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Objective:To explore the correlation between intraoperative cooling temperature and postoperative neurological prognosis in aortic arch surgery.Methods:We observed and collected data from 118 patients who underwent open arch replacement surgery by a single surgeon with mild-to-moderate hypothermic circulatory arrest, from January 2017 to December 2020, in Beijing Anzhen Hospital. According to the bladder temperature during the circulation arrest, 118 patients were divided into 3 groups: T1 group[n=39, (25.58±0.64)℃]; T2 group[n=39, (28.21±0.77)℃]; T3 group[n=40, (30.95±0.97)℃]. Clinical data and operative data were analyzed to assess difference between these 3 groups. Analyze the risk factors of postoperative neurological complications, and explore further the correlation between intraoperative core temperature and postoperative neurological prognosis.Results:Among the 118 patients, the average operation, cardiopulmonary bypass (CPB), block, circulatory arrest, and selective cerebral perfusion (SCP) time were 6.64 h, 188.5 min, 104.19 min, 23.93 min, 28.81 min, respectively. The in-hospital death occurred in 8 patients(6.78%), and permanent neurological dysfunction (PND) in 13 patients(11.02%), transient neurological dysfunction (TND) in 25 patients(21.19%). There was no significant difference in the deaths among the three groups. The incidence of TND and PND in the T3 group was significantly reduced ( P=0.042; P=0.045). In addition, the volume of drainage during the first 24 h and the incidence of re-exploration for bleeding had a relatively obvious decreasing trend ( P=0.005; P=0.012). Through multiple regression analysis, under the adjusted model, the core temperature was independently correlated with the incidence of postoperative PND ( OR=0.51; 95% CI: 0.27-0.97; P=0.0389); in group comparison, the relatively higher core temperature was an independent protective factor for postoperative PND ( OR=0.04; 95% CI: 0.00-0.91; P=0.0434). Conclusion:Our research had preliminary proved that in the open arch replacement surgery, mild hypothermia can reduce the incidence of some complications of deep hypothermia, at the same time improve the prognosis of the neurological prognosis, reduce the incidence of postoperative PND.
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Objective:To explore the application of cannulating the ischemic femoral and right axillary artery in Sun’s procedure for acute type A aortic dissection with lower extremity ischemia.Methods:Twelve patients of acute Stanford type A aortic dissection complicated by lower extremity ischemia were analyzed retrospectively between July 2017 and May 2019, and the right axillary and ischemic femoral artery were used for cardiopulmonary bypass. All the 12 patients were male and categorized as the complicated Stanford type A aortic dissection. The mean age was(48.4±8.4)years, and the median time from symptom onset to emergency operation was 24.00(18.50, 43.25)hours. Eleven patients presented with unilateral extremity ischemia, while bilateral extremity ischemia occurred in one. The prosthetic vessel, with a diameter of 8 mm, was anastomosed to the ischemic femoral artery via an end-to-side way. Both the right axillary artery and the prosthetic vessel were cannulated for CPB. For the proximal dissection in this cohort of patients, we performed Bentall procedure in 5 cases, ascending aortic replacement in 3, and the aortic valve commissure reconstruction with ascending aortic replacement in 4. Total arch replacement with stented elephant trunk implantation were carried out for arch and descending aortic lesion in 12 cases.Results:Early mortality was 8.3%(1/12). The time of CPB, aortic clamp, circulatory arrest, and selective cerebral perfusion averaged(204.6±26.3) min, (114.6±16.6) min, (23.4±8.5) min, and(33.5±11.0) min, respectively. Five patients underwent concomitant bypass procedures, including: ascending aorta-bilateral femoral artery bypass in 1, ascending aorta-right femoral artery bypass in 3, ascending aorta-left femoral artery bypass in 1. Acute renal failure with continuous renal replacement therapy occurred in 4 cases, re-thoratomy for hemaostsis in 1, and re-intubation in 1. One patient developed osteofascial compartment syndrome after aortic repair, and consequent left lower extremity compartment fasciotomy was performed. The mean follow-up time was(17.2±7.6)months, and no aortic-related adverse event was detected during follow up.Conclusion:To acute Stanford type A aortic dissection with lower extremity ischemia, cannulating the ischemic femoral and right axillary artery in Sun’s procedure were associated with lower perioperative mortality and better prognosis.
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Objective:To evaluate the application of moderate hypothermia circulatory arrest(MHCA)with a higher temperature(29℃) and bilateral selective antegrade cerebral perfusion(bSACP) in acute Stanford type A aortic dissection(TAAD] treated by total arch replacement with stented elephant trunk implantation.Methods:From July 2019 to January 2020, fifteen patients of acute TAAD undergoing emergent operations via MHCA with a core temperature of 29℃ and bSACP were analyzed retrospectively(modified group), and 26 patients treated by MHCA(25℃) and unilateral selective antegrade cerebral perfusion(uSACP) during the same period were defined as the traditional group. All cases were complicated type A dissection. The mean age in this cohort was 49 years, and 32 patients(78%) were male. Thirty six patients(87.8%) suffered from arterial hypertension. The proximal manipulations included: aortic sinus repair in 13 cases(31.7%), ascending aortic replacement in 29(70.7%), Bentall in 12(29.3%). Total arch replacement with stented elephant trunk implantation was performed in all cases.Results:The in-hospital death occurred in 2(4.9%), and cerebral infarction in 3(7.3%), transient neurologic deficit in 5(12.2%), paraplegia in 2(4.9%). The ratios of above-mentioned adverse events in the traditional and modified group were[2(7.7%) vs. 0, P=0.524], [3(11.5%)vs. 0, P=0.287], [4(15.4%) vs. 1(6.7%), P=0.636], [1(3.8%) vs. 1(6.7%), P=1.000] respectively. The major adverse events in the modified group were transient neurologic deficit and paraplegia in 1 each. Compared with the traditional group, the time of operation, CPB, cardiac arrest, circulatory arrest of the lower part, anterograde low flow cerebral perfusion, mechanical ventilation and ICU stay was shorter. The drainage of 48 hours after surgery was less also. The differences in new acute renal failure requiring CRRT and re-sternotomy for bleeding between groups were not statistical significance. Conclusion:The early results of MHCA(29℃) and bSACP applied in total arch replacement with stented elephant trunk implantation for acute TAAD were satisfactory. The time of mechanical ventilation and ICU stay was shorter in the modified group, and the drainage of 48 hours after surgery was less also.
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Objective To observe the clinical effect of isosorbide mononitrate combined with metoprolol in the treatment of coronary heart failure.Methods From January 2015 to May 2017,100 patients with coronary heart failure treated in the Second People's Hospital of Yuyao were randomly divided into two groups according to the digital table,with 50 cases in each group.The conventional group was treated with conventional therapy.The observation group was treated with isosorbide mononitrate combined with metoprolol on the basis of conventional treatment for 30 days.The clinical efficacy,cardiac function index and plasma BNP level were compared between the two groups.Results The total effective rate of the observation group was 96.0％ (48/50),which was higher than 78.0％ (39/50) in the conventional group(x2 =7.161,P ＜ 0.01).After treatment,the cardiac drainage index(CI) [(3.14 ± 0.53) L · min-1 · (m2)-1],cardiac output blood volume (CO) [(5.62 ± 0.95) L/min],each stroke volume (SV) [(79.24 ± 2.56) mL],left ventricular ejection fraction (LVEF) [(61.62 ± 4.95) ％] in the observation group were better than those in the conventional group[(2.41 ±0.45) L · min-1 · (m2)-1,(4.79 ± 0.23) L/min,(72.30 ± 2.78)mL,(53.79 ±4.23)％,t =7.043,5.696,12.318,8.066,all P ＜0.05].The BNP level of the observation group was (172.17 ± 10.36) pg/mL,which was lower than (215.47 ± 12.48) pg/mL of the conventional group (t =17.908,P ＜ 0.05).Conclusion The treatment of coronary heart failure with isosorbide mononitrate and metoprolol can improve the clinical effect and improve cardiac function.
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Objective To confirm the impact of renal malperfusion on early and late outcomes of patients undergoing sur-gery for type A aortic dissection(TAAD). Methods From June 2011 to July 2012,a total of 165 TAAD patients undergoing surgery in hospital were enrolled and divided into 2 groups based on the results:research group(complicated with renal malper-fusion),control group(without renal malperfusion). A cohort follow-up project was conducted among these patients. The pri-mary outcome was all-cause death. Baseline and operative characteristics,early and late outcomes were analyzed to assess difference between 2 groups. Cumlative survival rates within 72 months among the 2 groups was described with Kaplan-Meier curves. Cox proportional hazards model was used to estimate the hazard ratios(HR)and 95％ confidence intervals(95％ CI)of late mortality among the 2 groups. Results Renal malperfusion was detected in 38(23. 0％)of 165 TAAD patients. 30-day mortality was 15. 8％ and 3. 9％ in patients with and without renal malperfusion(P < 0. 05),respectively. The mean follow-up period was(67 ± 3)months,late survival was 68. 4％ in patients with renal malperfusion and 88. 2％ in patients without(P <0. 05). By Cox proportional hazards model,after adjusting forage,sex,group(acute or chronic),presence of cardiac tampon-ade,brachiocephalic vessels involvement,coronary arteries involvement,root replacement,total arch replacement,concomitant coronary artery bypass grafting(CABG)and other organ-malperfusion,when compared to the control group,the HR(95％ CI) of late mortality was 5. 18( 1. 07 - 5. 18)in the research group. Besides renal malperfusion,concomitant coronary artery bypass grafting was presented as an independent risk factor of long-term survival(HR = 10. 08,95％ CI:2. 28 - 44. 62,P = 0. 002). Conclusion Coexistence of renal malperfusion is associated with a substantially increased risk of death in patients undergoing surgery for TAAD. A more exact stratification that weight every malperfusion-affected organ but not base on the number of malp-erfusion-affected organ simply may be more helpful to TAAD patients with malperfusion syndrome.
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Objective This study aimed at exploring the causative genes and summarizing the clinical characteristics in two Chinese families with thoracic aortic aneurysm and dissection ( TAAD ) .Methods The whole exome capture and high throughput sequencing were applied to identify the causative gene.Family members were examined for features of syndromic ge-netic diseases by clinician and geneticist.Results Four known TAAD candidate genes were identified in family TAA01:rs140598(FBN1), rs185661462(MYH11), rs77620762(MYLK3), and rs111426349(TGFBR1).The TGFBR1 mutation (c.1459C>T) had been confirmed to co-segregate with the TAAD phenotype in all affected family members.Early onset of aortic root dilatation was significant in this family , and the average age at diagnosis of aortic root dilatation or aneurysm was23. 2 years.ACTA2(c.445C>T) was proved in family TAA02, and livedo reticularis was confirmed.Conclusion The causa-tive genes were identified via whole exome capture and high throughput sequencing in two TAAD families .Early onset of aortic root aneurysm was proved in TAA01, while livedo reticularis was found in TAA02.