The onset of acute type A aortic dissection following recovery of type B intramural haematoma: a case report.

BACKGROUND: Aortic intramural hematoma is a life-threatening condition reported with increasing frequency. It can be classified into Stanford type A or B depending on whether the ascending or descending aorta are involved, respectively. However, the onset of acute type A aortic dissection following recovery of type B intramural haematoma is rarely reported. CASE PRESENTATION: We present an uncommon case of acute Stanford type A aortic dissection developing 3 months after recovery of type B IMH in a 47-year-old female. She complained acute chest pain. The operation was successfully done. She was in good condition and asymptomatic at a 3-month follow-up. CONCLUSIONS: Type B intramural haematoma can lead to type A aortic dissection even after totally absorbed and the primary entry has the potential to be located in the ascending aorta. Unsatisfied blood pressure control may be the underlying cause.

Identification and surgical repair of familial thoracic aortic aneurysm and dissection caused by TGFBR1 mutation.

BACKGROUND: This study aimed at exploring the causative gene and summarizing the clinical characteristics in a Chinese thoracic aortic aneurysm and dissection (TAAD) family. METHODS: Family members were examined for features of syndromic genetic diseases by clinician and geneticist. Genomic DNA was extracted from 2 distantly related members with definite TAAD for exome sequencing. RESULTS: A pathogenic mutation (rs111426349, c.1459C >T) of transforming growth factor ß receptor 1 (TGFBR1) was confirmed, which result in the amino acid substitution p.R487W. Fourteen TGFBR1 mutation carriers were detected among 39 tested members in this family. The average age at diagnosis of aortic root dilatation or aneurysm was 23.2 ± 12.6 years (range 3-37 years). Early onset of aortic root dilatation was significant in this family without reported phenotypes. The David procedure was performed prophylactically in 3 carriers of this family. CONCLUSIONS: Familial TAAD caused by TGFBR1 mutation (c.1459C >T) was confirmed in a large Chinese Han ethnic family using exome sequencing. Aggressively prophylactic David procedure may be not necessary at a smaller aortic size in familial TAAD patients with TGFBR1 mutation and further observation is warranted.

Concomitant coronary artery bypass grafting during surgical repair of acute type A aortic dissection affects operative mortality rather than midterm mortality.

BACKGROUND: In this study, we investigated the impact of concomitant coronary artery bypass grafting (CABG) on operative and midterm mortality in patients with acute type A aortic dissection (ATAAD) undergoing surgical repair. METHODS: From January 2012 to December 2014, among 489 patients (mean age: 47.6 ± 10.4 years, 77.1% male) with ATAAD who received surgical repair at our institute, 21 patients (4.3%) underwent concomitant CABG. Isolated aortic repair was performed in the remaining 468 cases (95.7%). Coronary dissection was indicated in 15 patients (Neri classification type B in 2, type C in 13), concomitant coronary artery disease in five and coronary artery compression in one. The follow-up time was 97.3% at 44.1 ± 13.9 months. RESULTS: A total of 44 patients (9%) died from surgery, and operative mortality in the concomitant CABG group was significantly higher than that in the isolated aortic repair group (47.6%, 10/21 vs. 7.3%, 34/468; P < 0.001). Among the 11 survivors in the concomitant CABG group, no deaths occurred during the follow-up. Cox regression indicated that concomitant CABG increased the operative mortality risk by 9.2 times (HR, 9.26; 95% CI, 4.31-19.89; P < 0.001). Although it predicted a 5.2-fold increase in overall mortality (HR, 5.20; 95% CI, 2.55-10.61; P < 0.001), concomitant CABG did not affect midterm death (P = 0.996). CONCLUSIONS: Concomitant CABG carries a significant operative risk in ATAAD patients undergoing surgical repair. However, survivors may benefit from concomitant CABG and had similar midterm mortality compared with the other cases.

Mild hypothermic circulatory arrest with selective cerebral perfusion in open arch surgery.

BACKGROUND: This study aimed to evaluate whether the use of mild hypothermic circulatory arrest (HCA) with selective cerebral perfusion (SCP) in open arch procedure provides comparable perioperative results to moderate HCA for patients with dissected or degenerative arch pathologies. METHODS: Between January 2017 and September 2020, a total of 88 consecutive patients (mean age 47±11 years, 71 males) underwent open arch repair under a single surgeon at our institution with mild or moderate systemic hypothermia assisted by unilateral or bilateral SCP. Patients were divided into groups according to the nasopharyngeal temperature at the beginning of HCA: a moderate HCA group (n=47, 53.4%) and a mild HCA group (n=41, 46.6%). The postoperative mortality, morbidity, and visceral organ functions between these groups were analyzed retrospectively. RESULTS: Compared to the moderate HCA group, the mild HCA group had a significantly higher core temperature (nasopharynx: 24.4±0.8 vs. 28.5±2, P<0.001; bladder 25.9±0.9 vs. 30±1.2, P<0.001), and the incidence of major adverse events (MAE) in this group was markedly lower (21.3% vs. 4.9%, P=0.031). No differences were identified between the two groups refer to in-hospital mortality, permanent neurological deficit (PND), temporary neurological deficit (TND), and paraplegia (8.5% vs. 2.4%, P=0.366; 8.5% vs. 0, P=0.120; 6.4% vs. 7.3%, P=1.0; 4.3% vs. 2.4%, P=1.0, respectively). In the moderate HCA group, 6 patients (12.8%) developed acute renal failure needing replacement therapy, which did not occur in the mild HCA group (P=0.028). The duration of ventilator support and intensive care unit stay was shorter in the mild HCA group, as well as a decreased volume of drainage during the first 24 h and reduced platelet transfusion. CONCLUSIONS: The preliminary results of the mild HCA group with SCP applied in open arch repair, mainly in total arch replacement (TAR) and stented elephant trunk (SET) implantation for aortic dissection, were satisfactory. Furthermore, comparable inferior outcomes were obtained with mild HCA compared with that of the conventional moderate HCA strategy. These encouraging surgical and postoperative results favor this more aggressive hypothermia strategy in open arch repair.

The use of cIMT as a predictor of postoperative stroke in patients undergoing surgical repair of acute type a aortic dissection.

BACKGROUND: Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires surgical intervention. Stroke remains an extremely serious adverse outcome that can occur in ATAAD patients undergoing aortic arch repair, leading to higher rates of patient mortality and decreased postoperative quality of life. In the present study, we sought to determine whether carotid intima-media thickness (cIMT) is a reliable predictor of postoperative stroke risk. MATERIALS AND METHODS: This was a prospective study of 76 patients with ATAAD undergoing aortic arch repair. For all patients, cIMT was determined preoperatively through a Doppler-based method. Incidence of different forms of neurological dysfunction, including temporary neurological dysfunction (TND) and stroke, was monitored in these patients, and the relationship between cIMT and stroke incidence was assessed using a receiver-operating characteristic (ROC) curve. Prognostic variables associated with stroke risk were further identified through univariate and multivariate analyses. RESULTS: A total of 26/76 (34.2%) patients in the present study suffered from neurological dysfunction, of whom 16 (21.0%) suffered from TND and 10 (13.2%) suffered a stroke. The remaining 50 patients (65.8%) did not suffer from neurological dysfunction. The cIMT values in the stroke, TND, and neurological dysfunction-free patients in this study were 1.12 ± 0.19 (mm), 0.99 ± 0.13 (mm), and 0.87 ± 0.13 (mm), respectively. A total of 4 patients in this cohort died during the study, including 1 in the TND group and 3 in the stroke group. An ROC curve analysis indicated that cIMT could predict stroke with an area under the curve value of 0.844 (95% CI, 0.719-0.969; p < 0.001). A multivariate analysis revealed that cIMT > 0.9 mm was independently associated with stroke risk (p = 0.018). CONCLUSION: We found that cIMT can be used to predict postoperative stroke risk in ATAAD patients undergoing aortic arch repair, with a cIMT > 0.9 mm coinciding with increased stroke risk in these patients. TRIAL REGISTRATION: ChiCTR1900022289. Date of registration 4 April 2019 retrospectively registered.

Sun's total arch replacement and stent elephant trunk with modified branch-first technique for patients with Stanford type A aortic dissection.

BACKGROUND: Stanford type A aortic dissection (STAAD) is a critical cardiovascular disease, and surgical procedure is the first-choice treatment. The classical surgical procedure still leads to a high mortality rate and neurological complications. In this study, we introduce a new modified Sun's procedure and investigate the association between the branch-first technique and the postoperative outcomes of patients with STAAD. METHODS: A total of 108 consecutive patients with STAAD who underwent arch replacement and stent elephant trunk procedure at Beijing Anzhen Hospital between July, 2017 and November, 2018 were included in the analysis. The patients were divided into two groups: the branch-first group and the classic group. The branch-first group and the classic group comprised 24 patients (22.2%) and 84 patients (77.8%), respectively. RESULTS: Patients in the branch-first group had a significantly shorter cardiopulmonary bypass (CPB) duration (172.4±29.9 vs. 194.9±47.4 min; P=0.035), Intensive care unit (ICU) stay [17.0 (14.6-38.2) vs. 42.1 (19.7-87.2) hours; P<0.001], and mechanical ventilation time [15.5 (11.9-40.0) vs. 19.0 (17.0-45.6) hours; P=0.018] than patients in the classic group. The branch-first was associated with a reduction in postoperative neurological complications in all models. CONCLUSIONS: The benefits of the branch-first technique, including lower CPB duration, better bilateral cerebral perfusion, and higher nasopharyngeal temperature during hypothermic arrest, contributed to a shortened recovery time for patients after surgery.

Cardiopulmonary bypass duration is an independent predictor of adverse outcome in surgical repair for acute type A aortic dissection.

OBJECTIVE: This study aimed to investigate the relationship between the duration of cardiopulmonary bypass (CPB) and stroke or early death in patients with acute type A aortic dissection (ATAAD) receiving total aortic arch replacement with the frozen elephant trunk procedure (TAR with FET). METHODS: A retrospective cohort study of 258 consecutive patients was conducted at Beijing Anzhen Hospital from December 2014 to June 2016. Patients who received TAR with FET for ATAAD were included. An adverse outcome (AO) was defined as 30-day mortality or stroke. Additionally, an AO was compared using propensity score matching. RESULTS: The incidence of AO was 13.6% (n = 35). The 30-day mortality rate was 10.8% and the stroke rate was 9.3%. Patients were aged 47.9 ± 10.6 years old. The duration of CPB was an independent predictor of occurrence of AO after adjusting for confounding factors by multivariable logistic regression analysis (odds ratio 1.101, 95% confidence interval 1.003-1.208). In matched analysis, CPB duration remained a risk factor of AO. CONCLUSIONS: The duration of CPB is an independent predictor of AO in surgical repair for ATAAD. The underlying mechanisms of this association are important for developing improved prevention strategies.

Different hypothermic and cerebral perfusion strategies in extended arch replacement for acute type a aortic dissection: a retrospective comparative study.

BACKGROUND: The optimal hypothermic level in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection (aTAAD) has not been established, and the superiority of unilateral or bilateral cerebral perfusion remains a controversial issue. Therefore, we evaluated the application of moderate hypothermic circulatory arrest (MHCA) with a core temperature of 29 °C and bilateral selective antegrade cerebral perfusion in aTAAD treated by total arch replacement with stented elephant trunk implantation. METHODS: From July 2019 to January 2020, 25 aTAAD patients underwent total arch replacement with stented elephant trunk implantation via MHCA (29 °C) and bilateral selective antegrade cerebral perfusion (modified group). Thirty-six patients treated by the same procedure with MHCA (25 °C) and unilateral selective antegrade cerebral perfusion during this period were selected as controls. RESULTS: There were no differences between the two groups of patients in terms of age, sex, incidence of hypertension, malperfusion, and pericardial effusion, although the incidence of cardiac tamponade was higher in the modified group (control 2.8%, modified 20%; P = 0.038). The lowest mean circulatory arrest temperature was 24.6 ± 0.9 °C in the control group, and 29 ± 0.8 °C in the modified group (P <  0.001). In-hospital mortality was 4.9% (3/61) for the entire cohort (control 8.3%, modified 0; P = 0.262). The incidence of permanent neurologic deficit was 4.9% (control 8.3%, modified 0; P = 0.262). There were no significant differences in the occurrence of temporary neurological deficit, renal failure, and paraplegia between groups. The rate of major adverse events in the modified group was lower (30.6% vs. 4%, P = 0.019). A shorter duration of ventilation and ICU stay was identified in the modified group, as well as a reduced volume of drainage within the first 48 h and red blood cell transfusion. CONCLUSIONS: The early results of MHCA (29 °C) and bilateral selective antegrade cerebral perfusion applied in total arch replacement with stented elephant trunk implantation for aTAAD were acceptable, providing similar inferior cerebral and visceral protection compared with that of the conventional strategy. A higher core temperature may account for the shorter duration of ventilation and ICU stay, as well as a reduced volume of drainage and red blood cell transfusion.

"T-shaped" repair for commissural detachment in acute type A aortic dissection.

Aortic insufficiency in patients with type A aortic dissection is commonly seen and, in most cases, is the consequence of commissural detachment. We report our method of aortic valve repair in which the valve commissure and detached intima are repaired by using a "T-shaped" polyester patch that fits well within the aortic root after removal of the clots in the proximal false lumen. The early results have proved this is an easy and effective way to repair valve commissural detachment and reconstruct the aortic root.

Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection.

BACKGROUND: Acute type A aortic dissection (AAAD) remains one of the most lethal conditions requiring surgical repair, and is associated with a high rate of postoperative mortality and morbidity. Despite the satisfactory clinical outcomes achieved with the frozen elephant trunk technique so far, controversies still exist regarding the use of this aggressive approach in patients with AAAD. In this study, we seek to analyze the early outcomes of the Sun's procedure, which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta, and identify the risk factors for postoperative mortality and morbidity of the Sun's procedure in patients with AAAD. METHODS: Clinical data of 398 consecutive AAAD patients undergoing the Sun's procedure were analyzed. The associations between 20 preoperative and intraoperative variables and early mortality were assessed by univariate and multivariate analysis. RESULTS: Early mortality occurred in 31 patients (7.8%, 31/398), with leading causes including multi-organ failure in 16 patients (51.6%), permanent neurologic deficit in 6 (19.4%), and low cardiac output syndrome in 4 (12.9%). Permanent neurologic deficit and spinal cord injury occurred, each in 10 patients (2.5%, 10/398). Five significant risk factors for early mortality were identified with multivariate analysis: preexisting cerebrovascular disease [relative risk (RR) 14.76; P<0.001], acute heart failure (RR 18.18; P=0.001), spinal cord malperfusion (RR 60.13; P<0.002), visceral malperfusion (RR 30.25; P<0.001) and cardiopulmonary bypass time >190 minutes (RR 3.62; P=0.007). CONCLUSIONS: The Sun's procedure has generated a relatively lower mortality rate in 398 patients with AAAD. Patients with preexisting cerebrovascular disease, acute heart failure, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.