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Canadian Journal of Cardiology

The Aortic Wall Conundrum: Predicting Thoracic Aortic Disease Behaviour

  • Dominique Vervoort
    Affiliations
    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

    Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
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  • Jennifer Chia-Ying Chung
    Affiliations
    Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada

    Division of Cardiovascular Surgery, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Stephen E. Fremes
    Correspondence
    Corresponding author: Dr Stephen E. Fremes, Professor of Surgery, University of Toronto, Schulich Heart Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room H4 05, Toronto, Ontario M4N 3M5, Canada. Tel.: +1-416-480-6073.
    Affiliations
    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

    Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada

    Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
Published:August 18, 2022DOI:https://doi.org/10.1016/j.cjca.2022.08.006
      Most thoracic aortic aneurysms (TAAs) are benign throughout a lifetime or can be operated in a scheduled manner with relative safety when detected in time.
      • Guo M.H.
      • Appoo J.J.
      • Saczkowski R.
      • et al.
      Association of mortality and acute aortic events with ascending aortic aneurysm: a systematic review and meta-analysis.
      However, TAAs with unfavourable biomechanical characteristics remain associated with high morbidity and mortality, particularly as a result of aortic dissection.
      • Hagan P.G.
      • Nienaber C.A.
      • Isselbacher E.M.
      • et al.
      The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.
      Traditionally, size thresholds have been used to determine the risk of TAAs and guide the timing of intervention
      • Davies R.R.
      • Goldstein L.J.
      • Coady M.A.
      • et al.
      Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size.
      ; however, these thresholds have been found to be poor predictors of dissection, as half or more of dissections occur at aortic diameters below the thresholds.
      • Pape L.A.
      • Tsai T.T.
      • Isselbacher E.M.
      • et al.
      Aortic diameter ≥ 5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD).
      ,
      • Rylski B.
      • Branchetti E.
      • Bavaria J.E.
      • et al.
      Modelling of predissection aortic size in acute type A dissection: more than 90% fail to meet the guidelines for elective ascending replacement.
      In recent years, biomechanical metrics have emerged as potentially better predictors.
      • Chung J.C.Y.
      • Wong E.
      • Tang M.
      • et al.
      Biomechanics of aortic dissection: a comparison of aortas associated with bicuspid and tricuspid aortic valves.
      • Chung J.
      • Lachapelle K.
      • Wener E.
      • et al.
      Energy loss, a novel biomechanical parameter, correlates with aortic aneurysm size and histopathologic findings.
      • Boczar K.E.
      • Boodhwani M.
      • Beauchesne L.
      • et al.
      Aortic stiffness, central blood pressure, and pulsatile arterial load predict future thoracic aortic aneurysm expansion.
      These predictors include aortic stiffness, which has been found to be associated with aortic growth rates in Marfan patients.
      • Prakash A.
      • Adlakha H.
      • Hass C.
      • Morris S.A.
      • Geva T.
      • Lacro R.V.
      CMR-derived aortic stiffness is associated with more rapid aortic dilation and surgical replacement in children and young adults with connective tissue disorders.
      The carotid-femoral pulse-wave velocity (cfPWV), which records the speed by which an arterial pulse travels from the carotid to the femoral artery, has recently been explored as a related biomechanical metric in predicting aortic growth. Though promising, cfPWV requires applanation tonometry, which measures the arterial pressure at a given arterial location by means of high-fidelity pressure sensors, and the necessary expertise to conduct and interpret cfPWV analysis, posing barriers to adoption for smaller and lower-resourced centres. Novel metrics to predict aortic behaviour over time are therefore necessary; these metrics must fulfil the following criteria to be able to be translated into clinical practice: 1) correlate with the aortic wall microstructure, 2) correlate with aortic wall failure properties, and 3) be measurable easily and noninvasively.
      • Tang M.
      • Simmons C.A.
      • Chung J.C.Y.
      Searching for a physiologically meaningful parameter for aortic biomechanics—is energy loss the way?.
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