Acute aortic syndromes: aortic dissections,penetrating aortic ulcers and intramural aortic hematomas

Acute aortic syndromes, including dissections, intramural hematomas and penetrating aortic ulcers, are a catastrophic clinical entity that are relatively uncommon. A high index of clinical suspicion along with proper imaging modalities are critical in making a prompt and accurate diagnosis for immediate management and to improve survival of the patient.     

Acute aortic syndromes: aortic dissections, penetrating aortic ulcers and intramural aortic hematomas

Acute aortic syndromes, including dissections, intramural hematomas and penetrating aortic ulcers, are a catastrophic clinical entity that are relatively uncommon. A high index of clinical suspicion along with proper imaging modalities are critical in making a prompt and accurate diagnosis for immediate management and to improve survival of the patient.     

Quadricuspid aortic valve abnormality associated with aortic stenosis and aortic insufficiency.

Quadricuspid aortic valve is a rare congenital malformation of the aortic valve. Transthoracic 2-dimensional echocardiography can delineate aortic valve and diagnose most quadricuspid aortic valves. This article is a report of a quadricuspid aortic valve associated with aortic stenosis and aortic insufficiency diagnosed by transthoracic echocardiography.     

Acute aortic emergencies-part 1: aortic aneurysms

This article is a 2-part series about patients with aortic emergencies. Patients with acute aortic disease who present to the emergency department represent some of the highest acuity patients that emergency clinicians will ever encounter in acute care settings. Part 1 focuses on aortic aneurysms in the thorax or abdomen. An aortic aneurysm involves transverse dilatation, leading to rupture and hemorrhage. Diagnosis is largely based on clinical presentation and carefully selected imaging studies. Emergency interventions are guided by whether or not the patient is hypertensive or in shock. For patients in shock, attention should focus on restoring intravascular volume while not generating excessive blood pressure. Open surgical intervention or endovascularly placed stent grafting should then be expedited. Both options are not without complications, most commonly being stroke, paraplegia, and death. Part 2 will explore aortic dissection.     

Emergency aortic valve replacement for critical aortic stenosis

Objective: To demonstrate that emergency aortic valve replacement can be successfully performed in patients with critical aortic stenosis and reduced left ventricular function even in cardiogenic shock with associated severe multiple organ failure. Design: Retrospective, consecutive case series. Setting: Multidisciplinary intensive care unit of a tertiary care university hospital. Patients: Five patients admitted to the intensive care unit with critical aortic stenosis (aortic valve area 0.56 ± 0.13 cm²) and greatly reduced left ventricular ejection fraction (20 ± 3 %) in prolonged cardiogenic shock and associated multiple organ failure (Multiple organ failure score 6.8 ± 0.5; Acute Physiology, Age, and Chronic Health Evaluation III score 91 ± 27). Intervention: Emergency aortic valve replacement. Results: All patients survived with full recovery of organ function. At follow-up (18 ± 10 months) all patients were in New York Heart Association functional class I or II with improvement of left ventricular ejection fraction to 48 ± 25 %. Conclusions: This excellent outcome suggests that emergency aortic valve replacement should be strongly considered in patients with critical aortic stenosis even in cardiogenic shock and multiple organ failure.     

Abdominal aortic aneurysms and thoracic aortic atheromas.

BACKGROUND: Abdominal aortic aneurysm (AAA) is associated with atherosclerosis elsewhere. Thoracic aortic atheromas (ATHs) seen on transesophageal echocardiography (TEE) are an important cause of stroke and peripheral embolization. The purposes of this study were to determine whether an association exists between AAA and ATHs and to assess the importance of screening patients with ATHs for AAA. METHODS: For the retrospective analysis, 109 patients with AAA and 109 matched controls were compared for the prevalence of ATHs on TEE and for historical variables. For the prospective analysis, screening for AAA on ultrasonography was performed in 364 patients at the time of TEE. RESULTS: Results of the retrospective analysis showed that ATHs were present in 52% of patients with AAA and in 25% of controls (odds ratio [OR] = 3.3; P =.00003). There was a significantly higher prevalence of hypertension, myocardial infarction, heart failure, smoking, and carotid or peripheral arterial disease in patients with AAA. However, only ATHs were independently associated with AAA on multivariate analysis (P =.001). Results of the prospective analysis showed that screening at the time of TEE in 364 patients revealed AAA in 13.9% of those with ATHs and in 1.4% of those without ATHs (P <.0001; OR = 11.4). CONCLUSIONS: (1) There is a strong, highly significant association between abdominal aneurysm and thoracic atheromas. (2) Patients with AAA may be at high risk for stroke because of the concomitance of thoracic aortic atheromas. (3) The high prevalence of abdominal aneurysm in patients with thoracic atheromas suggests that screening for abdominal aneurysm should be carried out in all patients with thoracic atheromas identified by TEE.     

Indications for aortic valve replacement in aortic stenosis

Aortic stenosis is a common condition, particularly in the elderly. The treatment is surgical, and any patient with symptomatic severe aortic stenosis should be considered for aortic valve replacement. Aortic stenosis causes an increase in afterload to the left ventricle, which when severe can lead to hemodynamic instability. Although the therapy of aortic stenosis is valve replacement, determining whether a patient has symptoms and accurately assessing the severity of stenosis can be difficult. The management of patients with severe aortic stenosis in the intensive care unit setting can be very challenging, particularly when comorbid medical conditions make aortic valve replacement difficult. This article reviews the diagnosis of aortic stenosis, methods of assessing symptoms and severity, and management of severe symptomatic stenosis, particularly in the intensive care unit setting. Components of the history that suggest symptomatic aortic stenosis are presented. The role of physical examination is discussed, as are the echocardiographic means of determining stenosis severity. Other means of assessing severity are addressed, as are circumstances in which there can be difficulty in interpretation, such as severe aortic stenosis and left ventricular dysfunction. Management of patients, focusing on the intensive care unit setting, is reviewed, with a focus on the timing of aortic valve replacement.     

Perceval sutureless aortic valve replacement after ascending aortic replacement

In patients with a narrow sinotubular junction, small sinus of Valsalva, or extensibility loss in the aortic root, aortic valve replacement (AVR) with a standard valve is challenging due to limited surgical field. Detailed preoperative measurements of the aortic root render performing AVR using the Perceval valve easy.     

支架“象鼻子”技术和主动脉瓣成形治疗DeBakey Ⅰ型夹层主动脉瘤合并主动脉瓣关闭不全

目的 介绍支架"象鼻子"技术和主动脉瓣成形治疗DeBakey Ⅰ型夹层主动脉瘤合并主动脉瓣关闭不全的体会.方法 自2006-12～2007-12我们采用支架"象鼻子"技术、主动脉瓣成形、升主动脉和全主动脉弓置换治疗DeBakey Ⅰ型夹层主动脉瘤合并主动脉瓣关闭不全7例,手术采用胸部正中切口,右腋动脉插管,深低温停循环,选择性顺行脑灌注.通过交界悬吊和(或)部分窦切除进行主动脉瓣成形,用覆膜自膨胀支架血管置入左半弓和降主动脉近端形成"象鼻子".结果 无术中和术后大出血,选择性脑灌注时间和停循环时间20～30 min.术后恢复顺利,无住院死亡.随访2～14个月,无明显主动脉瓣膜关闭不全,覆膜支架膨胀良好,支架远段降主动脉真腔扩大,假腔缩小或消失,心功能Ⅰ级.结论 支架"象鼻子"技术、主动脉瓣成形、升主动脉和全主动脉弓置换是治疗DeBakey Ⅰ型夹层主动脉瘤合并主动脉瓣关闭不全安全、有效的方法.     

Fate of bicuspid aortic valves in patients undergoing aortic root repair or replacement for aortic root enlargement

OBJECTIVE: To better understand the outcome of the bicuspid aortic valve (BAV) after valve-sparing root replacement, we evaluated BAV function after its preservation at the time of the ascending aorta (AA) repair. PATIENTS AND METHODS: From January 1, 1994, through March 31, 2002, BAVs were preserved during repair of AA aneurysms in 21 patients (mean +/- SD age, 45+/-12 years; 13 males). We reviewed the clinical and surgical records of these patients for baseline characteristics, operative procedures, and data at latest follow-up. RESULTS: The primary indication for operation was AA enlargement (median diameter, 55 mm; range, 43-65 mm) in 18 patients and severe aortic regurgitation (AR) in 3 patients. Preoperatively, the BAV exhibited mild or moderate stenosis in 5 patients (mean gradient, 25 mm Hg; range, 19-34 mm Hg), moderate AR in 2, and severe AR in 3. Aortic valve repair was performed in 11 patients. Seventeen patients had excision and graft replacement of the enlarged AA, and 4 patients had primary AA repair. There were no perioperative deaths. Moderate or severe AR was relieved in all patients early postoperatively and during follow-up (median, 2.5 years; maximum, 7.6 years). One patient required aortic valve replacement at 4.8 years for AR. An additional patient had recurrent, severe AR but was asymptomatic and has not undergone reoperation. CONCLUSION: Repair of diseased BAVs or preservation of functionally normal BAVs during surgery for AA aneurysms has a low perioperative risk, and early results are encouraging. Additional observation is necessary to determine whether this strategy has real advantages over early aortic valve replacement.     

经导管主动脉瓣置换术在重度主动脉瓣狭窄合并主动脉瓣关闭不全患者中的应用

目的 分析经导管主动脉瓣置换术(TAVR)在重度主动脉瓣狭窄合并中重度主动脉瓣关闭不全患者中的应用.方法 选取18例诊断为重度主动脉瓣狭窄合并中重度主动脉瓣关闭不全的住院患者为A组,另选取22例同期诊断为单纯重度主动脉瓣狭窄或仅合并轻度主动脉瓣关闭不全患者为B组,均行TAVR术.随访6个月,比较2组基本资料、术后经胸超声心动图结果以及随访期间死亡率、出血情况等临床不良事件发生率等.结果 A组患者平均主动脉瓣环内径、二叶式畸形患者比率、升主动脉内径高于B组,钙化积分低于B组,差异有统计学意义(P＜0.05).2组手术入路、选择瓣膜尺寸及植入瓣中瓣率等比较,差异均无统计学意义(P＞0.05).2组术后即刻和术后6个月的跨主动脉瓣流速、主动脉瓣平均跨瓣压差以及术后6个月的左心室舒张末内径均低于术前,术后6个月的左心室射血分数高于术前,差异有统计学意义(P＜0.05).B组术后即刻、术后6个月的瓣周漏发生率低于A组,差异有统计学意义(P＜0.05).2组术后即刻、术后6个月的并发症发生率比较,差异无统计学意义(P＞0.05).结论 对于重度主动脉瓣狭窄合并中重度主动脉瓣关闭不全患者,TAVR术后能有效降低平均跨瓣压差,改善心功能,但瓣周漏发生率明显增加,且多为微量或轻度瓣周漏.     

Acquired aortic stenosis

Aortic stenosis is the most commonly encountered valvular disease in the elderly, with approximately 2-3% of individuals over 65 years of age afflicted. The most common cause of acquired aortic stenosis is calcific degeneration, characterized by a slowly progressive, asymptomatic period which can last decades. Once symptomatic, the clinical manifestation of aortic stenosis is from functional obstruction of left ventricular outflow and the additional hemodynamic effects on the left ventricle and vasculature. With advances in echocardiography, individuals with aortic stenosis are increasingly diagnosed in the asymptomatic latent period. However, echocardiographic measures alone cannot identify clinically significant outflow obstruction as there is considerable overlap in hemodynamic severity between symptomatic and asymptomatic individuals. Current clinical guidelines predicate the timing of surgical valve replacement on the presence or absence of symptoms. Management for symptomatic, significant stenosis is surgical valve replacement as there are no current medical therapies reliably proven to decrease aortic stenosis severity or improve long-term outcomes. However, recent retrospective studies have demonstrated an association between atherosclerotic disease risk factors, such as hyperlipidemia and aortic stenosis. Given these findings, there are now advocates for prospective primary prevention trials for aortic stenosis in patients with mild or moderate valvular disease. The following paper will discuss etiology, diagnostic evaluation and therapeutic options of acquired aortic stenosis. This review will discuss etiology, diagnostic evaluation, and therapeutic options of acquired aortic stenosis.     

Radiation-induced aortic occlusion

Arterial occlusion is a late complication of radiotherapy usually seen in extracranial vessels following treatment for head and neck malignancy. Determining the etiology behind vessel occlusion can be difficult and involves consideration of several factors. We present a case of radiotherapy induced aortic occlusion and discuss the relevant clinical and imaging factors that allow the diagnosis to be made.