Surgery for aortic regurgitation and aortic root dilatation in Takayasu arteritis

Long-term outcomes and prognostic factors after aortic valve surgery in patients with Takayasu arteritis

BACKGROUND

Aortic regurgitation (AR) is a common cardiovascular complication in patients with Takayasu arteritis (TAK), and complication after aortic valve surgery (AVS) is not rare. This study aimed to identify the long-term postoperative outcomes for significant AR in patients with TAK compared with those in patients without TAK.

METHODS

We included 35 patients with TAK with moderate-to-severe AR who underwent AVS and compared their postoperative outcomes with those of 105 age- and operation period-matched patients with severe AR but without TAK. The risk factors for poor outcomes [all-cause death and major adverse cardiac and cerebrovascular events (MACCE)] in patients with TAK were analyzed using multivariate Cox regression.

RESULTS

The 10-year overall survival rate was 70.5% in patients with TAK and 89.4% in those without TAK (p = 0.048). The MACCE and reoperation rates were significantly higher in patients with TAK (10-year freedom from MACCE, 58.2% vs. 86.4% [p < 0.001]; 10-year freedom from reoperation, 64.5% vs. 98.3% [p < 0.001]). Eighteen of the 35 patients with TAK (51.4%) had poor outcomes, and multivariate analysis revealed that significant coronary artery involvement [hazard ratio (HR), 4.178; 95% confidence interval (CI), 1.222-14.282; p = 0.023] and decreased estimated glomerular filtration rate (HR, 0.968; 95% CI 0.947-0.989; p = 0.003) were associated with poor outcomes.

CONCLUSION

The long-term postoperative outcomes for AR were poorer in patients with TAK than in those without TAK. The poor outcomes in patients with TAK were associated with coronary artery involvement and decreased renal function.

Risk factors of aortic regurgitation progression in Chinese patients with Takayasu's arteritis: a prospective cohort study

OBJECTIVE

To elucidate the 3-year follow-up outcomes and risk factors associated with aortic regurgitation progression in Takayasu's arteritis (TAK).

METHODS

This study was a prospective cohort study conducted among 77 patients with TAK at Zhongshan Hospital, Fudan University, China. All the participants were followed up and assessed with echocardiography for 3 years, and the baseline characteristics and dynamic changes in the aortic valve were recorded and investigated. A multivariable Cox model was used to explore the risk factors for aortic regurgitation progression.

RESULTS

The median onset age was 36.9 (26.0-44.4) years, and 57 patients (74.0%) were females. Fifty patients (64.9%) complained of aortic regurgitation, which was the most common valvular lesion at baseline. During the 3-year follow-up period, the progression of aortic regurgitation was observed in 29 (37.7%) patients with TAK. The progression group had higher baseline erythrocyte sedimentation rate (ESR; p = 0.013) and interleukin (IL)-6 (p = 0.029) levels and lower early treatment remission rates (p = 0.024). According to the Cox model, the elevated baseline IL-6 level [>13 pg/ml, hazard ratio (HR) = 2.4, 95% confidence interval (CI) = 1.0-5.8, p = 0.042] and absence of early treatment remission (HR = 3.3, 95% CI = 1.3-8.2, p = 0.010) were the independent risk factors for aortic regurgitation deterioration.

CONCLUSION

About one-third of patients with TAK experienced aortic regurgitation progression within 3 years from first admission. Elevated IL-6 levels at baseline and absence of early treatment remission were the two important risk factors for subsequent aortic regurgitation progression.

Risk factors and surgical prognosis in patients with aortic valve involvement caused by Takayasu arteritis

Objective

Aortic valve involvement is not uncommon in patients with Takayasu arteritis (TAK) and leading to poor prognosis. The aim of our study was to explore the risk factors of aortic valve involvement and to evaluate the prognosis in TAK patients with aortic valve involvement.

Method

In this retrospective study, 172 TAK patients were divided into groups with or without aortic valve involvement to identify the risk factors. Patients who underwent aortic valve surgical treatment were followed up to assess cumulative incidence of postoperative adverse events.

Results

A total of 92 TAK patients (53.49%) had aortic valvular lesion. The infiltration of inflammatory cells was found in surgical specimens of aortic valve. Numano type IIb, elevated high-sensitivity C-reactive protein (hs-CRP) level, and dilation of ascending aorta and aortic root were statistically associated with aortic valvular lesion in TAK patients (OR [95%CI] 6.853 [1.685–27.875], p=0.007; 4.896 [1.646–14.561], p=0.004; 4.509 [1.517–13.403], p=0.007; 9.340 [2.188–39.875], p=0.003). The 1-, 5-, and 7-year cumulative incidence of postoperative adverse events were 14.7%, 14.7%, and 31.8%, respectively. Surgical methods (p=0.024, hazard ratio (HR) 0.082) and postoperatively anti-inflammatory therapy (p=0.036, HR 0.144) were identified as potential predictors of postoperative adverse events.

Conclusions

Regularly echocardiogram screening is suggested in patients with Numano type IIb and aggressive treatment should be performed early in TAK patients. As for TAK patients with aortic valve surgery, aortic root replacement seems to be the preferred option and regular anti-inflammatory therapy may reduce the occurrence of adverse events of them.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02788-9.

Different treatment options for Takayasu arteritis patients with moderate-to-severe aortic regurgitation: long-term outcomes

OBJECTIVES

To determine the prognosis of Takayasu arteritis (TA) patients with moderate-to-severe aortic regurgitation treated with surgical vs conservative treatment and to identify independent prognostic factors of long-term outcomes.

METHODS

Between January 2002 and January 2017, 101 consecutive TA patients with moderate-to-severe aortic regurgitation treated with either surgical (n = 38) or conservative (n = 63) treatments were investigated in this retrospective observational case-control study. The primary end point was all-cause mortality, and the secondary end point comprised the combined end points of death, non-fatal stroke and cardiac events (non-fatal myocardial infarction and congestive heart failure). Propensity score matching was used to reduce the bias of baseline risk factors.

RESULTS

The unadjusted all-cause 10-year mortality in the conservative group was increased compared with the surgical group (28.2% vs 7.4%; log-rank P = 0.036), and the combined end points showed the same trend (52.1% vs 25.3%; log-rank P = 0.005). After an adjustment of baseline risk factors, the conservative treatment was associated with reduced survival rates of both all-cause mortality [hazard ratio (HR): 8.243; 95% CI: 1.069, 63.552; P = 0.007] and combined end points (HR: 6.341; 95% CI: 1.469, 27.375; P = 0.002). Conservative treatment (HR: 3.838, 95% CI: 1.333, 11.053; P = 0.013) and left ventricular end-diastolic diameter (HR: 1.036, 95% CI: 1.001, 1.071; P = 0.042) were risk factors for increased combined end points.

CONCLUSION

Surgical treatment improves the outcomes of patients with moderate-to-severe aortic regurgitation due to TA. The dilated left ventricle indicated a worse prognosis.

Physical Exercise in Managing Takayasu Arteritis Patients Complicated With Cardiovascular Diseases

Takayasu arteritis (TA) is a kind of large-vessel vasculitis that mainly affects the aorta and its branches, and the patients are usually women at a relatively young age. The chronic inflammation of arteries in TA patients leads to stenosis, occlusion, dilatation, or aneurysm formation. Patients with TA thereby have a high risk of cardiovascular disease (CVD) complications, which are the most common cause of mortality. This review summarizes the main cardiovascular complications and the risk factors of cardiovascular complications in patients with TA. Here, we discuss the benefits and potential risks of physical exercise in patients with TA and give recommendations about exercise prescription for TA patients to decrease the risks of CVD and facilitate rehabilitation of cardiovascular complications, which might maximally improve the outcomes.

Transcatheter aortic valve implantation for severe pure aortic regurgitation due to active aortitis

Aortitis is an uncommon systemic inflammatory disease affecting the aorta and its main branches. Severe aortic regurgitation (AR) represents a fearsome complication of aortitis and is associated with an increased mortality rate. Surgical aortic valve replacement represents the only treatment choice for these patients. However, it is associated with a higher risk of medium to long-term complications such as prosthetic valve detachment. This is the first reported case where severe AR secondary to aortitis was managed with transcatheter aortic valve implantation (TAVI). TAVI was safe and effective in this clinical setting and may be considered a viable alternative to high-risk surgery in these complex patients.

Cardiac valvular involvement of Takayasu arteritis

OBJECTIVE

This study aimed to investigate the imaging and serological features in Takayasu arteritis (TA) patients with valvular involvement and determine the relationship between them.

METHOD

This is a retrospective single-center study enrolled 103 TA patients fulfilling the American College of Rheumatology criteria. An independent medical chart review was performed by two senior rheumatologists from Beijing Anzhen Hospital, Capital Medical University. The logistic analysis was used to investigate the relationship between valvular involvement in TA patients and the imaging and serological features of them.

RESULTS

Sixty-six TA patients (64.08%) had cardiac valvular involvement in our study. Aortic insufficiency (62.12%) was the most common valvular involvement. Twelve (22.22%) patients developed heart failure. In patients with valvular involvement, the most common angiographic type was Numano type V, which was significantly higher than that in patients without valvular involvement (53.30% vs 32.43%, p = 0.044), followed by coronary involvement (28.79% vs 10.81%, p = 0.036) and Numano type IIb (21.21% vs 5.41%, p = 0.034). Serum levels of immunoglobulin A (2.84 ± 1.42 g/L vs 2.26 ± 0.97 g/L, p = 0.032) and immunoglobulin G (13.5 ± 4.71 g/L vs 11.42 ± 3.01 g/L, p = 0.015) were significantly higher in patients with valvular involvement. Numano type IIb is significantly related to moderate-severe aortic valvular regurgitation in TA patients (4.10 [1.03-16.33], p = 0.04). Elevated C-reactive protein (CRP) level is associated with moderate-severe mitral valve involvement in TA patients (p = 0.05, OR = 17.75, 95% CI 1.07-295.41).

CONCLUSIONS

CRP elevation and Numano type IIb are significantly related to different types of valvular involvement in TA patients. Key Points • The Numano types IIb and V were common in TA patients with valvular involvement. • CRP elevation and Numano type IIb are close related to valvular involvement in TA patient. • Echocardiogram screening and CRP level examination are reasonable to TA patients which might have valvular involvement.

Surgical Treatment in Patients With Aortic Regurgitation Due to Takayasu Arteritis

BACKGROUND

Aortic regurgitation is a common complication in patients with Takayasu arteritis. Severe aortic regurgitation requires surgical treatment. We investigated the outcomes of aortic valve replacement (AVR) and composite graft replacement (CGR) in patients with Takayasu arteritis and aortic regurgitation.

METHODS

We retrospectively reviewed the data from 41 patients with Takayasu arteritis and aortic regurgitation treated by AVR (n = 23) and CGR (n = 18) from January 1992 to December 2016.

RESULTS

The mean age at operation was 40.3 years, and 61.0% were women. Concurrent procedures were performed in 43.9% of patients. The preoperative aortic root diameter in the AVR and CGR groups was 41.5 ± 7.9 and 47.8 ± 9.5 mm, respectively. The cardiopulmonary bypass time was longer in the CGR group (140.2 ± 44.8 minutes) than in the AVR group (105.2 ± 32.5 minutes). No in-hospital death occurred. During a median follow-up of 6.6 years (interquartile range, 0.6-9.4) we observed 10 patients with composite adverse events in the AVR group (1 death, 3 reoperations, 3 residual ascending aorta aneurysms, 6 paravalvular leaks, and 1 valve detachment) and 2 composite events in the CGR group (2 deaths and 1 paravalvular leak). The unadjusted 5-year event-free rate was 55.8% and 91.7% in the AVR and CGR groups, respectively (log-rank P < .05). CGR was associated with nominally lower events on adjusted analysis (hazard ratio, 4.212; 95% confidence interval [0.910, 19.509]; P = .066).

CONCLUSIONS

Paravalvular leak was the main postoperative complication. CGR was associated with nominally fewer adverse events.

Management of Takayasu arteritis: a systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis

Objective

To collect available evidence on management of large vessel vasculitis to inform the 2018 update of the EULAR management recommendations.

Methods

Two independent systematic literature reviews were performed, one on diagnosis and monitoring and the other on drugs and surgical treatments. Using a predefined PICO (population, intervention, comparator and outcome) strategy, Medline, Embase and Cochrane databases were accessed. Eligible papers were reviewed and results condensed into a summary of findings table. This paper reports the main results for Takayasu arteritis (TAK).

Results

A total of 287 articles were selected. Relevant heterogeneity precluded meta-analysis. Males appear to have more complications than females. The presence of major complications, older age, a progressive disease course and a weaker inflammatory response are associated with a more unfavourable prognosis. Evidence for details on the best disease monitoring scheme was not found. High-quality evidence to guide the treatment of TAK was not found. Glucocorticoids are widely accepted as first-line treatment. Conventional immunosuppressive drugs and tumour necrosis factor inhibitors were beneficial in case series and uncontrolled studies. Tocilizumab failed the primary endpoint (time to relapse) in a randomised controlled clinical trial; however, results still favoured tocilizumab over placebo. Vascular procedures may be required, and outcome is better when performed during inactive disease.

Conclusions

Evidence to guide monitoring and treatment of patients with TAK is predominantly derived from observational studies with low level of evidence. Therefore, higher-quality studies are needed in the future.

Delayed dehiscence of modified mechanical Bentall 7 years postsurgery for Takayasu's arteritis

Following aortic surgery for vasculitis, the incidence and duration of onset of anastomotic breakdown is unclear. A case is presented of a young female patient with Takayasu's arteritis (TA) who was found to have frank dehiscence of a modified Bentall repair 7 years after surgery. The case highlights (i) the lack of normal healing following aortic surgery in TA, and (ii) need to differentiate imaging protocols for patients with defined vasculitis as opposed to degenerative aortic conditions. A recommendation is made for appropriate surveillance imaging modality alternating between computed tomography and magnetic resonance imaging in the often young patient population affected by vasculitis.

Cardiac Valve Involvement in Takayasu Arteritis Is Common: A Retrospective Study of 1,069 Patients Over 25 Years

BACKGROUND

Takayasu arteritis (TA) can involve the aortic root or cardiac valves, resulting in hemodynamic disorders. In this study, we focused on the prevalence and clinical characteristics of TA patients with valve regurgitation.

MATERIALS AND METHODS

We retrospectively assessed the clinical data in the electronic medical records of 1,069 consecutive patients with TA admitted to Fuwai Hospital from January 1992 to August 2017. We evaluated the valvular structure and function mainly by cardiac ultrasound.

RESULTS

Among the 1,069 patients, 373 (34.9%) had valve regurgitation. The female to male ratio was 4.8:1. The average age at symptom onset was 28.1 ± 10.6 years. The median duration from symptom onset to first hospitalization was 65.9 months. Of patients with valve involvement, 47.4% and 40.1% had a high erythrocyte sediment rate and C-reactive protein level, respectively, at the time of echocardiography. Most patients (69.7%) had aortic regurgitation, and nearly half had moderate to severe aortic regurgitation. A total of 38.8% of patients had aortic valve damage, and 23.3% had involvement of the ascending aorta. Most other valve insufficiency was mild, including mitral regurgitation in 39.1% of patients, tricuspid regurgitation in 34.6%, and pulmonary regurgitation in 11.8%. Valve stenosis was rare. Misdiagnosis of other cardiac diseases occurred in 13 patients.

CONCLUSIONS

Cardiac valve insufficiency is common in Chinese TA patients. Patients should undergo echocardiography once TA is diagnosed. In young women of reproductive age, TA should be considered when aortic regurgitation is detected.

Surgical strategy for refractory aortitis

In some instances, we encounter cases suffered from inflammatory aortic diseases (aortitis) in Japan, some of which are at the active stages with systemic inflammation. Most of them are refractory with some technical difficulties of surgical treatment. The aortic wall, particularly, at the active stage, is too fragile to hold the surgical sutures. Consequently, the suture reinforcement with Teflon felt is required. In the late stage after surgery, false aneurysms on the suture line, that is, suture detachment potentially occur. To prevent such sequelae in the early and late phases, continuous (life-long) as well as perioperative inflammation control using corticosteroid as an initial drug and/or other immunosuppression agents. This decade, instead of the conventional open surgical repairs, endovascular treatments have widely spread, predominantly for stenotic aortic/arterial lesions. In particular, for more difficult patients suffered from more troublesome Behçet disease, endovascular treatments would have greater advantages to avoid more occasionally occurred pseudo-aneurysm on the other parts as well as the surgical suture lines. The key issues on surgical treatment for refractory aortitis are perioperative inflammation control including the long term with corticosteroid and/or immunosuppressive agents, appropriate open surgical or endovascular treatment approaches, and sufficient reinforcement of surgical suture lines.

Reoperation for ascending aorta aneurysm after double valve replacement in a Takayasu's aortitis patient: a case report

Takayasu’s aortitis (TA) is a complicated disease. Surgical treatment, especially reoperation, can be difficult. Here, we report a case of reoperation for TA, which presented with three major complications (aortic aneurysm, valve detachment, and fistula) 3 years after surgical treatment. During the surgery, the aortic valve was reconsolidated and fixed to the mitral valve, the fistula was then repaired, and the aortic root was replaced with woven graft. Following an uncomplicated postoperative event, the patient was discharged at 24 days postoperatively. Follow-up echocardiography at 2 years showed no perivalvular leakage. In such reoperative cases, when double valve replacement is required, it may be better to proactively reconstruct the structure of the central fibrous body.

Severe aortic regurgitation complicating Takayasu's arteritis

We present an uncommon case of a 48-year-old female patient with symptomatic presentation of a severe aortic regurgitation with aneurysm of the ascending aorta and progressive dyspnea. Detailed investigation of laboratory tests and imaging identified Takayasu’s arteritis (TA) as the underlying etiology. Computed tomography scan revealed complete occlusion of the right carotid artery as well as stenosis at the origins of left subclavian and vertebral arteries. In addition, cardiac magnetic resonance angiogram showed aneurysm at the proximal segment of right subclavian artery. Intervention with corticosteroids effectively diminished the need for immediate surgical intervention. Treating physicians should always consider differential diagnosis of TA in the presence of atypical clinical findings in all patients with cardiac problems especially when there is valve involvement.

Vascular surgery: the main risk factor for mortality in 146 Takayasu arteritis patients

Takayasu arteritis (TA) is an idiopathic chronic inflammatory disease that affects the aorta and its main branches. According to disease involvement, patients may require surgical treatment mainly due ischemic lesions in association with medical therapy. We evaluated the impact of vascular interventions in a cohort of TA patients. Medical records from 146 TA patients were reviewed. Clinical features, medical, and surgical treatment were revised and disease activity was determined by clinical, laboratorial, and imaging parameters. Clinical parameters associated with mortality alongside vascular procedures were evaluated and their impact on mortality in our cohort was estimated. Ninety-four vascular interventions were performed in 61 patients (41.8%). A third of them were of endovascular procedures. The overall mortality was 4.1%, all due to early postoperative complications, which resulted in a rate of surgery-related mortality of 9.8%. All deaths occurred in patients with active disease. Clinical parameters known to be associated with mortality (aneurysm, secondary hypertension, aortic insufficiency, and cerebrovascular accident) were not found related with death. Patients whose disease began before age 20 years had an OR 3.54 of undergoing a vascular surgical intervention. The observed impact of vascular procedures on mortality in patients with Takayasu arteritis, especially during disease activity, supports the notion that such interventions should be performed with caution and preferably during periods of remission.