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BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is used in patients with thoracic aortic aneurysms (TAA) and uncomplicated type B acute aortic dissection (B-AAD) to reduce morbidity and mortality. Limited data are available for comparing outcomes of TEVAR in TAA vs B-AAD. METHODS: 49 patients with TAA and 37 patients with B-AAD between January 2005 and January 2015 were retrospectively identified. Baseline characteristics, thrombosis status of the false lumen with the extent of dissection, aortic pathologies including prior aortic surgeries, emergent vs elective procedures, landing zone location, extra anatomical major vessel bypass, types of grafts and outcome variables were reviewed by two physicians. T-test, Wilcoxon rank-sum test and chi-square test were used to generate pvalues. RESULTS: The sample population with TAA had a higher median age than those with B-AAD (72 years vs 59 years, p¼0.0001) (Table). Early events, 30-day mortality and 5-year outcomes were not significantly different between groups. Endoleak and all-cause mortality with TEVAR were not significantly different in the groups (Fig). CONCLUSION: This study confirms the feasibility of TEVAR for uncomplicated type B aortic dissection in the acute setting with no difference in short- or long-term outcomes of TEVAR between TAA and B-AAD populations

Influence of Differential Calcification in the Descending Thoracic Aorta on Aortic Pulse Pressure

Purpose: Multiple studies have shown pulse pressure (PP) to be a strong predictor of aortic calcification. However, no studies are available that correlate PP with aortic calcification at the segmental level. Methods: We identified 37 patients with aortic PP measured during cardiac catheterization. Their noncontrast chest computed tomography scans were evaluated for the presence of calcium in different segments (ascending aorta, arch of aorta [arch], descending aorta) and quantified. Patients with calcification (Calcified Group A) were compared against patients without calcification (Noncalcified Group B) in terms of PP, calcification and compliance. Results: The mean of the total calcium score was higher in the descending aorta than the arch or ascending aorta (691 vs 571 vs 131, respectively, P < 0.0001). PP had the strongest correlation with calcification in the descending aorta (r = 0.47, P = 0.004). Calcified Group A had a much higher PP than Noncalcified Group B, with the greatest difference in the descending aorta (20 mmHg, P < 0.0001), lesser in the ascending aorta (10 mmHg, P = 0.12) and the least in the arch (5 mmHg, P = 0.38). Calcified Group A patients also had much lower compliance than Noncalcified Group B patients, with the greatest difference among groups seen in the descending aorta (0.7 mL/mmHg, P = 0.002), followed by the ascending aorta, then arch. Conclusions: These are the first data to evaluate the relative impact of aortic segments in PP. Finding the greatest amount of calcification along with greatest change in PP and compliance in the descending aorta makes a case that the descending aorta plays a major role in PP as compared to other segments of the thoracic aorta

Comparative study on catheter directed thrombolysis – continuous tissue plasminogen activator vs angiojet catheter power pulse spray rheolytic thrombectomy outcome study – single-center experience

BACKGROUND: Acute arterial occlusion of native and graft vessels has a variety of treatment options, including catheter-directed thrombolysis (CDT), power pulse spray with rheolytic thrombectomy (PPSRT) and surgery. We studied acute limb ischemia (ALI) outcomes with CDT vs PPSRT with adjunctive CDT as crossover at a tertiary care center. METHODS: We undertook a comprehensive retrospective analysis of ALI (onset) patients treated with CDT (Group 1) and PPSRT with adjunctive CDT as crossover (Group 2). Data were collected from electronic medical records and billing codes. Continuous variables were expressed as mean ± standard deviation and range, and categorical variables as frequency and percentage. Differences between the groups were analyzed with t-tests or analysis of variance and chi-square or Fisher\u27s exact test. RESULTS:A total of 243 patients admitted for ALI were divided into Group 1 (n=165, 68%; mean age 67.3±13.8, females 48.5%) and Group 2 (n=78, 32%; mean age 68.5±14.4, females 53.8%). Based on propensity-matched comparison, there was less preprocedure tissue loss in Group 1 than Group 2 (5.5% vs 11%, p=0.022 [OR 0.35; 95% CI, 0.14-0.89]). Acute Rutherford IIa (26% vs 41%) and IIb (57% vs 36%) with p=0.059 were not statistically significant. Achieving complete lysis \u3e95% (72% vs 83%, p=0.134) was not statistically different between the two groups. Major bleeding (21% vs 9%, p=0.029 [OR 2.56; 95% CI, 1.08-6.07]), post-lysis 30-day embolectomy (16% vs 5%, p=0.017 [OR 3.52; 95% CI 1.19-10.45]), 30-day compartment syndrome (9% vs 1%, p=0.042 [OR 6.95; 95% CI, 0.9-53.88]), length of hospitalization (7% vs 4%, p=0.0004) and time to lysis (24 hrs vs 3 hrs, p CONCLUSIONS: Although there was no difference in achieving complete lysis in CDT or PPSRT with adjunctive CDT, there was less major bleeding, post-lysis 30-day embolectomy and 30-day compartment syndrome, as well as shorter length of hospitalization and time to lysis in Group 2. These data support the utility of PPSRT with adjunctive CDT over CDT alone

Cardiopulmonary Exercise Testing-Based Algorithm and Its Usefulness in Clinical Cardiology

Background: Only cardiopulmonary exercise (CPX) testing provides information on the ability of the cardiovascular system to meet the body’s metabolic demands in terms of oxygen consumption (VO2) and carbon dioxide production (VCO2). However, CPX testing is underutilized by cardiologists due to complex diagnostic algorithms involving up to 30 variables as well as lack of validation studies. In addition, CPX also provides oxygen (O2) pulse as a continuous measure of stroke volume, which is its superiority to other stress modalities in which systolic function is measured at peak stress and rest. In the literature, it has been recommended that a composite criterion (combining peak O2 pulse with O2 pulse curve pattern) should be used to assess the cardiac function. Furthermore, the operating test characteristics and optimal cutoff of O2 pulse for distinguishing cardiac from noncardiac causes of exercise limitation also are unknown. Purpose: We tested whether a 6-variable algorithm would discriminate cardiac from noncardiac causes of dyspnea when compared with comprehensive CPX testing to promote its use by cardiologists. We also tested several cutoff points along with the composite criterion against the clinical standard to define the optimal O2 pulse cutoff point. Methods: Consecutive patients (n = 54) referred for dyspnea underwent CPX test consisting of pulmonary (VO2, VCO2, 22 additional variables and invasive measurement of lactate and blood gases at peak and baseline) and cardiac (exercise ECG, heart rate and blood pressure response) components as well as medical record evaluation. Patients were categorized as normal or abnormal by an experienced pulmonologist. Abnormal patients were further categorized according to cause of dyspnea (cardiac, pulmonary, deconditioning, poor effort and miscellaneous). Subsequently, the 6-variable algorithm was applied by a cardiologist blinded to all of the information from CPX tests, and the patients were categorized similarly. The 6 variables used were peak O2 uptake, peak respiratory exchange ratio, O2 pulse, heart rate reserve, breathing reserve (1 – [peak ventilation (VE) / maximal voluntary ventilation]) and ventilatory efficiency (VE/VCO2). Seven O2 pulse reference cutoff points included nongender-based (\u3c 15 ml/beat), gender-based (\u3c 15 ml/beat for males and \u3c 10 ml/beat for females) and \u3c 80% of O2 pulse based on five different definitions of predicted VO2 max. The optimal cutoff obtained was then used to create the composite criterion. For the purpose of evaluating this composite criterion, the study population was recategorized as: noncardiac group (n = 18), normal patients according to the composite criterion; or cardiac group (n = 13), abnormal patients according to the composite criterion. Patients who were normal by only one component of the composite criterion were categorized as borderline (n = 23). Data were analyzed against the comprehensive CPX test by first excluding the borderline patients and then by including them with either the cardiac or noncardiac group. Results: The 6-variable algorithm performed well against comprehensive CPX test in discriminating cardiac from noncardiac causes of dyspnea, with 94% sensitivity, 92% specificity, 84% positive predictive value (PPV), 97% negative predictive value (NPV) and 93% accuracy. The results remained consistent for gender and referral source. O2 pulse, as defined by Wasserman, had the highest accuracy, specificity and PPV and therefore was used to define the composite criterion. The composite criterion had an accuracy of 87%, PPV of 77%, NPV of 94%, sensitivity of 91% and specificity of 85%, when borderline patients were excluded. Including borderline patients in the cardiac group (n = 36) improved sensitivity (94%) and maintained NPV (94%) but greatly decreased specificity (46%), PPV (44%) and accuracy (61%), whereas including these patients in the noncardiac group (n = 41) improved specificity (92%) and maintained similar PPV (77%) and accuracy (81%) but decreased sensitivity (59%) and NPV (83%). Conclusion: This is the first study to validate a diagnostic algorithm for patients undergoing CPX testing as well as demonstrate that a simplified 6-variable algorithm applied by a cardiologist without prior CPX experience is quite accurate to evaluate the optimal O2 pulse value at peak stress for discrimination of cardiac and noncardiac causes, and to provide the operating test characteristics for the common clinical practice of using composite criterion to diagnose cardiac versus noncardiac causes of dyspnea