Spectrum of ascending aortic aneurysms at a peri-urban tertiary hospital: an echocardiography-based study.

Introduction: Thoracic ascending aortic (TAA) aneurysms are an important cause of disability and death and require early detection for effective management. Currently, there is a paucity of data from Africa pertaining to TAA aneurysms. This study describes the spectrum of TAA aneurysms at a peri-urban tertiary hospital. Methods: A descriptive retrospective study based on clinical and echocardiographic imaging data of patients with TAA aneurysms from October 2017-October 2022. Advanced strain imaging was performed to measure left ventricular (LV) basal, apical, and global longitudinal strain as well as circumferential strain (CS) of the ascending aorta as a proxy measurement of aortic compliance. Results: The study comprised 139 cases of TAA aneurysms (52.5% females) with a mean age of 50 ± 14.8 years with 45 age and gender matched controls. Most cases (95%) were of African ethnicity. The main etiologies were hypertension (41.7%), HIV (36.6%), connective tissue disease (10.7%), congenital (2.2%) and mixed pathologies (8.6%). Two-thirds of patients (69.7%) presented in heart failure, 10% presented with aortic dissection. Thirty percent of the patients were classified as New York Heart Association (NYHA) class I, 59.7% NYHA II, 8.6% NYHA III and two patients NYHA class IV. Echocardiography revealed enlarged aortic dimensions compared to controls (P < 0.001). TAA aneurysms were complicated by severe aortic regurgitation (AR) in half (50.3%) of patients, moderate AR in 25.8%, and mild AR in 14.3%. The mean LV ejection fraction (46.9 ± 12.7%) was reduced compared to controls (P < 0.001). Aortic CS was reduced compared to controls [4.4 (3.2-6.2) % vs. 9.0 (7.1-13.4) %, P < 0.001]. Aortic stiffness was higher in the aortic aneurysm group compared to controls (15.39 ± 20.65 vs. 5.04 ± 2.09, P = 0.001). LV longitudinal strain (-13.9 ± 3.9% vs. 18.1 ± 6.7%), basal CS (-13.9 ± 5.6% vs. -17.9 ± 5.8%) and apical CS (-8.7 ± 8.5% vs. -30.6 ± 3.8%) were reduced compared to controls (P < 0.001). Most patients were on diuretic and anti-remodeling therapy. Surgery was performed in 29.4% and overall mortality was 7.9%. Mortality for acute aortic dissection was 40%. Conclusion: TAA aneurysms associated with hypertension and HIV are common in this predominantly African female population and are associated with considerable morbidity and mortality. Two-dimensional echocardiography and advanced strain imaging are potential tools for detecting and risk stratifying TAA aneurysms.

Evaluation of aortic wall strength in human immunodeficiency virus associated thoracic ascending aortic aneurysm: a pilot study.

Background: Human immunodeficiency virus (HIV) associated aortopathy is associated with considerable morbidity and mortality. The pathophysiology of aortic wall strength in HIV thoracic aortic aneurysm has not been studied. Methods: The patients with HIV associated thoracic ascending aortic aneurysm (TAAA) were enrolled in the study and underwent surgery as part of their routine management. We compared collagen quantity in aneurysmal and non-aneurysmal aortic tissue in TAAA with regards to hydroxyproline concentration as a surrogate measure for collagen content and sent aneurysmal aorta for routine clinical histological assessment. This data was analysed to identify potential relations between aortic aneurysm formation and the collagen content of the aortic wall. Results: The study included 12 patients with HIV aortopathy (9 females, median age 49 years). In total 33 tissue samples were investigated (14 aneurysmal, 13 non-aneurysmal aortic tissue and 6 aortic leaflets). There was no difference in hydroxyproline concentration of aneurysmal aortic tissue and seemingly normal tissue [19.40 (15.19-22.98) vs. 20.85 (15.55-25.83) µg/mg; P=0.82]. No difference was noted in hydroxyproline concentration among aneurysmal, seemingly normal aortic tissue and aortic valve leaflets [19.40 (15.19-22.98) vs. 20.85 (15.55-25.83) vs. 19.09 (13.94-22.00) µg/mg; P=0.86]. Histology showed fragmentation of elastin fibres in 50% of the cases. Conclusions: No difference in collagen concentration in the aneurysmal and non-aneurysmal aortic tissue was noted. However, most of the aneurysmal tissue had fragmentation of elastin fibres.

Perioperative outcomes of coronary artery bypass graft surgery in Johannesburg, South Africa.

BACKGROUND: The perioperative complications in patients with coronary artery disease undergoing coronary artery bypass graft (CABG) surgery have been reported predominantly from developed countries, with a paucity of data from sub-Saharan Africa. We aim to report on the clinical characteristics and perioperative complications in patients with obstructive coronary artery disease, managed with CABG surgery at a tertiary academic hospital in Johannesburg, South Africa. METHODS: We retrospectively reviewed data from adult patients who underwent CABG surgery during a 17-year period (January 2000 - December 2017). Data was collected from the cardiothoracic surgery department's pre- and postoperative reports, the cardiology department's medical records, and anaesthesiology's intra-operative reports. We collected demographic, biochemical, clinical, surgical, echocardiographic, and angiographic data. Outcomes data collected included perioperative complications and mortality. RESULTS: We analysed 1218 consecutive patient records. The study cohort consisted of 951 (78.1%) males, and the mean age was 60.1 ± 10.1 years. During the study period, 137 (11.2%) patients demised with cardiac and sepsis-related causes of death accounting for 49.6 and 37.2%, respectively. Other perioperative complications included excessive bleeding in 222 (18.2%), prolonged ventilation (exceeding 48 h) in 139 (11.4%), and sternal sepsis in 125 (10.3%). On univariate logistic regression analysis, advanced age, a lower left ventricular ejection fraction, smoking, increased cardiopulmonary bypass (CPB) time, and a higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) II were all significantly associated with mortality. The EuroSCORE II [OR: 0.15 95%CI: 0.09-0.22; p = 0.000], and prolonged CPB time [OR: 0.01 CI: 0.00-0.02; p = 0.000] were independent predictors of in-hospital all-cause mortality. CONCLUSIONS: In our study, the crude perioperative mortality rate was 11.2%. Our mortality rate was significantly higher than the mortality rates reported in other developed and developing countries. To better understand the factors driving this high mortality rate, a prospective outcomes registry has been initiated, and this promises to inform on our contemporary mortality and morbidity outcomes.

A Case of Severe Tricuspid Regurgitation Related to Traumatic Papillary Muscle Rupture.

A 25-year-old male presented after a motor vehicle accident with tricuspid valve (TV) regurgitation, due to a flail TV secondary to papillary muscle rupture. We highlight the importance of three-dimensional echocardiographic imaging of the tricuspid valve and its utility in aiding a successful surgical repair.