Showing papers by "Kim A. Eagle published in 2018"
TL;DR: The International Registry of Acute Aortic Dissection (IRAD) was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment as mentioned in this paper.
Abstract: Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. The International Registry of Acute Aortic Dissection was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment. Since then, >7300 cases have been included from >51 sites in 12 countries. Although presenting symptoms and physical findings have not changed significantly over this period, the use of computed tomography in the diagnosis has increased, and more patients are managed with interventional procedures: surgery in type A AAD and endovascular therapy in type B AAD; with these changes in care, there has been a significant decrease in overall in-hospital mortality in type A AAD but not in type B AAD. Herein, we summarized the key lessons learned from this international registry of patients with AAD over the past 20 years.
652 citations
TL;DR: It is highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
Abstract: Acute aortic syndromes (AAS) encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural haematoma, and penetrating atherosclerotic aortic ulcer. Given the non-specific symptoms and physical signs, a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur. In order to reduce the diagnostic time delay, a comprehensive flowchart for decision-making based on pre-test sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases and should be thus applied in the emergency scenario. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken if indicated by a highly specialized aortic team. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) is generally indicated. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts. Finally, it should be highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
208 citations
01 Oct 2018
TL;DR: Suggestions for clinical practice stated here are only the beginning of a process that must also involve the establishment of quality indicators, structures and processes for implementation, and outcome studies.
Abstract: Girls and women with Turner syndrome face a lifelong struggle with both congenital heart disease and acquired cardiovascular conditions. Bicuspid aortic valve is common, and many have left-sided heart obstructive disease of varying severity, from hypoplastic left-sided heart syndrome to minimal aortic stenosis or coarctation of the aorta. Significant enlargement of the thoracic aorta may progress to catastrophic aortic dissection and rupture. It is becoming increasingly apparent that a variety of other cardiovascular conditions, including early-onset hypertension, ischemic heart disease, and stroke, are the major factors reducing the life span of those with Turner syndrome. The presentations and management of cardiovascular conditions in Turner syndrome differ significantly from the general population. Therefore, an international working group reviewed the available evidence regarding the diagnosis and treatment of cardiovascular diseases in Turner syndrome. It is recognized that the suggestions for clinical practice stated here are only the beginning of a process that must also involve the establishment of quality indicators, structures and processes for implementation, and outcome studies.
126 citations
TL;DR: The proportion of patients eligible for the COMPASS trial within the Reduction of Atherothrombosis for Continued Health (REACH) registry is described, suggesting good external applicability, and COMPASS-Eligible patients experienced a higher rate of the primary outcome compared with COMPASS participants in the aspirin alone treatment arm.
Abstract: Aims The aims of the present study were to describe the proportion of patients eligible for the COMPASS trial within the Reduction of Atherothrombosis for Continued Health (REACH) registry, the reasons for ineligibility, and to put in perspective the characteristics and outcomes of trial-eligible patients from the REACH registry compared with those of patients enrolled in the reference aspirin arm of the COMPASS trial. Methods and results The COMPASS selection and exclusion criteria were applied to REACH patients with either coronary artery disease (CAD) or peripheral artery disease (PAD). We used the COMPASS primary composite outcome of cardiovascular (CV) death, myocardial infarction (MI), or stroke. In REACH, 31 873 patients had CAD or PAD and detailed information allowing evaluation of eligibility. Among these, 9518 (29.9%) patients had exclusion criteria and an additional 5480 patients (17.2%) did not fulfil the inclusion criteria and thus were not eligible. The 'COMPASS-Eligible' population therefore comprised 52.9% of the evaluable REACH patients (n = 16 875). The main reasons for exclusion were high-bleeding risk (51.8%), anticoagulant use (44.8%), requirement for dual antiplatelet therapy within 1 year of an ACS or PCI with stent, (25.9%), history of ischaemic stroke <1 year (12.4%), and severe renal failure (2.2%). Eligibility was highest among patients with PAD alone (68.4%). COMPASS-Eligible patients from REACH experienced higher annualized primary outcome event rates than patients actually enrolled in the reference aspirin arm of COMPASS (4.2% vs. 2.9% per year, P < 0.001). Conclusion COMPASS-Eligible patients represent a substantial fraction of stable CAD/PAD patients encountered in routine clinical practice in the large international REACH registry suggesting good external applicability. COMPASS-Eligible patients experienced a higher rate of the primary outcome compared with COMPASS participants in the aspirin alone treatment arm.
73 citations
TL;DR: Consistent evidence has been demonstrated only for two predictors: aortic size at presentation is associated with adverse events and total FL thrombosis has a protective role.
66 citations
TL;DR: Current evidence on TAAD patients with the complication of malperfusion, as enunciated by the International Registry of Acute Aortic Dissection (IRAD) investigators is assessed.
65 citations
TL;DR: Investigation of patients following thoracic aortic surgery with serial imaging studies can identify complications that may require reintervention, and imaging has played an integral role in development of new surgical and interventional methods.
Abstract: In diagnosing and following patients with acute aortic syndromes and thoracic aortic aneurysms, high-quality imaging of the thoracic aorta is indispensable. Mainstay modalities for thoracic...
44 citations
TL;DR: Endograft design has a significant impact on haemodynamic performance following Zone 0 endovascular repair, potentially affecting cerebral blood flow during follow-up, and the use of computational modelling for virtual testing of therapeutic interventions is demonstrated.
Abstract: Objectives Aortic arch repair remains a major surgical challenge. Multiple manufacturers are developing branched endografts for Zone 0 endovascular repair, extending the armamentarium for minimally invasive treatment of aortic arch pathologies. We hypothesize that the design of the Zone 0 endograft has a significant impact on the postoperative haemodynamic performance, particularly in the cervical arteries. The goal of our study was to compare the postoperative haemodynamic performance of different Zone 0 endograft designs. Methods Patient-specific, clinically validated, computational fluid dynamics simulations were performed in a 71-year-old woman with a 6.5-cm saccular aortic arch aneurysm. Additionally, 4 endovascular repair scenarios using different endograft designs were created. Haemodynamic performance was evaluated by calculation of postoperative changes in blood flow and platelet activation potential (PLAP) in the cervical arteries. Results Preoperative cervical blood flow and mean PLAP were 1080 ml/min and 151.75, respectively. Cervical blood flow decreased and PLAP increased following endovascular repair in all scenarios. Endografts with 2 antegrade inner branches performed better compared to single-branch endografts. Scenario 3 performed the worst with a decrease in the total cervical blood flow of 4.8%, a decrease in the left hemisphere flow of 6.7% and an increase in the mean PLAP of 74.3%. Conclusions Endograft design has a significant impact on haemodynamic performance following Zone 0 endovascular repair, potentially affecting cerebral blood flow during follow-up. Our results demonstrate the use of computational modelling for virtual testing of therapeutic interventions and underline the need to monitor the long-term outcomes in this cohort of patients.
41 citations
TL;DR: Presenting SBP showed a clear J-curve relationship with in-hospital mortality in patients with AAD, and although this association was related to increased rates of comorbid conditions at the edges of the curve, SBP ≤80 mm Hg was an independent correlate of in- hospital mortality.
40 citations
TL;DR: TEVAR in patients with genetically triggered aortic dissections can be lifesaving in the acute setting though associated with high risk of retrograde aorta dissection in acute TBAD, and for chronic dissection‐related DTA aneurysmal degeneration, TEVAR could potentially be lifes saving in patients deemed too high risk for open surgical repair.
31 citations
TL;DR: Overall, signs and symptoms leading to a definitive diagnosis or indicating immediate life threat reduced time to surgery, while factors suggesting other diagnoses correlated with delays, but a number of factors affected its extent.
TL;DR: Although a benign evolution is reported after implantation of heart rhythm devices, PCI and EP, major adverse events may occur after EVAR/TEVAR and TAVI at short- and mid-term follow up.
TL;DR: The American Heart Association/American College of Cardiology guidelines published in 2010 proposed using the Aortic Dissection Detection Risk Score (ADD-RS) as a primary screening tool and the study in 2538 cases validated that the ADD-RS has a high sensitivity.
Abstract: Articles, see p 250 and p 259
The diagnosis of acute aortic dissection (AD) can be difficult because of its rarity and varied presentation, and this often leads to underdiagnosis. Recent guidelines from both the United States (American Heart Association and American College of Cardiology)1 and Europe (European Society of Cardiology)2 have made recommendations on diagnostic algorithms to improve care.
The American Heart Association/American College of Cardiology guidelines published in 2010 proposed using the Aortic Dissection Detection Risk Score (ADD-RS) as a primary screening tool. The ADD-RS is based on scoring the presence of 3 categorical risks: high-risk conditions (Marfan syndrome, family history of aortic disease, known aortic valve disease, known thoracic aortic aneurysm, or previous aortic manipulation including cardiac surgery), pain features (chest, back, or abdominal pain described as being of abrupt onset, severe intensity, or ripping/tearing), and examination features (evidence of perfusion deficit including pulse deficit, systolic blood pressure difference or focal neurological deficit, or with aortic diastolic murmur and hypotension/shock). The presence of ≥1 markers within each of these categorical features is given a score of 1 with a maximum cumulative score of 3, if all 3 categorical features are present. A score of 0 is considered low risk, a score of 1 is considered intermediate risk, and a score of 2 or 3 is considered to be high risk. The ADD-RS was investigated in the International Registry of Acute Aortic Dissection database in 20113 using the International Registry of Acute Aortic Dissection’s large contemporary repository of AD cases with documentation of clinical presentation and features, management, and outcomes. The study in 2538 cases validated that the ADD-RS has a high sensitivity of 95.7%.
The …
TL;DR: Patients go without pacemaker, defibrillator, and cardiac resynchronization therapies ( devices) each year due to the prohibitive costs of devices.
Abstract: Background Patients go without pacemaker, defibrillator, and cardiac resynchronization therapies (devices) each year due to the prohibitive costs of devices. Objective We sought to examine data available from studies regarding contemporary risks of reused devices in comparison with new devices. Methods We searched online indexing sites to identify recent studies. Peer-reviewed manuscripts reporting infection, malfunction, premature battery depletion, and device-related death with reused devices were included. The primary study outcome was the composite risk of infection, malfunction, premature battery depletion, and death. Secondary outcomes were the individual risks. Results Nine observational studies (published 2009-2017) were identified totaling 2,302 devices (2,017 pacemakers, 285 defibrillators). Five controlled trials were included in meta-analysis (2,114 devices; 1,258 new vs 856 reused). All device reuse protocols employed interrogation to confirm longevity and functionality, disinfectant therapy, and, usually, additional biocidal agents, packaging, and ethylene oxide gas sterilization. Demographic characteristics, indications for pacing, and median follow-up were similar. There were no device-related deaths reported and no statistically significant difference in risk between new versus reused devices for the primary outcome (2.23% vs 3.86% respectively, P = 0.807, odds ratio = 0.76). There were no significant differences seen in the secondary outcomes for the individual risks of infection, malfunction, and premature battery depletion. Conclusions Device reuse utilizing modern protocols did not significantly increase risk of infection, malfunction, premature battery depletion, or device-related death in observational studies. These data provide rationale for proceeding with a prospective multicenter noninferiority randomized control trial.
TL;DR: AAD limited to the ascending aorta (DeBakey type II) appears to be associated with improved clinical outcomes compared with dissection that extend to the aortic arch or beyond, as was a trend toward reduced in-hospital mortality and 5-year survival.
Abstract: The DeBakey classification divides type A acute aortic dissection (AAD) into type I and type II; the latter limited to the ascending aorta. We endeavored to examine differences in DeBakey groups in a contemporary registry. We divided 1,872 patients with noniatrogenic AAD from the International Registry of Acute Aortic Dissection into type I (n = 1691, 90.3%) and type II (n = 181, 9.7%). Patients with type II AAD were older. On presentation, patients with type I AAD reported more back and abdominal pain and were more likely to have pulse deficit. Intramural hematoma was more frequent in type II AAD. Most patients with both types were treated surgically. Lower rates of renal failure, coma, mesenteric and limb ischemia were noted in those with type II AAD. In-hospital death was less frequent (16.6% vs 22.5%) after type II AAD, a trend that did not reach significance. There was no difference in the incidence of new dissection, rapid aortic growth, late aortic intervention or survival at 5 years. In conclusion, AAD limited to the ascending aorta (DeBakey type II) appears to be associated with improved clinical outcomes compared with dissection that extend to the aortic arch or beyond. Although fewer dissection-related complications were noted in patients presenting with type II AAD, as was a trend toward reduced in-hospital mortality, 5-year survival and descending aortic sequelae are not reduced in this contemporary report from International Registry of Acute Aortic Dissection.
TL;DR: Adjunctive LSA revascularization in the setting of zone 2 TEVAR coverage is associated with hemodynamic vertebral artery changes and future studies in larger sample sizes should evaluate whether these novel findings are an important determinant of postoperative neurologic events.
TL;DR: TAAAD patients presenting with abnormal ECG results are sicker, have more in-hospital complications, and are more likely to die, and the frequency of nonspecific ST-T abnormalities and its association with delay in diagnosis and treatment presents an opportunity for practice improvement.
TL;DR: The medication adherence rate for patients who survived an AAD was 64 per cent at a median of 7.1 yr after discharge, as per the Morisky scale, and medication non-adherence was associated with increased follow up recurrence of chest pain at one year of follow up.
Abstract: Background & objectives: Beta-blockers have been shown to improve survival in both type A and type B acute aortic dissection (AAD) patients. Calcium channel blockers have been shown to selectively improve survival only in type B AAD patients. There is a lack of data on medication adherence in AAD survivors. The purpose of this study was to assess medication adherence in patients who survived an AAD. Methods: This was a cross-sectional survey-based study of individuals from a single medical centre which was part of the larger International Registry of Acute Aortic Dissection (IRAD). Patients with type A or B AAD who survived to discharge were included in this study. Individuals who were deceased based on the results of an online Social Security Death Index were excluded from the study. Data were obtained from both a survey and also from abstraction from the local academic institution's IRAD registry. A survey packet was sent to patients. One section of this survey was dedicated to assessing medication adherence using the 4-item Morisky scale. Results: Eighty two completed surveys were returned; 74 patients completed the section of the survey pertaining to medication adherence (response rate 38%). Morisky score was ≥1.0 for 27 (36%) patients and 0 for 47 (64%) patients. Thirty three patients reported yes to 'forget to take medications' and eight reported yes to 'careless with medications.' Medication non-adherence (defined as a score of ≥1.0 on Morisky) was associated with increased follow up recurrence of chest pain at one year of follow up. Only two patients stopped their antihypertensive on their own and did not cite a reason for doing this. Interpretation & conclusions: The medication adherence rate for patients who survived an AAD was 64 per cent at a median (Q1, Q3) of 7.1 yr (5.6, 11.5) after discharge, as per the Morisky scale. The clinicians should educate their patients on the importance of antihypertensive therapy and assess for forgetfulness and carelessness at each clinic visit, as well as understand patients' beliefs about drug therapy, all of which have been shown to increase medication adherence.
TL;DR: Using reconditioned pacemakers for bradycardia therapy is proposed as a safe, efficacious, and ethical means of delivering this therapy in Africa.
Abstract: Pacemaker therapy is inaccessible to most patients with bradycardia in Africa. Use of reconditioned pacemakers has been proposed as a safe, efficacious, and ethical means of delivering this therapy. A collaboration between PASCAR, Pace4Life, and Project My Heart Your Heart is working to address this deficit in health care in Africa.
TL;DR: The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial, a international, multi-center 8,000 patient randomized trial comparing early revascularization of moderate to severe ischemia determined by stress imaging tests to aggressive medical therapy withRevascularization reserved for refractory symptoms or infarction, failed to offer a definitive answer.
TL;DR: It is in the context of oppressive burden of healthcare spending that the discussion about reusing catheters and devices should be considered.
Abstract: Cardiovascular disease has become the most common cause of death and morbidity throughout the world, not just the affluent societies. In 2015, there were 422 million prevalent cases of cardiovascular disease worldwide, and it accounted for an estimated 30% of deaths.1 2As most people live in low-income and middle-income countries, the burden of cardiovascular disease is the greatest in resource-poor countries. The cardiovascular epidemic has a direct impact on the health of the patients and also on the welfare of the economies in which those patients live and work. Poverty can be both a contributing cause and a consequence of cardiovascular disease. It is in the context of oppressive burden of healthcare spending that the discussion about reusing catheters and devices should be considered.
### Historical context
In the mid-20th century, most medical devices were made of metal, glass or rubber and were generally reusable. Technological developments in the 1960s and 1970s brought out a wave of new polymers, which could be harnessed and which would eventually transition a multiuse medical industry into a single-use paradigm. Many open surgical procedures were gradually replaced by laparoscopic or endovascular procedures. In the 1980s and 1990s, new concerns regarding transmission of bloodborne pathogens such as hepatitis B and C, and HIV coincided with the explosive development of new technologies. Advances in manufacturing techniques, and expectation of improved product performance and predictability deepened interest in single-use devices (SUDs). The confluence of all these factors led to the evolution and dramatic expansion of the SUD concept. Original equipment manufacturers (OEMs) began to submit applications to the United States Food and Drug Administration (FDA) asking for approval of their products as SUDs. In some instances, the manufacturers changed the labelling from multiuse to single use only without making significant structural changes to the devices.3 The designation …
01 Dec 2018
TL;DR: Presence of head and neck pain in Type A aortic dissection is associated with more arch involvement, intramural hematoma, and stroke, and when isolating those with head andneck pain only, there appear to be a higher rate of comorbidity burden and higher overall mortality.
Abstract: Background Head and neck pain is an atypical presentation of acute aortic dissection. Classic teaching associates this pain with proximal dissections, but this has not been extensively studied. Methods Patients enrolled in the International Registry of Acute Aortic Dissection from January 1996 to March 2015 were included in this study. We analyzed the demographics, presentation, treatment, and outcomes of Type A aortic dissection patients presenting with head and neck pain (n = 812, 25.8%) and compared it with those without these symptoms (n = 2,341, 74.2%). Results Patients with head and neck pain were more likely to be white, female, with a family history of aortic disease. Patients with head and neck pain had higher percentages of back pain (43.3% vs. 37.5%, p = 0.005) and chest pain (87.6% vs. 79.3%, p 65 years were significantly associated with increased mortality. Conclusion Presence of head and neck pain in Type A dissection is associated with more arch involvement, intramural hematoma, and stroke. When isolating those with head and neck pain only, there appear to be a higher rate of comorbidity burden and higher overall mortality.
TL;DR: This work analyzed 1324 patients with TBAD enrolled in the International Registry of Acute Aortic Dissection to investigate the relationship between PEff and the development of early or late complications.
TL;DR: A 2002 International Registry of Acute Aortic Dissection analysis determined the sensitivities for computed tomography, transesophageal echocardiography, and magnetic resonance imaging in the diagnosis of acute aortic dissection to be 93%, 88%, and 100%, respectively, with CT.
TL;DR: Anticoagulant therapy (ACT) in aortic dissection patients (AD) is often necessitated by comorbidities or mechanical valve placement during the index operation.
TL;DR: A 69 year old man with type 2 diabetes mellitus, obesity, hypertension, and coronary artery disease was referred for diabetic retinopathy screening after experiencing dizziness and intermittent weakness in the left hand over the past six months, prompting concern for carotid disease.
Abstract: A 69 year old man with type 2 diabetes mellitus, obesity, hypertension, and coronary artery disease was referred for diabetic retinopathy screening. He was also undergoing evaluation for transient ischaemic attack after experiencing dizziness and intermittent weakness in the left hand over the past six months. Visual acuities and intra-ocular pressures were normal, and slit lamp examination of the anterior segment of both eyes was unremarkable. Funduscopic examination (figs 1, 2) and wide field fluorescein angiography (fig 3) revealed unilateral retinopathy in the left eye. These unilateral findings prompted concern for carotid disease. Doppler carotid ultrasonography (fig 4) and computed tomography angiography found complete occlusion of the left internal carotid artery.
Fig 1
Ultrawide field …
TL;DR: Perioperative use of statins is one of the few interventions that has consistently demonstrated a cardioprotective effect, and these agents should be continued or initiated in the perioperative setting for high-risk patients.
Abstract: As the field of hospital medicine moves into its third decade, it is worthwhile to reflect on the evolution of perioperative cardiovascular risk stratification and risk reduction measures, and to l...
TL;DR: Pacing is widely available in the United States and other high-income countries and it is taken for granted that once a patient makes it to a medical facility in complete heart block, he or she will walk out of the hospital with a pacemaker.