Surgical strategy and clinical outcomes of reoperative aortic root replacement after prior aortic valve replacement / 中国胸心血管外科临床杂志

@#Objective    To summarize the surgical strategy of reoperative aortic root replacement after prior aortic valve replacement (AVR), and analyze the early and mid-term outcomes. Methods    From April 2013 to January 2020, 75 patients with prior AVR underwent reoperative aortic root replacement in Fuwai Hospital. There were 54 males and 21 females with a mean age of 56.4±12.7 years. An emergent operation was performed in 14 patients and an elective operation in 61 patients. The indications were aortic root aneurysm in 38 patients, aortic dissection involving aortic root in 30 patients, root false aneurysm in 2 patients, prosthesis valve endocarditis with root abscess in 2 patients, and Behçet's disease with root destruction in 3 patients. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test. Results    The operative procedures included prosthesis-sparing root replacement in 45 patients, Bentall procedure in 26 patients, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/75). A composite of adverse events occurred in 5 patients, including operative death (n=1), stroke (n=1), and acute renal injury necessitating hemodialysis (n=3). The follow-up was available for all 74 survivors, with the mean follow-up time of 0.5-92.0 (30.3±25.0) months. Four late deaths occurred during the follow-up. The survival rate at 1 year, 3 years and 6 years was 97.2%, 91.4% and 84.4%, respectively. Aortic events developed in 2 patients. The rate of freedom from aortic events at 1 year, 3 years, and 6 years was 98.7%, 95.0% and 87.7%, respectively. There was no difference in rate of survival or freedom from aortic events between the elective patients and the emergent patients. Conclusion    Reoperative aortic root replacement after prior AVR can be performed to treat the root pathologies after AVR, with acceptable early and mid-term outcomes.

Short-term outcomes of aortic root repair using a pericardial autograft for acute type A aortic dissection / 中华胸心血管外科杂志

Objective:To evaluate the short-term outcomes of aortic root repair using a pericardial autograft for acute type A aortic dissection.Methods:Between January 2020 and August 2021, 12 patients underwent aortic root repair using a pericardial autograft for type A aortic dissection. There were 8 males and 4 females, aged from 32.0 to 71.0 years, with a mean of (49.1±13.0) years, weight from 40.0 to 100.0 with a mean of (78.6±20.5) kg. Short-term outcomes were assessed by cardiopulmonary bypass time, cross-clamp time, circulatory arrest time, mechanical ventilation time, ICU time, postoperative stay time. The diameter of Valsalva sinus and aortic regurgitation were assessed before, after operation and during follow-up.Results:There were no postoperative and follow-up death. Cardiopulmonary bypass time was(256.4±60.6)min, ranging from 182.0 to 243.0 minutes; cross-clamp time was(195.0±52.5)minutes, ranging from 127.0 to 284.0 minutes; circulatory arrest time was(19.9±3.6)min, ranging from 15.0 to 25.0 min; mechanical ventilation time was (69.1±72.1)hours, ranging from 6.4 to 250.3 h; ICU time was (143.6±81.7) h, ranging from 56.9 to 288.0 h; postoperative stay time was (12.8±4.1) days, ranging from 8.0 to 20.0 days. One patient had transient paralysis (8.3%), and one patient needed hemofiltration due to acute kidney failure (8.3%), they all completely recovered before discharge. Follow-up time ranged from 10.0 to 21.0 months, with a median of 13 months. Heart function (NYHA) was I to II degrees. The mean diameter of aortic root was (36.7±5.8)mm(27.0-45.0 mm) preoperatively, (35.8±5.1)mm (25.0-44.8 mm) before discharge, and (35.7±5.9)mm (25.1-44.8 mm) during follow-up, respectively. There was no significant difference between them ( P>0.05). The preoperative aortic regurgitation was as follow: severe aortic regurgitation 2, moderate 1, mild to moderate 3, mild 1, trivial 1, none 4; postoperative aortic regurgitation: mild 2, trivial 2, none 8; follow-up aortic regurgitation: mild 3, trivial 1, none 8. Conclusion:Aortic root repair with a pericardial autograft is a safe and effective technique to treat acute type A dissection involving the sinus. Using this technique, residual dissection tissues could be significantly reduced, which subsequently decreases the risk of proximal bleeding, maintains the function of sinus, and increases long-term durability. Short-term results are satisfactory, and the long-term results need further follow-up.

Short-term outcomes of cuff wrapping technique using remnant aortic wall in modified bentall procedure / 中华胸心血管外科杂志

Objective:To evaluate the short-term outcomes of cuff wrapping technique using remnant aortic wall in modified Bentall procedure.Methods:Between January 2018 and December 2018, 23 patients underwent modified Bentall procedure with the remnant aortic wall as a cuff to cover the sewing area of composite valved graft and the aortic annulus for proximal hemostasis. After the sewing ring of the composite valved graft was sutured to the aortic annulus by continuous suture, the remnant aortic wall was sutured to the graft just distal to the sewing ring by continuous suture. There were 21 males and 2 females, aged from 22 to 72 with a mean of(50.96±13.23)years. Short-term outcomes were assessed by cardiopulmonary bypass time, clamp aorta time, mechanical ventilation time, ICU time, postoperative stay time, effusion drainage till the first postoperative day, Left ventricular end diastolic diameter(LVEDD), left ventricular ejection fraction(LVEF), and follow-up results.Results:There were no postoperative and follow-up death. Cardiopulmonary bypass time was(157.74±39.85)min, ranged from 114 to 275 min; clamp aorta time(122.61±30.25)min, ranged from 84 to 212 min; mechanical ventilation time(11.65±3.08)h, ranged from 7.87 to 20.33 h; ICU time(81.43±45.88) h, ranged from 15.18 to 184.77 h; postoperative stay time(8.73±2.80)days, ranged from 6 to 15 days. Effusion drainage was(336.82±117.65)ml, ranged from 200 to 670 ml till the first postoperative day. Follow-up was performed from 19 to 30 months, with a mean of(23.17±3.17)months. There were significant differences between preoperative LVEDD and postoperative LVEDD before discharge[(49.78±6.21)mm vs.(58.78±10.54)mm, P<0.05]; There were a little decrease of follow-up LVEDD compared with postoperative LVEDD, but no significant difference between them[(48.87±4.63)mm vs.(49.78±6.21)mm, P>0.05] . There were a little decrease of postoperative LVEF compared with preoperative LVEF, but no significant difference between them(0.57±0.07 vs. 0.59±0.05, P>0.05). There were significant differences between follow-up LVEF and preoperative LVEF(0.62±0.04 vs. 0.57±0.07, P<0.05), postoperative LVEF before discharge( P<0.05). Conclusion:Cuff wrapping technique using remnant aortic wall in modified Bentall procedure has got good short-term results. This modification may be a simple, effective way in controlling proximal bleeding.

Mid-term result of valve-sparing root replacement in acute type A aortic dissection: comparison of reimplantation versus remodeling / 中华胸心血管外科杂志

Objective:To compare the mid-term result of two different valve-sparing root replacement techniques in acute type A aortic dissection: including reimplantation and remodeling.Methods:From March 2009 to December 2019, 41 patients with acute type A dissection and root involvement, who underwent a valve-sparing root replacement using reimplantation(36 cases) or remodeling(5 cases) were retrospectively analyzed in current study. The average age was(44.63±11.34) years old, 36 males. The differences of perioperative variables, postoperative aortic insufficiency and postoperative survival were compared between the two groups.Results:Thirty-day mortality for two groups was 2.8% and 20%( P=0.23). Remodeling group was significantly inferior to reimplantation group in terms of blood consumption(red blood cells, plasma and platelets), postoperative mechanical ventilation time, reoperation for bleeding and hemofiltration for acute renal failure. The median follow-up time of 39 discharged survivors was 34.56(3-121) months, and the follow-up rate was 100%. There was no follow-up death, no bleeding or embolism events, and no cardiovascular reoperation. Grade 2 or sever aortic regurgitation in remodeling group was significantly higher than that in reimplantation group( P=0.02). A Cox regression analysis identified that the remodeling technique was the independent risk factors of postoperative aortic regurgitation. Conclusion:Compared with remodeling technique, reimplantation technique has better perioperative and mid-term results in patients with acute type A aortic dissection. The rate of reoperation for bleeding, the blood consumption and the postoperative aortic regurgitation are significantly reduced. The long-term results need further follow-up.

The short-term effect of aortic sinoplasty on repairing aortic roots of patients with acute type A aortic dissection / 中国胸心血管外科临床杂志

@#Objective    To investigate the feasibility, effectiveness and durability of aortic sinoplasty in repairing aortic roots of patients with acute type A aortic dissection. Methods    From January 2014 to July 2017, 43 consecutive patients with acute type A aortic dissection underwent aortic sinoplasty to repair aortic root in our institution, including 34 males and 9 females, aged 32-65 (50.1±8.1) years. The perioperative and follow-up data were retrospectively analyzed, and statistical analysis on the preoperative, postoperative and follow-up ultrasound indicators was performed. Results    Thirty-day mortality was 4.7%. Preoperative aortic regurgitation was corrected and false lumen was eliminated immediately after operation in all patients. There was no late death, or aortic root or valve re-intervention and two patients were lost during a follow-up of 18-45 (27.9±6.7) months. There was no residual dissection found. No patients had significant dilation of aortic root. No statistically significant difference was found when comparing the maximum of root diameter and aortic regurgitation grade between at discharge and follow-up. Conclusion    Aortic sinoplasty for aortic root repair in acute type A aortic dissection is a simple and reliable technique and demonstrates excellent early outcomes.

Aortic arch repair by "HENDO" technology clusters / 中国胸心血管外科临床杂志

@#Aortic arch disease is one of the research hotspots and treatment difficulties in the field of aorta, including aortic arch aneurysms, pseudoaneurysm, ulcer, dissection and intramural hematoma. By summarizing the clinical data of the vascular surgery center of Fuwai Hospital of Chinese Academy of Medical Sciences in the past five years and combining with the latest theories of the cutting-edge development of aortic surgery, the authors proposed the "HENDO" concept, including using hybrid technique (H), endovascular repair (Endo) and open surgery (O), properly to treat aortic arch pathologies individually. The authors advocated the establishment of HENDO team and cooperation mechanism in large aortic centers, to eliminate technical shortcomings of a single surgeon by fully mastering the three main technology clusters by teamwork. Accordingly, the best treatment for each patient can be administrated and the survival rate and quality of life can be improved eventually.

Outcomes after Surgical Repair of Thoracoabdominal Aortic Aneurysm with Distal Aortic Dissection:DeBakey Type Ⅰ versus Type Ⅲ / 中国医学科学院学报

To evaluate the early and mid-term results after surgical repair of thoracoabdominal aortic aneurysm(TAAA)in patients with DeBakey typeⅠor Ⅲ aortic dissection. The clinical data of 130 patients who underwent TAAA repair for chronic DeBakey typeⅠ(groupⅠ, =47)or type Ⅲ(group Ⅲ, =83)aortic dissections in our center between January 2009 and December 2017 were retrospectively analyzed.Early postoperative results,midterm survival,and re-interventions were compared between these two groups. The 30-day mortality rate was 6.9%(=9)in the overall cohort,with no statistic difference between groupⅠand group Ⅲ(10.6% 4.8%;=0.803, =0.370).The incidence of major adverse events(38.3% 51.8%;=2.199, =0.138),5-year actuarial survival rate [(81.7±5.9)% (87.2±4.2)%;=0.483, =0.487],and 5-year actuarial freedom from all reinterventions [(84.5±6.7)% (85.5±4.8)%;=0.010, =0.920] showed no significant differences between these two groups. The early and mid-term outcomes after surgical repair of TAAA are similar for DeBakey typeⅠ and type Ⅲ patients.However,studies with larger sample sizes are still required.

Standardized multidisciplinary spinal cord protection strategies reduce spinal cord injury during perioperative period of aortic surgery: an 8-year retrospective analysis / 中华危重病急救医学

Objective To observe the incidence of spinal cord injury (SCI) following aortic surgery in Fuwai Hospital of Chinese Academy of Medical Sciences, and evaluate the effect of standardized multidisciplinary spinal cord protection strategies, to summarize the experience in the prevention and treatment of SCI at perioperative period of aortic surgery. Methods The clinical data of patients underwent aortic surgery admitted to vascular center of Fuwai Hospital from January 2011 to December 2018 were retrospectively analyzed. The patients receiving traditional spinal cord protection strategies from January 2011 to December 2016 were defined as the control group, while the patients receiving standardized multidisciplinary spinal cord protection strategies from January 2017 to December 2018 were defined as the standardized treatment group. The standardized multidisciplinary treatment included preoperative cerebrospinal fluid drainage (CSFD), respiratory tract management, and maintenance of effective circulation of the lowest venous pressure; at the same time, anticoagulation, glucocorticoid, improve microcirculation, scavenge oxygen free radicals and other adjuvant treatments were started, and nerve function was monitored to prevent complications. The changes in SCI incidence after aortic surgery between the two groups were observed in order to evaluate the effect of standardized multidisciplinary spinal cord protection strategies. Meanwhile, the types of SCI after operation and the safety of CSFD were analyzed. Results During the 8-year period, 7 724 patients underwent aortic surgery at vascular center of Fuwai Hospital, 64 of which suffered from SCI after aortic surgery with total incidence of 0.83%. The onset of SCI was immediate in 39 patients (60.94%) and was delayed in 25 patients (39.06%), more than half of patients were immediate SCI. Of 64 patients with SCI, 52 patients (81.25%) underwent paraplegia and 12 (18.75%) underwent paraparesis. SCI persisted beyond discharge in 38 patients (59.38%) and 25 patients (39.06%) fully or partly recovered form SCI. One patient (1.56%) died. Compared with the control group, the incidence of SCI was decreased significantly after application of standardized multidisciplinary spinal cord protection strategies. The total incidence of SCI after aortic surgery was decreased from 1.06% (52/4 893) to 0.42% (12/2 831), the incidence after aortic arch replacement under deep hypothermic circulatory arrest was decreased from 3.66% (40/1 092) to 1.11% (5/450), and the incidence after thoraco-abdominal aortic replacement was decreased from 9.40% (11/117) to 2.47% (2/81) with statistically significant difference (all P < 0.05). Perioperative CSFD analysis showed that the incidence of CSFD-related complications was low, the overall incidence was 5.45% (3/55), including 1 patient of cerebrospinal fluid leakage, 2 patients of blood cerebrospinal fluid. No serious complications such as hemorrhage and infection of central nervous system occurred. Conclusions The main type of SCI after aortic surgery was immediate, about 39% SCI patients fully or partly recovered. Standardized multidisciplinary spinal cord protection strategies which included preoperative CSFD, reduced incidence of SCI after aortic surgery. The incidence of CSFD-related complications was low, which was safe and effective.

One-stop hybrid technique to treat coronary atherosclerotic disease concomitant with penetrating atherosclerotic ulcers in 23 patients / 中华胸心血管外科杂志

Objective Retrospectively reviewed the early outcomes of one-stop hybrid technique to treat coronary atherosclerotic disease concomitant with penetrating atherosclerotic ulcers (PAU).Methods This study enrolled in 23 cases (male 21,female 2) of coronary atherosclerotic disease concomitant with penetrating atherosclerotic ulcers from Jan 2016 to Dec 2017 in our institute,with the mean age(67.5 ±7.5) years (51-79 years).Coronary artery bypass graft (CABG) surgery was performed by cardiopulmonary bypass (CPB),the procedure to treat aortic arch lesion included isolated CABG + thoracic endovascular stent graft in 2 patients,CABG + brachiocephalic arteries debranching + thoracic endovascular stent graft in 18 patients,CABG + hybrid total aortic arch replacement + thoracic endovascular stent graft in 3 patients.Results Mean CPB time was(94.3 ±25.7) min(55-145 min),mean aortic cross-clamp time was (61.4 ± 19.3) min(26-97 min),intraoperative blood loss was (654.8 ± 78.7) ml (510-900 ml),20 patients (87.0％) needed blood transfusion therapy . Median mechanical ventilation time was 18 hours(9-249 hours),with 1 patient (4.3 ％)exceeded 48 hours.Median intensive care unit stay time was 2.8 days(1-23 days),with 6 patients(26.1％) exceeded 4 days.There was no in-hospital mortality.The postoperative complications included:paresis in 2 patients (8.7％),re-exploration for bleeding in 1 patient (4.3％),pleural effusion in 1 patient (4.3％),pneumothorax in 1 patient (4.3％),paraplegia、pulmonary infection、acute renal insufficiency、respiratory failure、re-intubation in 1 patient (4.3 ％).Conclusion The one-stop hybrid technique for treating coronary atherosclerotic disease concomitant with PAU was effective and safe.The early clinical outcome was satisfactory.Mid and long-term result need further follow-up to study.

Surgical strategy for treatment of Kommerell's diverticulum associated with aortic dissection / 中华胸心血管外科杂志

Objective To summarize the experience and strategy of surgical treatment of Kommerell diverticulum and related aortic dissection aneurysm.Methods From November 2012 to January 2018,4 patients(all males),with median age of 44 (from 40 to 49) years old,underwent surgical treatment in our institution.All the patients had fight-sided aortic arch and aberrant left subclavian artery.One patient had type A aortic dissection and other 3 had type B aortic dissection(one had chronic type B dissection).The patient with type A aortic dissection had Bentall procedure plus total arch replacement and frozen elephant trunk implantation.One patient with chronic type B aortic dissection received type 2 hybrid aortic arch repair.One patient with acute type B aortic dissection had ascending aorta and total arch replacement plus frozen elephant trunk implantation followed by TEVAR.The last patient underwent graft replacement of aorta,total arch and descending thoracic aorta.Results There was no operative mortality.The median mechanical ventilation time was 229 (from 13 to 485) hours,the median ICU stay was 12 (from 2 to 27) days.One patient died from respiratory and circulatory failure due to compression of left main bronchus on the 17th day after operation.One patient had irritating cough due to mild compression of bifucation of trachea and the symptom resolved spontaneously before discharge.One patient had critical illness polyneuropathy after operation and received mechanical ventilation therapy for 485 hours.He recovered through neurotrophic drug treatment.The median follow-up time is 15 (from 4 to 36) months.The patients with type A dissection had delayed dilation of descending thoracic aorta beyond the frozen elephant trunk and received TEVAR 6 months later.The CT scans of the other two patients during follow-up time showed good morphology and patency of graft and branches.There was no anastomotic leakage and pseudoaneurysm.Conclusion The decision making of treatment of Kommerell diverticulum and related aortic dissection should be on the basis of classification of aortic dissection.Operation combined with TEVAR is safe and effective.

Surgical treatment of Kommerell diverticulum and related aortic aneurysm / 中华胸心血管外科杂志

Objective To summarize the experience of surgical treatment of Kommerell diverticulum and related aortic arch and descending thoracic aneurysm. Methods From November 2012 to January 2018,6 patients(5 males,and 1 fe-male),with median age of 46(from 14 to 63)years old,underwent graft replacement of involved aortic segment in our institu-tion . All the patients had symptom including persistent backache(3 patients),hoarseness( 1 patient),recurrent pneumonia( 1 patient)and hemoptysis( 1 patient). All the patients had right-sided aortic arch and aberrant left subclavian artery. True aneu-rysm occurred in 5 patients and pseudoaneurysm occurred in 1 patients. The median diameter of the aneurysms was 65mm(53- 80 mm). Two kinds of approaches were used:left posterior thoracotomy(2 patients)and median sternotomy plus right poste-rior thoracotomy(4 patients). The left posterior thoracotomy was achieved through the fourth and seventh intercostal space with excellent exposure of the whole descending thoracic aneurysm. For each patient,the aneurysm was resected with the proximal and distal aortic segment were clamped and the ligamentum arteriosum were divided. A branched woven polyester graft was used to reconstruct the descending thoracic aneurysm. 1 or 2 subclavian arteries were replaced with 10mm collagen-impregnated pol-yester grafts. One patient received total arch and partial descending thoracic aorta replacement with reconstruction of 3 supra-arch vessels. Results There was no operative mortality. The median clamping time of descending aorta was 28(22 - 61)mi-nutes,the median mechanical ventilation time was 33. 5(6 - 485)hours,the median ICU stay was 4( 1 - 31)days. One pa-tient died from central respiratory and circulatory failure due to acute brain stem infarction on the 31st day after operation. One patient suffered from reentry to ICU due to hyoxemia and recovered through expectant treatment. One patient had critical illness polyneuropathy after operation and received mechanical ventilation therapy for 485 hours,he recovered through neurotrophic drug treatment. The median follow-up time is 5( 1 - 46)months. 5 patients lived with no discomfort and the CT scans during follow-up time showed good morphology and patency of graft and branches. There was no anastomotic leakage and pseudoaneu-rysm. Conclusion Surgical treatment of Kommerell diverticulum is safe and effective. Subclavian artery should be reconstruc-ted.

The surgical outcomes of acute type A aortic intramural hematoma: a curative effect analysis of 40 cases / 中华胸心血管外科杂志

Objective The aim of this study is to evaluate clinical outcomes of patients with acute type A intranural hematoma of the aorta(IMH) received surgical treatment.Methods We analyzed 40 consecutive patients with acute type A aortic IMH in Fuwai hospital.The patients are from 2012.1.1 to 2015.12.31.The average age of patients is(56 ± 11) years.Clinical outcomes and morphological evolution by CT were analyzed for 2 years.Results Most of the patients were treated medically during their initial hospitalization.There were 2 patients died in in-hospital and no 2-year mortality.16 patients (40％) were received acute surgery,24 patients(60％)were received normal surgery.Conclusion Surgical treatment would be a favorable treatment option in type A acute IMH.

"Clinical Experience for ""One-stop"" Performance of Thoracic Endovascular Aortic Repair and Coronary Artery Bypass Grafting" / 中国循环杂志

Objective: To explore the safety and strategy of thoracic endovascular aortic repair (TEVAR) combining coronary artery bypass grafting (CABG) as one-stop performance in treating the patients with coronary artery disease (CAD) and thoracic aorta disease. Methods: A total of 20 patients received one-stop treatment of TEVAR combining CABG in our hospital from 2009-04 to 2016-01 were retrospectively analyzed. There were 18 male and the mean age of patients was (65.2±8.5, 51-82) years. The performance strategy and peri-operative management were studied. Results: There were 1/20 patient received 2 stents implantation in thoracic aorta and 19 received 1 stent in thoracic aorta those including 1 case with endovascular repair of abdominal aortic aneurysm, 1 with right iliac artery stent implantation and 1 with carotid endarterectomy at meanwhile. The average number of coronary artery bypass branch was (2.4±0.94, 1-4) and 10 (50%) patients received internal mammary artery grafting. The average in-hospital time in all 20 patients was (22.4±11.6, 8-58) days. There were 6 (30%) patients received blood transfusion; 1 (5%) having low cardiac output syndrome received extracorporeal membrane oxygenation (ECMO), then received the second thoracotomy for hemostasis due to excessive pleural effusion; 2 (10%) patients died at 30 days post-operation. 1 patient lost contact and 17 received clinical or telephone follow-up visit at the average of (13.4+13.6, 1-49) months; 2 patients died for cerebral hemorrhage at 12 and 49 months post-operation, the rest 15 had disappeared symptoms and improved quality of life, no operation related death occurred. Conclusion: TEVAR combining CABG as one-stop performance presented good mid-term effect in treating the patients with CAD and thoracic aorta disease; in otherwise, the operative time and risk might be increased by two step performance.

Surgical outcomes of off-pump technique in extensive thoracoabdominal aorta replacement / 中华外科杂志

<p><b>OBJECTIVE</b>To assess the safety and efficacy of off-pump technique with normothemia to extend thoracoabdominal aortic aneurysm replacement compared with traditional hypothermic circulatory arrest.</p><p><b>METHODS</b>From January 2004 to December 2013, 128 consecutive patients underwent surgical repair of thoracoabdominal aortic aneurysm (type Crawford Ⅱ) in Fuwai Hospital. The mean age was (37±11) years. The patients included 74 cases (57.8%) with chronic Stanford A dissection, 34 cases (26.6%) with chronic Stanford B dissection, 20 cases (15.6%) with thoracoabdominal aortic true aneurysm. There were 71 patients who underwent hypothermic circulatory arrest surgery (cardiopulmonary bypass (CPB) group) and 57 patients who underwent off-pump surgery with normothermia (off-pump group). The clinic data was compared between the 2 groups using paired t tests and χ(2) test. Kaplan-Meier survival analysis was used for postoperative survival stays.</p><p><b>RESULTS</b>The mean CPB time in CPB group was (251 ±87) minuets and the circulatory arrest time was (45±24) minuets. Spinal cord ischemia time in the two groups was (21±12) minuets and (18±10) minuets (t=5.68, P=0.51). The operation time, ventilator time, length of ICU stay and length of hospital stay of off-pump group were shorter than CPB group ((408±114) minuets vs.(630±156) minuets, t=-7.67, P=0.05; (18±13) hours vs. (113±89) hours, t=-3.86, P=0.00; (4±2) days vs.(10±9) days, t=-4.19, P=0.00; (15±7) days vs.(25±14) days, t=-4.47, P=0.00). The intraoperative blood loss in off-pump group and CPB group was (900±750) ml and (1 400±400) ml (t=-2.23, P=0.04). The mortality was 1.7% and 9.8% in the off-pump group and CPB groups (χ(2)=3.544, P=0.05). The cerebral complication rate in the normal temperature group was 1.7% vs. 22.6% in extracorporeal group (χ(2)=9.35, P<0.05). A total of 113 patients were followed up, with a follow-up rate of 88.2%. Duration of follow-up was (78±54) months. Five patients died during the follow-up period, including 2 who died of cerebral infarction and 3 paraplegia patients who died of infection. Eight patients had phase Ⅱ aortic arch replacement after a mean time of 6 months. The overall postoperative survival rate was 97%, 93% and 87% at 3 years, 5 years and 7 years, respectively.</p><p><b>CONCLUSION</b>Off-pump technique with normothemia was associated with a lower risk of a composite outcome of mortality and major adverse cardiac and cerebrovascular events during repair of extensive thoracoabdominal aortic aneurysm.</p>

RIFLE criteria for impact of acute kidney injury on early and long-term outcome after acute type A dissection surgery / 中华胸心血管外科杂志

Objective To investigate the impact of acute kidney injury ( AKI ) on early and long-term outcome using RIFLEcriteria in patients after acute type A dissection surgery.Methods Between January 2006 and June 2011, 286 cases a-cute type A dissection patients underwent deep hypothermic circulatory arrest surgery were retrospectively analyzed .Using RIFLEcriteria to classfy AKI to risk, injury and failure stages and comparing 30-day mortality, dialysis, ventilation time, ICU stay, hospital stay and cost, and three-year mortality.Multivariate analyses were performed to identify predictors of failure stage.Results AKI was detected in 160 patients(55.9%), and risk 85 cases(29.7%), injury 39 cases(13.6%), failure 36 cases(12.6%).Dialysis rate, ventilation time, ICU stay, cost, and 30-day mortality increased with worsening severity of renal injury, and these was significant increased in failure stage than other groups .There was no association between severity of renal injury and 3-year mortality.Multiple logistic regression showed that malperfusion syndrome ( OR =3.499, 95%CI:1.019-12.013, P=0.047) and WBC(OR=1.121, 95%CI:1.017 -1.237, P=0.022) were independent predictors of renal failure.Conclusion Postoperative mild and morderate acute kidney injury were common in acute type A dissection pa-tients.The severe acute kidney injury had association with poor early outcome .

Analysis of in-hospital death of aortic arch replacement under deep hypothermic circulatory arrest and antegrade cerebral perfusion / 中华胸心血管外科杂志

Objective To analyze risk factors for in-hospital death of aortic arch replacement under deep hypothermic circulatory arrest and antegrade cerebral perfusion.Methods Between January 2005 and December 2011,626 cases aortic arch replacement under deep hypothermic circulatory arrest and antegrade cerebral perfusion were retrospectively analyzed.The cause of death were recorded and univariate and multivariate analysis (multiple logistic regression) were used to identify the risk factors.Results In-hospital death occurred in 29 cases (4.6％) and in them 2 cases because of aortic dissection rupture,5 cases severe neurological injury,11 cases low cardiac output syndrome and 11 cases multiple organ failure.Multiple logistic regression showed that stroke history(OR =6.703,95％ CI:1.664-27.000,P ＝ 0.007),preoperative hemodynamic instability(OR =6.441,95％ CI:1.213-34.212,P =0.029),eardiopulmonary bypass time(OR =1.008,95％ CI:1.002-1.014,P =0.007) and CABG(OP =4.525,95％ CI:1.542-13.279,P =0.006) were independent risk factors for in-hospital death.Conclusion Stroke history,preoperative hemodvnamic instability and coronary involvement indicate high risk in operation,and mortality maybe can be reduced by controlling CPB time.

Risk factors for cerebral neurological injury after operation of acute Stanford type A aortic dissection / 中华胸心血管外科杂志

Objective To analyze risk factors for cerebral neurological injury after operation of acute Stanford type A aortic dissection.Methods Between January 2005 and December 2011,329 cases of acute Stanford type A aortic dissection patients underwent aortic arch replacement were retrospectively analyzed.Univariate and multivariate analysis(multiple logistic regression) were used to identify the risk factors for postoperative cerebral neurological injury including permanent neurological dysfunction (PND) and temporary neurological dysfunction (TND).Results Cerebral neurological injury occurred in 77 cases (23.4％),PND 11 cases(3.3％) and TND 66 cases(20.1％).Multiple logistic regression showed that age(OR =1.087,95％ CI 1.013-1.166,P =0.020) and stroke history (OR =10.383,95 ％ CI 1.596-67.534,P =0.014)were independent risk factors for PND,serum creatinin (OR =1.013,95 ％ CI 1.004-1.023,P =0.006),WBC (OR =1.199,95 ％ CI 1.087-1.324,P =0.000) and peak intraoperative glucose level (OR =1.011,95％ CI 1.004-1.018,P =0.003) were independent risk factors for TND.Conclusion The older age or stroke history indicate the occurrence of PND,Whereas the higher WBC lever preoperative or higher intraoperative glucose level indicate the occurrence of TND.The incidence of TND probably will be reduced by controlling intraoperative hyperglycemia actively.

Reoperation on aortic disease in patients with previous aortic valve surgery / 中华胸心血管外科杂志

Objective Retrospectively analyze 47 cases received reoperation with aortic disease after aortic valve replacement to deepen the understanding of aortic valve disease.Methods From January 2003 to June 2012,47 patients with previous aortic valve replacement received aortic root or other aortic operation because of new aortic disease.38 male and 9 female,the interval (6.0 ± 3.8) years. All cases with new aortic disease were diagnosed by cardiac ultrasound and aortic computed tomography.Bentall's procedure were operated on 14 patients,total aortic arch replacement with elephant trunk procedure on 14 patients,aortic root and aortic arch with elephant trunk procedure on 7 patients,ascending aortic replacement on 10patients,total thoracic and abdominal aorta replacement on 2 cases.All patients were followed by clinic interview or telephone.Results Aortic dissection and aneurysmal dilatation were occurred on ascending aorta,each account for 50％,in patients with previous aortic valve replacement because of rheumatic valve disease and bicuspid aortic valve; 3 cases with Marfan syndrome occurred ascending aortic dilatation and 4 cases occurred aortic dissection.Diameter in ascending aorta increased (5.2 + 7.1)mm per year and aortic sinus (3.3 ± 3.1)mm per year.The value of ascending aortic dilatation per year in patients with rheumatic disease was higher than patients with Marfan syndrome(P ＜ 0.05).47 patients were re-operated in fuwai hospital,1 patients died in operating room because aortic dissection seriously involved right coronary artery.7 patients have renal insufficiency after operation and all were cured by hemofiltration; neurological complication occurred in 14 patients including that 7 patients stroked and 7 patients had transient brain dysfunciotn.There were no postoperative spinal cord deficits occurred.All patients were followed up,the mean follow up time were(53.49 +33.79) months.8 cases were died during follow-up and threeyear survival rate was 83％.There were no cases received operation due to aortic disease during follow-up.Conclusion Deepening the understanding of aortic valve disease combine ascending aorta changes,especially pay attention to patients with previous aortic valve replacement because of Marfan syndrome and rheumatic disease during follow-up after first operation,all efforts should decrease the occurrence of aortic adverse events in long term.

Risk factors for acute kidney injury after aortic arch operation under deep hypothermic circulatory arrest / 中华胸心血管外科杂志

Objective To analyze risk factors for acute kidney injury after aortic arch operation under deep hypothermic circulatory arrest.Methods Between January 2005 and June 2011,549 cases aortic arch replacement under deep hypothermic circulatory arrest were retrospectively analyzed.According to the occurrence of acute kidney injury they were divided into two groups.Univariate and multivariate analysis (multiple logistic regression) were used to identify the risk factors.Results AKI occurred in 102 cases (18.6％) and 27 cases(4.9％) had dialysis.Multiple logistic regression showed that body mess Index(OR =1.072,95％ CI:1.006-1.141,P =0.031),serum creatinin (OR =1.011,95％ CI:1.006-1.017,P =0.000),cardiopulmonary bypass time(OR =1.006,95 ％ CI:1.002-1.009,P =0.005) and the peak intraoperative glucose level (OR =1.007,95 ％ CI:1.002-1.011,P =0.003) were independent risk factors for AKI.Conclusion The higher BMI,serum creatinin level maybe indicate the occurrence of AKI,and AKI maybe can be reduced by controlling CPB time and intraoperative hyperglycemia.

Single-stage repair of extensive aortic aneurysms: extended experience with total or subtotal aortic replacement / 中华胸心血管外科杂志

Objective Retrospectively analyze the mid-term clinical results of single-stage repair of extensive aortic aneurysms with total or subtotal aortic replacement(T/STAR).This study describes our experience in this operation in single center of aortic disease at Fuwai Hospital.Methods From February 2004 to February 2011,21 patients with hypertension or Marfan syndrome underwent one-stage total or subtotal aortic replacement for aortic dissection or aortic aneurysms.16 male and 5 female,aged (34 ±9) years.Operations wore performed under circulatory arrest with profound hypothermia.Patients were opened with a mid-sternotomy and a thoracoabdominal incision.Extracorporeal circulation was instituted with two arterial cannulae and a single venous cannula in the right atrium.During cooling,the ascending aorta or aortic root was replaced.At the nasopharyngeal temperature of 20 ℃,the aortic arch was replaced with selective antegrade cerebral perfusion.Staged aortic occlusions allowed for replacement of descending thoracic and abdominal aorta.T6 to T12 intercostal arteries and L1,2 lumbar arteries were formed to a neo-intercostal artery in place and were connected to an 8 mm branch for keeping spinal cord blood perfusion.Visceral arteries were joined into a patch and anastomosed to the end of the main graft.Left renal artery was anastomosed to an 8mm branch or joined to the patch.The other 10 mm branches were anastomosed to iliac arteries.Results Early mortality was4.8％ ( 1/21 eases),the only one patient was dead result from renal failure and multiple organ failure.There were no postoperative spinal cord deficits occurred,two patients were stroked at day 5th and 7th respectively.Three patients were operated with tracheotomy because of respiratory insufficiency.Operation was undertaken on one patient with splenenctomy result of spleen rupture during first aortic aneurysms repair.All patients were follow-up,ranging from 18 to 84 months postoperatively,all 20 survivors were alive and had good functional status.One patient was reoperated with aortic valve replacement because of massive valve insufficiency after two years.Neo- intercostal arteries were clogged in 3 patients within follow-up,and two of those patients with Marfan syndrome underwent pseudoaneurysm after intercostal arteries reconstruction.Conclusion Single-stage repair of extensive aortic aneurysms with total or subtotal aortic replacement is safely and effectively.It is feasible with acceptable surgical risks and satisfactory results.It can eliminate the risk of remnant aortic aneurysm rupture in staged total aortic replacement and has satisfactory mid-term results.