Prognostic Value of Left Ventricular Longitudinal Function and Myocardial Fibrosis in Patients With Ischemic and Non-Ischemic Dilated Cardiomyopathy Concomitant With Type 2 Diabetes Mellitus: A 3.0 T Cardiac MR Study.

BACKGROUND: Poorly controlled type 2 diabetes mellitus (T2DM) is known to result in left ventricular (LV) dysfunction, myocardial fibrosis, and ischemic/nonischemic dilated cardiomyopathy (ICM/NIDCM). However, less is known about the prognostic value of T2DM on LV longitudinal function and late gadolinium enhancement (LGE) assessed with cardiac MRI in ICM/NIDCM patients. PURPOSE: To measure LV longitudinal function and myocardial scar in ICM/NIDCM patients with T2DM and to determine their prognostic values. STUDY TYPE: Retrospective cohort. POPULATION: Two hundred thirty-five ICM/NIDCM patients (158 with T2DM and 77 without T2DM). FIELD STRENGTH/SEQUENCE: 3T; steady-state free precession cine; phase-sensitive inversion recovery segmented gradient echo LGE sequences. ASSESSMENT: Global peak longitudinal systolic strain rate (GLPSSR) was evaluated to LV longitudinal function with feature tracking. The predictive value of GLPSSR was determined with ROC curve. Glycated hemoglobin (HbA1c) was measured. The primary adverse cardiovascular endpoint was follow up every 3 months. STATISTICAL TESTS: Mann-Whitney U test or student's t-test; Intra and inter-observer variabilities; Kaplan-Meier method; Cox proportional hazards analysis (threshold = 5%). RESULTS: ICM/NIDCM patients with T2DM exhibited significantly lower absolute value of GLPSSR (0.39 ± 0.14 vs. 0.49 ± 0.18) and higher proportion of LGE positive (+) despite similar LV ejection fraction, compared to without T2DM. LV GLPSSR was able to predict primary endpoint (AUC 0.73) and optimal cutoff point was 0.4. ICM/NIDCM patients with T2DM (GLPSSR < 0.4) had more markedly impaired survival. Importantly, this group (GLPSSR < 0.4, HbA1c ≥ 7.8%, or LGE (+)) exhibited the worst survival. In multivariate analysis, GLPSSR, HbA1c, and LGE (+) significantly predicted primary adverse cardiovascular endpoint in overall ICM/NIDCM and ICM/NIDCM patients with T2DM. CONCLUSIONS: T2DM has an additive deleterious effect on LV longitudinal function and myocardial fibrosis in ICM/NIDCM patients. Combining GLPSSR, HbA1c, and LGE could be promising markers in predicting outcomes in ICM/NIDCM patients with T2DM. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: 5.

Early and long-term outcomes of young adult patients ≤30 years old with acute type A aortic dissection.

OBJECTIVES: The aim of this study was to investigate the early and long-term outcomes after total arch replacement (TAR) and frozen elephant trunk (FET) implantation in adult patients ≤30 years with acute type A aortic dissection (ATAAD). METHODS: All young adult patients (≤30 years) with ATAAD who underwent TAR and FET between 2009 and 2017 were enrolled. The end points were major organ morbidity and mortality, aortic-related events and reoperation. RESULTS: The mean age of all 83 patients was 25.9 (standard deviation, 3.3) years. The in-hospital mortality was 9.64% (8/83), and 9 (10.8%) patients required re-exploration for bleeding. The aortic-related events risk was 42.7% (32/75) and the aortic reoperation risk was 17.3% (13/75). Overall survival was 85.5% [95% confidence interval (CI), 75.9-91.5%] at 5 years and 75.9% (95% CI, 63.3-84.7%) at 10 years. The cumulative incidence of aortic-related events was 35% (95% CI, 24-47%) at 5 years and 58% (95% CI, 36-75%) at 10 years; the cumulative reoperation rate was 15% (95% CI, 7.9-24%) at 5 years and 17% (95% CI, 9.2-27%) at 10 years. Marfan syndrome significantly increased the aortic-related events (P = 0.036) and reoperation (P = 0.041) risks. CONCLUSIONS: Despite extensive repair in young ATAAD patients, the late aortic dilatation and reoperation risk remain high. The TAR and FET procedures achieved satisfactory early outcomes and reduced late aortic dilatation and reoperation in young patients compared with other records. Close follow-up and aggressive early reintervention are essential for patients with aortic-related risk factors early in life.

Fate of the distal aorta following root replacement in Marfan syndrome: a propensity score matched study.

Objective: The aortic root is the most frequent segment involved in Marfan syndrome. However, Marfan syndrome is a systemic hereditary connective tissue disorder, and knowledge regarding the outcomes of the native distal aorta after prophylactic aortic root surgery is limited. Methods: From April 2010 to December 2020, 226 patients with Marfan syndrome and 1,200 patients without Marfan syndrome who underwent Bentall procedures were included in this study. By propensity score matching, 134 patients were assigned to each group. Clinical manifestations and follow-up data were acquired from hospital records and telephone contact. The cumulative incidence of aortic events was estimated in Marfan and non-Marfan patients with death as a competing risk. Results: Patients with and without Marfan syndrome had similar baseline characteristics after propensity score matching. Differences in the aortic root (62.25 ± 11.96 vs. 54.03 ± 13.76, P < .001) and ascending aorta (37.71 ± 9.86 vs. 48.16 ± 16.01, P < .001) remained after matching. No difference was observed in the frequency of aortic adverse events between the two groups (10.5% vs. 4.6%, P = 0.106). The cumulative incidence of aortic events was not different between Marfan and non-Marfan patients (15.03% ± 4.72% vs. 4.18% ± 2.06%, P = 0.147). Multivariate Cox regression indicated no significant impact of Marfan syndrome on distal aortic events (HR: 1.172, 95% CI: 0.263-5.230, P = 0.835). Descending and abdominal aortic diameter above normal at the initial procedure were associated with the risk of distal aortic events (HR: 20.735, P = .003, HR: 22.981, P = .002, respectively). Conclusions: New-onset events of the residual aorta in patients undergoing Bentall procedures between the Marfan and non-Marfan groups were not significantly different. Distal aortic diameter above normal at initial surgery was associated with a higher risk of adverse aortic events.

Aortic Arch-Clamping Technique in Hemiarch Replacement Without Circulatory Arrest.

The open anastomosis technique has become more popular since it was first used in hemiarch replacement; however, hypothermic circulatory arrest is unavoidable. This institution performed a novel surgical technique called the arch-clamping technique. It has been used in the treatment of patients with ascending aortic aneurysm extending to the proximal aortic arch and avoids the use of hypothermic circulatory arrest. Thirty patients had a hemiarch replacement with the arch-clamping technique from 2021 to 2022; all of them were discharged uneventfully.

Anzhen Risk Evaluation System for Acute Aortic Syndrome (AZSCORE-AAS): protocol for a multicentre prospective cohort study in northern China.

INTRODUCTION: Acute aortic syndrome (AAS) is a group of acute and critical conditions, including acute aortic dissection (AAD), acute intramural haematoma and penetrating aortic ulcer. High mortality and morbidity rates result in a poor patient prognosis. Prompt diagnoses and timely interventions are paramount for saving patients' lives. In recent years, risk models for AAD have been established worldwide; however, a risk evaluation system for AAS is still lacking in China. Therefore, this study aims to develop an early warning and risk scoring system in combination with the novel potential biomarker soluble ST2 (sST2) for AAS. METHODS AND ANALYSIS: This multicentre, prospective, observational study will recruit patients diagnosed with AAS at three tertiary referral centres from 1 January 2020 to 31 December 2023. We will analyse the discrepancies in sST2 levels in patients with different AAS types and explore the accuracy of sST2 in distinguishing between them. We will also incorporate potential risk factors and sST2 into a logistic regression model to establish a logistic risk scoring system for predicting postoperative death and prolonged intensive care unit stay in patients with AAS. ETHICS AND DISSEMINATION: This study was registered on the Chinese Clinical Trial Registry website (http://www. chictr. org. cn/). Ethical approval was obtained from the human research ethics committees of Beijing Anzhen Hospital (KS2019016). The ethics review board of each participating hospital agreed to participate. The final risk prediction model will be published in an appropriate journal and disseminated as a mobile application for clinical use. Approval and anonymised data will be shared. TRIAL REGISTRATION NUMBER: ChiCTR1900027763.

Association between preoperative serum myoglobin and acute kidney injury after Stanford Type A aortic dissection surgery.

BACKGROUND: Acute kidney injury (AKI) is a common complication after Type A aortic dissection (TAAD) surgery, and it is associated with poor outcomes. The nephrotoxic effect of myoglobin was established, but its correlation with AKI following TAAD repair still lacks sufficient evidence. We clarified the correlation between preoperative serum myoglobin (pre-sMyo) concentrations and AKI after TAAD surgery. METHOD: A retrospective analysis was performed on the perioperative data of 382 patients treated with TAAD surgery at Beijing Anzhen Hospital. AKI was defined and classified according to the criteria established by the Kidney Disease: Improving Global Outcomes Acute Kidney Injury Work Group. We attempted to determine the correlation between pre-sMyo concentrations and postoperative AKI. RESULTS: The incidences of Stage 1, 2, and 3 AKI were 37.3 % (57/153), 23.5 % (36/153), and 39.2 % (60/153), respectively. The pre-sMyo concentrations of the AKI group were significantly increased than the non-AKI group [43.1 (21.4, 107.5) vs 26.4 (18.0, 37.2), P < 0.001]. Pre-sMyo concentrations have a linear correlation with preoperative renal function-related indicators. The multivariable logistic regression analysis showed that Ln (pre-sMyo) was an independent risk factor for AKI. When the pre-sMyo concentration was at the fourth quartile [109.3 (64.8, 213.4) ng/ml], the risk of developing any-stage and severe AKI was significantly increased (OR = 4.333, 95 % CI: 2.364-7.943, P < 0.001; OR = 3.862, 95 %, CI: 2.011-7.419, P < 0.001). This difference persisted after adjustment (OR = 3.830, 95 % CI: 1.848-7.936, P < 0.001; OR = 2.330, 95 % CI: 1.045-5.199, P = 0.039). Furthermore, pre-sMyo concentrations were not affected by lower limb malperfusion, myocardial malperfusion, and cardiac tamponade. CONCLUSIONS: Increased pre-sMyo concentrations correlated with postoperative AKI in TAAD, which may increase the risk of developing any-stage AKI and severe AKI after TAAD surgery.

Redo Total Aortic Arch Replacement in Patients with Aortic Dissection After Open-Heart Surgery and Long-Term Follow-Up Results.

INTRODUCTION: The objectives of this study were to investigate the main treatment strategies and long-term follow-up results of aortic dissection surgery after open-heart surgery (ADSOHS) and to analyze the risk factors that cause ADSOHS. METHODS: One hundred thirty-seven patients with ADSOHS hospitalized in our hospital from January 2009 to December 2018 were selected as the research object. Long-term follow-up results, complications, mortality, and changes of cardiac function before and after operation were used to explore the value of Sun's operation. RESULTS: The length of stay in intensive care unit of these 137 patients ranged from 9.5 to 623.75 hours (average of 76.41±97.29 hours), auxiliary ventilation time ranged from 6.0 to 259.83 hours (average of 46.16±55.59 hours), and hospital stay ranged from six to 85 days (average of 25.06±13.04 days). There were seven cases of postoperative low cardiac output, 18 cases of coma and stroke, and six cases of transient neurological dysfunction. A total of 33 patients died; 19 patients died during the perioperative period, 18 died during Sun's operation and one died during other operation; and 14 patients died during follow-up (January 2021), 12 cases of Sun's operation and two cases of other operations. CONCLUSION: ADSOHS treatment strategy is of high application value, and the risk of neurological complications and mortality is low. The main risk factors are postoperative low cardiac output, coma, stroke, and transient neurological dysfunction. The extracorporeal circulation time is relatively long. Short- and long-term follow-up effects are good, and it is worthy of clinical promotion.

Surgical management and outcomes of coronary artery involvement secondary to acute type A aortic dissection: a retrospective cohort study.

Background: Coronary artery involvement (CAI) remains a fatal comorbidity in the context of acute type A aortic dissection (ATAAD). We evaluated the impact of CAI on the perioperative and short-term outcomes of patients with ATAAD who underwent total arch replacement (TAR) and frozen elephant trunk (FET) implantation and shared our surgical management experience with the involved coronary artery. Methods: In this retrospective cohort study, a total of 204 patients with ATAAD between June 2019 and December 2021 were enrolled and divided into the CAI group (n=67) and the non-CAI group (n=137). The characteristics of CAI lesions were described according to the Neri classification. Univariable and multivariable analyses were used to identify independent risk factors for in-hospital mortality. Survival analysis was performed using the Kaplan-Meier method and compared using the log-rank test. Results: Patients in the CAI group had a longer intraoperative duration of cardiopulmonary bypass (CPB) and cross-clamp, and experienced longer mechanical ventilation time and intensive care unit stays postoperatively. Regarding perioperative outcomes, the prevalence rates of new-onset continuous renal replacement therapy requirement (23.9% vs. 10.2%, P=0.01) and in-hospital mortality (17.9% vs. 7.3%, P=0.02) were higher in the CAI group. Coronary artery malperfusion (CAM) was an independent risk factor for in-hospital mortality. Short-term survival analysis was similar between the two groups (P=0.146). Conclusions: For patients with ATAAD undergoing TAR and FET implantation, concomitant CAI may complicate surgery and increase in-hospital morbidity and mortality. CAM secondary to CAI was identified as an independent risk factor. However, short-term survival after hospital discharge was comparable between the two groups. Coronary ostium repair is quick and operable for both type A and type B lesions, while optimal management still warrants further investigation.

Redo Total Aortic Arch Replacement in Patients with Aortic Dissection After Open-Heart Surgery and Long-Term Follow-Up Results

ABSTRACT Introduction: The objectives of this study were to investigate the main treatment strategies and long-term follow-up results of aortic dissection surgery after open-heart surgery (ADSOHS) and to analyze the risk factors that cause ADSOHS. Methods: One hundred thirty-seven patients with ADSOHS hospitalized in our hospital from January 2009 to December 2018 were selected as the research object. Long-term follow-up results, complications, mortality, and changes of cardiac function before and after operation were used to explore the value of Sun's operation. Results: The length of stay in intensive care unit of these 137 patients ranged from 9.5 to 623.75 hours (average of 76.41±97.29 hours), auxiliary ventilation time ranged from 6.0 to 259.83 hours (average of 46.16±55.59 hours), and hospital stay ranged from six to 85 days (average of 25.06±13.04 days). There were seven cases of postoperative low cardiac output, 18 cases of coma and stroke, and six cases of transient neurological dysfunction. A total of 33 patients died; 19 patients died during the perioperative period, 18 died during Sun's operation and one died during other operation; and 14 patients died during follow-up (January 2021), 12 cases of Sun's operation and two cases of other operations. Conclusion: ADSOHS treatment strategy is of high application value, and the risk of neurological complications and mortality is low. The main risk factors are postoperative low cardiac output, coma, stroke, and transient neurological dysfunction. The extracorporeal circulation time is relatively long. Short- and long-term follow-up effects are good, and it is worthy of clinical promotion.

Development and validation of a nomogram for postoperative severe acute kidney injury in acute type A aortic dissection.

BACKGROUND: Postoperative acute kidney injury (AKI) is a major complication associated with increased morbidity and mortality after surgery for acute type A aortic dissection (AAAD). To the best of our knowledge, risk prediction models for AKI following AAAD surgery have not been reported. The goal of the present study was to develop a prediction model to predict severe AKI after AAAD surgery. METHODS: A total of 485 patients who underwent AAAD surgery were enrolled and randomly divided into the training cohort (70%) and the validation cohort (30%). Severe AKI was defined as AKI stage III following the Kidney Disease: Improving Global Outcomes criteria. Preoperative variables, intraoperative variables and postoperative data were collected for analysis. Multivariable logistic regression analysis was performed to select predictors and develop a nomogram in the study cohort. The final prediction model was validated using the bootstrapping techniques and in the validation cohort. RESULTS: The incidence of severe AKI was 23.0% (n = 78), and 14.7% (n = 50) of patients needed renal replacement treatment. The hospital mortality rate was 8.3% (n = 28), while for AKI patients, the mortality rate was 13.1%, which increased to 20.5% for severe AKI patients. Univariate and multivariate analyses showed that age, cardiopulmonary bypass time, serum creatinine, and D-dimer were key predictors for severe AKI following AAAD surgery. The logistic regression model incorporated these predictors to develop a nomogram for predicting severe AKI after AAAD surgery. The nomogram showed optimal discrimination ability, with an area under the curve of 0.716 in the training cohort and 0.739 in the validation cohort. Calibration curve analysis demonstrated good correlations in both the training cohort and the validation cohort. CONCLUSIONS: We developed a prognostic model including age, cardiopulmonary bypass time, serum creatinine, and D-dimer to predict severe AKI after AAAD surgery. The prognostic model demonstrated an effective predictive capability for severe AKI, which may help improve risk stratification for poor in-hospital outcomes after AAAD surgery.

Perfusion management of arch-clamping technique in total arch replacement with frozen elephant trunk.

A technique called arch-clamping was used at our institute to ensure perfusion of the lower body and brain during total arch replacement with frozen elephant trunk (TAR and FET). The aortic arch clamp is inserted between the left common carotid artery and the left subclavian artery after inserting the stented elephant trunk into the true lumen of the descending aorta during the procedure, and then clamps the aorta and graft together as the distal anastomotic edge of the aorta. After the arch clamp was in place, lower body perfusion was resumed through the femoral artery was resumed and time to circulatory arrest was reduced to approximately 4 min. Cardiopulmonary bypass (CPB) flow was gradually restored to full rate. Thereafter, the left carotid artery anastomosis was completed and rewarming began. Finally, during the rewarming period, other branches of the aortic arch and ascending aorta were reconstructed. In this paper, we describe the perfusion management strategy, discuss intraoperative monitoring parameters, and examine the feasibility of the technique from a perfusion perspective.

Massive Bleeding After Surgical Repair in Acute Type A Aortic Dissection Patients: Risk Factors, Outcomes, and the Predicting Model.

Background: Massive bleeding throughout aortic repair in acute type A aortic dissection (ATAAD) patients is a common but severe condition that can cause multiple serious clinical problems. Here, we report our findings regarding risk factors, short-term outcomes, and predicting model for massive bleeding in ATAAD patients who underwent emergent aortic repair. Methods: A universal definition of perioperative bleeding (UDPB) class 3 and 4 were used to define massive bleeding and comprehensively evaluate patients. A total of 402 consecutive patients were enrolled in this retrospective study during 2019. Surgical strategies used to perform aortic arch procedures included total arch and hemiarch replacements. In each criterion, patients with massive bleeding were compared with remaining patients. Multivariable regression analyses were used to identify independent risk factors for massive bleeding. Logistic regression was used to build the model, and the model was evaluated with its discrimination and calibration. Results: Independent risk factors for massive bleeding included male sex (OR = 6.493, P < 0.001), elder patients (OR = 1.029, P = 0.05), low body mass index (BMI) (OR = 0.879, P = 0.003), emergent surgery (OR = 3.112, P = 0.016), prolonged cardiopulmonary bypass time (OR = 1.012, P = 0.002), lower hemoglobin levels (OR = 0.976, P = 0.002), increased D-dimer levels (OR = 1.000, P = 0.037), increased fibrin degradation products (OR = 1.019, P = 0.008), hemiarch replacement (OR = 5.045, P = 0.037), total arch replacement (OR = 14.405, P = 0.004). The early-stage mortality was higher in massive bleeding group (15.9 vs. 3.9%, P = 0.001). The predicting model showed a well discrimination (AUC = 0.817) and calibration (χ2 = 5.281, P = 0.727 > 0.05). Conclusion: Massive bleeding in ATAAD patients who underwent emergent aortic repair is highly associated with gender, emergent surgery, increased D-dimer levels, longer CPB time, anemia, and use of a complex surgical strategy. Since massive bleeding may lead to worse outcomes, surgeons should choose suitable surgical strategies in patients who are at a high risk of massive bleeding.

Blood Transfusion Predicts Prolonged Mechanical Ventilation in Acute Stanford Type A Aortic Dissection Undergoing Total Aortic Arch Replacement.

Background: This research aimed to evaluate the impacts of transfusing packed red blood cells (pRBCs), fresh frozen plasma (FFP), or platelet concentrate (PC) on postoperative mechanical ventilation time (MVT) in patients with acute Stanford type A aortic dissection (ATAAD) undergoing after total arch replacement (TAR). Methods: The clinical data of 384 patients with ATAAD after TAR were retrospectively collected from December 2015 to October 2017 to verify whether pRBCs, FFP, or PC transfusion volumes were associated with postoperative MVT. The logistic regression was used to assess whether blood products were risk factors for prolonged mechanical ventilation (PMV) in all three endpoints (PMV ≥24 h, ≥48 h, and ≥72 h). Results: The mean age of 384 patients was 47.6 ± 10.689 years, and 301 (78.39%) patients were men. Median MVT was 29.5 (4-574) h (h), and 213 (55.47%), 136 (35.42%), and 96 (25.00%) patients had PMV ≥24 h, ≥48 h, and ≥72 h, respectively. A total of 36 (9.38%) patients did not have any blood product transfusion, the number of patients with transfusion of pRBCs, FFP, and PC were 334 (86.98%), 286 (74.48%), and 189 (49.22%), respectively. According to the multivariate logistic regression of three PMV time-endpoints, age was a risk factor [PMV ≥ 24 h odds ratio (OR PMV≥24) = 1.045, p = 0.005; OR PMV≥48 = 1.060, p = 0.002; OR PMV≥72 = 1.051, p = 0.011]. pRBC transfusion (OR PMV≥24 = 1.156, p = 0.001; OR PMV≥48 = 1.156, p < 0.001; OR PMV≥72 = 1.135, p ≤ 0.001) and PC transfusion (OR PMV≥24 = 1.366, p = 0.029; OR PMV≥48 = 1.226, p = 0.030; OR PMV≥72 = 1.229, p = 0.011) were independent risk factors for PMV. FFP had no noticeable effect on PMV [OR PMV≥48 = 0.999, 95% confidence interval (CI) 0.998-1.000, p = 0.039; OR PMV≥72 = 0.999, 95% CI: 0.998-1.000, p = 0.025]. Conclusions: In patients with ATAAD after TAR, the incidence of PMV was very high. Blood products transfusion was closely related to postoperative mechanical ventilation time. pRBC and PC transfusions and age increased the incidence of PMV at all three endpoints.

Blood Transfusion and Acute Kidney Injury After Total Aortic Arch Replacement for Acute Stanford Type A Aortic Dissection.

AIM: To evaluate the effect of packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelet concentrate (PC) transfusions on acute kidney injury (AKI) in patients with acute Stanford type A aortic dissection (ATAAD) with total arch replacement (TAR). METHOD: From December 2015 to October 2017, 421 consecutive patients with ATAAD undergoing TAR were included in the study. The clinical data of the patients and the amount of pRBCs, FFP, and PC were collected. Acute kidney injury was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Logistic regression was used to identify whether pRBCs, FFP, and platelet transfusions were risk factors for KDIGO AKI, stage 3 AKI, and AKI requiring renal replacement therapy (RRT). RESULTS: The mean ± standard deviation age of the patients was 47.67±10.82 years; 77.7% were men; and the median time from aortic dissection onset to operation was 1 day (range, 0-2 days). The median transfusion amount was 8 units (range, 4-14 units) for pRBCs, 400 mL (range, 0-800 mL) for FFP, and no units (range, 0-2 units) for PC. Forty-one (41; 9.7%) patients did not receive any blood products. The rates of pRBC, PC, and FFP transfusions were 86.9%, 49.2%, and 72.9%, respectively. The incidence of AKI was 54.2%. Considering AKI as the endpoint, multivariate logistic regression showed that pRBCs (odds ratio [OR], 1.11; p<0.001) and PC transfusions (OR, 1.28; p=0.007) were independent risk factors. Considering KDIGO stage 3 AKI as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.15; p<0.001), PC transfusion (OR, 1.28; p<0.001), a duration of cardiopulmonary bypass (CPB) ≥293 minutes (OR, 2.95; p=0.04), and a creatinine clearance rate of ≤85 mL/minute (OR, 2.12; p=0.01) were independent risk factors. Considering RRT as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.12; p<0.001), PC transfusion (OR, 1.33; p=0.001), a duration of CPB ≥293 minutes (OR, 3.79; p=0.02), and a creatinine clearance rate of ≤85 mL/minute (OR, 3.34; p<0.001) were independent risk factors. CONCLUSIONS: Kidney Disease: Improving Global Outcomes-defined stage AKI was common after TAR for ATAAD. Transfusions of pRBCs and PC increased the incidence of AKI, stage 3 AKI, and RRT. Fresh frozen plasma transfusion was not a risk factor for AKI.

Incidence and Survival of Aortic Dissection in Urban China: Results from the National Insurance Claims for Epidemiological Research (NICER) Study.

BACKGROUND: Aortic dissection (AD) represents a significant mortality; however, there is rare epidemiologic information about the demography of AD in Chinese, especially its incidence rate. METHODS: A retrospective cohort study was established using the Urban Employee Basic Medical Insurance claims data covering 346.7 million residents from 23 provinces in China, 2015-2016. AD cases were then linked to database of the Urban Employee Basic Endowment Insurance for death information. Incidence rate was age- and sex-standardized to the 2010 China census population. The associations between AD and related factors were evaluated with Poisson regression models. Moreover, mortality and sex- and age-adjusted survival rate was estimated by Cox models. FINDINGS: 6084 adult AD cases were included in incidence analysis. Totally 4692(77.1%) were men and 5641(92.7%) were Han Chinese. The overall age- and sex-adjusted incidence rate of AD was 2.78(95%CI:2.59-2.98) per 100,000 person-years. In terms of geographic disparities, the crude incidence rate was significantly higher in Northwest China than South China (4.96[95%CI:4.17-5.75] vs. 2.04[95%CI:0.38-3.71] per 100,000 person-years; risk ratio: 2.67[95%CI: 2.34-3.04]). Moreover, survival analysis of 4518 AD patients with 683 recorded deaths during follow-up (median 2.2 years) showed that overall 3-year survival was 83.7%(95%CI:82.4-84.8). INTERPRETATION: This contemporary population-based cohort study provides a first comprehensive assessment of incidence of AD in urban Chinese adults. The distinct signatures of different incidence with respect to geographic variations may have important implications for clinical management of AD. FUNDING: Chinese Ministry of Science and Technology (2020YFC2003503, 2016YFC0903000), and National Natural Science Foundation of China (91846112, 81973132, 81961128006).

Early and Long-Term Follow-Up for Chronic Type B and Type Non-A Non-B Aortic Dissection Using the Frozen Elephant Trunk Technique.

Background: This study aimed to evaluate the early and long-term outcomes of a single center using a frozen elephant trunk (FET) procedure for chronic type B or non-A non-B aortic dissection. Methods: From February 2009 to December 2019, 79 patients diagnosed with chronic type B or non-A non-B aortic dissection who underwent the FET procedure were included in the present study. We analyzed operation mortality and early and long-term outcomes, including complications, survival and interventions. Results: The operation mortality rate was 5.1% (4/79). Spinal cord injury occurred in 3.8% (3/79), stroke in 2.5% (2/79), and acute renal failure in 5.1% (4/79). The median follow-up time was 53 months. The overall survival rates were 96.2, 92.3, 88.0, 79.8, and 76.2% at 1/2, 1, 3, 5 and 7 years, respectively. Moreover, 79.3% of patients did not require distal aortic reintervention at 7 years. The overall survival in the subacute group was superior to that in the chronic group (P = 0.047). Conclusion: The FET technique is a safe and feasible approach for treating chronic type B and non-A non-B aortic dissection in patients who have contraindications for primary endovascular aortic repair. The technique combines the advantages of both open surgical repair and endovascular intervention, providing comparable early and long-term follow-up outcomes and freedom from reintervention.

Comparison of Open Repair vs. the One-Stage Hybrid Extra-Anatomic Technique for Distal Aortic Arch Disease Treatment: Mid-term Outcomes With a Risk-Adjusted Analysis.

Objective: This study aims to compare the short- and mid-term outcomes of the stented elephant trunk (SET) procedure combined with supra-arch branch reconstruction and one-stage hybrid arch repair combined thoracic endovascular aortic repair (TEVAR) with extra-anatomic bypass in the management of distal arch disease. Methods: From January 2009 to January 2019, 97 patients underwent one-stage hybrid arch repair combined with TEVAR with extra-anatomic bypass (HAR group), and 206 patients underwent the SET procedure with supra-arch branch reconstruction (SET group). We used inverse-probability-of treatment weighting (IPTW) to adjust baseline differences. Results: Before IPTW adjustment, there was no significant difference in operative mortality between the two groups (5.2 vs. 1.0%, P = 0.064). The incidences of stroke, spinal cord injury (SCI), acute kidney injury (AKI), and endoleak also showed no significant differences (4.1 vs. 0.5%, P = 0.066; 2.1 vs. 1.5%, P = 1.000; 0 vs. 1.0%, P = 0.831; 6.2 vs. 1.9%, P = 0.113, respectively). After IPTW adjustment, the incidences of stroke, SCI, and AKI showed no significant differences between the two groups (1.8 vs. 1.1%, P = 0.138; 0.8 vs. 1.6%, P = 0.448; and 0 vs. 0.7%, P = 0.148, respectively). However, the HAR group tended to have higher operative mortality and incidence of endoleak than the SET group (12.4 vs. 1.3%, P = 0.01; 9.9 vs. 1.8%, P = 0.031, respectively). In the multivariate analysis, open repair decreased the risks of endoleak (odds ratio [OR], 0.171, 95% CI, 0.060-0.401; P < 0.001) and operative mortality (OR, 0.093, 95% CI, 0.027-0.238; P < 0.001). The overall survival and event-free survival of the HAR group were significantly lower than those of the SET group (P < 0.001). Conclusion: One-stage hybrid arch repair combined TEVAR with extra-anatomic bypass and the SET procedure with supra-arch branch reconstruction both provided good postoperative treatment outcomes for distal arch disease. However, hybrid arch repair increased the risks of endoleak and operative mortality. The SET procedure provided better mid-term survival than hybrid arch repair without increasing operative mortality. Carefully selecting the indications for the procedure, while receiving close long-term follow-up, may improve the survival rate of patients undergoing hybrid arch repair.

Association of IL1R1 Coding Variant With Plasma-Level Soluble ST2 and Risk of Aortic Dissection.

Objective: Aortic dissection (AD) is characterized by an acute onset, rapid progress, and high mortality. Levels of soluble ST2 (sST2) on presentation are elevated in patients with acute AD, which can be used to discriminate AD patients from patients with chest pain. sST2 concentrations were found to be highly heritable in the general population. The aim of this study was to investigate the associations of variations in ST2-related gene expression with sST2 concentrations and AD risk. Methods: This case-control study involving a total of 2,277 participants were conducted, including 435 AD patients and age- and sex-matched 435 controls in the discovery stage, and 464 patients and 943 controls in the validation stage. Eight ST2-related genes were selected by systematic review. Tag single-nucleotide polymorphisms (SNPs) were screened out from the Chinese population of the 1,000 Genomes Database. Twenty-one ST2-related SNPs were genotyped, and plasma sST2 concentrations were measured. Results: In the discovery stage, rs13019803 located in IL1R1 was significantly associated with AD after Bonferroni correction (p = 0.0009) and was correlated with circulating sST2 levels in patients with type A AD(AAD) [log-sST2 per C allele increased by 0.180 (95%) CI: 0.002 - 0.357] but not in type B. Combining the two stages together, rs13019803C was associated with plasma sST2 level in AAD patients [log-sST2 increased by 0.141 (95% CI: 0.055-0.227) for per C allele]. Odds ratio of rs13019803 on the risk of AAD is 1.67 (95% CI: 1.33-2.09). Conclusions: The IL1R1 SNP rs13019803C is associated with higher sST2 levels and increased risk of AAD.

Photocatalyst-independent photoredox ring-opening polymerization of O-carboxyanhydrides: stereocontrol and mechanism.

Photoredox ring-opening polymerization of O-carboxyanhydrides allows for the synthesis of polyesters with precisely controlled molecular weights, molecular weight distributions, and tacticities. While powerful, obviating the use of precious metal-based photocatalysts would be attractive from the perspective of simplifying the protocol. Herein, we report the Co and Zn catalysts that are activated by external light to mediate efficient ring-opening polymerization of O-carboxyanhydrides, without the use of exogenous precious metal-based photocatalysts. Our methods allow for the synthesis of isotactic polyesters with high molecular weights (>200 kDa) and narrow molecular weight distributions (M w/M n < 1.1). Mechanistic studies indicate that light activates the oxidative status of a CoIII intermediate that is generated from the regioselective ring-opening of the O-carboxyanhydride. We also demonstrate that the use of Zn or Hf complexes together with Co can allow for stereoselective photoredox ring-opening polymerizations of multiple racemic O-carboxyanhydrides to synthesize syndiotactic and stereoblock copolymers, which vary widely in their glass transition temperatures.