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Background Type B intramural hematoma (IMH) is considered a low-risk entity for aortic complications if aortic dilation, containing rupture or clinical instability are absent. However, the development of intimal disruptions (ID), present in >40% of cases, poses an unknown risk. Objectives To establish which ID characteristics imply a higher risk of aortic complications and, therefore, merit invasive treatment. Methods A systematic review and a meta-analysis were made following a search in EMBASE, MEDLINE and PsycINFO for articles published between January 1995 and December 2017. The combined endpoint was defined as aortic mortality, invasive treatment for aortic disease and/or increase in maximum aortic diameter ≥55 mm. Lesions with communicating orifice ≤3 mm were defined as tiny ID (TID) and those with >3 mm as focal ID (FID). Results Six studies with 564 participants diagnosed of type B IMH were included. Incidence of ID was 54.3% (306 individuals): 27.7% (156 individuals) initially met TID criteria; however, 13.9% of these (21 of 151 with morphologic evolution) evolved to FID within the first 6 months. Ninety-two cases suffered clinical aorta-related events (16.3%; mean follow-up range: 15–85 months; median: 52 months). Patients with TID had a similar risk of aorta-related events to those without ID (RR = 0.904; 95% CI, 0.335–2.440; P = 0.842; I2 = 42.5%), but lower than those with FID (RR = 0.299; 95% CI, 0.094–0.952; P = 0.041; I2 = 26.9%). Conclusions Tiny intimal disruption in type B IMH evolution is not related to an increased risk of complications and should not be considered an indication for invasive treatment. However, since 14% of TID evolve to FID within the first 6 months, close follow-up with imaging techniques is advisable.

Objectives This study evaluated predictors for aortic dilation (AD) in patients with repaired tetralogy of Fallot (rTOF) using magnetic resonance angiography (MRA). Background AD is common in patients with rTOF and may result in increased morbidity and mortality. There are no guidelines for evaluation of AD for rTOF patients. Methods All adults with rTOF who previously underwent MRA had retrospective aortic measurements at the sinuses of Valsalva (SoV) and ascending aorta (AsAo). Rate of change in diameter was determined in patients with multiple MRAs. Chart review identified risk factors for AD. Univariate and multivariate analyses tested predictors of AD. Results Of the 87 patients who met the inclusion criteria, 12 (14%) had AD. At baseline, mean diameter was 3.6±0.6cm and 3.1±0.6cm at the SoV and AsAo, respectively. The AsAo was larger than the SoV in 17%. Predictors of AD included male gender, age, right aortic arch, pregnancy, older age at complete repair, smoking, and systemic hypertension. Serial studies were available in 55 patients; the rate of growth was slow: 0.4±0.9mm/year (SoV) and 0.1±0.8mm/year (AsAo). Conclusions AD is common in rTOF at the SoV and AsAo. Transthoracic echocardiography, which does not always image the AsAo as well as MRA, may not image AD in rTOF in cases in which the AsAo is dilated. Although several risk factors correlate with AD in rTOF, the rate of aortic growth is slow, suggesting that rTOF patients may not require frequent aortic imaging.

DOI: 10.1016/j.ijcard.2016.04.184 Background/objectives The mechanisms underlying aortic dilation in bicuspid aortic valve (BAV) disease are unknown. Circulating endothelial microparticles (EMPs) have emerged as biomarkers of endothelial damage. We sought to evaluate the relationships among EMPs, BAV disease, and aortic dilation. Methods Four evaluations were used. Circulating EMPs (PECAM+, E-selectin+) were compared between BAV patients and tricuspid aortic valve (TAV) control subjects. The variables related to circulating EMPs were investigated in BAV patients. Circulating EMP levels were compared between BAV and TAV patients with a dilated aorta. Finally, circulating EMPs in BAV patients were evaluated over time with respect to aortic valve surgery (AVS) or aortic surgery. Results We observed higher levels of circulating PECAM+ EMPs in the BAV patients than in the control subjects (3.98 ± 0.2 vs. 2.39 ± 0.4 per log PECAM+ EMPs/μl, p = 0.001). Aortic dilation was the most significant variable that correlated with the PECAM+ EMP levels in the BAV patients (β = 0.321, p = 0.008). The BAV patients with aortic dilation exhibited higher PECAM+ EMP levels than the TAV patients with dilated aortas, and this correlation was independent of aortic valve function. We observed a drastic decrease in the circulating PECAM+ EMPs following AVS and aortic root replacement (4.27 ± 0.6 and 1.75 ± 0.3 per log PECAM+ EMPs/μl, p = 0.002). Conclusion The observed pattern of higher circulating PECAM+ EMP levels links BAV disease to endothelial damage and aortic dilation. Circulating PECAM+ EMPs were identified as a biological variable related to aortic dilation in patients with BAV disease.

The underlying cause of aneurysmal aortic dilation is uncertain in most patients. It is unclear whether atherosclerosis causes aneurysmal disease or vice versa, while familial clusters are suggestive of a possible genetic predisposition. The data obtained from well-designed molecular and clinical studies support a multifactorial, systemic, nonatherosclerotic causal hypothesis, such as a defect in vascular structural proteins, with atherosclerosis occurring as a secondary process.