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Concept: Aorta

171

Aortic root enlargement (ARE) procedures are believed to allow implantation of larger valve prostheses; however, little evidence exists to support the specific efficacy of various techniques.

Concepts: Aorta, Ascending aorta

169

Takayasu’s arteritis is an inflammatory arteriopathy which involves the aorta and its major branches, causing mainly stenosis of their lumen, though aneurysmal lesions can also occur. A young female with Takayasu’s disease presented to our hospital with acute lung oedema due to severe aortic insufficiency and ascending aorta dilatation. She had already undergone distal ascending aorta and hemiarch replacement due to Standford type A aortic dissection five years ago. The patient had also undergone reconstruction of abdominal arteries' stenoses with extraanatomical bypass. We performed a Bentall procedure with a valved conduit and implantation of the coronary ostia as buttons on the conduit. A mechanical valved graft was used instead of a bioprosthesis, due to possible early degradation of a bioprosthesis. The postoperative course was uneventful and the one year follow-up was normal. Valve-sparing aortic root replacement should be avoided in Takayasu’s arteritis due to high rate of recurrent regurgitation.

Concepts: Cardiology, Heart, Aortic aneurysm, Aortic dissection, Aorta, Ascending aorta, Takayasu's arteritis, Arteritis

122

Abdominal aortic aneurysm (AAA) is a pathological condition characterized by an abnormal, localized dilatation of the lower part of the aorta. Due to a lack of data on the natural history of AAA and risk of death from other cardiovascular diseases attributable to AAA, the true number of AAA-attributable deaths may be higher than currently estimated. This study aims to produce more realistic estimates of the burden of AAA.

Concepts: Death, Heart, Fish, Aortic aneurysm, Aneurysm, Aortic dissection, Aorta, Aneurysm of sinus of Valsalva

60

The diagnosis of heart failure may be challenging because symptoms are rather nonspecific. Elevated left ventricular (LV) filling pressure may be used to confirm the diagnosis, but cardiac catheterization is often not practical. Echocardiographic indexes are therefore used as markers of filling pressure.

Concepts: Blood, Cardiology, Heart, Right ventricle, Ventricle, Aorta, Mitral valve, Left ventricle

47

OBJECTIVESThe effect of the lunar cycle and seasonal variation on ascending aortic dissection surgery outcomes is unknown. We investigated these temporal effects on risk-adjusted hospital mortality and then on the length of stay (LOS) following surgery for survivors.METHODSWe examined prospectively collected data from cardiac operations at two major centres within a single state between January 1996 and December 2011. We first examined the relationship between the lunar cycle and seasonal variation, along with demographic and risk profile covariates, with mortality using univariate analyses, followed by multiple logistic regression modelling that controlled for demographic and patient risk variables including age, gender, risk profile (diabetes, hypertension, dyslipidaemia and renal failure), and two surgical groups: Group A, consisting of patients having repair of ascending aorta dissection repair only, and Group B, with those having ascending aorta repair plus aortic valve surgery or coronary bypass surgery or both. We further examined the relationship with LOS using both univariate and multiple regression analyses.RESULTSThere were 210 patients who had repair of dissection in the study period, with 109 patients in Group A and 101 in Group B. The average age of this sample was 59.5 (standard deviation = 16.0), 65.7% were male and 18.1% died prior to discharge following repair. The greatest percentage of deaths occurred in winter (31.6%, n = 12), while the least were in summer (21.1%, n = 8) and fall (21.1%, n = 8). An overall χ(2) test found there was no difference in mortality for season (P = 0.55). Univariate analyses also found the age of patients who died vs lived was significantly higher (65.9 vs 58.1 years; P = 0.001), and a significantly greater (P = 0.029) percentage of patients with diabetes vs without diabetes died (41.7 vs 16.7%). Univariate analyses found all other covariates were not significantly related to mortality. In the multiple logistic regression model, there was no significant effect for season, while the odds of dying increased with age (odds ratio [OR] = 1.04, 95% confidence interval [95% CI] = 1.01-1.07, P = 0.012), and the odds of dying in the full-moon cycle vs the new moon cycle was significantly reduced (OR = 0.21, 95% CI = 0.05-0.81, P = 0.024). No other covariate significantly increased or decreased the odds of death, including diabetes risk, which had been significantly related to death in the univariate analysis. Within a linear regression model that examined the relationship with LOS, Group B (P = 0.020), male sex (P = 0.036) and the full-moon lunar phase (P = 0.001) were significantly related to shorter LOS.CONCLUSIONSSeason had no effect on mortality or LOS following aortic dissection repair, while patient age significantly increased the odds of death. The full-moon cycle appeared to reduce the odds of death, and the full-moon cycle, along with being male and requiring a concomitant cardiac procedure, was associated with shorter LOS.

Concepts: Regression analysis, Linear regression, Death, Econometrics, Multivariate adaptive regression splines, Aortic dissection, Aorta, Errors and residuals in statistics

33

Background Aortic-root dissection is the leading cause of death in Marfan’s syndrome. Studies suggest that with regard to slowing aortic-root enlargement, losartan may be more effective than beta-blockers, the current standard therapy in most centers. Methods We conducted a randomized trial comparing losartan with atenolol in children and young adults with Marfan’s syndrome. The primary outcome was the rate of aortic-root enlargement, expressed as the change in the maximum aortic-root-diameter z score indexed to body-surface area (hereafter, aortic-root z score) over a 3-year period. Secondary outcomes included the rate of change in the absolute diameter of the aortic root; the rate of change in aortic regurgitation; the time to aortic dissection, aortic-root surgery, or death; somatic growth; and the incidence of adverse events. Results From January 2007 through February 2011, a total of 21 clinical centers enrolled 608 participants, 6 months to 25 years of age (mean [±SD] age, 11.5±6.5 years in the atenolol group and 11.0±6.2 years in the losartan group), who had an aortic-root z score greater than 3.0. The baseline-adjusted rate of change (±SE) in the aortic-root z score did not differ significantly between the atenolol group and the losartan group (-0.139±0.013 and -0.107±0.013 standard-deviation units per year, respectively; P=0.08). Both slopes were significantly less than zero, indicating a decrease in the degree of aortic-root dilatation relative to body-surface area with either treatment. The 3-year rates of aortic-root surgery, aortic dissection, death, and a composite of these events did not differ significantly between the two treatment groups. Conclusions Among children and young adults with Marfan’s syndrome who were randomly assigned to losartan or atenolol, we found no significant difference in the rate of aortic-root dilatation between the two treatment groups over a 3-year period. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00429364 .).

Concepts: Clinical trial, Cardiology, Aortic dissection, Aorta, Marfan syndrome, Pneumothorax, Beta blocker, Losartan

28

Valve-sparing aortic root reconstruction (VSRR) is an accepted method to treat patients with aortic root dilation. The role of the VSRR is less well defined for patients with bicuspid aortic valve, severe aortic valve insufficiency, congenital heart defects, and type A aortic dissection. We studied the clinical outcome of patients who underwent VSRR for expanded indications.

Concepts: Aortic aneurysm, Aortic dissection, Aorta, Congenital heart defect, Congenital heart disease, Aortic valve, Aortic insufficiency, Bicuspid aortic valve

28

Endovascular abdominal aortic aneurysm repair (EVAR) in patients with unfavorable proximal seal zones remains challenging. The purpose of this study was to identify the incidence of proximal extension cuff usage for type I endoleaks in patients with abdominal aortic aneurysms and unfavorable necks treated with the C3 Excluder repositionable endoprosthesis compared with the traditional Excluder stent-graft.

Concepts: Aortic aneurysm, Model theory, Aneurysm, Cerebral aneurysm, Aortic dissection, Aorta, Abdominal aortic aneurysm, Aneurysm of sinus of Valsalva

28

Purpose: To describe a bailout technique for in situ fenestration of an inadvertently covered internal iliac artery (IIA) associated with endovascular repair of an abdominal aortic aneurysm (AAA). Technique: The procedure is demonstrated in a 76-year-old patient who underwent elective repair of a 5-cm infrarenal AAA using an Excluder endovascular graft 2 years following thoracic aortic stent-graft repair of a chronic type B aortic dissection. A completion angiogram demonstrated unintentional coverage of the left IIA. The iliac limb of the stent-graft was not able to be displaced away from the ostium, so to preserve IIA perfusion in a patient with prior thoracic aortic stent-grafting, a bailout technique was performed using an Outback re-entry device to successfully fenestrate the polytetrafluoroethylene graft material. An iCast balloon-expandable stent was placed across the fenestration creating a patent side branch to maintain patency. Six-year follow-up demonstrates a stable repair. Conclusion: In situ fenestration of a stent-graft overlying the internal iliac artery can be a useful bailout technique when other options are unsuccessful.

Concepts: Aortic aneurysm, Aneurysm, Aortic dissection, Aorta, External iliac artery, Abdominal aortic aneurysm, Internal iliac artery, Vascular surgery

28

A 60 year-old woman presented with large extensive aneurysms in the thoracic aorta and infra-renal abdominal aorta with a normal segment of visceral aorta in between; the entire right common iliac artery was also aneurysmal. Concurrent endovascular repair of all aneurysmal regions was successfully performed using a left common iliac artery conduit to access the aorta, and multiple stent-grafts; a chimney graft preserved blood flow into the left subclavian artery. There were no features of spinal cord ischaemia despite coil embolisation of the right hypogastric artery. CT angiogram at six months showed patent stent-grafts with no endoleaks. The patient continued to do well at one-year clinical follow-up. Concurrent endovascular repair of thoracic and abdominal aortic aneurysms can be safely and successfully performed when anatomically feasible, and is an attractive alternative to staged or hybrid repair.

Concepts: Abdominal aorta, Aortic aneurysm, Brachiocephalic artery, Aorta, Descending aorta, Arteries of the thorax, Arteries of the abdomen, Common iliac artery