Research to Confront Climate Change Complexity: Intersectionality, Integration, and Innovative Governance.

Climate impacts increasingly unfold in interlinked systems of people, nature, and infrastructure. The cascading consequences are revealing sometimes surprising connections across sectors and regions, and prospects for climate responses also depend on complex, difficult-to-understand interactions. In this commentary, we build on the innovations of the United States Fifth National Climate Assessment to suggest a framework for understanding and responding to complex climate challenges. This approach involves: (a) integration of disciplines and expertise to understand how intersectionality shapes complex climate impacts and the wide-ranging effects of climate responses, (b) collaborations among diverse knowledge holders to improve responses and better encompass intersectionality, and (c) sustained experimentation with and learning about governance approaches capable of handling the complexity of climate change. Together, these three pillars underscore that usability of climate-relevant knowledge requires transdisciplinary coordination of research and practice. We outline actionable steps for climate research to incorporate intersectionality, integration, and innovative governance, as is increasingly necessary for confronting climate complexity and sustaining equitable, ideally vibrant climate futures.

Aortic events in pregnant patients with Marfan syndrome. Lessons from a multicenter study.

INTRODUCTION AND OBJECTIVES: Pregnancy in women with Marfan syndrome (MS) is associated with an increased risk of aortic events. The clinical evidence on pregnant patients with MS is limited and there is no specific consensus on their optimal management. We report our multicenter experience. METHODS: From January 2004 to January 2020, 632 patients with MS underwent periodic monitoring in Marfan units. During this period, we identified all pregnant women with MS and analyzed the incidence of aortic events during pregnancy and puerperium. RESULTS: There were 133 pregnancies in 89 women with MS (8 women with prior aortic surgery). There were no maternal deaths, but 5 women had aortic events during the third trimester and puerperium (type A dissections in 2, type B dissection in 1, and significant [≥ 3mm] aortic growth in 2). The aortic event rate was 3.7%. Pregestational aortic diameter≥ 40mm showed a nonsignificant association with aortic events (P=.058). Fetal mortality was 3% and 37.6% of births were cesarean deliveries. CONCLUSIONS: Women with MS have an increased risk of aortic events during pregnancy, especially in the third trimester and postpartum period. Patients with MS and aortic diameters ≥40mm should be assessed in experienced centers for prophylactic aortic surgery before pregnancy. It is important to provide early diagnosis, prepregnancy study of the aorta, beta-blocker administration, and close monitoring during pregnancy, especially during the last trimester and postpartum.

Aortic disease in Marfan syndrome is caused by overactivation of sGC-PRKG signaling by NO.

Thoracic aortic aneurysm, as occurs in Marfan syndrome, is generally asymptomatic until dissection or rupture, requiring surgical intervention as the only available treatment. Here, we show that nitric oxide (NO) signaling dysregulates actin cytoskeleton dynamics in Marfan Syndrome smooth muscle cells and that NO-donors induce Marfan-like aortopathy in wild-type mice, indicating that a marked increase in NO suffices to induce aortopathy. Levels of nitrated proteins are higher in plasma from Marfan patients and mice and in aortic tissue from Marfan mice than in control samples, indicating elevated circulating and tissue NO. Soluble guanylate cyclase and cGMP-dependent protein kinase are both activated in Marfan patients and mice and in wild-type mice treated with NO-donors, as shown by increased plasma cGMP and pVASP-S239 staining in aortic tissue. Marfan aortopathy in mice is reverted by pharmacological inhibition of soluble guanylate cyclase and cGMP-dependent protein kinase and lentiviral-mediated Prkg1 silencing. These findings identify potential biomarkers for monitoring Marfan Syndrome in patients and urge evaluation of cGMP-dependent protein kinase and soluble guanylate cyclase as therapeutic targets.

Resultados a largo plazo en la preservación valvular aórtica en el síndrome de Marfan / Long-term outcomes of aortic valve reimplantation in Marfan syndrome

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The influence of Marfans and bicuspid valves on outcomes following aortic valve reimplantation.

BACKGROUND: We analyzed our early and midterm results with aortic valve reimplantation surgery to determine the influence of Marfan syndrome and bicuspid valves on outcomes with this technique. METHODS: Between March 2004 and December 2015, 267 patients underwent aortic valve reimplantation operations. The mean diameter of the sinuses of Valsalva was 50 ± 3 mm and moderate/severe aortic regurgitation was present in 34.4% of these patients. A bicuspid aortic valve was present in 21% and 40% had Marfan syndrome. RESULTS: Overall 30-day mortality was 0.37% (1/267). Mean follow-up was 59.7 ± 38.7 months. Overall survival at 1, 3, and 5 years was 98 ± 8%, 98 ± 1%, and 94 ± 2%, respectively. Freedom from reoperation and aortic regurgitation >II was 99 ± 5%, 98 ± 8%, 96.7 ± 8%, and 99 ± 6%, 98 ± 1%, 98 ± 1%, respectively at 1, 3, and 5 years follow-up, with no differences between Marfan and bicuspid aortic valve groups. (p = 0.94 and p = 0.96, respectively). No endocarditis or thromboembolic complications were documented, and 93.6% of the patients did not receive any anticoagulation therapy. CONCLUSIONS: The reimplantation technique for aortic root aneurysms is associated with excellent clinical and functional outcomes at short and mid-term follow-up.

Early thrombosis of a tricuspid annuloplasty ring and mild hyperhomocysteinemia.

Tricuspid annuloplasty ring thrombosis is an extremely infrequent pathology, and no evidence-based antithrombotic management has been described. We present the case of a 40-year-old female with isolated mild hyperhomocysteinemia and early ring thrombus formation after surgical primary closure of an atrial septal defect and ring tricuspid annuloplasty. Clinical management, antithrombotic treatment, and hyperhomocysteinemia implications are discussed.

Factores predictores de mortalidad y reoperación en la cirugía de la disección aórtica aguda tipo A: 18 años de experiencia / Predictors of mortality and reoperation in acute type-A aortic dissection surgery: 18 years of experience

Introducción y objetivos. El objetivo de este estudio retrospectivo es mostrar nuestra experiencia en la cirugía de la disección aórtica aguda tipo A y analizar la influencia de la protección cerebral en nuestros resultados. Métodos. Entre marzo de 1990 y octubre de 2007, 98 pacientes consecutivos fueron intervenidos por disección aórtica aguda tipo A. En 85 pacientes se reemplazó la aorta ascendente, que en 13 se extendió al arco aórtico. La válvula aórtica fue sustituida en 34 pacientes y se preservó en el resto. La rotura intimal pudo identificarse en 83 pacientes. Resultados. La mortalidad hospitalaria fue del 15%. Los factores de riesgo de mortalidad hospitalaria fueron la edad ≥ 70 años y el shock cardiogénico preoperatorio (p < 0,05). La perfusión cerebral anterógrada se utilizó en los últimos 16 pacientes consecutivos y presentó una mortalidad hospitalaria del 6%. La ausencia de reoperación y la supervivencia fueron del 98,6% ± 1,3%, el 86,2% ± 4,6%, el 68,2% ± 8,9% y el 97,2% ± 1,9%, el 82,5% ± 4,8%, el 55,9% ± 7,9% tras 1, 5 y 10 años de seguimiento respectivamente. Resultaron factores de riesgo de reoperación la insuficiencia aórtica severa preoperatoria y la preservación de la válvula aórtica (p < 0,05). El único factor de riesgo de mortalidad tardía fue no realizar perfusión cerebral anterógrada (p < 0,05). Conclusiones. Pese a su extrema gravedad, la cirugía de la disección aórtica aguda presenta unos buenos resultados a corto y largo plazo. La perfusión cerebral ante-rógrada mejora el pronóstico de estos pacientes y está recomendada como método de protección cerebral de elección (AU)

Introduction and objectives. To describe our experience with acute type-A aortic dissection surgery, including an analysis of the effect of cerebral protection on outcome. Methods. Between March 1990 and October 2007, 98 consecutive patients underwent surgery for acute type-A aortic dissection. Of these, 85 had an ascending aorta replacement, while the entire arch was replaced in 13. The aortic valve was replaced in 34 patients but preserved in the rest. An intimal tear was observed in 83 patients. Results. The in-hospital mortality rate was 15%. Risk factors for in-hospital mortality were age ≥70 years and preoperative cardiogenic shock (P<.05). Antegrade cerebral perfusion was used in the last 16 consecutive patients, whose in-hospital mortality rate was 6%. The proportions of patients who survived and who did not require reoperation at 1, 5 and 10 years of follow-up were 98.6%(1.3%), 86.2%(4.6%) and 68.2%(8.9%), and 97.2%(1.9%), 82.5%(4.8%) and 55.9%±7.9% for the 2 outcomes, respectively. The risk factors for reoperation were found to be severe preoperative aortic regurgitation and preservation of the aortic valve (P<.05). The only risk factor for late mortality was not using antegrade cerebral perfusion (P<.05). Conclusions. Despite its seriousness, surgery for acute aortic dissection produces good early and long-term results. Antegrade cerebral perfusion improves the prognosis of these patients and should be the technique of choice for cerebral protection (AU)

Predictors of mortality and reoperation in acute type-a aortic dissection surgery: 18 years of experience.

INTRODUCTION AND OBJECTIVES: To describe our experience with acute type-A aortic dissection surgery, including an analysis of the effect of cerebral protection on outcome. METHODS: Between March 1990 and October 2007, 98 consecutive patients underwent surgery for acute type-A aortic dissection. Of these, 85 had an ascending aorta replacement, while the entire arch was replaced in 13. The aortic valve was replaced in 34 patients but preserved in the rest. An intimal tear was observed in 83 patients. RESULTS: The in-hospital mortality rate was 15%. Risk factors for in-hospital mortality were age > or = 70 years and preoperative cardiogenic shock (P< .05). Antegrade cerebral perfusion was used in the last 16 consecutive patients, whose in-hospital mortality rate was 6%. The proportions of patients who survived and who did not require reoperation at 1, 5 and 10 years of follow-up were 98.6%+/-1.3%, 86.2%+/-4.6% and 68.2%+/-8.9%, and 97.2%+/-1.9%, 82.5%+/-4.8% and 55.9%+/-7.9% for the two outcomes, respectively. The risk factors for reoperation were found to be severe preoperative aortic regurgitation and preservation of the aortic valve (P< .05). The only risk factor for late mortality was not using antegrade cerebral perfusion (P< .05). CONCLUSIONS: Despite its seriousness, surgery for acute aortic dissection produces good early and long-term results. Antegrade cerebral perfusion improves the prognosis of these patients and should be the technique of choice for cerebral protection.