Although many articles have described techniques for resection of thoracic aortic aneurysms, limited information on the natural history of this disorder is available to aid in defining criteria for surgical intervention. Data on 230 patients with thoracic aortic aneurysms treated at Yale University School of Medicine from 1985 to 1996 were analyzed. This computerized database included 714 imaging studies (magnetic resonance imaging, computed tomography, echocardiography). Mean size of the thoracic aorta in these patients at initial presentation was 5.2 cm (range 3.5 to 10 cm). The mean growth rate was 0.12 cm/yr. Overall survivals at 1 and 5 years were 85% and 64%, respectively. Patients having aortic dissection had lower survival (83% 1 year; 46% 5 year) than the cohort without dissection (89% 1 year; 71% 5 year). One hundred thirty-six patients underwent surgery for their thoracic aortic aneurysms. For elective operations, the mortality was 9.0%; for emergency operations, 21.7%. Median size at time of rupture or dissection was 6.0 cm for ascending aneurysms and 7.2 cm for descending aneurysms. The incidence of dissection or rupture increased with aneurysm size. Multivariable regression analysis to isolate risk factors for acute dissection or rupture revealed that size larger than 6.0 cm increased the probability by 32.1 percentage points for ascending aneurysms (p = 0.005). For descending aneurysms, this probability increased by 43.0 percentage points at a size greater than 7.0 cm (p = 0.006). If the median size at the time of dissection or rupture were used as the intervention criterion, half of the patients would suffer a devastating complication before the operation. Accordingly, a criterion lower than the median is appropriate. We recommend 5.5 cm as an acceptable size for elective resection of ascending aortic aneurysms, because resection can be performed with relatively low mortality. For aneurysms of the descending aorta, in which perioperative complications are greater and the median size at the time of complications is larger, we recommend intervention at 6.5 cm.

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Background MicroRNAs (miRNAs) are associated with cardiovascular disease (CVD), control gene expression, and are detectable in the circulation. Objective To test the hypothesis that circulating miRNAs would be associated with atrial fibrillation (AF). Methods Using a prospective study design powered to detect subtle differences in miRNAs, we quantified plasma expression of 86 miRNAs by high-throughput quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) in 112 participants with AF and 99 without AF. To examine parallels between cardiac and plasma miRNA profiles, we quantified atrial tissue and plasma miRNA expression using qRT-PCR in 31 participants undergoing surgery. We also explored the hypothesis that lower AF burden after ablation would be reflected in the circulating blood pool by examining change in plasma miRNAs after AF ablation (n=47). Results The mean age of the cohort was 59 years. 58% of participants were men. Plasma miRs-21 and 150 were 2-fold lower in participants with AF than in those without AF after adjustment (p ≤ 0.0006). Plasma levels of miRs-21 and 150 were also lower in participants with paroxysmal AF than in those with persistent AF (p <0.05). Expression of miR-21, but not miR-150, was lower in atrial tissue from patients with AF compared to no AF (p<0.05). Plasma levels of miRs-21 and 150 increased 3-fold after AF ablation (p ≤ 0.0006). Conclusions Cardiac miRs-21 and 150 are known to regulate genes implicated in atrial remodeling. Our findings show associations between plasma miRs-21 and 150 and AF, suggesting that circulating miRNAs provide insights into cardiac gene regulation.

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enetrating chest injuries involving the heart and great vessels are associated with high morbidity and require rapid determination of the anatomic compartment(s) involved to guide urgent therapy. The decision to explore the mediastinum and cardiac structures is often based on clinical signs, but cardiac penetration may occur without acute hemodynamic compromise or hemopericardium. We describe a case of a hemodynamically stable patient who presented to the emergency department (ED) after projectile lawn mower injury, describe the utility of computed tomography in this context, and review the literature regarding these wounds. CASE REPORTA 67-year-old ambulatory man with a medical history of chronic obstructive pulmonary disease and no known surgical history presented to the ED complaining of anterior right chest wound suffered while mowing the lawn. The patient described a fragment of chicken wire fence striking his chest, but claimed it fell out when he removed his shirt. There was no loss of consciousness, and he was alert and oriented ϫ3 in the ED. Physical examination revealed equal breath sounds bilaterally with no peripheral cyanosis, pericardial rub, or jugular venous distention. Blood pressure was 145/89, pulse was 62, and respiratory rate was 18. Oxygen saturation was 100% on room air, and electrocardiogram revealed normal sinus rhythm with first degree atrioventricular block and prolonged QT interval. Erect posteroanterior (PA) and lateral chest radiographs demonstrated a linear high attenuation foreign body overlying the anterior cardiac silhouette (Fig. 1). Transesophageal echocardiography performed in the ED revealed normal left ventral function with no evidence of hemopericardium or intracardiac shunt, but was unable to locate the foreign body.Urgent computed tomography (CT) was then performed and accurately depicted soft tissue stranding in a missile tract that extended inferiorly, posteriorly and leftward from the right parasternal chest wall wound (Fig. 2). The foreign body was readily identified as linear and metallic, lying between the cardiac base and the anterior aspect of the distal esophagus within the mediastinum (Fig. 3). Its position had clearly changed with assumption of supine position for CT (Fig. 1), and a determination of "tumbling" dependent pericardial missile was made. There was no evidence of hemopneumothorax or hemopericardium, and no indication the missile had entered the abdominal cavity.

We report the case of a 42-year-old woman with aortic regurgitation discovered to be caused by a quadricuspid aortic valve (QAV) diagnosed by intraoperative transesophageal echocardiogram. With improvements in echocardiographic imaging, the diagnosis of QAV is likely to be made more reliably in the future and should prompt close clinical follow-up given the frequent association of this lesion with valvular insufficiency.

Introduction: Atrial Fibrillation (AF) is the most common arrhythmia in clinical practice. MicroRNAs (miRs) are small RNAs that play a role in regulating cardiac remodeling and have been implicated in cardiac arrhythmogenesis. However, few studies have examined the association of atrial miR expression to AF. Hypothesis: Changes in miR expression (estimated as fold-difference in the delta cycle threshold compared to global mean) in human atria can be associated with AF. Methods: Thirty-one consecutive patients undergoing elective cardiac surgery were divided into 2 groups: those with history of AF (n=19) and those with no history of AF who stayed in sinus rhythm post-operatively (n=12). Atrial tissue samples were obtained from the right atrium in all but one (left atrium). Based on pilot data and prior literature, the expression of 82 miRs was assessed using high-throughput quantitative reverse-transcriptase polymerase chain reaction. We used logistic regression adjusting for age and sex to detect the associations between levels of atrial miRs and AF. Results: The mean age of the sample was 65 years (±13) and 71% were men. A history of coronary artery disease and heart failure was present in 42% and 36%, respectively. Among AF subjects, the age- and sex- adjusted odds ratios for the expression of miRs 411-5p, 21-5p, 409-3p and 320a were 0.08 (p= 0.02), 0.20 (p=0.02), 0.13 (p= 0.04) and 0.04 (p=0.048), respectively, compared to no AF. The fold-difference in atrial expression of miRs 411-5p, 21-5p, 409-3p and 320a were -0.567, -0.588, -0.375 and -0.427, respectively, in those with AF compared to no AF. Conclusion: In our study, the atrial expression of miRs 411, 21, 409 and 320 was lower in AF patients compared to those with no AF. Notably, these miRs regulate genes involved in atrial fibrosis, apoptosis, and ion channel function. Our findings further implicate miRs as important mediators of pathological atrial remodeling and suggest their usefulness as biomarkers in detecting AF.