Publications by authors named "Mohammad A Zafar"

58 Publications

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

Reply to Condello and Iacona.

Eur J Cardiothorac Surg 2021 Jun 28. Epub 2021 Jun 28.

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

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http://dx.doi.org/10.1093/ejcts/ezab303DOI 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

Machine learning: principles and applications for thoracic surgery.

Eur J Cardiothorac Surg 2021 Mar 22. Epub 2021 Mar 22.

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

Objectives: Machine learning (ML) has experienced a revolutionary decade with advances across many disciplines. We seek to understand how recent advances in ML are going to specifically influence the practice of surgery in the future with a particular focus on thoracic surgery.

Methods: Review of relevant literature in both technical and clinical domains.

Results: ML is a revolutionary technology that promises to change the way that surgery is practiced in the near future. Spurred by an advance in computing power and the volume of data produced in healthcare, ML has shown remarkable ability to master tasks that had once been reserved for physicians. Supervised learning, unsupervised learning and reinforcement learning are all important techniques that can be leveraged to improve care. Five key applications of ML to cardiac surgery include diagnostics, surgical skill assessment, postoperative prognostication, augmenting intraoperative performance and accelerating translational research. Some key limitations of ML include lack of interpretability, low quality and volumes of relevant clinical data, ethical limitations and difficulties with clinical implementation.

Conclusions: In the future, the practice of cardiac surgery will be greatly augmented by ML technologies, ultimately leading to improved surgical performance and better patient outcomes.
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http://dx.doi.org/10.1093/ejcts/ezab095DOI Listing
March 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

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

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

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

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

Predicting in-hospital rupture of type A aortic dissection using Random Forest.

J Thorac Dis 2019 Nov;11(11):4634-4646

Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.

Background: This study is to establish prediction tools for in-hospital rupture of type A aortic dissection (TAAD) patients, to better guide emergency surgical triage and patient counselling.

Methods: We retrospectively evaluated 1,133 consecutive patients with TAAD from January 2010 to December 2016. The study population was divided into training and testing datasets in a 70:30 ratio for further analysis using Random Forest.

Results: The Random Forest classification model was developed with the training dataset and 16 variables were confirmed as 'important': age, BMI, gender, syncope, lower limb numbness/pain, acute phase of the TAAD, BP >160 mmHg at admission; acute liver dysfunction, WBC >15×10/L, aortic size, aortic height index (AHI), periaortic hematoma, pleural effusion, brachiocephalic artery involvement, renal artery involvement, and hemopericardium. Validation of the model showed good discrimination with an AUC, sensitivity, specificity, positive predictive value and negative predictive value of 0.994, 1.000, 0.987, 0.998 and 1.000, respectively, in the training dataset, and 0.752, 0.990, 0.514, 0.945 and 0.857, respectively, in the testing dataset.

Conclusions: An easy-to-use tool to predict in-hospital rupture for TAAD patients was developed and validated (http://47.107.228.109/). Periaortic hematoma is the strongest predictor. Simple clinical information such as syncope can be very useful in in-hospital rupture risk stratification.
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http://dx.doi.org/10.21037/jtd.2019.10.82DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940214PMC
November 2019

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

Genes Associated with Thoracic Aortic Aneurysm and Dissection: 2019 Update and Clinical Implications.

Aorta (Stamford) 2019 Jun 16;7(4):99-107. Epub 2019 Dec 16.

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

Thoracic aortic aneurysm is a typically silent disease characterized by a lethal natural history. Since the discovery of the familial nature of thoracic aortic aneurysm and dissection (TAAD) almost 2 decades ago, our understanding of the genetics of this disorder has undergone a transformative amplification. To date, at least 37 TAAD-causing genes have been identified and an estimated 30% of the patients with familial nonsyndromic TAAD harbor a pathogenic mutation in one of these genes. In this review, we present our yearly update summarizing the genes associated with TAAD and the ensuing clinical implications for surgical intervention. Molecular genetics will continue to bolster this burgeoning catalog of culprit genes, enabling the provision of personalized aortic care.
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http://dx.doi.org/10.1055/s-0039-3400233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914358PMC
June 2019

Natural history and management of Kommerell's diverticulum in a single tertiary referral center.

J Vasc Surg 2020 06 7;71(6):2004-2011. Epub 2019 Nov 7.

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

Objective: The Kommerell diverticulum (KD) is an extremely rare developmental abnormality of the aorta related to an aberrant subclavian artery (ASCA). The objective of our study was to review the natural history of KD and ASCA using our single-center experience in diagnosing and managing KD and ASCA.

Methods: A retrospective review of the Yale radiological database from January 1999 to December 2016 was performed. Only patients with KD/ASCA and a computed tomography (CT) scan of the chest were selected for review. The primary goal was to examine the natural history of KD and ASCA and the secondary goals were to review the management and outcomes of those patients treated for KD and ASCA.

Results: There were 75 patients with KD/ASCA identified, with a mean age of 63 ± 19 years; 49 were female (65%). On CT scans, left- and right-sided aortas were present in 47 (63%) and 28 (37%) patients. A right ASCA or a left ASCA were present in 47 (63%) and 28 (37%) patients. Six patients were symptomatic on presentation. Symptoms included dysphagia, chest or back pain, and emboli to the fingers. The mean KD diameter was 21.8 ± 6.0 mm and the distance to the opposite aortic wall (DAW) was 48.3 ± 10.8 mm. Sixty-six patients were followed for a mean of 31.7 ± 32.5 months. One patient ruptured without repair. Nine patients underwent operative intervention, including eight open and one endovascular repair. Complications from operative intervention included ischemic stroke with hemorrhagic transformation, deep vein thrombosis and pneumonia. The mean growth rate for KD and DAW was 1.45 ± 0.39 mm/year and 2.29 ± 0.47 mm/year, respectively. On multivariable regression analysis, hypertension was a predictor of growth of DAW (P = .03).

Conclusions: KD is uncommon and shows a female predominance. The diverticulum grows, albeit slowly (KD and DAW growth rates of 1.45 ± 0.39 mm/year and 2.29 ± 0.47 mm/year). Most patients are asymptomatic, but dysphagia, chest/back pain, and distal emboli may occur. Rupture is rare. Symptomatic patients should be operated. Asymptomatic patients can be followed with serial CT scans.
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http://dx.doi.org/10.1016/j.jvs.2019.08.260DOI Listing
June 2020

Routine anterior spinal artery visualization prior to descending and thoracoabdominal aneurysm repair: High detection success.

J Card Surg 2019 Dec 9;34(12):1563-1568. Epub 2019 Nov 9.

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

Background: Paraplegia is adevastating complication of open descending (DTAA) and thoracoabdominal aortic aneurysm (TAAA) repair. Despite major advances in imaging and surgical techniques, paraplegia continues to be problematic. We present our experience with routine application of enhanced imaging techniques to detect the anterior spinal artery (ASA) before DTAA and TAAA repair.

Methods: We retrospectively reviewed 177 patients with DTAA and TAAA who underwent imaging to detect the ASA before open surgical repair. High definition CT angiography (CTA) and dual energy CT scanning (DECT) were our modalities of choice with angiography used earlier and magnetic resonance angiography (MRA) used when CT was contraindicated. Descriptive statistics and χ analyses were conducted.

Results: The imaging protocol successfully detected the level of the ASA in 132 (74.5%) patients, utilizing CTA in 67, DECT in 28, spinal angiography in 31, and MRA in 6. Cross sectional modalities with advanced visualization technique (CT, DECT, and MRA) were more successful at detecting the ASA than angiography (80.72%, 82.35%, 75% vs 59.62%, respectively, P = .04). Concerted efforts were made not to leave the operating room without continuity of the ASA with the circulation (via limited resection, beveled anastomosis, or reimplantation). Transient lower extremity weakness was observed in 11 (6.2%) patients, and permanent paraplegia in 2 (1.12%) patients.

Conclusion: Modern imaging technology provides multiple methodologies highly successful at detecting the ASA. The ASA can then be preserved intraoperatively, contributing to low paraplegia rates. We strongly recommend routine application of this technology to arm the surgeon with precise information about the specific patient's spinal cord blood supply.
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http://dx.doi.org/10.1111/jocs.14310DOI Listing
December 2019

Reply: Keen questions appreciated.

J Thorac Cardiovasc Surg 2019 Oct 21. Epub 2019 Oct 21.

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.2019.06.127DOI Listing
October 2019

Commentary: Toward truth in advertising.

J Thorac Cardiovasc Surg 2019 10 8;158(4):1055-1057. Epub 2019 Aug 8.

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.2019.07.053DOI Listing
October 2019

Fluoroquinolones and Aortic Diseases: Is There a Connection.

Aorta (Stamford) 2019 Apr 17;7(2):35-41. Epub 2019 Sep 17.

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

Fluoroquinolones (FQs) are one of the most commonly prescribed classes of antibiotics. Their high tissue distribution and broad-spectrum antibacterial coverage make their use very attractive in numerous infectious diseases. Although generally well tolerated, FQs have been associated with different adverse effects including dysglycemia and arrhythmias. FQs have been also associated with a series of adverse effects related to collagen degradation, such as Achilles tendon rupture and retinal detachment. Recently, an association between consumption of FQs and increased risk of aortic aneurysm and dissection has been proposed. This article reviews the pathogenesis of thoracic aortic diseases, the molecular mechanism of FQ-associated collagen toxicity, and the possible contribution of FQs to aortic diseases.
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http://dx.doi.org/10.1055/s-0039-1693468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748841PMC
April 2019

Ascending Aortic Length and Risk of Aortic Adverse Events: The Neglected Dimension.

J Am Coll Cardiol 2019 10 13;74(15):1883-1894. Epub 2019 Sep 13.

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

Background: Little information is available regarding the longitudinal changes of the aneurysmal ascending aorta.

Objectives: This study sought to outline the natural history of ascending thoracic aortic aneurysm (ATAA) based on ascending aortic length (AAL) and develop novel predictive tools to better aid risk stratification.

Methods: The ascending aortic diameters and lengths, and long-term aortic adverse events (AAEs) (rupture, dissection, and death) of 522 ATAA patients were evaluated using comprehensive statistical approaches.

Results: An AAL of ≥13 cm was associated with an almost 5-fold higher average yearly rate of AAEs compared with an AAL of <9 cm. Two AAL "hinge points" with a sharp increase in the estimated probability of AAEs were detected between 11.5 and 12.0 cm, and between 12.5 and 13.0 cm. The mean estimated annual aortic elongation rate was 0.18 cm/year, and aortic elongation was age dependent. Aortic diameter increased 18% due to dissection while AAL only increased by 2.7%. There was a noticeable improvement in the discrimination of the logistic regression model (area under the receiver-operating characteristic curve: 0.810) due to the introduction of aortic height index (AHI) (diameter height index + length height index). The AHIs <9.33, 9.38 to 10.81, 10.86 to 12.50, and ≥12.57 cm/m were associated with a ∼4%, ∼7%, ∼12%, and ∼18% average yearly risk of AAEs, respectively.

Conclusions: An aortic elongation of 11 cm serves as a potential intervention criterion for ATAA, which is even more reliable than diameter due to its relative immunity to dissection. AHI (including both length and diameter) is more powerful than any single parameter in this study.
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http://dx.doi.org/10.1016/j.jacc.2019.07.078DOI Listing
October 2019

Commentary: Should we routinely prescribe β-blockers after surgical repair of type A dissection?

J Thorac Cardiovasc Surg 2020 05 15;159(5):1706-1707. Epub 2019 Jun 15.

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.2019.06.006DOI Listing
May 2020

Subacute/chronic type A aortic dissection: a retrospective cohort study.

Eur J Cardiothorac Surg 2020 02;57(2):388-396

Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Beijing, China.

Objectives: Our goal was to outline the clinical presentations, surgical treatment and outcomes of subacute/chronic type A aortic dissection (TAAD).

Methods: A total of 1092 patients with TAAD were enrolled retrospectively and divided into 2 groups based on acuity of TAAD (181 subacute/chronic vs 911 acute cases of TAAD). Early and late outcomes were investigated and compared using propensity score matching.

Results: The top 3 symptoms for subacute/chronic TAAD were chest tightness (80/181, 44.2%), mild pain (65/181, 35.9%) and sweating (58/181, 32.0). Fifteen (15/181, 8.3%) patients were symptom-free. Typical symptoms of acute TAAD were less common in patients with subacute/chronic TAAD such as intense/sharp pain (48/181, 26.5%), tear-like pain (35/181, 19.3%) and radiating pain (30/181, 16.6%). Patients with subacute/chronic TAAD had better early and late survival rates, with an early mortality rate of 6.1% (11/181) compared to 11.6% (106/911) of those with acute TAAD (P = 0.038). Before propensity score matching, survival at 1, 3 and 5 years was 93.1% [95% confidence interval (CI) 89.4-96.9%], 88.4% (95% CI 83.1-93.9%) and 86.4% (95% CI 80.1-93.1%) for subacute/chronic TAAD and 86.9% (95% CI 84.7-89.2%), 82.6% (95% CI 79.9-85.3%) and 79.0% (95% CI 75.5-82.7%) for acute TAAD, respectively (P = 0.039). The propensity score matching analysis substantiated the foregoing results.

Conclusions: Subacute/chronic TAAD was clearly distinct from acute TAAD in terms of clinical presentations and had better early and late survival rates. Current surgical strategies for acute TAAD are applicable to subacute/chronic TAAD with excellent outcomes.
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http://dx.doi.org/10.1093/ejcts/ezz209DOI Listing
February 2020

Complex two-stage open surgical repair of an aortoesophageal fistula after thoracic endovascular aortic repair.

J Vasc Surg Cases Innov Tech 2019 Sep 25;5(3):261-263. Epub 2019 Jun 25.

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

Aortoesophageal fistula after thoracic endovascular aortic repair is a rare but fatal complication, and no clear guidelines exist in the literature for optimal management. Herein, we report a complex case of a patient with an infected thoracic endograft that led to an aortoesophageal fistula. The treatment comprised a two-stage open surgical approach-an extra-anatomic aortic bypass in the first stage, followed by explantation of the infected endograft with ligation of the descending thoracic aorta in the second. This approach controls the focus of infection while allowing flow to the aorta distal to the infected endograft, minimizing visceral ischemia time.
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http://dx.doi.org/10.1016/j.jvscit.2019.02.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6601018PMC
September 2019

Nonsyndromic Thoracic Aortic Aneurysms and Dissections-Is Screening Possible?

Semin Thorac Cardiovasc Surg 2019 Winter;31(4):628-634. Epub 2019 Jun 15.

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

Nonsyndromic thoracic aortic aneurysm and dissection (TAAD) account for 95% of all TAAD cases and comprise a subset in which the lack of obvious clinical signs makes diagnosis a challenge. Despite the potentially fatal natural history, timely diagnosis and prophylactic surgical intervention allow restoration of near-normal life expectancy in TAAD patients, underlining the critical importance of screening tests. To date, more than 30 TAAD disease-causing genes have been identified, and over 30% of nonsyndromic TAAD patients have a genetic mutation in 1 or more of these genes. Whole exome sequencing allows routine genetic testing in a clinical setting by screening for all TAAD-related genes, thus facilitating personalized aortic care. Additionally, increased vigilance upon diagnosis of certain TAAD-related diseases ("guilty associates") and the emergence of modern radiologic and novel serologic screening tests will further bolster efforts to detect undiagnosed asymptomatic nonsyndromic TAAD.
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http://dx.doi.org/10.1053/j.semtcvs.2019.05.035DOI Listing
January 2020

Fate of preserved bicuspid valves at time of ascending aortic aneurysmectomy.

J Card Surg 2019 May 21;34(5):318-322. Epub 2019 Mar 21.

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

Background: The fate of the spared bicuspid aortic valve in patients undergoing ascending aortic aneurysm surgery is relatively unknown. Our institutional policy has been to replace all aortic valves with significant abnormalities, as evidenced by intraoperative transesophageal echocardiography or direct visual inspection. In this study, we elaborate our experience regarding the long-term fate of preserved bicuspid aortic valves after ascending aortic aneurysm extirpation.

Materials And Methods: From 2000 to 2018, 407 consecutive ascending aortic aneurysm patients with concomitant bicuspid aortic valves underwent surgery by a single surgeon at our institution. Among these, 23 (5.65%) patients did not have their valve replaced, forming the study group. Postoperative and preoperative echocardiograms were compared to determine changes in valve function.

Results: Follow-up was complete in 100% of patients. The average time between preoperative and postoperative echocardiograms was 4.50 ± 4.09 years (0.19-15.63). Aortic stenosis or regurgitation changed from none to mild in 5 (21.7%) of patients, with an average echocardiographic interval follow-up of 3.08 years, and from none to severe in 2 (8.7%), with an interval of 11.7 years. One patient required reoperation, including aortic valve replacement, during follow-up.

Conclusion: Bicuspid aortic valves free of aortic stenosis or insufficiency before surgery and "healthy" appearing at surgery can safely be preserved.
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http://dx.doi.org/10.1111/jocs.14024DOI Listing
May 2019
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