False Lumen Flow Assessment and Outcomes in Aortic Dissection
Quick Takes
- In this single-center series of 131 patients discharged after aortic dissection, independent predictors of long-term aortic complications included type B dissection, initial aortic diameter ≥45 mm, and MRI flow pattern with high systolic entry flow and high diastolic reversal flow in the false lumen.
- Mean annual aortic diameter enlargement was greatest in patients with high entry flow and high diastolic reversal flow in the false lumen.
Study Questions:
In long-term follow-up after uncomplicated acute aortic dissection (AD), what are the prognostic implications of false lumen (FL) flow, as assessed by magnetic resonance imaging (MRI)?
Methods:
From 2000–2015, consecutive patients discharged after type A or type B AD were evaluated for inclusion in this single-center series. Notable exclusion criteria were age ≥80 years, total FL thrombosis, maximum aortic diameter ≥50 mm, and moderate to severe aortic regurgitation. All patients were followed clinically and with serial imaging, including computed tomographic angiography or MRI at 1-3 months after discharge and annually thereafter. The MRI protocol included three-dimensional angiography and blood flow volume quantification. Three different flow patterns were defined based on FL flow in systole and diastole. The composite clinical endpoint was elective aortic intervention, unexplained sudden death, or any acute aortic complication leading to surgical or endovascular treatment or death.
Results:
Of 334 consecutive patients discharged after AD, 131 patients (97 men, mean age 60.3 years, 78 with surgically treated type A AD, 53 with medically treated type B AD) were included in the series. During a median follow-up period of 8.0 years, 43 patients (32.8%) experienced AD-related events. In multivariable analysis, independent predictors of AD-related events were type B AD (hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.13-4.51), initial aortic diameter ≥45 mm (HR, 2.67; 95% CI, 1.38-5.19), and flow pattern III with high systolic entry flow and high diastolic reversal flow in the FL (HR, 33.46; 95% CI, 7.82-143.15). Mean annual aortic diameter enlargement was greatest in patients with flow pattern III (5.8 mm/year, as compared with <1 mm/year in others).
Conclusions:
FL flow pattern on MRI predicts long-term complications following AD, with a pattern of high systolic entry flow and high diastolic reversal flow conferring the greatest risk.
Perspective:
These results suggest that MRI with flow quantification can identify patients at highest risk of long-term complications following AD. Multicenter studies are needed to validate these findings and to determine whether patients with high systolic entry flow and high diastolic reversal flow in the FL can benefit from earlier intervention. MRI with flow quantification is not available in many centers, though aortic centers of excellence have multimodality imaging experts, and patients with AD should be referred for interdisciplinary care at these centers whenever possible.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Computed Tomography, Magnetic Resonance Imaging, Nuclear Imaging
Keywords: Aneurysm, Dissecting, Angiography, Computed Tomography Angiography, Aortic Valve Insufficiency, Cardiac Surgical Procedures, Death, Sudden, Diagnostic Imaging, Diastole, Dissection, Endovascular Procedures, Magnetic Resonance Imaging, Patient Discharge, Systole, Thrombosis, Vascular Diseases
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