Diagnosis Of Aortic Dissection Research Articles

Incidence and Outcome of Acute Myocardial Infarction in Patients With Aortic Dissection and Risk Factor Control.

Background and Aims: The contradiction of management modality between acute myocardial infarction(AMI) and aortic dissection(AD) may result in clinical catastrophe. Data on risk factors, incidence, and outcome of AD and AMI are limited, and there have been no studies on the long-term outcomes of AMI in patients with AD. So we aimed to investigate long-term outcomes after AMI in patients with AD, and propose a useful diagnostic paradigm.Methods: Consecutively enrolled patients with AD and AMI who were referred to our center from 2010 to 2017. Baseline patient characteristics, risk factors, all medical treatments, echocardiographic parameters, laboratory data, and treatment were recorded. All patients were followed up from the first hospitalization until a first heart event, death, or 17 March, 2018.Results: 0.13% in AMI and 7.49% in AD patients had a concomitant diagnosis of AD and AMI. The average patient age was 53.3 ± 12.1 years and 84.6% were male. The most prevalent vascular risk factors were hypertension (69.2%) and current smoker (64.1%). Of all the 39 patients, 66.7% were managed surgically. Overall in-hospital mortality was 10.3%. The 30-day and 5-year fatality rates were 23.1% and 35.9%, but were higher for female than for male (66.7 vs. 30.3%, log-rank P = 0.045) on 5-year mortality. The overall survival of females was inferior to the males (log-rank P = 0.045).Conclusions: Patients with AMI and AD exhibit high 5-year fatality rates. For these patients, surgical management tends to have lower mortality. Improved management of hypertension and smoking, may reduce future incidence rates.

Why the aortic dissection detection risk score is problematic in emergency departments

Acute aortic syndromes, including aortic dissection (AD), are rare. The AD detection risk score (ADDRS) and associated investigation pathway were developed to reduce missed diagnosis of AD. The methodology for its development was sub-optimal and it has not been robustly validated in the emergency department chest pain population. Recent research suggests that it will drive over-investigation and that the risks of missed diagnosis may not be in balance with the risks of the testing strategy. There are serious doubts about whether the score and investigation pathway are fit for purpose.

The potential value of the neutrophil to lymphocyte ratio for early differential diagnosis and prognosis assessment in patients with aortic dissection

ObjectivesThe aim of the study was to assess the diagnostic performance and clinical utility of the neutrophil to lymphocyte ratio (NLR) in patients with suspected aortic dissection (AD) and investigate its role in predicting in-hospital mortality in AD. MethodsNLR values were calculated and compared in 467 consecutive patients with initially suspected AD. A receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used to evaluate the discriminative accuracy and predictive capability of the NLR for AD. Clinical utility was determined by decision curve analysis (DCA). The association between NLR and in-hospital mortality was investigated by logistic regression analyses in patients diagnosed with AD. ResultsThe NLR was significantly elevated in patients with AD, and the optimal cut-off point for the NLR to distinguish AD from other acute chest pain diseases was 5.67 [AUC (95% CI): 0.877 (0.844–0.905)]. We recommended an NLR of 2.43 as the appropriate cut-off point with 96.9% sensitivity and a negative likelihood ratio (LR) of 0.09 to satisfy clinical requirements for diagnosis. DCA showed that the use of NLR had a positive net benefit. The deceased patients with AD had a higher NLR than the discharged patients. Moreover, the NLR was an independent predictor of in-hospital mortality for AD [adjusted odds ratio (OR): 1.084 (1.029–1.142)], and patients with higher NLR values tended to have a higher risk of in-hospital mortality. The optimal cut-off point for the NLR to predict in-hospital mortality was 9.20 [AUC (95% CI): 0.695 (0.619–0.765)]. ConclusionsAs an easily available and inexpensive parameter, the NLR could serve as a valuable clinical biomarker for early differential diagnosis and prognosis assessment of AD.

Expression and role of lumican in acute aortic dissection: A human and mouse study.

Aortic dissection (AD) is a life-threatening emergency, and lumican (LUM) is a potential Biomarker for AD diagnosis. We investigated LUM expression patterns in patients with AD and explored the molecular functions of Lum in AD mice model. LUM expression patterns were analyzed using aortic tissues of AD patients, and serum soluble LUM (s-LUM) levels were compared between patients with acute AD (AAD) and chronic AD (CAD). Lum-knockout (Lum-/-) mice were challenged with β-aminopropionitrile (BAPN) and angiotensin II (Ang II) to induce AD. The survival rate, AD incidence, and aortic aneurysm (AA) in these mice were compared with those in BAPN-Ang II-challenged wildtype (WT) mice. Tgf-β/Smad2, Mmps, Lum, and Nox expression patterns were examined. LUM expression was detected in the intima and media of the ascending aorta in patients with AAD. Serum s-LUM levels were significantly higher in patients with AAD than CAD. Furthermore, AD-associated mortality and thoracic aortic rupture incidence were significantly higher in the Lum-/- AD mice than in the WT AD mice. However, no significant pathologic changes in AA were observed in the Lum-/- AD mice compared with the WT AD mice. The BAPN-Ang II-challenged WT and Lum-/- AD mice had higher Tgf-β, p-Smad2, Mmp2, Mmp9, and Nox4 levels than those of non-AD mice. We also found that Lum expression was significantly higher in the BAPN-Ang II-challenged WT in comparison to the unchallenged WT mice. LUM expression was altered in patients with AD display increased s-LUM in blood, and Lum-/- mice exhibited augmented AD pathogenesis. These findings support the notion that LUM is a biomarker signifying the pathogenesis of injured aorta seen in AAD. The presence of LUM is essential for maintenance of connective tissue integrity. Future studies should elucidate the mechanisms underlying LUM association in aortic changes.

The diagnostic value of a non-contrast computed tomography scan-based radiomics model for acute aortic dissection.

To investigate the diagnostic value of a computed tomography (CT) scan-based radiomics model for acute aortic dissection.For the dissection group, we retrospectively selected 50 patients clinically diagnosed with acute aortic dissection between October 2018 and November 2019, for whom non-contrast CT and CT angiography images were available. Fifty individuals with available non-contrast CT and CT angiography images for other causes were selected for inclusion in the non-dissection group. Based on the aortic dissection locations on the CT angiography images, we marked the corresponding regions-of-interest on the non-contrast CT images of both groups. We collected 1203 characteristic parameters from these regions by extracting radiomics features. Subsequently, we used a random number table to include 70 individuals in the training group and 30 in the validation group. Finally, we used the Lasso regression for dimension reduction and predictive model construction. The diagnostic performance of the model was evaluated by a receiver operating characteristic (ROC) curve.Fourteen characteristic parameters with non-zero coefficients were selected after dimension reduction. The accuracy, sensitivity, specificity, and area under the ROC curve of the prediction model for the training group were 94.3% (66/70), 91.2% (31/34), 97.2% (35/36), and 0.988 (95% confidence interval [CI]: 0.970–0.998), respectively. The respective values for the validation group were 90.0% (27/30), 94.1% (16/17), 84.6% (11/13), and 0.952 (95% CI: 0.883–0.986).Our non-contrast CT scan-based radiomics model accurately facilitated acute aortic dissection diagnosis.

Murmurs other than the early diastolic murmur in aortic dissection.

The purpose of this review is to draw attention to the presence and significance of murmurs other than the murmur of aortic regurgitation, in patients with aortic dissection. For that purpose, a literature search was conducted using Pubmed and Googlescholar. The search terms were "dissecting aneurysm of the aorta", "systolic murmurs", "ejection systolic murmurs", "holosystolic" murmurs, "continuous murmurs", and "Austin-Flint" murmur. Murmurs other than the murmur of aortic regurgitation, which were associated with aortic dissection, fell into the categories of systolic murmurs, some of which were holosystolic, and continuous murmurs, the latter attributable to fistulae between the dissecting aneurysm and the left atrium, right atrium, and the pulmonary artery, respectively. Mid-diastolic murmurs were also identified, and these typically occurred in association with both the systolic and the early diastolic murmurs. Among patients with systolic murmurs clinical features which enhanced the pre-test probability of aortic dissection included back pain, stroke, paraplegia, unilateral absence of pulses, interarm differences in blood pressure, hypertension, shock, bicuspid aortic valve, aortic coarctation, Turner's syndrome, and high D-dimer levels, respectively. In the absence of the murmur of aortic regurgitation timely diagnosis of aortic dissection could be expedited by increased attention to parameters which enhance pretest probability of aortic dissection. That logic would apply even if the only murmurs which were elicited were systolic murmurs.

Nomogram to differentiate between aortic dissection and non-ST segment elevation acute coronary syndrome: a retrospective cohort study.

Aortic dissection (AD) and non-ST segment elevation acute coronary syndrome (ACS) are two of the most life-threatening diseases encountered in the emergency department (ED), but there are no rapid and reliable tools for differentiation. The purpose of this study is to develop and validate a nomogram that incorporates both the clinical characteristics and bedside laboratory tests available to differentiate between AD and non-ST segment elevation ACS (NSTE-ACS). Between January 2016 and July 2018, patients with AD and NSTE-ACS were enrolled and divided into training and validation groups. The least absolute shrinkage and selection operator (LASSO) regression model was used to select the factors with significant value of predicting the diagnosis of AD. A nomogram was built on the basis of multivariable logistic regression analysis. Area under the curve (AUC) of receiver operating characteristic (ROC) curve and the calibration curve were used to assess the performance of the nomogram. Decision curve analysis was performed to assess the clinical utility of the nomogram. A final cohort of 263 patients (94 patients with AD and 169 patients with NSTE-ACS) were enrolled. Six variables were incorporated in the nomogram: pain severity, tearing pain, pulse asymmetry, electrocardiogram (ECG), D-dimer level and troponin I level. The AUC of the nomogram to predict the probability of AD was 0.919 (95% CI, 0.876-0.962) in the training group and 0.938 (95% CI, 0.888-0.989) in the validation group. The calibration curve demonstrated a good consistency between the actual clinical results and the predicted outcomes. The decision curve analysis indicated that the nomogram had higher overall net benefits in predicting AD in both the training group and the validation group. We developed and validated a predictive nomogram that could be used as a tool to differentiate AD from NSTE-ACS rapidly and accurately.

10-Year Trends in Aortic Dissection: Mortality and Weekend Effect within the US Nationwide Emergency Department Sample (NEDS).

This study examined changes in aortic dissection (AD) mortality from 2006 to 2017 and assessed the impact of weekday versus weekend presentation upon mortality. This observational study analyzed all records in the Nationwide Emergency Department Sample (NEDS) database. NEDS aggregates discharge data from 984 hospitals in 36 states and the District of Columbia in the United States of America. All patients with thoracic and thoracoabdominal AD recorded as their principal diagnosis were identified via ICD codes. Patient characteristics (weekday|weekend) count: 26,759|9,640, P = 0.016; age (years): 65.2 ± 15.8|64.7 ± 16.2, P = 0.016; women: 11,318 (42.3%)|4,086 (42.4), P = 0.883; Charlson comorbidity index: 2.3 ± 1.7|2.3 ± 1.6, P = 0.025. There were 36,399 ED visits with diagnosed AD. Annual AD diagnoses increased by 70% from 2006 to 2017. From 2012-2017, patients had lower in-hospital mortality (9.9% versus 11.9%, P < 0.001) compared with 2006-2011. Patients reporting during the weekend had higher in-hospital mortality (11.8% versus 10.4%, P < 0.001) compared with weekdays. On multivariable analysis, year of presentation remained independently associated with in-hospital mortality, with 2012-2017 being associated with reduced mortality (odds ratio (OR) 0.90, 95% CI: 0.82, 0.99, P = 0.031), as compared with 2006-2011. Weekend presentation remained independently associated with worse in-hospital mortality (OR 1.17, 95% CI: 1.05, 1.29, P = 0.003) compared with weekday presentation. Although AD mortality is decreasing, the patients presenting on the weekend were 13% more likely to die in the hospital compared with patients presenting during the week.

Left Ventricular Concentric Geometric Patterns Are Associated With Worse Prognosis Among Patients With Type-A Aortic Dissection.

BackgroundThis study compared left ventricular (LV) characteristics between patients with type‐A and type‐B aortic dissection (AD) and evaluated the ability of LV remodeling phenotypes (hypertrophy, concentricity, or geometric patterns) to predict mortality in both AD types.Methods and ResultsWe evaluated 236 patients with type A and 120 patients with type B who had echocardiograms within 60 days before or after AD diagnosis (median [25th, 75th percentiles] time difference between echocardiogram and AD diagnosis=1 [0, 6] days) from 3 centers. Patients were stratified according to LV phenotypes, and early (90‐day) and late (1‐year) mortality after AD diagnosis were assessed. In adjusted logistic regression analysis, patients with type A had higher and lower odds of concentric and eccentric hypertrophy (odds ratio [OR], 2.56; 95% CI, 1.50–4.36; P<0.001; and OR, 0.55; 95% CI, 0.31–0.97; P=0.039, respectively) than those with type B. Results of multivariable Cox‐regression analysis showed that LV remodeling phenotypes were not related to mortality in patients with type B. By contrast, LV concentricity was associated with greater early and late mortality (hazard ratio [HR], 2.22; 95% CI, 1.24–3.96; P=0.007 and HR, 2.06; 95% CI, 1.20–3.54; P=0.009, respectively) in type A. In further analysis considering normal LV geometry as reference, LV concentric remodeling and concentric hypertrophy were associated with early mortality (HR, 7.78; 95% CI, 2.35–25.78; P<0.001 and HR, 4.38; 95% CI, 1.47–13.11; P=0.008, respectively), whereas concentric remodeling was associated with late mortality (HR, 5.40; 95% CI, 1.91–15.26; P<0.001) among patients with type A. Assessment of LV geometric patterns and concentricity provided incremental prognostic value in predicting early and late mortality beyond clinical variables in patients with type A based on net reclassification improvement and integrated discrimination improvement.ConclusionsLV geometric patterns derived from LV concentricity were associated with greater mortality among patients with type A and may be markers of adverse prognosis in this population.

Marijuana: An Underappreciated Risk Factor for Acute Type A Aortic Dissection?

Stimulants such as cocaine and amphetamines are well-established risk factors for acute aortic dissection. Despite the fact that marijuana is the most commonly used illicit drug in the United States, its relationship to acute aortic syndromes has not been well studied. A comprehensive retrospective review was undertaken of all consecutive patients who presented with acute Stanford type A aortic dissection from January 2017 to December 2019. Of 152 patients identified, 51 (33.6%) underwent comprehensive urine toxicology screening at clinical presentation. The characteristics and outcomes of the patients with urine results positive for tetrahydrocannabinol (THC) (n = 9, 17.6%) were compared with the 42 patients who had no evidence of recent marijuana consumption. Of the 51 dissection patients who underwent broad-spectrum urine toxicology screening upon presentation, 9 (17.6%) returned positive results for THC, a proportion higher than would be expected for the general population. All THC patients were male; 3 concurrently tested positive for cocaine, and 3 others had evidence of recent amphetamine use. The THC patients were significantly younger than the non-THC patients (mean ± standard deviation age 48 ± 11.3 versus 61.4 ± 12.3 years, respectively, P = .004). A greater proportion of the THC cohort had a known diagnosis of aortic aneurysm before the dissection (44.4% versus 4.8%, P = .006). All patients underwent expeditious surgical repair. Thirty-day mortality for the entire cohort of 51 patients was 19.6% (10 deaths); for the THC group, it was 11.1% (1 death). There was no difference in the incidence of major postoperative complications between the 2 groups. Marijuana is the third most commonly used substance in the United States, after alcohol and tobacco. Although marijuana use is understudied, our results suggest that marijuana may be a contributing risk factor for acute type A aortic dissection, particularly in patients with other predisposing risk factors. Given the recent national trend to legalize marijuana, with the concomitant potential for exponential increases in its consumption, we suggest that the diagnosis of aortic dissection be considered earlier in any younger patient who presents with suggestive symptoms, especially if there is a history of recent marijuana use.

Long-term fate of aortic branches in patients with aortic dissection

ObjectiveLate morbidity and mortality related to aortic branches in patients with aortic dissection (AD) have not been well described. We investigated the fate of aortic branches in a population cohort of patients with newly diagnosed AD. MethodsWe used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, Minnesota, residents with a diagnosis of AD from 1995 to 2015. Only patients with >30 days of available follow-up imaging studies were included in the present analysis. The primary outcome was freedom from any branch-related event (any intervention, aneurysm, malperfusion, rupture, or death occurring after the acute phase >14 days). The secondary outcome was the diameter change in the aortic branches. Univariate and multivariable Cox proportional hazards models were used to identify the predictors of branch-related events. Univariate and multivariate linear regression models were used to assess the aortic branch growth rate. ResultsOf 77 total incident AD cases, 58 patients who had survived and had imaging follow-up studies available were included, 28 (48%) with type A and 30 (52%) with type B AD. The presentation was acute in 39 patients (67%), 6 (10%) of whom had had branch malperfusion. Of 177 aortic branches involved by the AD, 81 (46%) had arisen from the true lumen, 33 (19%) from the false lumen, and 63 (36%) from both. After the acute phase, freedom from any branch-related event at 15 years was 48% (95% confidence interval [CI], 32%-70%). A total of 31 branch-related events had occurred in 19 patients within 15 years, including 12 interventions (76% freedom; 95% CI, 63%-92%), 10 aneurysms (67% freedom; 95% CI, 50%-90%), 8 cases of malperfusion (76% freedom; 95% CI, 61%-94%), and 1 rupture (94% freedom; 95% CI, 84%-100%). No branch-related deaths had occurred. Type B AD (hazard ratio [HR], 3.5; 95% CI, 1.1-10.8; P = .033), patency of the aortic false lumen (HR, 6.8; 95% CI, 1.1-42.2; P = .038), and malperfusion syndrome at presentation (HR, 6.0; 95% CI, 1.3-28.6; P = .023) were predictors of late aortic branch-related events. The overall growth rate of aortic branches was 1.3 ± 3.0 mm annually. Patency of the aortic false lumen, initial branch diameter, and Marfan syndrome were significantly associated with diameter increase. ConclusionsIn patients with AD, aortic branch involvement was responsible for significant long-term morbidity, without any related mortality. Type B AD, patency of the aortic false lumen, and malperfusion syndrome at presentation resulted in a greater risk of branch events during the long-term follow-up. Dilatation of the aortic branches was observed in one third of cases during follow-up, especially in the case of a patent aortic false lumen or the presence of Marfan syndrome.

The Application of Computed Tomography Angiography in Aortic Dissection

Aortic dissection (AD) is a life-threatening clinical emergency requiring rapid diagnosis and effective intervention to improve patient survival and prognosis. Computed tomography angiography (CTA) can be used to diagnose AD accurately and quickly, making it the first choice for diagnosing AD in an emergency. This article reviews the application of CTA in the diagnosis and treatment of AD.

The Combination of Biomarkers of Iron Metabolism With UA, eGFR, HDL and LDL Can Serve as a Comprehensive Indicator for the Differential Diagnosis of Aortic Dissection and Coronary Artery Disease

Background: The misdiagnosis of aortic dissection (AD) can lead to a catastrophic prognosis. There is currently a lack of stable serological indicators with excellent efficacy for the differential diagnosis of AD and coronary artery disease (CAD). Recent study has shown association between AD and iron metabolism. Thus, we investigated whether iron metabolism could discriminate AD from CAD. Methods: In this retrospective and multicenter cross-sectional study that investigated the efficacy of biomarkers of iron metabolism for the differential diagnosis of AD. We collected biomarkers of iron metabolism, liver function, kidney function and other biochemistry test and further Logistic regression analysis was applied. Findings: Between Oct. 8, 2020, to Mar. 1, 2021, we recruited 521 patients diagnosed with AD, CAD, and other cardiovascular diseases (OCDs) with the main symptoms of chest and back pain and assigned them to discovery set (n = 330) or validation set (n = 191). We found that six serum biomarkers, serum iron, low-density lipoprotein, uric acid, transferrin, high-density lipoprotein and estimated glomerular filtration rate, can serve as a novel comprehensive indicator (named FLUTHE) for the differential diagnosis of AD and CAD with sensitivity up to 95.4% and specificity 90.5% to differentially diagnose AD and CAD more than 72 hours past symptom onset. Interpretation: Iron metabolism showed great relationship with aortic dissection. Results suggest the novel combination, FLUTHE, was an ideal indicator in diagnosing AD especially when time from symptom onset was over 72 hours. Funding Information: The National Natural Science Foundation of China (NO. 82070488 and NO. 82000440). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The study was approved by the Ethics Review Board of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology.

Is Computed Tomography the Gold Standard in Aortic Dissection?

İntroduction:&#x0D; Aortic dissection is a disease with high mortality, which is characterized by a tear in the aortic wall. Thanks to early diagnosis and treatment, patients' survival rates are high. Chest pain is the most common symptom. Imaging methods help in diagnosis. Its treatment is surgery.&#x0D; Case report:&#x0D; A 47-year-old male patient was admitted to the emergency department with chest pain. The diagnosis of aortic dissection in computed tomography was evaluated as motion artifact and valve motion, and he was asked to be discharged from the emergency service after his diagnosis was missed. However, transesophageal echocardiography was performed because of the patient's clinical symptom and echocardiographic findings supported the aortic dissection. When a dissection flap was seen in transesophageal echocardiography, the patient was transferred to surgery. In surgery, a dacron graft was placed in the patient's aorta and a prosthetic valve was placed on the aortic valve, and left main coronary repair and right coronary is bypass were performed. The patient was discharged without any problem. &#x0D; Conclusion: &#x0D; Aortic dissection is a clinical diagnosis, it is a disease with high mortality. Imaging methods are helpful in diagnosis, but the fact that imaging methods rule out dissection does not always rule out the disease. The important thing is to suspect the disease and to consider the patient's current clinical symptoms and signs.

A death due to acute aortic dissection

Acute aortic syndrome (AAS) is a term used to describe a collection of life-threatening aortic disease conditions that have similar presentations, but differ in their demographic, pathological, clinical and other characteristics. The exact number of deaths due to AAS is unknown. However studies suggest that the majority of deaths in AAS are due to acute aortic dissection. A 51-year-old male developed sudden onset chest pain while he was taking a bath in the evening. It was a sharp, tearing type chest pain, which was radiating to the left side of his neck. On admission to hospital his low blood pressure was found to be low. He suffered cardiac arrest a few minutes later and died without regaining consciousness. Post-mortem examination revealed a massive haemopericardium (600 ml). Aortic dissection was identified extending from the aortic root to the lower part of the descending abdominal aorta. The thickest point of the dissection was 1.5 cm. There was an intimal tear inferiorly. The dissection extended through the aortic arch to the descending aorta ending 1 cm above the renal artery branching point. Sections of the aorta showed cystic medial degeneration with prominent pools of mucin. Mild atheroma was seen in some sections. The presence of aortic dissection was confirmed. The cause of death was given as haemopericardium due to ruptured aortic dissection. Acute aortic dissection may mimic other cardiovascular conditions, especially ischemic cardiac events. Therefore, the clinical suspicion and a comprehensive history-taking are the key for an early diagnosis. Careful dissection of the aorta and its branches is essential when making a post-mortem diagnosis of aortic dissection. Proper histopathology examination of the aorta assisted immensely in confirming the diagnosis.

Clinical Features and Outcomes of Pregnancy-Related Acute Aortic Dissection

Women with aortopathy conditions are at risk for pregnancy-related aortic dissection, and these conditions may not be recognized until after the aortic dissection occurs. To examine the clinical characteristics, imaging features, and outcomes in women with pregnancy-related acute aortic dissection. A cohort study, comprising data from the International Registry of Acute Aortic Dissection (IRAD) (February 1, 1998, to February 28, 2018). The multicenter referral center study included 29 women with aortic dissection during pregnancy or less than 12 weeks post partum in IRAD from 1998 to 2018. Clinical features of pregnancy-related aortic dissection to be studied included underlying aortopathy, aortic size, type of aortic dissection, timing of dissection, hypertension, and previous aortic surgery. A total of 29 women (mean [SD] age, 32 [6] years) had pregnancy-related aortic dissection, representing 0.3% of all aortic dissections and 1% of aortic dissection in women in the IRAD. Among women younger than 35 years, aortic dissection was related to pregnancy in 20 of 105 women (19%). Thirteen women (45%) had type A aortic dissection, and 16 women (55%) had type B. Aortic dissection onset was known in 27 women (93%): 15 during pregnancy, 4 in the first trimester, and 11 in the third trimester; 12 were post partum, occurring a mean (SD) of 12.5 (14) days post partum. At type A aortic dissection diagnosis, the mean (SD) aortic diameters were sinus of Valsalva, 54.5 (5) mm and ascending aorta, 54.7 (6) mm. At type B aortic dissection diagnosis, the mean (SD) descending aortic diameter was 32.5 (5) mm. Twenty women (69%) had an aortopathy condition or a positive family history: 13 women (65%) with Marfan syndrome, 2 women (10%) with Loeys-Dietz syndrome, 2 women (10%) with bicuspid aortic valves, 2 women (10%) with a family history of aortic disease, and 1 woman (5%) with familial thoracic aortic aneurysm. Aortopathy was not recognized until after aortic dissection in 47% of the women. Twenty-eight women (97%) survived aortic dissection hospitalization. Aortic dissection complicating pregnancy is rare. Most pregnancy-related aortic dissection is due to an aortopathy often not diagnosed until after aortic dissection. In this study, type A aortic dissections were associated with a dilated aorta, and type B aortic dissections often were not. Recognition of underlying conditions and risks for aortic dissection may improve management of pregnancy in women with aortopathy.

Malpractice perspective in cases of death due to aortic aneurysm because of misdiagnosis

While Cardiovascular System Diseases constitute a large part in sudden unexpected suspicious deaths, acute aortic dissection (AAD) is the most common pathology in sudden death among aortic diseases. True diagnosis is the best strategy to avoid malpractice. The diagnosis of aortic dissection remains clinically challenging and the outcomes from this disease are often fatal. For this reason, it was aimed to emphasize to 3 cases that were autopsyed by us, applied to health institutions with different symptoms, and the cause of death, bypassing the Acute Aortic Dissection, which died as a result of misdiagnosis and treatment, AAD can be difficult to recognize, diagnosis is therefore sometimes delayed or missed. Physicians who didn’t think that probability in their differential diagnosis will be always accused about malpractice.

Incidence and natural history of isolated abdominal aortic dissection: A population-based assessment from 1995 to 2015

BackgroundIsolated abdominal dissection (IAD) is an uncommon clinical problem that is less well-understood than thoracic aortic dissection (AD). We performed a population-based assessment of the incidence, natural history, and treatment outcomes of IAD to better characterize this disease. MethodsWe used the Rochester Epidemiology Project to identify all Olmsted County, MN residents with a diagnosis of AD, intramural hematoma or penetrating ulcer (1995-2015). Diagnostic imaging of all patients was reviewed to confirm the diagnosis of IAD for inclusion. Presentation, treatment, and outcomes were reviewed. Survival of IAD patients was compared to age- and sex-matched population controls 3:1. ResultsOf 133 residents with aortic syndrome (AD, intramural hematoma, or penetrating ulcer), 23 were initially diagnosed with IAD. Nine were reclassified as having a penetrating aortic ulcer and were excluded, leaving 14 patients for review (10 male [71%]; mean age, 71 years). Three patients (21%) were symptomatic (abdominal pain, back pain, hypertension) and none had malperfusion or rupture. Prior aortic dilatation was present in eight patients (57%) and Marfan syndrome in one (7%). Two patients (14%) had iatrogenic IAD. Initial management was medical in 13 and endovascular aneurysm repair in one (symptomatic subacute, infrarenal dissection with small aneurysm). The median clinical and imaging follow-up was 6.7 years (range, 0-17 years). An abdominal aortic aneurysm occurred in eight (six at the time of IAD diagnosis, one at 2.9 years, and one at 5.2 years after diagnosis). The average growth in the entire cohort was 0.9 ± 0.4 cm, which translated to an average growth rate of 0.09 cm/year. Subsequent intervention was performed in two patients; for severe aortic stenosis with claudication in one (infrarenal aortic stenting) and increasing aortic size in one (open repair). One patient required reintervention (thrombolysis and stenting for endovascular aneurysm repair limb thrombosis). Survival for IAD at 1, 3, and 5 years was 93%, 85%, and 76%, respectively, compared with population controls at 98%, 85%, and 71%, respectively (long rank P = .38). Mortality was due to cardiovascular causes in three patients (21%) and no deaths were aortic related. Major adverse cardiac events occurred in five patients (36%) owing to heart failure. ConclusionsIAD is rare. The initial management for asymptomatic patients is medical. The aortic growth rate is slow, with no aortic-related mortality and a low rate of aortic intervention. The overall mortality is similar to population controls. Heart failure and cardiac-related death are prevalent, suggesting that close cardiovascular care is needed in this patient population.

Burden and causes of readmissions following initial discharge after aortic syndromes

BackgroundAortic syndromes, including aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU), carry significant morbidity and mortality; few data exist regarding burden and causes of related rehospitalizations following initial discharge. MethodsThe study was conducted using the Rochester Epidemiology Project. All adult residents (age ≥18 years) with an incident diagnosis of AD, IMH, and PAU (1995-2015) were identified from the Rochester Epidemiology Project using the International Classification of Diseases, Ninth Revision and Tenth Revision codes and Hospital Adaptation of the International Classification of Diseases, second edition, codes. Assessment of any-cause (aortic and cardiovascular), aorta-related, or cardiovascular-related readmissions was determined following date of hospital discharge or diagnosis date (ie, the index event). ResultsA total of 117 patients of 130 cases of AD, IMH, and PAU included in the initial study population survived the index event and were evaluated. The median age of diagnosis was 74 years, and 70 (60%) were male. A total of 79 patients (68%) experienced at least one readmission. The median time to first any-cause, cardiovascular, and aortic readmission was 143, 861, and 171 days, respectively. The cumulative incidence of any-cause readmissions at 2, 4, and 10 years was 45%, 55%, and 69%, respectively. The cumulative incidence of cardiovascular readmissions at 2, 4, and 10 years was 15%, 20%, and 28%, respectively. The cumulative incidence of aortic readmissions at 2, 4, and 10 years was 38%, 46%, and 59%, respectively. Overall survival for the entire cohort at 2, 4, and 10 years was 84%, 75%, and 50%, respectively. ConclusionsReadmissions following initial discharge after diagnosis of aortic syndrome are common and not different across specific disease types. Whereas aorta-related rehospitalizations occur in more than half of patients but tend to be earlier, cardiovascular-related rehospitalizations tend to happen later in about one-third of patients. This may suggest the need for early follow-up focused on aortic complications, whereas later follow-up should address cardiovascular events.

Population-Based Assessment of Aortic-Related Outcomes in Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer

The aim of the study was to analyze aortic-related outcomes after diagnosis of aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) from a population-based approach. Retrospective review of an incident cohort of AD, IMH, and PAU patients in Olmsted County, Minnesota from 1995 to 2015. Primary end point was aortic death. Secondary end points were subsequent aortic events (aortic intervention, new dissection, or rupture not present at presentation) and first-time diagnosis of an aortic aneurysm. Outcomes were compared with randomly selected population referents matched for age and sex in a 3:1 ratio using Cox proportional hazards regression adjusting for comorbidities. Among 133 patients (77 AD, 21 IMH, and 35 PAU), 57% were males, and mean age was 71.8years (standard deviation, 14). Median follow-up was 10years. Of 73 deaths among AD/IMH/PAU patients, 23 (32%) were aortic-related. Estimated freedom from aortic death was 84%, 80%, and 77% at 5, 10, and 15years. There were no aortic deaths among population referents (adjusted hazard ratio [HR] for aortic death in AD/IMH/PAU, 184.7; 95% confidence interval [95% CI], 10.3-3,299.2; P<0.001). Fifty (38%) AD/IMH/PAU patients had a subsequent aortic event (aortic intervention, new dissection, or rupture), whereas there were 8 (2%) aortic events among population referents (all elective aneurysm repairs; adjusted HR for any aortic event and aortic intervention in AD/IMH/PAU patients, 33.3; 95% CI, 15.3-72.0; P<0.001 and 31.5; 95% CI, 14.5-68.4; P<0.001, respectively). After excluding aortic events/interventions ≤14days of diagnosis, AD/IMH/PAU patients remained at increased risk of any aortic event (adjusted HR, 10.8; 95% CI, 3.9-29.8; P<0.001) and aortic intervention (adjusted HR, 9.6; 95% CI, 3.4-26.8; P<0.001). Among those subjects with available follow-up imaging, the risk of first-time diagnosis of aortic aneurysm was significantly increased for AD/IMH/PAU patients when compared with population referents (adjusted HR, 10.9; 95% CI, 5.4-21.7; P<0.001 and 8.3; 95% CI, 4.1-16.7; P<0.001 for thoracic and abdominal aneurysms, respectively) and remained increased when excluding aneurysms that formed within 14days of AD/IMH/PAU (adjusted HR, 6.2; 95% CI, 1.8-21.1; P=0.004 and 2.8; 95% CI, 1.0-7.6; P=0.040 for thoracic and abdominal aneurysms, respectively). AD/IMH/PAU patients have a substantial risk of aortic death, any aortic event, aortic intervention, and first-time diagnosis of aortic aneurysm that persists even when the acute phase (≤14days after diagnosis) is uncomplicated. Advances in postdiagnosis treatment are necessary to improve the prognosis in these patients.