Rationale A number of randomized trials are underway, which will address the effects of angiotensin receptor blockers (ARBs) on aortic root enlargement and a range of other end points in patients ...with Marfan syndrome. If individual participant data from these trials were to be combined, a meta-analysis of the resulting data, totaling approximately 2,300 patients, would allow estimation across a number of trials of the treatment effects both of ARB therapy and of β-blockade. Such an analysis would also allow estimation of treatment effects in particular subgroups of patients on a range of end points of interest and would allow a more powerful estimate of the effects of these treatments on a composite end point of several clinical outcomes than would be available from any individual trial. Design A prospective, collaborative meta-analysis based on individual patient data from all randomized trials in Marfan syndrome of (i) ARBs versus placebo (or open-label control) and (ii) ARBs versus β-blockers will be performed. A prospective study design, in which the principal hypotheses, trial eligibility criteria, analyses, and methods are specified in advance of the unblinding of the component trials, will help to limit bias owing to data-dependent emphasis on the results of particular trials. The use of individual patient data will allow for analysis of the effects of ARBs in particular patient subgroups and for time-to-event analysis for clinical outcomes. The meta-analysis protocol summarized in this report was written on behalf of the Marfan Treatment Trialists' Collaboration and finalized in late 2012, without foreknowledge of the results of any component trial, and will be made available online ( http://www.ctsu.ox.ac.uk/research/meta-trials ).
Abstract Objective Postoperative myocardial infarction remains a serious complication in cardiac surgery. The incidence and impact of this condition in acute type A aortic dissection are poorly ...understood. Methods A total of 1445 patients with acute type A aortic dissection who underwent surgery were enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2013. Individuals with preoperative myocardial infarction at hospital presentation and a history of myocardial infarction were excluded. Patients with postoperative myocardial infarction (n = 38, 2.6%) were compared with those without postoperative myocardial infarction (n = 1407, 97.4%). Results The postoperative myocardial infarction group was more often of white race (100% vs 90%, P = .043) with bicuspid aortic valve (15.6% vs 4.5%, P = .015). Imaging demonstrated more aortic root involvement (75.8% vs 49.5%, P = .003), pericardial effusion (65.5% vs 44.1%, P = .022), and coronary artery compromise (27.3% vs 10.2%, P = .022). Patients with postoperative myocardial infarction were more frequently hypotensive or in shock during surgery (42.9% vs 25.5%, P = .021). Patients with postoperative myocardial infarction were more likely to have undergone root replacement (54.5% vs 33.3%, P = .011), coronary artery bypass grafting (28.6% vs 7.4%, P < .001), or aortic valve replacement (40.0% vs 23.8%, P = .027), and less likely to have had complete arch replacement (2.8% vs 14.0%, P = .050). Median circulatory arrest time was higher in postoperative myocardial infarction (60 vs 38 minutes, P = .024). In-hospital mortality (57.9% vs 16.3%, P < .001) and Kaplan–Meier estimates of 5-year mortality ( P = .007) were distinctly higher in postoperative myocardial infarction. Conclusions Postoperative myocardial infarction is a devastating complication of type A aortic dissection repair. It is associated with bicuspid aortic valve, root involvement, pericardial effusion, and extent of surgical repair. Patients with postoperative myocardial infarction have higher serious postoperative complications, in-hospital mortality, and 5-year mortality rates than those without postoperative myocardial infarction.
Little is known about the relation between type A acute aortic dissection (TAAAD) and pulse pressure (PP), defined as the difference between systolic and diastolic blood pressure. In this study, we ...explored the association between PP and presentation, complications, and outcomes of patients with TAAAD. PP at hospital presentation was used to divide 1,960 patients with noniatrogenic TAAAD into quartiles: narrowed (≤39 mm Hg, n = 430), normal (40 to 56 mm Hg, n = 554), mildly elevated (57 to 75 mm Hg, n = 490), and markedly elevated (≥76 mm Hg, n = 486). Variables relating to index presentation and in-hospital outcomes were analyzed. Patients with TAAAD in the narrowed PP quartiles were frequently older and Caucasian, whereas patients with markedly elevated PPs tended to be male and have a history of hypertension. Patients who demonstrated abdominal vessel involvement more commonly demonstrated elevated PPs, whereas patients with narrowed PPs were more likely to have periaortic hematoma and/or pericardial effusion. Narrowed PPs were also correlated with greater incidences of hypotension, cardiac tamponade, and mortality. Patients with TAAAD who were managed with endovascular and hybrid procedures and those with renal failure tended to have markedly elevated PPs. No difference in aortic regurgitation at presentation was noted among groups. In conclusion, patients with TAAAD in the third PP quartile had better in-hospital outcomes than patients in the lowest quartile. Patients with narrowed PPs experienced more cardiac complications, particularly cardiac tamponade, whereas those with markedly elevated PPs were more likely to have abdominal aortic involvement. Presenting PP offers a clue to different manifestations of acute aortic dissection that may facilitate initial triage and care.
Giant Aneurysm of the Interatrial Septum Fuertes-Kenneally, Laura; Angulo-Lara, Basilio; Forteza Gil, Alberto ...
JACC. Case reports,
02/2024, Letnik:
29, Številka:
4
Journal Article
Recenzirano
Odprti dostop
A 46-year-old woman presented for a routine echocardiogram, which revealed a giant atrial septal aneurysm (ASA) with an atrial septal defect (ASD). We surgically excised the ASA and closed the ASD ...with a pericardial patch. ASA, although rare, poses embolic risks, thus necessitating closure when associated with shunts. Optimal stroke prevention remains uncertain.
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Background Surgery for intervalvular fibrous body reconstruction in aortic and mitral valve replacement is a complex operation, although mandatory in some circumstances. The long-term result of this ...operation remains unknown. The objective of this study was to analyze the outcomes of this technique. Methods A descriptive and retrospective study was carried out to analyze operative morbidity and mortality in fibrous body reconstruction with the “David technique” and to evaluate the midterm and long-term results regarding durability and survival. Results A total of 40 consecutive patients underwent the David technique between 1997 and 2014. The mean age was 58 ± 15 years and 62.5% were male. The indications were active endocarditis with paravalvular and fibrous body abscesses in 26 patients (group A) and massive calcification of the intervalvular fibrous body in 14 patients (group B). Mean European system for cardiac operative risk evaluation I predicted risk of mortality was 36 ± 24 and 16 ± 15, respectively. The hospital mortality rate was 15.3% in group A and 7.1% in group B. Survival rate after 1, 5, and 10 years was 65.4%, 57.7%, and 50% for group A and 92.9%, 85.7%, and 78.6% for group B. Freedom from reoperation at 1, 5, and 10 years was 92.3%, 84.6%, and 76.9% for group A and 90.9%, 90.9%, and 90.9% for group B. Mean follow-up was 53 ± 8 months. Conclusions Although this complex operation is associated with high perioperative mortality, the long-term results are acceptable in patients where there are not suitable alternative procedures.
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