Special Issue "Thoracic Aorta"

A special issue of Hearts (ISSN 2673-3846).

Deadline for manuscript submissions: closed (30 June 2020).

Special Issue Editor

Prof. Dr. John Pepper
E-Mail Website
Guest Editor
Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, Chelsea, London, SW3 6NP, UK
Interests: The thoracic aorta and the aortic valve

Special Issue Information

Dear Colleagues,

This Special Issue arises from London Aorta 2019, an annual pan-London Aortic meeting. The essence of the meeting is the close collaboration between interventional cardiologists, non-interventional cardiologists and cardiac surgeons, radiologists and geneticists to provide the best advice and treatment for our patients. We have selected 10 papers which reflect the range of subjects discussed.

Disease of the thoracic aorta is mostly indolent and is only discovered in the context of an emergency, such as dissection, or by serendipity during a radiological investigation for another disease. The aorta has been called the orphan organ and there are many claimants at the orphanage: cardiac surgeons, vascular surgeons, interventional cardiologists or radiologists. There is a strong argument to apply a team approach and to make this a truly patient-centric speciality. The impact of advanced imaging, CT and MRI in particular, has transformed the management of patients with aortic disease. By combining the diagnostic and interventional skills of individuals from different specialities who have a passion for this intriguing group of diseases we can provide timely and appropriate treatment for the patient.

Much of the research undertaken on the thoracic aorta has been of a technical nature to reduce the mortality and the morbidity of surgical procedures on patients who in the elective setting are often asymptomatic. Much effort has been expended on protection of the brain and spinal cord and on the development of alternative surgical approaches, such as de-branching of the head vessels and on new procedures in endovascular aortic interventions. These developments, which have arisen from experimental work on large mammals, have proved to be very effective but they have not been tested in a randomised controlled trial. It is focussed aortic teams who will take forward the leading edge of endovascular treatment into the ascending aorta, using branched devices in the arch and the visceral segment and protecting the spinal cord. 

Research of a translational nature has been less common, but there is a growing interest in the role of inflammation as a trigger for aneurysm enlargement in the thoracic aorta. Much effort continues to be expended on the genetic and genomic mechanisms underlying inherited disease of the aortic valve, aortic root and ascending aorta, but this is yet to have a major impact in clinical decision making. Next generation sequencing with “aortic panels” are in use in specialist centres. These panels allow for genetic scrolling of the entire spectrum of aortic defects in one test.

Operations for diseases of the aorta, once considered to be too high risk for many surgeons, are now a part of the daily routine. We have learned something about the nature of the aorta, how to analyse the images and how to correct the defects. While major surgery of the thoraco-abdominal aorta is likely to decline, TEVAR is in the ascendancy. Although the early results are encouraging and the morbidity significantly less than for open surgery, the long-term results remain uncertain. Whether the future will lie in hybrid procedures or be dominated by a stent-based approach is uncertain. What is certain is that this area of activity will continue to fascinate and challenge all those who choose to tread this path.

Prof. Dr. John Pepper
Guest Editor

Manuscript Submission Information

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Published Papers (7 papers)

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Open AccessReview
Review of Studies Reporting the Incidence of Acute Type B Aortic Dissection
Hearts 2020, 1(3), 152-165; https://doi.org/10.3390/hearts1030016 - 10 Nov 2020
Viewed by 525
Abstract
Aortic dissection (AD) causes more deaths each year in the United Kingdom than road traffic collisions. Yet the incidence of AD is not known. The management of acute type B AD (TBAD) is changing, with the greater use of thoracic aortic stent grafts [...] Read more.
Aortic dissection (AD) causes more deaths each year in the United Kingdom than road traffic collisions. Yet the incidence of AD is not known. The management of acute type B AD (TBAD) is changing, with the greater use of thoracic aortic stent grafts (TEVAR) in treatment and fewer open surgical procedures performed. The study’s aim is to review the worldwide, English language published, literature on acute TBAD incidence and treatment, to report on its strengths and limitations, and better understand changes in incidence over time and between countries. Thirty-one studies were identified that focus on the epidemiology and treatment of TBAD. Eight of these studies report the incidence of acute TBAD as between of 0.5–6.3 per 100,000 person years. Hospital admissions for aortic dissection are reported to be increasing in six studies and stable in one study. The proportion of patients with TBAD operated on varies between studies (range 13% to 76%). Studies identify patient age (median 51–77 years), gender (range 48%–81% male) and prevalence of cardio-vascular risk factors, specifically hypertension, in the populations studied as independent factors influencing aortic dissection incidence. Treatment of acute TBAD remains largely conservative with analgesia, hypertension control and serial cross-sectional imaging (range 24%–87% TBAD medically treated). The use of TEVAR to treat acute AD is increasing worldwide (range 13%–76% TBAD treated with TEVAR). The incidence of TBAD is under-reported due to out of hospital deaths, variable clinical presentation (miss-diagnosis) and coding errors. Importantly for research, the single International Classification of Diseases (ICD) code for aortic dissection, I17.0, does not distinguish between acute, chronic, type A or type B dissection types. Similarly, the OPCS Classification of Interventions and Procedures version 4 (OPCS-4) codes for TEVAR, L27.4 and L28.4, do not distinguish between acute and chronic AD presentation, unlike the codes for open thoracic aortic replacement. Standardised reporting of aortic dissection type, and the urgency of both the initial presentation (acute or chronic) and treatment (emergency, urgent or planned) in future studies would allow more meaningful comparisons between populations. Full article
(This article belongs to the Special Issue Thoracic Aorta)
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Open AccessReview
A Review on the Surgical Management of Intramural Haematoma of the Aorta
Hearts 2020, 1(2), 75-85; https://doi.org/10.3390/hearts1020009 - 13 Aug 2020
Viewed by 643
Abstract
Intramural haematoma (IMH) of the aorta is one of the causes of acute aortic syndrome which often requires emergency or urgent life-saving surgery. In this review, we discuss the pathophysiology, epidemiology, clinical presentation, diagnostic imaging, surgery and clinical outcomes associated with IMH. Full article
(This article belongs to the Special Issue Thoracic Aorta)
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Open AccessReview
Intervention in Takayasu Aortitis: When, Where and How?
Hearts 2020, 1(2), 62-74; https://doi.org/10.3390/hearts1020008 - 05 Aug 2020
Viewed by 528
Abstract
Takayasu arteritis is a large vessel vasculitis which commonly affects the aorta and its major branches. Active arterial inflammation is characterised by the presence of T and B lymphocytes, natural killer cells, macrophages and occasional multinucleate giant cells. Uncontrolled vascular inflammation can progress [...] Read more.
Takayasu arteritis is a large vessel vasculitis which commonly affects the aorta and its major branches. Active arterial inflammation is characterised by the presence of T and B lymphocytes, natural killer cells, macrophages and occasional multinucleate giant cells. Uncontrolled vascular inflammation can progress to cause arterial stenosis, occlusion or aneurysmal dilatation. Medical treatment involves combination immunosuppression and more recently biologic therapies targeting TNF-α and IL-6. Due to the typical delays in diagnosis and accumulation of arterial injury, open and endovascular surgical intervention are important and potentially life-saving treatment options for Takayasu arteritis. Common indications for surgery include aortic coarctation and ascending aortic dilatation ± aortic valve regurgitation, renal artery stenosis, ischaemic heart disease, supra-aortic disease, mesenteric ischaemia, severe limb-threatening claudication and aneurysm repair. Surgical outcomes are markedly improved in patients with clinically inactive disease and those who receive adequate periprocedural immunosuppression. Decisions regarding surgical approaches are best made as part of a multi-disciplinary team. Full article
(This article belongs to the Special Issue Thoracic Aorta)
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Open AccessReview
The Role of Genetics in Risk Stratification of Thoracic Aortic Aneurysm Dissection
Hearts 2020, 1(2), 50-61; https://doi.org/10.3390/hearts1020007 - 03 Aug 2020
Viewed by 607
Abstract
Thoracic aortic aneurysms are prevalent in the Western population and are often caused by genetic defects. If undetected, aneurysms can dissect or rupture, which are events associated with a high mortality rate. Hitherto no cure exists other than elective surgery if aneurysm dimensions [...] Read more.
Thoracic aortic aneurysms are prevalent in the Western population and are often caused by genetic defects. If undetected, aneurysms can dissect or rupture, which are events associated with a high mortality rate. Hitherto no cure exists other than elective surgery if aneurysm dimensions reach a certain threshold. In the past decades, genotype-phenotype associations have emerged that enable clinicians to start stratifying patients according to risk for dissection. Nonetheless, risk assessment is—to this day—confounded by the lack of full comprehension of underlying genetics and modifying genetic risk factors that complicate the yet established genotype-phenotype correlations. Further research that focuses on identifying these additional risk markers is crucial. Full article
(This article belongs to the Special Issue Thoracic Aorta)
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Open AccessReview
Brain Protection in the Endo-Management of Proximal Aortic Aneurysms
Hearts 2020, 1(2), 25-37; https://doi.org/10.3390/hearts1020005 - 01 Jul 2020
Viewed by 564
Abstract
Neurological brain injury (NBI) remains the most feared complication following thoracic endovascular aortic repair (TEVAR), and can manifest as clinically overt stroke and/or more covert injury, detected only on explicit neuropsychological testing. Microembolic signals (MES) detected on transcranial Doppler (TCD) monitoring of the [...] Read more.
Neurological brain injury (NBI) remains the most feared complication following thoracic endovascular aortic repair (TEVAR), and can manifest as clinically overt stroke and/or more covert injury, detected only on explicit neuropsychological testing. Microembolic signals (MES) detected on transcranial Doppler (TCD) monitoring of the cerebral arteries during TEVAR and the high prevalence and incidence of new ischaemic infarcts on diffusion-weighted magnetic resonance imaging (DW-MRI) suggests procedure-related solid and gaseous cerebral microembolisation to be an important cause of NBI. Any intervention that can reduce the embolic burden during TEVAR may, therefore, help mitigate the risk of stroke and the covert impact of ischaemic infarcts to the function of the brain. This perspective article provides an understanding of the mechanism of stroke and reviews the available evidence regarding potential neuroprotective strategies that target high-risk procedural steps of TEVAR to reduce periprocedural cerebral embolisation. Full article
(This article belongs to the Special Issue Thoracic Aorta)
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Open AccessReview
Management of Uncomplicated Type B Aortic Dissection
Hearts 2020, 1(1), 14-24; https://doi.org/10.3390/hearts1010004 - 18 May 2020
Cited by 1 | Viewed by 824
Abstract
Acute aortic dissection has an incidence of approximately half that of symptomatic abdominal and thoracic aneurysm of the aorta and more than twice the mortality of population-based controls. While urgent undelayed open surgery is the strategy of choice in proximal dissection, medical management [...] Read more.
Acute aortic dissection has an incidence of approximately half that of symptomatic abdominal and thoracic aneurysm of the aorta and more than twice the mortality of population-based controls. While urgent undelayed open surgery is the strategy of choice in proximal dissection, medical management has been the mainstay of treatment for uncomplicated distal or type B aortic dissection, but endovascular intervention is now considered a potential treatment option for all type B dissection due to its success in complicated cases. Endovascular repair can be technically demanding in aortic dissection, and timing of the repair can have a significant influence on anatomical and clinical outcome. Observational reports of feasibility and reasonable safety are flanked by only two randomised trials; the Acute Dissection Stent Grafting or Best Medical Treatment (ADSORB) trial demonstrated improved remodelling in acute dissection and the INvestigation of STEnt grafts in patients with type B Aortic Dissections (INSTEAD) trial showed better long-term survival in patients treated endovascularly in the subacute phase. Meta-analyses and other large clinical studies have demonstrated mixed results. Due to some risks associated endovascular repair and the requirement of specialist aortic care (which is not always available), a pragmatic approach for current management could involve high intensity serial imaging in the acute phase of a type B aortic dissection, thereby identifying complicated cases for early intervention and selection of patients at high risk of disease progression for deferred endovascular management in the subacute phase within 90 days. Full article
(This article belongs to the Special Issue Thoracic Aorta)
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Other

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Open AccessPerspective
The Management of Penetrating Aortic Ulcer
Hearts 2020, 1(1), 5-13; https://doi.org/10.3390/hearts1010003 - 15 May 2020
Cited by 1 | Viewed by 1244
Abstract
Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may [...] Read more.
Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management. Full article
(This article belongs to the Special Issue Thoracic Aorta)
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