Come join in meeting and discussing the latest topics on Aortic Diseases.
Come join in meeting and discussing the latest topics on Aortic Diseases.
Ok…. Here we go! Monday, I am scheduled to meet with Dr. James Brevig, it’s been over 15 years since my original ER surgery to save my life. I will be interested to hear what he has to say. I also have an echo of my aorta. I have never had this done and I think the reasoning was that I had a CT/Angio last year and they wanted to hold off on the radiation. I also am scheduled to see Gabe at the U of W later in December.
My main cardiologist, Dr. David Liang says that I don’t need surgery just quite yet and I trust him so very much!
More to come……..Brian 🙂
OK.. 12/3… I met with Dr. Brevig for almost an hour, he was great and said that he could do my surgery and I had a 5-6% risk factor. I would have my aortic root and valve replaced. The one really thing I like about Dr. Brevig, he’s calm and cool and very confident! The plan is surgery in Late June and an echo in May as well as a procedure to check my coronary arteries.
My son was complaining about having a chest pains and he’d been off at college. He went to the WSU hospital and they said he had Mono. He wore a monitor for a few days and all tests came back clear. Then yesterday, he said he was still feeling pains and at dinner we ended up leaving and getting it to go.
Well, I took him to the ER at Providence Everett (where I had my surgery) and I told the ER doctor about my condition and that I wanted him to have a CT/Angio, D-dimer test and a partial echo. So, my wish was granted and he got all 3 and all the tests turned out clear. I was so scared that he might have some aortic condition or valve issue.
God IS GOOD! Jesus Christ is in charge!
Great success story!
Emergency doctors are being urged to collaborate with a patient-led campaign, which aims to reduce the number of patients dying in Irish Emergency Departments (EDs) from aortic dissection.
An aortic dissection refers to a tear in the body’s largest artery that carries blood away from the heart. Unless the condition is diagnosed rapidly and the patient undergoes surgery, it can prove fatal.
However, symptoms can be similar to other heart problems, such as a heart attack, which can lead to a misdiagnosis or a delay in diagnosis.
A patient support association, Aortic Dissection Awareness (UK and Ireland), is challenging the number of unnecessary deaths that occur due to the misdiagnosis of this condition in Irish hospitals.
It is calling on the Irish Association for Emergency Medicine (IAEM) to collaborate with it and introduce changes in relation to education, awareness and policy around the condition.
The chairperson, vice-chairperson and medical advisor of this patient association are attending the IAEM’s annual scientific meeting and conference in Dublin this week to urge doctors to get involved with the ‘Think Aorta’ campaign.
This campaign was inspired by the death of Tim Fleming, who was sent home from Dublin’s Tallaght Hospital in 2015 with an incorrect diagnosis of gastritis. Mr Fleming’s daughter, Catherine Fowler, who is vice-chairperson of Aortic Dissection Awareness, is a guest speaker at the conference.
“We had no idea when dad died of how common it is for aortic dissection to be missed in the ED. Over the last three years, the picture has become very clear. Sadly, I know of many other families in Ireland who have lost their relatives to missed aortic dissection in hospitals during that time. We must do something to change the future for others,” she said.
She pointed out that as a result of the ‘Think Aorta’ campaign in the UK, the Royal College of Emergency Medicine there has accepted that this is a real issue and it is working with the association to address this.
“I will be asking the IAEM to do the same,” Ms Fowler added.
Statistics show that aortic dissection is only considered in half of the patients who present with it, and one-third of patients are actively treated for something else, such as a heart attack.
The only definitive diagnostic tool for diagnosing the condition is a CT scan, however these are often not ordered until it is too late.
“Aortic dissection is not a difficult condition to diagnose. A doctor just has to be aware enough to ‘Think Aorta’ in the first place, then once their suspicion is raised, they must request an immediate CT scan to confirm.
“Experience in the UK shows that if EDs educate staff about aortic dissection and lower the barriers to CT scanning, lives will be saved,” Ms Fowler noted.
The IAEM annual scientific meeting and conference takes place in Castleknock Hotel from October 17-19. For more information on the ‘Think Aorta’ campaign, click here
MUNICH — Irbesartan in standard doses is linked to a significant decrease in the rate of aortic dilatation in patients with Marfan syndrome, according to data from the AIMS study presented at the European Society of Cardiology Congress.
In the AIMS trial, Michael Mullen, MBBS, MD, FRCP, from St. Bartholomew’s Hospital in London, and colleagues randomly assigned patients aged 6 to 40 years with Marfan syndrome at 22 centers in the United Kingdom to irbesartan or placebo. The researchers aimed to recruit 490 patients but only enrolled 192 patients.
After an initial run-in period during which all patients received irbesartan 75 mg, 104 patients were up-titrated to targets of 300 mg for patients weighing more than 50 kg and 150 mg for patients weighing less than 50 kg or placebo. Treatment with beta-blockers was not mandated but was encouraged because it is standard treatment, Mullen said.
Patients were followed for up to 5 years and underwent yearly echocardiograms, for which a core lab was used. The primary endpoint was annual change in aortic root diameter and secondary endpoints included annual change in z score and clinical events and requirement for surgery, including aortic dissection.
At baseline, there was a reasonable spread across various age groups, with approximately half of patients younger than 18 years and a good balance between male and female patients. Fifty-seven percent were also taking beta-blockers.
The overall study population was normotensive, and aortic root diameter was similar for the placebo (35.3 mm) and irbesartan groups (34.8 mm). The aortic z score was approximately 3 in both groups, “meaning that, compared with other trials, these patients were fairly early in pathogenesis of their disease,” Mullen said.
The rate of aortic dilatation was slower in patients taking irbesartan vs. placebo, with a mean annual rate of change in aortic root diameter of 0.53 mm in the treatment group vs. 0.74 mm in the placebo group (difference, –0.22 mm; 95% CI, –0.41 to –0.02). Significant differences in the change in aortic root diameter were apparent at 1 year and continued out to 5 years, according to Mullen.
In terms of safety, irbesartan was well-tolerated, with four patients in both the placebo and irbesartan groups failing to tolerate medication. There was also no difference in the rate of adverse events between groups. Four patients in both groups underwent cardiac surgery, but the study was again not powered to detect differences in clinical outcomes, according to Mullen. No deaths occurred during the study.
Aortic z score, which adjusted the aortic diameter for patients’ body surface area and particularly any changes in body surface area, appeared to be fairly stable in the irbesartan group (annual rate of change, 0.05; 95% CI, –0.2 to 0.11) when compared with the placebo group (annual rate of change, 0.15; 95% CI, 0.08-0.22). The difference of –0.1 (95% CI, –0.19 to –0.01) was statistically significant, Mullen noted.
The researchers also evaluated the effect of treatment on BP, as irbesartan is a well-recognized antihypertensive treatment, he said. Results showed a significant reduction in systolic BP in patients taking irbesartan vs. placebo (–0.42 mm Hg vs. 1.27; mean difference, –1.69 mm Hg), which was maintained out to 5 years.
There was no difference in treatment effect of irbesartan in patients taking beta-blockers vs. those who were not, suggesting that there was no interaction or synergy between the two drugs. The annual rate of change in aortic diameter between study groups was also not significantly different when analyzed according to aortic z score. Additionally, no statistically significant difference was noted based on patient age, although the effect size appeared to be numerically larger in younger patients.
However, Mullen noted that the study was significantly underpowered to analyze subgroups and suggested interpreting the results with caution.
The results of this study, according to Mullen, suggest that irbesartan may have potential benefits for patients with Marfan syndrome.
“The current treatment strategy is based around beta-blockade, based on small trials conducted many years ago, and monitoring aortic dimensions with timely surgical intervention. However, some patients will still experience aortic dissection prior to presentation or before reaching those thresholds for surgical intervention,” Mullen said. “If translated into clinical practice, long-term irbesartan treatment may impact favorably on clinical outcomes in patients with Marfan syndrome.”
During a discussion of the results, Artur Evangelista Masip, MD, PhD, from Hospital Universitari Vall d’Hebron in Barcelona, Spain, highlighted several issues that may affect these findings, including the study’s sample size.
Evangelista Masip also noted that the inclusion of children and adults in the same series complicates the ability to perform an accurate analysis of this study as well as other trials. The measurement of changes in aortic diameter in systole may also be affected by the reduction in systolic BP.
“It would be interesting to know their results measuring at end-diastole,” he said.
Additionally, Evangelista Masip said the difference in the rate of change in aortic root diameter between the irbesartan and placebo groups occurred mainly during the first year and was similar thereafter.
“This is an important study and I agree that long-term irbesartan treatment may impact favorably in the evolution of patients with Marfan syndrome,” he said. “However, we have to clarify some of the previous doubts and elucidate in future studies if the reduction or aortic enlargement is secondary to biological effect or related to the decrease of BP.” – by Melissa Foster
Mullen M. Hot Line Session 5. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.
Disclosures: Mullen and Evangelista Masip report no relevant financial disclosures.
ORONO, Maine — Orange County High School football standout Darius Minor died July 24 after he collapsed during a preseason football workout at the University of Maine, according to a university spokesperson. Minor, 18, was a first-year student at the university and was set to play defensive back on the school’s football team.
“The Athletics Department, our student-athletes and the entire campus mourn the loss of this bright and promising member of our community,” UMaine President Joan Ferrini-Mundy said. “We ask all to keep him, his family and his friends in your thoughts.”
Minor collapsed on the football field during a “supervised light workout” Tuesday at about 1:15 p.m., according to the university. The team’s training staff and first responders were not able to resuscitate him.
“Words cannot express the grief we have following this tragic loss,” UMaine head coach Joe Harasymiak said. “Our thoughts and prayers go out to Darius’ family and friends during this terrible time.”
In high school, Minor led his Orange County High School to three-consecutive post season appearances. He was named All-Central Virginia first-team wide receiver and second-team defensive back in 2017.
The Locust Grove teen was to be a political science major at the University of Maine.
Exposure to fluoroquinolones—one of the most popular classes of antibiotics in the world—is associated with more than double the risk of aortic aneurysm (AA) or aortic dissection (AD), according to a study published online in the Journal of the American College of Cardiology.
Using national databases from Taiwan, researchers analyzed fluoroquinolone prescriptions among 1,213 patients hospitalized for AA or AD from 2001 to 2011. They compared exposure to the drug in the 60 days leading up to the AA/AD event to a randomly selected 60-day interval between 60 and 180 days before the event.
Lead author Chien-Chang Lee, MD, ScD, and colleagues found 1.6 percent of patients had been exposed to fluoroquinolone in the two months leading up to their event, versus only 0.6 percent in a preceding 60-day period. That translated to a 2.71-fold risk of AA/AD related to more recent fluoroquinolone use.
In addition, Lee et al. found that prolonged exposure to the antibiotics further increased risk. Those who were prescribed the drugs for between three and 14 days showed a 2.41-fold increased risk versus no prescription at all, while those prescribed fluoroquinolones for more than 14 days demonstrated a 2.83-fold risk.
“Typically, AA/AD develop slowly in patients, but our data suggest that use of fluoroquinolone can contribute in the short term to aneurysm progression or rupture that may require emergency department visits and hospitalization,” wrote Lee, with the department of emergency medicine at National Taiwan University Hospital, and coauthors.
Population-based studies support that AA and AD are rare diseases, occurring in between three and 20 people per 100,000 population each year. However, annual incidence among elderly individuals rises to as much as 130 per 100,000 people, the researchers noted.
Despite the relative rarity of the conditions, Lee et al. suggested the rising prescriptions of fluoroquinolones may be cause for concern, particularly since AA and especially AD are life-threatening without timely treatment.
The authors estimated 25.2 million U.S. outpatients were prescribed fluoroquinolones in 2012, which they calculated would result in an additional 2,591 cases of AA/AD.
“In the United States alone, fluoroquinolone prescriptions have more than tripled, from 7 million in 1995 to 22 million in 2002. With an estimated 25 million people prescribed with fluoroquinolones in the United States annually, which is expected to increase even more, it is clear that fluoroquinolones may contribute substantially to the current and future burdens of AA/AD.”
In a related editorial, Sonal Singh, MD, MPH, and Amit Nautiyal, MD, noted fluoroquinolones “have been known to cause tendon rupture mediated by their adverse effects on collagenous structures”—and the aorta is rich in type I and type III collagen.
“Although the exact biological mechanism remains unknown, several plausible mechanisms have been proposed to explain how fluoroquinolones might affect the synthesis or structural integrity of collagen in the aortic wall,” Lee and colleagues wrote. “First, fluoroquinolones have chelating properties against several metal ions (e.g., calcium, magnesium, aluminum), which are essential for type 1 collagen synthesis. Second, fluoroquinolones can decrease collagen synthesis by increasing the expression of matrix metalloproteinases, which lead to extracellular matrix degradation and medial layer degeneration.”
Based on the biological plausibility of those experimental studies—as well as the consistently increased risk found in epidemiological research—Lee et al. believe there is strong evidence to support that fluoroquinolone contributes to the incidence of AA and AD.
“Although the rare incidence of AA/AD attenuates the public health impact, the rapid increase of fluoroquinolone consumption still poses a large burden of AA/AD in the general population,” they wrote. “Clinicians are advised to consider alternative antibiotic regimens in patients with pre-existing collagen-related disorder or aortic aneurysm.”
Singh and Nautiyal agreed, saying the “cumulative strength” of multiple studies, with different designs and different patient populations, makes it unlikely an unknown confounding factor is biasing all of the studies.
“It would be prudent to entertain the possibly of aortic aneurysms/aortic dissection associated with fluoroquinolones use in patients presenting with chest pain, shortness of breath, or syncope after recent exposure to the fluoroquinolones,” they wrote. “Although one should be careful in extrapolating from mechanistic studies, judicious use of fluoroquinolones may be particularly warranted among patients with risk factors for aortic aneurysms such as increasing age, the presence of smoking, hypertension, and Marfan’s syndrome.”
Hope this finds you well, I am working on the grant application for PCORI as I mentioned to you earlier. So more information will be coming in the next week.
“Also, I recently published these manuscripts recently that you may find to be of interest to your readership’
Association of variant arch anatomy with type B aortic dissection and hemodynamic mechanisms
· Type of Research: Retrospective cohort study
· Take Home Message: Compared with 367 controls, variant arch anatomy was observed on computed tomography scans of 40.5% of 185 patients with type B aortic dissection. On four-dimensional flow magnetic resonance imaging, patients with bovine arch had higher systolic wall shear stress compared with those with normal arch anatomy.
· Recommendation: This study suggests that aortic arch anatomy variants are more common in patients with type B aortic dissections, which might be explained by higher wall sheer shear stress.
Endovascular thoracic aortic repair in confirmed or suspected genetically triggered thoracic aortic dissection
· Type of Research: Retrospective analysis of prospectively collected National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) data
· Take Home Message: In 31 patients with descending thoracic aorta dissection treated with thoracic endovascular aortic repair, 13 (42%) required reintervention at a median of 7 months, 3 for retrograde ascending aorta dissection and 7 for thoracoabdominal aortic aneurysm repairs with stent graft explantation.
· Recommendation: This study suggests that patients with genetically triggered descending thoracic aorta dissection, treated with thoracic endovascular aortic repair, have a high risk of retrograde aortic dissection and reintervention.
Testing patterns for genetically triggered aortic and arterial aneurysms and dissections at an academic center
· Type of Research: Retrospective cohort study
· Take Home Message: In 36% of 75 patients suspected of having heritable mutations related to aortic or arterial aneurysms or dissections, genetic testing results were positive. Pathogenic mutation was confirmed in 57% of patients with a family history of diagnosed mutation and in 42% of those with a personal history of ascending aortic disease.
· Recommendation: The authors suggest appropriate genetic consultation and selective testing in patients suspected of having genetically triggered vascular disease and suggest the need for novel gene discovery.
Sherene Shalhub, MD MPH FACS
Associate Professor of Surgery
Division of Vascular Surgery
University of Washington
There was a low growth rate for moderately dilated ascending aorta, according to a systematic review and meta-analysis published in JAMA Network Open.
Ming Hao Guo, MD, of the division of cardiac surgery at University of Ottawa Heart Institute, Canada, and colleagues analyzed data from 8,800 patients (mean age, 58 years; 76% men) from 20 studies from 1946 to May 2017. Studies were included in the meta-analysis if they reported rate of dissection or rupture, growth rate or all-cause mortality in patients with ascending aortic aneurysm.
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Data that were extracted include study design, demographics, follow-up, sample size, initial aneurysm diameter, patient risk factors and comorbidities, incidence of dissection or rupture, aneurysm growth rate during follow-up, incidence of elective ascending aortic surgery, size at dissection or rupture and all-cause mortality. Total follow-up time was 31,823 patient-years.
At enrollment, the mean initial aneurysm size from 13 studies was 42.6 mm.
All studies had a combined effect estimate for annual growth rate of 0.61 mm per year (95% CI, 0.23-0.99; I2 = 92%). During a median follow-up of 4.2 years, the pooled incidence of elective aortic surgery was 13.82% (95% CI, 6.45-21.41; I2 = 56%).
The linearized rate of the composite outcome of aortic dissection, all-cause mortality and aortic rupture was 2.16% per patient-year (95% CI, 0.79-3.55, I2 = 64%). The linearized rate for all-cause mortality was 1.99% per patient-year (95% CI, 0.83-3.15; I2 = 84%).
Researchers did not find a significant relationship between the year of study completion and primary outcomes and initial aneurysm size.
“These results require cautious interpretation as a large number of patients in the studies who met guideline criteria for intervention underwent elective aortic surgery,” Guo and colleagues wrote. “More robust natural history data from prospective studies or randomized clinical trials are necessary to better inform clinical decision-making in patients with ascending aortic disease.”
In a related editorial, Thoralf M. Sundt, MD, chief of the division of cardiac surgery and director of the Corrigan Minehan Heart Center at Massachusetts General Hospital, wrote: “To be sure, for patients, once they have been told they have an aneurysm (read, ‘time bomb in your chest’), it is very hard to turn back the clock and reassure them that the likelihood of a catastrophe is low. I suspect the same is true, to some degree, among caregivers. Who among us wants to sit by watching and hoping that we do not get a phone call that an aorta has dissected? Furthermore, our outcome information is asymmetric. The absence of dissection is a nonevent; we do not see it because there is nothing to see. And, of course, we can never know how many of those aortas we replace would or would not have dissected.” – by Darlene Dobkowski
Disclosures: The authors and Sundt report no relevant financial disclosures.
Laurie Gonzales-Lewis of Idaho Falls nearly died during surgery to repair an aortic aneurism. | Courtesy photo
IDAHO FALLS – Members of the community are coming together to help an Idaho Falls woman.
Laurie Gonzales-Lewis recently suffered an aortic aneurism. Brittni Messenger, Lewis’ daugher, tells EastIdahoNews.com the aorta began to expand like a balloon. Fluid began leaking in to Lewis’ heart and started crushing it.
When doctors began surgery to repair the problem, they discovered Lewis had an aortic dissection, which was causing her aorta to unravel from the inside out.
“It was shooting blood clots straight up her brain and down to her leg,” Messenger says.
Gonzales-Lewis’ heart stopped twice during this procedure. She spent the next ten days in sedation. Messenger says her mom was declared brain dead and only given a 15-percent chance of survival.
Then, just two days later, Gonzales-Lewis woke up. For three days, everything seemed normal until doctors noticed something unusual.
“The clots were killing all the tissue. It was causing her excruciating pain until blood flow in the the top half of her right foot stopped,” Messenger says.
Doctors amputated her right leg from the knee down.
Gonzales-Lewis’ condition now requires constant care. Messenger says her step-dad is so busy taking care of her mom that he is unable to work. Disability and insurance benefits don’t kick in until October, leaving them with no means of financial support.
Now Messenger and others are hosting a fundraiser to help with medical costs and a prosthetic leg for Lewis.
The fundraiser kicks off at 5 p.m. Saturday inside York Hall at 954 W. 65th S. Dinner will be served, followed by a raffle around 6:30 p.m.
The cost is $18 for adults, $8 for kids six and up. Kids five and under are free. Each purchase comes with a $5 raffle ticket.
“Anything (people can contribute) is so appreciated right now. It’s been such a hard time for her. It’s completely changed her lifestyle and she’s had to readapt to everything. But it’s amazing that she’s here and we are grateful for the community support,” says Messenger.
York Hall is located in the vicinity of the Budweiser plant.
To learn more about the Benefit dinner and raffle, visit their Facebook page.
My name is Amy Johnson, and my husband, Pete, and I recently started the Rock from the Heart project. Pete is a musician (drummer) and had surgery last July to repair an ascending aortic aneurysm and replace his aortic valve. We know how fortunate he was that his condition was diagnosed in time to save his life. Before his surgery, Pete said, “if I survive this, I want to do something BIG to help others. I don’t want to just go on with life. I want to make a difference.” So, last December we came up with the Rock from the Heart idea. We reached out to several organizations and ended up partnering with the John Ritter Foundation and are planning the Rock from the Heart concert to raise awareness. Since your organization is also focused on the cause, we wanted to get the information to you.
Here is a link to our website: www.rockfromtheheart.org
The concert (scheduled for Feb 2019) will feature a nationally known music act and held at the Pantages Theater in downtown Minneapolis (seats 1000). Tickets will be $49 for the concert and $200 for a special VIP reception prior to the concert (at which some local and national celebrities will be in attendance.) We plan to announce the event and open ticket sales in mid to late August, but we are starting to pull together our event volunteers and fundraising efforts now. I’m reaching out to other organizations who might be willing to help us in some way, whether it is getting involved in the event planning/ fundraising, attending the event, or simply sharing the event (once the date is closer).
Let me know if you’d like to be involved in some way. Below are links to our Facebook, Twitter and Instagram accounts. Our mission is to raise awareness for aortic health, providing accurate information about bicuspid valve disease and aortic aneurysms by reaching out to the community through music.
Thanks for reading. I’ve visited your website and love how you are sharing valuable information in an easy to use format.
Here is a photo of me, my husband Pete, and Tia and Carin from Aortic Hope – they came out to see Pete drum last night:
Event Chair/ Project Director
Rock from the Heart
Predictors of acute aortic dissection diagnosis identified
Ohle R, et al. Acad Emerg Med. 2018;doi:10.1111/acem.13356.
April 11, 2018
Aortic aneurysm and hypotension were among the clinical features identified as putting patients at high risk for acute aortic dissection in a case-control study.
Robert Ohle, MSc, MA, MB, FRCPC, from the department of emergency medicine, the Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada, and colleagues conducted a historical matched case-control study of adults presenting to two tertiary care EDs or one regional cardiac referral center with possible acute aortic dissection between 2002 and 2014.
When to Intervene in Aortic Dissection
TEVAR may be preferable to medical management in…
Aortic valve replacement procedures increased in…
The researchers analyzed 194 patients with nontraumatic acute aortic dissection confirmed by CT or echocardiography and 776 age- and sex-matched controls who had a triage diagnosis of truncal pain but no clear diagnosis upon basic investigation (mean age, 65 years; 67% men).
Ohle and colleagues found that acute aortic dissection could be ruled out by absence of abrupt-onset pain (sensitivity = 95.9%; negative likelihood ratio = 0.07; 95% CI, 0.03-0.14).
They determined the following factors can help rule in a diagnosis of acute aortic dissection:
presence of tearing/ripping pain (specificity = 99.7%; positive likelihood ratio = 42.1; 95% CI, 9.9-177.5);
aortic aneurysm (specificity = 97.8%; positive likelihood ratio = 6.35; 95% CI, 3.54-11.42);
hypotension (specificity = 98.7%; positive likelihood ratio = 17.2; 95% CI, 8.8-33.6);
pulse deficit (specificity = 99.3%; positive likelihood ratio = 31.1; 95% CI, 11.2-86.6);
neurologic deficits (specificity = 96.9%; positive likelihood ratio = 5.26; 95% CI, 2.9-9.3); and
a new murmur (specificity = 97.8%; positive likelihood ratio = 9.4; 95% CI, 5.5-16.2).
“Patients with one or more high-risk feature … should be considered high risk, whereas patients with no high-risk and multiple low-risk features (absence of abrupt-onset pain, history of ischemic heart disease and diabetes) are at low risk for acute aortic dissection,” the researchers wrote.
History of ischemic heart disease decreased the probability of an acute aortic dissection diagnosis, but this was “likely due to it being a risk factor for an alternative diagnosis such as acute coronary dissection,” Ohle and colleagues wrote.
“Ohle [and colleagues] have done a great job at telling us how acute aortic dissection presents to emergency departments,” Lane McNeil Smith, MD, PhD, assistant professor, Lexington Emergency Medicine, Wake Forest Baptist Health, said in a press release. “Are we finally on the verge of a decision rule for this disease that improves our miss rate without ballooning nontherapeutic imaging and costs? This study is a step in the right direction and the authors are in a good position to find the right balance of improved accuracy and increased cost.” – by Erik Swain
Disclosures: The authors and Smith report no relevant financial disclosures.
At ISET 2018, Michael Dake summed up the unmet clinical needs for type A and chronic type B dissection, as well as for cases with arch involvement.
Michael Dake, MD (Stanford University, CA), who gave a rundown of what’s coming next at the International Symposium on Endovascular Therapy 2018 here, said that while the US Food and Drug Administration broadly approved thoracic endovascular aortic repair (TEVAR) for use in all type B dissections back in 2013, such “‘blanket approval’ comprises a number of different distinct entities associated with type B dissection—complicated, chronic, uncomplicated—all these things.”
Chronic type B dissection “stands out,” Dake said, as a poor fit for TEVAR. Good results are possible but not guaranteed, he continued. There may be continued perfusion and aneurysm degeneration distal to the treated area. Adjunctive false-lumen techniques, from coils to liquid embolics, abound, Dake acknowledged, “but there’s nothing definitive . . . that really can take care of this,” and branched devices involve “long procedures [with] high radiation and still carry significant frequency of endoleaks and complications.”
Instead, converting the type B dissection to aneurysm seems to be the best solution in the near term, Dake said.
Among the type B dissection subsets, “there’s a lot of not-so-subtle differences” that must be considered when thinking about “new horizons,” he observed. Additionally, there are many unanswered questions and unmet clinical needs, Dake said. For instance, he reported, half of attendees polled at last year’s Houston Aortic Symposium said they’d continue medical therapy in a patient with acute uncomplicated type B aortic dissection who was asymptomatic, while 48% chose TEVAR. “That’s a flip of a coin. We have complete equipoise here,” he stressed.
Over the last decade there’s been an attempt to find ways to predict which patients will have disease progression and late aortic events or mortality, in order to “justify a rationale of treating them early” when needed, Dake said. Numerous factors have been identified: aorta and false lumen size, use of calcium channel blockers, gender, age, ulcer-like projections, and the size, location, and number of tears, among other things.
“So, can we predict who is at high risk of expansion or late complications? Yes, we can, but we’re just not very accurate, and there’s a confusing array of too many predictors,” Dake said. Adding a single high-risk factor, specifically aortic diameter > 45 mm, to the scenario posed in the Houston poll tipped the scales, he reported. With that, fully 94% of those present recommended TAVR.
Importantly, though, it’s a question not just of who we should treat but also who we shouldn’t treat, according to Dake. He suggested that medical therapy is the best route for some patients, such as those with chronic type B dissection, connective tissue disease, or a need for chronic anticoagulation, or in cases where there’s unsuitable or unreconstructable access to the aorta. “There are pathology considerations, there are anatomic considerations,” he emphasized.
Who Can We Treat Better?
For dissection with arch involvement, another area in need, one potential solution may be the TAG thoracic branch endoprosthesis (Gore), which Dake and others are currently studying in a pivotal trial. He reported that 58 patients with type B dissection have been treated so far, with two strokes occurring (3.4%), both late.
Lastly, for type A dissection, Gore is conducting an early feasibility study to test a dedicated device, he said.
“A little more on the horizon is this idea of a combined valve conduit including the ascending aorta married to an endovascular valve,” Dake said. Despite proof-of-concept and first-in-human studies, he added, “it’s something that’s not ready for prime time.”
Until these efforts bear fruit, the “current focus of endovascular dissection management is expanding to include not only who we should treat, but who we should treat better,” he concluded. “[For example, the field is moving to increase our prognostic scope beyond how to assess the individual risk to a patient with uncomplicated type B dissection toward how to best predict the risk of disease progression after TEVAR.”
“You’re the last person I would have expected…,” he said trailing off, as I sat there for a check-up two weeks after emergency open heart surgery that saved my life.
Six months earlier, I had passed my annual physical with flying colors.
Years of aerobics, spinning, distance cycling and wrangling a 90 pound Golden Retriever on treks through the woods had left me in good stead. At 62, my heart was strong. My blood pressure was well within the bounds of normal. Everything looked fine.
Then we got to Labor Day.
Around noon, I went to my plot at the community garden about a mile from home to harvest the final fruits of summer for a cookout that evening. When I bent down I felt a sudden excruciating pain shoot through my sternum, up the side of my neck, around my ear and down my jaw.
It lasted maybe five seconds.
I thought about calling for help, but I didn’t collapse. I wasn’t short of breath and my chest didn’t hurt.
So, I gathered my harvest and headed home.
Later that afternoon, I began to feel nauseous. By the time we put the steaks on the grill, I couldn’t stand the smell of food.
My sister, who has been a nurse for years, called to chat and asked about my day.
When I told her what was going on, she was quick to respond.
“You’ve just described the symptoms of a heart attack in a woman. You need to get to the emergency room now,” she said.
When I balked, protesting that the ER would be too busy on a holiday weekend and said I would gladly go in the morning, she doubled down.
“You’ll be dead in the morning,” she said, growing angry at my reticence.
I’ll be wearing red on Friday for Go Red for Women Day, to raise awareness about women’s heart health, and I’m glad I listened to her.
After sitting in the ER for several hours, physicians baffled at my condition ordered a CT scan.
Shortly after the test, a doctor with a horrified look on his face came in and told me I needed to get to Pittsburgh, now.
It wasn’t a heart attack. My heart was fine. But I had suffered a thoracic aortic aneurysm dissection. A weak spot in the biggest artery in my body — the one in which oxygenated blood flows from the heart to nourish the rest of the body — had given out and I was slowly dying.
Within an hour, I was on a helicopter headed for UPMC Shadyside. A surgical team met me in the operating room in the early hours of the morning. They quickly sawed open my chest, stitched a Dacron patch around my aorta and closed me back up.
I’m told the patch should last a lifetime.
We’ve since learned that this condition tends to run in families. Doctors don’t know exactly what gene or genes hold the key to it, but they’ve seen patterns sufficient to raise red flags. In my case, it has emerged over the past 20 years as first my youngest son was diagnosed with an enlarged aorta and more recently as both my mother and her older sister had to have surgery for thoracic aortic aneurysms in their early 80s.
My surgeon assured me my heart was strong and I would recover quickly.
Four days later, I was back home. Within six weeks, I was able to complete a 5K around the track beside the Aerobic Center in Greensburg.
But as I said earlier, I’ll be wearing red this Friday. I’m aware that no one is invincible.
I had a sister who knew how heart issues manifested in women. We all should be so lucky.
Debra Erdley is a Tribune-Review staff writer. Reach her at 412-320-7996, firstname.lastname@example.org or via Twitter @deberdley_trib.
DALLAS– At the young age of 35 years-old, Mary Worthman is a wife, a mom, and a miracle — because she’s alive.
Click that article source button to watch the video please.
Surgeons saved Mary’s life of last year. Now, the Fort Worth woman is opening her heart, again. But, this time it’s to say thank you.
Mary had an aortic dissection, basically a tear in her heart. Most people who have one of those don’t ever even make it to the hospital. But, Mary did. And doctors saved her life.
Two open heart surgeries later, she’s meeting the doctors and nurses who saved her life.
“How the heck are you, Doc?” asks Mary’s husband as he grabs Dr. Michael Nazarian’s hand for a firm handshake. “Good to see you; you get a hug.” Dr. Narzarian tells Mary. “Aww, thanks.” she responds as she hugs him back.
“I try and not to focus on the things I can’t do, just be grateful that I am here and everything.” Mary tells the doctor and nurses.
“It’s always cool,” Dr. Narzarian says. “For me, that’s the fun. like you get to meet people in some very precarious situations, where they are in life-threatening situations, and you help them through it. And when results are good, which they usually are, it’s great.”
This type of celebration seems to be a thing now.
You may recall the teen whose video went viral online. He was looking for the nurse who saved his life during a car crash 17 years ago. A crash that killed his parents.
Caleb and his family Skyped with some caregivers at Medical City McKinney.
Dumfarth J, et al. – Researchers aimed at identifying the predictors for stroke after emergent surgery for acute type A aortic dissection. In addition, they analyzed the impact on morbidity, neurological recovery and mid-term survival. Independent preoperative predictors for postoperative stroke were recognized. Despite an association of postoperative stroke with significant morbidity and postoperative complications, data could not confirm a significant impairment in mid-term survival. Data revealed that postoperative stroke was associated with significant morbidity and postoperative complications, however, its association with significant impairment in mid-term survival could not be confirmed.
Articles, see p 250 and p 259
The diagnosis of acute aortic dissection (AD) can be difficult because of its rarity and varied presentation, and this often leads to underdiagnosis. Recent guidelines from both the United States (American Heart Association and American College of Cardiology)1 and Europe (European Society of Cardiology)2 have made recommendations on diagnostic algorithms to improve care.
The American Heart Association/American College of Cardiology guidelines published in 2010 proposed using the Aortic Dissection Detection Risk Score (ADD-RS) as a primary screening tool. The ADD-RS is based on scoring the presence of 3 categorical risks: high-risk conditions (Marfan syndrome, family history of aortic disease, known aortic valve disease, known thoracic aortic aneurysm, or previous aortic manipulation including cardiac surgery), pain features (chest, back, or abdominal pain described as being of abrupt onset, severe intensity, or ripping/tearing), and examination features (evidence of perfusion deficit including pulse deficit, systolic blood pressure difference or focal neurological deficit, or with aortic diastolic murmur and hypotension/shock). The presence of ≥1 markers within each of these categorical features is given a score of 1 with a maximum cumulative score of 3, if all 3 categorical features are present. A score of 0 is considered low risk, a score of 1 is considered intermediate risk, and a score of 2 or 3 is considered to be high risk. The ADD-RS was investigated in the International Registry of Acute Aortic Dissection database in 20113 using the International Registry of Acute Aortic Dissection’s large contemporary repository of AD cases with documentation of clinical presentation and features, management, and outcomes. The study in 2538 cases validated that the ADD-RS has a high sensitivity of 95.7%.