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Journal of Cardiothoracic Surgery May 2024To assess whether retrograde cerebral perfusion reduces neurological injury and mortality in patients undergoing surgery for acute type A aortic dissection. (Observational Study)
Observational Study
BACKGROUND
To assess whether retrograde cerebral perfusion reduces neurological injury and mortality in patients undergoing surgery for acute type A aortic dissection.
METHODS
Single-center, retrospective, observational study including all patients undergoing acute type A aortic dissection repair with deep hypothermic circulatory arrest between January 1998 and December 2022 with or without the adjunct of retrograde cerebral perfusion. 515 patients were included: 257 patients with hypothermic circulatory arrest only and 258 patients with hypothermic circulatory arrest and retrograde cerebral perfusion. The primary endpoints were clinical neurological injury, embolic lesions, and watershed lesions. Multivariable logistic regression was performed to identify independent predictors of the primary outcomes. Survival analysis was performed using Kaplan-Meier estimates.
RESULTS
Clinical neurological injury and embolic lesions were less frequent in patients with retrograde cerebral perfusion (20.2% vs. 28.4%, p = 0.041 and 13.7% vs. 23.4%, p = 0.010, respectively), but there was no significant difference in the occurrence of watershed lesions (3.0% vs. 6.1%, p = 0.156). However, after multivariable logistic regression, retrograde cerebral perfusion was associated with a significant reduction of clinical neurological injury (OR: 0.60; 95% CI 0.36-0.995, p = 0.049), embolic lesions (OR: 0.55; 95% CI 0.31-0.97, p = 0.041), and watershed lesions (OR: 0.25; 95%CI 0.07-0.80, p = 0.027). There was no significant difference in 30-day mortality (12.8% vs. 11.7%, p = ns) or long-term survival between groups.
CONCLUSION
In this study, we showed that the addition of retrograde cerebral perfusion during hypothermic circulatory arrest in the setting of acute type A aortic dissection repair reduced the risk of clinical neurological injury, embolic lesions, and watershed lesions.
Topics: Humans; Aortic Dissection; Female; Male; Circulatory Arrest, Deep Hypothermia Induced; Retrospective Studies; Middle Aged; Perfusion; Cerebrovascular Circulation; Aged; Postoperative Complications; Aortic Aneurysm, Thoracic
PubMed: 38811972
DOI: 10.1186/s13019-024-02814-8 -
BMC Cardiovascular Disorders May 2024Acute coronary syndrome due to coronary artery embolism in the setting of ascending aortic thrombus is an uncommon condition, even rarer when there is no aortic... (Review)
Review
BACKGROUND
Acute coronary syndrome due to coronary artery embolism in the setting of ascending aortic thrombus is an uncommon condition, even rarer when there is no aortic pathology such as aneurysm, severe atherosclerosis, aortic dissection, or thrombophilia (whether inherited or acquired).
CASE PRESENTATION
We report a case of a 58-year-old male presented with acute chest pain, electrocardiogram showing non-ST-elevation acute coronary syndrome. The computed tomography angiography of coronary artery revealed a mural thrombus in the proximal part of ascending aorta, located above the left coronary artery ostium, without any aortic pathologies. With the exception of hypertension and cigarette smoking, no other risk factors were identified in this patient that may increase the risk of thrombosis. Given the life-threatening risk of interventional therapy and surgery, the patient determinedly opted for anticoagulant and dual antiplatelet therapy. Then he experienced the reoccurrence of chest pain after 6-day treatment, progressed to anterior and inferior ST-segment elevation myocardial infarction. Coronary artery embolism originating from the ascending aortic thrombus was suspected. Considering the hemodynamic instability of the patient, the medical treatment was continued and bridged to warfarin and aspirin after discharge. Follow-up computed tomography angiography at 6 months showed no obstruction in coronary artery and complete resolution of the thrombus. No thromboembolic events occurred henceforward.
CONCLUSIONS
Acute coronary syndrome could be a manifestation of secondary coronary embolism due to ascending aortic thrombus. Currently, there is no standardized guideline for the treatment of aortic mural thrombus, individualized treatment is recommended. When surgical therapy is not applicable for the patient, anticoagulation and dual antiplatelet treatment are alternative treatments that may successfully lead to the resolution of the aortic thrombus.
Topics: Humans; Male; Middle Aged; Acute Coronary Syndrome; Treatment Outcome; Aortic Diseases; Recurrence; Thrombosis; Anticoagulants; Computed Tomography Angiography; Coronary Angiography; Platelet Aggregation Inhibitors; Non-ST Elevated Myocardial Infarction; Aortography
PubMed: 38811879
DOI: 10.1186/s12872-024-03956-2 -
British Journal of Cardiac Nursing Oct 2023Abdominal aortic aneurysm (AAA) is a condition in which the abdominal aorta becomes enlarged, posing a risk of rupture and life-threatening haemorrhage. Abdominal aortic...
Abdominal aortic aneurysm (AAA) is a condition in which the abdominal aorta becomes enlarged, posing a risk of rupture and life-threatening haemorrhage. Abdominal aortic aneurysm accounts for a substantial number of fatalities worldwide, with mortality rates of up to 80 percent. Abdominal aortic aneurysms are often asymptomatic and are frequently discovered incidentally during tests for unrelated conditions. Surgery is required for aneurysms exceeding 5.5cm in men and 5cm in women, but post-surgical complications such as intra-abdominal adhesions, limb ischaemia and renal failure are common. There is some evidence showing that exercise, including prehabilitation, may be effective in improving patient outcomes post-surgery. However, there is a dearth of literature that has synthesised existing evidence related to the effectiveness of prehabilitation on patient outcomes post-surgery, and which has expanded upon its implications for clinical practise. This commentary aims to critically appraise the most recent Cochrane review in this area, and expand upon these findings to inform clinical practice.
PubMed: 38808305
DOI: 10.12968/bjca.2023.0078 -
Cureus Apr 2024Marfan syndrome (MFS) is a rare hereditary connective tissue disorder with autosomal dominant inheritance associated with an increased risk of cardiovascular...
Marfan syndrome (MFS) is a rare hereditary connective tissue disorder with autosomal dominant inheritance associated with an increased risk of cardiovascular complications due to connective tissue fragility. Acute myocardial infarction during pregnancy is also a rare event associated with poor maternal and fetal outcomes. Herein, we report a case of a 30-year-old pregnant woman with a known history of MFS. The patient had been treated surgically for an ascending aorta aneurysm and mechanical prosthetic aortic valve repair. She presented at 12 weeks of gestation with severe chest pain, which proved to be acute myocardial infarction. This is believed to be the first case of this complex medical condition presented in the first trimester of pregnancy.
PubMed: 38807841
DOI: 10.7759/cureus.59182 -
Open Heart May 2024This study aims to compare aortic morphology between repaired coarctation patients and controls, and to identify aortic morphological risk factors for hypertension and...
OBJECTIVE
This study aims to compare aortic morphology between repaired coarctation patients and controls, and to identify aortic morphological risk factors for hypertension and cardiovascular events (CVEs) in coarctation patients.
METHODS
Repaired coarctation patients with computed tomography angiography (CTA) or magnetic resonance angiography (MRA) were included, followed-up and compared with sex-matched and age-matched controls. Three-dimensional aortic shape was reconstructed using patients' CTA or MRA, or four-dimensional flow cardiovascular magnetic resonance in controls, and advanced geometrical characteristics were calculated and visualised using statistical shape modelling. In patients, we examined the association of geometrical characteristics with (1) baseline hypertension, using multivariable logistic regression; and (2) cardiovascular events (CVE, composite of aortic complications, coronary artery disease, ventricular arrhythmias, heart failure hospitalisation, stroke, transient ischaemic attacks and cardiovascular death), using multivariable Cox regression. The least absolute shrinkage and selection operator (LASSO) method selected the most informative multivariable model.
RESULTS
Sixty-five repaired coarctation patients (23 years (IQR 19-38)) were included, of which 44 (68%) patients were hypertensive at baseline. After a median follow-up of 8.7 years (IQR 4.8-15.4), 27 CVEs occurred in 20 patients. Aortic arch dimensions were smaller in patients compared with controls (diameter p<0.001, wall surface area p=0.026, volume p=0.007). Patients had more aortic arch torsion (p<0.001) and a higher curvature (p<0.001). No geometrical characteristics were associated with hypertension. LASSO selected left ventricular mass, male sex, tortuosity and age for the multivariable model. Left ventricular mass (p=0.014) was independently associated with CVE, and aortic tortuosity showed a trend towards significance (p=0.070).
CONCLUSION
Repaired coarctation patients have a smaller aortic arch and a more tortuous course of the aorta compared with controls. Besides left ventricular mass index, geometrical features might be of importance in long-term risk assessment in coarctation patients.
Topics: Humans; Aortic Coarctation; Male; Female; Computed Tomography Angiography; Adult; Risk Factors; Young Adult; Magnetic Resonance Angiography; Follow-Up Studies; Time Factors; Aorta, Thoracic; Retrospective Studies; Magnetic Resonance Imaging, Cine; Risk Assessment; Treatment Outcome; Hypertension; Adolescent
PubMed: 38806222
DOI: 10.1136/openhrt-2024-002642 -
Heliyon May 2024Thoracic Aortic Aneurysm (TAA) poses significant health risks due to aortic dilation. Recent evidence suggests a pivotal role for the immune-inflammatory response in the...
BACKGROUND
Thoracic Aortic Aneurysm (TAA) poses significant health risks due to aortic dilation. Recent evidence suggests a pivotal role for the immune-inflammatory response in the mechanism of aortic aneurysm formation. In this study, we aim to investigate the causal relationship between circulating immune cells and TAA.
METHODS
This study employs a two-sample Mendelian Randomization (MR) approach, utilizing genome-wide association study (GWAS) summary statistics for 731 immune cell types and two TAA data from large-scale studies. Causal effects of both peripheral immune cells on TAA and TAA on peripheral immune cells are explored. To ensure more accurate results, we intersected the findings from two TAA data from large-scale studies, excluding results where the direction of the odds ratio (OR) was inconsistent.
FINDINGS
The study identifies specific immune cells associated with TAA. Notably, CD45 NKT cell (OR: 0.95, 95CI%: 0.90-0.99 in FinnGen study; OR: 0.91, 95CI%: 0.84-0.99 in CHIP + MGI study) and CD45 HLA-DR + CD8 T cells (OR: 0.95, 95CI%: 0.90-0.99 in FinnGen study; OR: 0.90, 95CI%: 0.82-0.99 in CHIP + MGI study) demonstrate a protective role against TAA. In addition, CD28 CD45RA- CD8 T cells (relative cell counts and absolute cell counts) and HVEM + CM + CD8 T cells are adversely affected by TAA.
INTERPRETATION
The findings indicate that the potential protective influence exerted by specific subsets of peripheral NKT cells and CD8 T cells in mitigating the development of TAA, while simultaneously highlighting the reciprocal effects of TAA on peripheral Treg cells subsets and T cell subsets. The complex interaction between immune cells and TAA could provide valuable clues for earlier detection and more efficacious treatment strategies for TAA.
PubMed: 38803862
DOI: 10.1016/j.heliyon.2024.e31198 -
The Lancet Regional Health. Europe Apr 2024Few studies have explored long-term trends and risk factors for peripheral arterial complications in type 2 diabetes compared to the general population. Our research...
BACKGROUND
Few studies have explored long-term trends and risk factors for peripheral arterial complications in type 2 diabetes compared to the general population. Our research focuses on identifying optimal risk factors, their significance, risk associated with multifactorial risk factor control, and trends for these complications in diabetic patients versus general controls.
METHODS
This study included persons with type 2 diabetes mellitus entered into the Swedish National Diabetes Register 2001-2019 and controls matched for age-, sex- and county of residence. Outcomes comprised of extracranial large artery disease, aortic aneurysm, aortic dissection, lower extremity arterial disease and diabetes foot disease. Standardized incidence rates and Cox regression were used for analyses.
FINDINGS
The study comprises 655,250 persons with type 2 diabetes mellitus; average age 64.2; 43.8% women. Among persons with type 2 diabetes mellitus, the incidence rates per 100,000 person years for each non-coronary peripheral arterial complication event changed between 2001 and 2019 as follows: extracranial large artery disease 170.0-84.9; aortic aneurysm 40.6-69.2; aortic dissection 9.3 to 5.6; lower extremity artery disease from 338.8 to 190.8; and diabetic foot disease from 309.8 to 226.8. Baseline hemoglobin A1c (HbA1c), systolic blood pressure (SBP), smoking status and lipid levels were independently associated with all outcomes in the type 2 diabetes mellitus cohort. Within the cohort with type 2 diabetes mellitus, the risk for extracranial large artery disease and lower extremity artery disease increased in a stepwise fashion for each risk factor not within target. Excess risk for non-coronary peripheral arterial complications in the entire cohort for persons with type 2 diabetes mellitus, compared to matched controls, were as follows: extracranial large artery disease adjusted hazard ratio (HR) 1.69 (95% confidence interval (CI), 1.65-1.73), aortic aneurysm HR 0.89 (95% CI, 0.87-0.92), aortic dissection HR 0.51 (95% CI, 0.46-0.57) and lower extremity artery disease HR 2.59 (95% CI, 2.55-2.64).
INTERPRETATION
The incidence of non-coronary peripheral arterial complications has declined significantly among persons with type 2 diabetes mellitus, with the exception of aortic aneurysm. HbA1c, smoking and blood pressure demonstrated greatest relative contribution for outcomes and lower levels of cardiometabolic risk factors are associated with reduced relative risk of outcomes.
FUNDING
Swedish Governmental and the County support of research and education of doctors, the Swedish Heart-Lung Foundation and Åke-Wibergs grant.
PubMed: 38803635
DOI: 10.1016/j.lanepe.2024.100888 -
The Lancet Regional Health. Europe Apr 2024Observational studies on long-term trends, risk factor association and importance are scarce for type 1 diabetes mellitus and peripheral arterial outcomes. We set out to...
BACKGROUND
Observational studies on long-term trends, risk factor association and importance are scarce for type 1 diabetes mellitus and peripheral arterial outcomes. We set out to investigate trends in non-coronary complications and their relationships with cardiovascular risk factors in persons with type 1 diabetes mellitus compared to matched controls.
METHODS
34,263 persons with type 1 diabetes mellitus from the Swedish National Diabetes Register and 164,063 matched controls were included. Incidence rates of extracranial large artery disease, aortic aneurysm, aortic dissection, lower extremity artery disease, and diabetic foot syndrome were analyzed using standardized incidence rates and Cox regression.
FINDINGS
Between 2001 and 2019, type 1 diabetes mellitus incidence rates per 100,000 person-years were as follows: extracranial large artery disease 296.5-84.3, aortic aneurysm 0-9.2, aortic dissection remained at 0, lower extremity artery disease 456.6-311.1, and diabetic foot disease 814.7-77.6. Persons with type 1 diabetes mellitus with cardiometabolic risk factors at target range did not exhibit excess risk of extracranial large artery disease [HR 0.83 (95% CI, 0.20-3.36)] or lower extremity artery disease [HR 0.94 (95% CI, 0.30-2.93)], compared to controls. Persons with type 1 diabetes with all risk factors at baseline, had substantially elevated risk for diabetic foot disease [HR 29.44 (95% CI, 3.83-226.04)], compared to persons with type 1 diabetes with no risk factors. Persons with type 1 diabetes mellitus continued to display a lower risk for aortic aneurysm, even with three cardiovascular risk factors at baseline [HR 0.31 (95% CI, 0.15-0.67)]. Relative importance analyses demonstrated that education, glycated hemoglobin (HbA1c), duration of diabetes and lipids explained 54% of extracranial large artery disease, while HbA1c, smoking and systolic blood pressure explained 50% of lower extremity artery disease and HbA1c alone contributed to 41% of diabetic foot disease. Income, duration of diabetes and body mass index explained 66% of the contribution to aortic aneurysm.
INTERPRETATION
Peripheral arterial complications decreased in persons with type 1 diabetes mellitus, except for aortic aneurysm which remained low. Besides glycemic control, traditional cardiovascular risk factors were associated with incident outcomes. Risk of these outcomes increased with additional risk factors present. Persons with type 1 diabetes mellitus exhibited a lower risk of aortic aneurysm compared to controls, despite presence of cardiovascular risk factors.
FUNDING
Swedish Governmental and the county support of research and education of doctors, the Swedish Heart and Lung Foundation, Sweden and Åke-Wibergs grant.
PubMed: 38803631
DOI: 10.1016/j.lanepe.2024.100852 -
Cureus Apr 2024Abdominal aortic aneurysm, characterized by a persistent dilation exceeding 3 cm or 50% of the aortic diameter, poses a substantial risk, particularly in males over 65....
Abdominal aortic aneurysm, characterized by a persistent dilation exceeding 3 cm or 50% of the aortic diameter, poses a substantial risk, particularly in males over 65. Despite its potentially asymptomatic nature, early detection is imperative due to the elevated mortality rates, reaching 90% following rupture. The presented case involves a 60-year-old male with progressively worsening abdominal pain, a history of cardiovascular disease, hypertension, and smoking. Initial examinations were inconclusive, requiring advanced imaging that revealed a large aneurysmal dilation. Therapeutic measures included endovascular aneurysm repair (EVAR), highlighting the significance of timely intervention. Despite elective surgery risks, mortality rates decrease significantly when the aneurysm diameter surpasses 43 mm. This report stresses the need for primary care physicians to conduct thorough screenings, recognize risk factors, and facilitate prompt referrals for advanced imaging. The case's pivotal lesson lies in the comprehensive management of abdominal aortic aneurysm, showcasing the potential for life-saving interventions and the critical role of early detection in mitigating the severe consequences associated with its rupture.
PubMed: 38800210
DOI: 10.7759/cureus.58894 -
Cureus Apr 2024A 68-year-old man underwent endovascular abdominal aortic aneurysm repair for a two-humped abdominal aortic aneurysm (AAA) with a short neck. The abdominal aorta had...
A 68-year-old man underwent endovascular abdominal aortic aneurysm repair for a two-humped abdominal aortic aneurysm (AAA) with a short neck. The abdominal aorta had severe calcification, suggesting a high risk for type Ia endoleak. Initially, a catheter was placed in the aneurysm sac, followed by stent graft deployment. Then, coils were inserted into the aneurysm neck. Subsequently, the type Ia endoleak was resolved. One year after the surgery, no evidence of endoleak was observed, and the aneurysm size had decreased by 10 mm. Therefore, this procedure may be effective for short-neck AAAs.
PubMed: 38800153
DOI: 10.7759/cureus.58988