines recommend open surgery for young, fit patients (Class I, Level C) and hybrid approaches for emergencies or patients unfit for open surgery (Class I, Level C). Our case exemplifies the feasibility of sternotomy in providing precise, effective correction for KD with AL in a single operation while minimizing risks associated with other approaches.

Point of care ultrasound for monitoring and resuscitation in patients with shock

Point-of-Care Ultrasound (POCUS), when used by experienced physicians, is a valuable diagnostic tool for the initial minutes of shock management and subsequent monitoring. It enables early diagnosis with high sensitivity (Sn) and specificity (Sp). Published protocols have advanced towards true multi-organ ultrasonographic exploration, with the RUSH (Rapid Ultrasound in Shock) protocol likely being the most well-known nowadays. Although there is no established order, cardiac evaluation, as well as vascular system assessments including intra- and extravascular volume, should be explored. Additionally, there are ultrasonographic evaluations particularly useful for diagnosing and monitoring response/tolerance to volume. Both the identification of B lines and the increase in left ventricular pressures bring us closer to a diagnosis of fluid overload in these patients. Velocity-time integral (VTI) of the left ventricle (LV) outflow tract (LVOT, LVOTVTI) or right ventricular outflow tract (RVOT, RVOTVTI) can be indicative of distributive shock if elevated, and help identifying volume responders through leg-raising manoeuvres or crystalloid bolus administration. Several index of the inferior vena cava (IVC) can also be helpful. In addition, different parameters to establish fluid responsiveness are being investigated at the carotid level. Venous congestion parameters have not yet been proven to identify volume responders but can identify patients with poor tolerance. Currently, it is essential that physicians treating critical patients use POCUS to enhance clinical outcomes.

Changes in Abdominal Artery Diameter in Patients Treated for Acute Aortic Dissection

BACKGROUND

Mesenteric ischemia significantly increases intraoperative mortality in patients with acute aortic dissection (AAD). The arterial diameter affects both blood flow and arterial resistance. There are no data in the literature on changes in arterial diameter in patients with AAD. It has already been demonstrated that changes in arterial diameter can be observed in patients with non-occlusive intestinal ischemia. The aim of this study was to compare the arterial branches of the abdominal aorta in patients with AAD preoperatively and postoperatively.

METHODS

Preoperative and postoperative contrast-enhanced computed tomography scans of 25 patients who had undergone the frozen elephant trunk procedure for the treatment of AAD were reconstructed and retrospectively analyzed with detailed medical data of the patients.

RESULTS

In patients without AAD at the level of the abdominal aorta, statistically significant differences were observed when comparing the diameter of the superior mesenteric artery (p < 0.001) and the renal arteries (p < 0.001) between preoperative and postoperative scans. Occlusion of the inferior mesenteric artery was more common in patients with AAD involving the abdominal aorta. Statistically significant differences in true and false lumen were observed at each level of the abdominal aorta after a successful frozen elephant trunk procedure.

CONCLUSION

Significant changes in visceral artery diameter were observed at the abdominal aortic level in patients both with and without aortic dissection. Chronic or non-occlusive mesenteric ischemia may be associated with a lack of adjustment in arterial diameter. Patients with AAD of the abdominal aorta are more susceptible to occlusion of the inferior mesenteric artery.

Diagnosis of bicuspid aortic valves: CT vs. TTE

Bicuspid aortic valfves (BAV) are a relatively common cardiac abnormality, with an associated risk of aortic stenosis, aortic regurgitation and aortopathy. First-line diagnosis is via transthoracic echocardiography (TTE), which may be impacted by valve calcification and operator variability. Electrocardiogram-gated computed tomography (CT) offers an alternative form of assessment. The aim of this systematic review and meta-analysis is to evaluate the diagnostic performance of TTE versus CT for BAV. Eligible studies were retrieved from inception through to March 2024 on OVID Medline, Embase and Cochrane Library. All primary studies regarding the diagnostic performance of TTE and/or CT with regards to BAV were included. The QUADAS-2 tool was utilized for quality assessment. Sensitivity and specificity data were statistically analyzed. Of 4698 records, 19 were eligible for inclusion, and 16 had sufficient data for inclusion in the meta-analysis. There was only data regarding TTE vs. retrospectively ECG-gated CT. There was a significant difference between the sensitivity of retrospectively ECG-gated cardiac CT (95.5% (95% CI: [91.3-97.5%]) and TTE (79.7%, 95% CI: [71.6-86.0%]) for identifying BAV. The specificity was high and not significantly different for both CT and TTE (96%, 95% CI: [92.5-98.2%] and 91.3%, 95% CI: [87.3-93.8%], respectively). Retrospectively ECG-gated CT demonstrates greater sensitivity for diagnosis of BAV compared to TTE. Both modalities are non-invasive and demonstrate good specificity for excluding BAV. Given that CT scans are easily accessible, they offer a reasonable second-line investigation for diagnosis of BAV when an initial TTE is inconclusive.

Present and future of aortic risk assessment in patients with heritable thoracic aortic diseases

Heritable thoracic aortic diseases (HTAD) are a group of diverse genetic conditions characterized by an increased risk of aortic complications. The standard surveillance of these patients involves monitoring aortic diameters until a defined threshold is reached, at which point preventive aortic surgery is recommended. However, assessing aortic risk in these patients is far more complex and, in many aspects, remains incompletely understood. Several factors contribute to this complexity, including the diversity and low prevalence of the conditions within HTAD and the limited understanding of the factors influencing the progression of aortic dilation and the advent of acute aortic events. This article reviews current knowledge on clinical, genetic, and imaging factors related to aortic risk in HTAD and explores their potential future roles in improving risk assessment. By advancing our understanding of these factors, we aim to enhance the precision of risk stratification and develop more effective, personalized management strategies for HTAD patients, with the final goal of improving clinical outcomes and quality of life in individuals affected by these genetic disorders.

Long-term outcomes of abdominal aortic aneurysm screening in patients undergoing transthoracic echocardiography

PURPOSE

Reports on the usefulness of abdominal aortic aneurysm (AAA) screening during transthoracic echocardiography (TTE) in Japan are limited. This study aimed to describe the prevalence of AAA among patients who underwent routine screening during TTE, as well as the long-term clinical outcomes of patients in whom AAA was detected.

METHODS

We screened 46,353 consecutive patients who underwent TTE for suspected cardiac disease at our institution. Among these, a total of 1133 patients were identified as having AAA, defined as an abdominal aorta diameter of 30 mm or greater. After excluding patients with prior aortic surgery, including endovascular repair (n = 104), those with known AAA (n = 569), and those with known aortic dissection (n = 25), the study population consisted of 435 patients, all diagnosed with AAA for the first time.

RESULTS

The overall prevalence of AAA among patients undergoing TTE was 0.94%. The mean age was 76.8 years, and the study population was predominantly males (81.6%). The prevalence of AAA in patients under 60 years of age was low: 0.24% for men and 0.076% for women. The left atrial volume index was 43.8 ± 23.1 ml/m2, the left ventricular mass was 164.9 ± 52.0 g, and the diameter of the sinus of Valsalva was 32.6 ± 4.4 mm, all of which were numerically higher than the normal values observed in a healthy Japanese population. During the median follow-up period of 2.0 years, 43 surgical or endovascular repairs of AAA, six aorta-related deaths, and 90 all-cause deaths occurred. The cumulative incidence of surgical or endovascular repair of AAA was 5.3% at 1 year, 11.5% at 3 years, and 18.1% at 5 years. The cumulative incidence of aorta-related death was modest: 0.3% at 1 year, 0.8% at 3 years, and 1.6% at 5 years.

CONCLUSION

The prevalence of newly diagnosed AAA among patients who underwent routine screening during TTE for suspected cardiac disease was 0.94% in the Japanese population, with the majority being 60 years or older. Approximately 10% of patients diagnosed with AAA underwent surgical or endovascular repair during follow-up, suggesting that this approach may be effective in preventing deaths caused by AAA.

Low rates of aortic surveillance imaging and clinical follow-up in patients with acute aortic dissection

OBJECTIVE

Patients that survive acute aortic dissection (AD) remain at high risk of morbidity/mortality from structural changes of the aorta. Aortic surveillance is challenging, especially within a tertiary referral center. Our aim was to identify follow-up imaging and appointment rates, and factors associated with incomplete surveillance in patients with acute AD.

METHODS

This was a single-center, retrospective study of acute AD patients at a tertiary care center from July 2012 to December 2022 who lived at least 1 year after AD. We defined complete surveillance as having computed tomography scans or magnetic resonance imaging scans of the chest and abdomen at 1 month (±14 days), 6 months (±1.5 months), 1 year (±3 months), and yearly thereafter. Data were obtained from the electronic health record. Predictors of absent imaging at the 1 year (±3 months) timepoint were evaluated using multivariable logistic regression.

RESULTS

Of the 272 patients in the study, 63.2% were male and 39.3% were White. The average age was 60.7 ± 14.7 years. Acute type A AD comprised 47.1% of our cohort; 91.4% underwent open repair within 1 week of presentation. Of the acute type B AD patients (52.9% of the cohort), 41.7% underwent thoracic endovascular aortic repair at the index admission. At the 1-year follow-up interval (±3 months), 26.5% were confirmed to have undergone aortic surveillance imaging, and 27.6% had an appointment with a cardiovascular specialist. Only 9.6% of the cohort was fully concordant with the recommended surveillance imaging in the first year of follow-up. On multivariate regression, non-English speakers (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.05-3.99; P = .03) and residence outside of hospital region (OR, 1.66; 95% CI, 1.02-3.17; P = .04) were independently-associated with lack of follow-up imaging at the 1-year timepoint, whereas longer length of stay was independently-associated with completed imaging at the 1-year timepoint (OR, 0.78; 95% CI, 0.41-0.89; P = .04).

CONCLUSIONS

This study highlights a low rate of surveillance and clinical follow-up for patients with acute AD and a significant disparity for non-English speaking patients and those who reside outside of the hospital region. This information should inform future quality initiatives to improve aortic surveillance following AD.

Endovascular Fenestration in Aortic Type-A Dissection With Hepatic Malperfusion Syndrome: A Case Report

Acute type-A aortic dissection with malperfusion syndromes represents challenging cases and should always be treated on an interdisciplinary basis, whereby interventional radiologic therapy can be a successful procedure, especially in patients who are not fit for surgery.

Impact of Clevidipine Versus Nicardipine on Time in Range when Lowering Blood Pressure

Background: Two intravenous medications commonly used as first-line therapy for rapid blood pressure control are nicardipine and clevidipine, both of which are available as titratable infusions. Despite pharmacokinetic differences, no data clearly support a preferred agent. Objective: To evaluate efficacy and safety outcomes associated with current use of these medications across a variety of indications in a hospital system. Methods: This study was a multi-center, retrospective chart review conducted within a hospital system from June 1, 2020 to June 30, 2021. Records of patients were matched in a one-to-one fashion based on indication for blood pressure control and similar pre-intervention blood pressure. The primary outcome was time within target blood pressure range. Results: A total of 569 patients were screened, resulting in 100 matched pairs. The percent of time in blood pressure range was similar between nicardipine and clevidipine when stratified by location of care (51.5% vs 51.7%, P = 0.970 for ED; 68.1% vs 68.8%, P = 0.913 for ICU). Overall, the median (IQR) time to target blood pressure range was significantly faster with clevidipine than nicardipine [20 (7-43) min. vs 34 (14.5-57) min., resp.; P = 0.013). There were numerically higher rates of hypotension with nicardipine than clevidipine, but this finding was not significant (17% vs 10%; P = 0.093). Conclusions: This study shows a statistically significant difference in time to target blood pressure range with clevidipine compared to nicardipine. Although there was no difference in the percentage of time in blood pressure range, nicardipine was associated with a non-significant increase in the incidence of hypotension.

Evaluation of a novel compliance-matching aortic graft in a swine model

The mismatch of elastic properties between the arterial tissue and the vascular grafts, commonly called compliance mismatch, is responsible for many deleterious post-operative complications. Currently, there is an absence of prostheses that conform with the compliance of healthy aortas. We aimed to evaluate the in vivo performance of novel compliance-matching grafts in a swine model and compare it to the native aorta and to gold-standard aortic grafts.We proposed a compliance-matching graft design, composed of a standard aortic graft surrounded by an optimized Nickel-Titanium compliance-augmenting layer. We replaced the thoracic aorta of six domestic pigs with compliance-matching grafts under cardiopulmonary bypass. We removed the compliance-regulating layer of the compliant grafts, so that gold-standard grafts remained implanted. The aortic pressure and flow rate were measured at the three stages of the experiment to assess hypertension and arterial stiffness. The compliance-matching grafts were implanted without inducing post-operative hypertension by maintaining systolic pressure (p = 0.26), aortic pulse wave velocity (p = 0.89) and aortic distensibility (p = 0.67) at healthy levels. The gold-standard grafts caused a significant rise in systolic pressure (p = 0.005), pulse wave velocity (p = 0.012) and they approximately doubled pulse pressure (p < 0.001). Our novel compliant grafts could diminish the complications caused by compliance-mismatch and they could surpass the clinical performance of existing prostheses. The proposed grafts comprise a step towards optimized treatment and improved life expectancy of patients subjected to aortic replacement.

GlycoRNA-rich, neutrophil membrane-coated, siMT1-loaded nanoparticles mitigate abdominal aortic aneurysm progression by inhibiting the formation of neutrophil extracellular traps

Abdominal aortic aneurysm (AAA) is a life-threatening vascular condition. Currently, there are no clinically available pharmacological interventions that can stop the progression of AAA, primarily due to the incomplete understanding of its pathogenesis and the absence of effective drug delivery systems. The present study aimed to develop a targeted therapy for AAA through a nanomedicine approach involving site-specific regulation of neutrophil extracellular trap (NET)-related pathological vascular remodeling. We found that metallothionein 1 (MT1) was upregulated in AAA lesions in both humans and mice. MT1 also facilitated the formation of NETs and subsequently induced phenotypic transformation and apoptosis in vascular smooth muscle cells. Additional in vivo studies revealed that the glycoRNA-rich membranes coated siMT1-loaded poly(lactic-co-glycolic acid) (PLGA)-polyethylene glycol (PEG) nanoparticles (GlycoRNA-NP-siMT1) effectively delivered siMT1 to AAA lesions, thereby inhibiting abdominal aortic dilation. Mechanistically, GlycoRNA-NP-siMT1 mitigated pathological remodeling of the abdominal aorta by reducing neutrophil infiltration and inhibiting the formation of NETs. Our study indicates that MT1 facilitates the progression of AAA by modulating the formation of NETs. Furthermore, GlycoRNA-NP-siMT1 show an inhibitory effect on AAA progression through a dual mechanism: they competitively inhibit neutrophil infiltration and release siMT1, which subsequently suppresses NET formation.

Systematic Review and Meta-analysis of Outcomes of the Advanta V12 or iCAST Bridging Stent Graft Used for Fenestrated and Branched Endovascular Aortic Repair

OBJECTIVE

Half of re-interventions after fenestrated and branched endovascular aortic repair (FB-EVAR) are target vessel related. Regarding bridging stent choice, existing data are controversial. This meta-analysis aimed to evaluate the performance of Advanta V12/iCAST as the bridging stent in FB-EVAR.

DATA SOURCES

The English medical literature was searched through MEDLINE, Embase (via Ovid), and Cochrane databases (end date 15 April 2024).

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and PICO (Patient, Intervention, Comparison, Outcome) model were followed. A predefined protocol was registered to PROSPERO (CRD42024556603). Randomised controlled trials and observational studies (2010 - 2024) reporting on Advanta V12/iCAST related target vessel outcomes were eligible. Risk of bias was assessed using ROBINS-I, and evidence quality was assessed via Grading of Recommendations Assessment, Development and Evaluations (GRADE). Primary outcomes were freedom from instability, stenosis and or occlusion, types Ic and IIIc endoleak, and re-intervention of target vessels bridged with the Advanta V12/iCAST. Prevalence and regression meta-analysis were performed.

RESULTS

From 1 439 articles, ten retrospective studies (7 525 target vessels; 3 890 target vessels bridged with Advanta V12/iCAST) were included. According to ROBINS-I, no study was of high quality. Mean follow up was 24.3 (95% confidence interval [CI] 23.9 - 24.7) months. Freedom from instability, stenosis and or occlusion, and types Ic and IIIc endoleak were 94% (95% CI 91 - 96%; p < .010; I2 = 91%; GRADE certainty, very low), 97% (95% CI 96 - 98%; p =  .070, I2 = 44%; GRADE certainty, low), and 97% (95% CI 94 - 98%; p < .010; I2 = 81%; GRADE certainty, very low), respectively. Freedom from target vessel re-intervention was 95% (95% CI 92 - 97%; p < .010; I2 = 85%; GRADE certainty, very low). Four studies provided extractable data on Advanta V12/iCAST in fenestrations and four in branches. No difference was detected in freedom from instability (p = .47), stenosis and or occlusion (p = .36), and types Ic and IIIc endoleak (p = .90). Freedom from re-intervention was 93% (95% CI 87 - 96%; p < .010; I2 = 90%) in fenestrations and 95% (95% CI 91 - 97%; p = .060, I2 = 64%) in branches.

CONCLUSION

The Advanta V12/iCAST bridging stent showed high freedom from target vessel instability, stenosis and or occlusion, and endoleak. Freedom from re-intervention was 95%, being similarly high in fenestrations and branches.

Rupture of Abdominal Aortic Aneurysm due to Listeria Monocytogenes infection

Infective native aortic aneurysms (INAA) caused by Listeria monocytogenes are rare, with most cases involving Streptococcus sp. We report a case of a woman in her mid-60s who presented with a contained rupture of an infrarenal abdominal aortic aneurysm (AAA) due to Listeria The woman presented with intermittent abdominal and lower back pain, malaise, nausea, elevated inflammatory markers and ketoacidosis. CT angiography revealed a 40 mm AAA with inflammation and rupture. Intravenous ampicillin and gentamicin were initiated, and emergency open aortic repair was performed. Cultures confirmed Listeria infection. Postoperative neurological symptoms resolved, and the patient improved with continued antibiotics. One month postoperatively, she was asymptomatic with normalised inflammatory markers. This case underscores the rarity of Listeria-induced aneurysms and highlights the need for international registries to guide the management of INAA and further research on optimal surgical management.

Feasibility of Noncontrast 3D MR Angiography on a Commercial Wide-Bore 0.55-T System: Comparison with 1.5-T MR Angiography

Purpose To evaluate a noncontrast electrocardiographically triggered, navigator-gated, three-dimensional, balanced steady-state free precession MR angiography (MRA) research sequence on a wide-bore 0.55-T commercial low-field-strength system, by comparing image quality and aortic dimension measurements against images obtained at 1.5 T. Materials and Methods Ten healthy volunteers (28.8 years ± 9.0 [SD]; four male) and 10 participants being evaluated for dilated thoracic aorta (53.6 years ± 10.7; six male) underwent noncontrast MRA scans at both 1.5 T and 0.55 T. Overall image quality, intrarater and interrater agreement in aortic dimensions, and diagnostic accuracy were evaluated between field strengths for both groups of individuals using Wilcoxon test, intraclass correlation coefficient, and Bland-Altman plots. Results Median image quality scores remained comparable between volunteers and participants across field strengths. Blood signal variability was greater at the ascending aorta at 1.5 T for volunteers (P = .01) and participants (P = .02). Blood-myocardium contrast was significantly higher at the ascending aorta and proximal arch at 1.5 T for volunteers and participants (P < .05). Excellent intra- and interrater agreement (intraclass correlation coefficient > 0.9) was demonstrated at 0.55 T and 1.5 T. Aortic dimensions (intraclass correlation coefficient > 0.9) and diagnosis of aortic dilatation did not demonstrate significant interfield differences. Conclusion Noncontrast, three-dimensional, balanced steady-state free precession MRA at 0.55 T demonstrated adequate image quality and no significant differences in quantitative measurements or diagnostic accuracy compared with 1.5 T. Keywords: Noncontrast MR Angiography, Low Field, 0.55 T, Obesity, Thoracic Aorta © RSNA, 2025.

Computed tomography-based anatomical suitability of an Endo-Bentall prosthesis for ascending aortic aneurysms

BACKGROUND

This study aimed to evaluate the suitability of a coronary-branched ascending aortic endograft, paired with aortic valve (AV) prosthesis (Endo-Bentall), for the endovascular repair of ascending aortic aneurysms.

METHODS

Preoperative ≤1 mm computed tomography angiographies of consecutive patients managed with Bentall procedure or ascending aortic replacement and AV reconstruction/replacement, in a single institution (from January 1, 2008, to December 31, 2023), were retrospectively analyzed. Dedicate software was used to assess (1) vascular access, (2) proximal landing zone, (3) coronary artery anatomy, and (4) distal landing. Eligibility criteria for Endo-Bentall were ≥8 mm iliac arteries, without severe calcification/tortuosity, proximal landing with an 18- to 29-mm aortic annulus diameter, ≥10 mm annulus-coronary ostium distance, no mechanical AV, absence of coronary grafts in the ascending aorta, no left ventricle thrombus, coronary arteries ≥3 mm wide and ≥10 mm long, with no anatomical abnormalities, ostial stent or stenosis, and ≥20 mm long and ≤38 mm wide distal landing zone within the ascending aorta or applicability of branched endovascular arch repair.

RESULTS

Twenty-nine patients (55.2% females) were included. All patients had adequate proximal landing zone in terms of annulus diameter (median, 25 mm; interquartile range [IQR], 5 mm). Two (6.8%) had inadequate iliac access (external iliac artery <8 mm). Two patients (6.8%) had a mechanical AV. Twenty-six patients (89.6%) had adequate landing zone for stenting of the left main coronary artery (median diameter, 5.2 mm; IQR, 1.8 mm) and 28 (96.6%) had adequate right coronary artery landing (median diameter, 4.1 mm; IQR, 1 mm). The left main coronary artery and right coronary artery were located at 5:00 minute and 10:50 minute clock positions, respectively. Three patients (20.7%) had an adequate distal landing zone within the ascending aorta. The remaining were suitable for extension with a branched arch device. According to the predefined criteria, 75.9% of patients were anatomically suitable for Endo-Bentall.

CONCLUSIONS

Three out of four patients with ascending aortic aneurysms may be considered as anatomically eligible for endovascular treatment with an Endo-Bentall prosthesis.

Echocardiographic analysis of abdominal aorta dimensions and their associations with demographic characteristics in a healthy population

INTRODUCTION

Determining the normal diameter of the abdominal aorta in different populations and its relationship with other demographic factors is crucial for diagnosing and managing abdominal aortic diseases. This study aimed to assess the size of the abdominal aorta in a healthy Iranian population.

METHODS

This cross-sectional study included healthy individuals. Various variables including age, sex, height, and weight were measured as part of this study. We performed an echocardiographic evaluation to assess the aortic sections.

RESULTS

The study encompassed 167 participants, predominantly women (67.7%). Notable differences in sizes of the ascending aorta, aortic arch, sinus of Valsalva, and abdominal aorta were observed across the four age groups. Men exhibited greater sizes in multiple aortic sections within the 45-64 age group. Correlation and regression analyses demonstrated significant positive relationships between abdominal aorta size and various aortic dimensions, with a one-millimeter increase in ascending or descending aorta diameter corresponding to a 0.23 and 0.35 mm increase, respectively, in abdominal aorta diameter. The relationship between abdominal aorta size and demographic factors such as gender, age, weight, BSA, and SBP was explored, revealing age as a significant predictor.

CONCLUSIONS

We observed significant differences in the sizes of distinct aortic sections across different age groups, underscoring the importance of considering age-related changes when evaluating aortic characteristics. These findings contribute to our understanding of the structural changes that occur in the aorta over time. Echocardiographic screening of the abdominal aorta would enable echocardiologists to diagnose the aneurysmal aorta.

Functional anti-inflammatory mesoporous silica nanoplatform for Synergistic and Targeted abdominal aortic aneurysm treatment

Abdominal aortic aneurysm (AAA) is a chronic inflammation-driven disease characterized by aortic wall destruction and expansion, leading to high morbidity and mortality. However, previous drug treatments for its common risk factors have not achieved favorable results, and the early prevention and treatment is still the main clinical dilemma. Anti-inflammation therapy is a promising therapeutical method targeting its pathogenesis mechanism, but it has not been explored in depth. Herein, interleukin-1 receptor antagonist-loaded manganese-doped mesoporous silica nanoparticles (IL-1Ra@MMSN) were designed and synthesized to target macrophage-mediated chronic aortic inflammation for AAA treatment. IL-1Ra@MMSN showed high IL-1Ra-loading efficiency, great stability and pH-responsive drug-releasing property. IL-1Ra@MMSN specially phagocytosed by macrophages can protect against oxidative stress injury and promoted the M2 polarization via transforming growth factor-β (TGF-β) signaling in vitro. Furthermore, IL-1Ra@MMSN exhibited good lesion targeting ability, hemocompatibility and biocompatibility in angiotensin II-induced murine AAA model. In vivo experiments also confirmed the excellent treatment efficacy in reducing AAA formation and progression via protecting aortic wall integrity and promoting anti-inflammatory microenvironment. Taken together, the current study demonstrated that IL-1Ra@MMSN is a promising nanoplatform for early intervention of AAA, which provides a novel treatment strategy based on anti-inflammatory immune regulation.

Through the gap: a case series on managing Type B aortic dissection with multiple lumens and tears

Aortic dissections are classified as Stanford Type A and B based on site of intimal dissection. Management of Type B dissections is guided by risk stratification. Complicated and high-risk Type B aortic dissections are managed either using endovascular or open surgical repair. Uncomplicated Type B dissections are managed medically. The role of the patency of the false lumen and the presence of reentry tears in the dissecting membrane are still contested. Here, we describe two cases of descending aortic dissections with varying anatomical features in the setting of cocaine use and uncontrolled hypertension. The first case uniquely had a triple lumen dissection with two true lumens, while the second case had two distal tears. Both patients initially had signs of reduced end organ perfusion that resolved with control of comorbid conditions. After multidisciplinary discussions, the decision was made to continue with anti-impulse treatment. Due to the radiological and biochemical absence of evidence of end organ injury even while visceral organs were supplied by the false lumen, our multidisciplinary team preferred conservative management with anti-impulse therapy. This serves as a demonstration of individualized management of Type B aortic dissection in patients with multiple comorbidities using carefully analyzed radiographic and biochemical evidence.

Editor's Choice - Outcomes of Endovascular Repair Confined to the Ascending Thoracic Aorta: A Systematic Review and Meta-Analysis

OBJECTIVE

High risk, inoperable patients with ascending aortic disease are increasingly managed with thoracic endovascular aortic repair (TEVAR). The aim of this study was to assess the available literature on TEVAR confined to the ascending aorta (a-TEVAR), describing study and patient characteristics, procedural and stent graft details, and outcomes.

DATA SOURCES

This was a systematic review and meta-analysis. MEDLINE, Web of Science, and Scopus were systematically searched for eligible studies reporting on outcomes after a-TEVAR (PROSPERO ID: CRD42023440826). Eligible studies reported outcomes after a-TEVAR without adjunctive supra-aortic vessel treatment.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The ROBINS-I and Joanna Briggs Institute Critical Appraisal Checklist were used as quality assessment tools. A Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence certainty analysis was performed for the main outcomes. The main outcome was death. A proportional meta-analysis was performed with a mean and 95% confidence interval (CI) for the main outcomes. All articles were included up to 1 January 2024.

RESULTS

Ninety four studies were included (19 cohort studies, 75 case reports or series), reporting on 259 patients (57.8% male). The mean age was 69.1 (95% CI 65.0 - 73.1) years and mean follow up 19.6 (95% CI 14.5 - 24.6) months. The most common comorbidity was prior cardiac or thoracic surgery (n = 191). The most frequent indications for a-TEVAR (52.1% urgent a-TEVAR) were type A aortic dissection (43.6%) and pseudoaneurysm (38.6%). The most commonly deployed stent grafts were Gore (44.5%), Cook (23.5%), and Medtronic (17.0%). The in hospital mortality rate was 7.3% (95% CI 4.7 - 11.2%), 30 day mortality rate 7.7% (95% CI 5.1 - 11.6%), and overall mortality rate 17.0% (95% CI 12.9 - 22.0%) during follow up. GRADE showed very low evidence certainty for all outcomes. Eighty eight complications were reported and there was a re-operation rate of 13.1% (95% CI 9.5 - 17.8%). In hospital and 30 day mortality rates for type A dissection were 12.4% (95% CI 7.5 - 19.7%) (n = 14) and 13.3% (95% CI 8.2 - 20.8%) (n = 15), respectively, and for pseudoaneurysm 4.0% (95% CI 1.6 - 9.8%) (n = 4) and 4.0% (95% CI 1.6 - 9.8) (n = 4), respectively.

CONCLUSION

Despite heterogeneous literature and very low GRADE evidence certainty, a-TEVAR seems technically feasible in high risk patients. In addition, there is need for a consensus on when and how to use a-TEVAR and a need for a specific endograft for use in the ascending aorta.

One-stage or two-stage elective coronary artery bypass graft surgery and abdominal aortic aneurysm open repair in low and moderate cardiac surgical risk patients

ObjectivesCoronary artery disease (CAD) and abdominal aortic aneurysm (AAA) are common arterial pathologies that might occur simultaneously; however, there is not enough evidence about the optimal strategy for patients with concomitant indications of coronary artery bypass grafting (CABG) and open repair of the AAA (AAOR). This study aims to present the outcomes in low and moderate cardiac surgical risk patients who underwent one-stage or two-stage elective CABG and AAOR in a middle-income country.MethodsAn observational, retrospective case series study was conducted. Patients who had low and moderate cardiac surgical risk (less than 8% mortality risk on the STS score) and had the concomitant indication for CABG and AAOR between December 2005 and August 2021 were included. Patients were assigned to one of three strategies: Group 1 underwent one-stage surgery for CABG and AAOR, Group 2 underwent two-stage surgery within the same in-patient stay, and Group 3 underwent two-stage surgery in a new in-patient stay within 6 months.ResultsTwenty seven, patients with simultaneous requirements of CABG and AAOR were identified, with a mean age of 69.5 ± 6.1 years and 92.6% were male. The most common comorbidities were hypertension at 77.8% and dyslipidemia at 55.6%. The average mortality risk calculated by the STS score was 2.09% ± 1.53%. In Group 1 (n = 9), 1/9 had in-hospital mortality and no reinterventions were needed. In Group 2 (n = 10), 1/10 had in-hospital mortality, and the most common postoperative complication was acute kidney injury 2/10. Furthermore, 2/10 required a reintervention. In Group 3 (n = 8), no in-hospital mortality was present, however, complications such as sepsis, atrial fibrillation, and acute kidney injury occurred in 2/8 patients each, and 2/8 required a reintervention.ConclusionPatients with CAD and AAA that need a concomitant surgical correction with CABG and an AAOR are uncommon in contemporary practice, given the advances in endovascular therapy. When indicated, one-stage surgery can be performed in patients with low cardiac surgical risk, proper patient selection plays a fundamental role and might be performed in experienced centers. However, two-staged surgeries at the same or different inpatient stay may be considered for asymptomatic AAA with close monitoring during the postoperative period. These findings can hold significance for addressing sociodemographic barriers in low and middle-income countries. More robust and extensive studies are needed to make clear comparisons between the different strategies.

Anesthesia Management for the Personalized External Aortic Root Support (PEARS) Procedure: A Single-Center Experience

OBJECTIVE

To delineate anesthesia management during the personalized external aortic root support (PEARS) procedure, with a focus on the use of multimodal monitoring and deliberate profound hypotension.

DESIGN

A single-center retrospective cohort study.

SETTING

Tertiary academic hospital.

PARTICIPANTS

Patients undergoing the PEARS procedure due to aortic aneurysm.

INTERVENTIONS

None.

METHODS

Patient characteristics and anesthesia management are described, with particular emphasis on multimodal hemodynamic, cerebral monitoring, and transesophageal echocardiography during the deliberate profound hypotension phase during the isolated PEARS procedure.

RESULTS

SEVENTY-THREE: patients underwent an isolated PEARS procedure in an academic hospital in The Netherlands between January, 2018, and December, 2023. Fifty-six patients were male (72.2%), and the mean patient age was 38 ± 15.7 years. Five patients required conversion to cardiopulmonary bypass. There were no in-hospital deaths, myocardial infarction, stroke, major bleeding, reoperation for any cause, prosthesis infection, or postoperative delirium. Postoperative atrial fibrillation occurred in 11 patients (15.1%). The mean duration of intensive care unit admission was 1.3 days, and the mean hospital length of stay was 7.6 days. All procedures were performed by a single surgeon.

CONCLUSIONS

The PEARS procedure appears to be a viable alternative for preventive replacement of the aorta in selected patients with aortic aneurysms. Anesthesia is safe; in particular, profound deliberate hypotension can be used without relevant complications using multimodal monitoring, with electroencephalographic burst suppression as the guiding factor for cerebral perfusion. As published by other groups, PEARS has excellent outcomes in experienced centers.

Ketorolac in the perioperative management of acute type A aortic dissection: a randomized double-blind placebo-controlled trial

BACKGROUND

Acute Type A Aortic Dissection (aTAAD) is a severe and life-threatening condition. While animal studies have suggested that ketorolac could slow the progression of aortic aneurysms and dissections, clinical data on its efficacy in aTAAD patients remain limited. This study seeks to evaluate the safety and effectiveness of ketorolac in this patient group.

METHODS

Patients were randomly assigned to receive either ketorolac or a placebo (0.9% saline). Treatment began at least 2 h prior to surgery (60 mg ketorolac or 2 ml saline administered once intramuscularly) and continued for 48 h post-surgery (30 mg ketorolac or 1 ml saline administered intramuscularly twice daily). The primary endpoints included assessing the safety and efficacy of ketorolac in improving the prognosis of aTAAD, focusing on mortality and organ malperfusion syndrome. Secondary endpoints included drug-related adverse events, blood test results, and other postoperative outcomes.

RESULTS

Of 179 patients who underwent aTAAD repair, 110 met the inclusion criteria and were randomized into two groups of 55. One patient discontinued the intervention due to erythroderma on the first postoperative day, leaving 54 patients in the ketorolac group and 55 in the placebo group for analysis. No significant differences were found in the primary endpoints. However, the ketorolac group showed lower intraoperative bleeding (median: 1.8 L vs. 2.0 L, P = 0.03), shorter intensive care unit (ICU) stays (median: 6.5 days vs. 8 days, P = 0.04), and lower total hospital costs (median: ¥170,430 vs. ¥187,730, P = 0.03).

CONCLUSIONS

Short-term ketorolac therapy did not alter the primary outcome but was associated with reduced intraoperative bleeding, shorter ICU stays, and potentially lower hospitalization costs. It demonstrates safety and a certain degree of effectiveness during the perioperative period. These findings suggest that ketorolac could be a viable option for perioperative management in patients with aTAAD.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Register ( www.chictr.org.cn , No: ChiCTR2300074394).

Imaging-based biomechanical parameters for assessing risk of aortic dissection and rupture in thoracic aortic aneurysms

OBJECTIVES

Imaging-based methods of measuring aortic biomechanics may provide superior and a more personalized in vivo risk assessment of patients with thoracic aortic aneurysms compared to traditional aortic size criteria such as maximal aortic diameter. We aim to summarize the data on in vivo imaging techniques for evaluation of aortic biomechanics.

METHODS

A thorough search of literature was conducted in MEDLINE, EMBASE and Google Scholar for evidence of various imaging-based biomechanics techniques. All imaging modalities were included. Data involving preclinical/animal models or exclusively focussed on abdominal aortic aneurysms were excluded.

RESULTS

The various imaging-based biomechanical parameters can be divided into categories of increasing complexity: strain-based, stiffness-based and computational modelling-derived. Strain-based and stiffness-based parameters are more simply calculated and can be derived using multiple imaging modalities. Initial studies are promising towards linking these parameters with clinically relevant end-points, including aortic dissection, though work is required for standardization. Computationally derived parameters provide detail of stress exerted on the aortic wall with great spatial resolution. However, they are highly dependent on the assumptions applied to the models, such as material properties of the aortic wall.

CONCLUSIONS

Imaging-based aortic biomechanics represent a major technical advancement for personalized in vivo risk stratification of patients with ascending thoracic aortic aneurysm. The next steps in clinical translation require large-scale validation of these markers towards predicting aortic dissections and comparison against the gold standard ex vivo aortic biomechanics as well as development of a user-friendly, low-cost algorithm that can be widely adopted.

Admission pulse pressure and in-hospital mortality in type A acute aortic dissection: result from a Chinese study in stable patients on admission

OBJECTIVES

In recent years, several epidemiologic studies have shown that pulse pressure (PP) is a powerful predictor of mortality from many cardiovascular diseases. However, few studies have reported the association between PP and adverse events during hospitalization in patients with type A acute aortic dissection (TAAAD). The aim of this study was to evaluate the relationship between admission PP and in-hospital all-cause mortality, in patients with TAAAD of relatively stable patients.

METHODS

Patients with TAAAD of relatively stable patients admitted from January 2015 to December 2021 were included and divided into four groups according to the PP values measured at the time of admission: reduced group (PP ≤ 40 mmHg), normal group (40 < PP ≤ 56 mmHg), mildly elevated group (56 < PP ≤ 75 mmHg), and significantly elevated group (PP > 75 mmHg). A multivariate binary logistic regression model was constructed, plotted using nomogram and evaluated with ROC curve.

RESULTS

Admission PP and in-hospital all-cause mortality showed a "J-curve" correlation and in-hospital all-cause mortality was significantly higher in the significantly elevated group and reduced group (P = 0.002), respectively. Multivariate binary logistic regression analysis showed that significantly elevated PP (PP > 75 mmHg) (P < 0.001) and reduced PP (P = 0.043), D-dimer (P < 0.001), ascending aortic diameter (P = 0.037), Abdominal visceral vessels involved (P = 0.017), and coronary atherosclerosis (P = 0.003) and emergent surgery (P < 0.001) were independent predictive factors for in-hospital all-cause mortality. The AUC of ROC plotted was 0.827 (95% CI 0.774-0.880).

CONCLUSIONS

Our findings demonstrated a "J-curve" association of admission PP with in-hospital all-cause mortality in TAAAD. Significantly elevated and reduced admission PP, D-dimer, ascending aortic diameter and coronary atherosclerosis were independent risk factors for in-hospital all-cause mortality in patients with TAAAD, and emergent surgery was a protective factor.

Prediction Model of in Hospital Death for Stanford Type A Aortic Dissection Based on a Meta-Analysis of 24 Cohorts

Patients with Stanford type A aortic dissection (TAAD) have high postoperative mortality. This study aimed to develop a prediction model for in-hospital death after surgery in patients with TAAD. The derivation cohort came from a meta-analysis. Major risk factors were counted. The corresponding hazard ratio was reported to establish a prediction model for in-hospital death in patients with TAAD. Validation cohorts from 2 centres were used to evaluate the prediction model. The meta-analysis included 24 cohort studies with a total of 11,404 patients and 1,554 patients died early after surgery. Risk factors for the prediction model included age, body mass index, smoking, coronary heart disease, preoperative stroke, shock, preoperative cardiopulmonary resuscitation, pericardial tamponade and malperfusion. Patients with TAAD admitted to the First and the Fourth Hospital of Hebei Medical University between January 2020 and June 2024 were retrospectively collected. Patients from the 2 hospitals constituted validation cohorts A (n = 262) and B (n = 138). Risk scores were calculated for model validation and the prediction model demonstrated better differentiation for validation cohort A, with an area under the curve of 0.886 (95% confidence interval 0.842 to 0.931). This study established a simple risk prediction model, including 13 risk factors, to predict in-hospital death in patients with TAAD. However, multicenter data is still needed to evaluate the prediction accuracy of the model.

Special considerations in assisted reproductive technology for patients with cardiovascular disease

Many individuals with cardiovascular disease can benefit from the availability of assisted reproductive technologies (ARTs) for family building. Its use for this population may be because of underlying infertility, a need for fertility preservation before disease worsening or heart transplant, a genetic cardiac condition they believe to avoid passing to offspring, or the need to use a gestational surrogate in the setting of cardiovascular contraindications to pregnancy. Cardiovascular disease exists on a spectrum, from mild and common diseases that pose minimal threat to maternal health during pregnancy to severe and rare diseases with a high risk of morbidity and maternal mortality if ART or pregnancy is pursued. In this review, we characterize the varying cardiovascular diseases from the lens of the reproductive-aged patient undergoing ART. We classify the necessary steps in the pre-ART evaluation from the multidisciplinary team, discuss risk stratification before ART treatment and possible subsequent pregnancy, and offer specific evidence-based guidance on the care of these patients during the in vitro fertilization and embryo transfer cycles.

Cardio-obstetrics in the Cardiac Intensive Care Unit: An Introductory Guide

The care of the cardio-obstetric population in the cardiac intensive care unit is challenging due to limited data in this patient population. Optimal care requires a broad multidisciplinary team of experts such that both maternal and fetal health are fully supported. A deep understanding of the interplay between the hemodynamics of pregnancy and the clinical manifestations of varied cardiac disease states is essential. The assessment, diagnostic testing, and treatment of patients who are pregnant require special consideration, especially as teams consider pharmacological and invasive therapies. Complex ethical decisions often arise and therapies may be limited by federal and state policy, which adds an additional layer of complexity. This review serves as an introductory guide to cardio-obstetric care in the cardiac intensive care unit.