Commentary: Taking a bite of the apple Sundt, Thoralf M.
The Journal of thoracic and cardiovascular surgery,
April 2021, 2021-04-00, 20210401, Volume:
161, Issue:
4
Journal Article
Abstract Background Recent studies have demonstrated that many patients with acute type A aortic dissection (AD) have aortic diameters of <55 mm at presentation, prompting discussion of lowering the ...prophylactic surgical guidelines. However, risk of dissection at these smaller diameters is poorly defined. Objectives The purpose of this study is to understand the risk of AD in moderately dilated ascending aortas using a large echocardiographic data set. Methods Using an institutional echocardiography database, we identified 4,654 nonsyndromic adults (age: 68.6 ± 13.1 years; 1,003 women) with maximal ascending aortic diameters of 40 to 55 mm. We performed competing risk analysis to determine the independent risk factors of AD or aortic rupture. Results Five hundred eighty-six individuals (12.6%) had bicuspid aortic valves (BAVs). During follow-up (14,431.5 patient-years), AD and rupture occurred in 13 and 1 patients, respectively, which demonstrated a linearized incidence of AD and/or rupture of 0.1% per patient-year. Elective ascending aortic repair was performed in 176 individuals. On multivariable analyses, independent predictors of AD and/or rupture were age (hazard ratio HR: 1.06; 95% confidence interval CI: 1.01 to 1.12; p= 0.024) and baseline aortic diameters (HR: 1.20; 95% CI: 1.05 to 1.36; p = 0.006). The presence of a BAV was not a significant factor (HR: 0.94; 95% CI: 0.10 to 8.40; p = 0.95). Estimated risks of AD and/or rupture within 5 years were 0.4%, 1.1%, and 2.9% at baseline aortic diameters of 45, 50, and 55 mm, respectively. Conclusions Risks of AD and/or rupture were significantly correlated with the aortic diameter and age in patients with moderately dilated ascending aortas. However, the risks were low for diameters <5.0 cm when timely elective aortic repair was performed, regardless of the morphology of the aortic valve.
ACC/AHA Task Force Members Jeffrey L. Anderson, MD, FACC, FAHA, Chair, Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect, Nancy M. Albert, PhD, CCNS, CCRN, FAHA, Biykem Bozkurt, MD, PhD, FACC, FAHA, ...Ralph G. Brindis, MD, MPH, MACC, Mark A. Creager, MD, FACC, FAHA§§Task Force member during the writing effort., Lesley H. Curtis, PhD, FAHA, David DeMets, PhD, Robert A. Guyton, MD, FACC§§, Judith S. Hochman, MD, FACC, FAHA, Richard J. Kovacs, MD, FACC, FAHA, E. Magnus Ohman, MD, FACC, Susan J. Pressler, PhD, RN, FAHA, Frank W. Sellke, MD, FACC, FAHA, Win-Kuang Shen, MD, FACC, FAHA, William G. Stevenson, MD, FACC, FAHA§§, Clyde W. Yancy, MD, FACC, FAHA§§ Table of Contents Preamble... An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist clinicians in selecting the best management strategy for an individual patient. ...clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. ...in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another are included for COR I and IIa, LOE A or B only.\n Charney Division of Cardiology; Associate Director, Health Care Center None None None None None None Craig R. Smith Content Reviewer Columbia University College of Physicians and Surgeons--Professor of Surgery; Chair, Department of Surgery; New York-Presbyterian Hospital/Columbia University Medical Center--Surgeon-in-Chief None None None Edwards Lifesciences--PI None None Ruth H. Strasser Content Reviewer--AIG Heart Centre,University Hospital, University of Technology, Dresden--Professor, Director, and Chair, Internal Medicine and Cardiology Clinic; Medical Director, Heart Centre None None None None Abbottdagger AstraZenecadagger Bayerdagger Biosensorsdagger Pfizerdagger None Rakesh Suri Content Reviewer Mayo Clinic--Associate Professor of Surgery None None None None Edwards Lifesciencesdagger Sorindagger St. Jude Medicaldagger None Vinod Thourani Content Reviewer--Surgeon Council Emory University Edward Lifesciences Sorin St. Jude Medical None Apica Cardiovasculardagger Maquet None None Alec Vahanian Content Reviewer Hospital Bichat--Department de Cardiologie Abbott Vascular Edwards Lifesciences Medtronic St. Jude Medical Valtech None None None None None Andrew Wang Content Reviewer Duke University Medical Center--Professor of Medicine None None None Abbott Vascularlow * Edwards Lifescienceslow * None Defendant, Sudden death, 2012 * This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document. Names are listed in alphabetical order within each category of review.According to the ACC/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person's household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document.AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; AHA, American Heart Association; AIG, Association of International Governors; ASE, American Society of Echocardiography; DSMB, Data and Safety Monitoring Board; MRI, magnetic resonance imaging; NIH, National Institutes of Health; NYU, New York University; PARTNERS, Placement Of Aortic Transcatheter Valves; PI, Principal Investigator; SCA, Society of Cardiovascular Anesthesiologists; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; and VA, Veterans Affairs.
Commentary: The devil is in the details Sundt, Thoralf M.
The Journal of thoracic and cardiovascular surgery,
June 2019, 2019-06-00, 20190601, Volume:
157, Issue:
6
Journal Article
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