Presentation, Diagnosis, and Outcomes of Acute Aortic Dissection: 17-Year Trends From the International Registry of Acute Aortic Dissection.

BACKGROUND: Diagnosis, treatment, and outcomes of acute aortic dissection (AAS) are changing. OBJECTIVES: This study examined 17-year trends in the presentation, diagnosis, and hospital outcomes of AAD from the International Registry of Acute Aortic Dissection (IRAD). METHODS: Data from 4,428 patients enrolled at 28 IRAD centers between December 26, 1995, and February 6, 2013, were analyzed. Patients were divided according to enrollment date into 6 equal groups and by AAD type: A (n = 2,952) or B (n = 1,476). RESULTS: There was no change in the presenting complaints of severe or worst-ever pain for type A and type B AAD (93% and 94%, respectively), nor in the incidence of chest pain (83% and 71%, respectively). Use of computed tomography (CT) for diagnosis of type A increased from 46% to 73% (p < 0.001). Surgical management for type A increased from 79% to 90% (p < 0.001). Endovascular management of type B increased from 7% to 31% (p < 0.001). Type A in-hospital mortality decreased significantly (31% to 22%; p < 0.001), as surgical mortality (25% to 18%; p = 0.003). There was no significant trend in in-hospital mortality in type B (from 12% to 14%). CONCLUSIONS: Presenting symptoms and physical findings of AAD have not changed significantly. Use of chest CT increased for type A. More patients in both groups were managed with interventional procedures: surgery in type A and endovascular therapy in type B. A significant decrease in overall in-hospital mortality was seen for type A but not for type B.

Aneurysms of medium-sized arteries in Marfan syndrome.

Marfan syndrome is a relatively common connective tissue disorder that causes skin, ocular, skeletal, and cardiovascular abnormalities. High morbidity and mortality occur with aortic aneurysm and dissection. Other large-artery aneurysms, including carotid, subclavian, and iliac artery aneurysms, have also been associated with Marfan syndrome. It is not clear whether small- to medium-sized artery aneurysms are associated with Marfan syndrome. This report describes 4 patients with Marfan syndrome who have associated small- to medium-sized artery aneurysms with several complications. Additional investigations are needed to determine whether Marfan syndrome can cause small- to medium-sized artery aneurysms and how patients with these aneurysms should be treated.

Failure of guideline adherence for intervention in patients with severe mitral regurgitation.

OBJECTIVES: This study sought to evaluate the incidence with which adult patients with significant mitral regurgitation (MR) do not undergo surgical intervention despite guideline recommendations, and the associated considerations resulting in no intervention. BACKGROUND: Despite the existence of accepted guidelines, many patients with severe symptomatic heart valve disease might not undergo intervention. METHODS: At a single large tertiary medical center, patients were retrospectively identified who had moderate-to-severe or severe MR on echocardiographic imaging during 2005. Clinical data were reviewed to determine indications for intervention and whether surgery was performed. RESULTS: During 2005, 300 patients were identified with significant MR, including 188 with functional MR and 112 with organic MR. Mitral surgery was performed in 30 of 188 patients with functional MR, mostly to treat heart failure or during another cardiac surgical procedure. Mitral surgery was performed in 59 (53%) of 112 patients with organic MR. Among unoperated patients with organic MR, common reasons included stable left ventricular size or function, absence of symptoms, and prohibitive comorbidities. Using American College of Cardiology/American Heart Association guidelines, 1 or more indication for intervention was present in 39 (74%) of 53 unoperated patients. Perioperative mortality risk was not higher for patients who did not undergo surgery (median 1.2%, interquartile range [IQR] 0.4% to 3.3%) than for those who did (median 1.1%, IQR 0.6% to 5.3%; p = 0.71). During follow-up, there were 12 cardiac and 2 unexplained deaths. CONCLUSIONS: Among patients with severe organic MR, surgical intervention occurred in approximately one-half. However, accepted guideline indications for intervention were present in the majority of unoperated patients. Objectively assessed operative risk was not prohibitive in many unoperated patients.

Exercise stress testing in asymptomatic severe aortic stenosis.

Aortic valve replacement is the accepted therapy for patients with severe symptomatic aortic stenosis (AS). However, the timing of surgery in asymptomatic patients is less well defined, as some -- but not all -- asymptomatic patients are at increased risk. Exercise stress testing is an attractive means to assess risk in such patients, as it is readily available, standardized, physiological, and presents a controlled environment in which to assess whether patients truly are asymptomatic. This review summarizes existing literature and current guideline recommendations addressing exercise testing in asymptomatic patients with AS, and provides a recommendation for its use in a subset of patients.