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Zamirpour S, Xuan Y, Wang Z, Gomez A, Leach JR, Mitsouras D, Saloner DA, Guccione JM, Ge L, Tseng EE. Height and body surface area versus wall stress for stratification of mid-term outcomes in ascending aortic aneurysm. Int J Cardiol Heart Vasc 2024; 51:101375. [PMID: 38435381 PMCID: PMC10909604 DOI: 10.1016/j.ijcha.2024.101375] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/13/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
Objectives Current diameter-based guidelines for ascending thoracic aortic aneurysms (aTAA) do not consistently predict risk of dissection/rupture. ATAA wall stresses may enhance risk stratification independent of diameter. The relation of wall stresses and diameter indexed to height and body surface area (BSA) is unknown. Our objective was to compare aTAA wall stresses with indexed diameters in relation to all-cause mortality at 3.75 years follow-up. Methods Finite element analyses were performed in a veteran population with aortas ≥ 4.0 cm. Three-dimensional geometries were reconstructed from computed tomography with models accounting for pre-stress geometries. A fiber-embedded hyperelastic material model was applied to obtain wall stress distributions under systolic pressure. Peak wall stresses were compared across guideline thresholds for diameter/BSA and diameter/height. Hazard ratios for all-cause mortality and surgical aneurysm repair were estimated using cause-specific Cox proportional hazards models. Results Of 253 veterans, 54 (21 %) had aneurysm repair at 3.75 years. Indexed diameter alone would have prompted repair at baseline in 17/253 (6.7 %) patients, including only 4/230 (1.7 %) with diameter < 5.5 cm. Peak wall stresses did not significantly differ across guideline thresholds for diameter/BSA (circumferential: p = 0.15; longitudinal: p = 0.18), but did differ for diameter/height (circumferential: p = 0.003; longitudinal: p = 0.048). All-cause mortality was independently associated with peak longitudinal stresses (p = 0.04). Peak longitudinal stresses were best predicted by diameter (c-statistic = 0.66), followed by diameter/height (c-statistic = 0.59), and diameter/BSA (c-statistic = 0.55). Conclusions Diameter/height improved stratification of peak wall stresses compared to diameter/BSA. Peak longitudinal stresses predicted all-cause mortality independent of age and indexed diameter and may aid risk stratification for aTAA adverse events.
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Affiliation(s)
- Siavash Zamirpour
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
- School of Medicine, University of California, San Francisco, USA
| | - Yue Xuan
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Zhongjie Wang
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Axel Gomez
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Joseph R. Leach
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Dimitrios Mitsouras
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - David A. Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Julius M. Guccione
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Liang Ge
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
| | - Elaine E. Tseng
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, USA
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Zamirpour S, Boskovski MT, Pirruccello JP, Pace WA, Hubbard AE, Leach JR, Ge L, Tseng EE. Sex differences in ascending aortic size reporting and growth on chest computed tomography and magnetic resonance imaging. Clin Imaging 2024; 105:110021. [PMID: 37992628 DOI: 10.1016/j.clinimag.2023.110021] [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: 08/06/2023] [Revised: 10/16/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE Diameter-based guidelines for prophylactic repair of ascending aortic aneurysms have led to routine aortic evaluation in chest imaging. Despite sex differences in aneurysm outcomes, there is little understanding of sex-specific aortic growth rates. Our objective was to evaluate sex-specific temporal changes in radiologist-reported aortic size as well as sex differences in aortic reporting. METHOD In this cohort study, we queried radiology reports of chest computed tomography or magnetic resonance imaging at an academic medical center from 1994 to 2022, excluding type A dissection. Aortic diameter was extracted using a custom text-processing algorithm. Growth rates were estimated using mixed-effects modeling with fixed terms for sex, age, and imaging modality, and patient-level random intercepts. Sex, age, and modality were evaluated as predictors of aortic reporting by logistic regression. RESULTS This study included 89,863 scans among 46,622 patients (median [interquartile range] age, 64 [52-73]; 22,437 women [48%]). Aortic diameter was recorded in 14% (12,722/89,863 reports). Temporal trends were analyzed in 7194 scans among 1998 patients (age, 68 [60-75]; 677 women [34%]) with ≥2 scans. Aortic growth rate was significantly higher in women (0.22 mm/year [95% confidence interval 0.17-0.28] vs. 0.09 mm/year [0.06-0.13], respectively). Aortic reporting was significantly less common in women (odds ratio, 0.54; 95% CI, 0.52-0.56; p < 0.001). CONCLUSIONS While aortic growth rates were small overall, women had over twice the growth rate of men. Aortic dimensions were much less frequently reported in women than men. Sex-specific standardized assessment of aortic measurements may be needed to address sex differences in aneurysm outcomes.
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Affiliation(s)
- Siavash Zamirpour
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA; School of Medicine, University of California San Francisco, CA, USA
| | - Marko T Boskovski
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - James P Pirruccello
- Division of Cardiology, Department of Medicine, University of California San Francisco, USA; Institute for Human Genetics, University of California San Francisco, USA
| | - William A Pace
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA; School of Medicine, University of California San Francisco, CA, USA
| | - Alan E Hubbard
- Division of Biostatistics, School of Public Health, University of California Berkeley, USA
| | - Joseph R Leach
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Liang Ge
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Elaine E Tseng
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
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Zamirpour S, Xuan Y, Wang Z, Gomez A, Leach J, Mitsouras D, Saloner DA, Guccione JM, Ge L, Tseng EE. Aortic area/height ratio, peak wall stresses, and outcomes in veterans with tricuspid versus bicuspid aortic valve-associated ascending thoracic aortic aneurysms. J Thorac Cardiovasc Surg 2023; 166:1583-1593.e2. [PMID: 37295642 DOI: 10.1016/j.jtcvs.2023.05.031] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND In ascending thoracic aortic aneurysm risk stratification, aortic area/height ratio is a reasonable alternative to maximum diameter. Biomechanically, aortic dissection may be initiated by wall stress exceeding wall strength. Our objective was to evaluate the association between aortic area/height and peak aneurysm wall stresses in relation to valve morphology and 3-year all-cause mortality. METHODS Finite element analysis was performed on 270 ascending thoracic aortic aneurysms (46 associated with bicuspid and 224 with tricuspid aortic valves) in veterans. Three-dimensional aneurysm geometries were reconstructed from computed tomography and models developed accounting for prestress geometries. Fiber-embedded hyperelastic material model was applied to obtain aneurysm wall stresses during systole. Correlations of aortic area/height ratio and peak wall stresses were compared across valve types. Area/height ratio was evaluated across peak wall stress thresholds obtained from proportional hazards models of 3-year all-cause mortality, with aortic repair treated as a competing risk. RESULTS Aortic area/height 10 cm2/m or greater coincided with 23/34 (68%) 5.0 to 5.4 cm and 20/24 (83%) 5.5 cm or greater aneurysms. Area/height correlated weakly with peak aneurysm stresses: for tricuspid valves, r = 0.22 circumferentially and r = 0.24 longitudinally; and for bicuspid valves, r = 0.42 circumferentially and r = 0.14 longitudinally. Age and peak longitudinal stress, but not area/height, were independent predictors of all-cause mortality (age: hazard ratio, 2.20 per 9-year increase, P = .013; peak longitudinal stress: hazard ratio, 1.78 per 73-kPa increase, P = .035). CONCLUSIONS Area/height was more predictive of high circumferential stresses in bicuspid than tricuspid valve aneurysms, but similarly less predictive of high longitudinal stresses in both valve types. Peak longitudinal stress, not area/height, independently predicted all-cause mortality. VIDEO ABSTRACT.
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Affiliation(s)
- Siavash Zamirpour
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif; Joint Medical Program, School of Public Health, University of California Berkeley, Berkeley, Calif, and School of Medicine, University of California, San Francisco, San Francisco, Calif
| | - Yue Xuan
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif
| | - Zhongjie Wang
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif
| | - Axel Gomez
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif
| | - Joseph Leach
- Department of Radiology and Biomedical Imaging, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif
| | - Dimitrios Mitsouras
- Department of Radiology and Biomedical Imaging, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif
| | - David A Saloner
- Department of Radiology and Biomedical Imaging, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif
| | - Julius M Guccione
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif
| | - Liang Ge
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif
| | - Elaine E Tseng
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, Calif.
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Pace WA, Smith K, Gamboa A, Zamirpour S, Ge L, Tseng E. Ascending thoracic aortic aneurysm size at presentation and growth by diameter. Clin Radiol 2023; 78:e1057-e1064. [PMID: 37833143 DOI: 10.1016/j.crad.2023.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/31/2023] [Indexed: 10/15/2023]
Abstract
AIM To investigate the hypothesis that lung cancer screening allows for earlier identification of ascending thoracic aortic aneurysms (aTAAs) and that growth rates for aTAAs are greatest at larger sizes. MATERIALS AND METHODS This single referral centre retrospective study manually gathered computed tomography (CT) data from 732 patients presenting from July 2002 to August 2022. Five hundred and seventeen patients with aTAA >39 mm were identified to compare presenting diameter by year of presentation. Four hundred and thirty-two patients had CT examinations >3 months apart, allowing for growth analysis. Patients were separated by initial examination date (before or after 12/31/2013) for presenting size comparison. Patients were then divided into five groups based on aTAA diameter for growth rate analysis. RESULTS At identification, patients had a median aTAA diameter of 44 mm (IQR 41-47 mm). Patients with aTAAs identified prior to December 2013 (n=129) had an average aTAA diameter 1.7 mm larger than those identified later (n=388; p=0.003). The growth analysis showed an average growth rate of 0.1 mm/year (p<0.001) across the entire cohort. Patients with an aTAA diameter of ≥55 mm (n=12) grew the fastest at 1.9 mm/year (p<0.001). In the <40 mm group (n=43), the aTAAs expanded at 0.2 mm/year, faster than the 0.1 mm/year of the slowest expanding 45-49 mm group (n=130; p=0.04). CONCLUSION aTAA size at discovery was larger before lung cancer screening guidelines took effect in December 2013. The largest aTAAs expanded fastest, but growth rates were slowest in the medium-sized 45-49 mm diameter group.
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Affiliation(s)
- W A Pace
- Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, Room S-321, San Francisco, CA 94143, USA.
| | - K Smith
- Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, Room S-321, San Francisco, CA 94143, USA
| | - A Gamboa
- Department of Biomedical Engineering, University of California Berkley, 306 Stanley Hall, Berkeley, CA 94720, USA
| | - S Zamirpour
- Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, Room S-321, San Francisco, CA 94143, USA
| | - L Ge
- Department of Surgery, San Francisco Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121, USA
| | - E Tseng
- Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, Room S-321, San Francisco, CA 94143, USA; Department of Surgery, San Francisco Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121, USA
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Pirruccello JP, Khurshid S, Lin H, Lu-Chen W, Zamirpour S, Kany S, Raghavan A, Koyama S, Vasan RS, Benjamin EJ, Lindsay ME, Ellinor PT. AORTA Gene: Polygenic prediction improves detection of thoracic aortic aneurysm. medRxiv 2023:2023.08.23.23294513. [PMID: 37662232 PMCID: PMC10473783 DOI: 10.1101/2023.08.23.23294513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background Thoracic aortic disease is an important cause of morbidity and mortality in the US, and aortic diameter is a heritable contributor to risk. Could a polygenic prediction of ascending aortic diameter improve detection of aortic aneurysm? Methods Deep learning was used to measure ascending thoracic aortic diameter in 49,939 UK Biobank participants. A genome-wide association study (GWAS) was conducted in 39,524 participants and leveraged to build a 1.1 million-variant polygenic score with PRScs-auto. Aortic diameter prediction models were built with the polygenic score ("AORTA Gene") and without it. The models were tested in a held-out set of 4,962 UK Biobank participants and externally validated in 5,469 participants from Mass General Brigham Biobank (MGB), 1,298 from the Framingham Heart Study (FHS), and 610 participants from All of Us. Results In each test set, the AORTA Gene model explained more of the variance in thoracic aortic diameter compared to clinical factors alone: 39.9% (95% CI 37.8-42.0%) vs 29.2% (95% CI 27.1-31.4%) in UK Biobank, 36.5% (95% CI 34.4-38.5%) vs 32.5% (95% CI 30.4-34.5%) in MGB, 41.8% (95% CI 37.7-45.9%) vs 33.0% (95% CI 28.9-37.2%) in FHS, and 34.9% (95% CI 28.8-41.0%) vs 28.9% (95% CI 22.9-35.0%) in All of Us. AORTA Gene had a greater AUROC for identifying diameter ≥4cm in each test set: 0.834 vs 0.765 (P=7.3E-10) in UK Biobank, 0.808 vs 0.767 in MGB (P=4.5E-12), 0.856 vs 0.818 in FHS (P=8.5E-05), and 0.827 vs 0.791 (P=7.8E-03) in All of Us. Conclusions Genetic information improved estimation of thoracic aortic diameter when added to clinical risk factors. Larger and more diverse cohorts will be needed to develop more powerful and equitable scores.
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Affiliation(s)
- James P. Pirruccello
- Division of Cardiology, University of California San Francisco, San Francisco, California, USA
- Institute for Human Genetics, University of California San Francisco, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California, USA
| | - Shaan Khurshid
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Honghuang Lin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, Massachusetts, USA
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Weng Lu-Chen
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Siavash Zamirpour
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Shinwan Kany
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Avanthi Raghavan
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Satoshi Koyama
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Ramachandran S. Vasan
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, Massachusetts, USA
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- Epidemiology Department, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Emelia J. Benjamin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, Massachusetts, USA
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- Epidemiology Department, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Mark E. Lindsay
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Patrick T. Ellinor
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Zamirpour S, Hubbard AE, Feng J, Butte AJ, Pirracchio R, Bishara A. Development of a Machine Learning Model of Postoperative Acute Kidney Injury Using Non-Invasive Time-Sensitive Intraoperative Predictors. Bioengineering (Basel) 2023; 10:932. [PMID: 37627817 PMCID: PMC10451203 DOI: 10.3390/bioengineering10080932] [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: 06/28/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/27/2023] Open
Abstract
Acute kidney injury (AKI) is a major postoperative complication that lacks established intraoperative predictors. Our objective was to develop a prediction model using preoperative and high-frequency intraoperative data for postoperative AKI. In this retrospective cohort study, we evaluated 77,428 operative cases at a single academic center between 2016 and 2022. A total of 11,212 cases with serum creatinine (sCr) data were included in the analysis. Then, 8519 cases were randomly assigned to the training set and the remainder to the validation set. Fourteen preoperative and twenty intraoperative variables were evaluated using elastic net followed by hierarchical group least absolute shrinkage and selection operator (LASSO) regression. The training set was 56% male and had a median [IQR] age of 62 (51-72) and a 6% AKI rate. Retained model variables were preoperative sCr values, the number of minutes meeting cutoffs for urine output, heart rate, perfusion index intraoperatively, and the total estimated blood loss. The area under the receiver operator characteristic curve was 0.81 (95% CI, 0.77-0.85). At a score threshold of 0.767, specificity was 77% and sensitivity was 74%. A web application that calculates the model score is available online. Our findings demonstrate the utility of intraoperative time series data for prediction problems, including a new potential use of the perfusion index. Further research is needed to evaluate the model in clinical settings.
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Affiliation(s)
- Siavash Zamirpour
- School of Medicine, University of California, San Francisco, CA 94143, USA
| | - Alan E Hubbard
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA 94704, USA
| | - Jean Feng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA 94158, USA
| | - Atul J Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA 94143, USA
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143, USA
| | - Andrew Bishara
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA 94143, USA
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143, USA
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Gulati A, Zamirpour S, Leach J, Khan A, Wang Z, Xuan Y, Hope MD, Saloner DA, Guccione JM, Ge L, Tseng EE. Ascending Thoracic Aortic Aneurysm Elongation Occurs in Parallel with Dilatation in a Nonsurgical Population. Eur J Cardiothorac Surg 2023:ezad241. [PMID: 37354525 PMCID: PMC10301688 DOI: 10.1093/ejcts/ezad241] [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: 06/16/2022] [Revised: 04/09/2023] [Accepted: 06/22/2023] [Indexed: 06/26/2023] Open
Abstract
OBJECTIVES Rapid diameter growth is a criterion for ascending thoracic aortic aneurysm repair; however, there is sparse data on aneurysm elongation rate. The purpose of this study was to assess aortic elongation rates in nonsyndromic, nonsurgical aneurysms to understand length dynamics and correlate with aortic diameter over time. METHODS Patients with <5.5 cm aneurysms and computed tomography angiography imaging at baseline and 3-5 years follow-up underwent patient-specific three-dimensional aneurysm reconstruction using MeVisLab. Aortic length was measured along the vessel centerline between the annulus and aortic arch. Maximum aneurysm diameter was determined from imaging in a plane normal to the vessel centerline. Average rates of aneurysm growth were evaluated using longest available follow-up. RESULTS Over the follow-up period, mean aortic length for 67 identified patients increased from 118.2(95% confidence interval: 115.4-121.1)mm to 120.2(117.3- 123.0)mm (p = 0.02) and 15 patients(22%) experienced a change in length of ≥ 5% from baseline. Mean annual growth rate for length (0.38[95% confidence interval : 0.11-0.65]mm/year) was correlated with annual growth rate for diameter (0.1[0.03-0.2]mm/year) (rho = 0.30, p = 0.01). Additionally, annual percentage change in length (0.3[0.1-0.5]%/year) was similar to percentage change in diameter (0.2[0.007-0.4]%/year, p = 0.95). CONCLUSIONS Aortic length increases in parallel with aortic diameter at a similar percentage rate. Further work is needed to identify whether elongation rate is associated with dissection risk. Such studies may provide insight into why patients with aortic diameters smaller than surgical guidelines continue to experience dissection events.
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Affiliation(s)
- Arushi Gulati
- Department of Surgery, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Siavash Zamirpour
- Department of Surgery, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Joseph Leach
- Department of Radiology, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Amir Khan
- Department of Surgery, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Zhongjie Wang
- Department of Surgery, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Yue Xuan
- Department of Surgery, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Michael D Hope
- Department of Radiology, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - David A Saloner
- Department of Radiology, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Julius M Guccione
- Department of Surgery, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Liang Ge
- Department of Surgery, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
| | - Elaine E Tseng
- Department of Surgery, University of California San Francisco (UCSF) and San Francisco VA Medical Center, San Francisco, CA
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Zamirpour S, Xuan Y, Wang Z, Gomez A, Hope MD, Leach J, Mitsouras D, Saloner DA, Guccione JM, Ge L, Tseng EE. Association of 3-Year All-Cause Mortality and Peak Wall Stresses of Ascending Thoracic Aortic Aneurysms in Veterans. Semin Thorac Cardiovasc Surg 2022; 35:447-456. [PMID: 35690227 DOI: 10.1053/j.semtcvs.2022.06.002] [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: 05/12/2022] [Accepted: 06/02/2022] [Indexed: 11/11/2022]
Abstract
Risk of aortic dissection in ascending thoracic aortic aneurysms is not sufficiently captured by size-based metrics. From a biomechanical perspective, dissection may be initiated when wall stress exceeds wall strength. Our objective was to assess the association between aneurysm peak wall stresses and 3-year all-cause mortality. Finite element analysis was performed in 273 veterans with chest computed tomography for surveillance of ascending thoracic aortic aneurysms. Three-dimensional geometries were reconstructed and models developed accounting for prestress geometries. A fiber-embedded hyperelastic material model was applied to obtain circumferential and longitudinal wall stresses under systolic pressure. Patients were followed up to 3 years following the scan to assess aneurysm repair and all-cause mortality. Fine-Gray subdistribution hazards were estimated for all-cause mortality based on age, aortic diameter, and peak wall stresses, treating aneurysm repair as a competing risk. When accounting for age, subdistribution hazard of mortality was not significantly increased by peak circumferential stresses (p = 0.30) but was significantly increased by peak longitudinal stresses (p = 0.008). Aortic diameter did not significantly increase subdistribution hazard of mortality in either model (circumferential model: p = 0.38; longitudinal model: p = 0.30). The effect of peak longitudinal stresses on subdistribution hazard of mortality was maximized at a binary threshold of 355kPa, which captured 34 of 212(16%) patients with diameter <5 cm, 11 of 36(31%) at 5.0-5.4 cm, and 11 of 25(44%) at ≥5.5 cm. Aneurysm peak longitudinal stresses stratified by age and diameter were associated with increased hazard of 3-year all-cause mortality in a veteran cohort. Risk prediction may be enhanced by considering peak longitudinal stresses.
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Affiliation(s)
- Siavash Zamirpour
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA; Joint Medical Program, School of Public Health, University of California, Berkeley, and School of Medicine, University of California, San Francisco, CA, USA
| | - Yue Xuan
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Zhongjie Wang
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Axel Gomez
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Michael D Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Joseph Leach
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Dimitrios Mitsouras
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - David A Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Julius M Guccione
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Liang Ge
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA
| | - Elaine E Tseng
- Department of Surgery, Division of Adult Cardiothoracic Surgery, University of California, San Francisco, and San Francisco Veterans Affairs Health Care System, CA, USA.
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9
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Normandin E, Solomon IH, Zamirpour S, Lemieux J, Freije CA, Mukerji SS, Tomkins-Tinch C, Park D, Sabeti PC, Piantadosi A. Powassan Virus Neuropathology and Genomic Diversity in Patients With Fatal Encephalitis. Open Forum Infect Dis 2020; 7:ofaa392. [PMID: 33094116 PMCID: PMC7566439 DOI: 10.1093/ofid/ofaa392] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 07/22/2020] [Accepted: 08/27/2020] [Indexed: 01/09/2023] Open
Abstract
Background Powassan virus (POWV) is an emerging cause of severe encephalitis; very little is known about human pathogenicity due to challenges in diagnosis and viral RNA recovery. We present 3 patients with fatal encephalitis due to POWV lineage II (deer tick virus). Methods We obtained 27 unique samples, including from brain biopsy and autopsy, and used metagenomic sequencing, quantitative reverse transcriptase polymerase chain reaction, and a newly developed CRISPR-based diagnostic assay to perform the first detailed characterization of POWV compartmentalization and genomics between and within human subjects. Results In all 3 patients, imaging and histopathology findings were notable for profound cerebellar involvement. All patients were initially diagnosed with POWV by metagenomic sequencing, and 2 of the 3 had negative clinical testing by serology. We detected POWV RNA in 13 clinical samples; levels were highest in the cerebellum, and there was very little involvement of peripheral tissue. We assembled complete POWV genomes from 8 samples, providing unique information about the strains of POWV lineage II (deer tick virus) that infect humans. Conclusions We demonstrate the utility of molecular assays for detecting POWV infection, including in seronegative patients, and nominate viral genomic features that may relate to human infection and neuropathogenicity. The cerebellum was identified as a key target POWV in fatal infection, by radiological and histopathological findings as well as molecular testing.
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Affiliation(s)
- Erica Normandin
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Systems Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Isaac H Solomon
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Siavash Zamirpour
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Harvard College, Cambridge, Massachusetts, USA
| | - Jacob Lemieux
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catherine A Freije
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,PhD Program in Virology, Division of Medical Sciences, Harvard University, Boston, Massachusetts, USA
| | - Shibani S Mukerji
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher Tomkins-Tinch
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, Massachusetts, USA
| | - Daniel Park
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Pardis C Sabeti
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, Massachusetts, USA.,Department of Immunology and Infectious Disease, Harvard School of Public Health, Boston, Massachusetts, USA.,Howard Hughes Medical Institute, Chevy Chase, Maryland, USA
| | - Anne Piantadosi
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
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10
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Piantadosi A, Kanjilal S, Ganesh V, Khanna A, Hyle EP, Rosand J, Bold T, Metsky HC, Lemieux J, Leone MJ, Freimark L, Matranga CB, Adams G, McGrath G, Zamirpour S, Telford S, Rosenberg E, Cho T, Frosch MP, Goldberg MB, Mukerji SS, Sabeti PC. Rapid Detection of Powassan Virus in a Patient With Encephalitis by Metagenomic Sequencing. Clin Infect Dis 2019; 66:789-792. [PMID: 29020227 PMCID: PMC5850433 DOI: 10.1093/cid/cix792] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/06/2017] [Indexed: 11/13/2022] Open
Abstract
We describe a patient with severe and progressive encephalitis of unknown etiology. We performed rapid metagenomic sequencing from cerebrospinal fluid and identified Powassan virus, an emerging tick-borne flavivirus that has been increasingly detected in the United States.
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Affiliation(s)
- Anne Piantadosi
- Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School, Boston.,Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge
| | - Sanjat Kanjilal
- Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School, Boston
| | - Vijay Ganesh
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Arjun Khanna
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Emily P Hyle
- Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School, Boston
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Tyler Bold
- Division of Infectious Diseases, Massachusetts General Hospital
| | - Hayden C Metsky
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge.,Department of Electrical Engineering and Computer Science, MIT, Cambridge
| | - Jacob Lemieux
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge.,Department of Medicine, Massachusetts General Hospital, Boston
| | - Michael J Leone
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Lisa Freimark
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge
| | - Christian B Matranga
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge
| | - Gordon Adams
- Division of Infectious Diseases, Massachusetts General Hospital
| | - Graham McGrath
- Division of Infectious Diseases, Massachusetts General Hospital
| | | | - Sam Telford
- Tufts School of Veterinary Medicine, North Grafton
| | - Eric Rosenberg
- Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School, Boston
| | - Tracey Cho
- Harvard Medical School, Boston.,Department of Neurology, Massachusetts General Hospital, Boston
| | - Matthew P Frosch
- Harvard Medical School, Boston.,Division of Neuropathology, Massachusetts General Hospital
| | - Marcia B Goldberg
- Division of Infectious Diseases, Massachusetts General Hospital.,Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge.,Department of Microbiology and Immunobiology, Harvard Medical School
| | - Shibani S Mukerji
- Harvard Medical School, Boston.,Department of Neurology, Massachusetts General Hospital, Boston.,Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston
| | - Pardis C Sabeti
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge.,FAS Center for Systems Biology, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge.,Department of Immunology and Infectious Disease, Harvard School of Public Health, Boston, Massachusetts.,Howard Hughes Medical Institute, Chevy Chase, Maryland
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