Showing papers by "Kim A. Eagle published in 2019"
TL;DR: TEVAR was associated with increased LV SW and mass during follow-up and medical device manufacturers should develop more compliant devices to reduce the stiffness mismatch with the aorta.
Abstract: Objectives Current endografts for thoracic endovascular aortic repair (TEVAR) are much stiffer than the aorta and have been shown to induce acute stiffening. In this study, we aimed to estimate the impact of TEVAR on left ventricular (LV) stroke work (SW) and mass using a non-invasive image-based workflow. Methods The University of Michigan database was searched for patients treated with TEVAR for descending aortic pathologies (2013-2016). Patients with available pre-TEVAR and post-TEVAR computed tomography angiography and echocardiography data were selected. LV SW was estimated via patient-specific fluid-structure interaction analyses. LV remodelling was quantified through morphological measurements using echocardiography and electrocardiographic-gated computed tomography angiography data. Results Eight subjects were included in this study, the mean age of the patients was 68 (73, 25) years, and 6 patients were women. All patients were prescribed antihypertensive drugs following TEVAR. The fluid-structure interaction simulations computed a 26% increase in LV SW post-TEVAR [0.94 (0.89, 0.34) J to 1.18 (1.11, 0.65) J, P = 0.012]. Morphological measurements revealed an increase in the LV mass index post-TEVAR of +26% in echocardiography [72 (73, 17) g/m2 to 91 (87, 26) g/m2, P = 0.017] and +15% in computed tomography angiography [52 (46, 29) g/m2 to 60 (57, 22) g/m2, P = 0.043]. The post- to pre-TEVAR LV mass index ratio was positively correlated with the post- to pre-TEVAR ratios of SW and the mean blood pressure (ρ = 0.690, P = 0.058 and ρ = 0.786, P = 0.021, respectively). Conclusions TEVAR was associated with increased LV SW and mass during follow-up. Medical device manufacturers should develop more compliant devices to reduce the stiffness mismatch with the aorta. Additionally, intensive antihypertensive management is needed to control blood pressure post-TEVAR.
56 citations
01 Jun 2019
TL;DR: Clinical genetic testing of known hereditary thoracic aortic dissection genes should be considered in patients with a thoracics with age-of-onset <50 years, family history of thoraco-aortic disease, and no history of hypertension, followed by cascade screening of family members.
Abstract: Background: Thoracic aortic dissection is an emergent life-threatening condition. Routine screening for genetic variants causing thoracic aortic dissection is not currently performed for patients o...
53 citations
TL;DR: The evidence for β-blocker therapy to reduce morbidity and mortality in Marfan syndrome is limited to a single small, prospective randomized and nonblinded clinical trial, suggesting that this study was underpowered to assess adverse aortic outcomes.
Abstract: Importance Thoracic aortic aneurysms leading to acute aortic dissections are a major cause of morbidity and mortality despite significant advances in surgical treatment, which remains the main intervention to prevent type A dissections. In the past 2 decades progress has been made toward a better understanding of molecular mechanisms that lead to aneurysm formation and dissections of the thoracic aorta. This focused review emphasizes the results of clinical trials using β-blocker, losartan potassium, and irbesartan in patients with Marfan syndrome and comments briefly on mechanisms of aortic remodeling, including fibrosis and transforming growth factor β signaling. Observation The major risk factors for the disease are increased hemodynamic forces, typically owing to poorly controlled hypertension, and heritable genetic variants. The altered genes predisposing to thoracic aortic disease have been shown or are predicted to decrease vascular smooth muscle cell contraction, decrease transforming growth factor β signaling, or alter the extracellular matrix. Preclinical models of Marfan syndrome showed promising results for losartan as a potential therapy to attenuate aortic dilation in mice. However, several clinical trials did not conclusively confirm that losartan attenuated aortic aneurysm expansion better than β-blockers. Most importantly, clinical trials assessing whether losartan therapy not only reduces aortic growth but also improves adverse aortic outcomes, including dissection, need for surgery, and death, have not been conducted. The largest trial to date to our knowledge, the Pediatric Heart Network trial, sponsored by the National Heart, Lung, and Blood Institute, showed a nonsignificant increase in adverse aortic outcomes, with almost a doubling of adverse events in patients randomized to losartan treatment compared with β-blockers, suggesting that this study was underpowered to assess adverse aortic outcomes. On the other hand, the evidence for β-blocker therapy to reduce morbidity and mortality in Marfan syndrome is limited to a single small, prospective randomized and nonblinded clinical trial. Conclusions and Relevance Taken together, these data emphasize the need for clinical trials adequately powered to assess both aortic aneurysm growth and adverse aortic outcomes to identify effective medical therapies for Marfan syndrome and other aortopathies.
47 citations
University of Milan1, Hospital of the University of Pennsylvania2, University of Bologna3, St. Michael's Hospital4, University of Vienna5, University of Michigan6, University of Tromsø7, Duke University8, University of Calgary9, Royal Prince Alfred Hospital10, Imperial College London11, Harvard University12, University of Pittsburgh13
TL;DR: Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient‐specific approach and it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.
25 citations
TL;DR: Circulating IL-6 and TIMP-1 were associated with aortic dimensions in patients with aortsopathies enrolled in the GenTAC cohort.
Abstract: Background Biomarkers that reflect progression of dilatation of the aorta in patients with aortic conditions are needed as surrogate tools to assist in monitoring the condition in a non-invasive manner in combination with imaging procedures. This study aimed to investigate whether biomarkers are associated with aortic dimensions in patients enrolled in the Genetically-Triggered Thoracic Aortic Conditions (GenTAC) registry. Methods Plasma samples of 159 patients enrolled in the GenTAC registry were assessed for circulating biomarkers [interleukin-6 (IL-6), matrix metalloproteinase-9 (MMP-9), tissue inhibitor of metalloproteinase-1 (TIMP-1), tissue inhibitor of metalloproteinase-2 (TIMP-2) and transforming growth factor-β1 (TGFβ1)]. Association of circulating biomarker levels with aortic dimensions was investigated. Results IL-6 showed significant positive correlations with aortic dimensions at each segment of the aorta, with the correlation increasing in more distal aortic regions (ascending aorta, R = 0.26, p = 0.004; proximal arch, R = 0.35, p<0.0001; transverse arch, R = 0.30, p = 0.0005; mid-descending thoracic aorta, R = 0.40, p<0.0001; thoracoabdominal aorta, R = 0.38, p<0.0001; suprarenal abdominal aorta, R = 0.42, p<0.0001; and infrarenal aorta, R = 0.43, p<0.0001). TIMP-1 showed a significant correlation albeit weaker than IL-6, and also showed increasing correlation towards the distal areas of the aorta. Conclusions Circulating IL-6 and TIMP-1 were associated with aortic dimensions in patients with aortopathies enrolled in the GenTAC cohort.
11 citations
9 citations
3 citations
01 Jun 2019
TL;DR: While the overall rate of surveillance imaging did not correlate with mortality, adverse imaging findings and related interventions peaked at 6 to 12 months after AAD, and imaging during this time was associated with improved survival.
Abstract: Background Guidelines recommend frequent follow-up after acute aortic dissection (AAD), but optimal rates of follow-up are not clear. Methods We examined rates of imaging and clinic visits in 267 individuals surviving AAD during recommended intervals (≤1, > 1–3, > 3–6, > 6–12 months, then annually), frequency of adverse imaging findings, and the relationship between follow-up and mortality. Results Type A and B AAD were noted in 46 and 54% of patients, respectively. Mean follow-up was 54.7 ± 13.3 months, with 52 deaths. Adverse imaging findings peaked at 6 to 12 months (5.6%), but rarely resulted in an intervention (3.4% peak at 6–12 months). Compared with those with less frequent imaging, patients with imaging for 33 to 66% of intervals (p = 0.22) or ≥66% of intervals (p = 0.77) had similar adjusted survival. In comparison to patients with fewer clinic visits, those with visits in 33 to 66% of intervals experienced lower adjusted mortality (hazards ratio: 0.47, 95% confidence interval: 0.23–0.97, p = 0.04), with no difference seen in those with ≥66% (vs. 0.05 for each). Conclusions Adverse imaging findings following AAD are common, but rarely require prompt intervention. Patients with the lowest and highest rates of clinic visits experienced increased mortality. While the overall rate of surveillance imaging did not correlate with mortality, adverse imaging findings and related interventions peaked at 6 to 12 months after AAD, and imaging during this time was associated with improved survival.
3 citations
TL;DR: Current American and European guidelines provide diameter-based recommendations regarding intervention for TAA, but most type A aortic dissections occur at much smaller diameters.
1 citations
TL;DR: Echo-Lab, Division of Cardiology, A. Cardarelli Hospital, Naples, Italy; Cardiovascular Imaging Unit, IRCCS SDN, Naples- Italy; University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA.
Abstract: Echo-Lab, Division of Cardiology, A. Cardarelli Hospital, Naples, Italy; Cardiovascular Imaging Unit, IRCCS SDN, Naples, Italy; University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA Correspondence to: Eduardo Bossone, MD, PhD, FCCP, FESC, FACC. Director, Cardiology Division, “Antonio Cardarelli” Hospital, Via A. Cardarelli, 9, 80131 Naples, Italy. Email: ebossone@hotmail.com.
1 citations
TL;DR: When I was training to be a physician nearly 40 years ago, I honestly cannot remember a single in-depth discussion with my many mentors about how I should approach the grieving family members of patients who had passed away under my care.
01 Jan 2019
TL;DR: Diverse options include the extent of repair to be attempted, use of hybrid endovascular modalities (such as frozen elephant trunk technique), cannulation site, and cerebral perfusion strategy, yet the optimal approach to surgery remains unknown.
Abstract: Acute aortic dissection has been among the most lethal entities in the medical literature for centuries. The incidence of acute type A aortic dissection (ATAAD) is 3.5–6 in 100,000 but increases with age and demonstrates a male predominance. Risk factors in older adults include traditional cardiovascular risk factors, while younger patients are more likely to have a connective tissue disorder. Dissection begins as a tear in the intima and if it involves the ascending aorta or arch only it is classified as type A in the Stanford system. The Penn classification is used to assess the degree of organ system malperfusion present in dissection. Clinical presentation as well as biomarkers, such as D-dimer, is used for diagnosis, while confirmation is typically made with imaging including CT, TEE, and MR. Guiding principles of dissection management involve prompt recognition, transfer to intensive care for monitoring, and immediate impulse control – specifically reduction in heart rate, blood pressure, and LV ejection force, or dp/dt. Surgical repair is the mainstay of acute type A aortic dissection treatment, yet the optimal approach to surgery remains unknown. Diverse options include the extent of repair to be attempted (such as arch replacement or root replacement), use of hybrid endovascular modalities (such as frozen elephant trunk technique), cannulation site, and cerebral perfusion strategy. Other acute aortic syndromes include intramural hematoma (blood from the vasa vasorum infiltrates the medial layer) and penetrating atherosclerotic ulcer (plaque erodes through the internal elastic lamina into the media).
Journal Article•
TL;DR: Patients with acute conditions such as myocardial infarction and cardiac arrest have been found to have worse outcomes when occurring at off hours.
Abstract: Introduction: Patients with acute conditions such as myocardial infarction and cardiac arrest have been found to have worse outcomes when occurring at off hours. Acute type A aortic dissection (TAA...
TL;DR: Type A acute aortic dissection patients are at increased risk of late events in the unrepaired distal dissected aorta, but it is difficult to ascertain which patients may be at risk.