Immunosuppression and Cardiac Function Improvement May Help Takayasu Arteritis Patients with Aortitis Avoid Cardiac Surgery

Immunosuppression and Cardiac Function Improvement May Help Takayasu Arteritis Patients with Aortitis Avoid Cardiac Surgery

Takayasu arteritis (TA) is a rare, chronic inflammatory disease that targets large blood vessels—most commonly the aorta, the body’s main artery. For patients with TA-related aortitis (inflammation of the aorta), the condition can damage the aortic root, valves, or ascending aorta, leading to life-threatening complications like heart failure, aortic stenosis, or aneurysms. While cardiac surgery is often necessary to treat these issues, new research from a team of Chinese rheumatologists and cardiologists suggests that early, targeted medical treatment may help some patients avoid surgery altogether.

What Is Takayasu Arteritis and Aortitis?

TA primarily affects women under 40, causing the immune system to attack the walls of large blood vessels. This creates granulomatous inflammation (a cluster of immune cells) that can narrow, weaken, or thicken vessels. When the aorta is inflamed (aortitis), it can spread to the aortic valve (causing leakage or stenosis) or the ascending aorta (leading to dilation or dissection). For many patients, this means facing cardiac surgery—like aortic valve replacement (AVR) or the Bentall procedure (which replaces the aortic root and valve)—to prevent rupture or heart failure.

The Study: Who Was Included and What Did It Measure?

Led by researchers from Zhongshan Hospital (Fudan University) and the East China Takayasu Arteritis (ECTA) Collaboration Group, the study analyzed data from 115 TA patients with confirmed aortitis. Participants were part of a prospective registry (an ongoing study that follows patients over time) started in 2009, with ethical approval from Zhongshan Hospital.

To be included, patients had:

• Imaging evidence (CT angiography, MRI, PET scans, or echocardiography) of aortitis;
• Intraoperative findings (e.g., vessel thickening, valve prolapse); or
• Biopsy results showing non-infectious inflammation in blood vessels or valves.

Patients with other conditions (atherosclerosis, infection, congenital heart disease) were excluded. The team tracked two key outcomes: primary cardiac surgery (first-time surgery for aortitis complications) and secondary surgery (reoperation, like for valve leakage or restenosis). They also measured disease activity (via the Kerr score) and cardiac function (via the New York Heart Association [NYHA] class—where Class I means no symptoms and Class IV means inability to do any activity without breathlessness).

Key Findings: Immunosuppression and Cardiac Function Matter Most

Over an average follow-up of 3.25 years (39 months), the team found:

• Most patients were active: 87.8% of participants had active TA at the start of the study, with 71.3% taking immunosuppressive medications (e.g., glucocorticoids alone or combined with drugs like hydroxychloroquine or cyclophosphamide).
• Meds improved outcomes: 57.4% of patients (66 total) achieved clinical remission (no new symptoms, normal inflammation markers like ESR/CRP, and low-dose glucocorticoids) and better cardiac function (NYHA Class I-II) with medication.
• Surgery risk linked to severe cardiac function: All patients who needed surgery had NYHA Class III-IV (severe heart impairment) at baseline—compared to just 28.8% of patients who avoided surgery.
• Immunosuppression reduced surgery risk: Patients who took immunosuppressants were 3x less likely to need surgery (odds ratio [OR] = 0.3) than those who did not. Notably, all patients who skipped meds needed surgery within 12 months.
• Post-op benefits: Patients who took meds before surgery had fewer reoperations. Of the 35 who had primary surgery, only 5 needed secondary surgery—all of whom had severe cardiac function (NYHA Class III-IV) at baseline.

Why This Matters for TA Patients and Doctors

For patients with active TA and aortitis, the study sends a clear message: early, adequate immunosuppression and improving cardiac function can prevent or delay surgery. Here’s what stands out:

• Severe cardiac function is a red flag: Patients with NYHA Class III-IV are 6.7x more likely to need surgery—so monitoring heart function closely is critical.
• Meds work quickly: The average time to remission with meds was 4.7 months, and meds delayed surgery by 11 months.
• Pre-op meds improve recovery: Patients who took immunosuppressants before surgery had better post-op outcomes, including fewer reoperations.

What’s Next?

The study builds on existing guidelines from the European League Against Rheumatism (EULAR), which recommend immunosuppression as first-line treatment for active large-vessel vasculitis like TA. For patients, it means that working closely with a rheumatologist to control inflammation before heart damage becomes severe could be life-changing. For doctors, it highlights the need to prioritize both disease activity and cardiac function when treating TA-related aortitis.

About the Researchers

The study was led by Xiao-Min Dai, Yu-Jiao Wang, and Lin-Di Jiang from the Department of Rheumatology at Zhongshan Hospital (Fudan University, Shanghai), with collaborators from Linyi People’s Hospital, Ruijin Hospital (Shanghai Jiaotong University), and Renji Hospital. It was published in the Chinese Medical Journal in 2021, with funding from the National Natural Science Foundation of China (No. 81771730).

Original Study Citation

Dai XM, Wang YJ, Zhang ZC, Yang CD, Wu R, Zhou ZY, Chen XX, Sun XN, Wang CS, Ma LL, Jiang LD, and the East China Takayasu Arteritis (ECTA) Collaboration Group. Immunosuppression medication and cardiac function improvement treatments might prevent Takayasu arteritis patients with aortitis from receiving cardiac surgery. Chinese Medical Journal 2021;134:625–627. doi:10.1097/CM9.0000000000001160

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