Research

Nonsyndromic Thoracic Aortic Aneurysm and Dissection: Outcomes With Marfan Syndrome Versus Bicuspid Aortic Valve Aneurysm

by

Sherrah AG, Andvik S, van der Linde D, Davies L, Bannon PG, Padang R, Vallely MP, Wilson MK, Keech AC, Jeremy RW

J. Am. Coll. Cardiol. 2016 Feb;67(6):618-26

PMID: 26868685

Abstract

BACKGROUND: Genetic aortopathy (GA) underlies thoracic aortic aneurysms (TAA) in younger adults. Comparative survival and predictors of outcomes in nonsyndromic TAA (NS-TAA) are incompletely defined compared to Marfan syndrome (MFS) and bicuspid aortic valve (BAV).

OBJECTIVES: The study sought to compare survival and clinical outcomes for individuals with NS-TAA, MFS, and BAV.

METHODS: From 1988 to 2014, all patients presenting with GA 16 to 60 years of age were enrolled in a prospective study of clinical outcomes. Risk factors for death and aortic dissection were identified by Cox proportional hazards modeling and a mortality risk score developed.

RESULTS: Diagnosis of GA was made for 760 patients (age 36.9 ± 13.6 years, 26.8% female; NS-TAA, n = 311; MFS, n = 221; BAV, n = 228). MFS patients were younger than NS-TAA and BAV. Presentation with aortic dissection was more common for NS-TAA than MFS or BAV. The 687 patients surviving >30 days after presentation were followed for a median of 7 years. Calculated 10-year mortality was 7.8% for NS-TAA, 8.7% for MFS, and 3.5% for BAV (NS-TAA and MFS vs. BAV p <0.05). Factors associated with all-cause mortality were MFS (p = 0.04), age at presentation, and family history of dissection.

CONCLUSIONS: Clinical outcomes for MFS and NS-TAA are similar but worse than BAV. Independent predictors of mortality, including family history of aortic dissection and age, can be included in an Aortopathy Mortality Risk Score to predict survival. Management of NS-TAA, including surgical intervention, should be similar to that of MFS.

Cardiac Magnetic Resonance Imaging Predictors of Short-Term Outcomes after High Risk Coronary Surgery

by

Sheriff MJ, Mouline O, Hsu C, Grieve SM, Wilson MK, Bannon PG, Vallely MP, Puranik R

Heart Lung Circ 2016 Jan;

PMID: 26839164

Abstract

BACKGROUND: The euroSCORE II is a widely used pre-coronary artery bypass graft surgery (CAGS) risk score, but its predictive power lacks the specificity to predict outcomes in high-risk patients (

METHODS: Fifty-two consecutive patients with high euroSCORE II (>16) and left ventricular (LV) dysfunction (<40%) based on 2D-echocardiography who underwent CAGS and in whom CMRI (1.5T) was performed preoperatively were retrospectively studied. Cardiac magnetic resonance imaging parameters were assessed in patients who either had complications immediately post-surgery (n=35), six weeks post-surgery (n=20) or were uncomplicated.

RESULTS: The average age of patients recruited was 69±5 years with high euroSCORE II (22±4) and low 2D-echocardiography LV ejection fraction (38%±2%). Cardiac magnetic resonance imaging results demonstrated that those with immediate complications had higher LV scar/infarct burden as a proportion of LV mass (17±3% vs 10±3%; p=0.04) with lower circumferential relaxation index (2.5±0.46 vs 2.8±0.56; p=0.05) compared to those with no complications. Early mortality from surgery was 17% (n=9) and was associated with lower RV stroke volume (55±12 vs 68±18; p=0.03) and higher LV infarct scar/burden (18±2% vs 10±2%, p=0.04). Cardiac magnetic resonance imaging showed patients with complications at six weeks post-surgery had higher LV scar/infarct burden (14.5±2% vs 6.8±2%, p=0.03) compared to those without complications.

CONCLUSION: Cardiac magnetic resonance imaging preoperative LV and RV parameters are valuable in assessing the likelihood of successful outcomes from CAGS in high-risk patients with LV dysfunction.

Measurement of tremor transmission during microsurgery

by

Verrelli DI, Qian Y, Wood J, Wilson MK

Int J Med Robot 2015 Dec;

PMID: 26647732

Abstract

BACKGROUND: Tremor is a major impediment to performing fine motor tasks, as in microsurgery. However, conventional measurements do not involve tasks representative of microsurgery.

METHOD: We developed a low-cost surgical simulator incorporating a force transducer capable of detecting and quantifying the effects of tremor upon high-fidelity silicone replicas of cardiac vessels and substrate muscle. Experienced and trainee surgeons performed simulated anastomoses on this rig. We characterized procedures in terms of tremor intensity, based on Lomb-Scargle periodograms.

RESULTS: Distinctive force oscillations occurred at 8-12 Hz, characteristic of enhanced physiological tremor, yielding peaks in power spectral density. These early results suggest a significantly lower transmission of tremor to the operative field by the experienced surgeon in comparison to the trainees.

CONCLUSIONS: This new device quantifies the action of tremor upon a manipulandum during a complex task, which may be used for assessment and providing feedback to trainee surgeons. Copyright © 2015 John Wiley & Sons, Ltd.

MRI in Chronic Aortic Dissection: A Systematic Review and Future Directions

by

Sherrah AG, Grieve SM, Jeremy RW, Bannon PG, Vallely MP, Puranik R

Front Cardiovasc Med 2015;2:5

PMID: 26664877

Abstract

The acute event of thoracic aortic dissection carries with it high mortality and morbidity. Despite optimal initial surgical or medical management strategies, the risk of further complications in the long-term, including aneurysmal dilatation and false lumen (FL) expansion, are not insignificant. Adequate follow-up of such conditions requires dedicated imaging where relevant prognostic indicators are accurately assessed. We perform a systematic review of the literature and report the current evidence for the use of magnetic resonance imaging (MRI) in assessment of chronic aortic dissection. We then make a comparison with traditional imaging modalities including computed tomography and echocardiography. We discuss new ways in which MRI may extend existing aortic assessment, including identification of blood-flow dynamics within the TL and FL using phase-contrast imaging.

Bilateral Internal Thoracic Artery Composite Y Grafts: Analysis of 464 Angiograms in 296 Patients

by

Robinson BM, Paterson HS, Naidoo R, Dhurandhar V, Denniss AR

Ann. Thorac. Surg. 2015 Oct;

PMID: 26507423

Abstract

BACKGROUND: The use of bilateral internal thoracic arteries (BITA) in coronary artery bypass graft surgery improves patient survival. The optimum BITA graft configuration is unknown. This study evaluates outcomes after the use of bilateral internal mammary Y grafting as the primary grafting strategy.

METHODS: Patients who underwent BITA composite Y grafting (n = 1,011) between October 1994 and March 2009 were identified from a cardiac surgical database. Follow-up (mean 12 years) was obtained by cross-reference with the state death registry and local cardiology databases.

RESULTS: Perioperative mortality was 1.6%. Kaplan-Meier 10-year survival was 87.2%. There were 464 episodes of postdischarge angiography in 296 patients, at an average of 5.5 years to first angiography. Graft failure occurred in 151 patients, predominately affecting the right ITA limb (n = 139). Degree of native vessel stenosis (odds ratio [OR] 0.66 per 10% increase), anatomic territory grafted (circumflex OR 2.64, right coronary OR 6.73 versus anterior), and end-to-side free wall anastomoses (OR 1.98) predicted anastomotic occlusion. The left anterior descending artery graft patency was unaffected by sequential grafting. Progression to graft failure after the first angiogram was rarely seen in the 111 patients who had serial angiography.

CONCLUSIONS: Outcomes of BITA Y grafting are similar to those for other BITA configurations. The rate of presentation with arterial graft dysfunction decreases over time. Although competitive flow affects anastomotic patency, there is no threshold at which risk of occlusion substantially increases.

Fibulin-3 levels in malignant pleural mesothelioma are associated with prognosis but not diagnosis

by

Kirschner MB, Pulford E, Hoda MA, Rozsas A, Griggs K, Cheng YY, Edelman JJ, Kao SC, Hyland R, Dong Y, László V, Klikovits T, Vallely MP, Grusch M, Hegedus B, Dome B, Klepetko W, van Zandwijk N, Klebe S, Reid G

Br. J. Cancer 2015 Sep;113(6):963-9

PMID: 26263483

Abstract

BACKGROUND: Fibulin-3 (FBLN3) was recently presented as a promising novel biomarker for malignant pleural mesothelioma (MPM), warranting independent validation studies.

METHODS: ELISA was used to measure cellular and secreted FBLN3 in cell lines, in plasma of xenograft tumour-bearing mice, in plasma from two independent series of MPM and non-MPM patients and in pleural fluid from a third series. Diagnostic and prognostic potential of FBLN3 was assessed by receiver operating characteristics curve analysis and Kaplan-Meier method, respectively.

RESULTS: FBLN3 was expressed in all MPM and benign mesothelial cell lines tested, and a correlation was observed between cellular protein expression and secreted levels. Human FBLN3 was detectable in plasma of tumour-bearing mice, suggesting that MPM cells contribute to levels of circulating FBLN3. Plasma FBLN3 was significantly elevated in MPM patients from the Sydney cohort, but not the Vienna cohort, but the diagnostic accuracy was low (63%, (95% CI: 50.1-76.4) and 56% (95% CI: 41.5-71.0), respectively). Although FBLN3 levels in pleural effusions were not significantly different between cases and controls, FBLN3 levels in pleural effusion fluid were found to be independently associated with prognosis (hazard ratio of 9.92 (95% CI: 2.14-45.93)).

CONCLUSIONS: These data confirm the potential prognostic value of pleural effusion FBLN3, but question the diagnostic value of this protein in MPM patients.

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