Publications by authors named "Bulat A Ziganshin"

155 Publications

Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair.

JTCVS Tech 2021 Apr 9;6:1-8. Epub 2021 Jan 9.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

Objective: We present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair.

Methods: We retrospectively reviewed 100 patients with descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) or who underwent CSFD insertion before open repair between 2006 and 2017. All CSFDs were inserted by the cardiovascular anesthesia team. The goal was to keep intracranial pressure <10 mm Hg during the surgical procedure by draining CSF at a rate of 20 to 30 mL/h. Postoperatively, CSFD was set to maintain the lumbar pressure <10 mm Hg to reduce the risk of postoperative paraplegia. CSFD was part of our standard cord protection regimen.

Results: The mean patient age was 65.4 ± 11.7 years, and 60 (60%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay was 11.9 ± 11.8 days, and hospital mortality was 6%. Postoperative transient paresis was observed in 4 patients (4%), and permanent paraplegia was seen in 2 (2%). CSFD-related complications were reported in 14 patients (14%). Complications included persistent CSF leakage and blood-tinged CSF with and without intracranial hemorrhage and spinal cutaneous fistula in 7 (7%), 9 (9%), and 1 (1%), respectively. Long-term survival was excellent (68.4% at 10 years).

Conclusions: CSFD is a safe practice when applied routinely as an adjunct strategy to prevent paraplegia in surgical management of DTAA and TAAA. We feel that this contributed to good early and late clinical results.
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http://dx.doi.org/10.1016/j.xjtc.2020.12.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8300913PMC
April 2021

Commentary: Surgery is an art.

JTCVS Tech 2020 Dec 10;4:7-9. Epub 2020 Oct 10.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

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http://dx.doi.org/10.1016/j.xjtc.2020.09.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8307428PMC
December 2020

Root Dilatation Is More Malignant Than Ascending Aortic Dilation.

J Am Heart Assoc 2021 Jul 9;10(14):e020645. Epub 2021 Jul 9.

Aortic Institute at Yale-New Haven Hospital Yale University School of Medicine New Haven CT.

Background Data from the International Registry of Acute Aortic Dissection indicate that the guideline criterion of 5.5 cm for ascending aortic intervention misses many dissections occurring at smaller dimensions. Furthermore, studies of natural behavior have generally treated the aortic root and the ascending aorta as 1 unit despite embryological, anatomical, and functional differences. This study aims to disentangle the natural histories of the aforementioned aortic segments, allowing natural behavior to define specific intervention criteria for root and ascending segments of the aorta. Methods and Results Diameters of the aortic root and mid-ascending segment were measured separately. Long-term complications (dissection, rupture, and death) were analyzed retrospectively for 1162 patients with ascending thoracic aortic aneurysm. Cox regression analysis suggested that aortic root dilatation (=0.017) is more significant in predicting adverse events than mid-ascending aortic dilatation (=0.087). Short stature posed as a serious risk factor. The dedicated risk curves for the aortic root and the mid-ascending aorta revealed hinge points at 5.0 and 5.25 cm, respectively. Conclusions The natural histories of the aortic root and mid-ascending aorta are uniquely different. Dilation of the aortic root imparts a significant higher risk of adverse events. A diameter shift for intervention to 5.0 cm for the aortic root and to 5.25 cm for the mid-ascending aorta should be considered at expert centers.
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http://dx.doi.org/10.1161/JAHA.120.020645DOI Listing
July 2021

A new 'angle' towards prediction of type A aortic dissection.

Eur J Cardiothorac Surg 2021 Jun 24. Epub 2021 Jun 24.

Aortic Institute at Yale New Haven, Yale University School of Medicine, New Haven, CT, USA.

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http://dx.doi.org/10.1093/ejcts/ezab270DOI Listing
June 2021

Risk reduction and pharmacological strategies to prevent progression of aortic aneurysms.

Expert Rev Cardiovasc Ther 2021 Jun 17:1-13. Epub 2021 Jun 17.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.

Introduction: While size thresholds exist to determine when aortic aneurysms warrant surgical intervention, there is no consensus on how best to treat this disease before aneurysms reach the threshold for intervention. Since a landmark study in 1994 first suggested ß-blockers may be useful in preventing aortic aneurysm growth, there has been a surge in research investigating different pharmacologic therapies for aortic aneurysms - with very mixed results.

Areas Covered: We have reviewed the existing literature on medical therapies used for thoracic and abdominal aortic aneurysms in humans. These include ß-blockers, angiotensin II receptor blockers, and angiotensin-converting enzyme inhibitors as well as miscellaneous drugs such as tetracyclines, macrolides, statins, and anti-platelet medications.

Expert Opinion: While multiple classes of drugs have been explored for risk reduction in aneurysm disease, with few exceptions results have been disappointing with an abundance of contradictory findings. The vast majority of studies have been done in patients with abdominal aortic aneurysms or thoracic aortic aneurysm patients with Marfan Syndrome. There exists a striking gap in the literature when it comes to pharmacologic management of non-Marfan Syndrome patients with thoracic aortic aneurysms. Given the differences in pathogenesis, this is an important future direction for aortic aneurysm research.
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http://dx.doi.org/10.1080/14779072.2021.1940958DOI Listing
June 2021

Aortic Delamination-A Possible Precursor of Impending Catastrophe.

Int J Angiol 2021 Jun 11;30(2):160-164. Epub 2021 Mar 11.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.

Aortic diameter is a powerful predictor of adverse aortic events, such as aortic rupture or dissection, forming the basis of prophylactic surgical repair criteria. Limited evidence is available regarding the association of aortic wall thickness (AWT) with these adverse aortic events. We present the case and surgical video of a 73-year-old man with chest pain and an increased AWT, who underwent ascending aortic repair and deep hemiarch placement under deep hypothermic circulatory arrest. Surgical pathology demonstrated evidence of aortic delamination and medial separation, indicative of an impending dissection. The patient recovered uneventfully, and his chest pain ultimately resolved after open repair. In this patient, increased AWT was felt to be the precursor to a potential aortic catastrophe.
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http://dx.doi.org/10.1055/s-0040-1718546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8159620PMC
June 2021

Accuracy of the "Thumb-Palm Test" for Detection of Ascending Aortic Aneurysm.

Am J Cardiol 2021 07 18;150:114-116. Epub 2021 May 18.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut. Electronic address:

We have noticed, in caring for thousands of patients with ascending aortic aneurysm (AscAA), that the "thumb palm test" is often positive (with the thumb crossing beyond the edge of the palm). It is not known how accurate this test may be. We conducted the thumb-palm test in 305 patients undergoing cardiac surgery with intra-operative transesophageal echocardiography (TEE) for a variety of disorders: ascending aneurysm in 59 (19.4%) and non-AscAA disease in 246 (80.6%) (including CABG, valve repair, and descending aortic aneurysm). The TEE provided a precise ascending aortic diameter. The thumb palm test gave us a discrete, binary positive or negative result. We calculated the accuracy (sensitivity and specificity) of the thumb palm test in determining presence or absence of AscAA (defined as ascending aortic diameter > 3.8cm). Maximal ascending aortic diameters ranged from 2.0 to 6.6 cm (mean 3.48). 93 patients (30.6%) were classified as having an AscAA and 212 (69.4%) as not having an AscAA. 10 patients (3.3%) had a positive thumb-palm test and 295 patients (96.7%) did not. Sensitivity of the test (proportion of diseased patients correctly classified) was low (7.5%), but specificity (proportion of non-diseased patients correctly classified) was very high (98.5%). This study supports the utility of the thumb-palm test in evaluation for ascending thoracic aortic aneurysm. That is to say, a positive test implies a substantial likelihood of harboring an ascending aortic aneurysm. A negative test does not exclude an aneurysm. In other words, the majority of aneurysm patients do not manifest a positive thumb-palm sign, but patients who do have a positive sign have a very high likelihood of harboring an ascending aneurysm. We suggest that the thumb-palm test be part of the standard physical examination, especially in patients with suspicion of ascending aortic aneurysm (e.g. those with a positive family history).
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http://dx.doi.org/10.1016/j.amjcard.2021.03.041DOI Listing
July 2021

Fate of Preserved Aortic Root Following Acute Type A Aortic Dissection Repair.

Semin Thorac Cardiovasc Surg 2021 May 9. Epub 2021 May 9.

Aortic Institute at Yale New-Haven, Yale University School of Medicine, New Haven, CT, USA. Electronic address:

We examined the long-term fate of the preserved aortic root after emergent repair of acute Type A aortic dissection. 144 patients (60% males, mean age 60.5 years) underwent supracoronary ascending aortic replacement for acute Type A aortic dissection. Long-term survival, as well as growth, reoperation, and adverse events of the aortic root (rupture, pseudoaneurysm, and persistent dissection) were retrospectively assessed. Operative mortality was 9%, and overall survival at 1, 5, and 10 years was 87.8%, 76.4%, and 64.6%, respectively. Reoperation on the proximal aorta was performed in 16 patients (12.2%) within a median of 2.45 years post-operatively. Indications were severe aortic insufficiency (AI) (n = 6), aortic root pseudoaneurysm (n = 8), pseudoaneurysm with severe AI (n = 1), and persistent dissection with severe AI (n = 1). The aortic root grew at 0.2mm/year (interquartile range 0-0.8). Among survivors (n = 131), 28 patients (21.3%) reached aortic root diameter ≥ 45 mm (mean diameter 47.6 mm, range 45-54 mm). Survival free from proximal aortic reoperation at 1, 5, and 10 years was 96.6%, 94.5%, and 92.2%, respectively. No non-reoperated patient-despite persistent, unoperated enlargement or distortion or pseudoaneurysm of the aortic root-developed free rupture or fistula to a cardiac chamber. Root-sparing ascending aortic replacement for acute Type-A aortic dissection showed satisfactory long-term outcomes with relatively low rates of re-intervention or serious aortic root adverse events despite dilatation and irregularity of aortic root contour. Dense adhesions from prior surgery, proximal aortic suture line, and Teflon felt seem to discourage free rupture or fistulization.
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http://dx.doi.org/10.1053/j.semtcvs.2021.04.002DOI Listing
May 2021

Commentary: Preventing the virulent lethality of ascending aortic aneurysm.

J Thorac Cardiovasc Surg 2021 Feb 19. Epub 2021 Feb 19.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

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http://dx.doi.org/10.1016/j.jtcvs.2021.02.046DOI Listing
February 2021

Interstage mortality in two-stage elephant trunk surgery.

J Card Surg 2021 Jun 26;36(6):1882-1891. Epub 2021 Feb 26.

Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA.

Purpose: Diffuse mega-aorta is challenging. Prior studies have raised concerns regarding the safety of the open two-stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to interstage mortality. This study evaluates the safety of the two-stage ET approach for management of extensive TAA.

Methods: Between 2003 and 2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5 ± 14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to-date has been performed in 54 patients (90%). (in the remaining patients, the ET was prophylactic for the long-term, with no plan for near-term utilization).

Results: In-hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median interstage interval was 5 weeks (range: 0-14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (interstage mortality of 8.3%). There were no cases of aortic rupture in the interstage interval. Stage II was completed in 58 patients (including four unplanned) with a 30-day mortality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia.

Conclusions: The overall mortality, including Stage I, interstage interval, and Stage II was 18.6%. This substantial cumulative mortality for the open two-staged ET approach for the treatment of extensive TAA appears commensurate with the severity of the widespread aortic disease in this patient group. Fear of interstage rupture should not preclude the aggressive Two-Stage approach to the management of extensive TAA.
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http://dx.doi.org/10.1111/jocs.15441DOI Listing
June 2021

Is Aortic Z-score an Appropriate Index of Beneficial Drug Effect in Clinical Trials in Aortic Aneurysm Disease?

Am J Cardiol 2021 03 9;143:145-153. Epub 2021 Jan 9.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut. Electronic address:

Aortic Z-score (Z-score) is utilized in clinical trials to monitor the effect of medications on aortic dilation rate in Marfan (MFS) patients. Z-scores are reported in relation to body surface area and therefore are a function of height and weight. However, an information void exists regarding natural, non-pharmacological changes in Z-scores as children age. We had concerns that Z-score decrease attributed to "therapeutic" effects of investigational drugs for Marfan disease connective tissue diseases might simply reflect normal changes ("filling out" of body contour) as children age. This investigation studies natural changes with age in Z-score in normal and untreated MFS children, teasing out normal effects that might erroneously be attributed to drug benefit. (1) We first compared body mass index (BMI) and Z-scores (Boston Children's Hospital calculator) in 361 children with "normal" single echo exams in four age ranges (0 to 1, 5 to 7, 10 to 12, 15 to 18 years). Regression analysis revealed that aging itself decreases ascending Z-score, but not root Z-score, and that increase in BMI with aging underlies the decreased Z-scores. (2) Next, we examined Z-score findings in both "normal" and Marfan children (all pharmacologically untreated) as determined on sequential echo exams over time. Of 27 children without aortic disease with sequential echos, 19 (70%) showed a natural decrease in root Z-score and 24 (89%) showed a natural decrease in ascending Z- score, over time. Of 25 untreated MFS children with sequential echos, 12 (40%) showed a natural decrease in root Z-score and 10 (33%) showed a natural decrease in ascending Z-score. Thus, Z-score is over time affected by natural factors even in the absence of any aneurysmal pathology or medical intervention. Specifically, Z-score decreases spontaneously as a natural phenomenon as children age and with fill out their BMI. Untreated Marfan patients often showed a spontaneous decrease in Z-score. In clinical drug trials in aneurysm disease, decreasing Z-score has been interpreted as a sign of beneficial drug effect. These data put such conclusions into doubt.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.025DOI Listing
March 2021

Commentary: "Incidental" total aortic stent graft in acute type A dissection surgery.

J Thorac Cardiovasc Surg 2020 Nov 9. Epub 2020 Nov 9.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.118DOI Listing
November 2020

Commentary: Fluoroquinolone guilt: The evidence mounts.

J Thorac Cardiovasc Surg 2020 Oct 29. Epub 2020 Oct 29.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.090DOI Listing
October 2020

Reply: Future prospects for thoracic aortic prediction.

J Thorac Cardiovasc Surg 2021 04 12;161(4):e257-e259. Epub 2020 Nov 12.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.047DOI Listing
April 2021

Commentary: The elusive perfect criterion for aortic intervention.

J Thorac Cardiovasc Surg 2021 04 25;161(4):1198-1201. Epub 2020 Jul 25.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.071DOI Listing
April 2021

Increased Virulence of Descending Thoracic and Thoracoabdominal Aortic Aneurysms in Women.

Ann Thorac Surg 2021 07 17;112(1):45-52. Epub 2020 Oct 17.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut. Electronic address:

Background: This study evaluates sex differences in the natural history of descending thoracic and thoracoabdominal aortic aneurysms (DTTAAs).

Methods: In all, 907 patients with descending thoracic and thoracoabdominal aortic sizes greater than 3 cm were retrospectively reviewed. Growth rate estimates were performed utilizing an instrumental variables approach. Yearly complication rates as a function of aortic size were computed.

Results: There were 615 men (67.8%) and 292 women (32.2%) treated between 1990 and 2018, with mean aortic diameters of 4.1 ± 1.4 cm and 4.8 ± 1.6 cm, respectively (P < .001). The mean growth rate of DTTAAs was 0.17 cm per year in men and 0.25 cm per year in women (P < .001), increasing with increasing aneurysm size. Dissection, rupture, or aortic death or the combination of the three occurred at double the rate for women compared with men (5.8% vs 2.3% per year for the combined endpoint). Diameter of DTTAA greater than 5 cm was associated with 26.3% (male) and 33.1% (female) average yearly rates of the composite endpoint of rupture, dissection, and death (P < .05). The probability of fatal complications (rupture and death) increased sharply at 5.75 cm in both sexes. Between 4.5 and 5.75 cm, there was another hinge-point of higher probability of fatal complications among women.

Conclusions: Women diagnosed with DTTAA fare worse. Faster aneurysm growth and higher rates of dissection, rupture, and aortic death are apparent among women. Current guidelines recommend surgical intervention at 5.5 to 6 cm for DTTAAs without sex considerations. Our findings suggest that increased virulence of DTTAA in women may indicate surgery at a somewhat smaller diameter.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.026DOI Listing
July 2021

Familial Legacy of Thoracic Aortic Aneurysm.

Circulation 2020 Sep 8;142(10):929-931. Epub 2020 Sep 8.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, CT.

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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.049124DOI Listing
September 2020

Direct measurement of ascending aortic diameter by intraoperative caliper assessment.

J Thorac Cardiovasc Surg 2021 02 6;161(2):e143-e146. Epub 2020 Aug 6.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.08.001DOI Listing
February 2021

To Perfuse or Not to Perfuse: That Is the Question.

Ann Thorac Surg 2020 11 3;110(5):1467-1468. Epub 2020 Sep 3.

Yale University School of Medicine, Aortic Institute at Yale-New Haven, Clinic Bldg CB-317, 789 Howard Ave, New Haven, CT 06519.

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http://dx.doi.org/10.1016/j.athoracsur.2020.06.079DOI Listing
November 2020

It Runs (Strongly) in the Family.

J Am Coll Cardiol 2020 09;76(10):1193-1196

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.

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http://dx.doi.org/10.1016/j.jacc.2020.07.029DOI Listing
September 2020

Reply: Imaging is not everything as regards the aorta: Tissue strength and blood pressure matter as well?

J Thorac Cardiovasc Surg 2020 09 18;160(3):e103-e105. Epub 2020 Jul 18.

Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Ga.

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http://dx.doi.org/10.1016/j.jtcvs.2020.05.029DOI Listing
September 2020

Thoracic aortic aneurysm gene dictionary.

Asian Cardiovasc Thorac Ann 2020 Jul 20:218492320943800. Epub 2020 Jul 20.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.

Thoracic aortic aneurysm is typically clinically silent, with a natural history of progressive enlargement until a potentially lethal complication such as rupture or dissection occurs. Underlying genetic predisposition strongly influences the risk of thoracic aortic aneurysm and dissection. Familial cases are more virulent, have a higher rate of aneurysm growth, and occur earlier in life. To date, over 30 genes have been associated with syndromic and non-syndromic thoracic aortic aneurysm and dissection. The causative genes and their specific variants help to predict the disease phenotype, including age at presentation, risk of dissection at small aortic sizes, and risk of other cardiovascular and systemic manifestations. This genetic "dictionary" is already a clinical reality, allowing us to personalize care based on specific causative mutations for a substantial proportion of these patients. Widespread genetic sequencing of thoracic aortic aneurysm and dissection patients has been and continues to be crucial to the rapid expansion of this dictionary and ultimately, the delivery of truly personalized care to every patient.
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http://dx.doi.org/10.1177/0218492320943800DOI Listing
July 2020

Nonusefulness of Antithrombotic Therapy After Surgical Bioprosthetic Aortic Valve Replacement.

Am J Cardiol 2020 08 18;129:71-78. Epub 2020 May 18.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut. Electronic address:

Controversy persists regarding the advisability of anticoagulation for the early period after biological surgical aortic valve replacement (AVR). We aim to examine the impact of various antithrombotic regimens on outcomes in a large cohort of biological AVR patients. Records of 1,111 consecutive adult patients who underwent surgical biological AVR at our institution between 2013 and 2017 were reviewed. Outcomes included stroke, bleeding, and death at 3 and 12 months. Treatment regimens included (1) no therapy, (2) anticoagulants (warfarin or Factor Xa inhibitors), (2) antiplateles (various), and (4) anticoagulants + antiplatelets. Kaplan-Meier analysis was used to track outcomes, and Cox-proportional hazards regression models were conducted to analyze effects of different therapies on adverse events. At 3 months, thromboembolic events were low and not significantly different between the no therapy group (2.2%) and anticoagulation (2.8%) or anticoagulation + antiplatelet (3.6%) or all groups (3.7%). The antiplatelet group was just significantly lower, at 2.2%. However, this was driven by non-stroke cardiovascular events in patients with coronary artery disease. The incidence of death at 3 months was low and not significantly different between all groups. At 12 months, there were no thromboembolic benefits between groups, but bleeding events were significantly higher in the anticoagulation group (no therapy (1.4%), anticoagulation (8.4%), antiplatelet (4.5%), anticoagulation + antiplatelet (7.9%)). In conclusion, none of the antithrombotic regimens showed benefits in stroke or survival at 3 or 12 months after biological AVR. Anticoagulation increased bleeding events. Routine anticoagulation after biological AVR appears to be unnecessary and potentially harmful.
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http://dx.doi.org/10.1016/j.amjcard.2020.05.018DOI Listing
August 2020

Cine-Computed Tomography for the Evaluation of Prosthetic Heart Valve Function.

Cardiology 2020 26;145(7):439-445. Epub 2020 May 26.

Aortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA,

Background: After aortic valve replacement (AVR), suspected prosthetic valve dysfunction (mechanical or biological) may arise based on echocardiographic transvalvular velocities and gradients, leading to reoperative surgical intervention being considered. Our experience has found that 4-dimensional (space and time) image reconstruction of ECG-gated computed tomography, termed cine-CT, may be helpful in such cases. We review and illustrate our experience.

Methods: Twenty-seven AVR patients operated previously by a single surgeon (who performs >100 AVRs/year) were referred for repeat evaluation of suspected aortic stenosis (AS) based on elevated transvalvular velocities and gradients. The patients were fully evaluated by cine-CT.

Results: In all but 2 cases, the cine-CT strikingly and visually confirmed normal leaflet function and excursion, with no valve thrombosis, restriction by pannus, or obstruction by clot. In only 2 cases did cine-CT reveal decreased mechanical valve leaflet excursion. Repeat surgery was required in only 1 case while all other patients continued clinically without cardiac events.

Conclusions: Echocardiography is an extraordinarily useful tool for the evaluation of prosthetic valve function. Increased pressure recovery beyond the valve and other factors may occasionally lead to exaggerated gradients. Cine-CT is emerging as an extremely valuable tool for further evaluation of suspected prosthetic valve AS. Our experience has been extremely helpful, as is shown in the dramatically reassuring images.
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http://dx.doi.org/10.1159/000507182DOI Listing
April 2021

Commentary: Do not "futz" with Laplace.

J Thorac Cardiovasc Surg 2020 Mar 19. Epub 2020 Mar 19.

Aortic Institute at Yale New-Haven, Yale University School of Medicine, New Haven, Conn.

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http://dx.doi.org/10.1016/j.jtcvs.2020.03.008DOI Listing
March 2020

Reply: Effective orifice area of prosthetic heart valves-not perfect, but still valuable.

J Thorac Cardiovasc Surg 2020 06 10;159(6):e330-e332. Epub 2020 Mar 10.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn.

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http://dx.doi.org/10.1016/j.jtcvs.2020.01.050DOI Listing
June 2020

Left Atrial to Femoral Artery Full Cardiopulmonary Bypass: A Novel Technique for Descending and Thoracoabdominal Aortic Surgery.

Int J Angiol 2020 Mar 9;29(1):19-26. Epub 2019 Dec 9.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.

Left atrial-femoral artery (LA-FA) bypass with a centrifugal pump and no oxygenator is commonly used for descending and thoracoabdominal aortic (DTAA) operations, mitigating the deleterious effects of cross-clamping. We present our initial experience performing DTAA replacement under LA-FA (left-to-left) cardiopulmonary bypass (CPB) with an oxygenator. DTAA replacement under LA-FA bypass with an oxygenator was performed in 14 consecutive patients (CPB group). The pulmonary vein and femoral artery (or distal aorta) were cannulated and the full CPB machine were used, including oxygenator, roller pump, pump suckers, and kinetically enhanced drainage. The CPB group was compared with 50 consecutive patients who underwent DTAA replacement utilizing traditional LA-FA bypass without an oxygenator (LA-FA group). Perioperative data were collected and statistical analyses were performed. All CPB patients maintained superb cardiopulmonary stability. The pump sucker permitted immediate salvage and return of shed blood. Superb oxygenation was maintained at all times. High-dose full CPB heparin was reversed without difficulty. The CPB group required markedly fewer blood transfusions than the LA-FA group (2.21 vs. 5.88 units,  < 0.004). The 30-day mortality rate was 7.1% (  = 1) and there were no paraplegia cases in the CPB group versus 7 (14%) deaths and 3 (6%) paraplegia cases in the LA-FA group. Traditional LA-FA bypass without an oxygenator avoids high-dose heparin. In the present era, heparin reversal is more secure. Our experience finds that the novel application of LA-FA CPB with an oxygenator is safe and suggests improved hemodynamics (immediate return of shed blood) and a hemostatic advantage (avoidance of loss of coagulation factors in the cell saver).
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http://dx.doi.org/10.1055/s-0039-3400479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7054066PMC
March 2020

The Genetics of Thoracic Aortic Aneurysms and Dissection: A Clinical Perspective.

Biomolecules 2020 01 24;10(2). Epub 2020 Jan 24.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06510, USA.

Thoracic aortic aneurysm and dissection (TAAD) affects many patients globally and has high mortality rates if undetected. Once thought to be solely a degenerative disease that afflicted the aorta due to high pressure and biomechanical stress, extensive investigation of the heritability and natural history of TAAD has shown a clear genetic basis for the disease. Here, we review both the cellular mechanisms and clinical manifestations of syndromic and non-syndromic TAAD. We particularly focus on genes that have been linked to dissection at diameters <5.0 cm, the current lower bound for surgical intervention. Genetic screening tests to identify patients with TAAD associated mutations that place them at high risk for dissection are also discussed.
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http://dx.doi.org/10.3390/biom10020182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7072177PMC
January 2020

Natural history of descending thoracic and thoracoabdominal aortic aneurysms.

J Thorac Cardiovasc Surg 2021 02 11;161(2):498-511.e1. Epub 2019 Nov 11.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn. Electronic address:

Objectives: Elucidating critical aortic diameters at which natural complications (rupture, dissection, and death) occur is of paramount importance to guide timely surgical intervention. Natural history knowledge for descending thoracic and thoracoabdominal aortic aneurysms is sparse. Our small early studies recommended repairing descending thoracic and thoracoabdominal aortic aneurysms before a critical diameter of 7.0 cm. We focus exclusively on a large number of descending thoracic and thoracoabdominal aortic aneurysms followed over time, enabling a more detailed analysis with greater granularity across aortic sizes.

Methods: Aortic diameters and long-term complications of 907 patients with descending thoracic and thoracoabdominal aortic aneurysms were reviewed. Growth rates (instrumental variables approach), yearly complication rates, 5-year event-free survival (Kaplan-Meier), and risk of complications as a function of aortic height index (aortic diameter [centimeters]/height [meters]) (competing-risks regression) were calculated.

Results: Estimated mean growth rate of descending thoracic and thoracoabdominal aortic aneurysms was 0.19 cm/year, increasing with increasing aortic size. Median size at acute type B dissection was 4.1 cm. Some 80% of dissections occurred below 5 cm, whereas 93% of ruptures occurred above 5 cm. Descending thoracic and thoracoabdominal aortic aneurysm diameter 6 cm or greater was associated with a 19% yearly rate of rupture, dissection, or death. Five-year complication-free survival progressively decreased with increasing aortic height index. Hazard of complications showed a 6-fold increase at an aortic height index of 4.2 or greater compared with an aortic height index of 3.0 to 3.5 (P < .05). The probability of fatal complications (aortic rupture or death) increased sharply at 2 hinge points: 6.0 and 6.5 cm.

Conclusions: Acute type B dissections occur frequently at small aortic sizes; thus, prophylactic size-based surgery may not afford a means for dissection protection. However, fatal complications increase dramatically at 6.0 cm, suggesting that preemptive intervention before that criterion can save lives.
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http://dx.doi.org/10.1016/j.jtcvs.2019.10.125DOI Listing
February 2021

Chronologic and Climatic Factors of Acute Aortic Dissection: Study of 1642 Patients in Two Continents.

Ann Thorac Surg 2020 08 28;110(2):575-581. Epub 2019 Dec 28.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China; Aortic Institute at Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut.

Background: The purpose of this study was to examine whether chronologic and climatic factors and lunar phases affect the onset of acute aortic dissection (AAD).

Methods: The frequencies of AAD were analyzed with regard to the chronologic and climatic factors and lunar phases on the day when AAD occurred for 1642 patients with AAD from two aortic referral centers in the United States and China.

Results: Mean age of patients was 51.6 ± 13.1 years, and 1260 (76.7%) were men. Dissection was type A in 1125 patients (68.5%) and type B in 517 (31.5%). Early mortality rate was 11.6% (190 of 1642), including 89 aortic ruptures before operation and 101 operative deaths. There was a winter peak in occurrence (33.6%, P < .01) with a relative risk of 1.519. In a week, the frequency was highest on Wednesday (15.5%) and Monday (15.2%), and lowest on Sunday (12.8%). Month-specific incidence was significantly inversely correlated to the mean temperature (rho = -0.650, P = .022) and directly correlated to the atmospheric pressure (rho = 0.706, P = .001). The proportion of type A dissection was significantly higher in the full moon phase compared with type B dissection (73.7% vs 66.9%, P = .012).

Conclusions: Acute aortic dissection exhibits significant chronologic variation in the frequency of occurrence, with a peak in winter and on Wednesdays, and nadir in summer and on Sundays. The incidence is significantly correlated to the mean temperature and atmospheric pressure. The proportion of type A dissection is higher in the full moon phase. These results are important for understanding the mechanisms involved in triggering AAD events and helpful for improving disease prevention and patient care.
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http://dx.doi.org/10.1016/j.athoracsur.2019.11.013DOI Listing
August 2020
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