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Degenerative ascending aortic aneurysm (AscAA) is a silent and potentially fatal disease characterized by excessive vascular inflammation and fibrosis. We aimed to characterize the cellular and molecular signature for the fibrotic type of endothelial mesenchymal transition (EndMT) that has previously been described in degenerative AscAA. Patients undergoing elective open-heart surgery for AscAA and/or aortic valve repair were recruited. Gene expression in the intima-media of the ascending aorta was measured in 22 patients with non-dilated and 24 with dilated aortas, and candidate genes were identified. Protein expression was assessed using immunohistochemistry. Interacting distal gene enhancer regions were identified using targeted chromosome conformation capture (HiCap) in untreated and LPS-treated THP1 cells, and the associated transcription factors were analyzed. Differential expression analysis identified SPP1 (osteopontin) as a key gene in the signature of fibrotic EndMT in patients with degenerative AscAA. The aortic intima-media expression of SPP1 correlated with the expression of inflammatory markers, the level of macrophage infiltration, and the aortic diameter. HiCap analysis, followed by transcription factor binding analysis, identified ETS1 as a potential regulator of SPP1 expression under inflammatory conditions. In conclusion, the present findings suggest that SPP1 may be involved in the development of the degenerative type of AscAA.Key messagesIn the original manuscript titled “SPP1/osteopontin, a driver of fibrosis and inflammation in degenerative ascending aortic aneurysm?” by David Freiholtz, Otto Bergman, Saliendra Pradhananga, Karin Lång, Flore-Anne Poujade, Carl Granath, Christian Olsson, Anders Franco-Cereceda, Pelin Sahlén, Per Eriksson, and Hanna M Björck, we present novel findings on regulatory factors on osteopontin (SPP1) expression in immune cells involved in degenerative ascending aortic aneurysms (AscAA).The central findings convey:SPP1 is a potential driver of the fibrotic endothelial-to-mesenchymal transition in AscAA.SPP1/osteopontin expression in AscAA is predominately by immune cells.ETS1 is a regulatory transcription factor of SPP1 expression in AscAA immune cells.

Aortic root dilatation has been proposed as hypertension-mediated organ damage (HMOD). Nevertheless, the role of the aortic root dilatation as a possible additional HMOD is still unclear since studies conducted so far are quite heterogeneous regarding the type of population analyzed, the aortic tract considered, and the type of outcomes accounted for. The aim of the present study is to assess whether the presence of aortic dilatation is associated with strong cardiovascular (CV) events (MACE: heart failure, CV death, stroke, acute coronary syndrome, myocardial revascularization) in a population of patients affected by essential hypertension. Four hundred forty-five hypertensive patients from six Italian hospitals were recruited as part of ARGO-SIIA study1. For all centers, follow-up was obtained by re-contacting all patients by telephone and through the hospital's computer system. Aortic dilatation (AAD) was defined through absolute sex-specific thresholds as in previous studies (41 mm for males, 36 mm for females). Median follow-up was 60 months. AAD was found to be associated with the occurrence of MACE (HR = 4.07 [1.81-9.17], p < 0.001). This result was confirmed after correction for main demographic characteristics such as age, sex and BSA (HR = 2.91 [1.18-7.17], p = 0.020). At penalized Cox regression, age, left atrial dilatation, left ventricular hypertrophy and AAD were identified as best predictor of MACEs and AAD resulted a significant predictor of MACEs even after correction for these confounders (HR = 2.43 [1.02-5.78], p = 0.045). The presence of AAD was found to be associated with an increased risk of MACE independently of for major confounders, including established HMODs. AAD ascending aorta dilatation, LAe left atrial enlargement, LVH left ventricular hypertrophy, MACEs major adverse cardiovascular events, SIIA Società Italiana dell'Ipertensione Arteriosa (Italian Society for Arterial Hypertension).

Accurate rupture risk assessment of ascending aortic aneurysms is important for reducing aneurysm-related mortality. More recently, computational models have been shown to better predict rupture risk than diameter-based measurements. However, it remains unclear whether finite element (FE) models of the ascending aorta can predict rupture location, and over what timeframe those predictions are reliable. The aim of this study was to evaluate FE models of the ascending aorta generated from computed tomography (CT) scans in predicting rupture location. Pre- and post-rupture CT scans were obtained of 12 patients who underwent emergency surgical repair for ascending aorta rupture with varying time intervals between scans (20 days – 6 years). A rigid iterative closest point (ICP) registration was used to overlay post-rupture aortic geometries with pre-rupture FE models and directly compare predicted regions of high equivalent strain with actual rupture. The FE model predicted the rupture location in the 5 patients with the shortest time intervals between the pre- and post-rupture scans (20 days – 2 years, 3 months). However, rupture location was not predicted in the 4/5 patients with greater than 3 years between scans. Achieving a physiological equivalent strain distribution in the FE model was highly dependent on the resolution of the pre-rupture scan and whether contrast agent was present. The results suggest there may be a time interval beyond which FE predictions of rupture location may not be reliable. The results in this study may help clinical validation of FE models of ascending aortic aneurysms predicting rupture risk.

We report the case of an incidental finding of a giant aneurysm of the ascending aorta with a congenital bicuspid aortic valve type 0-lateral. This severe condition was totally unknown to the patient, who was asymptomatic for cardiovascular disease. The aneurysmal mass involved the entire mediastinum, altering the normal atomical relations, so the operative strategy was modified intraoperatively, tailoring the surgical technique to the atomical conditions found. Despite a delayed awakening, the patient had an uncomplicated postoperative course. Therefore, this case highlights the importance of not underestimating nonspecific, seemingly harmless symptoms and signs that may reveal potentially catastrophic pathologies while also focusing on the surgical technique used. The modified Cabrol procedure, while an underutilized technique, if present in the cardiac surgeon’s “arsel” can represent a life-saving strategy in complex cases requiring an aortic valve and ascending aorta replacement.

Type A aortic dissections are pathologies with high mortality rates. Although ascending aortic aneurysms are typically planned for elective surgery, they are significant conditions in cardiovascular surgery due to their potential to cause type A aortic dissection. This study, which is the first to examine sirtuin 1 (SIRT1) in human ascending aortic tissues, aims to elucidate the relationship between ascending aortic pathologies and the SIRT1 protein. A case-control study was conducted using aortic tissues and demographic data from patients who underwent surgery for ascending aortic aneurysm and type A aortic dissection. Coronary artery bypass patients were selected as the control group. The groups were compared in terms of SIRT1 levels. The study included a total of 46 patients (16 in the aneurysm group, 14 in the dissection group, and 16 in the control group). The SIRT1 protein level was the highest in the ascending aortic aneurysm group (214, interquartile range [IQR] 79 - 270), followed by the dissection group (172, IQR 148 - 224), and the lowest in the control group (104, IQR 78 - 123) (P = 0.014). SIRT1 level was found to be low in patients with coronary artery disease (P = 0.001), peripheral artery disease (P = 0.008), and hypertension (P = 0.023). Type A aortic dissections are associated with elevated SIRT1 levels in the tissue. Systemic atherosclerotic diseases, such as coronary and peripheral artery diseases, are associated with decreased SIRT1 levels. There is also a relationship between hypertension and sirtuin1 levels.

The relationship between exposure to famine in early life and the risk of ascending aorta dilatation (AAD) in adulthood is still unclear; therefore, we aimed to examine the association in the Chinese population. We investigated the data of 2598 adults who were born between 1952 and 1964 in Guangdong, China. All enrolled subjects were categorised into five groups: not exposed to famine, exposed during fetal period, and exposed during early, mid or late childhood. AAD was assessed by cardiac ultrasound. Multivariate logistic regression and interaction tests were performed to estimate the OR and CI on the association between famine exposure and AAD. There were 2598 (943 male, mean age 58·3 ± 3·68 years) participants were enrolled, and 270 (10·4 %) subjects with AAD. We found that famine exposure (OR = 2·266, 95 % CI 1·477, 3·477, P = 0·013) was associated with elevated AAD after adjusting for multiple confounders. In addition, compared with the non-exposed group, the adjusted OR for famine exposure during fetal period, early, mid or late childhood were 1·374 (95 % CI 0·794, 2·364, P = 0·251), 1·976 (95 % CI 1·243, 3·181, P = 0·004), 1·929 (95 % CI 1·237, 3·058, P = 0·004) and 2·227 (95 % CI 1·433, 3·524, P < 0·001), respectively. Subgroup analysis showed that the effect of famine exposure on the association with AAD was more pronounced in female, current smokers, people with BMI ≥ 24 kg/m2 and hypertensive patients. We observed that exposure to famine during early life was linked to AAD in adulthood.

Acute type A aortic dissection (AADA) is a life-threatening cardiovascular emergency whose prognosis is closely linked to the timeliness of diagnosis and treatment. However, its low incidence and highly variable clinical presentation make early recognition challenging. In addition, poor therapeutic adherence and inadequate surveillance of predisposing factors, including hypertension and aortic aneurysm, contribute to diagnostic delays and worse clinical outcomes. A retrospective observational analysis was conducted using real-world administrative data from Italian healthcare facilities covering over 12 million individuals (2010-2024). Adult patients urgently hospitalized for AADA (ICD-9-CM 441.01) were identified. Clinical profile, comorbidities, pharmacological treatments, diagnostic procedures, and the presence of hypertension - defined as the number of annual prescriptions ≥ 9 (a proxy for diagnosis) of antihypertensive drugs - were evaluated. A total of 1625 patients were included (mean age 67.3 ± 13.4 years; 65.6% male). Diabetes was reported in 8.5% of cases, cardiovascular disease in 21.2%, and ascending aortic aneurysm or ectasia in 6%. In the year preceding hospitalization, 65.8% of patients had at least one antihypertensive prescription, but only 35% showed evidence of continuous treatment. Diagnostic procedures were infrequent: echocardiography was performed in 12.3% of patients, cardiac computed tomography/magnetic resonance angiography in 1.8%, and 24-h ambulatory blood pressure monitoring in 2.4%. This real-world analysis highlights major gaps in the pre-hospital management of AADA in Italy, characterized by suboptimal blood pressure control, poor therapeutic adherence, and limited use of diagnostic imaging in at-risk patients. These findings underscore the need for structured prevention and surveillance strategies aimed at the early recognition of predisposing conditions and the optimization of integrated care for patients at risk of acute aortic dissection.

In this study, we assessed the dynamic segmental anatomy of the entire ascending aorta (AA), enabling the determination of a favorable proximal landing zone and appropriate aortic sizing for the most proximal thoracic endovascular aortic repair (TEVAR). Methods: Patients with a non-operated AA (diameter < 40 mm) underwent electrocardiogram-gated computed tomography angiography (ECG-CTA) of the entire AA in the systolic and diastolic phases. For each plane of each segment, the maximum and minimum diameters in the systole and diastole phases were recorded. The Wilcoxon signed-rank test was used to compare aortic size values. Results: A total of 100 patients were enrolled (53% male; median age 82.1 years; age range 76.8–85.1). Analysis of the dynamic plane dimensions of the AA during the cardiac cycle showed significantly higher systolic values than diastolic values (p < 0.001). Analysis of the proximal AA segment showed greater distal plane values than proximal plane values (p < 0.001), showing a reversed funnel form. At the mid-ascending segment, the dynamic values did not notably differ between the distal plane and the proximal segmental plane, demonstrating a cylindrical form. At the distal segment of the AA, the proximal plane values were larger than the distal segmental plane values (p < 0.001), thus generating a funnel form. Conclusions: The entire AA showed greater systolic than diastolic aortic dimensions throughout the cardiac cycle. The mid-ascending and distal-ascending segments showed favorable forms for TEVAR using a regular cylindrical endograft design. The most proximal segment of the AA showed a pronounced conical form; therefore, a specific endograft design should be considered.

Implanting sutureless aortic valves enables a reduction in surgical times and related complications. Nonetheless, their application has been limited in cases involving aortic aneurysms due to anchor system concerns. We present a case of aortic valve replacement using a Perceval™ sutureless aortic valve in a patient with stage IV chronic kidney disease, an ascending aortic aneurysm, and a porcelain aorta. The procedure was performed concomitantly with coronary artery bypass grafting involving two grafts, as well as ascending aorta and hemiarch replacement. This case underscores the critical importance of time efficiency, technical modifications for valve implantation, and strategic surgical planning to mitigate potential intraoperative and postoperative complications.

Background The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm rupture. Case presentation We present some aspects of the anesthetic management of two parturients with ascending aortic aneurysm for cesarean sections; amongst, the use of remifentanil with its effects on patient and newborn. We emphasize the importance of a cardio-obstetric team in the context of preoperative planning of such patients. Also, we reviewed some literature on the anesthetic management with its effect on peri-operative hemodynamic stability. Conclusion Maintaining hemodynamic stability is paramount in the prevention of the rupture or dissection of ascending aortic aneurysm during labor of parturient.