Smaller Aortic Size Research Articles

Post-mortem examination of fatal acute type A aortic dissection: what does it teach us?

Acute type A aortic dissection (ATAAD) remains a highly life-threatening condition. This study investigates factors associated with fatal ATAAD prior to surgical treatment. We reviewed autopsy reports of ATAAD decedents who died before surgical intervention and underwent postmortem examination at our clinic from 1994 to 2022. Among 94 eligible cases, 50 (53.2%) decedents had DeBakey type I dissection, and 44 (46.8%) had DeBakey type II dissection. Most were males, 63 (67%), and 72 (77%) had a history of hypertension. The median age was 70.5 years, and the type II group was a decade older than the type I group (P < 0.001). Decedents in the type II group predominantly died during the first hour after symptoms onset 16 (52%), while in the type I group, fatalities occurred between 1 h and 1 day, 27 (66%). The most common site of the intimal tear was the midportion of the ascending aorta, 45 (48%). The median ascending aorta size was 5 cm for the entire cohort, 5.2 cm for type I and 4.6 cm for type II (P < 0.045). In this autopsy study of fatal acute aortic dissection, the median aortic size was below the current guideline threshold for elective repair. Type II acute aortic dissections were found more frequently than expected and were characterized by older age, advanced aortic atherosclerosis, smaller aortic size, a shorter interval from symptom onset to death and a higher frequency of syncope compared to type I dissection.

Thoracic aortic aneurysm gene dictionary.

Thoracic aortic aneurysm is typically clinically silent, with a natural history of progressive enlargement until a potentially lethal complication such as rupture or dissection occurs. Underlying genetic predisposition strongly influences the risk of thoracic aortic aneurysm and dissection. Familial cases are more virulent, have a higher rate of aneurysm growth, and occur earlier in life. To date, over 30 genes have been associated with syndromic and non-syndromic thoracic aortic aneurysm and dissection. The causative genes and their specific variants help to predict the disease phenotype, including age at presentation, risk of dissection at small aortic sizes, and risk of other cardiovascular and systemic manifestations. This genetic "dictionary" is already a clinical reality, allowing us to personalize care based on specific causative mutations for a substantial proportion of these patients. Widespread genetic sequencing of thoracic aortic aneurysm and dissection patients has been and continues to be crucial to the rapid expansion of this dictionary and ultimately, the delivery of truly personalized care to every patient.

Infrarenal Aortic Neck Diameter Is Unaltered by Treatment With Doxycycline

Development of abdominal aortic aneurysms (AAAs) evolves through stages from normal aortic size to mild ectasia and further dilation to small aneurysm. This study analyzed the proximal aortic neck, which may be susceptible to pharmacologic modification by metalloproteinase inhibition (with doxycycline) at a smaller aortic size. In addition, endovascular aneurysm repair is dependent on stability of this aortic neck for sealing and fixation, which could be compromised by aortic dilation. This study compared neck diameter during 2 years in patients from the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA3CT; NCT01756833) based on the randomized study arm.

Natural history of descending thoracic and thoracoabdominal aortic aneurysms

ObjectivesElucidating critical aortic diameters at which natural complications (rupture, dissection, and death) occur is of paramount importance to guide timely surgical intervention. Natural history knowledge for descending thoracic and thoracoabdominal aortic aneurysms is sparse. Our small early studies recommended repairing descending thoracic and thoracoabdominal aortic aneurysms before a critical diameter of 7.0 cm. We focus exclusively on a large number of descending thoracic and thoracoabdominal aortic aneurysms followed over time, enabling a more detailed analysis with greater granularity across aortic sizes. MethodsAortic diameters and long-term complications of 907 patients with descending thoracic and thoracoabdominal aortic aneurysms were reviewed. Growth rates (instrumental variables approach), yearly complication rates, 5-year event-free survival (Kaplan–Meier), and risk of complications as a function of aortic height index (aortic diameter [centimeters]/height [meters]) (competing-risks regression) were calculated. ResultsEstimated mean growth rate of descending thoracic and thoracoabdominal aortic aneurysms was 0.19 cm/year, increasing with increasing aortic size. Median size at acute type B dissection was 4.1 cm. Some 80% of dissections occurred below 5 cm, whereas 93% of ruptures occurred above 5 cm. Descending thoracic and thoracoabdominal aortic aneurysm diameter 6 cm or greater was associated with a 19% yearly rate of rupture, dissection, or death. Five-year complication-free survival progressively decreased with increasing aortic height index. Hazard of complications showed a 6-fold increase at an aortic height index of 4.2 or greater compared with an aortic height index of 3.0 to 3.5 (P < .05). The probability of fatal complications (aortic rupture or death) increased sharply at 2 hinge points: 6.0 and 6.5 cm. ConclusionsAcute type B dissections occur frequently at small aortic sizes; thus, prophylactic size-based surgery may not afford a means for dissection protection. However, fatal complications increase dramatically at 6.0 cm, suggesting that preemptive intervention before that criterion can save lives.

Small infrarenal Aortic size - what does this imply?

While a relationship between large infrarenal aortic diameter and both cardiovascular disease (CVD) prevalence and all-cause mortality has been previously suggested, there is also evidence that small aortic size may also be associated with increased CVD risk. We examined a total of 4882 elderly (>50 years) participants (mean age 69.4) by duplex ultrasound to assess infrarenal abdominal aortic diameters and correlated these with each individual's history of CVDs, including ischaemic heart disease (IHD), and associated risk factors. CVD prevalence showed a U-shaped relationship with aortic size (figure) and was significantly elevated in the upper and lower 12.5% tails of the aortic size distributions. These associations remained significant following adjustment for age, sex, diabetes, hypertension, dyslipidemia, obesity (body mass index) and smoking. A sub-group of 1032 participants were prospectively followed for 5 years to determine subsequent major adverse cardiovascular events (MACE) or death. In this group, small aortic size showed a significant unadjusted association with increased risk of MACE, while large aortic size showed an unadjusted association with (all-cause) mortality.The largest and smallest body surface area adjusted infrarenal aortic sizes appear to have a bimodal association with the prevalence of ischaemic heart disease. Small aortic size may also be a prospective indicator of poor CVD-related outcomes. Assessment of infrarenal aortic size may not only identify those with aneurysmal disease but also improve global CVD-event risk prediction.Locally weighted smoothed scatterplot showing the relationship between infrarenal aortic size and history of cardiovascular disease. ASI = absolute aortic diameter(cm)/ body surface area (m2). While a relationship between large infrarenal aortic diameter and both cardiovascular disease (CVD) prevalence and all-cause mortality has been previously suggested, there is also evidence that small aortic size may also be associated with increased CVD risk. We examined a total of 4882 elderly (>50 years) participants (mean age 69.4) by duplex ultrasound to assess infrarenal abdominal aortic diameters and correlated these with each individual's history of CVDs, including ischaemic heart disease (IHD), and associated risk factors. CVD prevalence showed a U-shaped relationship with aortic size (figure) and was significantly elevated in the upper and lower 12.5% tails of the aortic size distributions. These associations remained significant following adjustment for age, sex, diabetes, hypertension, dyslipidemia, obesity (body mass index) and smoking. A sub-group of 1032 participants were prospectively followed for 5 years to determine subsequent major adverse cardiovascular events (MACE) or death. In this group, small aortic size showed a significant unadjusted association with increased risk of MACE, while large aortic size showed an unadjusted association with (all-cause) mortality. The largest and smallest body surface area adjusted infrarenal aortic sizes appear to have a bimodal association with the prevalence of ischaemic heart disease. Small aortic size may also be a prospective indicator of poor CVD-related outcomes. Assessment of infrarenal aortic size may not only identify those with aneurysmal disease but also improve global CVD-event risk prediction. Locally weighted smoothed scatterplot showing the relationship between infrarenal aortic size and history of cardiovascular disease. ASI = absolute aortic diameter(cm)/ body surface area (m2).

Human aortic aneurysm genomic dictionary: is it possible?

Thoracic aortic aneurysm (TAA), a typically silent but frequently lethal disease, is strongly influenced by underlying genetics. Approximately 30 genes have been associated with syndromic and non-syndromic familial thoracic aortic aneurysm and dissection (TAAD) to date. An estimated 30% of patients with non-syndromic familial TAAD, which is typically inherited in an autosomal dominant manner, have a mutation in one of these genes. The underlying genetic mutation helps predict patients' clinical presentation, risk of aortic dissection at small aortic sizes (< 5.0cm), and risk of other cardiovascular disease. As a result, a TAAD genomic dictionary based on these genes is necessary to provide optimal patient care, but is not on its own sufficient as this disease is typically inherited with reduced penetrance and has widely variable expressivity. Next-generation sequencing has been and will continue to be critical for identifying novel genes and variants associated with TAAD as well as genotype-phenotype correlations that will allow for management to be targeted to not only the underlying gene harboring the pathogenic variant but also the specific mutation identified. The aortic dictionary, to which a clinician can turn to obtain information on clinical consequences of a specific genetic variants, is not only possible, but has been substantially written already. As additional entries to the dictionary are made, truly personalized, genetically based, aneurysm care can be delivered.

Identification and Surgical Repair of Familial Thoracic Aortic Aneurysm and Dissection Caused by TGFBR1 Mutation

This study aimed at exploring the causative gene and summarizing the clinical characteristics in a Chinese thoracic aortic aneurysm and dissection (TAAD) family. Family members were examined for features of syndromic genetic diseases by clinician and geneticist. Genomic DNA was extracted from 2 distantly related members with definite TAAD for exome sequencing. A pathogenic mutation (rs111426349, c.1459C >T) of transforming growth factor β receptor 1 (TGFBR1) was confirmed, which result in the amino acid substitution p.R487W. Fourteen TGFBR1 mutation carriers were detected among 39 tested members in this family. The average age at diagnosis of aortic root dilatation or aneurysm was 23.2 ± 12.6 years (range 3-37 years). Early onset of aortic root dilatation was significant in this family without reported phenotypes. The David procedure was performed prophylactically in 3 carriers of this family. Familial TAAD caused by TGFBR1 mutation (c.1459C >T) was confirmed in a large Chinese Han ethnic family using exome sequencing. Aggressively prophylactic David procedure may be not necessary at a smaller aortic size in familial TAAD patients with TGFBR1 mutation and further observation is warranted.

Predictors of in-hospital adverse outcomes in aortic surgery

Results We included 235 pts (61±13y, 66%male). Group 1 (aneurysms 61%) and Group 2 (dissections, ulcer, hematoma 36%). Others: 3%. Procedures: aortic root replacement (26,5%), Bentall procedure (23,5%), endovascular (28%), hybrid surgery (19%), aortoplasty and Tirone (3%); concomitant procedures in 20% of cases. Group 2 had higher BP, more urgent and hybrid procedures, greater pump/ ischemia time, smaller aortic size and less Bentall procedure. Mortality was 8,5% (Group 1, 4,6%; Group 2, 15,5%, p=0,004). Rate of MACCE was 19,2% (Group 1, 11,3%; Group 2, 33,7%, p < 0,001). Reoperation occurred in 7,3%, complications 34,2%, stroke 4,3%, AKIN 7,3%, respiratory complications 15,9%. Medullary ischemia developed in 2 patients (0,8%). By multivariate logistic regression, independent predictors of death were hybrid procedure [OR = 7,51 (1,05–53,4) p = 0,044], aortic size [OR = 1,05 (1,02-1,10) p = 0,005] and pump time [OR=1,10 (1,01–1,20) p = 0,034]; predictors of MACCE were urgent surgery [OR = 7,17 (1,10-49,5) p = 0,045], combined aneurysms [22,4 (1,42-353) p = 0,027], and concomitant mitral valve surgery [OR = 46,5 (1,3-166) p = 0,035]. Endovascular procedure was independently associated with reduction of MACCE incidence [OR = 0,05 (0,004-0,730) p = 0,045].

Echocardiographic Ratio Indices in Overtly Healthy Boxer Dogs Screened for Heart Disease

Boxer dogs are routinely screened by echocardiography to exclude congenital and acquired heart disease. Individuals of a given breed may span a large range of body sizes, potentially invalidating linear regression of M-mode measurements against body weight. Echocardiographic ratio indices (ERIs) provide a novel method of characterizing echocardiographic differences between Boxers and other dog breeds. ERIs obtained from overtly healthy Boxer dogs presented for cardiac screening will be different from ERIs established for normal non-Boxer dogs, and those differences will be unrelated to aortic velocity or systolic blood pressure. Eighty-one Boxers with no outward clinical signs of heart disease were studied. All dogs were examined by 2-dimensional, M-mode, and Doppler echocardiography. M-mode measurements were used to perform ERI calculations, and the indices in Boxers were compared between Boxers with varying severity of arrhythmia and those of normal non-Boxer dogs. Differences in weight-based ERIs, which reflect increased thickness of the left ventricular free wall (LVW) and interventricular septum (IVS) and smaller aortic size, were found in overtly healthy Boxer dogs compared with normal non-Boxer dogs. ERIs of left atrial and LV cavity size in overtly healthy Boxers were not significantly different from those of non-Boxer dogs. Boxer dogs may have an increased relative thickness of the LVW and IVS that is independent of aortic size, aortic velocity, or arterial blood pressure, and this morphology should be taken into consideration when screening Boxers by echocardiography.

Clinical and hemodynamic results of cardiac valve replacement with the Monostrut Björk-Shiley prosthesis

Between May 1983 and April 1986, 318 patients underwent cardiac valve replacement with the Monostrut Björk-Shiley prosthesis. There were 136 aortic valve replacements, 128 mitral valve replacements, and 54 multiple replacements. A total of 373 valves were implanted. Associated procedures were done in 79 (25%) of the patients. Hospital (30-day) mortality rate was 5.6% (18 patients): 2.9% (n = 4) after aortic, 7.8% (n = 10) after mitrals and 7.4% (n = 4) after multiple valve replacement. Follow-up was obtained in all 300 operative survivors, for a total of 500 patient-years (mean 18 months). Actuarial survival rate, excluding operative deaths, at 4 years was 94.7% +/- 1.5% (mean +/- standard error of the mean). There were 16 thromboembolic episodes (3.2/100 patient-years). Freedom from all valve-related complications was 87% +/- 2.4% at 3 1/2 years. Neither valve thrombosis nor structural failure has been observed. Eighty percent of the patients are in New York Heart Association functional class I. Forty-two patients (26 with aortic and 16 with mitral valve replacement) underwent cardiac catheterization a mean of 6 1/2 months after the operation. In the aortic position, peak gradients were an average of 6.9 +/- 1.2 mm Hg. Mean systolic gradients were 12.4 +/- 6.3 mm Hg and did not increase with exercise. In the mitral position, end-diastolic gradients were an average of 2.1 +/- 2 mm Hg and mean gradients, 5.9 +/- 2 mm Hg. Discharge coefficient (estimated orifice area/geometric area) was 0.63 +/- 0.2 for the aortic and 0.53 +/- 0.2 for the mitral prostheses. Disc opening was maximal in most patients. These results indicate that the Monostrut prosthesis has a low rate of thromboembolic events, no structural failures or thrombotic obstructions and excellent hemodynamic performance, especially in the small aortic sizes (discharge coefficient for 19 and 21 mm valves, 0.77).