Beyond the Usual Suspects (Aortic Dissection in Patients with Chronic Kidney Disease)

A comprehensive differential diagnosis is essential in the emergency department, even when patient presentations are atypical. Timely recognition of life-threatening conditions, such as aortic dissection, hinges on this critical diagnostic approach.

Transcatheter aortic valve replacement in low-risk young population:A double edge sword?

Since the advent of transcatheter aortic valve replacement(TAVR)in 2002,it has now become the default interventional strategy for symptomatic patients presenting with severe aortic stenosis,particularly in intermediate to highsurgical risk patients.In 2019,the United States Food and Drug Administration approved TAVR in low-risk patients based on two randomized trials.However,these breakthrough trials excluded patients with certain unfavorable anatomies and odd profiles.While currently there is no randomized study of TAVR in young patients,it may be preferred by the young population given the benefits of early discharge,shorter hospital stay,and expedite recovery.Nonetheless,it is important to ruminate various factors including lifetime expectancy,risk of pacemaker implantation,and the need for future valve or coronary interventions in young cohorts before considering TAVR in these patients.Furthermore,the data on long-term durability(>10 years)of TAVR is still unknown given most of the procedures were initially performed in the high or prohibitive surgical risk population.Thus,this editorial aims to highlight the importance of considering an individualized approach in young patients with consideration of various factors including lifetime expectancy while choosing TAVR against surgical aortic valve replacement.

Application of multi-planar reconstruction technique in endovascular repair of aortic dissection

BACKGROUND Endovascular repair of aortic dissection is an effective method commonly used in the treatment of Stanford type B aortic dissection.Stent placement during the operation was one-time and could not be repeatedly adjusted during the operation.Therefore,it is of great significance for cardiovascular physicians to fully understand the branch status,position,angle,and other information regarding aortic arch dissection before surgery.AIM To provide more references for clinical cardiovascular physicians to develop treatment plans.METHODS Data from 153 patients who underwent endovascular repair of aortic dissection at our hospital between January 2021 and December 2022 were retrospectively collected.All patients underwent multi-slice spiral computed tomography angiography.Based on distinct post-image processing techniques,the patients were categorized into three groups:Multiplanar reconstruction(MPR)(n=55),volume reconstruction(VR)(n=46),and maximum intensity projection(MIP)(n=52).The detection rate of aortic rupture,accuracy of the DeBakey classification,rotation,and tilt angles of the C-arm during the procedure,dispersion after stent release,and the incidence of late complications were recorded and compared.RESULTS The detection rates of interlayer rupture in the MPR and VR groups were significantly higher than that in the MIP group(P<0.05).The detection rates of De-Bakey subtypesⅠ,Ⅱ,andⅢin the MPR group were higher than those in the MIP group,and the detection rate of typeⅢin the MPR group was significantly higher than that in the VR group(P<0.05).There was no statistically significant difference in the detection rates of typesⅠandⅡcompared to the VR group(P>0.05).The scatter rate of markers and the incidence of complications in the MPR group were significantly lower than those in the VR and MIP groups(P<0.05).CONCLUSION The application of MPR in the endovascular repair of aortic dissection has improved the detection rate of dissection rupture,the accuracy of anatomical classification,and safety.

Carotid versus axillary artery cannulation for descending aorta remodeling in type A acute aortic dissection

BACKGROUND Arterial cannulation sites for the surgical repair of type A aortic dissection(AAD)have evolved from right axillary artery(AA)cannulation to bilateral carotid artery(CA)based of femoral artery(FA)cannulation.Postoperative descending aorta remodeling is closely linked to the false lumen area ratio(FLAR),defined as false lumen area/aortic area,as well as to the incidence of renal replacement therapy(RRT).AIM To investigate the effect of the updated arterial cannulation strategy on descending aortic remodeling.METHODS A total of 443 AAD patients who received FA combined cannulation between March 2015 and March 2023 were included in the study.Of these,209 received right AA cannulation and 234 received bilateral CA cannulation.The primary outcome was the change in FLAR,as calculated from computed tomography angiography in three segments of the descending aorta:Thoracic(S1),upper abdominal(S2),and lower abdominal(S3).Secondary outcomes were the incidence of RRT and the serum inflammation response,as observed by the levels of high sensitivity C reaction protein(hs-CRP)and Interleukin-6(IL-6).RESULTS The postoperative/preoperative ratio of FLAR in S2 and S3 was higher in the AA group compared to the CA group(S2:0.80±0.08 vs 0.75±0.07,P<0.001;S3:0.57±0.12 vs 0.50±0.12,P<0.001,respectively).The AA group also had a significantly higher incidence of RRT(19.1%vs 8.5%,P=0.001;odds ratio:2.533,95%CI:1.427-4.493)and higher levels of inflammation cytokines 24 h after the procedure[hr-CRP:117±17 vs 104±15 mg/L;IL-6:129(103,166)vs 83(69,101)pg/mL;both P<0.001]compared to the CA group.CONCLUSION The CA cannulation strategy was associated with better abdominal aorta remodeling after AAD repair compared to AA cannulation,as observed by a greater change in FLAR and lower incidence of RRT.

Trans-Frame Aortic Regurgitation of New-Generation Aortic Bioprosthesis

A widely used aortic valve bioprosthesis is susceptible to regurgitation between the sewing ring and the frame of the valve due to its relatively thin fabric coverage. In some cases this leak has been shown to resolve with administration of protamine, however, tension on this area from annular sutures placed in an asymmetric bicuspid valve annulus may exacerbate the defect.

Correlation Study of Aortic Velocity Propagation, Abdominal Aortic Intima-Media Thickness, and Epicardial Adipose Tissue Thickness in Subclinical Hypothyroidism Patients

Objective:To explore the correlation between epicardial fat thickness(EFT),aortic velocity propagation(AVP),and abdominal aortic intima-media thickness(AA-IMT)in patients with subclinical hypothyroidism(SH).Additionally,to compare these indicators between SH patients and healthy individuals,providing a new theoretical basis for the clinical prevention and treatment of cardiovascular diseases.Method:Clinical data from 50 SH patients(23 males and 27 females)and 50 healthy outpatient examinees(22 males and 28 females)were analyzed.The participants were selected from January 2022 to December 2023 at Loudi Central Hospital.EFT,AVP,and AA-IMT were measured,and their correlations were analyzed.Results:SH patients had significantly higher EFT and AA-IMT levels than the control group,while their AVP was significantly lower,with these differences being statistically significant(P<0.05).Correlation analysis revealed a significant negative correlation between EFT and AVP(P<0.001),a significant positive correlation between EFT and AAO-IMT(P<0.001),and a significant negative correlation between AVP and AAO-IMT(P<0.001).Multivariate binary logistic regression analysis identified increased EFT,decreased AVP,and increased AAO-IMT as independent risk factors for SH patients.Conclusion:In SH patients,EFT and AAO-IMT are elevated,whereas AVP is reduced.EFT and AVP are significantly correlated with AAO-IMT.EFT and AAO-IMT can serve as reliable indicators for evaluating subclinical atherosclerosis in SH patients,providing a diagnostic basis for clinical practice.

Current knowledge for the risk factors of early permanent pacemaker implantation following transcatheter aortic valve replacement and what is next for the primary prevention?

In this editorial,we comprehensively summarized the preoperative risk factors of early permanent pacemaker implantation after transcatheter aortic valve replacement(TAVR)among patients with severe aortic stenosis from several renowned clinical studies and focused on the primary prevention of managing the modifiable factors,e.g.,paroxysmal atrial fibrillation before the TAVR.

Patient-specific bicuspid aortic valve hemodynamics study based on computer simulation and in vitro experiment

Bicuspid aortic valve(BAV)is a common congenital malformation of the aortic valve with various structural characteristics.Different types of BAV can cause secondary aortic diseases,including calcific aortic valve stenosis and aortic dilation,although their pathogenesis remains unclear.In this study,we first established patient-specific BAV simulation models and silicone models(Type 0 A-P,Type 1 R-N,and Type 1 L-R)based on clinical computed tomography angiography(CTA)and pressure data.Next,we applied a research method combining fluid-structure interaction(FSI)simulation and digital particle image velocimetry(DPIV)experiment to quantitatively analyze the hemodynamic,structural mechanical,and flow field characteristics of patients with different BAV types.Simulation-based hemodynamic parameters and experimental results were consistent with clinical data,affirming the accuracy of the model.The location of the maximum principal strain in the patientspecific model was associated with the calcification site,which characterized the mechanism of secondary aortic valve stenosis.The maximum wall shear stress(WSS)of the patient-specific model(>67.1 Pa)exceeded 37.9 Pa and could cause endothelial surface injury as well as remodeling under long-term exposure,thus increasing the risk of aortic dilation.The distribution of WSS was mainly caused by BAV type,resulting in different degrees of dilation in different parts guided by the type.The patient-specific model revealed a maximum viscous shear stress(VSS)value of 5.23 Pa,which was smaller than the threshold for shear-induced hemolysis of red blood cells(150 Pa)and platelet activation(10 Pa),but close to the threshold for platelet sensitization(6 Pa).The results of flow field characteristics revealed a low risk of hemolysis but a relative high risk of thrombus formation in the patient-specific model.This study not only provides a basis for future comprehensive research on BAV diseases,but also generates relevant insights for theoretical guidance for calcific aortic valve stenosis and aortic dilation caused by different types of BAV,as well as biomechanical evidence for the potential risk of hemolysis and thrombus formation in BAV,which is of great value for clinical diagnosis and treatment of BAV.

Is primary transcatheter aortic valve implantation the new normal?

Degenerative calcific aortic valve stenosis(AS)is the most common valvular heart disease in elderly.^[1] It is well documented that symptomatic severe AS follows a malignant course leading to cardiogenic shock(CS).

The incidence rate and histological characteristics of intimal hyperplasia in elastase-induced experimental abdominal aortic aneurysms in mice

Intimal hyperplasia(IH)is a negative vascular remodeling after arterial injury.IH occasionally occurs in elastase-induced abdominal aortic aneurysm(AAA)mouse models.This study aims to clarify the incidence and histological characteristics of IH in aneurysmal mice.A retrospective study was conducted by including 42 male elastaseinduced mouse AAA models.The IH incidence,aortic diameters with or without IH,and hyperplasia lesional features of mice were analyzed.Among 42 elastase-induced AAA mouse models,10 mice developed mild IH(24%)and severe IH was found in only 2 mice(5%).The outer diameters of the AAA segments in mice with and without IH did not show significant difference.Both mild and severe IH lesions show strong smooth muscle cell positive staining,but endothelial cells were occasionally observed in severe IH lesions.There was obvious macrophage infiltration in the IH lesions of the AAA mouse models,especially in mice with severe IH.However,only a lower numbers of T cells and B cells were found in the IH lesion.Local cell-secreted matrix metalloproteinases(MMP)2 was highly expressed in all IH lesions,but MMP9 was only overexpressed in severe lesions.In conclusion,this study is the first to demonstrate the occurrence of aneurysmal IH and its histological characteristics in an elastaseinduced mouse AAA model.This will help researchers better understand this model,and optimize it for use in AAA-related research.

Isogeometric Analysis of Hyperelastic Material Characteristics for Calcified Aortic Valve

This study explores the implementation of computed tomography(CT)reconstruction and simulation techniques for patient-specific valves,aiming to dissect the mechanical attributes of calcified valves within transcatheter heart valve replacement(TAVR)procedures.In order to facilitate this exploration,it derives pertinent formulas for 3D multi-material isogeometric hyperelastic analysis based on Hounsfield unit(HU)values,thereby unlocking foundational capabilities for isogeometric analysis in calcified aortic valves.A series of uniaxial and biaxial tensile tests is executed to obtain an accurate constitutive model for calcified active valves.To mitigate discretization errors,methodologies for reconstructing volumetric parametric models,integrating both geometric and material attributes,are introduced.Applying these analytical formulas,constitutive models,and precise analytical models to isogeometric analyses of calcified valves,the research ascertains their close alignment with experimental results through the close fit in displacement-stress curves,compellingly validating the accuracy and reliability of the method.This study presents a step-by-step approach to analyzing themechanical characteristics of patient-specific valves obtained fromCT images,holding significant clinical implications and assisting in the selection of treatment strategies and surgical intervention approaches in TAVR procedures.

Bicuspidization Using the Open-Sleeve Technique for Congenital Aortic Stenosis during Infancy

Congenital aortic stenosis(cAS)frequently requires intervention during the neonatal or infantile period.However,surgical repair is challenging because of the narrow surgical space.We performed bicuspidization using the open-sleeve technique for cAS with a unicuspid aortic valve in two patients.Postoperatively,the patients were doing well without reintervention for the aortic valve for 8 and 6 years,respectively.Their aortic annular diameter increased along with somatic growth.Bicuspidization for neonates or infancy can be performed safely using the open-sleeve technique as its midterm results have been satisfactory.

A novel mouse model of calcific aortic valve stenosis

Background:Calcific aortic valve stenosis(CAVS)is one of the most challenging heart diseases in clinical with rapidly increasing prevalence.However,study of the mecha-nism and treatment of CAVS is hampered by the lack of suitable,robust and efficient models that develop hemodynamically significant stenosis and typical calcium deposi-tion.Here,we aim to establish a mouse model to mimic the development and features of CAVS.Methods:The model was established via aortic valve wire injury(AVWI)combined with vitamin D subcutaneous injected in wild type C57/BL6 mice.Serial transthoracic echocardiography was applied to evaluate aortic jet peak velocity and mean gradi-ent.Histopathological specimens were collected and examined in respect of valve thickening,calcium deposition,collagen accumulation,osteogenic differentiation and inflammation.Results:Serial transthoracic echocardiography revealed that aortic jet peak velocity and mean gradient increased from 7 days post model establishment in a time depend-ent manner and tended to be stable at 28 days.Compared with the sham group,sim-ple AVWI or the vitamin D group,the hybrid model group showed typical pathological features of CAVS,including hemodynamic alterations,increased aortic valve thicken-ing,calcium deposition,collagen accumulation at 28 days.In addition,osteogenic dif-ferentiation,fibrosis and inflammation,which play critical roles in the development of CAVS,were observed in the hybrid model.Conclusions:We established a novel mouse model of CAVS that could be induced efficiently,robustly and economically,and without genetic intervention.It provides a fast track to explore the underlying mechanisms of CAVS and to identify more effec-tive pharmacological targets.

Impact of D-dimer on in-hospital mortality following aortic dissection:A systematic review and meta-analysis

BACKGROUND The utility of D-dimer(DD)as a biomarker for acute aortic dissection(AD)is recognized.Yet,its predictive value for in-hospital mortality remains uncertain and subject to conflicting evidence.AIM To conduct a meta-analysis of AD-related in-hospital mortality(ADIM)with elevated DD levels.METHODS We searched PubMed,Scopus,Embase,and Google Scholar for AD and ADIM literature through May 2022.Heterogeneity was assessed using I2 statistics and effect size(hazard or odds ratio)analysis with random-effects models.Sample size,study type,and patients’mean age were used for subgroup analysis.The significance threshold was P<0.05.RESULTS Thirteen studies(3628 patients)were included in our study.The pooled prevalence of ADIM was 20%(95%CI:15%-25%).Despite comparable demographic characteristics and comorbidities,elevated DD values were associated with higher ADIM risk(unadjusted effect size:1.94,95%CI:1.34-2.8;adjusted effect size:1.12,95%CI:1.05-1.19,P<0.01).Studies involving patients with a mean age of<60 years exhibited an increased mortality risk(effect size:1.43,95%CI:1.23-1.67,P<0.01),whereas no significant difference was observed in studies with a mean age>60 years.Prospective and larger sample size studies(n>250)demonstrated a heightened likelihood of ADIM associated with elevated DD levels(effect size:2.57,95%CI:1.30-5.08,P<0.01 vs effect size:1.05,95%CI:1.00-1.11,P=0.05,respectively).CONCLUSION Our meta-analysis shows elevated DD increases in-hospital mortality risk in AD patients,highlighting the need for larger,prospective studies to improve risk prediction models.

Rates, predictors, and causes of readmission after transcatheter aortic valve replacement in patients with chronic kidney disease

BACKGROUND Transcatheter aortic valve replacement(TAVR)is a revolutionary procedure for severe aortic stenosis.The coexistence of chronic kidney disease(CKD)and TAVR introduces a challenge that significantly impacts patient outcomes.AIM To define readmission rates,predictors,and causes after TAVR procedure in CKD stage 1-4 patients.METHODS We used the national readmission database 2018 and 2020 to look into readmission rates,causes and predictors after TAVR procedure in patients with CKD stage 1-4.RESULTS Out of 24758 who underwent TAVR and had CKD,7892(32.4%)patients were readmitted within 90 days,and had higher adjusted odds of being females(adjusted odds ratio:1.17,95%CI:1.02-1.31,P=0.02)with longer length of hospital stay>6 days,and more comorbidities including but not limited to diabetes mellitus,anemia,and congestive heart failure(CHF).CONCLUSION Most common causes of readmission included CHF(18.0%),sepsis,and complete atrioventricular block.Controlling readmission predictors with very close followup is warranted to prevent such high rate of readmission.

Animal Model of Aortic Valve Calcification: Their Methodology Helps Us Understand Aortic Valve Calcification

Aortic valve calcification disease (CAVD) is the most prevalent degenerative valve disease in humans, leading to significant morbidity and mortality. Despite its common occurrence, our understanding of the underlying mechanisms remains incomplete, and available treatment options are limited and risky. A more comprehensive understanding of the biology of CAVD is essential to identify new therapeutic strategies. Animal models have played a crucial role in advancing our knowledge of CAVD and exploring potential treatments. However, these models have inherent limitations as they cannot fully replicate the complex physiological mechanisms of human CAVD. In this review, we examine various CAVD models ranging from pigs to mice, highlighting the unique characteristics of each model to enhance our understanding of CAVD. While these models offer valuable insights, they also have limitations and shortcomings. We propose that the guide wire model shows promise for future CAVD research, and streamlining the methodology could enhance our understanding and expand the research scope in this field.

Risk of permanent pacemaker implantation following transcatheter aortic valve replacement:Which factors are most relevant?

Transcatheter aortic valve replacement(TAVR)has emerged as a formidable treatment option for severe symptomatic aortic stenosis ahead of surgical aortic valve replacement.The encouraging results from large randomized controlled trials has resulted in an exponential rise in the use of TAVR even in the low-risk patients.However,this is not without challenges.Need for permanent pacemaker(PPM)post-TAVR remains the most frequent and clinically relevant challenge.Naturally,identifying risk factors which predispose an individual to develop high grade conduction block post-TAVR is important.Various demographic factors,electrocardiographic features,anatomic factors and procedural characteristics have all been linked to the development of advanced conduction block and need for PPM following TAVR.Amongst these electrophysiological variables,most notably a prolonged QRS>120 ms regardless of the type of conduction block seems to be one of the strongest predictors on logistic regression models.The index study by Nwaedozie et al highlights that patients requiring PPM post-TAVR had higher odds of having a baseline QRS>120 ms and were more likely to be having diabetes mellitus that those who did not require PPM.

Predictors of permanent pacemaker implantation following transcatheter aortic valve replacement-the search is still on!

Several anatomical,demographic,clinical,electrocardiographic,procedural,and valve-related variables can be used to predict the probability of developing con-duction abnormalities after transcatheter aortic valve replacement(TAVR)that necessitate permanent pacemaker(PPM)implantation.These variables include calcifications around the device landing zone and in the mitral annulus;pre-existing electrocardiographic abnormalities such as left and right bundle branch blocks(BBB),first-and second-degree atrioventricular blocks,as well as bifas-cicular and trifascicular blocks;male sex;diabetes mellitus(DM);hypertension;history of atrial fibrillation;renal failure;dementia;and use of self-expanding valves.The current study supports existing literature by demonstrating that type 2 DM and baseline right BBB are significant predictors of PPM implantation post-TAVR.Regardless of the side of the BBB,this study demonstrated,for the first time,a linear association between the incidence of PPM implantation post-TAVR and every 20 ms increase in baseline QRS duration(above 100 ms).After a 1-year follow-up,patients who received PPM post-TAVR had a higher rate of hospital-ization for heart failure and nonfatal myocardial infarction.

Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection

Aortic dissection is the deadliest disease of the cardiovascular system.Type B aortic dissection accounts for 30%-60%of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair(TEVAR).However,patients are prone to various complications after surgery,with central nervous system injury being the most common,which seriously affects their prognosis and increases the risk of disability and death.Therefore,exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.AIM To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.METHODS We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022.The patients were categorized into injury(n=159)and non-injury(n=147)groups based on central nervous system injury following surgery.The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups.Multivariate logistic regression analysis was performed.RESULTS The Association between age,history of hypertension,blood pH value,surgery,mechanical ventilation,intensive care unit stay,postoperative recovery times on the first day after surgery,and arterial partial pressure of oxygen on the first day after surgery differed substantially(P<0.05).Multivariate logistic regression analysis indicated that age,surgery time,history of hypertension,duration of mechanical ventilation,and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection(P<0.05).CONCLUSION For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection,early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.

Comparing pharmacotherapy and transcranial magnetic stimulation for the treatment of anxiety and depression after aortic dissection surgery

BACKGROUND Aortic coarctation is a potentially fatal condition that is primarily treated surgically.Despite successful procedures,patients frequently experience postoperative anxiety and depression,which can hinder recovery and worsen outcomes.Pharmacological interventions,such as 5-hydroxytryptamine(5-HT)and norepinephrine reuptake inhibitors,are commonly prescribed;however,their efficacy alone or in combination with non-invasive brain stimulation techniques,such as repetitive transcranial magnetic stimulation(TMS),remains unclear.AIM To assess the effect of medications and TMS on post-aortic surgery anxiety and depression.METHODS We analyzed the outcomes of 151 patients with anxiety and depression who were hospitalized for aortic dissection between January 2020 and September 2022.Using the random number table method,75 and 76 patients were allocated to the normal control and study groups,respectively.All the patients were treated using routine procedures.The control group was administered anti-anxiety and antidepression drugs,whereas the study group was treated with TMS in addition to these medications.The patients in both groups showed improvement after two courses of treatment.The Hamilton Anxiety Scale(HAMA)and the Hamilton Depression Scale(HAMD)were used to assess anxiety and depression,respectively.The serum levels of brain-derived neurotrophic factor(BDNF)and 5-HT were determined using enzyme-linked immunosorbent assay.The Pittsburgh Sleep Quality Index(PSQI)was used to estimate sleep quality,and the Repeatable Battery for the Assessment of Neuropsychological Status(RBANS)was used to assess cognitive function.RESULTS The HAMD and HAMA scores reduced in 2 groups,with the study group achieving a lower level than control(P<0.05).In the control group,43 patients recovered,17 showed improvement,and 15 were deemed invalid.In the study group,52 recovered,20 improved,and four were invalid.The efficacy rate in study group was 94.74%compared to 80.00%in control(P<0.05).The BDNF and 5-HT levels increased in both groups,with higher levels observed in the experimental group(P<0.05).Moreover,the PSQI scores decreased in 2 groups,but were lower in the intervention group than control(P<0.05).The scores of the RBANS items increased,with the study group scoring higher than control(P<0.05).CONCLUSION Combining anti-anxiety and anti-depressive drugs with repetitive TMS after aortic surgery may enhance mood and treatment outcomes,offering a promising clinical approach.