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European Heart Journal. Case Reports Jun 2024The surface of the aorta generally does not show motion unless mobile atheroma, thrombi, vegetations, or intimal flaps are present. We previously described unusual...
BACKGROUND
The surface of the aorta generally does not show motion unless mobile atheroma, thrombi, vegetations, or intimal flaps are present. We previously described unusual mobile filamentous structures in the carotid artery. Here, we describe similar findings in the aorta and their possible cause.
CASE SUMMARY
An 88-year-old female with progressive exertional dyspnoea and severe aortic stenosis had a successful transcatheter aortic valve replacement (TAVR). A filamentous structure was noted on the focused pre-operative 2D transoesophageal echocardiography in the proximal descending aorta and post-TAVR as long strand-like structures attached to the thickened intimal wall with a planar component on 3D imaging. These findings were not associated with symptoms or clinical sequelae on short- and long-term follow-up.
DISCUSSION
The mobile structures that we describe are atypical for atheroma, thrombi, vegetations, and dissections in terms of their form and clinical presentation. 2D imaging showed that the filaments had focal thickening and emerged from the aortic surface. These findings suggest a relationship with the intima, perhaps from atherogenesis or injury with disruption or lifting of the intimal surface. No clinical sequelae were detected that may also relate to their position in the descending aorta and not the arch.
PubMed: 38938470
DOI: 10.1093/ehjcr/ytae263 -
JACC. Advances Oct 2023Clinical outcomes of bicuspid aortic valve (BAV) patients with ascending aortic diameters ≥50 mm who are under surveillance are poorly defined.
BACKGROUND
Clinical outcomes of bicuspid aortic valve (BAV) patients with ascending aortic diameters ≥50 mm who are under surveillance are poorly defined.
OBJECTIVES
The purpose of this study was to assess clinical outcomes in BAV patients with ascending aorta ≥50 mm.
METHODS
Multicenter retrospective cohort study of BAV adults with ascending aorta diameters ≥50 mm by transthoracic echocardiography (TTE). Patients were categorized into 50 to 54 mm and ≥55 mm groups. Clinical outcomes were aortic dissection (AoD), aorta surgery, surgical mortality, and all-cause death.
RESULTS
Of 875 consecutive BAV patients (age 60 ± 13 years, 86% men, aortic diameter 51 mm [interquartile range (IQR): 50-53 mm]), 328 (37%) underwent early surgery ≤3 months from index TTE. Of the remaining 547 patients under surveillance, 496 had diameters 50 to 54 mm and 51 had diameters ≥55 mm and were collectively followed for 7.51 (IQR: 3.98-12.20) years. Of 496 patients with diameters 50 to 54 mm under surveillance, 266 (54%) underwent surgery 2.0 (IQR: 0.77-4.16) years from index TTE. AoD occurred in 9/496 (1.8%) patients for an incidence of 0.4 cases per 100 person-years, surgical mortality was 5/266 (1.9%); and ≥moderate aortic stenosis (but not aorta size) was associated with all-cause death, hazard ratio: 2.05 (95% CI: 1.32-3.20), = 0.001. Conversely, in 547 total patients under surveillance (including 50-54 mm and ≥55 mm), both aorta size and ≥moderate aortic stenosis were associated with all-cause death (both ≤ 0.027). AoD rate in patients ≥55 mm under surveillance was 5.9%.
CONCLUSIONS
In BAV patients with ascending aorta 50 to 54 mm under surveillance, AoD incidence is low and the overall rates of AoD and surgical mortality are similar, suggesting clinical equivalence between surgical and surveillance strategies. Conversely, patients with aortas ≥55 mm should undergo surgery. Aortic stenosis is associated with all-cause death in these patients.
PubMed: 38938356
DOI: 10.1016/j.jacadv.2023.100626 -
JACC. Advances Oct 2023
PubMed: 38938354
DOI: 10.1016/j.jacadv.2023.100624 -
JACC. Advances Oct 2023
PubMed: 38938345
DOI: 10.1016/j.jacadv.2023.100627 -
JACC. Advances Oct 2023Acute aortic dissection (AAD) often leads to out-of-hospital cardiac arrest (OHCA) and death before hospital arrival.
BACKGROUND
Acute aortic dissection (AAD) often leads to out-of-hospital cardiac arrest (OHCA) and death before hospital arrival.
OBJECTIVES
The purpose of this study was to investigate differences in AAD incidence by sex.
METHODS
A population-based study in a city with 121,180 residents was conducted using postmortem computed tomography data to identify patients with AAD who died before hospital arrival in 2008-2020. The incidence rate ratio and odds ratio were estimated using Poisson regression and univariable logistic regression, respectively.
RESULTS
A total of 266 patients with incident AAD were enrolled: 84 patients with OHCA, 137 women [n = 137], and 164 patients with type A AAD. The crude and age-adjusted incidence of AAD was 16.2 and 14.3/100,000 person-years, respectively. The incidence of AAD was comparable by sex (men, 16.7/100,000 person-years; women, 15.7/100,000 person-years; incidence rate ratio: 0.94; 95% CI: 0.74-1.20; = 0.64). Compared with men with AAD, women with AAD were older (77 ± 11 years vs 70 ± 14 years; < 0.001), and a higher proportion had type A AAD (76% vs 47%; < 0.001). Women with AAD had higher prehospital mortality than men with AAD (37% vs 21%; = 0.004; OR: 2.24; 95% CI: 1.30-3.87; = 0.004). Among 1,373 patients with OHCA, the proportion of women with AAD was significantly higher than the proportion of men with AAD (11% vs 3.9%; < 0.001; OR: 2.90; 95% CI: 1.86-4.53; < 0.001). AAD was most common in women aged 60 to 69 years (16.4%).
CONCLUSIONS
Women had a higher incidence of AAD presenting as prehospital death than men.
PubMed: 38938331
DOI: 10.1016/j.jacadv.2023.100623 -
Colorectal Disease : the Official... Jun 2024Incisional herniation (IH) is a frequent complication following midline abdominal closure with significant associated morbidity. Randomized controlled trials have...
AIM
Incisional herniation (IH) is a frequent complication following midline abdominal closure with significant associated morbidity. Randomized controlled trials have demonstrated that the small bites technique (SBT) and prophylactic mesh augmentation (PMA) may reduce IH compared to mass closure techniques, but data are lacking on their implementation in contemporary surgical practice. This survey aimed to evaluate the use of the SBT and PMA and to identify factors associated with their adoption.
METHOD
Between 22 January 2023 and 16 March 2023, consultant surgeons across the UK were asked to complete a 25-question survey on closure of an elective primary midline incision.
RESULTS
Responses were received from 267 of 675 eligible surgeons (39.6%) in 38 NHS Trusts. Respondents were evenly split between tertiary centres (47.6%) and district general hospitals (49.4%). SBT and PMA were used by 19.9% and 3.0% of respondents, respectively. Compared to other techniques, surgeons using the SBT were more likely to close the anterior aponeurotic layer only, use single suture filaments, 2-0 gauge sutures and sharp needle points and routinely dissect abdominal layers to aid closure (all p < 0.001). Attendance at lectures/conferences on SBT (p = 0.043) and basing practice on available evidence (p < 0.001) were independently associated with use of the SBT. The commonest barriers to adopting SBT were a perceived lack of evidence (23.8%) and belief that personal IH rates were low (16.8%).
CONCLUSION
A minority of UK consultant surgeons have adopted the SBT or PMA. Practice change should be driven by more widespread dissemination of current evidence and procedural information.
PubMed: 38937910
DOI: 10.1111/codi.17081 -
Journal of Cardiothoracic Surgery Jun 2024Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is...
BACKGROUND
Thoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is required when treating patients with involvement of LSA. The best antiplatelet therapy after LSA reconstruction is presently uncertain.
METHODS
This study retrospectively analyzed 245 type B aortic dissection patients who underwent left subclavian artery revascularization during TEVAR. Out of 245 patients, 159 (64.9%) were in the single antiplatelet therapy (SAPT) group, receiving only aspirin, and 86 (35.1%) were in the dual antiplatelet therapy (DAPT) group, receiving aspirin combined with clopidogrel. During the 6-month follow-up, primary endpoints included hemorrhagic events (general bleeding and hemorrhagic strokes), while secondary endpoints comprised ischemic events (left upper limb ischemia, ischemic stroke, and thrombotic events), as well as death and leakage events. Both univariate and multivariate Cox regression analyses were performed on hemorrhagic and ischemic events, with the Kaplan-Meier method used to generate the survival curve.
RESULTS
During the six-month follow-up, the incidence of hemorrhagic events in the DAPT group was higher (8.2% vs. 30.2%, P < 0.001). No significant differences were observed in ischemic events, death, or leakage events among the different antiplatelet treatment schemes. Multivariate Cox regression analysis showed that DAPT (HR: 2.22, 95% CI: 1.07-4.60, P = 0.032) and previous chronic conditions (HR:3.88, 95% CI: 1.24-12.14, P = 0.020) significantly affected the occurrence of hemorrhagic events. Chronic conditions in this study encompassed depression, vitiligo, and cholecystolithiasis. Carotid subclavian bypass (CSB) group (HR:0.29, 95% CI: 0.12-0.68, P = 0.004) and single-branched stent graft (SBSG) group (HR:0.26, 95% CI: 0.13-0.50, P < 0.001) had a lower rate of ischemic events than fenestration TEVAR (F-TEVAR). Survival analysis over 6 months revealed a lower risk of bleeding associated with SAPT during hemorrhagic events (P = 0.043).
CONCLUSIONS
In type B aortic dissection patients undergoing LSA blood flow reconstruction after synchronous TEVAR, the bleeding risk significantly decreases with the SAPT regimen, and there is no apparent ischemic compensation within 6 months. Patients with previous chronic conditions have a higher risk of bleeding. The CSB group and SBSG group have less ischemic risk compared to F-TEVAR group.
Topics: Humans; Male; Female; Retrospective Studies; Platelet Aggregation Inhibitors; Subclavian Artery; Middle Aged; Aortic Dissection; Endovascular Procedures; Aortic Aneurysm, Thoracic; Aged; Clopidogrel; Aspirin; Aorta, Thoracic; Treatment Outcome; Blood Vessel Prosthesis Implantation; Postoperative Complications; Endovascular Aneurysm Repair
PubMed: 38937841
DOI: 10.1186/s13019-024-02932-3 -
Journal of Cardiothoracic Surgery Jun 2024The surgical evaluation and management of non-A non-B aortic dissections, in the absence of ascending aortic involvement, remains a grey area. It is in these scenarios...
BACKGROUND
The surgical evaluation and management of non-A non-B aortic dissections, in the absence of ascending aortic involvement, remains a grey area. It is in these scenarios when thorough evaluation of patient/family history, clinical presentation, but also overall lifestyle, is of immense importance when determining an optimal intervention.
CASE PRESENTATION
We present a 38-year-old patient with a physically demanding lifestyle as a professional wrestler, uncontrolled hypertension due to history of medical non-adherence, and family history of aortic dissection who presented with acute non-A non-B aortic dissection. He was spared a total arch replacement by undergoing a hybrid approach of complete aortic debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR). The patient was able to benefit from reduced cardiopulmonary bypass (CPB) time, avoidance of aortic cross clamp, circulatory arrest, and hypothermic circulation.
CONCLUSIONS
This patient's unique composition of a physically demanding lifestyle, personal history of medical non-adherence, family history of aortic dissection, and clinical presentation required a holistic approach to understanding an ideal intervention that would be best suited long-term. Due to this contextualization, the patient was able to be spared a total arch replacement, or suboptimal medical management, by instead undergoing a hybrid-approach with total aortic arch debranching with antegrade TEVAR.
Topics: Humans; Adult; Male; Aortic Dissection; Endovascular Procedures; Aortic Aneurysm, Thoracic; Aorta, Thoracic; Blood Vessel Prosthesis Implantation; Acute Disease; Endovascular Aneurysm Repair
PubMed: 38937775
DOI: 10.1186/s13019-024-02917-2 -
Scientific Reports Jun 2024There is no treatment for acute aortic dissection (AAD) targeting inflammatory cells. We aimed to identify the new therapeutic targets associated with inflammatory...
There is no treatment for acute aortic dissection (AAD) targeting inflammatory cells. We aimed to identify the new therapeutic targets associated with inflammatory cells. We characterized the specific distribution of myeloid cells of both human type A AAD samples and a murine AAD model generated using angiotensin II (ANGII) and β-aminopropionitrile (BAPN) by single-cell RNA sequencing (scRNA-seq). We also examined the effect of an anti-interleukin-1β (IL-1β) antibody in the murine AAD model. IL1B inflammatory macrophages and classical monocytes were increased in human AAD samples. Trajectory analysis demonstrated that IL1B inflammatory macrophages differentiated from S100A8/9/12 classical monocytes uniquely observed in the aorta of AAD. We found increased infiltration of neutrophils and monocytes with the expression of inflammatory cytokines in the aorta and accumulation of inflammatory macrophages before the onset of macroscopic AAD in the murine AAD model. In blocking experiments using an anti-IL-1β antibody, it improved survival of murine AAD model by preventing elastin degradation. We observed the accumulation of inflammatory macrophages expressing IL-1β in both human AAD samples and in a murine AAD model. Anti-IL-1β antibody could improve the mortality rate in mice, suggesting that it may be a treatment option for AAD.
Topics: Aortic Dissection; Interleukin-1beta; Animals; Humans; Macrophages; Mice; Disease Models, Animal; Male; Aminopropionitrile; Angiotensin II; Inflammation; Monocytes; Aorta; Mice, Inbred C57BL; Female
PubMed: 38937528
DOI: 10.1038/s41598-024-65931-3 -
Digestive Diseases and Sciences Jun 2024
PubMed: 38937396
DOI: 10.1007/s10620-024-08532-4