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Objective:To introduce a new method of root reconstruction for proximal repair of acute type A aortic dissection, and to retrospectively analyze its short-term efficacy.Methods:From January 2018 to October 2019, a total of 455 patients with acute Stanford type A aortic dissection received surgical treatment. Among them, 343 patients underwent double-jacket-wrapping(DJW) root reinforcement(11 patients underwent leaflet suspension), 81 patients underwent Bentall surgery, 15 Wheat operations, 12 untreated roots, and 4 David operations. Compared 343 patients who underwent double-jacket-wrapping root reconstruction and 81 patients who underwent Bentall surgery. The perioperative indicators and short-term survival of the two groups were compared.Results:No patients died intraoperatively. The 30-day mortality rate in the DJW group and the Bentall group were 10.5% and 7.4%, respectively( P=0.403); cardiopulmonary bypass time were(218.8±68.4) min and(240.2 ± 59.8), P=0.011; aortic clamp time were(150.6 ± 47.9) min and(181.3 ±45.6)min, P=0.000. There was no difference between the operation time and the deep hypothermia circulatory time between the two groups. The mean follow-up was(11.7±6.4) months. Seven and two follow-up deaths occurred in the DJW group and the Bentall group, respectively, and the cause of death was not related to the aortic root. The degree of aortic regurgitation after DJW was 0.7±0.5, which was significantly lower than that before surgery( P=0.000). Conclusion:Compared with Bentall surgery, DJW method is a safe and effective method for the repair of acute type A aortic dissection roots, which can obtain good perioperative and early curative effects.
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This paper analyzed the current status of standardized training for specialists in China using American "milestone concept" and its competency training and assessment system for specialists as references. To achieve the goal of training high-standard and homogeneous cardiothoracic surgeons, a "milestone plan" focusing on the cultivation of diagnosis and treatment capacity of specialists, their mastery ability of medical knowledge, communication ability, professional ability, system-based clinical practice ability, practice-based learning ability and the ability of pursuing improvement was explored. In addition, daily assessment and summary assessment were carried out by means of self-evaluation, superior evaluation and peer evaluation. At the end, training of six core competencies and multi-dimensional evaluation system for cardiothoracic surgeons were constructed, which provided significant references to the construction of training and assessment system for specialists in China.
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Objective To summarize the surgical treatment strategy of acute Stanford A aortic dissection with coronary malperfusion.Methods From January 2010 to November 2015,307 patients of acute Stanford A aortic dissection underwent operation were included.The mean age was (51.3 ± 13.0) years,ranged from 22 to 83.The BMI was (25.4 ± 3.7) kg/m2 and 239 (77.9％) were men.There were 210 (71.2％) with hypertension,9 (2.9％) with Marian syndrome,and 44 (14.3％) with cardiac tamponade.Coronary malperfusion was confirmed in 43(14.0％) patients with 34 in right coronary artery,5 in left coronary artery,and 4 in both.There were 26 type A,8 type B,9 type C in Neri system.We performed coronary ostia repair in 12 patients,Bentall in 16,coronary artery bypass grafting(CABG) in 9,and Bentall plus CABG in 6.CABG was also performed in 1 Bentall,1 aortic valve repair,and 5 ascending aorta replacement in 264 patients without coronary malperfusion.Results The rate of CABG,cardiopulmonary bypass(CPB) time,aorta cross-clamp time were significantly higher in patients with coronary malperfusion(P ＜0.01).The in-hospital mortality was 32.6％ in patients with coronary malperfusion and 14.4％ in patients without coronary malperfusion.Thus,coronary malperfusion significantly increased in-hospital mortality(P ＜0.01).The mean follow-up time was(19.2 ± 18.0) months with a 95％ follow-up rate.The total follow-up survival rate is 97.5％ and the rate of patients with coronary malperfusion is 100％.Multivariate logistic regression analysis shows that cardiac tamponade(OR =4.8,P ＜0.01) and CPB time(OR =1.0,P ＜0.01) was the independent risk factor of post-operation inhospital mortality of acute Stanford A aortic dissection.Conclusion Acute Stanford A aortic dissection with coronary malperfusion has a significantly high in-hospital mortality with the indeed need of revascularization of coronary arteries rapidly.The treatment strategy depends on the specific clinical condition.
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Objective@#To explore the plasma chemokines expressions and related clinical implication in patients with Stanford type A aortic dissection (AD).@*Methods@#We retrospectively analyzed the data of 65 patients with Stanford type A aortic dissection, hypertensive patients and 11 healthy subjects admitted in our department from October 2013 to December 2014, they were divided into four groups: NH-CON group (11 healthy subjects), H-AD group (29 AD patients with hypertension), NH-AD group (21 AD patients without hypertension), and H-CON group (14 hypertension patients). Four plasma samples from AD patients and 4 plasma samples from healthy subjects were collected randomly with random numbers table, and the levels of different chemokines were examined by protein array analysis. Then, plasma levels of chemokines including macrophage inflammatory protein 1β(MIP-1β), epithelial neutrophil activating peptide 78(ENA-78), interleukin 16(IL-16), interferon inducible protein 10(IP-10) and FMS-like tyrosine kinase 3(Flt-3) ligand were analyzed by luminex. Pearson analysis was used to determine the correlations between the chemokines and serum C reactive protein (CRP) levels.@*Results@#Plasma levels of MIP-1β(34.0(29.3, 47.2) ng/L vs. 51.0(28.2, 80.7) ng/L, P<0.05) and ENA-78(110.5(59.1, 161.4) ng/L vs. 475.7(299.3, 837.3) ng/L, P<0.05) were significantly lower in H-AD group, while plasma IL-16 level was significantly higher in H-AD group(54.7(16.3, 187.8) ng/L vs. 17.5(11.9, 20.8) ng/L, P<0.05) than in H-CON group. Plasma levels of MIP-1β(48.3(26.4, 62.1) ng/L, P<0.05) were significantly lower in H-AD patients than in NH-AD patients. Plasma level of ENA-78 was significantly lower in NH-AD group than in NH-CON group (95.0(58.0, 155.0) ng/L vs. 257.7(85.2, 397.8) ng/L, P<0.05). The levels of IP-10 and Flt-3 ligand were similar among the 4 groups (all P>0.05). Pearson analysis showed that there were no correlation between MIP-1β(r2=0.01, P>0.05), ENA-78(r2=0.02, P>0.05), IL-16(r2=0.02, P>0.05), IP-10(r2=0.00, P>0.05), Flt-3 ligand(r2=0.02, P>0.05) and CRP levels in patients with Stanford type A aortic dissection.@*Conclusions@#Lower plasma levels of MIP-1β and ENA-78 and higher plasma levels of IL-16 may associate with the occurrence and development of type A aortic dissection, but their concentrations are not correlated with serum CRP levels. There is no significant change on plasma levels of IP-10 and Flt-3 in the Stanford type A aortic dissection patients.
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Objective@#To discuss the perioperative and follow-up results of different surgical methods for acute Stanford type A aortic dissection patients and analyzed the results.@*Methods@#The clinic data of 351 acute Stanford type A aortic dissection patients received surgical therapy at Department of Thoracic and Cardiovascular Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital from January 2008 to December 2015 were analyzed retrospectively. There were 272 male and 79 female patients, aging from 22 to 83 years with a mean age of (52±13) years. According to root size, aortic valve structure and the status of dissection involvement, these patients were devided into three major groups: 218 cases with root reconstruction using Dacron felts, 34 cases with root reconstruction concomitant with aortic valve resuspension repair and 99 cases in with Bentall procedure. Proper shape based on the status of dissection involvement of Dacron patch was cut and put between the middle and outerlayer of aorta, then inside the inner layerone band Dacron felt was sutured with the aorta and the new middle layer with Dacron patch as mentioned above. In some cases the prolapsed aortic valve was re-suspended to the aortic cusp. Clinical outcomes among the 3 procedures were compared by χ2 test, Fisher′s exact test, t test and analysis of variance.@*Results@#Cardiopulmonary bypass, cross-clamp, and circulatory arrest times of all the patients were (250±78), (171±70) and (31±10) minutes, respectively. The 30-day mortality was 9.2%(33/351), while no difference among the 3 procedures (9.6%, 8.8% and 9.1%). In the average follow-up time of (26.0±23.0) months (range from 0.5 to 90.0 months), survival rates were similar among the 3 procedures (77.7%, 77.4% and 77.8%). Only one patient received redo Bentall procedure because of severe aortic regurgitation and dilated aortic root (diameter of 50 mm).@*Conclusions@#The indication of root management of acute Stanford type A aortic dissection is based on the diameter of aortic root, structure of aortic leaflets, and the dissection involvement. For most acute Stanford type A aortic dissection patients, aortic root reconstruction is a feasible and safe method.
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Objective To explore the plasma expressions of monocyte chemotaxis proteins(MCPs) in patients with type A aortic dissection and their clinical significance.Methods 51 patients with type A aortic dissection were enrolled,in which 29 combined with hypertension.Fourteen hypertension patients and 1 1 hcalthy subjects were enrolled as control.Plasma samples were collected and we examined the levels of MCP-1,MCP-2 and MCP-4 by enzyme linked immunosorbent assay (ELISA).Results Plasma levels of MCP-1 and MCP-2 significantly decreased in patients with type A aortic dissection compared to healthy subjects(P ＜0.001),while MCP-4 had no change.Type A aortic dissection patients with or without hypertension both showed significant decreased plasma MCP-1 and MCP-2 levels compared to hypertension patients(P ＜0.001).There was no change of MCP-4 among different groups.Furthermore,Spearman correlation analysis showed that there was no correlation between serum CRP levels and plasma MCP-1,MCP-2 concentrations.Conclusion Plasma MCP-1 and MCP-2 may participate in the pathogenesis of type A aortic dissection,and their concentrations were not correlated with hypertension or serum CRP levels.The detailed mechanism needs further observations.
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Objective To analyze the early outcomes of the Sun' s procedure,which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta,and observe the mortality,morbidity and mid-term clinical results of postoperative in patients with acute type A aortic dissection (AAAD).Methods Clinical data of 61 consecutive AAAD patients undergoing the Sun' s procedure were analyzed.There were 53 male and 8 female,aged (54 ± 12) years.61 patients had postoperative follow-up and the clinical effect of Sun' s procedure were retrospectively analyzed.Results Cardiopulmonary bypass time was (229 ± 46) min,aortic clamping time was (147 ± 37) min and unilateral selective cerebral perfusion time was (35 ± 9) min.Reoperation for excessive bleeding in 5 cases (8.2％),acute renal failure in 3(4.9％),tracheotomy patients for pulmonary infection in 3(4.9％),and spinal cord injury in 2 (3.3％),delayed thoracic incision healing in 1 (1.6％),and osteofascial compartment syndrome of the right lower limb in 1 (1.6％).The 30 day mortality is 8.2％,and the leading causes was low cardiac output syndrome in 2(3.3％),multi-organ failure in 1 (1.6％),pulmonary infection in 1 (1.6％) and ruptured of abdominal aortic dissection in 1 (1.6％).The average follow-up time is(5.1 ± 0.7) years.Postoperative 1 year survival rate was 91.8％,5 year survival rate was 83.6％.Conclusion The Sun' s procedure has generated a relatively lower mortality rate in 61 patients with AAAD.Postoperative survival rate is high,and the reoperation rate is low.
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Objective To investigate the differences in clinical symptoms and risk factors between non-elderly and elderly patients with acute pulmonary thromboembolism(PTE).Methods Totally141 patients with acute PTE and 100 sex and age-matched healthy controls were enrolled in the study.The final diagnosis was confirmed by CT pulmonary angiography (CTPA) and/or pulmonary angiography and/or pulmonary perfusion imaging as well as medical history.The patients with acute PTE were divided into two groups according age:elderly group (n=78,age≥60 years),young group (n =63,age ＜ 60 years).Multivariate Logistic regression analysis was performed to identify independent risk factors of PTE and to confirm the risk of each factor.Results The morbidity rate of dyspnea,cough,chest distress and chest pain were 88.5％ (69 cases),76.9％ (60 cases),56.4％ (44 cases),15.4％ (12 cases) in elderly group,which was similar to 84.1％ (53 cases),69.8％ (44 cases),63.5％ (40 cases),25.4％ (16 cases) in young group (all P＞0.05)； while the morbidity rate of hemoptysis in elderly group [9.0％ (7 cases)] was lower than in young group [23.8％(15 cases)](P＜0.05).9％ (7 cases) in elderly patients without any symptoms were more than 1.6％ (1 cases) in young patients,but no significant differene (P＞0.05).There were more risk factors in the elderly group accompanying with diabetes (x2 =7.41,P ＜ 0.01),hypertension (x2 =14.51,P＜ 0.01),chronic obstructive pulmonary diseases (COPD) (x2 =7.42,P＜0.01) and previous stroke (x2 =4.91,P＜0.05)compared with young group.Independent risk factors for elderly acute PTE included COPD (OR:3.29,95％CI:1.04-10.46),previous deep veneus thrombosis(DVT) (OR:4.72,95％CI:1.68-13.27),cancers (OR:4.35,95％CI:1.00-18.13) and previous stroke (OR:5.13,95％CI:1.15-24.52).Independent risk factors for non-elderly PTE included previous DVT (OR:11.94,95％ CI:3.35-42.60)and cancers (OR:11.44,95％CI:1.44-89.92).Conclusions Much attention should be paid to the identification of diagnosis of acute PTE depending on the non-specific clinical features,although dyspnea may be the most frequency symptoms,but unexplained cough and chest distress should be alert for PTE.COPD,cancer,DVT and previous stroke are independent and important risk factors for elderly acute PTE.