Wall stress analyses in patients with ≥5 cm versus &lt;5 cm ascending thoracic aortic aneurysm

Wang, Zhongjie; Flores, Nick; Lum, Matthew; Wisneski, Andrew D.; Xuan, Yue; Inman, Justin; Hope, Michael D.; Saloner, David; Guccione, Julius M.; Ge, Liang; Tseng, Elaine E.

doi:10.1016/j.jtcvs.2020.02.046

Cited by 34 publications

(24 citation statements)

References 28 publications

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“…In a previous editorial comment, 2 we stated that more modern methods than simple imaging, such as computational modeling and biomechanics, may provide important information regarding aneurysm geometry in general and The authors reported no conflicts of interest.…”

Section: Reply: Accurate Evaluation Of the Risk Of Acute Aortic Events: Still Room For Improvement Reply To The Editormentioning

confidence: 99%

“…Computational models to better assess the wall properties of the thoracic aorta and thus the individual risk assessment of a subsequent acute aortic syndrome (eg, intramural hematoma, aortic dissection) would be extremely welcome in daily clinical work. The article by Wang and colleagues, 1 the comment by Carrel and Schoenhoff, 2 and the letter to the editor by Ma and colleagues 3 clearly demonstrate not only the interest in, but also the importance of this field, given that inaccurate prediction may lead to an unexpected higher risk of acute aortic complications.…”

Section: Reply: Accurate Evaluation Of the Risk Of Acute Aortic Events: Still Room For Improvement Reply To The Editormentioning

confidence: 99%

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Reply: Novel aortic imaging modalities: Mine detectors or just metal detectors

Bakaeen

Roselli

Svensson

2020

The Journal of Thoracic and Cardiovascular Surgery

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1 about the potential limitations of the finite element analysis and 3-dimensional models derived from computed tomography angiography of the thoracic aorta used by Wang and colleagues 2 to measure wall stress. Indeed, unlike tricuspid aortic valves, bicuspid valves are associated with different hemodynamic parameters and thoracic aortic wall substrates that can influence wall stress and the associated clinical downstream consequences. In fact, the study by Wang and colleagues 2 made many assumptions, including identical aortic wall composition and thickness and physiologic pressures among allcomers. Although they used patient-derived imaging data in their modeling, as pointed out by Ma and colleagues, 1 it lacked validation and clinical correlation. Furthermore, fluid-structure interaction is critical to account for in an analysis of the aorta and the oscillatory forces within it. Nevertheless, it was an important contribution because it rightly challenged the disproportionate importance assigned to aortic diameter when it comes to making recommendations about timing of surgery. Smaller (<5 cm) thoracic aortas can experience substantial wall stress and this may explain aortic dissections in patients who do not meet the guidelines-based size criteria for intervention.With regard to biomechanical data derived from in vivo multimodality imaging, 1 the jury is still out on their specificity and predictive value when it comes to aortic dissection or rupture. Those modalities, although promising, are not yet ready for prime time because they need rigorous evaluation and actual risk calibration. With the expansion of computational power and associated advances in analysis of fluid-structure interaction, rapid modeling based on patient-specific data-including physiologic and anatomic details-is now feasible. As we mentioned before, 3 the goal of early and more accurate identification of patients who will benefit from preventative aortic replacement using precision medicine techniques will become a reality soon. In the meantime, there is no substitute for good surgical judgment and skill when deciding on the timing of prophylactic aortic surgery.

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Section: Reply: Accurate Evaluation Of the Risk Of Acute Aortic Events: Still Room For Improvement Reply To The Editormentioning

confidence: 99%

Section: Reply: Accurate Evaluation Of the Risk Of Acute Aortic Events: Still Room For Improvement Reply To The Editormentioning

confidence: 99%

Reply: Novel aortic imaging modalities: Mine detectors or just metal detectors

Bakaeen

Roselli

Svensson

2020

The Journal of Thoracic and Cardiovascular Surgery

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“…Wang and colleagues 1 are to be congratulated for their excellent article on wall stress analysis in ascending thoracic aortic aneurysms (TAAs), 1 which presents a valuable and promising contribution to understanding the biomechanics of TAA disease.…”

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confidence: 99%

Commentary: Do not “futz” with Laplace

Elefteriades

Sun

Ziganshin

2021

The Journal of Thoracic and Cardiovascular Surgery

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“…However, wall stress can be calculated with finite element analysis (FEA). In our article, we applied a practical method for screening patients with aTAA for operative repairaortic wall stress calculated through models integrating patient-specific anatomy with material property data gathered in ex vivo testing from aTAA specimens 2. We believe this approach can advance our ability to predict dissection and be applied at scale to the surge of newly diagnosed aTAAs in a streamlined, clinical approach.At the most basic level, diameter already screens patients on the basis of wall stress using Laplace's Law, which states that stress in the thin-walled cylinder is proportional to its diameter (Figure1).…”

mentioning

confidence: 99%

“…In our study, we examined the relationship of aneurysm diameter and FEA-calculated wall stress. Diameter correlated poorly with peak wall stress, which may explain why a large proportion of acute dissections occur in aneurysms that do not meet size guidelines for surgery-high stress occurred due to local geometry, not overall diameter 2. In the absence of aneurysm tissue, further improvements to stress calculation accuracy can be made through refinement of FEA models, which require zero-pressure geometry, wall material properties, wall thickness, and residual stress.…”

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confidence: 99%

Reply from authors: Aortic aneurysm biomechanics: Perfect is the enemy of good

Tseng

Wang

2020

The Journal of Thoracic and Cardiovascular Surgery

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The primary criterion used clinically to evaluate the risk of lifethreatening type A dissection is maximum ascending thoracic15370 aortic aneurysm (aTAA) diameter of 5.5 cm or greater. What this approach achieves in simplicity it lacks in accuracy-approximately 60% of patients with acute dissection had diameters less than 5.5 cm-and improved indicators for surgery are an unmet clinical need. 1 One paradigm is to use biomechanics-based risk stratification. Biomechanics dictate that dissection can occur when stress in the aortic wall exceeds its strength. Direct measurement of aortic wall strength requires destructive testing, merely estimated by surrogate markers.

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Wall stress analyses in patients with ≥5 cm versus <5 cm ascending thoracic aortic aneurysm

Cited by 34 publications

References 28 publications

Reply: Novel aortic imaging modalities: Mine detectors or just metal detectors

Reply: Novel aortic imaging modalities: Mine detectors or just metal detectors

Commentary: Do not “futz” with Laplace

Reply from authors: Aortic aneurysm biomechanics: Perfect is the enemy of good

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