Himanshu Jagdish Patel

Exercise is widely recognized for its cardiovascular benefits; however, its safety and role in patients with thoracic aortic aneurysms (TAAs) remains complex due to its distinctive biomechanical vulnerabilities. Fundamentally different from abdominal aortic aneurysms, TAAs develop from distinct pathophysiological processes that affect their hemodynamic responses to stressors and influence their risk of adverse aortic events. Exercise induces acute hemodynamic changes, including increased stroke volume, systolic and pulse pressures, and transient aortic stiffening. These changes impose mechanical stress on the aortic wall, potentially accelerating aneurysm progression or triggering adverse aortic events. Although moderate aerobic exercise generally appears safe with potential cardiovascular benefits, evidence supporting safe practices in TAAs is limited. Current guidelines frequently extrapolate from abdominal aortic aneurysm data, which overlook the specificities of the thoracic aorta. This review underscores the urgent need for comprehensive research, using advanced imaging, biomarker profiling, and real‐time hemodynamic monitoring to understand how different exercise modalities and intensities affect TAAs. Well‐designed prospective studies are crucial to improve risk stratification, optimize antihypertensive strategies, develop personalized exercise prescriptions, and provide evidence‐informed guidance to patients. Perioperative strategies like prehabilitation and structured postoperative rehabilitation show promise but lack rigorous evaluation. Ultimately, this work advocates a paradigm shift from conservative inactivity toward informed, individualized physical activity regimens tailored to each patient's risk profile. This approach aims to maximize cardiovascular benefits while minimizing adverse aortic events, thereby improving overall health and quality of life in patients with TAAs.

Objectives: Most ascending aortic replacements for acute type A aortic dissection (ATAAD) are performed utilizing hypothermic circulatory arrest with an “open” distal anastomosis (“hemiarch”), whereas some are completed without ever removing the aortic cross-clamp. We sought to determine the impact of distal anastomotic technique in ascending aortic replacement for ATAAD repair. Methods: All patients in the IRAD Interventional Cohort database who underwent ATAAD repair between 2010 and 2020 were identified (n = 2559). Data for distal anastomotic technique were available in 2031 patients who underwent ascending aortic replacement, divided into 2 groups, based on whether they underwent hypothermic circulatory arrest (Clamp Off, n = 1900 [93.5%]) or not (Clamp On, n = 131, [6.5%]). We then propensity-matched 101 pairs of patients and analysed operative data and short- and mid-term outcomes. Results: In-hospital mortality for the unmatched population was 13.1% (266 deaths), not statistically different between the matched groups (Clamp Off, 11.0% vs Clamp On, 5.1% P = .22). There were no statistically significant differences observed in 3-year post-discharge survival curves between matched cohorts (Clamp Off, 89.5% vs Clamp On, 90.4%; stratified log-rank P-value = .46). Major perioperative complications (renal failure requiring dialysis, reoperation for bleeding, respiratory insufficiency) were not significantly different between the groups, notably including stroke (Clamp Off, 10.2% vs Clamp On, 5.8%, P = .32). Conclusions: In this propensity-matched cohort, postoperative mortality, major morbidity, and mid-term survival were comparable between open distal anastomosis and clamp-on strategies in selected patients undergoing ascending aortic replacement for ATAAD.

Objectives: The impact of diagnosis and management of ascending thoracic aortic aneurysm (ATAA) on patients’ quality of life (QoL) is not well characterized. This study aims to compare QoL with surgery versus surveillance in patients with moderate ATAAs. Methods: Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance is a multicentre randomized trial for patients with ATAA between 5.0 and 5.4 cm and includes a registry of patients who underwent either surgery or surveillance. From May 2019 to December 2022, 157 patients from 15 centres were enrolled in the surveillance (n = 105) or surgery (n = 52) registry and completed baseline and follow-up 36-item short form survey (SF-36) for QoL assessment. The primary outcomes were changes in physical component summary and mental component summary (MCS) scores. Propensity matching was performed to adjust for baseline differences. Results: Patients in the surveillance arm were older and had higher prevalence of hypertension, dyslipidaemia, and atrial fibrillation (all P < 0.05). The overall mean duration between baseline and follow-up SF-36 questionnaire was 13.2 ± 3.6 months. After propensity match, compared to scores at baseline, patients in the surgery arm experienced significantly greater improvement in scores in MCS (4.1 ± 10.9 vs 0.1 ± 7.7; P = 0.04), general health (7.2 ± 17.6 vs –0.7 ± 14.5; P = 0.02), and mental health (9.5 ± 17.5 vs 1.4 ± 13.4; P = 0.01). Conclusions: In a multicentre, prospective, non-randomized comparison of patients with moderate ATAAs, surgical treatment was associated with improvement in mental components of QoL at 1 year compared to surveillance.

Objectives: Stentgrafts in the thoracic aorta, whether placed during the frozen elephant trunk procedure or thoracic endovascular repair, have been associated with thrombosis. This study aimed to evaluate its incidence, risk factors, and clinical consequences. Methods: PubMed, Web of Science, and SCOPUS were systematically searched for relevant studies. Quality assessment was performed using the Risk of Bias in Non-Randomized Studies of Interventions tool for cohort studies and the Joanna Briggs Institute checklist for case reports. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Results: Seventeen studies were included: 4 cohort studies (825 patients) and 3 case reports on frozen elephant trunk, 3 cohort studies (142 patients), and 12 case reports on thoracic endovascular repair. The pooled incidence of intra-stent graft thrombosis after frozen elephant trunk was 8.6% (95% CI: 5.7-12.9), typically occurring within 1 week and significantly associated with older age, female sex, aneurysmal disease, and higher rates of dialysis (43% vs 16%) and mortality (25% vs 8%). Thoracic endovascular repair cohorts were heterogeneous and could not be pooled; therefore, findings were synthesized narratively. One trauma cohort reported an incidence of 20.6%. All 12 case reports involved patients treated for trauma, with a mean time to diagnosis of 12 ± 6.3 months; 8 presented with spinal cord injury; 11 underwent an intervention to address the thrombosis. Conclusions: Intra-stent graft thrombosis is relatively common after frozen elephant trunk and may be underrecognized after thoracic endovascular repair, particularly in trauma patients. Structured imaging follow-up and individualized treatment strategies are warranted.

OBJECTIVES: Aortic arch tears, including distal anastomosis new entry tears and residual arch tears, have been associated with adverse outcomes (false lumen growth, distal reoperation) after hemi-arch repair for DeBakey Type I aortic dissection. However, no study has compared distal anastomosis new entry tears and RATs as independent entities despite their distinct aetiologies and preventative strategies which may inform surgical management. METHODS: Retrospective cohort study of adult patients with hemi-arch repair for DeBakey Type I aortic dissection at a tertiary referral centre (1996–2021). We included patients who survived beyond their initial hospitalization with good-quality post-operative CT angiograms. Distal anastomosis new entry tears and residual arch tears metrics were collected from the first good-quality post-operative CT. Maximal aortic diameters (distal to graft) were collected from pre- and post-hemi-arch repair CT angiograms. Presence and imaging characteristics of distal anastomosis new entry tears and RATs were examined for prediction of false lumen growth and distal aortic intervention. RESULTS: We included 272 patients, and 24.5% (69) had distal anastomosis new entry tears, which on multivariable analysis was associated with a post-operative descending diameter change of +6.2 mm (95% confidence interval [CI]: 4.5, 7.9) and greater risk of distal intervention, hazard ratio 3.24 (95% CI: 1.57, 6.68); residual arch tears were not significantly associated, hazard ratio 0.72 (95% CI: 0.28, 1.83). Distal anastomosis new entry tears located on the greater curvature versus lesser curvature (58% vs 42%, P = 0.044) were more likely to lead to reoperation (45% vs 17%, P = 0.033). CONCLUSIONS: Distal anastomosis new entry tears, not residual arch tears, correlate strongly with negative descending aorta remodelling and distal intervention after hemi-arch repair for DeBakey I aortic dissection. Therefore, additional strategies are warranted to prevent distal anastomosis new entry tears, a result of anastomotic technical challenge, during operative repair.

Background: Thoracic aortic aneurysm (TAA) is an indolent, potentially fatal disease, which progresses at variable rates that are influenced by pathogenesis and patient characteristics. We conducted a systematic review and meta‐analysis to synthesize the current evidence on growth rate (GR) and predictive factors among patients with syndromic and nonsyndromic heritable thoracic aortic disease, bicuspid aortic valve, and sporadic TAA. Methods and Results: Online databases were searched for studies that reported aortic growth on adult patients with asymptomatic TAA. Pooled GRs were calculated for 3 different TAA groups: syndromic heritable thoracic aortic disease, bicuspid aortic valve, and sporadic TAA. The search yielded 6297 studies, of which 85 were included in the systematic review, and 55 in the meta‐analysis of growth rate (10 syndromic heritable thoracic aortic disease, 31 bicuspid aortic valve, and 34 sporadic subgroups). Mean observed TAA GR was 0.25 mm/y (95% CI, −0.18 to 0.68) in Turner syndrome, 0.45 mm/y (95% CI, 0.00–0.90) in Marfan syndrome, and 0.81 mm/y (95% CI, −0.46 to 2.08) in Loeys–Dietz syndrome. The mean observed GR in patients with bicuspid aortic valve before aortic valve surgery was 0.37 mm/y (95% CI, 0.29–0.46), compared with 0.18 mm/y (95% CI, 0.14–0.33) in postsurgical studies. Mean observed GR in sporadic ascending TAA was 0.33 mm/y (95% CI, 0.13–0.52) and 2.71 mm/y (95% CI, 0.53–4.88) in descending TAA. Conclusions: Considering all pathogeneses, ascending TAAs typically grow at 0.25 to 1 mm/y, and thus annual surveillance is likely too frequent to detect growth in most patients. Studies vary widely in populations, methodology, and outcomes, with few high‐quality longitudinal studies and no predictors of aortic GR.

Background: Patients with Marfan syndrome (MFS) are at a high risk of type B aortic dissection (TBAD). Aortic growth and elongation have been suggested as risk factors for TBAD. Vascular deformation mapping is an image analysis technique for mapping 3‐dimensional aortic growth on routine computed tomography angiography (CTA) scans. We aimed to use vascular deformation mapping to examine the value of aortic growth rate in the descending thoracic aorta, among other imaging biomarkers, to identify the factors associated with risk of TBAD in MFS. Methods: Computed tomography angiography scans spanning 2004 to 2023 from adult patients with MFS with native descending thoracic aorta were analyzed by vascular deformation mapping. Other measurements included multilevel thoracoabdominal aortic diameters and the length of the descending thoracic aorta by centerline analysis. Results: Among the 105 patients with MFS analyzed, 63.8% were men, with median age of 40 (range, 18–73) years and a median surveillance interval of 5.3 (range, 2.0–18.3) years. During surveillance, 12 (11.4%) patients developed TBAD. Patients with TBAD had a higher radial growth rate (0.63 versus 0.23 mm/year; P P <0.001), on univariate and multivariable analysis, but predissection descending aortic diameter was not significantly different. Predictors of growth rate included younger age, higher baseline maximal diameter of the descending thoracic aorta, smoking history, and warfarin use. Conclusions: Radial growth and elongation rates of the descending thoracic aorta were independent predictors of TBAD occurrence in MFS. TBAD often occurred at nonaneurysmal diameters (<4.0 cm). These findings emphasize the role of growth over absolute diameter in risk stratification for TBAD in MFS.

Safety, efficacy, and durability are important considerations when selecting a bioprosthesis for aortic valve replacement (AVR). This study assessed 7-year clinical outcomes and haemodynamic performance of the Avalus bioprosthesis. Patients indicated for surgical AVR were enrolled in this prospective, nonrandomized trial, conducted across 39 sites globally. The primary end-point of this analysis was freedom from surgical explant or percutaneous valve-in-valve reintervention due to structural valve deterioration (SVD) at 7 years of follow-up, determined using Kaplan–Meier (KM) analysis. We also evaluated a composite end-point of SVD or severe haemodynamic dysfunction (SHD) requiring reintervention. Survival, valve-related safety events, and haemodynamic performance were assessed. Deaths and safety events were adjudicated by an independent clinical events committee. A total of 1132 patients underwent surgical AVR. Mean age was 70 years; 854 patients (75%) were men. Mean STS risk of mortality was 2.0 ± 1.4%, and 659 patients (58%) had a NYHA classification of I/II. One or more concomitant procedures were performed in 577 patients (51%). At 7 years, the Kaplan–Meier rate of freedom from SVD/SHD requiring reintervention was 1.2% (0.5–2.5%) with no cases adjudicated as SVD. The survival rate was 82.6% (79.5–85.0%). The KM event rate was 5.7% (4.3–7.7%) for reintervention, 6.3% (4.9–8.3%) for endocarditis, and 0.4% (0.1–1.1%) for valve thrombosis. Mean aortic gradient, dimensionless velocity index, and effective orifice area were 13.8 ± 5.9 mmHg, 0.42 ± 0.09, and 1.99 ± 0.53 cm², respectively. This analysis demonstrated excellent durability of the Avalus valve with good clinical outcomes and stable haemodynamic performance through 7 years of follow-up. www.clinicaltrials.gov ID: NCT02088554

Background: Patients with ascending thoracic aortic aneurysm are recommended to undergo routine imaging surveillance. Although maximal diameter is the primary metric of disease severity, recent American College of Cardiology/American Heart Association guidelines emphasize the importance of aortic growth in determining surgical candidacy and risk. As diameter increases, it is assumed that aortic growth rate accelerates because of increased wall tension; however, this relationship is poorly studied. We aim to investigate the relationship between ascending thoracic aortic aneurysm diameter and growth rate using vascular deformation mapping, a validated technique for 3‐dimensional growth mapping with submillimeter accuracy. Methods and Results: We retrospectively identified adult patients with ascending aortic dilation (≥4.0 cm) and serial gated computed tomography angiograms separated by ≥2 years, excluding confirmed heritable thoracic aortic disease. Ascending growth rate was defined as 90th percentile radial wall deformation by vascular deformation mapping. Maximal diameter measurements were derived from the baseline computed tomography angiogram, and aortic length and body size–adjusted indexes were calculated. Among 258 included patients (63.2% men; age of 63 years [interquartile range, 55–69 years]), mean±SD baseline diameter was 46.3±3.6 mm and median growth rate was 0.21 mm/year (interquartile range, 0.13–0.38 mm/year). No correlation was noted between growth rate and baseline diameter ( r =0.02, P =0.74) or other aortic size metrics. On multivariate analysis, age was independently predictive of growth rate (β=−0.007, P =0.021), alongside weight (β=0.003, P =0.016) and the presence of moderate or severe aortic valve insufficiency (β=0.146, P =0.049). Conclusions: Maximal aortic diameter is not predictive of aortic growth rate, in this contemporary cohort of patients with sizes under current surgical thresholds (<55 mm).

Background: Patients with Marfan syndrome (MFS) are at a high risk of type B dissection (TBAD). Aortic growth and elongation have been suggested as risk factors for TBAD. Vascular deformation mapping (VDM) is an image analysis technique for mapping 3D aortic growth on rouine computed tomography angiography (CTA) scans. We aimed to use VDM to examine the value of aortic growth rate in the descending thoracic aorta (DescAo), among other imaging biomarkers, to identify the factors associated with risk of TBAD in MFS. Methods and Results: CTA scans spanning 2004-2023 from adult MFS patients with native DescAo were analyzed by VDM. Other measurements included multi-level thoracoabdominal aortic diameters and the length of the DescAo by centerline analysis. Among the 105 MFS patients analyzed, 63.8% were male, with median age of 40 years (range 18-73) and a median surveillance interval of 5.3 years (range 2.0-18.3). During surveillance, 12 (11.4%) patients developed TBAD. Patients with TBAD had higher radial growth rate (0.63 vs. 0.23 mm/year; p < 0.001) and elongation rate (2.4 vs. 0.5 mm/year; p < 0.001), on univariate and multivariable analysis, but pre-dissection descending aortic diameter was not significantly different. Predictors of growth rate included younger age, higher baseline maximal diameter of the DescAo, smoking history and warfarin use. Conclusions: Radial growth and elongation rates of the DescAo were independent predictors of TBAD occurrence in MFS. TBAD often occurred in at non-aneurysmal diameters (<4.0 cm). These findings emphasize the role of growth over absolute diameter in risk stratification for TBAD in MFS.