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In this study, children and young adults with Marfan's syndrome were randomly assigned to receive atenolol or losartan and were followed for 3 years. There was no significant difference between the two groups in the rate of aortic-root dilatation. Marfan's syndrome is an autosomal dominant disorder of connective tissue affecting approximately 1 in 5000 people. 1 Cardiovascular disease, mainly progressive aortic-root dilatation and dissection, is the leading cause of death in Marfan's syndrome. After an open-label, randomized trial comparing propranolol with no therapy, published in 1994, showed a reduced rate of aortic enlargement among treated patients, beta-adrenergic receptor antagonists (beta-blockers) became the mainstay of medical management. 2 Current management includes serial cardiac imaging, exercise restriction, administration of beta-blockers, and elective aortic-root replacement. 3 Although early diagnosis and refined medical and surgical treatment have improved survival, patients with Marfan's syndrome continue to have . . .

This randomized controlled trial was aimed to compare 1-year morphologic changes of the no-touch saphenous vein graft as Y-composite (Composite group) versus aortocoronary (Aorta group) configurations in coronary artery bypass grafting. The primary endpoint was intima-media thickness of the saphenous vein graft as measured by intravascular ultrasound (IVUS) at the 1-year angiographic evaluation. Recruitment of 25 patients in each group was necessary based on a superiority design. Among the 50 patients, IVUS data were obtained in 22 and 24 patients from the Composite and Aorta groups, respectively. Mean age was 64.8 ± 9.2 years, and the proportion of females was 20.0%. The numbers of distal anastomoses per saphenous vein graft were 2.7 ± 1.1 and 2.6 ± 0.8 in the Composite and Aorta groups, respectively. The intima-media thickness of the saphenous vein graft 1 year after surgery were 0.25 ± 0.04 mm and 0.24 ± 0.06 mm in the Composite and Aorta groups, respectively (P for superiority = .99). Other IVUS parameters of saphenous vein grafts, including vessel diameter, luminal diameter, and the ratio of intima-media thickness to vessel diameter, also demonstrated no differences between the groups. No neointimal hyperplasia or plaque formation was detected using IVUS. All study patients underwent 1-year angiographic evaluation, and the patency rates were 94.7%(89 out of 94 anastomoses) and 100.0%(90 out of 90 anastomoses) in the Composite and Aorta groups, respectively. The intima-media thickness of the saphenous vein graft 1 year after surgery demonstrated no significant difference between the Y-composite and aortocoronary configurations (NCT04782492). Trial Registration: ClinicalTrials.gov NCT04782492.

Background Self-expandable valves (SEVs) and balloon-expandable valves (BEVs) are the most widely used transcatheter heart valves. In patients with ascending aortic dilation (AAD) who undergo transcatheter aortic valve replacement (TAVR), comparison of two type of valves is lacking. Methods The AAD-CHOICE trial is a multi-center, randomized controlled, open-label study. The trial will randomly assign 100 patients with AAD (ascending aortic diameter ≥ 45 mm) who undergo TAVR in 1:1 ratio to either SEV group or BEV group. Participants will be followed for a minimum of 1 year. The primary end point is device success, 30-day all-cause mortality and 30-day adverse aortic events. The key secondary end point is 1-year all-cause mortality, 1-year cardiovascular mortality, adverse aortic events, major adverse cardiovascular and cerebrovascular events, and aortic expansion rate ≥ 3 mm/year. Discussion The study will provide evidence regarding the performance of SEVs and BEVs in patients with AAD who undergo TAVR. Trial registration ClinicalTrials.gov NCT06009588. Registered on August 12, 2023.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method to provide temporary control of noncompressible torso hemorrhage in trauma patients. Previous research on REBOA has mainly focused on animals and patients. This study aims to explore whether thigh cuff inflation combined with simulated hemorrhage can serve as an experimental human model for zone 3 REBOA. Lower body negative pressure is a model of hypovolemia. A zone 3 REBOA occludes aorta at its bifurcation, essentially excluding the pelvis and lower extremities from the circulation. Bilateral proximal thigh cuffs will occlude blood vessels to and from the lower extremities. Twenty healthy volunteers will be exposed to bilateral proximal thigh cuff inflation to suprasystolic pressures to simulate the hemodynamic effects of REBOA during experimental hemorrhage using lower body negative pressure (LBNP). Each participant will complete two experimental conditions in a randomized order within one study visit. In the one condition, subjects will undergo only 60 mmHg LBNP for six minutes. In the alternate condition, 60 mmHg LBNP will be applied for six minutes, adding thigh cuff inflation during the final three minutes. Continuous, non-invasive monitoring of systemic hemodynamic parameters—including arterial blood pressure, stroke volume, and heart rate—will be conducted. Cerebral hemodynamics will be assessed by measuring middle cerebral artery blood velocity and cerebral oxygenation. Pain related to thigh cuff inflation will be assessed using a verbal numerical rating scale. The impact of thigh cuff inflation on systemic and cerebral hemodynamics will be evaluated using mixed-effects regression modeling. This study aims to examine the systemic and cerebral hemodynamic effects of combined thigh cuff inflation and lower body negative pressure in healthy volunteers. Based on the feasibility and findings, the potential of this combination as a model for zone 3 REBOA in simulated hemorrhage will be discussed.

Following surgical repair of acute type A aortic dissection(ATAAD), distal aortic degeneration and growth may occur. Previous evidence has suggested that false lumen(FL) communications and flow may influence postoperative aortic remodeling, although the contribution of branch vessel dissection and FL communications is unclear. Patients who underwent ATAAD repair from 2017 to 2023 at a single center with at least 1 year of follow-up imaging were included in this study. Patients were grouped based on aortic pathology and surgical repair. Preoperative and postoperative measurements were taken at the level of zone 1 and between zones 4/5. 63 patients were included in this study. 87.3% received a hemiarch repair, 34.9% received hemiarch + AMDS Hybrid prosthesis, and 12.7% received a total arch replacement. Proximal aortic remodeling was not reliably predicted by the presence of FL communications or surgical approach. Distal aortic growth was independently associated with ≥ 3 or 4 visceral vessel dissections( p  = 0.04 − 0.005). In conclusion, distal aortic remodeling following ATAAD repair was predicted by visceral vessel involvement. While the aortic arch is often emphasized at the time of ATAAD repair, features of the distal aorta may help to risk stratify patients for long-term adverse events, helping to guide initial management and post-ATAAD repair follow-up.

Background Aortic structural damage (ASD) may complicate the course of patients with giant cell arteritis (GCA). However the frequency and outcome of ASD has not been assessed in long term prospective studies. Methods In a previous screening of 54 biopsy proven GCA patients, significant ASD was detected in 12 (22.2%) after a median follow-up of 5.4 years. These patients were periodically evaluated (every 4 years) over a median of 10.3 years (range 4–16.6 years) in order to investigate the development of new ASD and the outcome of previously detected abnormalities. Results 18 of the 54 patients abandoned the study due to death or other reasons. The remaining 36 patients were subjected to a second screening and 14 to a third screening. 12 (33.3%) of the 36 patients re-screened and 16 (29.6%) of the initial cohort developed ASD, all but one in the thoracic aorta. Aortic diameters at the ascending and descending aorta significantly increased over time. One patient (1.9% of the initial cohort) died from aortic dissection. Surgery was advised in eight (50%) patients with ASD but could only be performed in three patients (37.7%). The development of ASD was not associated with persistence of detectable disease activity. Conclusions The incidence of ASD is maximal within the first 5 years after diagnosis but continues developing over time, affecting up to 33.3% of individuals after long term follow-up. Once ASD occurs, dilatation increases over time, underlining the need for periodic evaluation. Surgical repair is feasible in about one-third of candidates.

Repair of Abdominal Aortic Aneurysm This clinical trial compared endovascular with open repair of unruptured abdominal aortic aneurysm. An early survival advantage with endovascular repair was not sustained after 3 years. Aneurysm rupture remains a concern with this type of repair. Each year, 40,000 patients in the United States undergo elective procedures to repair abdominal aortic aneurysms. 1 These procedures result in about 1250 perioperative deaths — more than for any other general or vascular surgical procedure, with the exception of colectomy. 2 Endovascular repair was introduced in the 1990s as a less invasive method than traditional open repair. Randomized trials have shown that endovascular repair reduces perioperative mortality, 3 – 5 but in the United Kingdom Endovascular Aneurysm Repair 1 (EVAR 1) trial 3 and the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, 4 this advantage was lost within 2 years owing to excess late deaths . . .

A randomized, multicenter trial that compared endovascular repair with open repair of abdominal aortic aneurysm showed no significant difference between these approaches in overall survival after 8 years.

Cardiovascular surgery is often complicated by significant bleeding due to perioperative coagulopathy. The effectiveness of treatment with fibrinogen concentrate to reduce the perioperative blood transfusion rate after thoracic aortic replacement surgery in prior studies has shown conflicting results. Therefore, we conducted a double-blind randomized controlled trial to investigate if a single dose of intraoperative fibrinogen administration reduced blood loss and allogeneic transfusion rate after elective surgery for thoracic arch aneurysm with deep hypothermic circulatory arrest. Twenty patients were randomized to fibrinogen concentrate (N = 10) or placebo (N = 10). The recruitment of study patients was prematurely ended due to a low inclusion rate. Perioperative transfusion, 5-minute bleeding mass after study medication and postoperative blood loss were not different between the groups with fibrinogen concentrate or placebo. Due to small volumes of postoperative blood loss and premature study termination, a beneficial effect of fibrinogen concentrate on the number of blood transfusions could not be established. However, treatment with fibrinogen efficiently restored fibrinogen levels and clot strength to preoperative values with a more effective preserved postoperative thrombin generation capacity. This result might serve as a pilot for further multicenter studies to assess the prospective significance of automated and standardized thrombin generation as a routine assay for monitoring perioperative coagulopathy and its impact on short- and long-term operative results.

Background Haemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury. Methods Pragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective. Discussion This study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice. Trial registration ISRCTN16184981