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Katsarou M, Mandigers TJ, Berczeli M, Mujeeb Zubair M, Belvroy VM, Bissacco D, van Herwaarden JA, Trimarchi S, Bismuth J. Sex-Specific Morphometric Analysis of Ascending Aorta and Aortic Arch for Planning Thoracic Endovascular Aortic Repair: A Retrospective Cohort Study. J Endovasc Ther 2023:15266028231210228. [PMID: 37936418 DOI: 10.1177/15266028231210228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
OBJECTIVE In many studies on aortic disease, women are underrepresented. The present study aims to assess sex-specific morphometric differences and gain more insight into endovascular treatment of the ascending aorta (AA) and arch. METHODS Electrocardiogram-gated cardiac computed tomography scans of 116 consecutive patients who were evaluated for transcatheter aortic valve replacement were retrospectively reviewed. Measurements of the AA and aortic arch were made in multiplanar views, perpendicular to the semi-automatic centerline. Multiple linear regression analysis was performed to identify predictors affecting AA and aortic arch diameter in men and women. Propensity score matching was used to investigate whether sex influences aortic morphology. RESULTS In both sexes, body surface area (BSA) was identified as a positive predictor and diabetes as a negative predictor for aortic diameters. In men, age was identified as a positive predictor and smoking as a negative predictor for aortic diameters. Propensity score matching identified 40 pairs. Systolic and diastolic mean diameters and AA length were significantly wider in men. On average, male aortas were 7.4% wider than female aortas, both in systole and diastole. CONCLUSIONS The present analysis demonstrates that, in women, increased BSA is associated with increased aortic arch diameters, while diabetes is associated with decreased AA and arch diameters. In men, increased BSA and age are associated with increased AA and arch diameters, while smoking and diabetes are associated with decreased AA and arch diameters. Men were confirmed to have 7.4% greater AA and arch diameters than women. CLINICAL IMPACT Men had 7.4% greater ascending aorta and arch diameters than women in a retrospective cohort, gated computed tomography-based study of 116 patients. Sex-specific differences in ascending aortic and arch size should be considered by aortic endovascular device manufacturers and physicians when developing ascending and arch endografts and planning aortic interventions.
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Affiliation(s)
- Maria Katsarou
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy
| | - Tim J Mandigers
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marton Berczeli
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular Surgery, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - M Mujeeb Zubair
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Viony M Belvroy
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Daniele Bissacco
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Joost A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Jean Bismuth
- Division of Vascular Surgery, LSU School of Medicine, New Orleans, LA, USA
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Pirruccello JP, Khurshid S, Lin H, Lu-Chen W, Zamirpour S, Kany S, Raghavan A, Koyama S, Vasan RS, Benjamin EJ, Lindsay ME, Ellinor PT. AORTA Gene: Polygenic prediction improves detection of thoracic aortic aneurysm. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.23.23294513. [PMID: 37662232 PMCID: PMC10473783 DOI: 10.1101/2023.08.23.23294513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background Thoracic aortic disease is an important cause of morbidity and mortality in the US, and aortic diameter is a heritable contributor to risk. Could a polygenic prediction of ascending aortic diameter improve detection of aortic aneurysm? Methods Deep learning was used to measure ascending thoracic aortic diameter in 49,939 UK Biobank participants. A genome-wide association study (GWAS) was conducted in 39,524 participants and leveraged to build a 1.1 million-variant polygenic score with PRScs-auto. Aortic diameter prediction models were built with the polygenic score ("AORTA Gene") and without it. The models were tested in a held-out set of 4,962 UK Biobank participants and externally validated in 5,469 participants from Mass General Brigham Biobank (MGB), 1,298 from the Framingham Heart Study (FHS), and 610 participants from All of Us. Results In each test set, the AORTA Gene model explained more of the variance in thoracic aortic diameter compared to clinical factors alone: 39.9% (95% CI 37.8-42.0%) vs 29.2% (95% CI 27.1-31.4%) in UK Biobank, 36.5% (95% CI 34.4-38.5%) vs 32.5% (95% CI 30.4-34.5%) in MGB, 41.8% (95% CI 37.7-45.9%) vs 33.0% (95% CI 28.9-37.2%) in FHS, and 34.9% (95% CI 28.8-41.0%) vs 28.9% (95% CI 22.9-35.0%) in All of Us. AORTA Gene had a greater AUROC for identifying diameter ≥4cm in each test set: 0.834 vs 0.765 (P=7.3E-10) in UK Biobank, 0.808 vs 0.767 in MGB (P=4.5E-12), 0.856 vs 0.818 in FHS (P=8.5E-05), and 0.827 vs 0.791 (P=7.8E-03) in All of Us. Conclusions Genetic information improved estimation of thoracic aortic diameter when added to clinical risk factors. Larger and more diverse cohorts will be needed to develop more powerful and equitable scores.
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Affiliation(s)
- James P. Pirruccello
- Division of Cardiology, University of California San Francisco, San Francisco, California, USA
- Institute for Human Genetics, University of California San Francisco, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California, USA
| | - Shaan Khurshid
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Honghuang Lin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, Massachusetts, USA
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Weng Lu-Chen
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Siavash Zamirpour
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Shinwan Kany
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Avanthi Raghavan
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Satoshi Koyama
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Ramachandran S. Vasan
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, Massachusetts, USA
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- Epidemiology Department, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Emelia J. Benjamin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, Massachusetts, USA
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- Epidemiology Department, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Mark E. Lindsay
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Patrick T. Ellinor
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Ban E, Kalogerakos PD, Khosravi R, Ziganshin BA, Ellauzi H, Ramachandra AB, Zafar MA, Humphrey JD, Elefteriades JA. Extended law of laplace for measurement of the cloverleaf anatomy of the aortic root. Int J Cardiovasc Imaging 2023; 39:1345-1356. [PMID: 37046157 PMCID: PMC10250276 DOI: 10.1007/s10554-023-02847-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/27/2023] [Indexed: 04/14/2023]
Abstract
The cross-sectional shape of the aortic root is cloverleaf, not circular, raising controversy regarding how best to measure its radiographic "diameter" for aortic event prediction. We mathematically extended the law of Laplace to estimate aortic wall stress within this cloverleaf region, simultaneously identifying a new metric of aortic root dimension that can be applied to clinical measurement of the aortic root and sinuses of Valsalva on clinical computerized tomographic scans. Enforcing equilibrium between blood pressure and wall stress, finite element computations were performed to evaluate the mathematical derivation. The resulting Laplace diameter was compared with existing methods of aortic root measurement across four patient groups: non-syndromic aneurysm, bicuspid aortic valve, Marfan syndrome, and non-dilated root patients (total 106 patients, 62 M, 44 F). (1) Wall stress: Mean wall stress at the depth of the sinuses followed this equation: Wall stress = BP × Circumscribing circle diameter/(2 × Aortic wall thickness). Therefore, the diameter of the circle enclosing the root cloverleaf, that is, twice the distance between the center, where the sinus-to-commissure lines coincide, and the depth of the sinuses, may replace diameter in the Laplace relation for a cloverleaf cross-section (or any shaped cross-section with two or more planes of symmetry). This mathematically derived result was verified by computational finite element analyses. (2) Diameters: CT scan measurements showed a significant difference between this new metric, the Laplace diameter, and the sinus-to-commissure, mid-sinus-to-mid-sinus, and coronal measurements in all four groups (p-value < 0.05). The average Laplace diameter measurements differed significantly from the other measurements in all patient groups. Among the various possible measurements within the aortic root, the diameter of the circumscribing circle, enclosing the cloverleaf, represents the diameter most closely related to wall stress. This diameter is larger than the other measurements, indicating an underestimation of wall stress by prior measurements, and otherwise provides an unbiased, convenient, consistent, physics-based measurement for clinical use. "Diameter" applies to circles. Our mathematical derivation of an extension of the law of Laplace, from circular to cloverleaf cross-sectional geometries of the aortic root, has implications for measurement of aortic root "diameter." The suggested method is as follows: (1) the "center" of the aortic root is identified by drawing three sinus-to-commissure lines. The intersection of these three lines identifies the "center" of the cloverleaf. (2) The largest radius from this center point to any of the sinuses is identified as the "radius" of the aortic root. (3) This radius is doubled to give the "diameter" of the aortic root. We find that this diameter best corresponds to maximal wall stress in the aortic root. Please note that this diameter defines the smallest circle that completely encloses the cloverleaf shape, touching the depths of all three sinuses.
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Affiliation(s)
- Ehsan Ban
- Department of Biomedical Engineering, Yale University, New Haven, USA
| | | | - Ramak Khosravi
- Department of Biomedical Engineering, Yale University, New Haven, USA
| | - Bulat A Ziganshin
- Aortic Institute, Yale School of Medicine, CB-3, 789 Howard Ave., New Haven, CT, 06510, USA
| | - Hesham Ellauzi
- Aortic Institute, Yale School of Medicine, CB-3, 789 Howard Ave., New Haven, CT, 06510, USA
| | | | - Mohammad A Zafar
- Aortic Institute, Yale School of Medicine, CB-3, 789 Howard Ave., New Haven, CT, 06510, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, USA
| | - John A Elefteriades
- Aortic Institute, Yale School of Medicine, CB-3, 789 Howard Ave., New Haven, CT, 06510, USA.
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Pirruccello JP, Lin H, Khurshid S, Nekoui M, Weng LC, Ramachandran VS, Isselbacher EM, Benjamin EJ, Lubitz SA, Lindsay ME, Ellinor PT. Development of a Prediction Model for Ascending Aortic Diameter Among Asymptomatic Individuals. JAMA 2022; 328:1935-1944. [PMID: 36378208 PMCID: PMC9667326 DOI: 10.1001/jama.2022.19701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
IMPORTANCE Ascending thoracic aortic disease is an important cause of sudden death in the US, yet most aortic aneurysms are identified incidentally. OBJECTIVE To develop and validate a clinical score to estimate ascending aortic diameter. DESIGN, SETTING, AND PARTICIPANTS Using an ongoing magnetic resonance imaging substudy of the UK Biobank cohort study, which had enrolled participants from 2006 through 2010, score derivation was performed in 30 018 participants and internal validation in an additional 6681. External validation was performed in 1367 participants from the Framingham Heart Study (FHS) offspring cohort who had undergone computed tomography from 2002 through 2005, and in 50 768 individuals who had undergone transthoracic echocardiography in the Community Care Cohort Project, a retrospective hospital-based cohort of longitudinal primary care patients in the Mass General Brigham (MGB) network between 2001-2018. EXPOSURES Demographic and clinical variables (11 covariates that would not independently prompt thoracic imaging). MAIN OUTCOMES AND MEASURES Ascending aortic diameter was modeled with hierarchical group least absolute shrinkage and selection operator (LASSO) regression. Correlation between estimated and measured diameter and performance for identifying diameter 4.0 cm or greater were assessed. RESULTS The 30 018-participant training cohort (52% women), were a median age of 65.1 years (IQR, 58.6-70.6 years). The mean (SD) ascending aortic diameter was 3.04 (0.31) cm for women and 3.32 (0.34) cm for men. A score to estimate ascending aortic diameter explained 28.2% of the variance in aortic diameter in the UK Biobank validation cohort (95% CI, 26.4%-30.0%), 30.8% in the FHS cohort (95% CI, 26.8%-34.9%), and 32.6% in the MGB cohort (95% CI, 31.9%-33.2%). For detecting individuals with an ascending aortic diameter of 4 cm or greater, the score had an area under the receiver operator characteristic curve of 0.770 (95% CI, 0.737-0.803) in the UK Biobank, 0.813 (95% CI, 0.772-0.854) in the FHS, and 0.766 (95% CI, 0.757-0.774) in the MGB cohorts, although the model significantly overestimated or underestimated aortic diameter in external validation. Using a fixed-score threshold of 3.537, 9.7 people in UK Biobank, 1.8 in the FHS, and 4.6 in the MGB cohorts would need imaging to confirm 1 individual with an ascending aortic diameter of 4 cm or greater. The sensitivity at that threshold was 8.9% in the UK Biobank, 11.3% in the FHS, and 18.8% in the MGB cohorts, with specificities of 98.1%, 99.2%, and 96.2%, respectively. CONCLUSIONS AND RELEVANCE A prediction model based on common clinically available data was derived and validated to predict ascending aortic diameter. Further research is needed to optimize the prediction model and to determine whether its use is associated with improved outcomes.
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Affiliation(s)
- James P. Pirruccello
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiology, University of California San Francisco
| | - Honghuang Lin
- Framingham Heart Study, Boston University, Framingham, Massachusetts
- University of Massachusetts Medical School, Worcester
- National Heart, Lung, and Blood Institute, Framingham, Massachusetts
| | - Shaan Khurshid
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mahan Nekoui
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Lu-Chen Weng
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Vasan S. Ramachandran
- Framingham Heart Study, Boston University, Framingham, Massachusetts
- National Heart, Lung, and Blood Institute, Framingham, Massachusetts
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
- Epidemiology Department, Boston University School of Public Health, Boston, Massachusetts
| | - Eric M. Isselbacher
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Thoracic Aortic Center, Massachusetts General Hospital, Boston
| | - Emelia J. Benjamin
- Framingham Heart Study, Boston University, Framingham, Massachusetts
- National Heart, Lung, and Blood Institute, Framingham, Massachusetts
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
- Epidemiology Department, Boston University School of Public Health, Boston, Massachusetts
| | - Steven A. Lubitz
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
- Novartis Institutes for Biomedical Research, Cambridge, Massachusetts
| | - Mark E. Lindsay
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Thoracic Aortic Center, Massachusetts General Hospital, Boston
| | - Patrick T. Ellinor
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
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