Initiating a New Era of Cardiovascular Diagnosis and Therapy in Acute Aortic Syndromes: The Mainz–Essen Experience (Part I)—Imaging and Biomarkers

Abstract

Acute aortic syndromes (AAS) encompass a group of life-threatening medical conditions (acute aortic dissection [AAD], intramural hematoma, and penetrating aortic ulcer) with a common pathophysiological pathway. Due to overlapping symptoms and signs with other cardiovascular emergencies, the diagnosis remains challenging resulting in time delays and related increased in-hospital and long-term morbidity and mortality. The Cardiovascular Department of Johannes Gutenberg University in Mainz at West-German Heart Centre in Essen (Germany) first described (in 1984) AAD by transesophageal echocardiography, AAD diagnostic features, and furtherly explored the implementation of “invasive” imaging techniques, namely, intravascular ultrasound and intraluminal phased-array imaging. Furthermore, pioneer studies were undertaken on the biomarker and imaging interplay, namely, D-dimer and F-fluorodeoxyglucose positron emission tomography/computed tomography. We discuss the unique 35-year-long Mainz–Essen experience on the diagnostic and prognostic role of serological and imaging biomarkers in AAS.

Keywords

acute aortic syndromes - Mainz–Essen - acute aortic dissection - hybrid operating room - heart team concept

^* Equally contributed.

Publication History

Received: 05 June 2020

Accepted: 25 February 2021

Article published online:
08 November 2021

• References

• 1 Erbel R, Aboyans V, Boileau C. et al; ESC Committee for Practice Guidelines, The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J 2014; 35 (41) 2873-2926
• 2 DeMartino RR, Sen I, Huang Y. et al. Population-based assessment of the incidence of aortic dissection, intramural hematoma and penetrating ulcer, and its associated mortality from 1995 to 2015. Circ Cardiovasc Qual Outcomes 2018; 11 (08) e004689
• 3 Howard DP, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM. Oxford Vascular Study. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation 2013; 127 (20) 2031-2037
• 4 Clouse WD, Hallett Jr. JW, Schaff HV. et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc 2004; 79 (02) 176-180
• 5 Evangelista A, Isselbacher EM, Bossone E. et al; IRAD Investigators. Insights from the International Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research. Circulation 2018; 137 (17) 1846-1860
• 6 Jánosi RA, Gorla R, Tsagakis K. et al. Thoracic endovascular repair of complicated penetrating aortic ulcer: an 11-year single-center experience. J Endovasc Ther 2016; 23 (01) 150-159
• 7 Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet 2015; 385 (9970): 800-811
• 8 Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J 2018; 39 (09) 739-749d
• 9 Hiratzka LF, Bakris GL, Beckman JA. et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121 (13) e266-e369
• 10 Börner N, Erbel R, Braun B, Henkel B, Meyer J, Rumpelt J. Diagnosis of aortic dissection by transesophageal echocardiography. Am J Cardiol 1984; 54 (08) 1157-1158
• 11 Erbel R, Börner N, Steller D. et al. Detection of aortic dissection by transoesophageal echocardiography. Br Heart J 1987; 58 (01) 45-51
• 12 Erbel R, Engberding R, Daniel W, Roelandt J, Visser C, Rennollet H. Echocardiography in diagnosis of aortic dissection. Lancet 1989; 1 (8636): 457-461
• 13 Mohr-Kahaly S, Erbel R, Rennollet H. et al. Ambulatory follow-up of aortic dissection by transesophageal two-dimensional and color-coded Doppler echocardiography. Circulation 1989; 80 (01) 24-33
• 14 Erbel R, Oelert H, Meyer J. et al; The European Cooperative Study Group on Echocardiography. Effect of medical and surgical therapy on aortic dissection evaluated by transesophageal echocardiography. Implications for prognosis and therapy. Circulation 1993; 87 (05) 1604-1615
• 15 Mohr-Kahaly S, Erbel R, Kearney P, Puth M, Meyer J. Aortic intramural hemorrhage visualized by transesophageal echocardiography: findings and prognostic implications. J Am Coll Cardiol 1994; 23 (03) 658-664
• 16 Epperlein S, Mohr-Kahaly S, Erbel R, Kearney P, Meyer J. Aorta and aortic valve morphologies predisposing to aortic dissection. An in vivo assessment with transoesophageal echocardiography. Eur Heart J 1994; 15 (11) 1520-1527
• 17 Bartel T, Eggebrecht H, Müller S. et al. Comparison of diagnostic and therapeutic value of transesophageal echocardiography, intravascular ultrasonic imaging, and intraluminal phased-array imaging in aortic dissection with tear in the descending thoracic aorta (type B). Am J Cardiol 2007; 99 (02) 270-274
• 18 Weintraub AR, Erbel R, Görge G. et al. Intravascular ultrasound imaging in acute aortic dissection. J Am Coll Cardiol 1994; 24 (02) 495-503
• 19 Jánosi RA, Gorla R, Rogmann K. et al. Validation of intravascular ultrasound for measurement of aortic diameters: Comparison with multi-detector computed tomography. Minim Invasive Ther Allied Technol 2015; 24 (05) 289-295
• 20 Lortz J, Tsagakis K, Rammos C. et al. Intravascular ultrasound assisted sizing in thoracic endovascular aortic repair improves aortic remodeling in Type B aortic dissection. PLoS One 2018; 13 (04) e0196180
• 21 Lortz J, Tsagakis K, Rammos C. et al. Hemodynamic changes lead to alterations in aortic diameters and may challenge further stent graft sizing in acute aortic syndrome. J Thorac Dis 2018; 10 (06) 3482-3489
• 22 Rylski B, Muñoz C, Beyersdorf F. et al. How does descending aorta geometry change when it dissects?. Eur J Cardiothorac Surg 2018; 53 (04) 815-821
• 23 Kuehl H, Eggebrecht H, Boes T. et al. Detection of inflammation in patients with acute aortic syndrome: comparison of FDG-PET/CT imaging and serological markers of inflammation. Heart 2008; 94 (11) 1472-1477
• 24 Gorla R, Erbel R, Kuehl H. et al. Prognostic value of (18)F-fluorodeoxyglucose PET-CT imaging in acute aortic syndromes: comparison with serological biomarkers of inflammation. Int J Cardiovasc Imaging 2015; 31 (08) 1677-1685
• 25 Eggebrecht H, Naber CK, Bruch C. et al. Value of plasma fibrin D-dimers for detection of acute aortic dissection. J Am Coll Cardiol 2004; 44 (04) 804-809
• 26 Eggebrecht H, Mehta RH, Metozounve H. et al. Clinical implications of systemic inflammatory response syndrome following thoracic aortic stent-graft placement. J Endovasc Ther 2008; 15 (02) 135-143
• 27 Gorla R, Erbel R, Kahlert P. et al. Diagnostic role and prognostic implications of D-dimer in different classes of acute aortic syndromes. Eur Heart J Acute Cardiovasc Care 2017; 6 (05) 379-388
• 28 Gorla R, Erbel R, Kahlert P. et al. Accuracy of a diagnostic strategy combining aortic dissection detection risk score and D-dimer levels in patients with suspected acute aortic syndrome. Eur Heart J Acute Cardiovasc Care 2017; 6 (05) 371-378
• 29 Gorla R, Erbel R, Kahlert P. et al. Clinical features and prognostic value of stent-graft-induced post-implantation syndrome after thoracic endovascular aortic repair in patients with type B acute aortic syndromes. Eur J Cardiothorac Surg 2016; 49 (04) 1239-1247
• 30 Gorla R, Tsagakis K, Horacek M. et al. Impact of preoperative anemia and postoperative hemoglobin drop on the incidence of acute kidney injury and in-hospital mortality in patients with type B acute aortic syndromes undergoing thoracic endovascular aortic repair. Vasc Endovascular Surg 2017; 51 (03) 131-138
• 31 Erbel R. Transesophageal echocardiography. New window to coronary arteries and coronary blood flow. Circulation 1991; 83 (01) 339-341
• 32 Erbel R. Role of transesophageal echocardiography in dissection of the aorta and evaluation of degenerative aortic disease. Cardiol Clin 1993; 11 (03) 461-473
• 33 Jánosi RA, Buck T, Erbel R. Mechanism of coronary malperfusion due to type-a aortic dissection. Herz 2009; 34 (06) 478
• 34 Jánosi RA, Erbel R. A better echocardiographic view to aortic dissection. Eur Heart J 2010; 31 (04) 398-400
• 35 Erbel R. Diseases of the thoracic aorta. Heart 2001; 86 (02) 227-234
• 36 Lortz J, Papathanasiou M, Rammos C. et al. High intimal flap mobility assessed by intravascular ultrasound is associated with better short-term results after TEVAR in chronic aortic dissection. Sci Rep 2019; 9 (01) 7267
• 37 Bartel T, Konorza T, Arjumand J. et al. Intracardiac echocardiography is superior to conventional monitoring for guiding device closure of interatrial communications. Circulation 2003; 107 (06) 795-797
• 38 Görge G, Ge J, Haude M. et al. Intravascular ultrasound for evaluation of coronary arteries. Herz 1996; 21 (02) 78-89
• 39 Eggebrecht H, Baumgart D, Herold U. et al. Interventional management of aortic dissection. Herz 2002; 27 (06) 539-547
• 40 Bartel T, Eggebrecht H, Erbel R. Safe biopsy of aortic masses guided by intraluminal two dimensional ultrasonography. Heart 2004; 90 (09) 974
• 41 Nienaber CA, Spielmann RP, von Kodolitsch Y. et al. Diagnosis of thoracic aortic dissection. Magnetic resonance imaging versus transesophageal echocardiography. Circulation 1992; 85 (02) 434-447
• 42 Nienaber CA, von Kodolitsch Y, Nicolas V. et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993; 328 (01) 1-9
• 43 Just M, Mohr-Kahaly S, Kreitner KF. et al. [Magnetic resonance tomography of chronic aortic dissection] (in German). RoFo Fortschr Geb Rontgenstr Nuklearmed 1993; 158 (02) 109-114
• 44 Nienaber CA, von Kodolitsch Y, Petersen B. et al. Intramural hemorrhage of the thoracic aorta. Diagnostic and therapeutic implications. Circulation 1995; 92 (06) 1465-1472
• 45 Kodolitsch Y, Spielmann RP, Petersen B. et al. [Intramural hemorrhage of the thoracic aorta as a precursor of dissection] (in German). Z Kardiol 1995; 84 (11) 939-946
• 46 Krukenberg E. Beitrage zu frage des aneurysma dissecans. Beitr Pathol Anat Allg Pathol 1920; 67: 329-351
• 47 Gore I. Pathogenesis of dissecting aneurysm of the aorta. AMA Arch Pathol 1952; 53 (02) 142-153
• 48 Yamada T, Tada S, Harada J. Aortic dissection without intimal rupture: diagnosis with MR imaging and CT. Radiology 1988; 168 (02) 347-352
• 49 Eggebrecht H, Kühl H, Kaiser GM. et al. Feasibility of real-time magnetic resonance-guided stent-graft placement in a swine model of descending aortic dissection. Eur Heart J 2006; 27 (05) 613-620
• 50 Rogers AM, Hermann LK, Booher AM. et al; IRAD Investigators. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation 2011; 123 (20) 2213-2218
• 51 Nazerian P, Mueller C, Soeiro AM. et al; ADvISED Investigators. ADvISED Investigators. diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED prospective multicenter study. Circulation 2018; 137 (03) 250-258