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Pucci A, Rossetti M, Lenzi C, Buja LM. The Cardiovascular Pathologist in the Aortic Team. Cardiovasc Pathol 2024:107649. [PMID: 38703970 DOI: 10.1016/j.carpath.2024.107649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 04/14/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024] Open
Abstract
Aortic diseases require a multidisciplinary management for diagnosis, treatment and follow-up with better outcomes in referral centers using a team-based approach. The setting up of a multi-disciplinary aortic team for the discussion of complex cases has been already proposed; it is also supported by the ACC/AHA. Surgeons and radiologists, more or less other physicians such as cardiologists, geneticists, rheumatologists/internal medicine specialists and pathologists are involved into such a team. The role of the cardiovascular pathologist is to examine the aortic specimens, to diagnose and classify the aortic lesions. Herein, the role of the pathologist in the aortic team is discussed and the pathobiology of aortic diseases is reviewed for reference by pathologists. The aortic specimens are mainly obtained from emergency or elective surgical procedures on the thoracic aorta, less frequently from organ/tissue (including cardiac or heart valve) donors, post-mortem procedures or abdominal aortic surgery. In the last decade, together with the progress of medical sciences, the histological definitions and classifications of the aortic pathology are undergoing thorough revisions that are addressed to an etiopathogenetic approach because of possible clinico-pathological correlations, therapeutic and prognostic impact. Pathologists may also have an important role in research and teaching. Therefore, histological analyses of the aortic specimens require adequate sample processing and pathologist expertise because histology contributes to definite diagnosis, correct management of patients and even (in genetic diseases) families, but also to research in the challenging field of aortopathies.
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Affiliation(s)
- Angela Pucci
- Department of Histopathology, Pisa University Hospital, Pisa, Italy.
| | - Martina Rossetti
- Department of Histopathology, Pisa University Hospital, Pisa, Italy
| | - Chiara Lenzi
- Department of Histopathology, Pisa University Hospital, Pisa, Italy
| | - L Maximilian Buja
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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2
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Buja LM, Zhao B, Sadaf H, McDonald M, Segura AM, Li L, Cecchi A, Prakash SK, Afifi RO, Miller CC, Estrera AL, Milewicz DM. Insights From the Histopathologic Analysis of Acquired and Genetic Thoracic Aortic Aneurysms and Dissections. Tex Heart Inst J 2024; 51:e238253. [PMID: 38345902 DOI: 10.14503/thij-23-8253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
OBJECTIVE The purpose of this study was to apply contemporary consensus criteria developed by the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology to the evaluation of aortic pathology, with the expectation that the additional pathologic information may enhance the understanding and management of aortic diseases. METHODS A scoring system was applied to ascending aortic specimens from 42 patients with heritable thoracic aortic disease and known genetic variations and from 86 patients from a single year, including patients with known genetic variations (n = 12) and patients with sporadic disease (n = 74). RESULTS The various types of lesions of medial degeneration and the overall severity of medial degeneration overlapped considerably between those patients with heritable disease and those with sporadic disease; however, patients with heritable thoracic aortic disease had significantly more overall medial degeneration (P = .004) and higher levels of elastic fiber fragmentation (P = .03) and mucoid extracellular matrix accumulation (P = .04) than patients with sporadic thoracic aortic disease. Heritable thoracic aortic disease with known genetic variation was more prevalent in women than in men (27.2% vs 9.8%; P = .04), and women had more severe medial degeneration than men (P = .04). Medial degeneration scores were significantly lower for patients with bicuspid aortic valves than for patients with tricuspid aortic valves (P = .03). CONCLUSION The study's findings indicate considerable overlap in the pattern, extent, and severity of medial degeneration between sporadic and hereditary types of thoracic aortic disease. This finding suggests that histopathologic medial degeneration represents the final common outcome of diverse pathogenetic factors and mechanisms.
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Affiliation(s)
- L Maximilian Buja
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
- Department of Cardiovascular Pathology Research, The Texas Heart Institute, Houston, Texas
| | - Bihong Zhao
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Humaira Sadaf
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Michelle McDonald
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Ana M Segura
- Department of Cardiovascular Pathology Research, The Texas Heart Institute, Houston, Texas
| | - Li Li
- Department of Pathology, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Alana Cecchi
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Siddharth K Prakash
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Dianna M Milewicz
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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Vilacosta I, Ferrera C, San Román A. [Acute aortic syndrome]. Med Clin (Barc) 2024; 162:22-28. [PMID: 37640592 DOI: 10.1016/j.medcli.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023]
Abstract
Acute aortic syndrome embraces a group of heterogenous pathological entities involving the aortic wall with a common clinical profile. The current epidemiology, clinical presentation, diagnosis and treatment strategy are discussed in this review. Besides, the importance of multidisciplinary aortic teams, aortic centers and the implementation of an aortic code are emphasized.
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Affiliation(s)
- Isidre Vilacosta
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, España.
| | - Carlos Ferrera
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, España
| | - Alberto San Román
- Instituto de Ciencias del Corazón, Hospital Clínico Universitario de Valladolid, Valladolid, España
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Waldron C, Zafar MA, Ziganshin BA, Weininger G, Grewal N, Elefteriades JA. Evidence Accumulates: Patients with Ascending Aneurysms Are Strongly Protected from Atherosclerotic Disease. Int J Mol Sci 2023; 24:15640. [PMID: 37958625 PMCID: PMC10650782 DOI: 10.3390/ijms242115640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Ascending thoracic aortic aneurysms may be fatal upon rupture or dissection and remain a leading cause of death in the developed world. Understanding the pathophysiology of the development of ascending thoracic aortic aneurysms may help reduce the morbidity and mortality of this disease. In this review, we will discuss our current understanding of the protective relationship between ascending thoracic aortic aneurysms and the development of atherosclerosis, including decreased carotid intima-media thickness, low-density lipoprotein levels, coronary and aortic calcification, and incidence of myocardial infarction. We also propose several possible mechanisms driving this relationship, including matrix metalloproteinase proteins and transforming growth factor-β.
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Affiliation(s)
- Christina Waldron
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06519, USA; (C.W.); (M.A.Z.); (B.A.Z.)
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06519, USA; (C.W.); (M.A.Z.); (B.A.Z.)
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06519, USA; (C.W.); (M.A.Z.); (B.A.Z.)
- Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, 420012 Kazan, Russia
| | - Gabe Weininger
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06519, USA; (C.W.); (M.A.Z.); (B.A.Z.)
| | - Nimrat Grewal
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06519, USA; (C.W.); (M.A.Z.); (B.A.Z.)
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Banceu CM, Gurzu S, Satala CB, Ghiga D, Neamtu MH, Voth V, Liebrich M, Suciu H. Histopathological Gap in Aortic Diseases: A Prospective Analysis. Int J Mol Sci 2023; 24:15470. [PMID: 37895149 PMCID: PMC10607681 DOI: 10.3390/ijms242015470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/08/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Aortic dissection (AD) is a critical cardiovascular condition with the potential for devastating consequences. This study evaluated the histological changes in the aorta wall in patients with AD and aortic aneurysm (AA) who received surgical aortic replacement. Histopathological data showed that modifications of the media layer (p = 0.0197), myxomatous aspect (p = 0.0001), and subendothelial layer degeneration (p = 0.0107) were more frequently seen in AA versus AD samples. Patients with AA were approximately twice as likely to develop histological changes than those with AD (p = 0.0037). Patients with moderate or severe medial degeneration had a higher chance of developing AD (p = 0.0001). Because the histopathological score proved to be a predictor of both in-hospital and overall mortality, its evaluation should become the standard of care in any patients who undergo aortic replacement. Individualized postoperative management might be influenced by the histopathological aspect of the aortic layer.
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Affiliation(s)
- Cosmin Marian Banceu
- I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania;
- Department of Surgery M3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania;
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
| | - Simona Gurzu
- Department of Pathology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania;
- Research Center for Oncopathology and Translational Medicine (CCOMT), George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
- Romanian Academy of Medical Sciences, 030167 Bucharest, Romania
| | - Catalin-Bogdan Satala
- Department of Pathology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania;
| | - Dana Ghiga
- Department of Medical Scientific Research Methodology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania;
| | - Mihai Halic Neamtu
- Swiss Federal Institute of Forest, Snow and Landscape Research WSL, 8903 Birmensdorf, Switzerland;
- Institute of Environmental Engineering, ETH Zurich, 8039 Zurich, Switzerland
| | - Vladimir Voth
- Sana Cardiac Surgery, Herdweg 2, 70174 Stuttgart, Germany; (V.V.); (M.L.)
| | - Markus Liebrich
- Sana Cardiac Surgery, Herdweg 2, 70174 Stuttgart, Germany; (V.V.); (M.L.)
| | - Horatiu Suciu
- Department of Surgery M3, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540139 Targu Mures, Romania;
- Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, 540136 Targu Mures, Romania
- Romanian Academy of Medical Sciences, 030167 Bucharest, Romania
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Wei C, Li J, Du E, Miao Y, Li P, Guan W. Clinical and imaging differences between Stanford Type B intramural hematoma-like lesions and classic aortic dissection. BMC Cardiovasc Disord 2023; 23:378. [PMID: 37507680 PMCID: PMC10386763 DOI: 10.1186/s12872-023-03413-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/22/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Intramural hematoma (IMH) and Aortic dissection (AD) have overlapping features. The aim of this study was to explore the differences between them by comparing the clinical manifestations and imaging features of patients with acute Stanford type B IMH-like lesions and acute Stanford type B AD (ATBAD). METHODS This study retrospectively analysed the clinical and computed tomography angiography (CTA) imaging data of 42 IMH-like lesions patients with ulcer-like projection (ULP) and 38 ATBAD patients, and compared their clinical and imaging features. RESULTS (1) The IMH-like lesions patients were older than the ATBAD patients (64.2 ± 11.5 vs. 50.9 ± 12.2 years, P < 0.001). The D-dimer level in the IMH-like lesions group was significantly higher than that in the ATBAD group (11.2 ± 3.6 vs. 9.2 ± 4.5 mg/L, P < 0.05). The incidence rate of back pain was significantly higher in the ATBAD group than in the IMH-like lesions group (71.1% vs. 26.2%, P < 0.05). (2) The ULPs of IMH-like lesions and the intimal tears of ATBAD were concentrated in zone 4 of the descending thoracic aorta. The ULPs of IMH-like lesions and the intimal tears of ATBAD were mainly in the upper quadrant outside the lumen (64.3% vs. 65.8%, P > 0.05). (3) The maximum diameter of the ULPs in IMH-like lesions was smaller than that of the intimal tears in ATBAD (7.4 ± 3.4 vs. 10.8 ± 6.8 mm, P = 0.005). The lumen compression ratio in the ULPs plane and the maximum compression ratio of the aortic lumen in the IMH-like lesions group were smaller than that in the ADBAD group (P < 0.05). Fewer aortic segments were involved in IMH-like lesions patients than in ATBAD patients (5.6 ± 2.2 vs. 7.1 ± 1.9 segments, P < 0.005). The IMH-like lesions group had less branch involvement than that of the ATBAD group (P < 0.001). CONCLUSION The degree of intimal tears, lumen compression ratio, extent of lesion involvement, and impact on branch arteries in ATBAD are more severe than that of IMH-like lesions. But for the ULPs of IMH-like lesions and intimal tears of ATBAD, they have astonishing similarities in the location of the partition and the lumen quadrant, we have reason to believe that intimal tear is the initial factor in the pathogenesis of this kind of disease, and their clinical and imaging manifestations overlap, but the severity is different. Concerning similarities between these two conditions, these two may be a spectrum of one disease.
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Affiliation(s)
- Chuanbin Wei
- The Third Clinical College of Xinxiang Medical University, Xinxiang, China
| | - Jinping Li
- Department of Radiology, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Enhui Du
- The Third Clinical College of Xinxiang Medical University, Xinxiang, China
| | - Yulu Miao
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Pinpin Li
- Department of Radiology, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Wenhua Guan
- Department of Radiology, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China.
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di Gioia CRT, Ascione A, Carletti R, Giordano C. Thoracic Aorta: Anatomy and Pathology. Diagnostics (Basel) 2023; 13:2166. [PMID: 37443560 DOI: 10.3390/diagnostics13132166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
The aorta is the largest elastic artery in the human body and is classically divided into two anatomical segments, the thoracic and the abdominal aorta, separated by the diaphragm. The thoracic aorta includes the aortic root, the ascending aorta, the arch, and the descending aorta. The aorta's elastic properties depend on its wall structure, composed of three distinct histologic layers: intima, media, and adventitia. The different aortic segments show different embryological and anatomical features, which account for their different physiological properties and impact the occurrence and natural history of congenital and acquired diseases that develop herein. Diseases of the thoracic aorta may present either as a chronic, often asymptomatic disorder or as acute life-threatening conditions, i.e., acute aortic syndromes, and are usually associated with states that increase wall stress and alter the structure of the aortic wall. This review aims to provide an update on the disease of the thoracic aorta, focusing on the morphological substrates and clinicopathological correlations. Information on anatomy and embryology will also be provided.
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Affiliation(s)
- Cira Rosaria Tiziana di Gioia
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Andrea Ascione
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Raffaella Carletti
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Carla Giordano
- Department of Radiology, Oncology and Pathology, Sapienza, University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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8
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Stejskal V, Karalko M, Krbal L. Histopathological findings of diseased ascending aortae with clinicopathological correlation - A single-centre study of 160 cases. Pathol Res Pract 2023; 246:154526. [PMID: 37172524 DOI: 10.1016/j.prp.2023.154526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Abstract
The most common reason for ascending aorta resection is an aneurysm or dissection. Aortic dissection is a life-threatening condition in which an aneurysm is a crucial risk factor. The essential criteria for aneurysm resection include the diameter, genetic predisposition, and aortic valve disease. This study aimed to compare the histological findings in aneurysms and dissections and correlate them with clinical parameters to determine whether histopathological findings correspond with the current clinical approach. A total of 160 ascending aorta surgical specimens, separate or with an aortic valve, were collected and divided into four groups: aneurysm-tricuspid (n = 40; median 67 y), aneurysm-malformed (n = 68; median 50 y), dissection-tricuspid (n = 48; median 65.5 y), and dissection-malformed (n = 4; median 52.5 y). Male preponderance was observed in all groups; the youngest patients were in the aneurysm-malformed group. None of the specimens showed normal aortic histology. The most common finding in the aortic samples was medial degeneration, which was the most severe and most common in dissection. The mildest findings were found in the aneurysm-malformed group. Atherosclerosis was predominant and most severe in the aneurysm-tricuspid group, while only mild in both dissection groups, suggesting its protective effect against this complication. Chronic aortitis was the least common pathology, found only in the aneurysm-tricuspid group. The aortic valve was resected and examined simultaneously with the ascending aorta in 76 cases, most commonly in the aneurysm-malformed group (n = 53). Myxoid degeneration was the major finding in the tricuspid aortic valves, with calcifications in the malformed. Comparing the histopathological results with the clinical aspects, aneurysms with a malformed aortic valve seem to be managed appropriately, with the findings not reaching the severity as in patients with a tricuspid valve. In contrast, in patients with a tricuspid valve, there were more dissections than aneurysms, with a significant subset of aneurysms showing histological findings almost identical to those of dissections. Supported by histological findings, patients with a diseased ascending aorta and tricuspid aortic valve represent an underdiagnosed risk group that would benefit from earlier diagnosis and intervention to prevent dissection. There is a need to find a marker for dissection risk other than the aortic diameter.
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Affiliation(s)
- Vaclav Stejskal
- The Fingerland Department of Pathology, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Czech Republic.
| | - Mikita Karalko
- The Department of Cardiosurgery, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Czech Republic
| | - Lukas Krbal
- The Fingerland Department of Pathology, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Czech Republic
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9
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Morello F, Bima P, Castelli M, Nazerian P. Acute aortic syndromes: An internist's guide to the galaxy. Eur J Intern Med 2022; 106:45-53. [PMID: 36229285 DOI: 10.1016/j.ejim.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/05/2022] [Accepted: 10/05/2022] [Indexed: 11/03/2022]
Abstract
Acute aortic syndromes (AASs) are severe conditions defined by dissection, hemorrhage, ulceration or rupture of the thoracic aorta. AASs share etiological and pathophysiological features, including long-term aortic tissue degeneration and mechanisms of acute aortic damage. The clinical signs and symptoms of AASs are unspecific and heterogeneous, requiring large differential diagnosis. When evaluating a patient with AAS-compatible symptoms, physicians need to integrate clinical probability assessment, bedside imaging techniques such as point-of-care ultrasound, and blood test results such as d-dimer. The natural history of AASs is dominated by engagement of ischemic, coagulative and inflammatory pathways at large, causing multiorgan damage. Medical treatment, multiorgan monitoring and outcome prognostication are therefore paramount, with internal medicine playing a key role in non-surgical management of AASs.
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Affiliation(s)
- Fulvio Morello
- S.C. Medicina d'Urgenza U (MECAU), A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy; Dipartimento di Scienze Mediche, Università degli Studi di Torino, Italy
| | - Paolo Bima
- S.C. Medicina d'Urgenza U (MECAU), A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy; Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Matteo Castelli
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy.
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10
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Chou EL, Chaffin M, Simonson B, Pirruccello JP, Akkad AD, Nekoui M, Cardenas CLL, Bedi KC, Nash C, Juric D, Stone JR, Isselbacher EM, Margulies KB, Klattenhoff C, Ellinor PT, Lindsay ME. Aortic Cellular Diversity and Quantitative Genome-Wide Association Study Trait Prioritization Through Single-Nuclear RNA Sequencing of the Aneurysmal Human Aorta. Arterioscler Thromb Vasc Biol 2022; 42:1355-1374. [PMID: 36172868 PMCID: PMC9613617 DOI: 10.1161/atvbaha.122.317953] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/16/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mural cells in ascending aortic aneurysms undergo phenotypic changes that promote extracellular matrix destruction and structural weakening. To explore this biology, we analyzed the transcriptional features of thoracic aortic tissue. METHODS Single-nuclear RNA sequencing was performed on 13 samples from human donors, 6 with thoracic aortic aneurysm, and 7 without aneurysm. Individual transcriptomes were then clustered based on transcriptional profiles. Clusters were used for between-disease differential gene expression analyses, subcluster analysis, and analyzed for intersection with genetic aortic trait data. RESULTS We sequenced 71 689 nuclei from human thoracic aortas and identified 14 clusters, aligning with 11 cell types, predominantly vascular smooth muscle cells (VSMCs) consistent with aortic histology. With unbiased methodology, we found 7 vascular smooth muscle cell and 6 fibroblast subclusters. Differentially expressed genes analysis revealed a vascular smooth muscle cell group accounting for the majority of differential gene expression. Fibroblast populations in aneurysm exhibit distinct behavior with almost complete disappearance of quiescent fibroblasts. Differentially expressed genes were used to prioritize genes at aortic diameter and distensibility genome-wide association study loci highlighting the genes JUN, LTBP4 (latent transforming growth factor beta-binding protein 1), and IL34 (interleukin 34) in fibroblasts, ENTPD1, PDLIM5 (PDZ and LIM domain 5), ACTN4 (alpha-actinin-4), and GLRX in vascular smooth muscle cells, as well as LRP1 in macrophage populations. CONCLUSIONS Using nuclear RNA sequencing, we describe the cellular diversity of healthy and aneurysmal human ascending aorta. Sporadic aortic aneurysm is characterized by differential gene expression within known cellular classes rather than by the appearance of novel cellular forms. Single-nuclear RNA sequencing of aortic tissue can be used to prioritize genes at aortic trait loci.
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Affiliation(s)
- Elizabeth L. Chou
- Division of Vascular and Endovascular Surgery,
Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
| | - Mark Chaffin
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
| | - Bridget Simonson
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
| | - James P. Pirruccello
- Cardiology Division, Massachusetts General Hospital,
Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
- Demoulas Center for Cardiac Arrhythmias, Massachusetts
General Hospital, Boston, Massachusetts, USA
| | - Amer-Denis Akkad
- Precision Cardiology Laboratory, Bayer US LLC, Cambridge,
MA, USA 02142
| | - Mahan Nekoui
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Demoulas Center for Cardiac Arrhythmias, Massachusetts
General Hospital, Boston, Massachusetts, USA
| | - Christian Lacks Lino Cardenas
- Cardiology Division, Massachusetts General Hospital,
Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
| | - Kenneth C. Bedi
- Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA 19104
| | - Craig Nash
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
| | - Dejan Juric
- Cancer Center, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - James R. Stone
- Department of Pathology, Massachusetts General
Hospital, Boston, Massachusetts, USA
| | - Eric M. Isselbacher
- Cardiology Division, Massachusetts General Hospital,
Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Thoracic Aortic Center, Massachusetts General Hospital,
Boston, Massachusetts, USA
| | - Kenneth B. Margulies
- Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA 19104
| | - Carla Klattenhoff
- Precision Cardiology Laboratory, Bayer US LLC, Cambridge,
MA, USA 02142
| | - 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,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
- Demoulas Center for Cardiac Arrhythmias, Massachusetts
General Hospital, 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,
Cambridge, Massachusetts, USA
- Thoracic Aortic Center, Massachusetts General Hospital,
Boston, Massachusetts, USA
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11
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Stejskal V, Karalko M, Smolak P, Hanusova M, Steiner I. Medial degeneration and atherosclerosis show discrete variance around the circumference of ascending aorta aneurysms. Virchows Arch 2022; 481:731-738. [PMID: 35982277 DOI: 10.1007/s00428-022-03397-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/06/2022] [Accepted: 08/14/2022] [Indexed: 11/28/2022]
Abstract
Medial degeneration is the most common histological finding in ascending aortic aneurysms with lesser but significant involvement by atherosclerosis. The overall extent and severity can be potentially underrated because of their uneven distribution and macroscopic inconspicuousness of medial degeneration. This study aims to compare the distribution of degenerative and atherosclerotic lesions around ascending aorta circumference, also considering aortic valve cuspidity. We evaluated 88 cases of resected ascending aortae, 25 with a tricuspid aortic valve and 63 with a malformed aortic valve, oriented by a cardiac surgeon and sent for pathological examination. We applied the consensus documents from 2015 and 2016 for microscopic evaluation of aortic specimens. The medial degeneration and atherosclerosis were graded semi-quantitatively for each aortic quadrant: convexity, anterior wall, concavity, and posterior wall. Nearly all quadrants showed at least mild medial degeneration; more severe findings of medial degeneration and atherosclerosis were in the aneurysms associated with the tricuspid valve. In the aneurysms with the tricuspid aortic valve, there was more frequent and more severe atherosclerosis at the concavity than at the anterior wall (p = .046); the frequency and severity of medial degeneration did not differ significantly. The aneurysms with a malformed aortic valve showed more severe medial degeneration at the concavity compared to the convexity (p = .011); atherosclerosis was less common and did not show any significant differences. More than half of the samples also revealed at least a one-grade (mostly one-grade) difference among the quadrants in individual cases for both atherosclerosis and medial degeneration. Extreme differences were rare except for atherosclerosis in the tricuspid group. The results revealed only slight overall differences around the aortic circumference, with concavity being the most susceptible. Still, thanks to occurring inter- and intraindividual variability, the examination of all quadrants seems meaningful not to miss the most severe changes and to underscore the findings.
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Affiliation(s)
- Vaclav Stejskal
- The Fingerland Department of Pathology, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.
| | - Mikita Karalko
- The Department of Cardiosurgery, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Petr Smolak
- The Department of Cardiosurgery, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Michaela Hanusova
- The Department of Forensic Medicine, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Ivo Steiner
- The Fingerland Department of Pathology, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
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12
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Vilacosta I, San Román JA, di Bartolomeo R, Eagle K, Estrera AL, Ferrera C, Kaji S, Nienaber CA, Riambau V, Schäfers HJ, Serrano FJ, Song JK, Maroto L. Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:2106-2125. [PMID: 34794692 DOI: 10.1016/j.jacc.2021.09.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023]
Abstract
The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.
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Affiliation(s)
- Isidre Vilacosta
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain.
| | - J Alberto San Román
- Instituto de Ciencias del Corazón, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - Kim Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, UTHealth, Houston, Texas, USA; Memorial Hermann Heart and Vascular Institute. University of Texas, Houston, Texas, USA
| | - Carlos Ferrera
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital, Osaka, Japan
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, The Royal Brompton and Harefield MHS Trust, London, United Kingdom
| | - Vicenç Riambau
- Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Hans-Joachim Schäfers
- Klinik für Thorax- und Herz-Gefäßchirurgie Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | | | - Jae-Kwan Song
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Luis Maroto
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
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13
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Stejskal V, Karalko M, Šteiner I. Ascending aorta dissection in a new classification system: Clinicopathological features of 62 cases. Pathol Res Pract 2021; 224:153542. [PMID: 34246045 DOI: 10.1016/j.prp.2021.153542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/29/2022]
Abstract
Herein we present a single institution 5-year experience with ascending aorta dissection biopsies depicting the clinicopathological features of 62 cases. To detect microscopic abnormalities in the aortic wall beside the dissection itself, we applied a new histopathological classification scheme from the consensus documents issued by The Society for Cardiovascular Pathology and The Association for the European Cardiovascular Pathology in 2015 and 2016. The most common finding was medial degeneration (MD) - 61 cases (98.4%); atherosclerosis (AS) was found in 19 aortae (30.6%), and chronic aortitis- giant cell pattern described in one aorta (1.6%). The medial degeneration constituents included mucoid matrix accumulation, smooth muscle cells and elastic fibers abnormalities, and medial fibrosis. The consensus document application led to increased MD reporting compared to older studies and to our previous experience, probably due to assessing more subtle and focal changes such as intralamellar fibrosis, intralamellar mucoid matrix accumulation, and loss of smooth muscle cell nuclei- these changes being also the most common MD abnormalities we are reporting. We have compared the results in patients with bicuspid (n = 7; 11.3%) versus tricuspid (n = 55; 88.7%) aortic valve, suggesting no significant differences except for translamellar fibrosis, which appeared to be more severe in the bicuspid valve group (p = 0.0397). The results might imply similar histopathological findings regardless of the aortic valve cuspidity in aortic dissection. These findings are in contrast to ascending aorta dilation (aneurysm), where more severe medial degeneration changes have been described in patients with the tricuspid aortic valve.
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Affiliation(s)
- Václav Stejskal
- The Fingerland Department of Pathology, University Hospital Hradec Králové and Faculty of Medicine in Hradec Králové, Charles University, Czech Republic.
| | - Mikita Karalko
- The Department of Cardiosurgery, University Hospital Hradec Králové and Faculty of Medicine in Hradec Králové, Charles University, Czech Republic
| | - Ivo Šteiner
- The Fingerland Department of Pathology, University Hospital Hradec Králové and Faculty of Medicine in Hradec Králové, Charles University, Czech Republic
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14
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Delsart P, Soquet J, Ramdane N, Ramond C, Mugnier A, Rousse N, Ledieu G, Bical A, Loobuyck V, Jegou B, Modine T, Hysi I, Fabre O, Juthier F, Vincentelli A, Mounier-Vehier C. Aortic morphology post type A acute aortic syndrome: Prognosis significance and association with 24-hour blood pressure-monitoring parameters. J Card Surg 2020; 35:981-987. [PMID: 32176383 DOI: 10.1111/jocs.14512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND After an emergent surgery for type A acute aortic syndrome, medical management is based on optimal blood pressure (BP) control. We assessed the prognostic significance of BP monitoring and its relationship with aortic morphology following type A acute aortic syndrome. METHODS The data of 120 patients who underwent BP monitoring after a type A acute aortic syndrome from January 2005 to June 2016 were retrospectively collected. The first CT angiogram performed after surgery was used for the morphological analysis. RESULTS The population included 79 males, with an overall mean age of 60 ± 12 years. Seven patients (5.8%) died during a median follow-up of 5.5 years. The median delay between BP monitoring and discharge was 3 (1-5) months. The mean 24-hour BP of the cohort was 127/73 mm Hg ± 10/17. During follow-up, different parameters of BP monitoring were not associated with the risk of aortic events. However, the diameter of the false lumen of the descending thoracic aorta was the best predictor associated with the risk of new aortic events during follow-up, particularly for the threshold of 28 mm or more (P < .001; Hazard ratio 4.7[2.7-8.2]). The diameter of the false lumen was associated with night-time systolic BP (P = .025; r = .2), 24-hour pulse pressure (P = .002; r = .28), and night-time pulse pressure (P = .008; r = .24). CONCLUSION The risk of new aortic events following type A acute aortic syndrome is associated with the size of the residual false lumen, but not directly with BP parameters. Night-time BP parameters are associated with the size of the residual false lumen.
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Affiliation(s)
| | - Jérôme Soquet
- CHU Lille, Institut Cœur Poumon, Lille, France.,University of Lille, CHU Lille, Inserm U1011, Lille, France
| | - Nassima Ramdane
- METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, University of Lille, CHU Lille, ULR 2694, Lille, France
| | | | | | - Natacha Rousse
- CHU Lille, Institut Cœur Poumon, Lille, France.,University of Lille, CHU Lille, Inserm U1011, Lille, France
| | | | - Antoine Bical
- CHU Lille, Institut Cœur Poumon, Lille, France.,University of Lille, CHU Lille, Lille, France
| | - Valentin Loobuyck
- CHU Lille, Institut Cœur Poumon, Lille, France.,University of Lille, CHU Lille, Inserm U1011, Lille, France
| | - Bruno Jegou
- CHU Lille, Institut Cœur Poumon, Lille, France
| | | | - Ilir Hysi
- Department of Cardiac Surgery of Artois, Centre Hospitalier de Lens et Hôpital Privé de Bois Bernard, Ramsay Générale de Santé, Lens, France
| | - Olivier Fabre
- Department of Cardiac Surgery of Artois, Centre Hospitalier de Lens et Hôpital Privé de Bois Bernard, Ramsay Générale de Santé, Lens, France
| | - Francis Juthier
- CHU Lille, Institut Cœur Poumon, Lille, France.,University of Lille, CHU Lille, Inserm U1011, Lille, France
| | - Andre Vincentelli
- CHU Lille, Institut Cœur Poumon, Lille, France.,University of Lille, CHU Lille, Inserm U1011, Lille, France
| | - Claire Mounier-Vehier
- CHU Lille, Institut Cœur Poumon, Lille, France.,University of Lille, CHU Lille, Lille, France
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15
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Patel V, Ghanta RK. Commentary: Under pressure: The role of inflammation in aortic aneurysm pathophysiology. J Thorac Cardiovasc Surg 2019; 160:1444-1445. [PMID: 31627956 DOI: 10.1016/j.jtcvs.2019.09.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Vivek Patel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Ravi K Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
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16
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Leone O, Corsini A, Pacini D, Corti B, Lorenzini M, Laus V, Foà A, Bacchi Reggiani ML, Di Marco L, Rapezzi C. The complex interplay among atherosclerosis, inflammation, and degeneration in ascending thoracic aortic aneurysms. J Thorac Cardiovasc Surg 2019; 160:1434-1443.e6. [PMID: 31706551 DOI: 10.1016/j.jtcvs.2019.08.108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/11/2019] [Accepted: 08/26/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To assess the histopathological findings of a large series of ascending thoracic aortic aneurysm (TAA) surgical specimens applying the updated classification on noninflammatory degenerative and inflammatory aortic diseases proposed by the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology clinicopathological correlations. METHODS A total of 255 patients surgically treated for ascending TAA were enrolled. Surgical ascending aorta specimens were examined. RESULTS The histopathological substrate of ascending TAAs was mainly degenerative (67.5%), but with a remarkable prevalence of atherosclerotic lesions (18.8%) and aortitis (13.7%). Degenerative patients more frequently had bicuspid aortic valve (37.2%; P = .002). Patients in the atherosclerotic group were older (median age, 69 years; P < .001), more often with a history of hypertension (87.5%; P = .059), hypercholesterolemia (75%; P = .019), diabetes (16.6%; P = .054), current smoking (22.9%; P = .066), and a history of coronary artery disease (18.7%; P = .063). Patients with aortitis represented the older group (median age, 75 years, P < .001), were mostly females (68.6%; P < .001), and had a larger ascending aorta diameter (median, 56 mm; P < .001). Both patients with atherosclerosis and aortitis presented a higher incidence of concomitant abdominal aortic aneurysm (20.8% and 22.8%, respectively; P < .001). CONCLUSIONS Although degenerative histopathology is the most frequent substrate in ascending TAA, atherosclerosis and inflammation significantly contribute to the development of chronic aortic thoracic disease.
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Affiliation(s)
- Ornella Leone
- Cardiovascular Pathology Unit, Department of Pathology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Anna Corsini
- Cardiology, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Barbara Corti
- Cardiovascular Pathology Unit, Department of Pathology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Massimiliano Lorenzini
- University College London Institute for Cardiovascular Science and Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Vera Laus
- Cardiology, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Alberto Foà
- Cardiology, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maria Letizia Bacchi Reggiani
- Cardiology, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Cardiac Surgery, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Claudio Rapezzi
- Cardiology, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
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17
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Wojnarski CM. Are all patients subject to the same follow-up after type A dissection repair? J Thorac Cardiovasc Surg 2018; 156:1786. [DOI: 10.1016/j.jtcvs.2018.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 10/14/2022]
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18
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Lumsden AB, Reardon MJ. Go big or go home: But think small. J Thorac Cardiovasc Surg 2018; 156:1772. [PMID: 29934006 DOI: 10.1016/j.jtcvs.2018.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 04/30/2018] [Accepted: 05/01/2018] [Indexed: 10/14/2022]
Affiliation(s)
- Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex
| | - Michael J Reardon
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex.
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