High risk for vascular events in patients with protruding aortic atheromas: A prospective study

Objectives. The purpose of this study was to prospectively evaluate the risk of vascular events in patients with protruding aortic atheromas.Background. Protruding atheromas of the thoracic aorta have been shown to be associated with embolic disease in previous retrospective studies.Methods. During a 1-year period, 521 patients had transesophageal echocardiography. Of these, 42 patients had protruding atheromas and no other source of emboli. They were followed up for up to 2 years (mean follow-up 14 months) and compared with a control group without atheromas, matched for age, gender and hypertension.Results. Of 42 patients with atheromas, 14 (33%) had 19 vascular events during follow-up (5 brain, 2 eye, 4 kidney, 1 bowel, 7 lower extremity). Of 42 control patients, 3 (7%) had vascular events (2 brain, 1 eye). Univariate analysis identified only protruding atheromas as significantly correlating with events (p = 0.003). There was no positive correlation of events with age, gender, hypertension, smoking, family history, atrial fibrillation, valve replacement, antithrombotic drug use, diabetes or coronary disease. Multivariate analysis showed that only protruding atheromas independently predicted events (p = 0.005, odds ratio 4.3, 95% confidence interval 1.2 to 15.0). Nine patients died in the atheroma group versus six in the control group, but this was not statistically significant (p = 0.39).Conclusions. Protruding atheromas seen on transesophageal echocardiography predict future vascular events.     

Atheromas of the thoracic aorta: clinical and therapeutic update

Atherosclerotic lesions of the thoracic aorta have recently been recognized as an important cause of stroke and peripheral embolization, which may result in severe neurologic damage as well as multiorgan failure and death. Their prevalence is approximately 27% in patients with previous embolic events. Transesophageal echocardiography is the modality of choice for the diagnosis of these atheromas, although computed tomography, magnetic resonance imaging and intraoperative epiaortic ultrasound are complementary. Two clinical syndromes account for the embolic phenomena, atheroemboli and, more commonly, thromboemboli. In addition to such superimposed thrombi, plaque thickness (especially > or =4 mm) also correlates with embolic risk. This risk is high, with 12% of patients having a recurrent stroke within approximately one year, and up to 33% of patients having a stroke or peripheral embolus. In addition, aortic atheromas (as seen with intraoperative transesophageal echocardiography and intraoperative epiaortic ultrasound) are an important cause of stroke during heart surgery requiring cardiopulmonary bypass. Such strokes occur during approximately 12% of cardiac operations employing cardiopulmonary bypass when aortic arch atheromas are seen with transesophageal echocardiography (six times the general intraoperative stroke rate). Although anticoagulant strategies have been reported with encouraging results in nonrandomized studies, prospective, randomized data must be developed before an effective and safe treatment strategy can be determined. This review details the current state of knowledge in this area, including the clinical and pathologic evidence that thoracic aortic atherosclerosis is an important embolic source, data which guide current therapy and future directions for clinical investigation.     

Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography.

Protruding atheromas of the aortic arch identified by transesophageal echocardiography have been implicated as a cause of stroke in elderly patients. One hundred thirty patients greater than or equal to 65 years of age were studied with intraoperative transesophageal echocardiography to detect aortic arch protruding atheromas and determine if these patients were at higher risk for perioperative stroke. Protruding atheromas were identified in 23 (18%) of 130 patients. In 19 (83%) of these 23 patients, palpation of the aortic arch at operation did not identify significant abnormalities. Five patients (4%) had perioperative stroke. Logistic regression identified aortic arch atheroma as the only historical or procedural variable that was predictive of stroke (odds ratio 5.8, 95% confidence interval 1.2 to 27.9, p less than 0.03). A history of peripheral or cerebrovascular disease, presence of aortic calcification, cardiac risk factors, age and duration of cardiopulmonary bypass did not predict stroke. In contrast, patients with protruding atheromas with mobile components were at highest risk. There were 3 (25%) of 12 patients with a mobile atheroma who had a stroke versus 2 (2%) of 118 patients without a mobile atheroma (chi-square = 10.3, p = 0.001). Displacement and detachment of the frail, protruding atherosclerotic material by aortic arch cannulation or by the high pressure jet emanating from the cannula tip may play an important role in the creation of embolization and stroke.     

Aortic Atheromas: Current Concepts and Controversies—A Review of the Literature

The frequent use of transesophageal echocardiogram (TEE) has led to the increased recognition of aortic atheromas. Retrospective and prospective follow-up studies have reported an association between aortic atheromas and stroke in the high-risk patient population, with complex plaques being more likely to embolize than simple plaques. However, TEE-based studies in the low-risk cohorts have failed to show a similar association. There is growing body of evidence suggesting that aortic atheroma is a marker of generalized atherosclerosis. Although magnetic resonance (MR) imaging and computed tomography (CT) scan are emerging as a powerful noninvasive tool for characterization of aortic atheromas, TEE is the imaging modality of choice. Currently, treatment of aortic atheromas is not well defined, and mixed outcomes have been reported for anticoagulation therapy with warfarin. Statins appear promising based on their plaque stabilization properties. However, there are no randomized control trials to establish the role of both anticoagulation and statins in patients with aortic atheromas, and are warranted in the future .     

Aortic atheromas: current concepts and controversies-a review of the literature.

The frequent use of transesophageal echocardiogram (TEE) has led to the increased recognition of aortic atheromas. Retrospective and prospective follow-up studies have reported an association between aortic atheromas and stroke in the high-risk patient population, with complex plaques being more likely to embolize than simple plaques. However, TEE-based studies in the low-risk cohorts have failed to show a similar association. There is growing body of evidence suggesting that aortic atheroma is a marker of generalized atherosclerosis. Although magnetic resonance (MR) imaging and computed tomography (CT) scan are emerging as a powerful noninvasive tool for characterization of aortic atheromas, TEE is the imaging modality of choice. Currently, treatment of aortic atheromas is not well defined, and mixed outcomes have been reported for anticoagulation therapy with warfarin. Statins appear promising based on their plaque stabilization properties. However, there are no randomized control trials to establish the role of both anticoagulation and statins in patients with aortic atheromas, and are warranted in the future.     

Protruding atheromas in the thoracic aorta: a newly recognized source of cerebral and systemic embolization

Up to 40% of stroke patients do not have an obvious etiology for their illness. Because transthoracic echocardiography is often negative in these patients, there has been increasing enthusiasm for transesophageal echocardiography (TEE) as a newer tool for evaluating patients with embolic disease. In a study of patients referred because of unexplained stroke or transient ischemic attacks, the most common finding was protruding atheroma in the aortic arch. In a case control study, protruding aortic atheromas were found in 33 of the 122 patients with emboli (27%). Mobile components to the atheromas were found in 11 case patients, and there were no mobile components found in any control patients. It is also possible that protruding aortic atheromas may play a role in patients with other sources of emboli (e.g., carotid disease). Atheromas may also cause emboli during catheterization, balloon pump placement, and cardiopulmonary bypass. The pathological composition of the lesions seen on TEE has been atheroma with superimposed thrombus. The correct treatment for patients with embolization due to protruding aortic atheromas has not yet been determined, although anticoagulation may play a role, since the mobile components to these lesions appear to be thrombus. We have recommended surgery for several patients. However, the operation is a major one with major potential complications, including aortic dissection. TEE should be done in patients with unexplained emboli, and it may also play a role in patients with other sources of embolization. TEE should be considered in elderly patients or those with extensive vascular disease before cardiac catheterization or heart surgery. In addition, cannulation techniques during bypass can be modified to avoid atheromas. The ideal medical and/or surgical approaches to patients with protruding atheromas remain to be clarified.     

Splenic and mesenteric emboli in a patient with protruding aortic arch atheroma

Protruding atheromas in the thoracic aorta are an important cause of embolic disease. Transesophageal echocardiography (TEE) is the modality of choice for diagnosis of these lesions. We present a patient with splenic infarction in whom TEE revealed a large mobile atheroma in the aortic arch. A few hours following the disappearance of this mass from the aortic arch, the patient developed mesenteric artery embolism requiring subtotal small-bowel resection. We discuss the importance of the aortic arch as a source of peripheral emboli and the treatment modalities in these patients.     

Atheromatous disease of the thoracic aorta and systemic embolism. Clinical picture and therapeutic challenge

Systemic embolism is a frequent cause of stroke. At the beginning of the last decade by introduction of transesophageal echocardiography and other imaging techniques atheromatosis of the aortic arch has been recognized as an important source of embolism. Formerly in the pre-TEE era, this entity was included into cryptogenic strokes. Aortic atheromas are found in about one quarter of patients presenting with embolic events. The severity of atherosclerosis graded by TEE correlates with the risk for future embolism, especially if mobile lesions or superimposed thrombi are present. Independent of plaque extension, patients with unstable plaques characterized by echo-lucency, inhomogenity, lacking of calcifications, ulceration, mobile parts and concomitant spontaneous echo contrast within the aorta have a higher risk for embolic events. However, the diagnosis of aortic atheromatosis is mostly established if an embolic event has already occurred. Therefore, it is important to identify patients at risk, especially before they undergo interventions with manipulation at the aorta like coronary bypass surgery. Risk factors are age above 70, diabetes mellitus, hyperlipidemia, arterial hypertension, aortic calcifications on standard chest X-ray, elevated serum levels of C-reactive protein, other inflammatory markers, and an activated coagulation. Randomized studies for treatment of patients with severe aortic atheromatosis are not yet existing. Warfarin has been shown to prevent stroke in patients with mobile atheromas and superimposed thrombi, but there are case reports about aggravation of cholesterol embolism under warfarin treatment. It is concluded from other atherosclerotic manifestations that plaque stabilizing treatment with statins and ACE inhibitors is also beneficial.     

Embolic stroke secondary to an aortic arch tumor--a case report

An acute stroke from an aortic arch tumor is reported. These tumors are rare and have to be differentiated from atheromas. Aortic atheromas commonly present with embolic phenomena and occasionally as masses. Aortic tumors are more likely to produce obstructive phenomena, presenting as a coarctation or dissection. Magnetic resonance imaging with gadolinium can facilitate the diagnosis. A literature review of aortic masses and their diagnosis and treatment are presented.     

A measured approach to managing the aortic root in patients with bicuspid aortic valve disease

Bicuspid (or bicommissural) aortic valve (BAV) is the most common cardiovascular malformation in humans, with a prevalence of 1% to 2% in the general population and a 2:1 male:female ratio. BAV is frequently associated with other cardiovascular malformations, including aortic root dilatation, which affects about 40% of individuals with BAVs and is thought to be associated with increased risk of dissection and/or rupture. Currently, no agreement exists about the optimal management of these patients. We review the pathophysiology and possible determinants of aortic disease associated with BAV, the natural history of aortic wall size progression, and suggest management strategies to prevent acute aortic events.     

Is Cardiac Catheterization Necessary in the Era of Echocardiography?

Definitive evaluation of cardiovascular disease is traditionally accomplished by cardiac catheterization. Advances in transthoracic and transesophageal Doppler echocardiography provides an accurate and cost-effective approach when compared to cardiac catheterization. Recent data suggests that for most adult patients with aortic or mitral valve disease, Doppler echocardiographic data enables the clinician to make the same decision reached with catheterization data. Echo and Doppler studies are useful in guiding certain therapeutic interventional procedures, and in the diagnosis of aortic dissection, mechanical complications of myocardial infarction, and in identifying aortic atheromas as a potential source of embolism. Future research will need to demonstrate that not only is echocardiography cost-effective, but that it will change the outcome of the patient.     

Involvement of the heart valves and great vessels in homozygote familial hypercholesterolemia]

Homozygous familial hypercholesterolaemia is characterized by cutaneous xanthoma development from infancy, precocious and accelerated atherosclerosis with clinical signs of ischemic heart disease and frequent involvement of left heart valves resulting in stenosis and/or incompetence. Two cases are described of this condition, both associated with aortic stenosis. In one case mitral incompetence and thromboembolic pulmonary hypertension were also found. The mitral valve is involved in the atherosclerotic process at the level of the cusps. These become thickened and stiff. Aortic stenosis is mainly due to atheromas infiltrating the Valsalva sinuses and the ascending aorta. Pulmonary hypertension, never reported before in this disease, is probably due to concomitant atheromatosis involving the pulmonary artery with secondary fatty embolism.     

Nonobstructive aortic valve calcium as a window to atherosclerosis of the aorta

Aortic valve calcium without stenosis and mitral annulus calcium (MAC) are known to correlate with atherosclerotic risk factors. Recently, it has been reported that MAC is associated with atherosclerosis of the cardiovascular system, suggesting MAC as an atherosclerotic process by itself. Hence, the aim of the present study was to determine whether a similar association between aortic valve calcium and aortic atheroma exists. Ninety-six patients (54 men and 42 women, mean age 72 +/- 12 years) with aortic valve calcium who underwent transesophageal echocardiography (TEE) formed the study group. They were compared with 92 sex- and age-matched patients without aortic valve calcium who underwent TEE for the same indications during the same period. The presence and echocardiographic features of aortic atheromas were evaluated by TEE. No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the aortic valve calcium group for prevalence of aortic atheroma (86% vs 30%, p = 0.001). This significant trend was also consistent with the dimension and complexity of the atheromas. On multivariate analysis aortic valve calcium, and MAC were the only independent predictors of aortic atheroma (p = 0.0001, 0.006 respectively). We conclude that there is a significant association between the presence of aortic valve calcium and the presence and severity of aortic atheroma. Thus, aortic valve calcium may serve as a window to atherosclerosis of the aorta.     

C-reactive protein and coronary heart disease: diagnostic and therapeutic implications for primary prevention

Coronary heart disease (CHD) is the leading cause of death in the industrialized world. Recent laboratory and clinical studies have shown that inflammation plays a pivotal role in the inception, progression, and destabilization of atheromas. The acute-phase reactant C-reactive protein (CRP) has been shown to reflect systemic and, perhaps, vascular inflammation and to predict future cardiovascular events in asymptomatic individuals. The relative risk associated with CRP is independent of other cardiovascular disease risk factors. High-sensitivity assays (hs-CRP) are needed for the measurement of CRP concentration for the purpose of predicting the risk of future coronary events. Available assays must be standardized because patients' results will be interpreted using population-based cutpoints. An algorithm for risk stratification incorporating hs-CRP and total cholesterol to high-density lipoprotein cholesterol ratio has been developed. Statin class drugs and aspirin appear to modulate CHD risk in those with increased hs-CRP concentration. Several prospective studies are now underway to specifically develop novel clinical utilities and therapeutic strategies for hs-CRP.     

Protruding atheromas in the thoracic aorta and systemic embolization

OBJECTIVE: To determine whether protruding atheromas in the thoracic aorta are a risk factor for systemic embolization. DESIGN: Case-control study. SETTING: A referral hospital. PATIENTS: A total of 122 patients with a history of stroke, transient ischemic attack, or peripheral emboli and an equal number of age- and sex-matched control patients. MEASUREMENTS: Evaluation using transesophageal echocardiography was done in case patients to detect protruding atheromas in the thoracic aorta and in control patients for cardiac indications other than emboli. MAIN RESULTS: Matched logistic regression showed that the presence of protruding atheromas was strongly related to the occurrence of embolic symptoms (odds ratio, 3.2; 95% Cl, 1.6 to 6.5; P less than 0.001). Furthermore, atheromas with mobile components were present only in case patients. When known risk factors for stroke (hypertension and diabetes) were added to the model, the presence of protruding atheromas remained an independent risk factor for embolic symptoms (odds ratio, 3.8). Hypertension was also independently associated with embolic symptoms (odds ratio, 2.7), but diabetes was not (odds ratio, 1.0). CONCLUSION: Protruding atheromas in the thoracic aorta can be detected by transesophageal echocardiography and should be considered as a cause of strokes, transient ischemic attacks, and peripheral emboli.     

The use of ultrasound to assess aortic biomechanics: Implications for aneurysm and dissection

Arterial stiffening, which occurs when conduit arteries thicken and lose elasticity, has been associated with cardiovascular disease and increased risk for future cardiovascular events. Specifically, aortic stiffening plays a large role in the pathogenesis of vascular diseases, such as aneurysm formation and dissection. Current parameters used to assess risk of aortic rupture include absolute diameter and growth rate. However, these properties lack the reliability required to accurately risk-stratify patients. As with any elastic conduit, it is important to assess the biomechanical properties of the aorta in order to assess cardiovascular risk and prevent disease progression. There are several invasive and noninvasive methods by which stiffness of the large arteries can be assessed. Of particular interest are ultrasound-based methods, such as tissue Doppler imaging and speckle-tracking echocardiography, due to their noninvasive and feasible nature. In this review, we summarize studies demonstrating utility of noninvasive ultrasound imaging methods for measuring aortic biomechanics for the assessment and management of aortic aneurysms.     

Elevated prothrombin and activated protein C resistance in patients with thoracic aortic atheroma

Patients with protruding aortic atheroma containing mobile emboli are at risk for peripheral emboli and stroke. This risk may possibly be reduced by anticoagulation, but whether or not such patients have an increased prevalence of thrombotic risk factors has not been previously determined. Twenty-two patients were studied (11 with protruding thoracic aortic atheromas and superimposed mobile thrombi on transesophageal echocardiography were compared to 11 age-matched controls). The authors evaluated activated protein C resistance (APC-R) by measuring the prolongation of the partial thromboplastin time (PTT) in response to activated protein C (APC). Concentrations of fibrinogen, antithrombin III (AT III), factor II, factor V, and D-dimer were also determined in all patients. There was significant resistance to APC (a smaller prolongation in PTT) in patients with atheromas and thrombi. They also had significantly higher concentrations of factor II. Factor V and fibrinogen were higher, and AT III lower, in patients than in controls; however, these latter differences did not reach statistical significance. Patients with aortic atheroma and mobile thrombi may have an increased prevalence of thrombotic risk factors. There is significantly increased resistance to activated protein C in patients with protruding atheroma and mobile thrombi in their thoracic aorta. There was also a trend toward elevated fibrinogen, homocysteine, and apo (a) concentrations as well as lower antithrombin III concentrations in these patients.     

Central pressure: variability and impact of cardiovascular risk factors: the Anglo-Cardiff Collaborative Trial II

Pulse pressure varies throughout the arterial tree, resulting in a gradient between central and peripheral pressure. Factors such as age, heart rate, and height influence this gradient. However, the relative impact of cardiovascular risk factors and atheromatous disease on central pressure and the normal variation in central pressure in healthy individuals are unclear. Seated peripheral (brachial) and central (aortic) blood pressures were assessed, and the ratio between aortic and brachial pulse pressure (pulse pressure ratio, ie, 1/amplification) was calculated in healthy individuals, diabetic subjects, patients with cardiovascular disease, and in individuals with only 1 of the following: hypertension, hypercholesterolemia, or smoking. The age range was 18 to 101 years, and data from 10 613 individuals were analyzed. Compared with healthy individuals, pulse pressure ratio was significantly increased (ie, central systolic pressure was relatively higher) in individuals with risk factors or disease (P<0.01 for all of the comparisons). Although aging was associated with an increased pulse pressure ratio, there was still an average+/-SD difference between brachial and aortic systolic pressure of 11+/-4 and 8+/-3 mm Hg for men and women aged >80 years, respectively. Finally, stratifying individuals by brachial pressure revealed considerable overlap in aortic pressure, such that >70% of individuals with high-normal brachial pressure had similar aortic pressures as those with stage 1 hypertension. These data demonstrate that cardiovascular risk factors affect the pulse pressure ratio, and that central pressure cannot be reliably inferred from peripheral pressure. However, assessment of central pressure may improve the identification and management of patients with elevated cardiovascular risk.     

Penile Doppler ultrasound: contribution to the management of erectile dysfunction

Erectile dysfunction (ED) is a common multifactorial disease, in most situations arising from an organic or mixed cause. Most cases of ED classified as arterial are linked to endothelial dysfunction in relation to the key factors of cardiovascular risk. ED is an indicator of vascular health in general. It is also a predictor of cardiovascular events, including coronary heart disease. It has also been associated with lower peripheral arterial disease and stroke. At the present time, penile Doppler ultrasound examination is relatively little used in the management of ED, knowledge of the etiologic factors being most often not necessary for therapeutic management, but also because of the absence of standardization. Nonetheless, recent large-scale studies have shown that the vascular nature of ED, based on Doppler parameters recorded after intracavernous injection of vasoactive drugs, was also predictive of cardiovascular events and cardiovascular mortality, warranting greater interest in this test.     

Hypertension in older people: part 1

Once considered part of the normal aging process, the development of isolated systolic hypertension represents a late manifestation of increased arterial stiffness in older people. Furthermore, isolated systolic hypertension is the single most frequent subtype of hypertension in the US adult population. Indeed, central arterial stiffness rather than peripheral vascular resistance becomes the dominant hemodynamic factor in both normotensive and hypertensive individuals after the age of 50-60 years. Stiffening disease, an age-related degeneration of the elastic elements of the thoracic aorta, is associated with a widening of brachial pulse pressure. Brachial pulse pressure predicts future cardiovascular disease events. However, pressure wave amplification produces higher brachial than aortic pressures and, therefore, central rather than peripheral blood pressure indices are more reliable measures of cardiovascular risk. Stiffening disease of aging is accompanied by early wave reflection, which results in a significant augmentation of central systolic pressure in late systole and further adds to increased cardiac afterload--so-called ventricular-vascular uncoupling. Diabetes, impaired renal function, and untreated or poorly treated hypertension may lead to premature arterial stiffening; its consequences are stiffening and hypertrophy of the left ventricle and predisposition to coronary heart disease, heart failure, stroke, vascular dementia, and chronic kidney disease.