Arch-clamping technique for surgical repair of acute Type A aortic dissection / 中华胸心血管外科杂志

Objective:To evaluate the efficacy of arch-clamping technique in Sun’s procedure to repair acute type A aortic dissection.Methods:20 consecutive patients[17 males with mean age of (49.7±10.9)years old] with acute type A aortic dissection who underwent total arch replacement and frozen elephant trunk implantation (TAR+ FET) from May 2019 to April 2020 were divided into group with using arch-clamping technique during operation (arch-clamping group) or group without (traditional group). Circulatory arrest time, cardiopulmonary bypass time, recovery time, ventilation time, platelet count during the first 3 days postoperatively, blood loss during the first 12 h postoperatively, death, cerebral infarction and acute renal failure were compared. Patients with advanced age(age>70 years old ), or malperfusion syndrome preoperatively or who did not receiving TAR+ FET surgery were excluded from this study.Results:Circulatory arrest time[(4.1±0.6 )min vs. (17.2±2.6)min, P=0.001] and cardiopulmonary bypass time[(158.4±6.8 )min vs. (198.2±12.6)min, P=0.01] were significantly lower in arch-clamping group, compared with traditional group. Postoperative recovery time[(8.9±2.6 )h vs. (16.0±7.3)h, P=0.94] and ventilation time[(13.6±2.2)h vs. (34.1±14.3)h, P=0.18] were non significantly lower in arch-clamping group. Although postoperative platelet counts were higher in arch-clamping group during the first three days, those difference did not reach statistical significance ( P>0.05). All patients were discharged alive. There was no significant difference among the two group with respect to drainage during the first 12 h postoperatively, death, cerebral infarction and acute renal failure. Conclusion:Arch-clamping technique decrease circulatory arrest time dramatically and provide good protection of brain, coagulation and renal function by shortening ischemia time, thereby reducing postoperative complications. It is a safe and feasible innovative approach to effectively improve surgical outcome of Sun’s procedure for repair of acute type A aortic dissection.

The long-term outcomes of one-stage hybrid procedure for aortic arch pathologies / 中华胸心血管外科杂志

Objective:To analyze the long-term outcomes of hybrid arch repair(HAR) treating aortic arch pathologies.Methods:Between January 2009 and January 2018, 87 consecutive patients underwent HAR for aortic arch pathologies at Beijing Anzhen Hospital. 76 were males. 2 cases were in zone 0, 46 cases were in zone 1, and 39 cases were in zone 2. The zones of the aortic arch were defined following the Ishimaru classification.Results:Five(5.7%) operative death occurred. 13 patients(19.1%) died during the follow-up. The overall survival rate was 88.4%, 83.3%, 83.3%, 49.8% at 1, 3, 5, 10 year, respectively. Multivariate Cox proportional risk analysis showed that stroke( HR=20.626, 95% CI: 2.698-157.685, P=0.004) was an independent risk factor for short-term death. Stroke( HR=16.234, 95% CI: 4.103-64.229, P<0.001) and spinal cord infury( HR=11.060, 95% CI: 2.150-56.893, P=0.004) were independent risk factors for long-term death. Conclusion:In conclusion, HAR could be an alternative procedure for the patients that are not suitable for open repair under the premise of strict control of indications. In the future, the risk assessment system and uniform operational indications for HAR should be further established.

Analysis of risk factors for massive bleeding in patients with acute Stanford type A aortic dissection undergoing moderate hypothermic circulatory arrest repair / 中华胸心血管外科杂志

Objective:To study the risk factors of massive bleeding in patients with acute Stanford type A aortic dissection undergoing moderate hypothermic circulatory arrest repair.Methods:From January 2016 to October 2017, 486 consecutive patients with acute type A aortic dissection were included in the study. All operations were performed with moderate hypothermic circulatory arrest. The basic clinical data of patients were collected retrospectively. Massive bleeding was defined according to definition of Universal Definition of Perioperative Bleeding(UDPB) 4 class and the Blood Conservation Using Antifibrinolytics in a Randomized Trial(BART). Significant variables in univariate analysis were included in multivariate logistic regression analysis. Results:Thirty-four patients(7.00%) died in hospital. A total of one hundred and eighty-seven patients(38.48%) fulfilled criteria of the definition of BART massive bleeding. Forty-five patients(9.26%), 8 patients(1.65%), 114 patients(23.46%), 147 patients(30.25%) and 172 patients(35.39%) were in grade 0, grade 1, grade 2 and grade 4, respectively. With BART as the end point, the result of multivariate logistic regression showed that female gender( OR=3.32, P<0.001), anemia( OR=2.24, P=0.04), clearance creatine≤85 ml/min( OR=1.93, P=0.01), D-dimer level(every 500 ng/ml increase, OR=1.02, P=0.003), cardiopulmonary bypass(CPB) time( OR=1.01, P<0.001), total arch replacement(TAR, OR=2.40, P=0.02) were independent risk factors for massive bleeding, and the time from onset to operation( OR=0.86, P=0.01) was protective factor. With UDPB 4 class as the end point, multivariate logistic regression showed that creatinine clearance≤85 ml/min( OR=2.05, P=0.001), CPB time( OR=1.01, P=0.04) were independent risk factors for massive bleeding. The time from anset to operation( OR=0.85, P=0.002) and Bentall procedure( OR=0.65, P=0.04) were the protective factors. Conclusion:Massive bleeding was more common in acute Stanford type A aortic dissection. Female gender, poor preoperative renal function, high D-dimer level, early time accepting surgical operation and long CPB were independent risk factors. For high-risk patients, simple and effective surgical methods should be taken to reduce the risk of bleeding.

Renal artery involvement: independent risk factors of KDIGO stage 3 in acute renal injury after moderate hypothermic circulatory arrest in acute Stanford type A aortic dissection / 中华胸心血管外科杂志

Objective:To explore whether renal artery involvement is an independent risk factor of acute renal injury (AKI) KDIGO stage 3 after moderate hypothermic circulatory arrest in patients with acute Stanford type A aortic dissection.Methods:From December 2015 to October 2017, 492 consecutive patients with acute Stanford A-type aortic dissection received surgical treatment, 486 of them were included in the study. All patients underwent aortic CTA to determine the extent of aortic dissection and renal artery involvement. According to the standard of Improving Global Outcomes (KDIGO), the renal function of patients after operation was graded. The risk factors of AKI KDIGO stage 3 were analyzed.Renal artery involvement and other risk factors were included in univariate analysis, and significant variables in univariate analysis were included in multivariate logistic regression analysis.Results:In 492 patients, 40 (8.13%) died in hospital, of which 6 died of severe bleeding during operation or failed to wean from cardiopulmonary bypass which lead to unable to leave the Weaning from cardiopulmonary bypass and these 6 patients were excluded in the research. Among 486 patients included in the study, 251 (51.64%) had AKI. Among them, 83 (17.08%) were in the KDIGO stage 1, 56 (11.52%) in stage 2 and 112 (23.05%) in stage 3.The results of univariate analysis showed that there were significant differences in renal artery involvement, age, time from onset to operation, D-dimer, leukocytes and platelets in peripheral blood, creatinine clearance rate, time of cardiopulmonary bypass during operation and aortic cross-clamping time( P>0.05). The above risk factors were included in multivariate logistic regression. The results showed that preoperative renal artery involvement ( OR=1.94, P=0.02), age ( OR=1.03, P=0.02), creatinine clearance rate<85 ml/min ( OR=2.28, P=0.001), and intraoperative cardiopulmonary bypass time ( OR=1.01, P=0.02) were independent risk factors. The incidence of AKI in patients with renal artery involvement was 54.65%, significantly higher than 41.98% in patients without renal artery involvement ( P>0.05). Conclusion:Renal artery involvement is an independent risk factor of AKI KDIGO stage 3 after moderate deep hypothermic circulatory arrest of acute Stanford type A aortic dissection.

Comprehensive management of aortic dissection during pregnancy / 中国胸心血管外科临床杂志

@#The aortic dissection (AD) carries high mortality which increases by 1%-2% per hour after onset in untreated patients. Fifty percent of patients will die in 48 hours, and 70%-80% patients will die in 2 weeks without treatment. Moreover, acute AD during pregnancy is a rare and much catastrophic disease with high lethality for the mother and fetus simultaneously. At present, AD is so rare that most articles are mainly small cohort studies and case reports. Therefore, we reviewed literatures in order to provide clinical reference for the comprehensive treatment of AD.

Surgical treatment strategy for traumatic aortic injury / 中华胸心血管外科杂志

Objective:To summarize the surgical treatment strategy for aortic injury caused by trauma.Methods:From January 2009 to January 2018, 34 patients with TAI were treated in Beijing Anzhen Hospital. 10 had hypertension. 23 cases were males. There were 31 cases caused by traffic accidents, 2 cases were fall injuries, and 1 case was bruise. 9 cases were thoracic aortic pseudoaneurysm, 6 cases were thoracic aorta, and 19 cases were aortic dissection. 29 patients underwent TEVAR and 5 patients underwent OR (2 patients with type A aortic dissection undergoing Bentall + Sun's procedure, 1 patient with type B aortic dissection and 2 patients with thoracic aortic pseudoaneurysm undergoing stented elephant trunk procedure).Results:The follow-up time was (45.09±23.10) months. The mean age of patients undergoing OR or TEVAR was (44.80±20.57) years old, (45.93±11.01) years old; the mean operation time was(403.20±30.30) minutes, (105.72±27.76) minutes; the mean hospitalization (19.00±6.04), (5.76±3.08) days. There were no deaths in the two groups. 2 patients uundergoing TEVAR had left upper limb numbness.Conclusion:The treatment of patients with TAI should be based on the general condition, the classification of injury, the involving regions and anatomical features to choose different treatments. In addition, the long-term prognosis of patients remains to be determined.

The impact of preoperative dual antiplatelet therapy on early outcome of acute type A aortic dissection patients undergoing aortic surgery / 中华胸心血管外科杂志

Objective@#To evaluate the impact of preoperative dual antiplatelet therapy on early outcome of acute type A aortic dissection(ATAAD) patients undergoing aortic surgery.@*Methods@#From December 2015 to November 2017, 45 consecutive patients with ingestion of aspirin and clopidogrel underwent aortic repair surgery at our center. 37 out of 45 patients(83%) were propensity-matched with 74 control ATAAD patients without antiplatelet therapy undergoing aortic surgery in 1∶2 fashion. Thereby, bleeding-related outcome(death, reoperation for bleeding, postoperative blood loss within 12 h ≥2 000 ml and usage of rFⅦa) and blood transfusion requirement were compared.@*Results@#Bleeding-related outcome occurred in 14(18.9%) and 9(24.3%) patients in control and antiplatelet group respectively(P=0.51). Postoperative blood loss within 12 hours was 490 ml in control group, compared to 500 ml in the antiplatelet group(P=0.85). There were no significant differences among the two groups in transfusion requirements of red blood cells, platelets and fresh frozen plasma. Multivariate regression analysis identified antiplatelet therapy as an nonsignifcant risk factor for bleeding-related outcome(OR=2.97, 95%CI: 0.87-10.21, P=0.08).@*Conclusion@#Preoperative dual antiplatelet therapy was not associated with increased risk of bleeding-related outcome and transfusion requirement, and was not a contraindication of emergent surgery for ATAAD patients.

Risk factors of renal replacement therapy after Sun's procedure for acute Stanford A aortic dissection / 中华胸心血管外科杂志

Objective To explore the risk factors of renal replacement therapy for acute Stanford A aortic dissection patients with acute renal injury (AKI) after Sun's operation.Methods From January 2016 to October 2017,144 patients with Stanford A aortic dissection who underwent Sun's procedure were enrolled in the study.Univariate analysis and logistic regression analysis were used to analyze the risk factors of continuous renal replacement therapy (CRRT).Variables with statistical difference from univariate analysis were included in multivariate logistic regression analysis.Results 8 patients (5.55％)died in hospital.16 patients (11.11％) needed CRRT for AKI.5 of them (31.25％) died in hospital.Of the 11 surviving patients,5 had complete recovery of renal function within 2 weeks after operation and stopped renal replacement therapy.The remaining 6 patients recovered their renal function within 3 months and stopped renal replacement therapy.Univariate analysis showed that there were significant differences in preoperative age,creatinine clearance,peripheral white blood cell count,D-dimer,myoglobin,double renal arteries in false lumen,aortic cross clamp time and red blood cell transfusions between the two groups.The above risk factors were included in multivariate logistic regression.The results showed that double renal arteries in false lumen (OR =24.64,P =0.002),serum creatinine clearance ＜ 85 ml/min (OR =4.99,P =0.02) and red blood cell transfusions (OR =1.17,P ＜ 0.001) were independent risk factors.Conclusion Double renal arteries in false lumen,serum creatinine clearance ＜ 85ml/min and red blood cell transfusions were independent risk factors for CRRT after Sun's procedure for acute Stanford A aortic dissection.For high-risk patients with double renal arteries in false lumen,and markedly decreased creatinine clearance before operation,red blood cell transfusions should be reduced as much as possible to reduce the risk of AKI after operation.

One-stage repair for adults aortic coarctation concomitant with cardiac diseases: ascending aorta-abdominal aorta by-pass combined with cardiac operation / 中华胸心血管外科杂志

Objective Evaluate the surgical result of ascending aorta-abdominal aorta bypass combined with cardiac op-eration for adults aortic coarctation concomitant with cardiac diseases.Methods Between February 2009 and September 2012, total 24 consecutive patients underwent ascending aorta-abdominal aorta bypass combined with cardiac operation.Of these pa-tients, 2 patients who underwent off-pump coronary artery bypass grafting combined with ascending aorta-abdominal aorta by-pass did not required cardiopulmonary bypass.Other 22 patients underwent one stage repair under cardiopulmonary bypass. The mean artery pressure of upper-lower limb was(38.0 ±9.34)mmHg.Results There was no in-hospital mortality.The mean artery pressure of upper-lower limb was(11.44 ±2.59)mmHg.The mean cardiopulmonary bypass time was(107.27 ± 34.56) min.The mean aorta clamp time was(72.59 ±28.98)min.The mean intensive care unit stay time is(35.22 ± 50.41)h.The mean mechanical ventilation time was(19.50 ±17.64)h.2 patients required prolonged mechanical ventilation for respiratory dysfunction.Of these 2 patients, 1 patient required ECMO support for respiratory failure.Total 1 patient needed temporary continuous renal replacement therapy.No re-exploration for bleeding and gastrointestinal complications were ob-served.Aorta CTA scan was performed for all patients before discharged from hospital.The grafts were patent for all patients and no graft-related complications were observed.Conclusion Ascending aorta-abdominal aorta bypass combined with cardiac operation is a safe and effective one stage repair technique for adults aortic coarctation concomitant with cardiac diseases is a safe and effective technique.

Sun' s procedure with preservation of autologous brachiocephalic vessels for chronic type A aortic dissection / 中华胸心血管外科杂志

Objective To summarize the clinical outcomes and surgical indications for chronic type A aortic dissection (CTAD) by using Sun's procedure with preservation of autologous brachiocephalic vessels.Methods From September 2010 to December 2013, 23 patients with CTAD underwent Sun's procedure with preservation of autologous brachiocephalic vessels under moderate hypothermic circulatory arrest combined with selective cerebral perfusion in our center .The data was collected and analysed retrospectively.There were 20 males and 3 females patients with a mean age of(49.91 ±10.05) years.Preopera-tive comorbidities included Marfan syndrome in 1 patient, isolated left vertebral artery in 1, hypertension in 19, coronary artery disease in 2, heart dysfunction in 1, renal insufficiency in 1, mitral regurgitation in 1, and pulmonary infection in 1.Previous operation history included thoracic endovascular aortic repair in 3, percutaneous coronary intervention in 1, aortic valve re-placement in 1, Bentall procedure in 1, and coronary artery bypass grafting in 1.Results The average operation time, car-diopulmonary bypass time, aortic cross clamping time and selective cerebral perfusion time was(6.43 ±1.03) h,(167.07 ± 49.62) min,(80.74 ±29.00) min, and(27.35 ±6.03) min, respectively.Concomitant procedures included Bentall proce-dure in 6 patients, ascending aorta replacement in 17, ascending aorta-femoral artery bypass in 1, mitral valvuloplasty in 1, and CABG in 1.There were 2(8.70%) in hospital deaths.Three patients suffered temporary renal dysfunction, and 1 with re-nal failure recieved continuous renal replacement therapy .Postoperative hypoxemia were found in 2 patients, and 1 of them re-ceived reintubation.These patients recovered before discharge.The mean follow-up time was(52.52 ±9.89) months with a follow-up rate of 95.23%(20/21).One patient suffered cerebral embolism but recovered soon after treatment.The others were free from any complications.Conclusion Sun's procedure with preservation of autologous brachiocephalic vessels simplified the aortic arch surgery and obtained satisfactory outcomes for suitable patients with CTAD , but surgical indications should be strictly considered.

The mid-term results of the staged total aortic replacement in Stanford type A aortic dissection / 中华胸心血管外科杂志

Objective To explore the mid-term results of the staged total aortic replacement in Stanford type A aortic dissection.Methods During March 2009 to September 2016,a total of 49 patients with Stanford type A aortic dissection in Beijing Anzhen Hospital cardiovascular center underwent total aortic replacement with a median age of 36 (27,41 years),male 36 (73.5％) cases.30 (61.2％) cases of them combined with Marfan syndrome.Results The interval between two stage operation was 23 (10,57) months.In the first stage operation,45 (91.8％) cases underwent Sun's procedure,2 (4.1％) underwent total aortic arch replacement,2 (4.1％) cases underwent classic elephant trunk and total aortic arch replacement.All patients underwent thoracoabdominal aortic repair(TAAAR).Deep hypothermic circulatory arrest surgery was 12(24.5％)cases in the second stage.7 (14.3％)cases dead postoperative.Spinal cord related complications happened in 3 (6.1％) cases with stroke in 2(4.1％) cases,acute renal insufficiency in 7(14.3 ％) cases,respiratory insufficiency in 7 cases (14.3％),re-operation for hemostasis in 3 (6.1％) cases and gastrointestinal bleeding in 3 cases(6.1％).Univariate analysis showed that the interval between two stage operation,operation time,deep hypothermic circulatory arrest surgery are risk factors for in-hospital mortality;multivariate analysis showed that deep hypothermic circulatory arrest surgery and the interval between two stage operation were independent risk factors for in-hospital mortality.3 years,5 years survival rate were 94.4％ and 78.7％.Conclusion For Stanford type A dissection especially the thoracoabdominal aortic expands,staged total aortic replacement shows good mid-term results.Block stentgraft can reduce the use of deep hypothermic circulatory arrests to decrease the mortality.

Discovery of stent graft mis-deployed into false lumen during aortic dissection treatment and re-deployment / 中华放射学杂志

Objective To discuss the discovery of stent graft mis-deployed into false lumen during aortic dissection treatment and re-deployment.Methods Retrospective analysis of the data of deployment of the stent-graft into the false lumen in the initial treatment of aortic dissection between January 2013 to December 2017.Of the five cases,there were three males and two females,range from 28 to 52 year old.Two patients,suffered from acute Stanford type A aortic dissection,with aortic surgical replacement and circulatory elephant trunk technique,displayed the visceral ischemia and internal environment disorder postoperatively.An emergency CT angiography showed that the deployed stent-graft was in the false lumen.Another two cases with sub-acute Stanford type B aortic dissection underwent TEVAR.The stent-grafts were put in the false lumen intra-operatively,one patient with pregnancy-induced hypertension suffered from acute Stanford type B aortic dissection.An emergency endovascular repair was set under general anesthesia to deal with this problem.New stent-graft was utilized to correct the blood flow into true lumen via flap fenestration or secondary intimal tear.Results The successful rate of this operation was 100％.Time of surgery spanned from 45 minutes to 120 minutes,and blood loss was estimated to be from 50 ml to 100 ml.Five stent grafts were placed with 160 mm length and 6 mm taper and one was 120 mm length and 10 mm taper.Patients were observed in ICU for three days and discharged from hospital after seven days.No complications such as paraplegia,visceral ischemia,etc occurred.Postoperative aortic CTA one month later showed no complications,such as endoleak,etc.The stents were in ideal position,with fluent blood flow of aorta and major visceral artery.Conclusions Deployment of the stent-graft in the false lumen is a rare and critical complication in the treatment of aortic dissection.In addition to clinical manifestations and laboratory tests,aortic CTA could identify this complication quickly and accurately.Endovascular repair was recommended as primary treatment of choice,which could re-direct the blood flow into true lumen via flap fenestration or secondary intimal tear technology quickly and effectively.

Open stented elephant trunk procedure for the repair of complicated type B dissection with an isolated left vertebralartery / 中华胸心血管外科杂志

Objeetive To summarize the resuhs of the surgical management of complicated type B dissection with an iso lated left vertebral artery(ILVA) using the stented elephant trunk technique.Methods Between February 2009 and September 2016,12 patients with complicated type B dissection(acute in 7 and chronic in 5) underwent the stented elephant trunk procedure under moderate circulatory arrest with selective antegrade cerebral perfusion.11 patients were males with a mean age of(50.9 ± 6.1) years(ranged 42-59 years).Preoperative limb ischaemia was obscrved in 2 patients,renal dysfunction in 1 patient.Results There was no in-hospital death.1 patient was suffered permanent hoarseness after the surgery.The cardiopulmonary bypass time was 143.1 ± 26.3 min and selective cerebral perfusion time was (27.2 ± 11.2) min.The follow-up time was 6-92 months,mean (40.9 ± 30.6) months.1 of the ischaemia of the limb patients was ameliorated after surgical stentgraft implantation,the other 1 was ameliorated after surgical stent-graft implantation combined with a bypass of the ascending aorta to the right femoral artery.No neurological deficits were observed in any patients prior to hospital discharge.2 patients underwent thoracic endovascular aortic repair and total thoracoabdominal aortic aneurysm repair respectively due to distal aortic aneurysm within the mean follow-up period.Conclusion Surgical repair of complicated type B dissection with an ILVA using the stented elephant trunk technique can obtain a satisfactory med-term clinical results.

Using the Delphi method to establish a Chinese experts' consensus of the surgical management for type A aortic dissection / 中华胸心血管外科杂志

Objective To establish a Chinese expert consensus of the surgical management for type A aortic dissection (TAAD) by using the Delphi method.Methods A systematic review of the previously published literature related to management of TAAD at home and abroad was conducted to formulate a questionnaire of clinical consensus of the surgical treatment for TAAD.This questionnaire including seven aspects of surgical management for TAAD,namely contraindications to operative management,cannulation site,target temperature during circulation arrest,cerebral perfusion strategy,surgical procedure,distal anastomotic technique and surgical management for patients with connective tissue disease such as Marfan syndrome.From October 2015 to April 2016,we performed two rounds Delphi survey in which the current professional opinions from 55 experienced and representative cardiovascular surgeons in China,were gathered and analysed.Results The responses rates of two rounds were 80.0％ (44/55) and 77.27％ (34/44).The scores of authoritative coefficient was 0.87 and 0.83.The coefficient of concordance were 0.31 (P ＜ 0.05) and 0.32 (P ＜ 0.05).After two rounds of consultation,consensus of the surgical management for TAAD was reached on 16 items of seven aspects.Conclusion This Delphi study established an initial Chinese expert consensus concerning the surgical management for TAAD,which drew credible results and reliable conclusions.This study will helo to standardize the surgical management of TAAD in China.

Open stented elephant trunk procedure for the repair of complicated type B dissection with an isolated left vertebralartery / 中华胸心血管外科杂志

Objeetive To summarize the resuhs of the surgical management of complicated type B dissection with an iso lated left vertebral artery(ILVA) using the stented elephant trunk technique.Methods Between February 2009 and September 2016,12 patients with complicated type B dissection(acute in 7 and chronic in 5) underwent the stented elephant trunk procedure under moderate circulatory arrest with selective antegrade cerebral perfusion.11 patients were males with a mean age of(50.9 ± 6.1) years(ranged 42-59 years).Preoperative limb ischaemia was obscrved in 2 patients,renal dysfunction in 1 patient.Results There was no in-hospital death.1 patient was suffered permanent hoarseness after the surgery.The cardiopulmonary bypass time was 143.1 ± 26.3 min and selective cerebral perfusion time was (27.2 ± 11.2) min.The follow-up time was 6-92 months,mean (40.9 ± 30.6) months.1 of the ischaemia of the limb patients was ameliorated after surgical stentgraft implantation,the other 1 was ameliorated after surgical stent-graft implantation combined with a bypass of the ascending aorta to the right femoral artery.No neurological deficits were observed in any patients prior to hospital discharge.2 patients underwent thoracic endovascular aortic repair and total thoracoabdominal aortic aneurysm repair respectively due to distal aortic aneurysm within the mean follow-up period.Conclusion Surgical repair of complicated type B dissection with an ILVA using the stented elephant trunk technique can obtain a satisfactory med-term clinical results.

Surgical repair of left-sided cervical aortic arch aneurysm / 中华胸心血管外科杂志

Objective To summarize our experience of surgical repair for cervical aortic arch(CAA) aneurysm and eval-uate early and midterm results of these patients.Methods From January 2010 to December 2014, 22 patients with left-sided CAA aneurysm admitted in our center.There were 6 male and 16 female patients with a mean age of(34.09 ±13.14) years. Comorbidities included pseudocoarctation in 9 patients, hypertension in 4 patients, and aortic valve insufficiency, Stanford type B aortic dissection and middle cerebral artery aneurysm each had 1 patient.All of the patients underwent surgical aortic arch re-construction using artificial graft replacement.Among them, 4(4/22, 18.18%) were performed under moderate hypothermic circulatory arrest(MHCA) combined with selective antegrade cerebral perfusion(SACP) via a median sternotomy, and concom-itant aortic valve replacement(AVR) was implemented in 1 patient.18(18/22, 81.82%) were performed via posterolateral left thoracotomy through the 4th intercostal space, and adjunct methods applied included partial CPB and “simple clamping” in 10 and 8 of these patients respectively.Results The average mechanical ventilation time and ICU stay time was (13.05 ± 4.73)h and(19.14 ±8.08) h respectively.1 patient required repeat thoracotomy for bleeding, 1 patient with delayed wound healing and 1 patient suffered transient liver dysfunction.There were no in-hospital deaths.Mean follow-up time was 34.73 months, and 3 patients were lost during follow-up.There were no late deaths during follow-up.Conclusion Repair of CAA is indicated for the patients with arch aneurysm formation .According to the locations and types of aneurysms and other concomi-tant proximal cardiovascular diseases, performing one-stage surgical aortic arch reconstruction with individualized incisions , ad-junct methods and operative procedures can obtain satisfactory clinical outcomes in patients with CAA aneurysm .

Preliminary exploration of mathematical model in predicting the prognosis of Chinese people undergoing aortic surgery / 中华胸心血管外科杂志

Objective To establish the risk scoring system in predicting prolonged intensive care unit(ICU) stay after Sun' s procedure(total aortic arch replacement with stented elephant trunk implantation) for Stanford type A aortic dissection.Accumulate experience in establishing the mathematical model in predicting the prognosis of Chinese people undergoing aortic surgery.Methods Between February 2009 and February 2012,data from 384 consecutive patients in Bejing Anzhen Hospotal,who underwent aortic surgery using Sun' s procedure,were collected retrospectively.Lengths of ICU stay longer than 7 days was defined as prolonged ICU stay.All the factors related to prolonged ICU stay were entered into univariate analysis.Then the variables with statistical difference were entered into multiple logistic analysis.The mathematical model was established based on the logistic analysis.The C-statistic was used to test discrimination of the model.Calibration was assessed with the Hosmer-Lemeshow goodness-of-fit statistic.Results The in-hospital mortality was 8.07％.The mean length of ICU stay was 3.06 days.42 patients stayed in ICU for 7 days or more.Logistic regression identified that preoperative stroke history(P =0.001,0R =9.40,regression coefficient =2.24),creatinine clearance ≤ 50 ml/min (P =0.03,OR =2.91,regression coefficient =1.07) surgical period from symptom onset shorter than 1 week (P =0.003,OR =2.89,regression coefficient =1.06),combining with coronary artery bypass grafting(P =0.03,OR =3.14,regression coefficient =1.15) were final independent risk factor for prolonged ICU stay.Simple logistic score were defined as:stroke history 22 points,creatinine clearance ≤50 ml/min 11 points,surgical period from symptom onset shorter than 1 week 11 points,combining with coronary artery bypass grafting 12 points.Additive score was defined as:stroke history 9 points,surgical period from symptom onset shorter than 1 week 3 points,creatinine clearance≤50 ml/min 11 points 3 points,combining with coronary artery bypass grafting 3 points.C statistic (receiver operating characteristic curve) for logistic algorithm was 0.72 and for additive model was 0.71.However,Hosmer Lemeshow goodness-of-fit was good (P ＞ 0.05) for logistic algorithm,was poor for additive model(P ＜ 0.05).Conclusion Using logistic regression to establish a scoring system predicting the prognosis of aortic surgery is feasible.The predicting model utilizing regression coefficient is accurate and is convenient for clinical using.Additive algorithm is not accurate and should be abandoned.

Reoperation is not the risk factor for mortality after Sun's procedure for Stanford type A aortic dissection involving aortic arch / 中华胸心血管外科杂志

Objective The aim of this study was to evaluate whether the reoperation is the risk factor for mortality after Sun's procedure(Total aortic arch replacement + frozen elephant trunk) for Stanford type A aortic dissection involving aortic arch.Methods Between February 2009 to February 2012,data from 383 patients who underwent Sun's procedure for Stanford type A aortic dissection involving aortic arch were collected retrospectively.35 patients had history of cardiac surgery.Of these patients,16 patients had underwent Bentall procedure,7 patients ascending aortic replacement,4 patients Wheat surgery,4 patients aortic valve replacement,2 patents Bentall combined with mitral valve replacement or plasty,1 patient bivalve replacement,1 patient atrial septal defect repair,1 patient coronary artery surgery.All the risk factors related to mortality were analyzed by univariate statistical analysis.Significant univariate variables were entered into multiple logistic analysis.Results Total 31 patients died in the hospital and the mortality was 8.07％.Of the 35 patients with history of cardiac surgery,3 patients died and the mortality was 8.33％.Univariate analysis showed that symptom onset before surgery less than 1 week,preoperative limb ischemia,combining with coronary artery surgery and cardiopulmonary bypass time longer than 300 minutes in the operative were risk factors for mortality.After these factors were entered into multiple logistic regression analysis,the result showed that symptom onset before surgery less than 1 week (P =0.038,OR =2.43),cardiopulmonary bypass time longer than 300 minutes(PP ＜0.001,OR =12.05) were final independent risk factors for mortality.Reoperation was not the independent risk factor for mortality.The intensive care unit and mechanical ventilation length of reoperation group was (2.09 ± 1.89) days and(30.09 ±33.42) hours respectively,while that of primary group was(2.71 ±3.01) days (P =0.25) and(33.86 ±40.98) hours(P =0.61) respectively.The incidence of postoperative bleeding of reoperation group was 3.03％,while that of primary group was 1.88％ (P =0.50).Conclusion Reoperation was not the independent risk factor for mortality after Sun's procedure for Stanford type A aortic dissection involving aortic arch and the morbidity was also not higher than primary surgery.For these patients,sun' s procedure should be advocated.

The validation of EuroSCORE Ⅱ in predicting the mid-term outcome of patients undergoing Sun's procedure for Stanford type A dissection / 中华胸心血管外科杂志

Objective EuroSCORE is a widely used objective risk scoring model.The aim of this study was to evaluate the validation of EuroSCORE Ⅱ in predicting mid-term survival after total aortic arch replacement with stented elephant trunk implantation(sun' s procedure) for Stanford Type A aortic dissection.Methods Total 90 patients entered the study randomly.All the patients underwent aortic surgery using total aortic arch replacement with stented elephant trunk implantation (Sun's procedure).The patients were divided into three groups based on the predicting mortality by EuroSCORE Ⅱ.Ggroup 1:0 ＜:P ≤ 5 ％,Group 2:5 ％ ＜ P ≤ 10％,Group 3:P ＞ 10％.Kaplan-Meier method was used to evaluate the long term survival of three groups.Receiver operating characteristic curve was used to test discrimination of the EuroSCORE.Calibration was assessed with a Hosmer-Lemeshow goodness-offit statistic.Results 87 patients were followed umil October,2013.The mean follow-up time was(33.32 ± 11.11) months.Total 5 patients died during the follow-up time.Three patients died in group 1,2 patients died in group 2 and 1 in group 3.There was no statistical difference for the mid-term survival rate between 3 groups (P =0.054).Conclusion Although EuroSCORE Ⅱ is the newest risk model for cardiac surgery,it is not accurate when it is applied for predicting mid-term survival after aortic surgery.A new risk evaluating system specially designed for aortic surgery should be developed in the future.

The surgical repair for Stanford type A aortic dissection after cardiac surgery / 中华胸心血管外科杂志

Objective To summarize the experience of surgical repair for Stanford type A aortic dissection after cardiac surgery.Methods From February 2009 to December 2011,11 patients who underwent previous cardiac surgery accepted the aortic surgery for Stanford type A aortic dissection.There were 8 males and 3 females.The range of age was from 29 to 64 years,the mean age was(52.27±9.90) years.In these patients,one patient had underwent ventrical septal defect,one patient atrial septal defect,nine patients aortic valve replacement.The interval between the two operations was 1-26 years.The types of aortic dissection was A1S(4 patients),A1C(1 patient),A2S(1 patient),A2C(4 patients),A3C(1 patient).All the patients underwent aortic surgery for aortic dissection.Results The time of cardiopulmonary bypass was 75-409 minutes,the mean value was(185.36± 99.67) minutes.Aortic cross clamp time was 37-203 minutes,the mean value was (84.09± 48.36) minutes.Total six patients needed deep hypothermia and selective cerebral perfusion time was 8-32 minutes.The mean value was(17.71 ± 9.48) minutes.One patient dead in the hospital and the mortality was 9％.The morbidity was 27％.Ten patients followed up 16-45 months.No aortic rupture,paraplegia and death were observed in follow-up time.Conclusion The delayed Stanford type A aortic dissection after cardiac surgery should be attached great importance and always need emergency surgery to save patients' life.The technique is demanding and risk is great for surgeons and patients.For the patients who suffered aortic valve disease combined with dilation of ascending aorta larger than 4.5 cm,the ascending aorta also should be repaired while aortic valve replacement is performed,which could avoid delayed aortic dissection in the future.