Stanford type B aortic dissection (TBAD) is a life-threatening disease. Current therapeutic guidelines recommend medical therapy with aggressive blood pressure lowering for patients with acute TBAD ...unless they have fatal complications. Although patients with uncomplicated TBAD have relatively low early mortality, aorta-related adverse events during the chronic phase worsen the long-term clinical outcome. Recent advances in thoracic endovascular aortic repair (TEVAR) can improve clinical outcomes in patients with both complicated and uncomplicated TBAD. According to present guidelines, complicated TBAD patients are recommended for TEVAR. However, the indication in uncomplicated TBAD remains controversial. Recent results of randomized trials, which compared the clinical outcome in patients treated with optimal medical therapy and those treated with TEVAR, suggest that preemptive TEVAR should be considered in uncomplicated TBAD with suitable aortic anatomy. However, these trials failed to show improvement in early mortality in patients treated with TEVAR compared with patients treated with optimal medical therapy, which suggest the importance of patient selection for TEVAR. Several clinical and imaging-related risk factors have been shown to be associated with early disease progression. Preemptive TEVAR might be beneficial and should be considered for high-risk patients with uncomplicated TBAD. However, an interdisciplinary consensus has not been established for the definition of patients at high-risk of TBAD, and it should be confirmed by experts including physicians, radiologists, interventionalists, and vascular surgeons. This review summarizes the current understanding of the therapeutic strategy in patients with TBAD based on evidence and expert consensus.
Patients with type B aortic dissection are treated medically unless they have fatal complications. In the acute phase of medical treatment, it is important to keep the heart rate below 60 and the ...systolic blood pressure below 120 mmHg. In addition, it is necessary to watch for organ ischemia and enlargement of the dissected aorta. In uncomplicated type B dissections, the early mortality rate with medical therapy is relatively low, but the 5-year mortality rate for patients alive at discharge is reported to be 12–28%. Recently, it has been shown that thoracic endovascular aortic stent graft (TEVAR) within the first year of disease onset can provide effective remodeling of dissected aorta and improve prognosis. However, because of the potential for fatal complications, TEVAR is currently recommended only for high-risk patients, who are more likely to have a poor prognosis. Various studies have been conducted to define high-risk patients and many risk factors have been reported. The future challenge is to determine the indication of preemptive TEVAR through accurate risk stratification to improve the prognosis of patients with type B aortic dissection.
Although aortic valve calcification (AVC) had long been considered as a passive and degenerative process, it has more recently been considered as an active and highly regulated pathophysiological ...process and histologically similar to atherosclerosis. The progression of AVC has been suggested to have two different phases. The early phase is the atherosclerotic process, which is associated with dyslipidemia and inflammation. The second phase of calcium accumulation and ossification is considered to be unrelated to vascular risk factors. Many previous studies have suggested that the early phase of AVC is strongly associated with atherosclerosis of the vascular system including coronary artery disease. For example, several studies have demonstrated a significant association between AVC and increased risk of coronary events and all-cause mortality. Moreover, AVC has been reported to be a marker of subclinical coronary artery disease and can serve as a window to the atherosclerosis of coronary arteries.
Abstract
The patient was a 67-year-old woman with a history of advanced lung adenocarcinoma. Eight days after pegfilgrastim administration, her computed tomography scan revealed thickened bilateral ...common carotid arteries and thoracic aorta, which led to the diagnosis of pegfilgrastim-associated aortitis. Thirty-six days after pegfilgrastim administration, asymptomatic Stanford type B aortic dissection was detected. Her serum biomarker analysis suggested that interleukin-6 might be involved in the pathogenesis. Physicians should be aware of these adverse effects of filgrastim.
Abstract The incidence of heart failure (HF) hospitalization and its impact on long-term outcomes have not been well evaluated in contemporary patients with ST-segment elevation myocardial infarction ...(STEMI) following primary percutaneous coronary intervention (PCI). The CREDO-Kyoto Acute Myocardial Infarction (AMI) Registry is a multicenter registry enrolling 5429 consecutive AMI patients undergoing PCI from 2005 to 2007. The present study population consisted of 3682 patients with STEMI who underwent primary PCI within 24 hours of symptom onset and discharged alive. The incidence rate of HF hospitalization was 4.4%/year during the first year after the index STEMI, which attenuated to approximately 1.0%/year beyond 1-year to 5-year with the median follow-up period of 1956 days. The independent risk factors for HF hospitalization within 1 year included older age, prior myocardial infarction, heart failure at STEMI, left ventricular dysfunction, anterior AMI, and onset to balloon time >3 hours, use of beta blocker and non-use of statin at discharge. By the landmark analysis at 1-year, the cumulative incidences of all-cause death and HF hospitalization beyond 1-year and up to 5-year were significantly higher in patients with HF hospitalization within 1-year of STEMI than in patients without (36.3% vs. 10.1%, P<0.001, and 40.4% vs. 4.3%, P<0.001, respectively). Even after adjusting for confounders, HF hospitalization within 1-year remained independently associated with a higher risk for death and HF hospitalization beyond 1-year (hazard ratio HR 1.64, 95% confidence interval CI 1.02-2.52, P=0.04, and HR: 5.72, 95% CI: 3.46-9.22, P<0.001, respectively). In conclusion, HF hospitalization within 1-year was independently associated with a higher risk for all-cause death and HF hospitalization beyond 1-year.
Objective We sought to evaluate the impact of early surgery in the active phase on long-term outcomes in patients with left-sided native valve infective endocarditis. Methods Clinical data were ...retrospectively reviewed in 212 consecutive patients with left-sided native valve infective endocarditis from 1990 to 2009. Early surgery in the active phase (within 2 weeks after the initial diagnosis) was performed in 73 patients, and the conventional treatment strategy was applied in 139 patients. In the conventional treatment group, 99 patients underwent late surgical intervention. To minimize selection bias, propensity score was used to match patients in the early operation and conventional treatment groups. Major adverse cardiac event was defined as a composite of infective endocarditis-related death, repeat surgery, and recurrence of infective endocarditis during follow-up. Results The mean follow-up period was 5.5 years. In-hospital mortality was lower in the early operation group than in the conventional treatment group (5% vs 13%, P = .08). For 57 propensity score-matched pairs, the estimated actuarial 7-year survivals free from infective endocarditis-related death and major adverse cardiac events were significantly higher in the early operation group than in the conventional treatment group (infective endocarditis-related death: 94% ± 5% vs 82% ± 5%, P = .011, major adverse cardiac events: 88% ± 5% vs 69% ± 7%, P = .006, respectively). Conclusions Compared with conventional treatment, early surgery in the active phase was associated with better long-term outcomes in patients with left-sided native valve infective endocarditis. Further prospective randomized studies with large study populations are necessary to evaluate more precisely the optimal timing of surgery in patients with native valve infective endocarditis.
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We assessed the clinical features of cerebral microbleeds (CMBs) and their association with clinical outcomes in active infective endocarditis patients. From January 2009 to June ...2015, 132 active IE patients diagnosed per the modified Duke's criteria were retrospectively reviewed. Brain magnetic resonance imaging was performed in 102 patients, and 74 patients whose image data were available to assess CMBs were enrolled. CMBs were defined as hypointense lesion <10 mm in diameter, seen on T2* or susceptibility-weighted imaging. Forty patients had CMB and 34 did not. Patients with CMB were older, and the proportion of prior antiplatelet therapy, staphylococcal infection, and prosthetic valve endocarditis were higher than in patients without CMB. Surgery was performed in 25 (63%) patients with CMB and 24 (71%) patients without CMB. There was no significant difference in the de novo stroke incidence postoperatively (16% vs 17%, P = 0.95). Although all-cause mortality rate tended to be higher in patients with CMB, there were no significant differences in the in-hospital mortality rate and estimated 1-year major adverse event rate between the 2 groups (13% vs 12%, P = 0.92; 20% vs 19%, P = 0.35). Cox regression analysis adjusting age and operative risk did not show that CMB was a significant risk factor for all-cause death and major adverse event. Patients with CMB were older than those without, and microbleeds were associated with antiplatelet therapy, staphylococcal infection, and prosthetic valve endocarditis. However, the mid-term clinical outcomes of patients with CMB and those without were comparable.
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