血清淀粉样蛋白A在急性主动脉夹层中的研究进展

急性主动脉夹层(AAD)是一种非常凶险的心血管急症,尽管目前在诊断和救治方面取得了一定进展,但AAD的死亡率仍居高不下。由于AAD是一种多因素参与的疾病,参与其发病的病理生理学机制尚未完全阐述清楚,因此其临床治疗效果有限,死亡率极高。大量研究表明,血清淀粉样蛋白A(SAA)作为急性期反应产生的主要炎症蛋白,与心血管疾病的发生发展密切相关。因此,SAA或可成为AAD诊断和治疗的候选靶点。本综述探讨了SAA与炎症反应、血管功能异常、血栓形成、细胞外基质重塑之间的关系以及作为AAD潜在生物标志物的可能性。     

微小RNA在主动脉夹层中差异性表达与发病机制的研究进展

主动脉夹层(AD)是临床一种死亡率极高的心血管危急重症,具有起病急骤、进展快、表现复杂多样、病程凶险、死亡率高、预后差等特点。虽然目前AD的具体发病机制尚未完全阐明,但近年来发现,微小RNA(miRNA)在许多心血管疾病的发生及发展过程中起着重要作用。通过应用基因芯片技术分析等相关研究发现,AD患者组织与正常主动脉组织的一些miRNA存在显著的差异性表达,这显然有助于AD的诊断。诸多研究表明miRNA在AD的发病机制及疾病诊断中可能扮演着重要角色。本文就miRNA在AD的差异性表达与发病机制的研究进展作一综述。     

Infective endocarditis following transcatheter aortic valve implantation

Trans-catheter aortic valve implantation (TAVI) has recently emerged as a less invasive alternative to surgical aortic valve replacement (SAVR) in high risk patients. Although several procedures have been performed worldwide, infective endocarditis (IE) has been reported to be a rare TAVI complication, nevertheless if IE occurs it represents a life-threatening condition and treatment is challenging. TAVI-IE are thus normally treated conservatively by targeted antibiotic therapy with a high reported mortality (40%). Surgical explant represent the definitive strategy but, the intervention is at a high risk (risk of complication 87%, with an in hospital mortality of about 47%). In the present paper, we report the case of a 71-year-old patient affected by an early endocarditis after TAVI (TAVI-IE) treated at our Institution by surgical explant. The case highlights a paradox: if TAVI procedures are indicated over traditional surgical valve replacement in treatment of high surgical risk patients, what should be the best management when TAVI-IE occurs in these same population of patients?     

Quadricuspid aortic valve: a case report and review of the literature

Quadricuspid aortic valve (QAV) is a rare congenital anomaly that can present as aortic insufficiency later in life. We report a case of aortic regurgitation associated with a QAV, treated by aortic valve replacement. The patient presented with breathlessness, lethargy and peripheral oedema. Echocardiography and cardiac magnetic resonance revealed abnormal aortic valve morphology and coronary angiography was normal. The presence of a quadricuspid aortic valve was confirmed intra-operatively. This was excised and replaced with a bioprosthetic valve and the patient recovered well postoperatively. Importantly, the literature indicates that specific QAV morphology and associated structural abnormalities can lead to complications. Hence, early detection and diagnosis of QAV allows effective treatment. Aortic valve surgery is the definitive treatment strategy in patients with aortic valve regurgitation secondary to QAV. However, the long-term effects and complications of treatment of this condition remain largely unknown.     

Delivery balloon‐induced ascending aortic dissection: An unusual complication during transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a relatively mature technique that is generally accepted as a promising treatment for inoperable patients and those who are high‐risk candidates for surgical aortic replacement. Although severe complications in the aortic valve complex, such as annular or aortic root rupture, are not frequently observed, these events could easily lead to catastrophic outcomes, and therefore remain major issues during TAVI. However, there remains a paucity of data describing these catastrophic complications because of their low incidence. We encountered the case of an 88‐year‐old woman complicated by a dissection of the ascending aorta during TAVI from an “unusual” cause: injury due to the delivery of a balloon‐expandable valve to a very narrow and heavily calcified sinotubular junction (STJ). This is the first report to demonstrate the mechanism of this complication; even a delivery balloon, not a stent frame, with low inflation pressure might injure a narrow STJ and lead to an aortic dissection. Therefore, the use of oversized delivery balloons should be avoided in patients with a narrow and calcified STJ. © 2015 Wiley Periodicals, Inc.     

D-dimer can be a diagnostic marker for cisplatin-related aortic thrombosis: A case report

Rationale:Cisplatin is one of the key drugs that is frequently used for treating various types of malignancies. Although renal and digestive toxicities are well-known cisplatin-related toxicities, attention should also be paid to acute aortic thrombosis, a relatively rare but potentially fatal disorder caused by cisplatin. Additionally, D-dimer is mainly measured to detect venous thromboembolism or disseminated intravascular coagulation, whereas its usefulness for detecting aortic thrombosis remains unclear. Here, we report a case of squamous cell lung cancer treated with cisplatin-based chemotherapy, wherein acute aortic thrombosis was diagnosed based on elevated D-dimer levels.Patient concerns:A 65-year-old man with stage IV squamous cell lung cancer presented with elevated D-dimer levels during treatment with second-line chemotherapy with cisplatin and S-1. Contrast-enhanced computed tomography (CT) revealed an intramural thrombus, which had not been previously identified, extending from the abdominal aorta to the common iliac artery.Diagnoses:We diagnosed the patient as having acute aortic thrombosis caused by cisplatin.Interventions:The patient received intravenous administration of unfractionated heparin for 9 days followed by oral warfarin.Outcomes:One month after initiating treatment, the patient''s D-dimer levels decreased to the normal range, and contrast-enhanced CT revealed that the thrombi had nearly completely disappeared without any sequelae or organ damage.Lessons:Our findings revealed that cisplatin can cause acute aortic thrombosis and that regular measurements of D-dimer levels before and during chemotherapy may contribute to the early detection of acute aortic thrombosis.     

Diagnosis of acute symptomatic aortic aneurysm--ultrasonography an important tool.

Symptomatic aortic aneurysm is an extremely acute condition with manifest or threatening aortic rupture. The mortality is high and urgent surgery is essential and often life-saving. A correct diagnosis needs to be made without delay, a fact which places great demands on the doctor--often not a surgeon--who is first consulted by the patient. The differential diagnosis and emergency management are discussed here against the background of the course of events in four patients with aortic aneurysm who were referred erroneously for admission to a coronary intensive care unit during a 12-month period. Two of the patients died. The ultrasonographic findings were decisive for the outcome in the two surviving patients and yielded a rapid diagnosis in one further case. Ultrasonography is recommended as the method of first choice for verifying or excluding this condition when it is suspected on clinical grounds.     

Symptomatic colonic lipoma: differential diagnosis of large bowel tumors

Symptomatic colonic lipomas, although unusual, continue to present difficulties in the preoperative differential diagnosis between malignant and benign colonic neoplasm. Although new imaging techniques are available, they are frequently diagnosed at laparotomy, and definitive histology is required. Local excision is adequate treatment, but segmental excision may be necessary when there is doubt about the diagnosis, or when a complication occurs. Accepted: 10 September 1997     

Different clinical features of aortic intramural hematoma versus dissection involving the descending thoracic aorta

OBJECTIVE: The objective of this study is to test the hypothesis that the absence of flow communication in aortic intramural hematoma (IMH) involving the descending aorta may have a different clinical course compared with aortic dissection (AD). METHODS: We prospectively evaluated clinical and echocardiographic data in AD (76 patients) and IMH (27 patients) of the descending thoracic aorta. RESULTS: Patients did not differ with regard to age, gender, or clinical presentation. IMH and AD had the same predictors of complications at follow-up: aortic diameter (>5 cm) at diagnosis and persistent back pain. Surgical treatment was more frequently selected in AD (39% vs. 22%, P < 0.01) and AD patients who underwent surgical treatment had higher mortality than those with IMH (36% vs. 17%, P < 0.01). There was no difference in mortality with medical treatment (14% in AD vs. 19% in IMH, P = 0.7). During follow-up, of 23 patients with IMH, 11 (47%) showed complete resolution or regression, 6 (26%) increased the diameter of the descending aorta, and typical AD developed in 3 patients (13%). No changes occurred in 14% of the group. Three-year survival rate did not show significant differences between both groups (82 +/- 6% in IMH vs. 75 +/- 7% in AD, P = 0.37). CONCLUSION: IMH of the descending thoracic aorta has a relatively frequent rate of complications at follow-up, including dissection and aneurysm formation. Medical treatment with very frequent imaging and timed elective surgery in cases with complications allows a better patient management.     

Quadricuspid aortic valves

Quadricuspid aortic valves (QAV) are a rare but well recognized cause of significant aortic regurgitation. The first case was found reported in 1862. Since then there have been 110 reported cases of QAV and we report 4 more. Previously, these were diagnosed at the time of surgery or postmortem examination. With advances in echocardiography, including harmonic imaging, and also the advent of transesophageal echocardiography, more cases are being diagnosed prior to surgery. We describe four more cases, three diagnosed preoperatively and one at the time of surgery, and then review the previously reported cases. Of the 114 cases reported, 46 had the aortic valve replaced, most commonly in the 5th and 6th decade of life. Hurwitz and Roberts classified quadricuspid valves according to the size of the leaflets. It has previously been believed that QAVs with four equal sized leaflets were less likely to develop significant aortic regurgitation; however, on review of the available cases, this would not appear to be the case. The preoperative diagnosis of QAVs is important as they can be associated with abnormally placed coronary ostium. Of the 114 cases reported, there are 10 reports of abnormally placed ostia. There has been at least one reported case of death occurring because of obstruction of an abnormally placed right coronary ostium by a prosthetic aortic valve.     

An insight into transcatheter aortic valve implantation—a perspective from multidetector‐computed tomography

Transcatheter aortic valve implantation (TAVI) has now become an acceptable alternative to surgical aortic valve replacement for patients with severe aortic stenosis at high risk. The early enthusiasm for this technology has not diminished but rather has developed at an unprecedented rate over the last decade. Alongside the developments in implantation technique, transcatheter design, and postprocedural care, cardiac imaging modalities have also had to concurrently evolve to meet the perpetual demand for lower peri‐ and postprocedural complication rates. Although transthoracic and transesophageal echocardiography remain vital in patient's selection and periprocedural guidance, there is now emerging evidence that indicates that multidetector‐computed tomography (MDCT) may also have an equally important role to play. The aim of the current review is to examine the modern role of MDCT in assessing patients with aortic stenosis being considered for TAVI. © 2012 Wiley Periodicals, Inc.     

Balloon aortic valvuloplasty to improve candidacy of patients evaluated for transcatheter aortic valve replacement

Objectives

Evaluate the role of balloon aortic valvuloplasty (BAV) in improving candidacy of patients for transcatheter aortic valve replacement (TAVR).

Background

Patients who are not candidates for TAVR may undergo BAV to improve functional and clinical status.

Methods

117 inoperable or high‐risk patients with critical aortic stenosis underwent BAV as a bridge‐to‐decision for TAVR. Frailty measures including gait speed, serum albumin, hand grip, activities of daily living (ADL); and NYHA functional class before and after BAV were compared.

Results

Mean age was 81.6 ± 8.5 years and the mean Society of Thoracic Surgeons predicted risk of mortality was 9.57 ± 5.51, with 19/117 (16.2%) patients non‐ambulatory. There was no significant change in mean GS post‐BAV, but all non‐ambulatory patients completed GS testing at follow‐up. Albumin and hand grip did not change after BAV, but there was a significant improvement in mean ADL score (4.85 ± 1.41 baseline to 5.20 ± 1.17, P = 0.021). The number of patients with Class IV congestive heart failure (CHF) was significantly lower post BAV (71/117 [60.7%] baseline versus 18/117 [15.4%], P = 0.008). 78/117 (66.7%) of patients were referred to definitive valve therapy after BAV.

Conclusions

When evaluating frailty measures post BAV, we saw no significant improvement in mean GS, however, we observed a significant improvement in non‐ambulatory patients and ADL scores. We also describe improved Class IV CHF symptoms. With this improved health status, the majority of patients underwent subsequent valve therapy, demonstrating that BAV may improve candidacy of patients for TAVR.     

Acute aortic regurgitation caused by non-bacterial thrombotic endocarditis

A case of non-bacterial thrombotic endocarditis, which causedacute aortic regurgitation in a middle-aged, otherwise healthywoman, is presented. The diagnosis was confirmed with echocardiographyand documented by a histopathological study of the excised aorticvalve after operation for valve replacement.     

Clinical,diagnostic, and management perspectives of aortic dissection

The incidence of aortic dissection ranges from 5 to 30 cases per million people per year, depending on the prevalence of risk factors in the study population. Although the disease is uncommon, its outcome is frequently fatal, and many patients with aortic dissection die before presentation to the hospital or prior to diagnosis. While pain is the most common symptom of aortic dissection, more than one-third of patients may develop a myriad of symptoms secondary to the involvement of the organ systems. Physical findings may be absent or, if present, could be suggestive of a diverse range of other conditions. Keeping a high clinical index of suspicion is mandatory for the accurate and rapid diagnosis of aortic dissection. CT scanning, MRI, and transesophageal echocardiography are all fairly accurate modalities that are used to diagnose aortic dissection, but each is fraught with certain limitations. The choice of the diagnostic modality depends, to a great extent, on the availability and expertise at the given institution. The management of aortic dissection has consisted of aggressive antihypertensive treatment, when associated with systemic hypertension, and surgery. Recently, endovascular stent placement has been used for the treatment of aortic dissection in select patient populations, but the experience is limited. The technique could be an option for patients who are poor surgical candidates, or in whom the risk of complications is gravely high, especially so in the patients with distal dissections. The clinical, diagnostic, and management perspectives on aortic dissection and its variants, aortic intramural hematoma and atherosclerotic aortic ulcer, are reviewed.     

利尿钠肽在主动脉瓣狭窄中的作用

主动脉瓣狭窄是临床最常见的瓣膜疾病之一,可导致心力衰竭和死亡风险增加,其发病率在未来20年内可能会随着人口老龄化而翻倍。目前有症状的严重主动脉瓣狭窄患者的首选治疗方法是手术或经导管主动脉瓣置换术,然而无症状严重主动脉瓣狭窄患者的最佳手术时机仍存在争议,警惕的等待策略既安全又可行,但猝死的风险每年几乎达到5%。研究发现,血浆利尿钠肽水平与主动脉瓣狭窄的严重程度、症状的发展以及预后相关,有助于监测疾病进展,并确定哪些患者将从早期治疗干预中获益最大,从而降低长期不良事件的风险。文章概述了利尿钠肽在主动脉瓣狭窄的诊断、临床管理、风险分层和潜在治疗意义中的作用。     

Progression of valvar aortic stenosis: a long-term retrospective study

Aortic valve stenosis is a potentially serious condition. Progression from mild to severe aortic stenosis is well-recognized but there are few data as to the likely rate of progression. Clinical outcome and cardiac catheterization data were reviewed for 65 patients with valvar aortic stenosis. Each patient had been investigated by cardiac catheterization on at least two occasions, the interval between studies ranging between 1 and 17 years (mean 7 years). In 60 cases the aortic valve gradient had increased, from a median of 10 mmHg (range 0-60) to a median of 52 mmHg (range 15-120). The mean rate of increase of gradient was 6.5 mmHg per year, and was significantly faster in patients in whom there was aortic valve calcification or aortic regurgitation present at the first catheter study (P less than 0.02). This study shows that progression of aortic stenosis may be very rapid, and correlates with valve calcification and regurgitation. If cardiac surgery is proposed for co-existing coronary or mitral valve disease in patients with mild or moderate aortic valve gradients, then aortic valve replacement should be considered at that time.     

Impact of valvular calcification on the diagnostic accuracy of transesophageal echocardiography for the detection of congenital aortic valve malformation

BACKGROUND: Degeneration of congenital bicuspid or unicuspid aortic valves can progress more rapidly than that of tricuspid valves, and an early diagnosis significantly impacts decision making and outcome. We hypothesized that the extent of valvular calcification would negatively influence the diagnostic accuracy of multiplane transesophageal echocardiography (TEE) for the diagnosis of congenital aortic valve disease. METHODS: TEE was performed in 57 patients undergoing aortic valve replacement surgery for aortic stenosis (n = 46), pure regurgitation (n = 9), or significant regurgitation with less than severe aortic stenosis (n = 2). The degree of aortic valve calcification and the number of valve cusps were determined at surgery. RESULTS: Surgical inspection confirmed 14 bicuspid and 43 tricuspid aortic valves. Sensitivity and specificity of TEE for the diagnosis of congenital aortic valve malformation was 93% (13/14) and 91% (39/43) (P = 0.0001), respectively. In patients with no or mild aortic valve calcification (n = 13), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 100% (5/5) and 100% (8/8) (P = 0.001), respectively. In patients with moderate or marked aortic valve calcification (n = 44), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 89% (8/9) and 89% (31/35) (P<0.0001), respectively. In this subgroup of 44 patients, there were four false-positive and one false-negative diagnoses due to valvular calcification. CONCLUSIONS: Although TEE is highly sensitive and specific for the detection of congenital aortic valve malformations, presence of moderate or marked calcification of the aortic valve may result in false positive and false negative diagnoses.     

Diagnosis and management of thoracic aortic dissection:An update

Acute thoracic aortic dissection is part of the acute aortic syndrome triad.Caused by an intimal tear in the lumen of the aorta,it leads to the creation and propagation of a false lumen.In the acute setting this can lead to malignant hypertension,pain and end organ malperfusion.In the chronic setting it can lead to aneurysm formation and rupture.It remains the most common aortic emergency,affecting up to 4 per 100000 people per year in the United Kingdom and United States.Despite advances in treatment and centralisation of vascular services,it continues to be associated with a high pre-admission and in-hospital mortality.Dissection is classified in several ways according to anatomical extent,timing and underlying pathology,all of which guides clinical management.Traditionally,medical management has been the mainstay of treatment in patients with uncomplicated disease.Surgery has been used in symptomatic patients.With published information now available from several prospective international registries,we are beginning to see the advantages of newer surgical treatment options such as endovascular repair,in the acute setting.This review provides an update on diagnosis and management of aortic dissection,including new information that has become available in recent years.     

A neglected symptom of contained aortic laceration—Dysphagia aortica successfully treated by endovascular stentgrafting

Purpose : Dysphagia aortica describes an esophageal swallowing disorder caused by external compression from an ectatic, tortuous, or aneurysmal thoracic aorta. Although well recognized among specialists, dysphagia aortica is rarely considered in the differential diagnosis of dysphagia. Case Report : We present the case of a 75‐year‐old woman with a history of swallowing difficulty and retrosternal pressure sensation. Her symptoms had been attributed to sliding axial hernia along with gastroesophageal reflux disease for the last 12 months. Diagnostic workup at our institution revealed a giant penetrating ulcer of the descending aorta as a culprit of esophageal compression. Expeditious endovascular stentgraft exclusion of the aneurysm was performed because of its symptomatic nature and high propensity of spontaneous rupture. On a recent consultation 2 years after the endovascular procedure, the patient confirmed a complete remission of impaired swallowing and freedom from thoracic discomfort. Conclusions : Dysphagia aortica should be considered in the numerous differential diagnoses of esophageal swallowing disorders in the elderly, as delayed identification may harbor catastrophic outcome for affected individuals. © 2011 Wiley Periodicals, Inc.     

Percutaneous aortic valve closure for patients with left ventricular assist device‐associated aortic insufficiency

The development of de novo aortic insufficiency (AI) is a significant complication of long‐term LVAD support, which can lead to ineffective support, decreased device durability, end organ malperfusion, and increased mortality. Surgical aortic valve (AV) closure has been the standard treatment for symptomatic patients, but is associated with high mortality and recurrence of AI. Percutaneous AV closure using the Amplatzer cribriform device is a feasible and may be the preferable option to treat LVAD‐associated severe AI in high‐surgical risk patients. Certain technical issues with this procedure should be taken into consideration to achieve optimal results. © 2015 Wiley Periodicals, Inc.