TEVAR for complicated aTBAD results in low 30-day and 1-year mortality rates, with higher reintervention rates than observed with open operations. TEVAR is effective in thrombosing and stabilizing the size of the thoracic FL. The abdominal aortic FL remains patent and must be carefully scrutinized for long-term aneurysm formation.
Background.-Optimal medical therapy (OMT) for uncomplicated type B aortic dissection (uTBAD) provides excellent short-term outcomes but is associated with a high incidence of failure. This study identified predictors of aortic intervention and mortality in uTBAD patients undergoing OMT. Methods.-A retrospective review of the Emory University School of Medicine aortic database identified 314 uTBAD patients undergoing OMT from 2000 to 2016. Two hundred sixty-three (84%) patients had imaging at presentation analyzed for maximum aortic diameters (ADs), false lumen (FL) status, and visceral vessel perfusion. Cox proportional hazards models were constructed to estimate hazards ratios (HRs) and identify predictors of OMT failure. Results.-The mean age of patients was 58 ± 12 years, and 67% were men. FL status was patent in 59.4%, partially thrombosed in 39.8%, and completely thrombosed in 0.8% of patients. Over a median follow-up of 5.6 (interquartile range, 1.4 to 8.5) years, 44.9% of patients failed OMT and underwent intervention (n = 58 open, n = 83 endovascular). The estimated incidence of OMT failure was 46%. Multivariate analysis identified the presence of diabetes, renal failure, DeBakey 3B dissection, and a descending thoracic AD of 4.5 cm or greater (HR, 1.39; 95% confidence interval, 1.24 to 1.56; p < 0.001) to be independent predictors of failure of OMT. FL status or the distribution of visceral vessels arising from the FL did not predict OMT failure. Conclusions.-There is a significant incidence of OMT failure in uTBAD patients. A descending thoracic AD of 4.5 cm or greater at the time of diagnosis is an independent predictor of failure of OMT. Optimal medical therapy (OMT) has traditionally been the treatment of choice for patients presenting with acute uncomplicated type B aortic dissection (uTBAD). Currently, surgical or endovascular intervention is reserved for the treatment of complications that arise in the chronic phase. Although OMT is associated with excellent in-hospital and 1-year outcomes, the long-term survival with OMT alone remains poor. Mortality approaches 40% at 5 years
<b><i>Background:</i></b> In patients with pulmonary hypertension (PHT), the assessment of left ventricular (LV) diastolic function by echocardiography may not be reliable. PHT can affect Doppler parameters of LV diastolic function such as mitral inflow velocities and mitral annular velocities. The current guidelines for the assessment of LV diastolic function do not recommend specific adjustments for patients with PHT. <b><i>Methods:</i></b> We analyzed 36 patients from the PHT clinic that had an echocardiogram and right heart catheterization performed within 6 months of each other. Early mitral inflow velocity (E), lateral mitral annular velocity (lateral e’), septal mitral annular velocity (septal e’), tricuspid free wall annular velocity (RV e’) were measured and compared to the invasively measured intracardiac pressures including pulmonary capillary wedge pressure (PCWP), mean pulmonary artery pressure, and right ventricular end-diastolic pressure. <b><i>Results:</i></b> Among patients with PHT, the specificity of the septal e’ for LV diastolic dysfunction was 0.19, and the positive predictive value was 0.13 (lower than the lateral e’ or E/average e’). By receiver-operating characteristic curve analysis, the area under the curve (AUC) of lateral and septal e’ was just 0.64 (<i>p</i> = 0.9) and 0.53 (<i>p</i> = 0.6), respectively, while the AUC of average E/e’ was 0.94 (<i>p</i> < 0.001). The septal e’ was paradoxically lower at 6.5 ± 1.9 cm/s for normal PCWP compared to 6.9 ± 1.7 cm/s for elevated PCWP (<i>p</i> = 0.04). 81 versus 40% (<i>p</i> = 0.017) of patients with normal versus elevated PCWP had an abnormal septal e’ <7 cm/s. By linear regression, there was no correlation between the Doppler parameters of LV diastolic function and the PCWP. <b><i>Conclusion:</i></b> Our study suggests E/average e’ may be the only reliable tissue Doppler parameter of LV diastolic dysfunction in patients with PHT, and that septal e’ is paradoxically decreased in patients with PHT and normal left-sided filling pressures.
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