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Milojevic M, Sousa-Uva M, Marin-Cuartas M, Kaul S, Nikolic A, Mandrola J, Sádaba JR, Myers PO. Same evidence different recommendations: a methodological assessment of transatlantic guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2024; 65:ezae184. [PMID: 38733575 DOI: 10.1093/ejcts/ezae184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/12/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVES The aim of this study was to identify methodological variations leading to varied recommendations between the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) valvular heart disease guidelines and to suggest foundational steps towards standardizing guideline development. METHODS An in-depth analysis was conducted to evaluate the methodologies used in developing the transatlantic guidelines for managing valvular heart disease. The evaluation was benchmarked against the standards proposed by the Institute of Medicine. RESULTS Substantial discrepancies were noted in the methodologies utilized in development processes, including Writing Committee composition, evidence evaluation, conflict of interest management and voting processes. Furthermore, despite their mutual differences, both methodologies demonstrate notable deviations from the Institute of Medicine standards in several essential areas, including literature review and evidence grading. These dual variances likely influenced divergent treatment recommendations. For example, the ESC/EACTS recommends transcatheter edge-to-edge repair for patients with chronic severe mitral regurgitation ineligible for mitral valve surgery, while the ACC/AHA recommends transcatheter edge-to-edge repair based on anatomy, regardless of surgical risk. ESC/EACTS guidelines recommend a mechanical aortic prosthesis for patients under 60, while ACC/AHA guidelines recommend it for patients under 50. Notably, the ACC/AHA and ESC/EACTS guidelines have differing age cut-offs for surgical over transcatheter aortic valve replacement (<65 and <75 years, respectively). CONCLUSIONS Variations in methodologies for developing clinical practice guidelines have resulted in different treatment recommendations that may significantly impact global practice patterns. Standardization of essential processes is vital to increase the uniformity and credibility of clinical practice guidelines, ultimately improving healthcare quality, reducing variability and enhancing trust in modern medicine.
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Affiliation(s)
- Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Miguel Sousa-Uva
- Department of Cardiothoracic Surgery, Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Sanjay Kaul
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem-Sistina Hospital, Skopje, North Macedonia
| | | | - J Rafael Sádaba
- Cardiac Surgery Department, Hospital Universitario de Navarra, Pamplona, Spain
| | - Patrick O Myers
- Division of Cardiac Surgery, Lausanne University Hospital, Lausanne, Switzerland
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Yin L, Wang J, Qiu Z, Chen X, Su C. Comparison of surgical and conservative treatment outcomes for type a aortic intramural hematoma. J Cardiothorac Surg 2024; 19:111. [PMID: 38448934 PMCID: PMC10919045 DOI: 10.1186/s13019-024-02533-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/28/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVE This study aimed to compare hospital and long-term clinical outcomes associated with various treatment methods for Stanford A type aortic intramural hematoma (IMH) to provide a reference for clinical decision-making. METHODS In this single-center cohort study, we retrospectively analyzed 73 patients with Type A IMH treated at our center from August 1, 2018 to August 1, 2021. Among these patients, 26 were treated conservatively, and 47 underwent surgical intervention. We next compared this IMH cohort with 154 patients with acute type A aortic dissection (AD) who were treated surgically during the same study period. RESULTS Computed tomography angiography revealed that the diameter of the ascending aorta of IMH patients treated with surgery was higher than IMH patients treated with conservative therapy (44.92 ± 7.58 mm vs. 51.22 ± 11.85 mm, P < 0.05), while there was no significant difference in other clinical parameters. The in-hospital mortality of patients with IMH who underwent surgical treatment was lower than those undergoing conservative treatment (0% vs. 11.5%, P < 0.05). The long-term mortality of the conservative IMH group was higher than the surgical IMH group (26.1% vs. 8.5%, P < 0.05). There was no significant difference in the surgical parameters and postoperative complications between AD and IMH surgery patients. The proportion of circulatory arrest time in the lower body (19.98 ± 9.39 min vs. 17.51 ± 3.97 min) and arch involvement (98 (63.6%) vs. 22 (46.8%)) in the IMH surgery group was lower than in the AD surgery group (P < 0.05). CONCLUSIONS Compared with conservative treatment, surgical treatment of IMH significantly improves the survival rate of patients. Thus, surgical intervention should be considered the primary treatment option if feasible. Furthermore, The safety of IMH surgery can be guaranteed just like AD. But we still need in the future evidence on bigger samples.
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Affiliation(s)
- Li Yin
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, People's Republic of China
| | - Jiankai Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, People's Republic of China
| | - Zhibing Qiu
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, People's Republic of China
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, People's Republic of China.
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu, People's Republic of China.
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Ahmad RA, Orelaru F, Arora A, Ling C, Kim KM, Fukuhara S, Patel H, Deeb GM, Yang B. Acute type A intramural hematoma: The less-deadly acute aortic syndrome? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00090-4. [PMID: 38280668 DOI: 10.1016/j.jtcvs.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/05/2024] [Accepted: 01/19/2024] [Indexed: 01/29/2024]
Abstract
OBJECTIVE To evaluate the short- and midterm outcomes of surgically managed acute type A intramural hematoma (IMH) versus classic acute type A aortic dissection (ATAAD). METHODS From 1996 to February 2023, a total of 106 patients with acute type A IMH and 795 patients with classic ATAAD presented for open aortic repair at our institution. Data were obtained from the local Society of Thoracic Surgeons' Data Warehouse and medical chart review. RESULTS Compared with the classic ATAAD group, the IMH group was older (65 vs 59 years, P < .001) and more likely to be female (45% vs 32%, P = .005), with fewer comorbidities such as severe aortic insufficiency (5.0% vs 25%, P < .001), acute stroke (2.8% vs 8.3%, P = .05), acute renal failure (5.7% vs 13%, P = .04), and malperfusion syndrome (8.5% vs 26%, P < .001) but more cardiac tamponade (18% vs 11%, P = .03). The IMH group had less aortic root replacement (15% vs 33%, P < .001), zone 2 arch replacements (9.4% vs 18%, P = .02), and shorter crossclamp times (120 minutes vs 150 minutes, P < .001). The operative mortality was significantly lower in the IMH group (0.9% vs 8.8%, P = .005) and a multivariable regression model showed IMH to be protective, odds ratio of 0.11, P = .03. The 10-year survival was similar between the 2 groups (65% vs 61%, P = .35). The hazard ratio of IMH for midterm mortality after surgery was 0.73, P = .12. CONCLUSIONS Acute type A IMH could be treated with emergency open aortic repair with excellent short- and midterm outcomes.
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Affiliation(s)
| | - Felix Orelaru
- Department of General Surgery, Trinity Health, Ann Arbor, Mich
| | - Akul Arora
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Carol Ling
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - Himanshu Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - G Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
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Wada T, Takahashi M, Matsunaga H, Kawai G, Kaneshima R, Machida M, Fujita N, Matsuoka Y. An automated screening model for aortic emergencies using convolutional neural networks and cropped computed tomography angiography images of the aorta. Int J Comput Assist Radiol Surg 2023; 18:2253-2260. [PMID: 37326817 DOI: 10.1007/s11548-023-02979-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/25/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE Patients with aortic emergencies, such as aortic dissection and rupture, are at risk of rapid deterioration, necessitating prompt diagnosis. This study introduces a novel automated screening model for computed tomography angiography (CTA) of patients with aortic emergencies, utilizing deep convolutional neural network (DCNN) algorithms. METHODS Our model (Model A) initially predicted the positions of the aorta in the original axial CTA images and extracted the sections containing the aorta from these images. Subsequently, it predicted whether the cropped images showed aortic lesions. To compare the predictive performance of Model A in identifying aortic emergencies, we also developed Model B, which directly predicted the presence or absence of aortic lesions in the original images. Ultimately, these models categorized patients based on the presence or absence of aortic emergencies, as determined by the number of consecutive images expected to show the lesion. RESULTS The models were trained with 216 CTA scans and tested with 220 CTA scans. Model A demonstrated a higher area under the curve (AUC) for patient-level classification of aortic emergencies than Model B (0.995; 95% confidence interval [CI], 0.990-1.000 vs. 0.972; 95% CI, 0.950-0.994, respectively; p = 0.013). Among patients with aortic emergencies, the AUC of Model A for patient-level classification of aortic emergencies involving the ascending aorta was 0.971 (95% CI, 0.931-1.000). CONCLUSION The model utilizing DCNNs and cropped CTA images of the aorta effectively screened CTA scans of patients with aortic emergencies. This study would help develop a computer-aided triage system for CT scans, prioritizing the reading for patients requiring urgent care and ultimately promoting rapid responses to patients with aortic emergencies.
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Affiliation(s)
- Tomoki Wada
- Department of Radiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, Japan.
| | - Masamichi Takahashi
- Department of Radiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, Japan
| | - Hiroki Matsunaga
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, Japan
| | - Go Kawai
- Department of Radiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, Japan
| | - Risa Kaneshima
- Department of Radiology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, Japan
| | - Munetaka Machida
- Department of Radiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, Japan
| | - Nana Fujita
- Department of Radiology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Yujiro Matsuoka
- Department of Radiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, Japan
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Kim MS, Kim TH, Lee H, Song SW, Yoo KJ. Tailored treatment modality in acute type A intramural hematoma. J Thorac Cardiovasc Surg 2023; 166:1400-1410. [PMID: 35221028 DOI: 10.1016/j.jtcvs.2022.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 01/02/2022] [Accepted: 01/24/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Intramural hematoma may be generated by a minimal intimal tear. Most surgeries for acute type A intramural hematoma are performed on the proximal aorta alone regardless of the intimal tear site. Under the assumption that major adverse aortic events (MAAEs) would be related to the location of primary intimal tear, we reviewed preoperative computed tomography scan findings. METHODS Sixty patients with acute type A intramural hematoma who underwent surgery from January 2008 to December 2019 were retrospectively analyzed. The maximal diameter, maximal thickness of the intramural hematoma, and hematoma thickness ratio of the ascending and descending aortae were measured. MAAEs were defined as newly developed aortic dissection, rupture, newly developed penetrating aortic ulcer (PAU), enlargement of the PAU, and aortic death. RESULTS The number of patients with PAU in the descending aorta (dPAU) was significantly higher in the MAAE (+) group. The MAAE (+) group showed lower measurements of the ascending aorta and higher measurements of the descending aorta than the MAAE (-) group. In the univariate analysis, dPAU, hematoma thickness ratio of the ascending and descending aortae, and descending aorta hematoma thickness >8.58 mm were risk factors of MAAE. Intimal tear noted intraoperatively and ascending aorta hematoma thickness >10.25 mm were protective factors of MAAE. CONCLUSIONS Aortopathies (ie, PAU, ulcer-like projections, and the hematoma thickness ratio) are important clues to determine the location of intimal tear. Occurrence of MAAEs seems to be highly related to the pathology of the descending aorta. The modalities of treatment for stable acute type A intramural hematoma that do not meet the existing guidelines should be tailored to the location of the intimal tear.
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Affiliation(s)
- Myeong Su Kim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ha Lee
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Kyung-Jong Yoo
- Department of Cardiovascular Surgery, Yonsei Cardiovascular Hospital, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Agbalessi M, Lalande A, Bouchot O, Hayase T, Christophe JJ, Fernández MA, Lombardi D. Tracking of Blood Vessels Motion from 4D-flow MRI Data. Cardiovasc Eng Technol 2023; 14:577-604. [PMID: 37578731 DOI: 10.1007/s13239-023-00677-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 07/19/2023] [Indexed: 08/15/2023]
Abstract
This paper presents a novel approach to track objects from 4D-flow MRI data. A salient feature of the proposed method is that it fully exploits the geometrical and dynamical nature of the information provided by this imaging modality. The underlying idea consists in formulating the tracking problem as a data assimilation problem, in which both position and velocity observations are extracted from the 4D-flow MRI data series. Optimal state estimation is then performed in a sequential fashion via Kalman filtering. The capabilities of the method are extensively assessed in a numerical study involving synthetic and clinical data.
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Affiliation(s)
- Mocia Agbalessi
- Sorbonne Université, CNRS, Inria, Paris, France
- ImVia Laboratory, University of Burgundy, Dijon, France
| | - Alain Lalande
- ImVia Laboratory, University of Burgundy, Dijon, France
- Department of Magnetic Resonance Imaging, Dijon University Hospital, Dijon, France
| | - Olivier Bouchot
- Department of Cardiovascular and Thoracic Surgery, Dijon University Hospital, Dijon, France
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Kim H, Cho S, Sakalihasan N, Hultgren R, Joh JH. Prevalence and Risk Factors of Abdominal Aortic Aneurysms Detected with Ultrasound in Korea and Belgium. J Clin Med 2023; 12:jcm12020484. [PMID: 36675413 PMCID: PMC9861924 DOI: 10.3390/jcm12020484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
The objective was to investigate the prevalence of abdominal aortic aneurysms (AAAs) and the diameters of the aorta and common iliac arteries (CIAs) in a Korean cohort and secondly to analyze the differences in aortic diameter by comparison with a European cohort. The Korean cohort included participants ≥ 50 years who consented to AAA screening and data were analysed retrospectively. Aortic and common iliac diameters were measured using the outer-to-outer diameter method and prevalence rates were calculated. Common risk factors such as smoking, body mass index, pulmonary disease, hypertension, diabetes, hyperlipidaemia, ischaemic heart disease, and cerebrovascular disease were reported in association with AAA occurrence and AAA development. The aortic diameters were then compared with those in a Belgian cohort of 2487 participants identified in the Liège AAA Screening Program. An aortic size index (ASI) was also calculated to account for the potential size differences in the Belgian and Korean populations. A total of 3124 Korean participants were examined using ultrasound. The prevalence of AAAs in this cohort was 0.7%. The combined prevalence of subaneurysmal dilatation and AAA was 1.5%. The prevalence in male smokers older than 65 years was 2.7% (19/715). The mean infrarenal aortic diameter was 17.3 ± 3.1 mm in men and 15.7 ± 2.7 mm in women; the corresponding values in Belgian participants were 19.4 ± 3.0 mm in men and 17.9 ± 2.4 mm in women. The median aortic size index was 0.99 (interquartile range 0.88-1.12). The mean infrarenal aortic diameter was significantly smaller in the Korean cohort than in the Belgian cohort. Considering the observed prevalence of AAAs in different age groups, the age groups which would contribute to most cases was male persons above 66 years in both cohorts.
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Affiliation(s)
- Hyangkyoung Kim
- Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Medical Center, Seoul 07985, Republic of Korea
| | - Sungsin Cho
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul 05278, Republic of Korea
| | - Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire Liège, University of Liège, 4000 Liège, Belgium
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17177 Solna, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, 17164 Stockholm, Sweden
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul 05278, Republic of Korea
- Correspondence: ; Tel.: +82-2-440-6261
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Thoracic Aortic Dilation: Implications for Physical Activity and Sport Participation. Diagnostics (Basel) 2022; 12:diagnostics12061392. [PMID: 35741202 PMCID: PMC9222193 DOI: 10.3390/diagnostics12061392] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 12/04/2022] Open
Abstract
Thoracic aortic dilatation is a progressive condition that results from aging and many pathological conditions (i.e., connective tissue, inflammatory, shear stress disorders, severe valvular heart disease) that induce degenerative changes in the elastic properties, leading to the loss of elasticity and compliance of the aortic wall. Mild aortic root enlargement may be also observed in athletes and is considered as a normal adaptation to regular exercise training. On the other hand, high-intensity physical activity in individuals with a particular genetic substrate, such as those carrying gene variants associated with Marfan syndrome or other inherited aortopathies, can favor an excessive aortic enlargement and trigger an acute aortic dissection. The evaluation of the aortic valve and aortic root diameters, as well as the detection of a disease-causing mutation for inherited aortic disease, should be followed by a tailored decision about sport eligibility. In addition, the risk of aortic complications associated with sport in patients with genetic aortic disease is poorly characterized and is often difficult to stratify for each individual athlete. This review aims to describe the relationship between regular physical activity and aortic dilation, focusing on patients with bicuspid aortic valve and inherited aortic disease, and discuss the implications in terms of aortic disease progression and sport participation.
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Jubouri M, Bashir M, Tan SZCP, Bailey D, Anderson R, Nienaber CA, Coselli JS, Williams I. What is the optimal timing for thoracic endovascular aortic repair in uncomplicated Type B aortic dissection? J Card Surg 2021; 37:993-1001. [PMID: 34967980 DOI: 10.1111/jocs.16190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Uncomplicated Stanford Type B aortic dissection (un-TBAD) is characterized by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimized cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is both safe and effective in the treatment of un-TBAD with improved long-term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified. AIMS This review critically addresses current state-of-the-art comparing TEVAR with OMT and corresponding clinical outcomes for un-TBAD based on timing of intervention. METHODS We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection. RESULTS TEVAR has proven to be a safe and effective treatment for un-TBAD in combination with OMT through comparable survival outcomes, improved aortic remodeling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un-TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention. CONCLUSIONS Further research is required into both short- and long-term outcomes of TEVAR in addition to its optimal therapeutic window for un-TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold-standard intervention for un-TBAD with definitive timeframe guidelines.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales, Cardiff, Wales, UK
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Division of Cardiothoracic Surgery, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St Luke's-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
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Elsisy MF, Pochettino A, Dearani JA, Bower TC, McBane RD, Graham GC, Deyle DR, Bonnichsen CR, Stephens EH. Early and Late Outcomes of Cardiovascular Surgery in Patients With Ehlers-Danlos Syndrome. World J Pediatr Congenit Heart Surg 2021; 12:773-777. [PMID: 34846964 DOI: 10.1177/21501351211049253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cardiovascular surgical outcomes reports are few for vascular type IV of Ehlers- Danlos Syndrome (vEDS) compared to non-vascular types I-III (nEDS). METHODS To define cardiovascular surgical outcomes among adult patients (≥18 years) with EDS types, a review of our institution's in-house STS Adult Cardiac Surgery Database-compliant software and electronic medical records from Mayo Clinic (1993-2019) was performed. Outcomes were compared for vEDS patients and nEDS patients. Demographics, baseline characteristics, operative, in-hospital complications and follow-up vital status were analyzed. RESULTS Over the study time frame, 48 EDS patients underwent surgery (mean age 52.6 ± 14.6 years; 48% females). Of these, 17 patients had vEDS and 31 patients had nEDS. Six patients (12.5%) underwent prior sternotomy. Urgent or emergent surgery was performed in 10 patients (20.8%). Aortic (vEDS 76.5% vs. nEDS 16.1%) and mitral procedures (vEDS 11.8% vs. nEDS 48.4%) were the two most common cardiovascular surgeries performed (p < .01 and p = .007, respectively). Cardiopulmonary bypass time (CPB) (165 ± 18 vs. 90 ± 13 min; p = .015) and aortic cross clamp times (140 ± 14 vs. 62 ± 10 min; p < .001) were longer for vEDS patients. There was 1 (2.1%) early and 7 (14.6%) late deaths; 6 among vEDS and 2 among nEDS patients. Survival at 5 (80% vs. 93%), 10 (45% vs. 84%) and 15 years (45% vs. 84%) was lower in patients with vEDS (p = .015 for each comparison). CONCLUSION Cardiovascular surgeries are significantly more complex with longer bypass and cross clamp times for type IV vEDS compared to nEDS patients. Reduced overall survival underscores the complexity and fragility of vEDS patients.
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Affiliation(s)
- Mohamed F Elsisy
- 6915Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alberto Pochettino
- 6915Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph A Dearani
- 6915Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Thomas C Bower
- 6915Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert D McBane
- 6915Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gabriel C Graham
- 6915Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - David R Deyle
- 6915Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Wang Z, Flores N, Lum M, Wisneski AD, Xuan Y, Inman J, Hope MD, Saloner DA, Guccione JM, Ge L, Tseng EE. Wall stress analyses in patients with ≥5 cm versus <5 cm ascending thoracic aortic aneurysm. J Thorac Cardiovasc Surg 2021; 162:1452-1459. [PMID: 32178922 PMCID: PMC8589466 DOI: 10.1016/j.jtcvs.2020.02.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Current guidelines for elective surgery of ascending thoracic aortic aneurysms (aTAAs) use aneurysm size as primary determinant for risk stratification of adverse events. Biomechanically, dissection may occur when wall stress exceeds wall strength. Determining patient-specific aTAA wall stresses by finite element analysis can potentially predict patient-specific risk of dissection. This study compared peak wall stresses in patients with ≥5.0 cm versus <5.0 cm aTAAs to determine correlation between diameter and wall stress. METHODS Patients with aTAA ≥5.0 cm (n = 47) and <5.0 cm (n = 53) were studied. Patient-specific aneurysm geometries obtained from echocardiogram-gated computed tomography were meshed and prestress geometries determined. Peak wall stresses and stress distributions were determined using LS-DYNA finite element analysis software (LSTC Inc, Livermore, Calif), with user-defined fiber-embedded material models under systolic pressure. RESULTS Peak circumferential stresses at systolic pressure were 530 ± 83 kPa for aTAA ≥5.0 cm versus 486 ± 87 kPa for aTAA <5.0 cm (P = .07), whereas peak longitudinal stresses were 331 ± 57 kPa versus 310 ± 54 kPa (P = .08), respectively. For aTAA ≥5.0 cm, correlation between peak circumferential stresses and size was 0.41, whereas correlation between peak longitudinal wall stresses and size was 0.33. However, for aTAA <5.0 cm, correlation between peak circumferential stresses and size was 0.23, whereas correlation between peak longitudinal stresses and size was 0.14. CONCLUSIONS Peak patient-specific aTAA wall stresses overall were larger for ≥5.0 cm than aTAA <5.0 cm. Although some correlation between size and peak wall stresses was found in aTAA ≥5.0 cm, poor correlation existed between size and peak wall stresses in aTAA <5.0 cm. Patient-specific wall stresses are particularly important in determining patient-specific risk of dissection for aTAA <5.0 cm.
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Affiliation(s)
- Zhongjie Wang
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Nick Flores
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Matthew Lum
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Andrew D Wisneski
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Yue Xuan
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Justin Inman
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Michael D Hope
- Department of Radiology, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - David A Saloner
- Department of Radiology, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Julius M Guccione
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Liang Ge
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif
| | - Elaine E Tseng
- Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Medical Centers, San Francisco, Calif.
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12
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Kim MS, Kim TH, Lee H, Song SW, Heo W, Sim SA, Yoo KJ. Note the descending aorta: predictors of postoperative major adverse aortic event in pure acute type A intramural hematoma. J Thorac Dis 2021; 13:4935-4946. [PMID: 34527332 PMCID: PMC8411190 DOI: 10.21037/jtd-21-674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/14/2021] [Indexed: 01/16/2023]
Abstract
Background Intramural hematomas (IMHs) may originate from small intimal tears. Although most surgeries for acute type A IMH are conventionally performed solely at the proximal aorta, regardless of the primary intimal tear site, the remnant aortic remodeling stays important during the follow-up period after surgery. Methods Forty-seven patients with “pure” acute type A IMHs who underwent surgery from January 2008 to December 2019 were retrospectively analyzed. Acute type A IMH in the entire region without penetrating aortic ulcer (PAU) and aortic dissection (AD), which upon initial computed tomography (CT), can be considered as an intimal tear site, was defined as “pure” type. The maximal diameter of the aorta, maximal thickness of the IMH, and hematoma thickness ratio (HTR) of the ascending and descending aortae were measured from the preoperative computed tomographic scan. The hematoma thickness index was defined as the HTR of the descending aorta divided by that of the ascending aorta. Major adverse aortic events (MAAEs) were defined as AD, rupture, or newly developed PAU and aortic death. Predictors for postoperative MAAEs were analyzed using preoperative computed tomographic findings. Results The measurements of the descending aorta were larger and those of the ascending aorta were smaller in the MAAEs group, than in the corresponding other. The hematoma thickness index was significantly higher in the group with MAAEs, than in the group without; this variable was an independent predictor of MAAEs. During surgery, intimal tears were found in 16/47 (34%) patients. The hematoma thickness index was significantly smaller in the group with intimal tears than in the group without the tears. The aortic measurement appears to reflect the tear site. Conclusions Hematoma thickness index was an independent predictor of MAAE after acute type A IMH surgery. Long-term periodical follow-up with early reintervention may, therefore, be necessary to improve outcome in these patients. As the optimal treatment method is still controversial, inferring the location of the primary tear through the hematoma thickness index can be helpful in determining the treatment method.
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Affiliation(s)
- Myeong Su Kim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ha Lee
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woon Heo
- Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Seo-A Sim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Jong Yoo
- Department of Cardiovascular Surgery, Yonsei Cardiovascular Hospital, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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13
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Harky A, Hussain SMA, MacCarthy-Ofosu B, Ahmad MU. The Role of Thoracic Endovascular Aortic Repair (TEVAR) of Thoracic Aortic Diseases in Patients with Connective Tissue Disorders - A Literature Review. Braz J Cardiovasc Surg 2020; 35:977-985. [PMID: 33306324 PMCID: PMC7731863 DOI: 10.21470/1678-9741-2019-0367] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To review the currently available literature to define the role of thoracic endovascular aortic repair (TEVAR) in patients with connective tissue disorders (CTD). METHODS A comprehensive electronic database search was performed in PubMed, SCOPUS, Embase, Google scholar, and OVID to identify all the articles that reported on outcomes of utilizing TEVAR in patients with CTD during elective and emergency settings. The search was not limited to time or language of the published study. RESULTS All the relevant studies have been summarized in its correspondence section. The outcomes were analyzed in narrative format. The role of TEVAR has been elaborated as per each study. Currently, there is limited large cohort size studies outlining the use of TEVAR in patients with CTD. The use of endovascular repair in patients with CTD is limited due to progressive aortic dilatations and high possibility of further reinterventions at later stage of life. CONCLUSION Open repair remains the gold standard method of intervention in young patients with progressive CTD, especially in the setting of acute type A aortic dissection. However, TEVAR can be sought as a reliable alternative in emergency setting of diseases involving the descending thoracic aorta; yet the long-term data needs to be published to support such practice.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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14
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Warnink-Kavelaars J, van Oers HA, Haverman L, Buizer AI, Alsem MW, Engelbert RHH, Menke LA. Parenting a child with Marfan syndrome: Distress and everyday problems. Am J Med Genet A 2020; 185:50-59. [PMID: 33034422 PMCID: PMC7756496 DOI: 10.1002/ajmg.a.61906] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/06/2020] [Accepted: 09/20/2020] [Indexed: 12/25/2022]
Abstract
Marfan syndrome (MFS) is a multisystemic, autosomal dominant connective tissue disorder that occurs de novo in 25%. In many families, parent and child(ren) are affected, which may increase distress in parents. To assess distress, 42 mothers (29% MFS) and 25 fathers (60% MFS) of 43 affected children, completed the validated screening‐questionnaire Distress thermometer for parents of a chronically ill child, including questions on overall distress (score 0–10; ≥4 denoting “clinical distress”) and everyday problems (score 0–36). Data were compared to 1,134 control‐group‐parents of healthy children. Mothers reported significantly less overall distress (2, 1–4 vs. 3, 1–6; p = .049; r = −.07) and total everyday problems (3, 0–6 vs. 4, 1–8; p = .03; r = −.08) compared to control‐group‐mothers. Mothers without MFS reported significantly less overall distress compared to mothers with MFS, both of a child with MFS (1, 0–4 vs. 3.5, 2–5; p = .039; r = −.17). No significant differences were found between the father‐groups, nor between the group of healthy parents of an affected child living together with an affected partner compared to control‐group‐parents. No differences in percentages of clinical distress were reported between mothers and control‐group‐mothers (33 vs. 42%); fathers and control‐group‐fathers (28 vs. 32%); nor between the other groups. Distress was not associated with the children's MFS characteristics. Concluding, parents of a child with MFS did not show more clinical distress compared to parents of healthy children. However, clinical distress was reported in approximately one‐third and may increase in case of acute medical complications. We advise monitoring distress in parents of a child with MFS to provide targeted support.
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Affiliation(s)
- Jessica Warnink-Kavelaars
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Hedy A van Oers
- Psychosocial Department, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Lotte Haverman
- Psychosocial Department, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Annemieke I Buizer
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands.,Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mattijs W Alsem
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Raoul H H Engelbert
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands.,Center of Expertise Urban Vitality, University of Applied Sciences, Faculty of Health, Amsterdam, The Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Leonie A Menke
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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15
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Bathen T, Krohg-Sørensen K, Lidal IB. Multidisciplinary aortopathy clinics: A systematic scoping review of the literature and evaluation of patient experiences from a newly started clinic in Norway. Am J Med Genet A 2020; 182:2552-2569. [PMID: 32812338 PMCID: PMC7693247 DOI: 10.1002/ajmg.a.61827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/02/2020] [Accepted: 07/25/2020] [Indexed: 12/30/2022]
Abstract
Background International guidelines recommend hereditary thoracic aortic diseases (HTADs) to be managed in multidisciplinary aorta clinics. Aim To study HTAD patient's experiences with a aortopathy clinic in Norway and to review the literature on aortopathy clinics. Methods (a) A systematic scoping review of research on multidisciplinary clinics for HTADs. (b) A cross‐sectional postal questionnaire study to investigate patient experiences with the health‐services. Fifty consecutive patients from the aortopathy clinic and 50 controls in usual care were invited to participate. Results The review identified eight publications on aortopathy clinics. Although the papers were not judged for quality, these showed promising results from such clinics in terms of diagnostics and increased adherence to guideline‐directed therapy. The survey constituted thirty‐seven (74%) patients and 22 (44%) controls who responded to postal questionnaires. Both groups reported delays in diagnostics and follow‐up appointments prior to the start of the clinic. Patients indicated high satisfaction with the aortopathy clinic, whereas controls reported poor coordination of medical follow‐up. Individuals in both groups struggled with disease self‐management. Conclusion Norwegian patient experiences found the aortopathy clinic beneficial. According to studies included in the review, disease management in aortopathy clinics may improve patient satisfaction, diagnostics and follow‐up. Effect studies may further document the benefits of clinic organization, treatment, cost‐efficiency and patient experiences.
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Affiliation(s)
- Trine Bathen
- TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesodden, Norway
| | - Kirsten Krohg-Sørensen
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ingeborg B Lidal
- TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesodden, Norway
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16
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Saw ST, Leong BDK, Abdul Aziz DA. Early Detection of Undiagnosed Abdominal Aortic Aneurysm and Sub-Aneurysmal Aortic Dilatations in Patients with High-Risk Coronary Artery Disease: The Value of Targetted Screening Programme. Vasc Health Risk Manag 2020; 16:215-229. [PMID: 32606718 PMCID: PMC7293413 DOI: 10.2147/vhrm.s250735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) and coronary artery disease (CAD) share common risk factors. The objective of this study was to determine the prevalence of undiagnosed AAA in patients with angiographically diagnosed significant CAD. PATIENTS AND METHODS Male patients aged 50 years and above (including indigenous people) with angiographically diagnosed significant CAD in the recent one year were screened for AAA. Standard definition of abdominal aortic aneurysm and CAD was used. All new patients were followed up for six months for AAA events (ruptured AAA and AAA-related mortality). RESULTS A total of 277 male patients were recruited into this study. The total prevalence of undiagnosed AAA in this study population was 1.1% (95% CI 0.2-3.1). In patients with high-risk CAD, the prevalence of undiagnosed AAA was 1.7% (95% CI 0.3-4.8). The detected aneurysms ranged in size from 35.0mm to 63.8mm. Obesity was a common factor in these patients. There were no AAA-related mortality or morbidity during the follow-up. Although the total prevalence of undiagnosed AAA is low in the studied population, the prevalence of sub-aneurysmal aortic dilatation in patients with significant CAD was high at 6.6% (95% CI 3.9-10.2), in which majority were within the younger age group than 65 years old. CONCLUSION This was the first study on the prevalence of undiagnosed AAA in a significant CAD population involving indigenous people in the island of Borneo. Targeted screening of patients with high-risk CAD even though they are younger than 65 years old effectively discover potentially harmful asymptomatic AAA and sub-aneurysmal aortic dilatations.
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Affiliation(s)
- Siong Teng Saw
- Faculty of Medicine, Universiti Kebangsaan Malaysia; Hospital Queen Elizabeth II, Kota Kinabalu, Sabah88300, Malaysia
| | | | - Dayang Anita Abdul Aziz
- Faculty of Medicine, Universiti Kebangsaan Malaysia, UKM Medical Center, Kuala Lumpur56000, Malaysia
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17
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Kitamura T, Torii S, Miyamoto T, Mishima T, Ohkubo H, Fujioka S, Yakuwa K, Araki H, Kondo S, Tamura Y, Tadokoro Y, Onishi Y, Miyaji K. Watch-and-wait strategy for type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta: a Japanese single-centre experience. Eur J Cardiothorac Surg 2020; 58:590-597. [DOI: 10.1093/ejcts/ezaa080] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 02/08/2020] [Accepted: 02/12/2020] [Indexed: 01/16/2023] Open
Abstract
Abstract
OBJECTIVES
In this study, we investigated the early and midterm outcomes of initial watch-and-wait strategy for Stanford type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta in patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection in the ascending aorta.
METHODS
Inpatient and outpatient records were retrospectively reviewed.
RESULTS
Of the 81 patients with type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta between April 2011 and April 2019, a watch-and-wait strategy was selected in 46 patients. The mean age of the patients was 68 years, and 22 (48%) patients were female. Ten patients underwent emergency pericardial drainage for cardiac tamponade at the time of presentation and 8 patients underwent aortic repair during hospitalization for new ulcer-like projection, re-dissection or rupture. In-hospital mortality occurred in 2 (4%) patients. During follow-up, survival at 1 and 2 years was 95% and 92%, respectively. There was no significant difference in survival or aortic events between patients in whom the watch-and-wait strategy and emergency surgical treatment were indicated.
CONCLUSIONS
The early and midterm outcomes of the initial watch-and-wait strategy were favourable for type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta in Japanese patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection. Further study is required to show the safety of this strategy.
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Affiliation(s)
- Tadashi Kitamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Shinzo Torii
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Takashi Miyamoto
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Toshiaki Mishima
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Hirotoki Ohkubo
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Shunichiro Fujioka
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kazuki Yakuwa
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Haruna Araki
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Shin Kondo
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshimi Tamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yuki Tadokoro
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshihiko Onishi
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
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18
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Li Z, Liu C, Wu R, Zhang J, Pan H, Tan J, Guo Z, Guo Y, Yu N, Yao C, Chang G. Prognostic value of clinical and morphologic findings in patients with type B aortic intramural hematoma. J Cardiothorac Surg 2020; 15:49. [PMID: 32293486 PMCID: PMC7092490 DOI: 10.1186/s13019-020-1067-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 01/16/2023] Open
Abstract
Background Aortic intramural hematoma (IMH) is a subset of acute aortic syndrome, and its prognosis may differ between races. This study aimed to study the prognosis of Chinese type B IMH patients and to find out risk factors. Methods A total of 71 type B IMH patients with or without penetrating atherosclerosis ulcer (PAU) administrated in our center between September 2013 and October 2017 were retrospectively studied. Both clinical and imaging data were collected and analyzed. The primary end point was aorta-related death, and the secondary end point was progression, which was defined as enlargement of aorta, increased aortic wall thickness, and aortic dissection or aneurysm formation. Kaplan-Meier survival analysis and Cox regression analysis were used for prognostic analysis. Results Among these 71 patients, 21 had simple type B IMH, when 50 had type B IMH in association with PAU. Twenty-five patients received optimal medical therapy (OMT) alone, while 46 patients received surgery and OMT. The mean follow-up time was 27.5 ± 13.5 months. For type B IMH patients, association with PAU indicated poor prognosis and required more intensive management (HR = 16.68, 1.96~141.87), while maximum aortic diameter (MAD) was an independent risk factor (HR = 1.096, 1.016~1.182). For patients with PAU-IMH, MAD was an independent risk factor (HR = 1.04, 1.021~1.194), while surgical treatment was independent protective factor (HR = 0.172, 0.042~0.696). Conclusion Association with PAU and MAD were independent risk factors for type B IMH patients. Surgery may improve the outcomes for type B IMH in association with PAU.
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Affiliation(s)
- Zilun Li
- Division of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chenshu Liu
- Division of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ridong Wu
- Division of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center of Sun Yat-Sen University, Guangzhou, China
| | - Hong Pan
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jinghong Tan
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Zhuang Guo
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yingying Guo
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Nan Yu
- Division of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chen Yao
- Division of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guangqi Chang
- Division of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. .,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. .,Guangdong Provincial Engineering and Technology Center for Diagnosis and Treatment of Vascular Diseases, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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19
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Tian DH, Chakos A, Hirst L, Chung STW, Yan TD. Surgery for type A intramural hematoma: a systematic review of clinical outcomes. Ann Cardiothorac Surg 2019; 8:518-523. [PMID: 31667148 DOI: 10.21037/acs.2019.08.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Management of type A intramural hematoma (IMH) remains controversial, with opinions divided as to whether patients should be treated with early aggressive surgery or a more conservative approach. The present systematic review aims to evaluate the mortality and morbidities following surgery for type A IMH. Methods Electronic searches were performed on five databases from dates of inception to December 2018. All studies with surgical outcomes for type A intramural hematoma were identified by two independent researchers and relevant data extracted. Random-effects meta-analysis of proportions or meta-analysis of means were performed to aggregate the data. Survival data were pooled using reconstructed individual patient data derived from Kaplan-Meier curves. Results Fifteen studies with 744 patients were identified. Ten studies were from Asian countries (73% of patients). Overall mortality was 8.2% [95% confidence interval (CI): 4.6-13.9%]. Mortality from Asian centers was 5.3% (95% CI: 3.6-7.7%) and 18.9% (95% CI: 7.0-40.4%) in Western centers. Postoperative complications were poorly reported and hence not analyzable. Overall pooled survival of 343 patients from four studies at 1-, 2-, 3-, 5-, and 10-year was 91.8%, 90.2%, 89.2%, 87.7%, and 71.1%, respectively. Conclusions There is an acceptable level of risk of death after surgery for type A IMH, though significant variations exist between results from Asian and Western centers. More detailed studies are required to clarify the controversies surrounding management of type A IMH.
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Affiliation(s)
- David H Tian
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | - Adam Chakos
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Lucy Hirst
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Sally T W Chung
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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20
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Chakos A, Twindyawardhani T, Evangelista A, Maldonado G, Piffaretti G, Yan TD, Tian DH. Endovascular versus medical management of type B intramural hematoma: a meta-analysis. Ann Cardiothorac Surg 2019; 8:447-455. [PMID: 31463207 DOI: 10.21037/acs.2019.06.11] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Aortic intramural hematoma constitutes one of the three classifications of acute aortic syndrome (AAS). Type B intramural hematoma (IMH-B) is localized to the descending thoracic aorta and can be managed through medical, endovascular or surgical means. Data comparing contemporary management with thoracic endovascular aortic repair (TEVAR) versus traditional medical management (MM) is sparse and only moderate strength recommendations for TEVAR are provided in guidelines. This meta-analysis aimed to pool available data from comparative studies between TEVAR and MM and examine differences in outcomes. Methods Literature search of electronic medical databases was conducted to identify studies comparing TEVAR and MM for management of IMH-B. Data extraction from studies fulfilling the inclusion criteria was performed by two authors and meta-analysis using a random-effects model applied to pool baseline data and examine risk ratios (RR) for management outcomes. Results Of the initial 2,349 studies, nine studies were identified for analysis. There were 161 TEVAR patients and 166 who were medically managed. The mean age of the cohort was 62.2 years [95% confidence interval (CI): 55.8-68.7 years]. Patients with complicating features of IMH-B at presentation were more likely to appear in the TEVAR group, with more penetrating atheromatous ulcer (PAU) [risk difference (RD), 0.565, 95% CI: 0.240-0.889, P=0.001], ulcer-like projection (ULP) (RD 0.240, 95% CI: 0.965-0.384, P=0.001), and greater IMH size (mean difference, MD 5.47 mm, 95% CI: 0.320-10.6, P=0.037). There was no statistical difference between TEVAR and MM for the primary endpoints of aortic-related death (RR 0.535, 95% CI: 0.191-1.5, P=0.234) or IMH-B regression (RR 1.25, 95% CI: 0.859-1.81, P=0.246). Of the secondary endpoints, TEVAR had both significantly less dissection during follow-up (RR 0.295, 95% CI: 0.0881-0.989, P=0.048) and less rupture during follow-up (RR 0.206, 95% CI: 0.0462-0.921, P=0.039). Conclusions A small number of series comparing TEVAR and MM for management of IMH-B are available and random-effects meta-analysis did not reveal any statistically significant difference between treatments for aortic related death or IMH-B regression at a mean follow-up of 37 months. TEVAR was found to be associated with lower risk of dissection and lower risk of rupture during follow-up. Baseline data meta-analysis showed patients with complicating features of PAU, ULP, and larger IMH size were more likely to be managed with TEVAR.
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Affiliation(s)
- Adam Chakos
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | | | - Arturo Evangelista
- Servei de Cardiologia, Hospital Vall d'Hebron, VHIR, CIBER-CV, Barcelona, Spain.,Instituto del Corazón, Quironsalud Teknon, Barcelona, Spain
| | - Giuliana Maldonado
- Servei de Cardiologia, Hospital Vall d'Hebron, VHIR, CIBER-CV, Barcelona, Spain
| | - Gabriele Piffaretti
- Department of Medicine and Surgery, University of Insubria School of Medicine, ASST Settelaghi Circolo University Teaching Hospital, Varese, Italy
| | - Tristan D Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H Tian
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
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Rurali E, Perrucci GL, Gaetano R, Pini A, Moschetta D, Gentilini D, Nigro P, Pompilio G. Soluble EMMPRIN levels discriminate aortic ectasia in Marfan syndrome patients. Am J Cancer Res 2019; 9:2224-2234. [PMID: 31149040 PMCID: PMC6531292 DOI: 10.7150/thno.30714] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/06/2019] [Indexed: 11/05/2022] Open
Abstract
Marfan syndrome (MFS) is a rare genetic disease characterized by a matrix metalloproteases (MMPs) dysregulation that leads to extracellular matrix degradation. Consequently, MFS patients are prone to develop progressive thoracic aortic enlargement and detrimental aneurysm. Since MMPs are activated by the extracellular MMP inducer (EMMPRIN) protein, we determined whether its plasmatic soluble form (sEMMPRIN) may be considered a marker of thoracic aortic ectasia (AE). Methods: We compared plasma sEMMPRIN levels of 42 adult Caucasian MFS patients not previously subjected to aortic surgery with those of matched healthy controls (HC) by ELISA. In the MFS cohort we prospectively evaluated the relationship between plasma sEMMPRIN levels and the main MFS-related manifestations. Results: MFS patients had lower plasma sEMMPRIN levels (mean±SD: 2071±637 pg/ml) than HC (2441±642 pg/ml, p=0.009). Amongst all considered MFS-related clinical features, we found that only aortic root dilatation associated with circulating sEMMPRIN levels. Specifically, plasma sEMMPRIN levels negatively correlated with aortic Z-score (r=-0.431, p=0.004), and were significantly lower in patients with AE (Z-score≥2, 1788±510 pg/ml) compared to those without AE (Z-score<2, 2355±634 pg/ml; p=0.003). ROC curve analysis revealed that plasma sEMMPRIN levels discriminated patients with AE (AUC [95%CI]: 0.763 [0.610-0.916], p=0.003) with 85.7% sensitivity, 76.2% specificity, and 81% accuracy. We defined plasma sEMMPRIN levels ≤2246 pg/ml as the best threshold discriminating the presence of AE in MFS patients with an odds ratio [95%CI] of 19.2 [3.947-93.389] (p<0.001). Conclusions: MFS patients are characterized by lower sEMMPRIN levels than HC. Notably, plasma sEMMPRIN levels are strongly associated with thoracic AE.
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