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Ye Z, Lane C, Beachey J, Medina-Inojosa J, Galian L, Dentamaro I, Calvo-Iglesias F, Alegret J, Sanchez V, Moral S, Bellino M, Enriquez-Sarano M, Bagnati R, Evangelista A, Michelena H. Clinical outcomes in patients with bicuspid aortic valves and ascending aorta dilatation equal or above 50mm. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Little is known about clinical outcomes in patients with bicuspid aortic valve (BAV) and ascending aortic diameters ≥50 mm where the elective surgical-indication zone begins.
Purpose
To assess incident aortic dissection (AoD), post-surgical survival and guideline implementation.
Methods
Multi-center retrospective study of BAV patients (≥18 years) with maximal root or tubular-ascending aortic diameters ≥50mm detected by transthoracic echocardiography at baseline. Ascertainment of aortic surgery, AoD and death was carried-out at their respective institutions. The primary outcome was AoD: “confirmed” AoD by surgery or death certificate, or “possible” AoD defined as sudden cardiac death of unknown cause by death certificate. Secondary outcomes were aortic surgery, post-surgical survival and guideline implementation.
Results
We included 506 consecutive BAV patients, mean age 61±14 years, 83% men, mean maximal aortic diameter 52±2 mm at baseline, ascending aorta was the most common segment ≥50mm (85%). During a median follow-up of 7.7 years, 356 (71%) underwent elective surgery (89% of class 1 patients). Early-surgery (≤6 months from baseline) occurred in 195 patients and 311 patients remained “under-surveillance”. Surgery under-surveillance (>6 months from baseline) occurred in 161/311 (52%) patients at 2.6 [IQR: 1.5–4.7] years of follow-up. Surgical mortality was 1.4%. Ten-year post-surgical survival was >90% and similar between early-surgery and surgery under-surveillance (p=0.8). Of 8 AoD events, 3 confirmed and 5 possible (all occurring in unoperated patients under-surveillance), 5 events occurred with maximal aortic baseline diameter ≥55 mm and/or >1 year without clinical follow-up; therefore, under guideline non-compliance. Incidence of confirmed plus possible aortic dissection was 0.37% per year with size 50–54mm, 1.13% per year between 55–59mm, and 10.41% per year with size ≥60mm. Aortic stenosis was associated with AoD (p=0.04) and all-cause death in unoperated patients (p=0.001).
Conclusions
Our results suggest that BAV patients can be safely followed as per guidelines after aortic diameters enter the elective surgical zone (≥50mm), with excellent post-surgical survival regardless of whether surgery is early- or under-surveillance. Appropriate guideline implementation for surgical thresholds and interval clinical follow-up could have prevented most AoD events. Valvular disease guideline should also be followed to prevent AoD and improve survival in these patients.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- Z Ye
- Mayo Clinic , Rochester , United States of America
| | - C Lane
- Mayo Clinic , Rochester , United States of America
| | - J Beachey
- Mayo Clinic , Rochester , United States of America
| | | | - L Galian
- University Hospital Vall d'Hebron , Barcelona , Spain
| | - I Dentamaro
- University Hospital Vall d'Hebron , Barcelona , Spain
| | | | - J Alegret
- University Hospital Sant Joan de Reus, Cardiology , Reus , Spain
| | - V Sanchez
- University Hospital 12 de Octubre, Cardiology , Madrid , Spain
| | - S Moral
- University Hospital de Girona Dr. Josep Trueta, Cardiology , Girona , Spain
| | - M Bellino
- University Hospital San Giovanni di Dio e Ruggi dAragona, Cardiovascular and Thoracic , Salerno , Italy
| | | | - R Bagnati
- Hospital Italiano de Buenos Aires, Cardiology , Buenos Aires , Argentina
| | - A Evangelista
- University Hospital Vall d'Hebron , Barcelona , Spain
| | - H Michelena
- Mayo Clinic , Rochester , United States of America
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Durani U, Gallo de Moraes A, Beachey J, Nelson D, Robinson S, Anavekar NS. Epithelioid angiosarcoma: A rare cause of pericarditis and pleural effusion. Respir Med Case Rep 2018; 24:77-80. [PMID: 29977765 PMCID: PMC6010620 DOI: 10.1016/j.rmcr.2018.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 11/25/2022] Open
Abstract
Angiosarcomas are rare cancers accounting for less than 2% of all soft tissue sarcomas. We report the case of an unusual presentation of pleural epithelioid angiosarcoma in a patient with constrictive pericarditis and recurrent pleural effusion. A 62 year old smoker presented with acute chest pain. ECG showed diffuse elevation of ST segments in the precordial leads. After extensive evaluation, he was diagnosed with viral pericarditis and treated with colchicine. Two weeks later the patient presented to the emergency department with a large right pleural effusion. Evaluation of the pleural fluid obtained from a thoracentesis revealed an exudative effusion with negative microbial studies and no evidence of malignant cells. His pleural effusion re-accumulated rapidly, requiring repeated thoracenteses over several weeks. Medical thoracoscopy was performed and pleural biopsy revealed primary pleural epithelioid angiosarcoma. Staging PET scan revealed malignant enhancement of right pleura, pericardium, right iliac bone and right shoulder. He died suddenly within 6 weeks of diagnosis, prior to initiating palliative chemotherapy. Pleural angiosarcoma should be considered in the differential diagnosis of recurrent pleural effusions of unknown etiology. Negative cytology does not rule out the diagnosis; excisional biopsy is required. Reported risk factors include asbestos exposure, prior chest radiation, active smoking and history of complicated pleural tuberculosis. Pleural epithelioid angiosarcomas carry a very poor prognosis, with the majority of patients dying within months of diagnosis.
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Affiliation(s)
- Urshila Durani
- Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Joel Beachey
- Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Darlene Nelson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Steven Robinson
- Department of Medicine, Division of Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.,Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Abstract
A 33-year-old man presented with new-onset, asymmetric, migratory oligoarthritis in the setting of several weeks of nausea and vomiting, diarrhoea, fevers and dysuria. He was initially treated in the inpatient setting with broad-spectrum antibiotics due to concern for an evolving sepsis presentation. Arthrocentesis of a large right knee effusion revealed inflammatory synovial fluid without findings suggestive of septic arthritis. Human leucocyte antigen B27 was positive and, taken together with the antecedent history of gastroenteritis, dysuria and inflammatory oligoarthritis, the clinical diagnosis was most consistent with reactive arthritis. Antibiotics were discontinued. His treatment course proved refractory to non-steroidal anti-inflammatory drugs and intra-articular and systemic glucocorticoid therapy with concurrent use of sulfasalazine and ultimately necessitated treatment with a tumour necrosis factor alpha inhibitor.
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Affiliation(s)
- Patrick Hoversten
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joel Beachey
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Pham
- Department of Rheumatology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Anjali Bhagra
- General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Hoversten P, Kamboj AK, Slostad J, Beachey J, Aakre C. Pneumomediastinum and pneumoperitoneum following partial sphincterotomy for choledocholithiasis. Intern Emerg Med 2018; 13:461-462. [PMID: 29110134 DOI: 10.1007/s11739-017-1767-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/27/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Patrick Hoversten
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Amrit K Kamboj
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jessica Slostad
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Joel Beachey
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher Aakre
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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