The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology.

Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.

Pain interference in young adulthood and work participation.

ABSTRACT: Chronic pain is associated with reduced work participation, but longitudinal data on the work impact of chronic pain are limited. We used data from the National Longitudinal Survey of Youth-1997 cohort to analyze how pain interference in early adulthood was associated with subsequent exit from the labor force in a longitudinal survey. Pain interference at age 29 and employment status were self-reported at subsequent biennial interviews. Exit from the labor force, return to employment, and development of new health-related work limitations after age 29 were analyzed using survival analysis methods. Among 5819 respondents, 10% and 3% endorsed "a little" or "a lot" of pain interference at age 29, respectively. During follow-up (median of 26 months until censoring or labor force exit), 43% of respondents had exited the labor force at least once and 10% developed a new work-related health limitation. The highest pain interference group (compared with no pain interference) had higher hazard of labor force exit (hazard ratio: 1.26; 95% confidence interval: 1.01-1.57; P = 0.044) and of developing new health-related work limitations (hazard ratio: 2.45; 95% confidence interval: 1.64-3.67; P < 0.001), with similar results for the group experiencing "a little" pain interference at age 29. In this nationally representative cohort, any level of pain interference reported at age 29 was found to predict increased hazards of subsequent labor force exit and health-related work limitation. Early identification and treatment of pain problems among young workers can help reduce burdens of future unemployment and disability.

Sex Differences in Trends in Incidence of Thoracic Aortic Aneurysm Repair and Aortic Dissection: 2005-2015.

Background: The purpose of this study was to examine trends in the incidence of thoracic aortic aneurysm (TAA) repair and aortic dissection. Methods: A retrospective study was conducted of patients from the period 2005-2015 with thoracic aortic disease. Unadjusted mortality was compared in women vs men. Rates of scheduled TAA repair, dissection events, acute type A aortic dissection (TAAD) repair, and aorta-related mortality were obtained from our institution's clinical registry and administrative data sources and used to calculate the age-adjusted incidence for each sex, adjusted to the Canadian standard population. Weighted linear regression was performed to analyze trends over time. Results: A total of 382 scheduled TAA repair operations, 345 dissection events, 85 TAAD repairs, and 182 aorta-related mortalities were identified. Women accounted for 23% of TAA repairs, 39% of dissection events, 22% of TAAD repairs, and 45% of aorta-related mortalities. The incidence of TAA repair was 3.5 per 100,000 person-years (95% confidence interval [CI]: 3.2-3.9), and increased in men (P = 0.02) but not women (P = 0.10) over time. The incidence of aortic dissection was 3.4 per 100,000 (95% CI: 3.1-3.8) and was stable over time (P = 0.43). The average annual age-adjusted incidence of TAAD repair was 0.8 per 100,000 (95% CI: 0.6-1.0) and increased over time (P = 0.001). The overall incidence of aorta-related mortality was 1.8 per 100,000 (95% CI: 1.5-2.0) and decreased over time (P = 0.02). Conclusion: The incidence of TAA repair is increasing in men but not women. Although aorta-related mortality is decreasing overall, disparities exist between the male and female population.

Introduction: L'objectif de cette étude était d'examiner les tendances relatives à l'incidence des réparations d'anévrisme de l'aorte thoracique (AAT) et de dissection aortique. Méthodes: Nous avons mené une étude rétrospective de patients atteints d'une maladie de l'aorte thoracique de la période 2005-2015. Nous avons comparé la mortalité non ajustée entre les femmes et les hommes. Nous avons obtenu les taux de réparations planifiées d'AAT, de dissections, de dissections aortiques de type A (DATA) à la phase aiguë et de mortalité d'origine aortique du registre clinique de notre établissement et des sources de données administratives, et les avons utilisés pour calculer l'incidence ajustée selon l'âge pour chacun des sexes, ajustée à la population canadienne type. Nous avons effectué une régression linéaire pondérée pour analyser les tendances temporelles. Résultats: Nous avons recensé un total de 382 réparations planifiées d'AAT, 345 dissections, 85 réparations de DATA et 182 cas de mortalité d'origine aortique. Les femmes représentaient 23 % des cas de réparation d'AAT, 39 % des cas de dissection, 22 % des cas de réparations de DATA et 45 % des cas de mortalité d'origine aortique. L'incidence des réparations d'AAT était de 3,5 par 100 000 années-personnes (intervalle de confiance [IC] à 95 % : 3,2-3,9) et augmentait chez les hommes (P = 0,02), mais non chez les femmes (P = 0,10) avec le temps. L'incidence des dissections aortiques était de 3,4 par 100 000 (IC à 95 % : 3,1-3,8) et était stable au fil du temps (P = 0,43). L'incidence moyenne annuelle selon l'âge de réparations de DATA était de 0,8 par 100 000 (IC à 95 % : 0,6-1,0) et augmentait avec le temps (P = 0,001). L'incidence globale de mortalité d'origine aortique était de 1,8 par 100 000 (IC à 95 % : 1,5-2,0) et diminuait avec le temps (P = 0,02). Conclusion: L'incidence des réparations d'AAT augmente chez les hommes, mais non chez les femmes. Bien que la mortalité d'origine aortique tende dans l'ensemble à diminuer, il existe des disparités entre la population masculine et la population féminine.

Increased Travel Time to the Tertiary Centre Is Associated With Decreased Long-term Survival Following Ascending Aortic Operations.

BACKGROUND: The association between travel time from tertiary care centre and outcomes after ascending thoracic aortic surgery is unknown. We determined the effect of travel time from the tertiary care centre on outcomes in ascending aortic repair in Nova Scotia. METHODS: A retrospective analysis of patients undergoing elective and emergent ascending thoracic aortic operations from 2005 to 2015 was carried out. Patient's residential geographic coordinates were used to calculate travel time to the tertiary care centre, and patients who resided < 1 hour vs ≥ 1 hour were compared. Multivariable logistic regression was performed to determine the effect of travel time on in-hospital outcomes. Cox-proportional hazard modelling and Kaplan-Meier survival estimates were created to determine the effect on long-term survival. RESULTS: A total of 476 patients underwent ascending thoracic aortic surgery from 2005 to 2015. Patients who resided < 1 hour from the tertiary care centre vs patients who resided ≥ 1 hour had similar rates of in-hospital mortality (4.4% vs 6.1%, P = 0.42), in-hospital composite complications (66.7% vs 67.7%, P = 0.80), hospital length of stay (median 9 days; interquartile range [7-16] vs 10 [7-17], P = 0.41), and discharge disposition other than home (9.7% vs 11.7%, P = 0.55). Compared with patients who resided < 1 hour from the tertiary centre, patients who resided ≥ 1 hour were at higher risk for long-term mortality (hazard ratio, 2.19; 95% confidence interval, 1.13-4.28; P = 0.02). CONCLUSIONS: Patients who reside remotely from the tertiary centre experience equivalent in-hospital outcomes but decreased long-term survival following ascending aortic operations. These findings may guide resource expansion for postoperative follow-up.

Short- and Long-Term Health Consequences of Gaps in Health Insurance Coverage among Young Adults.

In cross-sectional data, gaps in health insurance coverage are associated with worse health and lower utilization of preventive services. The authors investigated if these associations persisted 2-6 years after disruption of insurance coverage in a cohort of young adults. Data from the National Longitudinal Survey of Youth 1997, a longitudinal cohort study of participants who were ages 13-17 years in 1997, were analyzed. Annual interview data from 2007 through 2017 were included and analyzed in 2021. Health outcomes (general self-rated health, annual preventive care use, and work-related health limitations) in each year were regressed on insurance coverage status, classified as: continuous private coverage, continuous public coverage, gap in coverage, or year-round lack of coverage. In a series of models, insurance coverage status was lagged by 2, 4, or 6 years to capture long-term associations with health outcomes. The analytic sample included 8197 young adults contributing 49,580 observations. Contemporaneous gaps in coverage were associated with 17% lower odds of reporting better self-rated health (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.78, 0.88; P < 0.001), compared to year-round private insurance. This association remained similar when the insurance covariate was lagged 2, 4, or 6 years (eg, 6-year lagged OR: 0.82; 95% CI: 0.72, 0.93; P = 0.002). Results were similar for preventive care use and work-related health limitation. Among young adults, gaps in coverage are adversely associated with health status and health care utilization up to 6 years later. Policy efforts should target insurance continuity during this life course stage.

A mutation update on the LDS-associated genes TGFB2/3 and SMAD2/3.

The Loeys-Dietz syndrome (LDS) is a connective tissue disorder affecting the cardiovascular, skeletal, and ocular system. Most typically, LDS patients present with aortic aneurysms and arterial tortuosity, hypertelorism, and bifid/broad uvula or cleft palate. Initially, mutations in transforming growth factor-ß (TGF-ß) receptors (TGFBR1 and TGFBR2) were described to cause LDS, hereby leading to impaired TGF-ß signaling. More recently, TGF-ß ligands, TGFB2 and TGFB3, as well as intracellular downstream effectors of the TGF-ß pathway, SMAD2 and SMAD3, were shown to be involved in LDS. This emphasizes the role of disturbed TGF-ß signaling in LDS pathogenesis. Since most literature so far has focused on TGFBR1/2, we provide a comprehensive review on the known and some novel TGFB2/3 and SMAD2/3 mutations. For TGFB2 and SMAD3, the clinical manifestations, both of the patients previously described in the literature and our newly reported patients, are summarized in detail. This clearly indicates that LDS concerns a disorder with a broad phenotypical spectrum that is still emerging as more patients will be identified. All mutations described here are present in the corresponding Leiden Open Variant Database.

A Woman With Marfan Syndrome in Pregnancy: Managing High Vascular Risk With Multidisciplinary Care.

BACKGROUND: Women with connective tissue disorders are at risk for cardiovascular complications during pregnancy, but there are no guidelines for pregnant women with aortic root diameter>45 mm or with rapid aortic widening. We describe the issues of practical significance in the management of pregnancy and delivery in a woman with Marfan syndrome (MFS). CASE: A pregnant woman with MFS presented for tertiary care at 26 weeks' gestation. Rapid aortic dilatation triggered a decision to undertake delivery preterm, with a resulting good neonatal outcome. A multidisciplinary approach aided in optimizing the monitoring and timing of delivery and subsequent aortic repair, and allowed planning for the management of a potential vascular catastrophe. CONCLUSION: Having optimal maternal and neonatal outcomes for pregnant women with Marfan syndrome depends on a highly responsive and coordinated team effort, including meticulous planning for a vascular catastrophe.

Contexte : Bien que les femmes qui présentent des troubles affectant les tissus conjonctifs soient exposées à des risques de complications cardiovasculaires pendant la grossesse, nous ne disposons d'aucune ligne directrice en ce qui concerne les femmes enceintes dont le diamètre de l'anneau aortique est supérieur à 45 mm ou qui connaissent un élargissement rapide de l'aorte. Nous décrivons les facteurs significatifs sur le plan pratique dans le cadre de la prise en charge de la grossesse et de l'accouchement chez une femme atteinte du syndrome de Marfan.  Cas : Une femme enceinte atteinte du syndrome de Marfan nous a consultés pour obtenir des soins tertiaires à 26 semaines de gestation. La dilatation rapide de l'aorte a mené à la décision de procéder à un accouchement préterme (lequel a donné lieu à une bonne issue néonatale). Le recours à une approche multidisciplinaire a contribué à l'optimisation du monitorage et de la chronologie de l'accouchement (et à la réparation subséquente de l'aorte), en plus de permettre la planification de la prise en charge d'une potentielle catastrophe vasculaire.  Conclusion : Dans le cas des femmes enceintes qui sont atteintes du syndrome de Marfan, l'obtention d'issues maternelles et néonatales optimales dépend de la mise en œuvre d'un effort d'équipe grandement attentif et coordonné (y compris celle d'une planification méticuleuse de la prise en charge d'une potentielle catastrophe vasculaire).

Identifying opportunities to address the congestive heart failure burden: the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) study.

BACKGROUND: Medical, social and economic costs of congestive heart failure (CHF) continue to rise. There exists a 'care gap' between what the optimal care populations with CHF should receive and actually do receive. Central to the goal to develop effective strategies against the 'care gap' is accurate measurement of the CHF burden. Administrative data are limited in detail and accuracy and clinical databases suffer from limited size. Improving Cardiovascular Outcomes in Nova Scotia (ICONS) is a province-wide population-based disease management study with access to all patient health data including outcomes. METHODS: Medical records of all patients admitted to any Nova Scotia health care institution with a cardiovascular disorder were prospectively examined by trained abstractors. Patients were followed up and health outcomes measured through assignment of unique identifier numbers and linkage with Vital Statistics Nova Scotia. This report summarizes baseline data for the population admitted to hospital with a diagnosis of CHF between October 15, 1997 and October 14, 1998. RESULTS: There were 2637 unique patients enrolled with 3547 hospitalizations. The median length of stay was eight days, with in-hospital mortality of 18.2%; 10.8% were discharged to long term care. The mortality rate was 38.7% at 12 months and the rehospitalization rate was 39.9%. Average age was 75 +/- 10 years (median 76) and 52% were female. There were 4.5 comorbidities per patient. Left ventricular ejection fraction (LVEF) was measured in fewer than 40%; of these, fewer than 39% had a documented ejection fraction less than 40%. At discharge, 61.3% of survivors were prescribed angiotensin-converting enzyme (ACE) inhibitors, 6.0% angiotensin blockers, 42.1% beta-blockers, 75.6% diuretics, 26.1% calcium channel blockers and 19.3% warfarin. Females were older and had lower rate of LVEF testing and ACE and warfarin usage. CONCLUSION: The burden of disease for CHF in Nova Scotia is large and affects an elderly population with multiple comorbidities. Adverse outcomes such as death, rehospitalization and admission to a chronic care facility are common. Measurement of the 'care gap' requires consideration of these factors and of elderly and female patients regardless of left ventricular function. Successful strategies will likely be multidisciplinary in scope with a focus toward improving access to care.