Thoracic endovascular repair versus medical management for acute uncomplicated type B aortic dissection.

BACKGROUND: Current treatment options and outcomes for acute uncomplicated thoracic Type-B aortic dissection (TBAD) remain unclear between medical management (MED) and thoracic endovascular aortic repair (TEVAR). In this study we aim to compare both strategies in terms of all-cause mortality, aortic dilation, and aortic rupture. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1990 through March 2017. Only studies comparing TEVAR to MED for acute uncomplicated TBAD were included. Random-effects meta-analysis was used to pool outcomes across studies. Study outcomes included short (1 month), intermediate (1 year), and mid-term (2-5 year) all-cause mortality. Additional outcomes included aortic dilation and rupture at 1 year. RESULTS: A total of 1,960 patients (64.3 years; 75.8% male) were included from six studies (one prospective and five retrospective). No difference was observed in short-term (odd ratio [OR] 0.73 with 95% confidence interval [CI] 0.47 to 1.12, P = 0.15), intermediate (OR 0.99 with 95% CI 0.56 to 1.73, P = 0.96), or mid-term all-cause mortality (OR 1.12 with 95% CI 0.54 to 2.32, P = 0.75). No difference in aortic dilation with either modality was noted at 1-year (OR 1.11 with 95% CI 0.76 to 1.64, P = 0.59). TEVAR was associated with a significantly lower 1-year risk of aortic rupture (OR 2.49 with 95% CI 1.23 to 5.06, P = 0.01). CONCLUSION: There were no short, intermediate, or mid-term differences in mortality between TEVAR or MED in patients with acute uncomplicated TBAD. Although the dilation rate was similar between both groups, TEVAR was associated with lower likelihood of aortic rupture at 1 year.

The Role of Cardiac Magnetic Resonance Imaging in Hypertrophic Cardiomyopathy.

Until recently, the only imaging technique for the diagnosis and management of hypertrophic cardiomyopathy (HCM) was two-dimensional echocardiography, and the use of cardiac magnetic resonance imaging (cMRI) was limited to patients with poor acoustic windows. Now, cMRI has gained an essential role in the diagnosis of HCM, providing superior visualization of myocardial hypertrophy-even in remote zones of the left ventricle-and visualization of subtle changes in thickness and contractility over time. The morphologic accuracy of cMRI allows for the differentiation of HCM from other pathologic conditions with hypertrophic phenotype. Moreover, cMRI sheds light on the in vivo fibrotic changes in cardiac ultrastructure, offering an important advantage in the understanding of pathologic mechanisms of the disease, allowing early identification, risk stratification, and timely therapeutic management.

New paradigms in the management of acute type B aortic dissection.

PURPOSE OF REVIEW: Type B aortic dissection is a relatively uncommon and multifaceted disease, whose management is ongoing debated. Its wide range of clinical presentations and anatomical features hamper the early identification and medical management. In the past few years, the introduction of endovascular techniques opened new paradigms in comprehension and management of aortic diseases. Aim of this review is to discuss contemporary therapeutic approaches of acute type B aortic dissections highlighting the growing role of thoracic endovascular aortic repair (TEVAR) in focusing its complex physiopathology. RECENT FINDINGS: Prompt medical therapy followed by endovascular repair should be considered as the gold standard in complicated acute type B aortic dissection. Moreover, recent findings also suggest a potential benefit in case of uncomplicated cases. SUMMARY: Management of acute type B aortic dissection is progressively shifting into endovascular approach. However, further studies are warranted to define the optimal treatment strategy in each subset of patients and anatomical features.

Stroke and outcomes in patients with acute type A aortic dissection.

BACKGROUND: Stroke is a highly dreaded complication of type A acute aortic dissection (TAAAD). However, little data exist on its incidence and association with prognosis. METHODS AND RESULTS: We evaluated 2202 patients with TAAAD (mean age 62 ± 14 years, 1487 [67.5%] men) from the International Registry of Acute Aortic Dissection to determine the incidence and prognostic impact of stroke in TAAAD. Stroke was present at arrival in 132 (6.0%) patients with TAAAD. These patients were older (65 ± 12 versus 62 ± 15 years; P=0.002) and more likely to have hypertension (86% versus 71%; P=0.001) or atherosclerosis (29% versus 22%; P=0.04) than patients without stroke. Chest pain at arrival was less common in patients with stroke (70% versus 82%; P<0.001), and patients with stroke presented more often with syncope (44% versus 15%; P<0.001), shock (14% versus 7%; P=0.005), or pulse deficit (51% versus 29%; P ≤ 0.001). Arch vessel involvement was more frequent among patients with stroke (68% versus 37%; P<0.001). They had less surgical management (74% versus 85%; P<0.001). Hospital stay was significantly longer in patients with stroke (median 17.9 versus 13.3 days; P<0.001). In-hospital complications, such as hypotension, coma, and malperfusion syndromes, and in-hospital mortality (adjusted odds ratio, 1.62; 95% confidence interval, 0.99-2.65) were higher among patients with stroke. Among hospital survivors, follow-up mortality was similar between groups (adjusted hazard ratio, 1.15; 95% confidence interval, 0.46-2.89). CONCLUSIONS: Stroke occurred in >1 of 20 patients with TAAAD and was associated with increased in-hospital morbidity but not long-term mortality. Whether aggressive early invasive interventions will reduce negative outcomes remains to be evaluated in future studies.

Meta-analysis of bioabsorbable versus durable polymer drug-eluting stents in 20,005 patients with coronary artery disease: an update.

OBJECTIVES: To perform an updated meta-analysis comparing biodegradable polymer drug eluting stents (BP-DES) and durable polymer drug eluting stents (DP-DES). BACKGROUND: BP-DES have been suggested to reduce late stent thrombosis (LST) rates as compared to first generation DP-DES. Recently, second generation DP-DES have replaced older DES, but comparison of these stents with BP-DES has not yielded consistent results. METHODS: Medline/Web databases were searched for studies comparing BP-DES and DP-DES, and reporting rates of overall/cardiac mortality, myocardial infarction (MI), LST, target lesion revascularization (TLR) and target vessel revascularization (TVR) and late lumen loss (LLL), with a follow-up ≥6 months. RESULTS: Twenty studies (20,005 patients) were included in the meta-analysis. Median follow-up time was 1 year. Compared with DP-DES, BP-DES showed lower LLL (in stent: weighted mean difference WMD -0.45 mm, 95% CI -0.66 to -0.24 mm, P = 0.00001; in segment: WMD -0.15 mm, 95% CI = -0.24 to -0.06 mm, P = 0.001) and lower rates of LST (OR 0.51, 95% CI = 0.30 to 0.86, P = 0.01), although they did not improve mortality, MI, TLR, and TVR rates. BP-DES coated with sirolimus or novolimus, in comparison with biolimus or paclitaxel, were associated with reduced LLL (P < 0.0001 for subgroups). CONCLUSIONS: In comparison with DP-DES, BP-DES significantly reduce LLL and LST rates, without clear benefits on harder endpoints. The efficacy of BP-DES in preserving lumen patency seems larger for sirolimus and novolimus DES.

Marfan and Loeys-Dietz aortic phenotype: A potential tool for diagnosis and management.

Objective: In heritable aortic diseases, different vascular involvement may occur with potential variable implications in aortic dilation/dissection risk. This study aimed to analyze the aortic anatomy of individuals with Marfan syndrome and Loeys-Dietz syndrome to identify possible morphological differences. Methods: Computed tomography and magnetic resonance imaging of the thoracoabdominal aorta from the proximal supra-aortic vessels to the femoral bifurcation level of 114 patients with Marfan and Loeys-Dietz syndromes and 20 matched control subjects were examined. Aortic diameters, areas, length, and tortuosity were measured in different aortic segments using specific vessel analysis software. Results: Patients with Marfan syndrome showed a higher prevalence of ascending aorta and aortic root dilation (P = .011), larger and longer aortic roots (P = .013) with pear-shaped phenotype, larger isthmus/descending aorta diameter ratio (P = .015), and larger suprarenal aorta and iliac arteries. Patients with Loeys-Dietz syndrome showed longer indexed segments and a significantly longer arch (P = .006) with type 2/3 arch prevalence (P = .097). Measurement ratios analysis provided cut-off values (aortic root to ascending aorta length/aortic root diameter, aortic root/sinotubular junction, aortic root/ascending aorta diameter) differentiating patients with Marfan syndrome from patients with Loeys-Dietz syndrome, even in the early stage of the disease. Conclusions: Both syndromes show peculiar anatomic patterns at different aortic levels irrespective of aortic dilation and disease severity. These features may represent the expression of different genetic mutations on aortic development, with a potential impact on prognosis and possibly contributing to better management of the diseases. The systematic adoption of whole body imaging with magnetic resonance or computed tomography should always be considered, because they allow a complete vascular assessment with practical indicators of differential diagnosis.

Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection.

BACKGROUND: Acute aortic intramural hematoma (IMH) is an important subgroup of aortic dissection, and controversy surrounds appropriate management. METHODS AND RESULTS: Patients with acute aortic syndromes in the International Registry of Acute Aortic Dissection (1996-2011) were evaluated to examine differences between patients (based on the initial imaging test) with IMH or classic dissection (AD). Of 2830 patients, 178 had IMH (64 type A [42%], 90 type B [58%], and 24 arch). Patients with IMH were older and presented with similar symptoms, such as severe pain. Patients with type A IMH were less likely to present with aortic regurgitation or pulse deficits and were more likely to have periaortic hematoma and pericardial effusion. Although type A IMH and AD were managed medically infrequently, type B IMH were more frequently treated medically. Overall in-hospital mortality was not statistically different for type A IMH compared to AD (26.6% versus 26.5%; P=0.998); type A IMH managed medically had significant mortality (40.0%), although less than classic AD (61.8%; P=0.195). Patients with type B IMH had a hospital mortality that was less but did not differ significantly (4.4% versus 11.1%; P=0.062) from classic AD. One-year mortality was not significantly different between AD and IMH. CONCLUSIONS: Acute IMH has similar presentation to classic AD but is more frequently complicated with pericardial effusions and periaortic hematoma. Patients with IMH have a mortality that does not differ statistically from those with classic AD. A small subgroup of type A IMH patients are managed medically and have a significant in-hospital mortality.

Correlates of delayed recognition and treatment of acute type A aortic dissection: the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: In acute aortic dissection, delays exist between presentation and diagnosis and, once diagnosed, definitive treatment. This study aimed to define the variables associated with these delays. METHODS AND RESULTS: Acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and January 2007 were evaluated for factors contributing to delays in presentation to diagnosis and in diagnosis to surgery. Multiple linear regression was performed to determine relative delay time ratios (DTRs) for individual correlates. The median time from arrival at the emergency department to diagnosis was 4.3 hours (quartile 1-3, 1.5-24 hours; n=894 patients) and from diagnosis to surgery was 4.3 hours (quartile 1-3, 2.4-24 hours; n=751). Delays in acute aortic dissection diagnosis occurred in female patients; those with atypical symptoms that were not abrupt or did not include chest, back, or any pain; patients with an absence of pulse deficit or hypotension; or those who initially presented to a nontertiary care hospital (all P<0.05). The largest relative DTRs were for fever (DTR=5.11; P<0.001) and transfer from nontertiary hospital (DTR=3.34; P<0.001). Delay in time from diagnosis to surgery was associated with a history of previous cardiac surgery, presentation without abrupt or any pain, and initial presentation to a nontertiary care hospital (all P<0.001). The strongest factors associated with operative delay were prolonged time from presentation to diagnosis (DTR=1.35; P<0.001), race other than white (DTR=2.25; P<0.001), and history of coronary artery bypass surgery (DTR=2.81; P<0.001). CONCLUSIONS: Improved physician awareness of atypical presentations and prompt transport of acute aortic dissection patients could reduce crucial time variables.

Valiant thoracic stent-graft deployed with the new captivia delivery system: procedural and 30-day results of the Valiant Captivia registry.

PURPOSE: To evaluate procedural and 30-day outcomes of thoracic endovascular aortic repair (TEVAR) employing the Valiant Thoracic Stent Graft with the Captivia Delivery System. METHODS: Enrollment in the study ( www.ClinicalTrials.com identifier NCT01181947) included all eligible patients implanted with the Valiant Captivia System retrospectively and prospectively at 15 sites in Europe and Turkey between October 2009 and June 2010. In the 100 treated patients (81 men; mean age 64.6 ± 12.0 years, range 25-87), indications included descending thoracic aortic aneurysm (TAA, 49.0%) and aortic dissection (42.0%). RESULTS: Technical success was 100.0%, with no misaligned deployments or aortic perforations. Mean follow-up was 68.9 ± 34.9 days (range 20-147, median 61). The 30-day rate of all-cause mortality was 4.0% (all 4 cases procedure-related, 3 device-related). Retrograde type A dissection occurred in 2 patients. The only conversion to open surgery was successful in a patient experiencing intraoperative aneurysm rupture. Stroke occurred in 4 (4.0%) patients and paraplegia in 1 (1.0%). Among 66 patients with 30-day imaging studies evaluable for endoleak, 4 (6.1%) had type I and 7 (10.6%) had type II endoleak; there were no types III or IV. Within 30 days, no secondary endovascular procedures were required due to endoleak. One patient with type II endoleak died 3 weeks postimplantation before scheduled embolization. CONCLUSION: In this analysis of procedural and 30-day results, the high technical success and clinical outcome rates showed that the Valiant Thoracic Stent Graft with the new Captivia Delivery System has promising capacity to treat a variety of thoracic aortic conditions in a range of anatomies.

Thoracic endovascular aneurysm repair for complicated type B aortic dissection.

Endovascular reconstruction of the true lumen by use of minimally invasive stent grafting or stenting is becoming increasingly popular and may have the potential to emerge as the first-line therapy for acute complicated type B dissection. Thoracic aortic dissection can be classified as complicated vs uncomplicated (stable), or anatomically according to the origin of the intimal tear or whether the dissection involves the ascending aorta. Although the outcomes of so-called complicated type B dissection are known to be disastrous with open surgery and disappointing with medical management alone, those patients with complications, such as organ malperfusion syndrome, impending rupture, ongoing pain, and resistant hypertension, may qualify preferentially for endovascular reconstruction of the true lumen. Cumulative extraction of currently available outcomes data and meta-analytic interpretation of the available observational evidence suggest that endovascular stent grafts provide improved survival in the setting of complicated type B dissection today.

Acute type B aortic dissection: current management strategies.

PURPOSE OF REVIEW: Endovascular techniques are increasingly employed to treat patients with acute and chronic diseases of the thoracic aorta. This review focuses on current indication and results of thoracic endovascular stent-graft repair in patients with acute type B aortic dissection. RECENT FINDINGS: In patients with type B acute dissections, endovascular treatment should be considered in the presence of complications such as impending rupture, malperfusion, aneurysmal expansion, and uncontrolled pain or blood pressure. No data exist showing improved outcomes after prophylactic endovascular repair of uncomplicated acute dissections. Thus, primary treatment of asymptomatic patients remains medical. SUMMARY: Endovascular stent-graft repair of complicated type B acute dissection is associated with favorable short-term and mid-term results. Longer-term follow-up is warranted to assess its durability and potential progression of the disease at the downstream aorta.

Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) represents a novel concept for type B aortic dissection. Although life-saving in acute emergencies, outcomes and survival of TEVAR in stable dissection are unknown. METHODS AND RESULTS: One hundred forty patients in stable clinical condition at least 2 weeks after index dissection were randomly subjected to elective stent-graft placement in addition to optimal medical therapy (n=72) or to optimal medical therapy alone (n=68) with surveillance (arterial pressure according to World Health Organization guidelines < or =120/80 mm Hg). The primary end point was all-cause death at 2 years, whereas aorta-related death, progression (with need for conversion or additional endovascular or open surgery), and aortic remodeling were secondary end points. There was no difference in all-cause deaths, with a 2-year cumulative survival rate of 95.6+/-2.5% with optimal medical therapy versus 88.9+/-3.7% with TEVAR (P=0.15); the trial, however, turned out to be underpowered. Moreover, the aorta-related death rate was not different (P=0.44), and the risk for the combined end point of aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgery) was similar (P=0.65). Three neurological adverse events occurred in the TEVAR group (1 paraplegia, 1 stroke, and 1 transient paraparesis), versus 1 case of paraparesis with medical treatment. Finally, aortic remodeling (with true-lumen recovery and thoracic false-lumen thrombosis) occurred in 91.3% of patients with TEVAR versus 19.4% of those who received medical treatment (P<0.001), which suggests ongoing aortic remodeling. CONCLUSIONS: In the first randomized study on elective stent-graft placement in survivors of uncomplicated type B aortic dissection, TEVAR failed to improve 2-year survival and adverse event rates despite favorable aortic remodeling.

Partial thrombosis of the false lumen in patients with acute type B aortic dissection.

BACKGROUND: Patency or thrombosis of the false lumen in type B acute aortic dissection has been found to predict outcomes. The prognostic implications of partial thrombosis of the false lumen have not yet been elucidated. METHODS: We examined 201 patients with type B acute aortic dissection who were enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2003 and who survived to hospital discharge. Kaplan-Meier mortality curves were stratified according to the status of the false lumen (patent, partial thrombosis, or complete thrombosis) as determined during the index hospitalization. Cox proportional-hazards analysis was performed to identify independent predictors of death. RESULTS: During the index hospitalization, 114 patients (56.7%) had a patent false lumen, 68 patients (33.8%) had partial thrombosis of the false lumen, and 19 (9.5%) had complete thrombosis of the false lumen. The mean (+/-SD) 3-year mortality rate for patients with a patent false lumen was 13.7+/-7.1%, for those with partial thrombosis was 31.6+/-12.4%, and for those with complete thrombosis was 22.6+/-22.6% (median follow-up, 2.8 years; P=0.003 by the log-rank test). Independent predictors of postdischarge mortality were partial thrombosis of the false lumen (relative risk, 2.69; 95% confidence interval [CI], 1.45 to 4.98; P=0.002), a history of aortic aneurysm (relative risk, 2.05; 95% CI, 1.07 to 3.93; P=0.03), and a history of atherosclerosis (relative risk, 1.87; 95% CI, 1.01 to 3.47; P=0.05). CONCLUSIONS: Mortality is high after discharge from the hospital among patients with type B acute aortic dissection. Partial thrombosis of the false lumen, as compared with complete patency, is a significant independent predictor of postdischarge mortality in these patients.

Coronary calcifications in end-stage renal disease patients: a new link between osteoprotegerin, diabetes and body mass index?

The aim of the study was to assess the factors potentially involved in coronary artery calcifications (CAC) in end-stage renal disease patients. 253 hemodialysis (HD) patients (92 females, 161 males), aged 62.5 +/- 13.5, who had been on HD treatment for at least 6 months, were enrolled in a cross-sectional study. Calcium-phosphate product (Ca x P), body mass index (BMI), fetuin-A, osteoprotegerin (OPG), osteopontin, transforming growth factor-beta1 (TGF-beta1), fibroblast growth factor-23 (FGF-23) and matrix Gla protein (MGP) were considered. CAC was assessed using multislice spiral computed tomography and calcium score was quantified by means of the Agatston score. The median calcium score was 364 Agatston (range 0-7,336). CAC was detected in 228/253 patients (90.1%). Multivariate regression analysis, adjusted for age and for dialysis vintage, showed that TGF-beta1, OPG and days with Ca x P >55 mg/dl are independent predictors of CAC, while MGP was shown to be a protective factor. Surprisingly, results showed that BMI was a protective factor too: the interpolation with cubic spline function revealed a significant reduction in calcium score in patients with a high BMI (>28). However, when diabetes was considered in the regression analysis, only OPG emerged as a predictor of a high CAC score. The interpolation with spline function continued to show a significant reduction in CAC score in nondiabetic and in diabetic patients with the highest BMI quartile. The protective effect of a high BMI on CAC might represent another example of inverse biology in dialysis patients but it needs to be further addressed in larger longitudinal studies.

Contrast-induced nephropathy in patients undergoing computed tomography (CONNECT) - a clinical problem in daily practice? A multicenter observational study.

BACKGROUND: Although several studies have examined contrast-induced nephropathy (CIN) following computed tomography (CT) procedures under closely controlled clinical trial conditions, less is known about the incidence of CIN (or its key predictive factors) in a "real world" clinical setting. PURPOSE: A multicenter, observational registry study was undertaken in Italian hospital radiology departments to retrospectively assess the incidence of CIN in at-risk patients undergoing iodixanol-enhanced CT procedures. MATERIAL AND METHODS: Each department used center-specific (nonstandardized) CT protocols. Data were available from 493 at-risk patients; most (76.4%) had 1 risk factor for CIN, 19.8% had 2, and 3.4% had 3. In all, 169 patients (34.3%) had reduced renal function (estimated glomerular filtration rate [eGFR] <60 ml/min/1.73m(2)). Prophylactic volume expansion was not used in 70.6% of the study population. RESULTS: The overall incidence of CIN (defined as a > or =44.2 micromol/l [0.5 mg/dl] increase in serum creatinine from baseline 72 h postprocedure) was 2.6%; in the subpopulation of patients with renal impairment (with or without other risk factors), CIN incidence was 4.7%. Multivariate analysis identified renal insufficiency as the only risk factor predictive of CIN (relative risk, 3.850; 95% confidence interval, 1.200-12.348; P=0.023). CONCLUSION: In the clinical setting of hospital CT radiology practice, where guideline-recommended strategies for CIN prevention may not be consistently followed, use of the iso-osmolar agent iodixanol appears to be associated with a low incidence of CIN in at-risk patients.

Intramural Hematoma as Unexpected Complication of COVID-19 Infection.

Novel coronavirus disease-2019 (COVID-19) is an ominous infectious disease that seems capable to attack any organ system, leading in the most severe cases to patient death. COVID-19 has been associated with multiple cardiovascular complications of inflammatory and immune origin, leading to a wide spectrum of vascular damage, myocardial injury, stroke, and pulmonary obstruction. We report the case of a patient with COVID-19 infection who developed an acute aortic syndrome with the characteristics of aortic intramural hematoma.

Devices for thoracic endovascular aortic repair of type B aortic dissection: is there any chance for Marfan syndrome?

INTRODUCTION: Type B aortic dissection (TBAD) is a threatening event that may lead to death for aortic rupture or multivisceral malperfusion in the acute phase and offers a poor prognosis for long term survivors. Thoracic endovascular aortic repair (TEVAR) has become the preferential therapy in acute and chronic complicated cases for its less invasivity compared to open surgery. However TEVAR is still encumbered by a significant number of reinterventions, caused by aortic neck aneurysmal degeneration, endoleaks and stent-graft induced new entry (SINE). This is even more true in patients with particularly fragile aortic wall like Marfan Syndrome (MS) in contrast to the excellent results of elective open surgery. AREAS COVERED: This review analyzes the current available TEVAR devices and techniques in TBAD and their technological advancements, especially those most suitable to TBAD anatomy, according to current literature. EXPERT OPINION: The continuous technological evolution of materials and device solutions ensures solid results of TEVAR in acute TBAD and may also potentially overcome some of the limitations of endovascular devices in this setting, paving the way for safer and more durable results and allowing for expanded indications in the future, even in the delicate population of collagenopathies, especially in MS.

Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice MDCT imaging in patients scheduled for coronary angiography (NIMISCAD-Non Invasive Multicenter Italian Study for Coronary Artery Disease).

This was a prospective, multicenter study designed to evaluate the utility of MDCT in the diagnosis of coronary artery disease (CAD) in patients scheduled for elective coronary angiography (CA) using different MDCT systems from different manufacturers. Twenty national sites prospectively enrolled 367 patients between July 2004 and June 2006. Computed tomography (CT) was performed using a standardized/optimized scan protocol for each type of MDCT system (> or =16 slices) and compared with quantitative CA performed within 2 weeks of MDCT. A total of 284 patients (81%) were studied by 16-slice MDCT systems, while 66 patients (19%) by 64-slice MDCT scanners. The primary analysis was on-site/off-site evaluation of the negative predictive value (NPV) on a per-patient basis. Secondary analyses included on-site evaluation on a per-artery and per-segment basis. On-site evaluation included 327 patients (CAD prevalence 58%). NPV, positive predictive value (PPV), sensitivity, specificity, and diagnostic accuracy (DA) were 0.91 (95% CI 0.85-0.95), 0.91 (95% CI 0.86-0.95), 0.94 (95% CI 0.89-0.97), 0.88 (95% CI 0.81-0.93), and 0.91 (95% CI 0.88-0.94), respectively. Off-site analysis included 295 patients (CAD prevalence 56%). NPV, PPV, sensitivity, specificity, and DA were 0.73 (95% CI 0.65-0.79), 0.93 (95% CI 0.87-0.97), 0.73 (95% CI 0.65-0.79), 0.93 (95% CI 0.87-0.97), and 0.82 (95% CI 0.77-0.86), respectively. The results of this study demonstrate the utility of MDCT in excluding significant CAD even when conducted by centers with varying degrees of expertise and using different MDCT machines.

Correlations of phenotype and genotype in relation to morphologic remodelling of the aortic root in patients with Turner's syndrome.

BACKGROUND: Patients with Turner's syndrome are at risk of aortic dilation and dissection. Currently, it is not known whether such dilation is related to associated cardiovascular abnormalities, or to the genetic anomaly itself. METHODS: We studied echocardiographically 107 patients with genetically proven Turner's syndrome, with heterogeneous underlying karyotypes, and without associated cardiac lesions. Their average age was 19.6 plus or minus 8.4 years. We compared the finding with those from 71 age-matched healthy female volunteers. The diameter of the aorta was measured at the level of the basal attachments of the aortic valvar leaflets, the sinuses of Valsalva, the sinutubular junction, and its ascending component. RESULTS: Compared to control subjects, the patients with Turner's syndrome had larger diameters of the aorta at the level of the sinuses of Valsalva, at 23.4+/-4.8 versus 25.5+/-4.1 millimetres (p = 0.0014), the sinutubular junction, at 19.9+/-3.8 versus 23.3+/-4.1 millimetres (p < 0.0001), and the ascending aorta, at 22.3+/-4.9 versus 24.6+/-4.4 millimetres (p = 0.0011). Dilation of the sinutubular junction, found in just over one-quarter of the patients, was more common than dilation of the ascending aorta, the latter found in less than one-tenth. The patients with Turner's syndrome, therefore, presented with remodelling of the aortic root, with relative dilation of the sinutubular junction. The underlying karyotype influenced both the dimensions of the sinutubular junction (p = 0.0054), and the ascending aorta (p = 0.0064), so that patients with the karyotype 45X had larger aortas. The karyotype was the strongest predictor by multivariate analysis for dilation at both these sites (p = 0.0138 and 0.0085, respectively). CONCLUSIONS: Dilation at the sinutubular junction is frequent in patients with Turner's syndrome, and is more common than dilation of the ascending aorta. The syndrome is associated with a remodelling of the aortic root, with prominent dilation of the sinutubular junction. There seems to be a relation between aortic dilation and the underlying genotype.

The Clinical Impact of Imaging Surveillance and Clinic Visit Frequency after Acute Aortic Dissection.

BACKGROUND: Guidelines recommend frequent follow-up after acute aortic dissection (AAD), but optimal rates of follow-up are not clear. METHODS: We examined rates of imaging and clinic visits in 267 individuals surviving AAD during recommended intervals (≤1, > 1-3, > 3-6, > 6-12 months, then annually), frequency of adverse imaging findings, and the relationship between follow-up and mortality. RESULTS: Type A and B AAD were noted in 46 and 54% of patients, respectively. Mean follow-up was 54.7 ± 13.3 months, with 52 deaths. Adverse imaging findings peaked at 6 to 12 months (5.6%), but rarely resulted in an intervention (3.4% peak at 6-12 months). Compared with those with less frequent imaging, patients with imaging for 33 to 66% of intervals (p = 0.22) or ≥66% of intervals (p = 0.77) had similar adjusted survival. In comparison to patients with fewer clinic visits, those with visits in 33 to 66% of intervals experienced lower adjusted mortality (hazards ratio: 0.47, 95% confidence interval: 0.23-0.97, p = 0.04), with no difference seen in those with ≥66% (vs. < 33%) interval visits (p = 0.47). Imaging at 6 to 12 months (vs. none) was associated with decreased adjusted mortality (hazards ratio: 0.50, 95% confidence interval: 0.27-0.91, p = 0.02), while imaging during other intervals, or clinic visits during any specific intervals, was not associated with a difference in mortality (p > 0.05 for each). CONCLUSIONS: Adverse imaging findings following AAD are common, but rarely require prompt intervention. Patients with the lowest and highest rates of clinic visits experienced increased mortality. While the overall rate of surveillance imaging did not correlate with mortality, adverse imaging findings and related interventions peaked at 6 to 12 months after AAD, and imaging during this time was associated with improved survival.