-
Aorta (Stamford, Conn.) May 2024Conventional elephant trunk (cET) and frozen elephant trunk (FET) are two distinct approaches to the surgical treatment of thoracic aortic aneurysms and dissections....
Conventional elephant trunk (cET) and frozen elephant trunk (FET) are two distinct approaches to the surgical treatment of thoracic aortic aneurysms and dissections. With the advent and growing uptake of endovascular technologies, FET is becoming increasingly popular for its potential to be performed as a single-stage operation with better aortic remodeling and less risk of graft kinking than the traditional two-stage cET procedure. However, FET has been associated with a higher risk of spinal cord ischemia and its use in patients with connective tissue disorder remains controversial. The current review aimed to reflect on recent evidence surrounding the application of cET and FET to different types of aortic pathology in both acute and elective settings. Another scope of this review was to compare the characteristics of the currently available FET commercial devices on the global market. Our findings highlight that when the pathology is confined to the proximal descending aorta, such as in Dsine, intervention is often single-staged and false lumen (FL) thrombosis is achieved with good effect. FET remains limited by spinal cord injury and applicability in patients with connective tissue disorder, although some groups have started to circumvent associated complications, likely due to growing surgical expertise. Many other aortic diseases do require second-stage intervention, and even in these cases, there appears to be lower in-hospital mortality when using FET over cET. This is possibly due to the higher rate of endovascular completion facilitated by the completed landing zones created during FET. FET is trending toward becoming the universal treatment modality for extending repair to the descending aorta.
PubMed: 38754437
DOI: 10.1055/s-0044-1786352 -
BioRxiv : the Preprint Server For... Apr 2024Smooth muscle cells (SMCs) of cardiac and neural crest origin contribute to the developing proximal aorta and are linked to disease propensity in adults. We analyzed...
Smooth muscle cells (SMCs) of cardiac and neural crest origin contribute to the developing proximal aorta and are linked to disease propensity in adults. We analyzed single-cell transcriptomes of SMCs from mature thoracic aortas in mice to determine basal states and changes after disrupting transforming growth factor-β (TGFβ) signaling necessary for aortic homeostasis. A minority of Myh11 lineage-marked SMCs differentially expressed genes suggestive of embryological origin. Additional analyses in Nkx2-5 and Wnt1 lineage-marked SMCs derived from cardiac and neural crest progenitors, respectively, showed both lineages contributed to a major common cluster and each lineage to a minor distinct cluster. Common cluster SMCs extended from root to arch, cardiac subset cluster SMCs from root to mid-ascending, while neural crest subset cluster SMCs were restricted to the arch. The neural crest subset cluster had greater expression of a subgroup of TGFβ-dependent genes suggesting specific responsiveness or skewed extracellular matrix synthesis. Nonetheless, deletion of TGFβ receptors in SMCs resulted in similar transcriptional changes among all clusters, primarily decreased extracellular matrix molecules and modulators of TGFβ signaling. Many embryological markers of murine aortic SMCs were not confirmed in adult human aortas. We conclude: (i) there are multiple subtypes of cardiac- and neural crest-derived SMCs with shared or distinctive transcriptional profiles, (ii) neural crest subset SMCs with increased expression of certain TGFβ-inducible genes are not spatially linked to the aortic root predisposed to aneurysms from aberrant TGFβ signaling, and (iii) loss of TGFβ responses after receptor deletion is uniform among SMCs of different embryological origins.
PubMed: 38746256
DOI: 10.1101/2024.04.28.591539 -
Journal of Thoracic Disease Apr 2024Blood flow assessment is an emerging technique that allows for assessment of hemodynamics in the heart and blood vessels. Recent advances in cardiovascular imaging... (Review)
Review
BACKGROUND AND OBJECTIVE
Blood flow assessment is an emerging technique that allows for assessment of hemodynamics in the heart and blood vessels. Recent advances in cardiovascular imaging technologies have made it possible for this technique to be more accessible to clinicians and researchers. Blood flow assessment typically refers to two techniques: measurement-based flow visualization using echocardiography or four-dimensional flow magnetic resonance imaging (4D flow MRI), and computer-based flow simulation based on computational fluid dynamics modeling. Using these methods, blood flow patterns can be visualized and quantitative measurements of mechanical stress on the walls of the ventricles and blood vessels, most notably the aorta, can be made. Thus, blood flow assessment has been enhancing the understanding of cardiac and aortic diseases; however, its introduction to clinical practice has been negligible yet. In this article, we aim to discuss the clinical applications and future directions of blood flow assessment in aortic surgery. We then provide our unique perspective on the technique's translational impact on the surgical management of aortic disease.
METHODS
Articles from the PubMed database and Google Scholar regarding blood flow assessment in aortic surgery were reviewed. For the initial search, articles published between 2013 and 2023 were prioritized, including original articles, clinical trials, case reports, and reviews. Following the initial search, additional articles were considered based on manual searches of the references from the retrieved literature.
KEY CONTENT AND FINDINGS
In aortic root pathology and ascending aortic aneurysms, blood flow assessment can elucidate postoperative hemodynamic changes after surgical reconfiguration of the aortic valve complex or ascending aorta. In cases of aortic dissection, analysis of blood flow can predict future aortic dilatation. For complicated congenital aortic anomalies, surgeons may use preoperative imaging to perform "virtual surgery", in which blood flow assessment can predict postoperative hemodynamics for different surgical reconstructions and assist in procedural planning even before entering the operating room.
CONCLUSIONS
Blood flow assessment and computational modeling can evaluate hemodynamics and flow patterns by visualizing blood flow and calculating biomechanical forces in patients with aortic disease. We anticipate that blood flow assessment will become an essential tool in the treatment planning and understanding of the progression of aortic disease.
PubMed: 38738252
DOI: 10.21037/jtd-23-1795 -
Journal of Thoracic Disease Apr 2024Aortic aneurysm, characterized by abnormal dilation of the aorta, poses significant health risks. This study aims to investigate the interaction between...
BACKGROUND
Aortic aneurysm, characterized by abnormal dilation of the aorta, poses significant health risks. This study aims to investigate the interaction between 5-aminolevulinate synthase 2 () and GATA-binding protein 1 () in ferroptosis and oxidative stress responses in aortic aneurysm.
METHODS
A weighted gene co-expression network analysis (WGCNA) was performed on the differentially expressed genes (DEGs) within the GSE9106 dataset to identify the key module. Subsequently, protein-protein interaction (PPI) network analysis was performed on the key module. Mouse aortic vascular smooth muscle cells (MOVAS) were treated with hydrogen peroxide (HO) to induce oxidative stress, and ferroptosis inducers and inhibitors were added to evaluate their effects on iron content and oxidative stress markers. Through a series of cellular experiments, we assessed cell viability, expression levels of GATA1 and iron mutation-associated proteins, as well as cellular phenotypes such as inflammatory responses and apoptosis rates.
RESULTS
Three candidate genes (, , and ) were upregulated in the thoracic aortic aneurysm (TAA) samples of the GSE9106 dataset. The HO treatment increased the MOVAS cells' iron content and oxidative stress, upregulated ALAS2 protein levels, and decreased the ferroptosis-related protein levels. overexpression reversed HO-induced apoptosis and increased the inflammatory cytokine levels. Additionally, the knockdown of partially reversed the protective mechanism of overexpressed on HO-induced ferroptosis.
CONCLUSIONS
overexpression reduced HO-induced oxidative damage and iron-induced apoptosis in MOVAS cells, and knockdown partially reversed this protective effect. These findings suggested that the and regulatory pathways may be potential therapeutic targets in aortic aneurysms.
PubMed: 38738239
DOI: 10.21037/jtd-24-370 -
Frontiers in Cardiovascular Medicine 2024Due to its favorable outcome regarding late morbidity and mortality, thoracic endovascular repair (TEVAR) is becoming more popular for uncomplicated type B aortic...
OBJECTIVE
Due to its favorable outcome regarding late morbidity and mortality, thoracic endovascular repair (TEVAR) is becoming more popular for uncomplicated type B aortic dissection (TBAD). This study aimed to compare preemptive endovascular treatment and optimal medical treatment (OMT) and OMT alone in patients presenting uncomplicated TBAD with predictors of aortic progression.
DESIGN
Retrospective multicenter study.
METHODS
We analyzed patients with uncomplicated TBAD and risk factors of progression in two French academic centers. Aortic events [defined as aortic-related (re)intervention or aortic-related death after initial hospitalization], postoperative complications, non-aortic events, and radiologic aortic progression and remodeling were recorded and analyzed. Analysis was performed on an intention-to-treat basis.
RESULTS
Between 2011 and 2021, preemptive endovascular procedures at the acute and early subacute phase (<30 days) were performed on 24 patients (group 1) and OMT alone on 26 patients (group 2). With a mean follow-up of 38.08 ± 24.53 months, aortic events occurred in 20.83% of patients from group 1 and 61.54% of patients from group 2 ( < .001). No patient presented aortic-related death during follow-up. There were no differences in postoperative events ( = 1.00) and non-aortic events ( = 1.00). OMT patients had significantly more aneurysmal progression of the thoracic aorta ( < .001) and maximal aortic diameter ( < .001). Aortic remodeling was found in 91.67% of patients in group 1 and 42.31% of patients in group 2 ( < .001). A subgroup analysis of patients in group 1 showed that patients treated with preemptive TEVAR and STABILISE had reduced maximum aortic diameters at the 1-year ( = .010) and last follow-up ( = .030) compared to those in patients treated with preemptive TEVAR alone.
CONCLUSION
Preemptive treatment of uncomplicated TBAD with risk factors of progression reduces the risk of long-term aortic events. Over 60% of medically treated patients will require intervention during follow-up, with no benefit in terms of postoperative events. Even after surgical treatment, patients in the OMT group had significantly more aneurysmal progression, along with poorer aortic remodeling.
PubMed: 38737713
DOI: 10.3389/fcvm.2024.1362576 -
Scientific Reports May 2024The age, creatinine, and ejection fraction (ACEF) score has been accepted as a predictor of poor outcome in elective operations. This study aimed to investigate the...
The age, creatinine, and ejection fraction (ACEF) score has been accepted as a predictor of poor outcome in elective operations. This study aimed to investigate the predictive value of ACEF score in acute type A aortic dissection (AAAD) patients after total arch replacement. A total of 227 AAAD patients from July 2021 and June 2022 were enrolled and divided into Tertiles 1 (ACEF ≤ 0.73), Tertiles 2 (0.73 < ACEF ≤ 0.95), and Tertiles 3 (ACEF > 0.95). Using inverse probability processing weighting (IPTW) to balance the baseline characteristics and compare the outcomes. Cox logistic regression was used to further evaluate the survival prediction ability of ACEF score. The in-hospital mortality was 9.8%. After IPTW, in the baseline characteristics reached an equilibrium, a higher ACEF score before operation still associated with higher in-hospital mortality. After 1 year follow-up, 184 patients (90.6%) survival. Multivariable analysis revealed that ACEF score (adjusted hazard ratio 1.68; 95% confidence interval 1.34-4.91; p = 0.036) and binary ACEF score (adjusted HR 2.26; 95% CI 1.82-6.20; p < 0.001) was independently associated with 1-year survival. In addition, net reclassification improvement (NRI) and integrated differentiation improvement (IDI) verified that the ACEF score and binary ACEF score is an accurate predictive tool in clinical settings. In conclusions, ACEF score could be considered as a useful tool to risk stratification in patients with AAAD before operation in daily clinical work.
Topics: Humans; Female; Male; Aortic Dissection; Middle Aged; Creatinine; Hospital Mortality; Aged; Stroke Volume; Age Factors; Prognosis; Predictive Value of Tests; Aorta, Thoracic; Retrospective Studies; Aortic Aneurysm, Thoracic
PubMed: 38734750
DOI: 10.1038/s41598-024-58608-4 -
Canadian Association of Radiologists... May 2024The Canadian Association of Radiologists (CAR) Cardiovascular Expert Panel is made up of physicians from the disciplines of radiology, cardiology, and emergency...
The Canadian Association of Radiologists (CAR) Cardiovascular Expert Panel is made up of physicians from the disciplines of radiology, cardiology, and emergency medicine, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 30 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 48 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 125 recommendation statements across the 30 scenarios (27 unique scenarios as 2 scenarios point to the CAR Thoracic Diagnostic Imaging Referral Guideline and the acute pericarditis subscenario is included under 2 main scenarios). This guideline presents the methods of development and the referral recommendations for acute chest pain syndromes, chronic chest pain, cardiovascular screening and risk stratification, pericardial syndromes, intracardiac/pericardial mass, suspected valvular disease cardiomyopathy, aorta, venous thrombosis, and peripheral vascular disease.
PubMed: 38733286
DOI: 10.1177/08465371241246425 -
Diagnostics (Basel, Switzerland) Apr 2024Reduced iodine loads for computed tomography (CT)-based vascular assessment prior to transcatheter aortic valve implantation (TAVI) may be feasible in conjunction with a...
Reduced iodine loads for computed tomography (CT)-based vascular assessment prior to transcatheter aortic valve implantation (TAVI) may be feasible in conjunction with a spectral detector CT scanner. This prospective single-center study considered 100 consecutive patients clinically referred for pre-TAVI CT. They were examined on a dual-layer detector CT scanner to obtain an ECG-gated cardiac scan and a non-ECG-gated aortoiliofemoral scan. Either a standard contrast media (SCM) protocol using 80 mL Iohexol 350 mgI/mL (iodine load: 28 gI) or a body-mass-index adjusted reduced contrast media (RCM) protocol using 40-70 mL Iohexol 350 mgI/mL (iodine load: 14-24.5 gI) were employed. Conventional images and virtual monoenergetic images at 40-80 keV were reconstructed. A threshold of 250 HU was set for sufficient attenuation along the arterial access pathway. A qualitative assessment used a five-point Likert scale. Sufficient attenuation in the thoracic aorta was observed for all patients in both groups using conventional images. In the abdominal, iliac, and femoral segments, sufficient attenuation was observed for the majority of patients when using virtual monoenergetic images (SCM: 96-100% of patients, RCM: 88-94%) without statistical difference between both groups. Segments with attenuation measurements below the threshold remained qualitatively assessable as well. Likert scores were 'excellent' for virtual monoenergetic images 50 keV and 55 keV in both groups (RCM: 1.2-1.4, SCM: 1.2-1.3). With diagnostic image quality maintained, it can be concluded that reduced iodine loads of 14-24.5 gI are feasible for pre-TAVI vascular assessment on a spectral detector CT scanner.
PubMed: 38732294
DOI: 10.3390/diagnostics14090879 -
Diagnostics (Basel, Switzerland) Apr 2024This study evaluated a deep neural network (DNN) algorithm for automated aortic diameter quantification and aortic dissection detection in chest computed tomography...
This study evaluated a deep neural network (DNN) algorithm for automated aortic diameter quantification and aortic dissection detection in chest computed tomography (CT). A total of 100 patients (median age: 67.0 [interquartile range 55.3/73.0] years; 60.0% male) with aortic aneurysm who underwent non-enhanced and contrast-enhanced electrocardiogram-gated chest CT were evaluated. All the DNN measurements were compared to manual assessment, overall and between the following subgroups: (1) ascending (AA) vs. descending aorta (DA); (2) non-obese vs. obese; (3) without vs. with aortic repair; (4) without vs. with aortic dissection. Furthermore, the presence of aortic dissection was determined (yes/no decision). The automated and manual diameters differed significantly ( < 0.05) but showed excellent correlation and agreement (r = 0.89; ICC = 0.94). The automated and manual values were similar in the AA group but significantly different in the DA group ( < 0.05), similar in obese but significantly different in non-obese patients ( < 0.05) and similar in patients without aortic repair or dissection but significantly different in cases with such pathological conditions ( < 0.05). However, in all the subgroups, the automated diameters showed strong correlation and agreement with the manual values (r > 0.84; ICC > 0.9). The accuracy, sensitivity and specificity of DNN-based aortic dissection detection were 92.1%, 88.1% and 95.7%, respectively. This DNN-based algorithm enabled accurate quantification of the largest aortic diameter and detection of aortic dissection in a heterogenous patient population with various aortic pathologies. This has the potential to enhance radiologists' efficiency in clinical practice.
PubMed: 38732280
DOI: 10.3390/diagnostics14090866 -
Journal of Clinical Medicine Apr 2024The treatment of DeBakey type I aortic dissection remains a major challenge in the field of aortic surgery. To upgrade the standard of care hemiarch replacement, a novel... (Review)
Review
The treatment of DeBakey type I aortic dissection remains a major challenge in the field of aortic surgery. To upgrade the standard of care hemiarch replacement, a novel device called an "Ascyrus Medical Dissection Stent" (AMDS) is now available. This hybrid device composed of a proximal polytetrafluoroethylene cuff and a distal non-covered nitinol stent is inserted into the aortic arch and the descending thoracic aorta during hypothermic circulatory arrest in addition to hemiarch replacement. Due to its specific design, it may result in a reduced risk for distal anastomotic new entries, the effective restoration of branch vessel malperfusion and positive aortic remodeling. In this narrative review, we provide an overview about the indications and the technical use of the AMDS. Additionally, we summarize the current available literature and discuss potential pitfalls in the application of the AMDS regarding device failure and aortic re-intervention.
PubMed: 38731123
DOI: 10.3390/jcm13092593