Stanford Classification Research Articles

Reply to Urbanski

We thank Dr Urbanski for his kind comments and demonstration of his personal results [1]. There is an obvious misunderstanding in the interpretation of our surgical principles in assuming that a complete resection of all dissected aortic walls was not performed in all patients. On the contrary, all dissected aortic walls were removed in all Type II patients according to our modification of DeBakey’s original classification with extension to the end of the aortic arch, as indicated in the ‘Surgical management’ section [2]. This means that, in 44 patients with Type II dissection, complete removal of the dissected aortic wall was achieved by the sole ascending aortic replacement in 12 (27%), by hemiarch in 16 (36%) and total arch replacement in another 16 (36%) patients. Beyond this, the intention of our article is to demonstrate, that after removal of all dissected tissue, none of the survivors faced any late complications of the downstream aorta. Reiteration of the data pool of the presented Type II patients by January 2012, with continuing complete follow-up from now up to 10 years (mean ± SD 2.8 ± 2 years), confirms the observation from our article that none of the patients developed later downstream aortic dissection or associated pathologies, besides one isolated, infrarenal aortic aneurysm. This indicates that DeBakey’s original assumption that ‘complete resection of the dissected (ascending) aorta could be curative’ holds true for the aortic arch as well [3]. Dr Urbanski’s plea for a different classification, taking into consideration the extent of dissection and the location of the intimal tear, is in good company with several historic attempts to better conceive the anatomical and pathophysiological situation, as described by Dr Kirsch in his thoughtful editorial comment on our article [4]. What all those alternative classifications have in common is their complexity or even impracticability for daily use. In our opinion, the Stanford classification remains the keystone classification in fast clinical decision making, and the DeBakey classification, in its upgraded version based on today’s knowledge and imaging capacities, is the best tool for prognostic judgement after surgical repair. The major intention of our article is to provoke other established groups in the field of thoracic aortic surgery to check with their data bases and ascertain whether or not our, as well as Dr Urbanski’s, observation holds true, that the resection of all dissected aortic tissue renders a very favourable prognosis in regard to cure of the aortic disease. Since up to 40% of all thoracic aortic dissection cases are included in this subgroup, long-term follow-up studies should be undertaken by separating this large subgroup from the Type A patients, which represent the vast preponderance of all publications worldwide. This, however, would mean that up to 40% of those Type A patients would not expect late complications like patients with Type I dissection and persisting false lumen. The consequence would be that there is an enormous underestimation of late risk for downstream complications as judged today. Attempts to treat a dissected descending aorta simultaneously with the ascending aorta and/or arch would be even more justified than today.

Acute aortic dissection in the ED: risk factors and predictors for missed diagnosis

ObjectiveThis study aims to explore the risk factors and predictors involved in the missed diagnosis of acute aortic dissection (AAD) among patients in the emergency medicine department (EMD). MethodsThis is a single-center retrospective chart review conducted over a 10-year period (January 1998 to December 2008). Records with a diagnosis of “dissection of aorta” (International Classification of Diseases, Ninth Revision code 441.0) from the hospital discharge database and hospital death register were selected. Acute aortic dissection was defined as missed if diagnostic imaging to diagnose AAD or cardiothoracic surgeon consult was not elicited while in the EMD. We compared the history, clinical findings, and investigations between patients who had the diagnosis of AAD missed in the EMD and those who did not. ResultsA total of 68 patients were included in the analysis during the study period, of which 38.2% had a missed diagnosis. There was 63.2% of type A AAD by Stanford classification. Neither age, sex, nor a history of hypertension were significant risk factors for missed diagnosis of AAD. The likelihood of missed diagnosis was significantly higher in the absence of a pulse deficit (odds ratio, 35.76; 95% confidence interval, 3.70-345.34) and absence of widened mediastinum on chest radiography (odds ratio, 33.16; 95% confidence interval, 5.74-191.49). ConclusionWell-known risk factors for AAD such as age, male sex, and hypertension were not risk factors for missed diagnosis for AAD presenting in the EMD. The absence of pulse deficit or widened mediastinum does not exclude the diagnosis of AAD.

Endovascular Treatment of Chronic Complicated Type B Aortic Dissection

ABSTRACT Background Endovascular repair of aortic diseases is a well-established therapeutic alternative for patients with the appropriate anatomy and/or high surgical risk, as it provides lower morbidity and mortality rates. This study aimed to analyse the outcomes of asymptomatic patients undergoing endovascular treatment of thoracic aortic dissections with an aortic diameter > 5.5 cm or endoleaks. Technical success, therapeutic success, morbidity, mortality, and perioperative complication and reintervention rates were assessed. Methods The present retrospective study, which was performed at a reference centre from January, 2010 to July, 2011, analysed consecutive patients undergoing endovascular repair of chronic complicated type B aortic dissections based on the Stanford classification. Results Twenty-six patients were treated. The mean age was 56.4 ± 7 years, and 61.5% were males. Technical and therapeutic success rates were 100% and 74%, respectively. The perioperative mortality was 7.6%, and the mortality rate in the first year of follow-up was 19.3%. The reintervention rate was 15.3%. Conclusions In the present study, endovascular treatment of chronic type B aortic dissections proved to be a feasible method associated with acceptable perioperative complication rates. The therapeutic success and reintervention rates indicated the necessity for stringent and careful clinical follow-up of these patients.

Stopping a Killer

Aneurysms and acute dissections are the major diseases affecting the ascending thoracic aorta. These conditions are related; the natural history of an aneurysm involving the ascending aorta is to progressively and asymptomatically enlarge over time, ultimately leading to an acute ascending aortic dissection (type A dissection based on the Stanford classification, type I and II dissections based on the DeBakey classification). Although medical treatments can slow the enlargement of an aneurysm, the mainstay of treatment to prevent dissections is surgical repair of the ascending aortic aneurysm. This is typically recommended when the aneurysm diameter reaches 5.0 to 5.5 cm1; however, studies on patients presenting with acute ascending dissections indicate that up to 60% present with aneurysms 1200 patients presenting with ascending aortic dissection to emergency departments participating in the International Registry of Acute Aortic Dissections (IRAD).4 Article see p 1911 Many of the factors associated with a delay in …

Role of Noninvasive Imaging in the Diagnosis of Cardiac Allograft Vasculopathy

Cardiac allograft vasculopathy (CAV) is common, with a prevalence of 52% at 10 years after transplantation, and represents a leading cause of death beyond the first year, responsible for approximately 15% of deaths annually.1 It is characterized by diffuse and concentric intimal proliferation, typically involving the intramural as well as epicardial coronary arteries. Its diagnosis is difficult to establish clinically because of denervation of the transplanted heart. Consequently, it presents late with silent myocardial infarction, progressive heart failure, or arrhythmic sudden death.2 Screening is therefore required for its early detection. Although coronary intravascular ultrasound (IVUS) is considered the gold-standard technique for detecting the anatomic features of CAV (Table 1), its broad clinical use in this context is limited by cost and lack of widespread expertise, and its evaluation is limited to epicardial vessels.3 Coronary angiography, performed annually or biannually, remains the most common clinical screening method.4 However, because of the diffuse nature of CAV with a lack of normal reference segments and the relatively late occurring luminal narrowing, the sensitivity of angiography is as low as 30% when compared with IVUS (Figure 1).5 As a result, complications frequently occur before disease is evident angiographically.6 Furthermore, angiography is associated with significant albeit uncommon complications (overall complication rate, 7.4/1000 procedures, including rates of 0.65/1000, 1.6/1000, and 0.72/1000 for cerebrovascular accidents, vascular complications, and death, respectively), is disliked by transplant recipients, is costly, and repeated studies are associated with an important cumulative radiation dose.7 View this table: Table 1. Stanford Classification of CAV Severity on IVUS Figure 1. Invasive assessment of cardiac allograft vasculopathy (CAV) in a patient with severe disease, highlighting the limited sensitivity of conventional coronary angiography. Although no left anterior descending (LAD) flow-limiting stenoses are seen on angiography ( A ), intravascular ultrasound ( B ) shows significant intimal thickening, measuring up to …

Relationship between angiographic graft vessel disease and microvascular reaction after heart transplantation

This study tests the correlation of coronary angiographic findings with the extent of microvascular reaction in right ventricular endomyocardial biopsies (EMBs) in transplanted hearts. In EMBs (n = 209) of 30 heart transplant patients (8 female, 22 male, mean age 48 years) microvascular reaction, i.e. endothelial cell swelling and vascular wall thickening (both grade 0-2), was graded by light microscopy at ×200. Patients' first and last coronary angiography (CA) (mean time after heart transplantation [HTx] 8 and 44 months) were graded according to the Stanford Classification and the presence of diameter irregularities was evaluated semi-quantitatively. We found a correlation of angiographic type B lesions with endothelial cell swelling during the first 5 months and vascular wall thickening during the fifth to fourteenth month after HTx (p <0.05). In patients with diameter irregularities and type B1 lesions in their first CA and type C lesions in their last CA, there was pronounced endothelial cell swelling in the early postoperative period (p <0.05). There was a tendency towards an increased vascular wall thickening in these patients during the later postoperative period. Graft vessel disease affects large and small coronary arteries and capillaries. Small vessel disease is characterized by architectural changes in blood vessel walls. Serial investigations of EMBs for diagnosis of small vessel disease complement the present diagnostic tools.

Magnetic resonance assessment of left ventricular diastolic dysfunction for detecting cardiac allograft vasculopathy in recipients of heart transplants

Cardiac allograft vasculopathy (CAV) is a major late complication in heart transplant recipients, graded based on intravascular ultrasound (IVUS), and accelerates left ventricular (LV) diastolic dysfunction. We investigated the clinical feasibility of using magnetic resonance (MR) to assess LV diastolic dysfunction noninvasively in transplant recipients. Thirty-eight asymptomatic recipients (25 men, 37.2 ± 14.9 years) underwent both IVUS and cardiac MR. Based on IVUS, we divided the individuals into 2 groups using Stanford classification to categorize CAV development as either nonsignificant or advanced. We measured LV peak filling rate (PFR) and systolic function parameters, including LV ejection fraction (EF), stroke volume (SV), and cardiac output (CO) using cine MR; compared those values between groups; calculated receiver operating characteristic curve in the relationship between PFR value and CAV; and assessed myocardial late gadolinium enhancement (LGE) on contrast-enhanced MR. We classified CAV as advanced in 20 patients (53%) and nonsignificant in 18 (47%). LV EF, SV, and CO values were not significantly different. PFR was significantly lower in the advanced (3.63 ± 0.90 EDV/s) than nonsignificant group (4.43 ± 0.84 EDV/s, P = 0.01). The area under the curve was 0.76. We observed no myocardial LGE. MR measurement of PFR may permit noninvasive assessment of diastolic dysfunction associated with CAV before LV systolic dysfunction and myocardial infarction or scar formation develop.

Repair of Acute Type A Dissection: Our Experiences and Results

Significant advances in the diagnosis and therapy have greatly improved surgical outcomes of acute type A dissection. However, surgical management of acute type A dissection still poses formidable challenges, particularly in "developing" countries. We present our surgical management strategy of acute type A dissection in a single center in China. On the basis of Stanford classification, acute type A dissection was subclassified at our center. Aortic root lesions were divided into three subtypes (A(1), A(2), and A(3)) and distal aortic lesions into two subtypes (C and S) according to lesion severity. The corresponding surgical procedure was scheduled according to each subtype. According to this subclassification, 257 patients (67 females, 190 males) with acute type A dissection underwent surgical treatment from January 2003 to March 2008. The overall prevalence of in-hospital death was 4.67% (12 of 257) and deaths at follow-up were 3.27% (8 of 245) during a follow-up of 35 months. Stroke occurred in five patients, paraplegia in two patients, paraparesis in two patients, respiratory failure in 15 patients, renal failure in two patients, hepatic failure in one patient, and multiple-organ failure in one patient. Injury to the spinal cord and visceral organ ischemia were not observed in patients who underwent stented elephant trunk implantation during follow-up. Six patients underwent late distal aortic reoperation. The encouraging and satisfactory surgical outcomes and postoperative results demonstrating a low prevalence of morbidity and mortality showed the substantial improvement in surgery for acute type A dissection using our surgical strategy at a center in China.

Multidetector CT of Aortic Dissection: A Pictorial Review

Aortic dissection is the most common acute emergency condition of the aorta and often has a fatal outcome. Outcome is determined by the type and extent of dissection and the presence of associated complications (eg, cerebral sequelae, aortic branch involvement, pericardial involvement, and visceral involvement), with early diagnosis and treatment being essential for improved prognosis. Aortic dissections are classified on the basis of the site of the intimal tear according to the Stanford classification system. Type A aortic dissection involves the ascending thoracic aorta and may extend into the descending aorta, whereas in a type B dissection the intimal tear is located distal to the left subclavian artery. Type A dissection typically requires urgent surgical intervention, whereas type B dissection can often be treated medically. Modern multidetector computed tomography (CT) is a fast, widely available imaging modality with high sensitivity and specificity. Multidetector CT allows the early recognition and characterization of aortic dissection as well as determination of the presence of any associated complications, findings that are essential for optimizing treatment and improving clinical outcomes.

Axillary Artery Cannulation for Cardiopulmonary Bypass during Surgery on the Ascending Aorta and Arch

Performing axillary artery cannulation, during cardiopulmonary bypass in patients with an atherosclerotic ascending aorta or acute dissection of the ascending aorta and arch, is of growing interest. Our aim is to present our experience, to describe the surgical technique, and to demonstrate the sufficient cerebral and total body perfusion through axillary artery cannulation. Twenty-two patients (17 male, five female) underwent surgical treatment with the axillary technique. The log euro SCORE ranged from 6.77% to 70% (mean 28.28). Nine of these patients underwent elective procedure. Eight underwent aortic surgery for pathologies of the aorta and in one patient we performed combined aortic valve replacement and coronary artery bypass grafting. Thirteen patients underwent emergency operation because of acute dissection of the aorta. Twelve of these patients had a type A dissection (according to Stanford classification) and one patient had a type B aortic dissection. The majority of complications were associated with ruptured dissection of the thoracoabdominal aorta and acute dissection of ascending aorta. Despite preoperative disease states that placed our patients at high risk of stroke and visceral end-organ injury, no clinically demonstrable permanent postoperative deficits were observed. Our patients had no neurological dysfunction, stroke, or other complications. Antegrade cerebral perfusion is of paramount importance in cases of aortic atherosclerosis or aortic dissection. The axillary artery provides an excellent site for safe antegrade perfusion, which may play a role in preventing stroke.

15-Prostaglandin Dehydrogenase Expression Alone or in Combination with ACSM1 Defines a Subgroup of the Apocrine Molecular Subtype of Breast Carcinoma

Established histopathological criteria divide invasive breast carcinomas into defined groups. Ductal of no specific type and lobular are the two major subtypes accounting for around 75 and 15% of all cases, respectively. The remaining 10% include rarer types such as tubular, cribriform, mucinous, papillary, medullary, metaplastic, and apocrine breast carcinomas. Molecular profiling technologies, on the other hand, subdivide breast tumors into five subtypes, basal-like, luminal A, luminal B, normal breast tissue-like, and ERBB2-positive, that have different prognostic characteristics. An additional subclass termed "molecular apocrine" has recently been described, but these lesions did not exhibit all the histopathological features of classical invasive apocrine carcinomas (IACs). IACs make up 0.5-3% of the invasive ductal carcinomas, and despite the fact that they are morphologically distinct from other breast lesions, there are presently no standard molecular criteria available for their diagnosis and as a result no precise information as to their prognosis. Toward this goal our laboratories have embarked in a systematic proteomics endeavor aimed at identifying biomarkers that may characterize and subtype these lesions as well as targets that may lead to the development of novel targeted therapies and chemoprevention strategies. By comparing the protein expression profiles of apocrine macrocysts and non-malignant breast epithelial tissue we have previously reported the identification of a few proteins that are specifically expressed by benign apocrine lesions as well as by the few IACs that were available to us at the time. Here we reiterate our strategy to reveal apocrine cell markers and present novel data, based on the analysis of a considerably larger number of samples, establishing that IACs correspond to a distinct molecular subtype of breast carcinomas characterized by the expression of 15-prostaglandin dehydrogenase alone or in combination with a novel form of acyl-CoA synthetase medium-chain family member 1 (ACSM1). Moreover we show that 15-prostaglandin dehydrogenase is not expressed by other breast cancer types as determined by gel-based proteomics and immunohistochemistry analysis and that antibodies against this protein can identify IACs in an unbiased manner in a large breast cancer tissue microarray making them potentially useful as a diagnostic aid.

Acute gastrointestinal haemorrhage: a rare presentation of aortic dissection

A 72-year-old woman presented with a 24-hour history of severe upper jaw pain and more recent onset central chest pain. She denied difficulty breathing or nausea. Her ast medical history included cluster headaches, mild chronic obstructive airways disease and hypertension. She had been well on review in outpatient clinic the day before. On examination, she was apyrexial, blood pressure 130/60 mmHg, pulse 95 beats per minute and regular, oxygen saturation 96% on room air. Clinical examination was unremarkable. There were no new electrocardiogram changes and a chest X-ray was reported as normal. Blood tests showed haemoglobin 9 g/dl, a 2 g/dl drop from the previous day in clinic. The remaining laboratory tests were normal. With no identified source of bleeding or associated rise in urea, her full blood count was repeated to exclude a spurious result. Over the next 24 hours, her chest and jaw pain eased but she developed diarrhoea and tachycardia. Her blood pressure remained stable at 140/65 mmHg. The haemoglobin drop was confirmed with a repeat value of 8.7 g/dl but still no source of bleeding was identified. Over the course of the day, the patient's diarrhoea continued with increasing abdominal discomfort, until she suddenly passed fresh blood per rectum associated with a blood pressure drop to 70 mmHg systolic. She was resuscitated promptly and a decision made to manage her conservatively with oesophagogastroduodenoscopy and colonoscopy scheduled for 24 hours later, as it was the weekend and endoscopy services were limited. However, she continued to pass fresh blood per rectum and suffer severe generalized abdominal pain, and so an urgent computed tomography scan with contrast was performed (Figure 1). This showed a type A aortic dissection extending from the left coronary artery to involve the carotid arteries and extend down below the renal arteries. The Stanford classification divides dissections into 2 types: A and B. Type A involves the ascending aorta, type B does not. The ascending and transverse colon appeared thickened and oedematous on the scan. The most likely cause of bleeding in this case was ischaemic colitis, secondary to aortic dissection impeding inferior mesenteric artery blood flow. Cardiomegaly raised the probability of pericardial involvement. On the basis of these findings, the patient was immediately reviewed by the on-call vascular surgical team. Given the extent of the dissection, surgery was not felt to be an option. Shortly afterwards she became profoundly hypotensive and died. The most likely cause of death was cardiac tamponade, although an echocardiogram was never performed. The family declined a post mortem.

The utility of multiple imaging modalities to diagnose acute aortic dissection

A 21-year-old man with Marfan syndrome and known aortic root aneurysm presented to our emergency department with symptoms suggestive of acute aortic dissection. The patient was hemodynamically stable and bilateral upper extremity blood pressures were similar. There was no mediastinal widening on portable chest radiograph. Both contrast CT and retrograde angiography of the aorta failed to identify dissection. Subsequent transesophageal echocardiography demonstrated a Stanford classification type A dissection. This case demonstrates the utility of multiple imaging modalities for identifying aortic dissection in high-risk patients.

Aortic Dissection and Third‐Degree Atrioventricular Block in a Patient With a Hypertensive Crisis

A 55-year-old man with a history of uncontrolled hypertension was admitted because of an episode of severely elevated blood pressure. An electrocardiogram revealed complete atrioventricular block while imaging showed a dissecting aneurysm of the descending thoracic and abdominal aorta, type B according to the Stanford classification. Laboratory tests revealed significant increases in serum C-reactive protein. Coronary arteriography was performed and was negative for coronary artery disease. A VDD pacemaker was placed, and a combination of 4 antihypertensive agents was used as treatment. Type B aortic dissection may present with a wide range of manifestations. The authors suggest that measurement of C-reactive protein may be used in hypertensive patients to help reflect vascular injury and its degree, progression, and prognosis. Disorders of intraventricular conductivity are rarely seen in both types of dissection of the aorta (type A, B). Atrioventricular conductivity disorders that result in complete atrioventricular block have been reported only in patients with type A dissection (before the bifurcation of the subclavian artery). In this particular case, however, the authors diagnosed an atrioventricular conductivity disorder causing atrioventricular block in a patient with type B dissection. Consequently, the authors speculate that myocardial fibrosis, as a result of long-standing hypertension, could be the main pathogenetic mechanism leading to the development of such phenomena, resulting from a potential expanding of the fibrotic process to the atrioventricular conduction system.

Aortic dissection: from aetiology to therapeutic management

Abstract Acute aortic dissection remains a challenging clinical emergency with a high mortality rate. The peak incidence of aortic dissection is in the sixth and seventh decade of life; men are affected twice as commonly as women. Two classification systems predominate, the DeBakey and the Stanford classification. In both systems, aortic dissections with and without ascending aortic involvement are distinguished for prognostic and therapeutic reasons. In general, surgery is indicated in dissections involving the ascending aorta, where as medical management or endovascular stent-graft implantation is reserved for dissections without ascending aortic involvement. Echocardiography, contrast-enhanced CT, MRI and aortography are currently used to confirm the diagnosis. Their diagnostic accuracies are similar, but they differ in the ability to detect complications associated with dissection. Initial therapeutic aims include elimination of pain and reduction of systolic blood pressure to 120 mm Hg or less by the use of s-blockers and vasodilators. Long-term medical therapy to control hypertension is of greatest importance in all patients who have survived aortic dissection, to reduce late complications such as recurrent dissection, formation of an aneurysm or impending rupture of a dissecting aneurysm. The primary aim of long-term surveillance is early detection of unstable aortic lesions and requires subsequent surgical or interventional measures.

Surveillance for Transplant Coronary Artery Disease in Infant, Child and Adolescent Heart Transplant Recipients: An Intravascular Ultrasound Study

Transplant coronary arteriopathy (TCAD) limits graft survival after heart transplantation in adult and pediatric heart transplant recipients. Intravascular ultrasound (IVUS) provides a highly sensitive technique to detect TCAD. However, its use to determine factors associated with TCAD in pediatric recipients has been limited and its utility in surveillance for symptomatic TCAD in this population is uncertain. One hundred fifty-eight IVUS studies from 66 patients (27 <1 year and 39 >1 year at time of transplant) were performed 12 to 144 months after transplantation within the routine surveillance for TCAD. Maximal intimal thickness (MIT) and intimal index (II) were measured, and the Stanford classification was utilized to grade overall severity of disease. Mixed repeated-measures linear regression models were used to investigate the main and interaction effects of age at transplant, age at time of study, time since transplant and rejection events. Age at catheterization (p = 0.0002), transplantation at age >12 months (p = 0.014), increasing time after transplantation (p = 0.021) and the combination of late rejection and hemodynamic compromising rejection (p = 0.05) were significantly associated with increasing MIT. Age at catheterization (p = 0.0149), transplantation at age >12 months (p = 0.016), time from transplantation (p = 0.0076) and rejection with hemodynamic compromise (p = 0.01) were significantly associated with increased II. Nine patients developed evidence of severe (Stanford Class 4) TCAD by IVUS, but only 2 (22%) developed symptomatic TCAD, with a median follow-up of 44 months. Four of the 7 patients who developed symptomatic TCAD had no or minimal TCAD (Stanford Class 0 or 1) on a surveillance examination within 18 months of the onset of symptoms. Increasing time after transplantation, recipient age and age at transplantation as well as rejection history, especially rejection with hemodynamic compromise, are associated with the development of TCAD as detected by IVUS in pediatric heart transplant recipients. Severe TCAD detected by IVUS does not often rapidly progress to symptomatic TCAD. Symptomatic TCAD may develop rapidly even in patients with little or no TCAD detected by IVUS.

Norman E. Shumway, M.D., Ph.D. (1923 – 2006) Surgical Innovator

Norman E. Shumway, M.D., Ph.D. (1923 – 2006) Surgical Innovator

Prevalence of graft vessel disease after paediatric heart transplantation: a single centre study of 54 patients

The study tested the prevalence of graft vessel disease (GVD) in 54 paediatric heart transplant (HTx) patients (32 male, age 0-17 years) who underwent coronary angiographic investigations (N=117). These were evaluated according to the Stanford classification and additional criteria (peripheral obliterations, diameter fluctuations, pathologic tapering) were applied for risk assessment (no GVD/minimal lesions, GVD without Stanford lesions, accelerated GVD). In H&E stainings from right ventricular endomyocardial biopsies (EMB=169) diagnosis of acute cellular rejection (ACR, ISHLT) and microvasculopathy were performed. Mild rejection was found in 43% (N=44) and severe rejection in 7% (N=7) of EMB early (1st year) and mild rejection in 31% (N=32) and severe in 8% (N=9) late (>3 years) after HTx. Microvasculopathy was present in 22% of EMB. Risk assessment of coronary angiographies showed no GVD/minimal disease in 25% (N=29), GVD without Stanford lesions in 12% (N=14) and different grades of accelerated GVD in 74% (N=74) of studies. All patients dying due to cardiac related causes of death (N=6, 3-12 years after HTx) had evidence of GVD. The data show GVD to be an important cause of late cardiac related deaths in this population.

Intracoronary Ultrasound Assessment Late After the Arterial Switch Operation for Transposition of the Great Arteries

This research was undertaken to assess the status of the coronary wall morphology late after the arterial switch operation (ASO) for transposition of the great arteries employing intravascular ultrasound (IVUS). Long-term patency of the reimplanted coronary arteries is a key issue after ASO. Follow-up studies have demonstrated coronary obstruction in up to 8% of patients that may be related to progressive fibrocellular intimal thickening. Twenty-two asymptomatic children were enrolled at a median age of 9.5 years (range 5 to 22 years); IVUS images were obtained in 20 children at cardiac catheterization 5.0 to 21.6 years after the operation (in two cases IVUS study was not feasible due to technical constraints). Quantitative analysis was performed in 37 coronary arteries involving segments with a mean length of 28.4 +/- 1.8 mm. Thirty-three arteries (89%) displayed variable degrees of proximal eccentric intimal proliferation, with the maximal intimal thickening being 0.26 +/- 0.14 mm (range 0.06 to 0.71 mm) at the most thickened site. According to the Stanford classification, all children had coronary artery involvement with 50% having moderate-to-severe lesions (>0.3 mm). No risk factors for such abnormalities were encountered, including age, origin of the coronary arteries, hemodynamics, and follow-up duration after surgery. Intravascular ultrasound assessment late after the ASO revealed proximal eccentric intimal thickening in most of the studied vessels. This observation suggests the development of early atherosclerosis in the reimplanted coronary arteries, which may have a role in the genesis of late coronary events.

Epicardial and microvascular graft vessel disease in children

Graft vessel disease (GVD) is one of the main limiting factors to long-term survival after adult heart transplantation (HTx). The incidence of epicardial and microvascular GVD in paediatric patients was studied. A total of 137 coronary angiographies from 130 paediatric HTx and heart and lung transplant (HLTx) patients (70 male, 60 female, aged 0-18 y) were evaluated according to the Stanford classification and its supplements (minor vessel alterations). In H&E stainings from right ventricular endomyocardial biopsies (EMB = 397), light microscopic diagnosis of acute cellular rejection (ISHLT classification) and vascular reaction (morphology of endothelial cells and vessel walls) was performed. Moderate rejection was present in 32.8% and severe rejection in 13.3% of EMB. Microvascular EC swelling was found in 33.5% and vessel wall thickening in 53.8% of EMB. The results of the coronary angiographic investigations were: Stanford lesions = 61.2%, peripheral obliterations = 52.5%, diameter fluctuations = 86.3%, pathologic tapering = 64.0%, calcifications = 10.8%. Long-term survivors (> or =5 y) showed macrovascular alterations in 78% of cases and microvascular alterations in 67% of cases. The development of micro- and macrovascular GVD is one of the predominant complications in long-term survivors after paediatric HTx and HLTx.