Comparison of Minimally Invasive Direct Coronary Artery Bypass and Percutaneous Coronary Intervention Using Second-Generation Drug-Eluting Stents for Coronary Artery Disease　- Propensity Score-Matched Analysis.

BACKGROUND: Some studies comparing minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) have reported MIDCAB's superiority, but they did not investigate contemporary PCI with newer generation drug-eluting stents (DES). We compared clinical outcomes after MIDCAB with previously reported outcomes after PCI with second-generation DES.Methods and Results:We retrospectively reviewed the records of patients treated with MIDCAB. Baseline characteristics and clinical outcomes after MIDCAB were compared with those for left anterior descending artery disease treated via PCI. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), a composite of cardiovascular death, non-fatal myocardial infarction, ischemic stroke, and target vessel revascularization (TVR). A propensity score-matching (PSM) analysis was conducted to adjust for between-group differences in baseline characteristics. We analyzed 77 patients treated with MIDCAB and 2,206 treated with PCI. The MIDCAB group was older and had more severe coronary disease and a higher incidence of left ventricular dysfunction. Over a 3-year follow-up, the PCI group had favorable MACCE outcomes. After PSM, there were no between-group differences in MACCE (MIDCAB, 15.6% vs. PCI, 23.4%; hazard ratio [HR], 0.80; 95% CI: 0.38-1.68, P=0.548) or TVR (MIDCAB, 2.6% vs. PCI, 5.2%; HR, 0.51; 95% CI: 0.10-3.09, P=0.509). CONCLUSIONS: Clinical outcomes were similar between MIDCAB and PCI using second-generation DES over 3 years of follow-up.

The safety of resternotomy in the intensive care unit for postcardiotomy bleeding control.

OBJECTIVE: This study aimed to investigate the efficiency and safety of resternotomy performed in the intensive care unit (ICU) for emergent bleeding control after cardiac surgery when transport of the patient to the operating room (OR) was unsafe or delayed. METHODS: Medical records were retrospectively reviewed for 101 patients who underwent resternotomy for bleeding control after cardiac surgery between July 2003 and July 2013. A reoperation was performed in the OR for 61 patients (the OR group) and in the ICU for 40 patients (the ICU group). Perioperative features and outcomes were compared between the two groups. RESULTS: The ICU group had a higher incidence of cardiopulmonary resuscitation before resternotomy (27.5% vs 3.3%, p < 0.05) and bleeding from the cardiac cannulation or suture sites (46.3% vs 23.3%, p < 0.05). Less time was needed for bleeding control in the ICU group (105.8 ± 40.0 min vs 144.3 ± 50.1 min, p < 0.05). There was no difference in 24-hour chest tube drainage, amount of red blood cell transfusion, need of second resternotomy, ICU and hospital stays, incidence of mediastinal infection (ICU 2.5% vs OR 4.9%, p = 0.542), superficial wound complications (ICU 12.5% vs OR 4.9%, p = 0.168), and in-hospital mortality rate (ICU 22.5% vs OR 13.1%, p = 0.218). Three deaths resulted from cardiac arrest, which occurred during the wait or transportation to the OR for a resternotomy in the OR group. CONCLUSIONS: Resternotomy in the ICU was feasible and allows for more efficient management of bleeding-related instabilities without increasing the risk of infectious complications.

Clinical outcomes of valve-sparing root replacement in acute type A aortic dissection.

OBJECTIVES: The early and late outcomes of valve-sparing root replacement (VSR) in type A aortic dissection (AAD) are unknown. The aim of this study was to review the outcomes of VSR in AAD. We also compared the outcomes of VSR with the Bentall operation, which served as a standard reference technique. DESIGN: We retrospectively reviewed 52 patients who underwent surgery for AAD and concomitant root replacement between 1998 and 2013 at Samsung Medical Center. Patients were divided into two groups: Bentall (n = 34) and VSR (n = 18). Two out of six surgeons performed VSR. The mean follow-up duration was 62.3 ± 46.5 months. RESULTS: Preoperative characteristics were similar between the two groups except age (Bentall, 48 ± 11 years; VSR, 37 ± 11 years, p = 0.011). The aortic cross-clamping time was longer in the VSR group (Bentall, 185.8 ± 63.8; VSR, 241.4 ± 44.3 min, p = 0.002). There was no early death in the VSR group, but there was one in the Bentall group (p = 1.000). Despite the higher reoperation rate for aortic valve in the VSR group (Three reoperations) than in the Bentall group (no reoperation), major valve-related events and overall mortality did not differ between the two groups(p = 0.876 and 0.119, respectively). In multivariable analysis, the root replacement technique was not a risk factor for major valve-related events. CONCLUSIONS: VSR seems to be equivalent to the Bentall procedure for AAD in terms of early and late outcomes. VSR can be considered as a viable option, particularly for young patients with favorable aortic valve leaflets undergoing surgery at an experienced center.

Features and outcomes of focal intimal disruption in acute type B intramural haematoma.

OBJECTIVES: A focal intimal disruption (FID) is a risk factor for adverse aorta-related events in patients with acute type B intramural haematoma. This study evaluated the impact of FIDs on overall survival with a selective intervention strategy for large or growing FIDs. Additionally, this study evaluated the risk factors associated with the growth of FIDs. METHODS: This retrospective study included all consecutive patients admitted for acute type B intramural haematomas between November 2004 and April 2021. The primary outcome was overall survival. The secondary outcome was the cumulative incidence of composite aortic events and the growth of FIDs. The latter was calculated on centreline-reconstructed computed tomography images. RESULTS: A total of 105 patients were included. A total of 106 FIDs were identified in 73 patients (73/105, 69.5%). The 1- and 5-year cumulative incidence rates of composite aortic events were 36.2% and 39.2%, respectively. The 1- and 5-year overall survival was 93.3% and 81.5%, respectively. Initial maximal aortic diameter and large FIDs during acute phase were significant risk factors for composite aortic events, but not risk factors for overall survival. The early appearance interval of an FID was a significant risk factor for growth of an FID. CONCLUSIONS: With a selective intervention strategy for large or growing FIDs, the presence of large FIDs during the acute phase does not affect overall survival. The early appearance interval was associated with the growth of FIDs.

Acute type A aortic dissection features and outcomes in octogenarians: a propensity score analysis.

OBJECTIVES: The clinical characteristics and early outcomes of surgical repair in octogenarians with acute type A aortic dissection were compared with those in nonoctogenarians. METHODS: All patients who underwent emergency surgical repair for acute type A aortic dissection in our institution between 2003 and 2022 were included in this study. The patients were divided into an octogenarian group and a nonoctogenarian group. The patients in the 2 groups were propensity score matched at a ratio of 1:1. Before matching, the baseline characteristics were compared between 2 groups. The major complication and 30-day mortality rates were compared in the matched population. RESULTS: A total of 495 patients were screened, and 471 were included in the analysis, with 48 in the octogenarian group and 423 in the nonoctogenarian group. Before matching, DeBakey type II dissection was significantly more prevalent in the octogenarians (42% vs 14% in the octogenarians and nonoctogenarians, respectively, P < 0.001). Additionally, intramural haematomas (39.6% vs 14.4%, P < 0.001) were more prevalent in the octogenarians. However, severe aortic regurgitation (4.2% vs 15.4%, P = 0.046) and root enlargement (0% vs 13.7%, P = 0.009) were less prevalent in the octogenarians. After matching (36 pairs), the incidence of postoperative delirium was higher in the octogenarians (56% vs 25%, P = 0.027). However, there were no significant differences in 30-day and in-hospital mortality rates, intensive care unit stay or major complications, including stroke, paraplegia, respiratory complications, mediastinitis and haemodialysis. CONCLUSIONS: The octogenarians with acute type A aortic dissection had higher incidences of DeBakey type II dissection and intramural haematomas and lower incidences of severe aortic regurgitation and aortic root enlargement than the nonoctogenarians. Being an octogenarian was not associated with an increased risk of early major complications or mortality after surgery for acute type A aortic dissection.

Thrombocytopenia after Aortic Valve Replacement Using Sutureless Valves.

Background: Sutureless valves are widely used in aortic valve replacement surgery, with Perceval valves and Intuity valves being particularly prominent. However, concerns have been raised about postoperative thrombocytopenia with Perceval valves (Corcym, UK). We conducted a comparative analysis with the Intuity valve (Edwards Lifesciences, USA), and assessed how thrombocytopenia affected patient and transfusion outcomes. Methods: Among 595 patients who underwent aortic valve replacement from June 2016 to March 2023, sutureless valves were used in 53 (Perceval: n=23; Intuity: n=30). Platelet counts were monitored during hospitalization and outpatient visits. Daily platelet count changes were compared between groups, and the results from patients who underwent procedures using Carpentier Edwards Perimount Magna valves were used as a reference group. Results: Compared to the Intuity group, the Perceval group showed a significantly higher amount of platelet transfusion (5.48±1.64 packs vs. 0.60±0.44 packs, p=0.008). During the postoperative period, severe thrombocytopenia (<50,000/µL) was significantly more prevalent in the Perceval group (56.5%, n=13) than in the Intuity group (6.7%, n=2). After initial postoperative depletion, daily platelet counts increased, with significant differences observed in the extent of improvement between the Perceval and Intuity groups (p<0.001). However, there was no significant difference in early mortality or the incidence of neurological complications between the 2 groups. Conclusion: The severity of postoperative thrombocytopenia differed significantly between the Perceval and Intuity valves. The Perceval group showed a significantly higher prevalence of severe thrombocytopenia and higher platelet transfusion volumes. However, thrombocytopenia gradually recovered during the postoperative period in both groups, and the early outcomes were similar in both groups.

Influence of Preoperative COVID-19 Vaccination on Outcomes After Coronary Artery Bypass Grafting-A Propensity Score-Matched Analysis.

BACKGROUND: Reports of intravascular thrombosis and cardiac complications have raised concerns about the safety of COVID-19 vaccinations, particularly in patients with high cardiovascular risk. Herein, we aimed to analyze the impact of preoperative COVID-19 vaccination on outcomes after coronary artery bypass grafting (CABG). METHODS AND RESULTS: Among 520 patients who underwent isolated CABG from 2020 to 2022, 481 patients (mean±SD age: 67±11 years, 86 women) whose COVID-19 vaccination status could be confirmed were included. A total of 249 patients who had not received any COVID-19 vaccine before CABG (never vaccinated group) and 214 patients who had completed primary vaccination (fully vaccinated group) were subjected to 1:1 propensity score matching, and 156 pairs of patients were matched. There was no significant difference in early mortality between the 2 groups after matching. After matching, overall survival (P=0.930) and major adverse cardiovascular and cerebrovascular event-free survival (P=0.636) did not differ between the 2 groups. One-year graft patency also did not differ significantly between the 2 groups; all patent grafts in 85/104 patients (82%) and 62/73 patients (85%) in the never vaccinated and fully vaccinated groups, respectively (P=0.685). Subgroup analysis showed equivalent overall and major adverse cardiovascular and cerebrovascular event-free survival among AstraZeneca and Pfizer vaccine recipients and between those with ≤30 days versus >30 days from vaccination to CABG. CONCLUSIONS: Despite the very high cardiovascular risk for patients undergoing CABG, COVID-19 vaccination did not affect major outcomes after CABG. Therefore, there is no reason for patients with coronary artery disease requiring CABG to avoid preoperative COVID-19 vaccination.

Candidates and major determinants for endovascular repair of abdominal aortic aneurysms in Korean patients.

The purpose of this study was to determine what proportion of patients with an abdominal aortic aneurysm (AAA) would be eligible for endovascular aneurysm repair (EVAR) and to examine the major determinants for suitability of EVAR with the currently available indications. We retrospectively reviewed 3-D reconstructed computed tomography angiography of 88 patients with an atherosclerotic AAA who underwent open repair or EVAR between October 2003 and October 2010 at the Cardiovascular Center, Seoul National University Bundang Hospital. Of the 88 patients, 71 (80.7%) were treated with open repair and 17 (19.3%) were treated with EVAR. The rate of minor complications, postprocedural intensive care unit stay, and total hospital stay were significantly lower in the EVAR group. When the suitability of EVAR was reevaluated using morphologic criteria, a total of 33 (37.5%) patients were considered eligible for EVAR. Multivariate analysis revealed that proximal neck length, proximal neck angle, and aneurismal sac size were independent determinants for suitability of EVAR. Taking into account the increased clinical experience and the availability of new devices, EVAR would be applicable in about 40% of atherosclerotic AAA cases in this series of Korean patients. Accurate identification of candidates for EVAR by detailed preoperative evaluation, especially for morphologic characteristics, is essential.

Elevated troponin I is associated with a worse long-term prognosis in patients undergoing beating-heart coronary surgery.

OBJECTIVES: The impacts of elevated troponin I levels after coronary artery bypass grafting (CABG) on long-term outcomes were investigated. METHODS: A total of 996 patients who underwent elective isolated CABG for stable or unstable angina were enrolled. Patients were divided into higher and lower groups based on 80th percentile postoperative peak troponin I (ppTnI) levels. The relationship between ppTnI and long-term clinical outcomes was analysed. RESULTS: The median ppTnI was 1.55 (2.74) ng/ml and was significantly higher in the conventional CABG subgroup than in the beating-heart CABG subgroup: 4.04 (4.71) vs 1.24 (1.99) ng/ml, P < 0.001. The 80th percentile of ppTnI was 3.3 ng/ml in the beating-heart CABG subgroup and 8.9 ng/ml in the conventional CABG subgroup. In the conventional CABG subgroup (n = 150), 10-year overall survival showed no significant difference between the higher (≥8.9 ng/ml) and lower (<8.9 ng/ml) ppTnI groups: 71% (10%) vs 76% (5%), P = 0.316. However, the beating-heart CABG subgroup (n = 846) showed significantly worse 10-year overall survival in the higher ppTnI group (≥3.3 ng/ml) than in the lower ppTnI group (<3.3 ng/ml): 64% (6%) vs 73% (3%), P = 0.010. In the beating-heart CABG subgroup, multivariable analysis showed that ppTnI exceeding the 80th percentile was a risk factor for overall death (hazard ratio: 1.505, 95% confidence interval: 1.019-2.225, P = 0.040). CONCLUSIONS: Higher ppTnI over the 80th percentile was associated with worse long-term survival in beating-heart CABG, but not in conventional CABG.

Improved clinical outcomes following introduction of an attending intensivist for patients admitted to the cardiac surgical intensive care unit after valvular heart surgery: a single-center experience.

Background: Although numerous studies have documented the improved clinical outcomes of patients undergoing cardiac surgery following introduction of attending intensivist, most of these studies included heterogeneous patient populations. We aimed to investigate the impact of an attending intensivist on the clinical outcomes of patients admitted to the cardiac surgical intensive care unit (CSICU) following valvular heart surgery. Methods: Patients who underwent valvular heart surgery between January 2007 and December 2012 (control group, n=337) were propensity matched (1:1) between January 2013 and June 2017 (intensivist group, n=407). Results: During the propensity score matching analysis, 285 patients were extracted from each group. Patients in the intensivist group underwent mechanical ventilation for a significantly shorter time than those in the control group (21.8±69.8 vs. 39.2±115.3 hours, P=0.021). More patients were extubated within 6 hours in the intensivist group than in the control group (53.7% vs. 42.8%, P=0.015). The incidence of ventilator-associated pneumonia (1.4% vs. 4.9%, P=0.031), cardiac arrest due to cardiac tamponade associated with post-cardiotomy bleeding (0.4% vs. 3.9%, P=0.002), and acute kidney injury (2.8% vs. 7.7%, P=0.011) in the intensivist group was significantly lower than that in the control group. The 30-day mortality rate of the intensivist group was significantly lower than that of the control group (2.1% vs. 6.7%, P=0.015). Conclusions: Critical care provided in the CSICU staffed by an attending intensivist is associated with a lower 30-day mortality rate and reduced incidence of postoperative complications.

Computerized tomography may underestimate the patency of internal thoracic artery composite grafts.

BACKGROUND: Multidetector-row computerized tomography (MDCT) has been regarded as useful for noninvasive assessment of the bypass grafts after coronary artery bypass grafting (CABG), but there have been few reports validating its accuracy in assessment of composite arterial graft patency. METHODS: In 108 patients who underwent CABG with a Y-composite graft made of bilateral internal thoracic arteries (ITAs), early postoperative (mean interval, 4.9 months) MDCT findings were compared with the findings of subsequent conventional coronary angiography (19 patients, mean 4.7 months after initial MDCT) or later MDCT (89 patients, mean 31.0 months after surgery). A total of 248 grafts with 409 distal anastomoses (mean 3.8/patient) were assessed. RESULTS: In the early MDCT, the left ITA was patent in 94.4%. The right ITA with multiple sequential anastomoses was completely patent in 73.8% and partially patent in 21.4%. Discrepancy of findings between early computed tomography (CT) and later imaging studies was found in 18 patients (16.7%). Fourteen (42.4%, 4 left and 10 right ITAs) among the 33 initially nonvisualized grafts showed improved patency in later MDCT or conventional angiogram. The positive predictive value of the early MDCT for ITA composite graft occlusion was calculated at 57.6% or lower, whereas the negative predictive value was 97.8% or higher. CONCLUSIONS: For a composite graft made of bilateral ITAs, especially for those with multiple sequential anastomoses, MDCT may reflect only the functional patency and underestimate the actual anatomic patency.

Transsternal and Transpericardial Approach to Descending Thoracic Aorta via Median Sternotomy-An Option for Extensive Aortic Surgery.

We describe a technique for approaching the distal descending thoracic aorta via median sternotomy and posterior pericardiotomy, which enabled us to perform the extensive aortic repair. While this approach shared the lesser invasiveness of the frozen elephant trunk procedure with less confinement by anatomic features, the advantage was counterbalanced by the high incidence of spinal cord ischemia. This approach can be an option in highly selected patients who require extensive aortic repair but have factors prohibiting other conventional approaches.

Coronary artery disease in aortic aneurysm and dissection.

Coexisting coronary artery disease is a significant risk factor of untoward outcomes after surgical and endovascular aortic repair. This article reviewed the data, consensus, and remaining controversy about the diagnosis and management of coexisting coronary artery disease in the patients who require intervention for aortic aneurysm and dissection. It can be summarized as follows: (1) the current guidelines generally recommend the same diagnostic algorithm, including indications of coronary artery angiography, as one for non-surgical patients; (2) they also recommend the same indications of coronary revascularization; and (3) there are minor, but important, remaining issues regarding the details of management and surgical techniques most of which are still at the discretion of individual surgeons and institutions. Because it is not likely to get large-scale investigational data about these issues, the collection of individual experiences should be promoted in future scientific meetings to build up the consensus.

Long-term patency of bilateral internal thoracic artery Y composite coronary artery bypass grafts-determinants and impact on survival.

Background: Bilateral internal thoracic artery Y-composite grafting with sequential anastomoses is a well-established strategy for multi-arterial coronary artery bypass grafting. This study investigated the factors affecting long-term patency of bilateral internal thoracic artery Y-composite grafts and their influence on survival. Methods: Patients who underwent coronary artery bypass grafting using bilateral internal thoracic artery Y-composite grafts due to triple-vessel disease were included. In total, 415 cases (2003-2020) with at least 1 postoperative coronary computed tomography or angiography examination were enrolled. Through a retrospective review of medical records and computed tomography, risk factors for graft events (string sign or occlusion) were analysed, and the influence of string sign or occlusion in the initial postoperative computed tomography on long-term survival was evaluated. Results: Patients' mean age was 66±9 years and 324 were male (78%). The mean number of anastomoses from bilateral internal thoracic artery grafts was 4.0±0.9. The mean follow-up duration was 8.0±4.0 years (interquartile range: 4.8-11.5 years). Beating-heart surgery negatively affected the patency of grafts to the left circumflex and right coronary artery territories (P=0.015 and P=0.030, respectively), but in the left anterior descending territory, the graft patency did not differ (P=0.053). Non-severe (<90%) native-vessel stenosis was a risk factor for poor patency in the left anterior descending, left circumflex, and right coronary artery territories (P<0.001 for all). Twenty-four of the 104 nonvisible or narrowed grafts (23%) on early imaging later became widely patent. Occlusion of the grafts or the string sign within postoperative 1 year did not have a negative impact on long-term survival (P=0.421). Conclusions: The patency rate was suboptimal in case of non-severe target-vessel stenosis (<90%). The beating-heart technique may negatively influence the patency of anastomoses to the left circumflex and right coronary artery territories. Compromised graft patency observed on initial computed tomography did not lead to worse survival.

The future of Asian Cardiovascular Annals: Goals and quality.

The positional statement of the Asian Cardiovascular and Thoracic Annals is presented.

Fate of remaining dissected aorta after descending thoracic or thoracoabdominal aorta replacement for chronic dissection.

OBJECTIVES: After performing descending thoracic or thoraco-abdominal aorta replacement for chronic aortic dissection, the fate of the remaining dissected aorta, without significant enlargement, is not well known. This study aimed to investigate the changes in the remaining aorta and the risk factors for late composite aortic events. METHODS: In 98 patients with chronic type A or B aortic dissection who underwent descending thoracic or thoraco-abdominal aorta replacement, the immediate postoperative and last follow-up computed tomography scans were reviewed. Aortic area-derived diameter was measured using the centreline reconstruction method at the levels of the 10 zones of the aorta and iliac arteries. The incidence of and risk factors for late composite aortic events (aortic death, rupture, reoperation, last follow-up aortic area-derived diameter >60 mm) were analysed. RESULTS: The median follow-up and computed tomography follow-up durations were 88.5 and 63.7 months, respectively. Nine late deaths occurred. The median growth rate of the remaining aorta was the greatest in the dissected infrarenal abdominal aorta at 0.8 mm/year. Of 16 late composite aortic events, the majority (2 ruptures and 8 reoperations) occurred in the distal contiguous segment. The 5- and 10-year cumulative incidence of events in the distal contiguous segment were 4.9% and 16.1%, respectively. Young age and Marfan syndrome were significant risk factors. CONCLUSIONS: Late composite aortic events were not negligible, especially in the distal contiguous segment. In young or Marfan syndrome patients, a greater distal extent of replacement may have to be considered at experienced aortic centres.

Robot-Assisted Repair of Atrial Septal Defect: A Comparison of Beating and Non-Beating Heart Surgery.

BACKGROUND: Robot-assisted repair of atrial septal defect (ASD) can be performed under either beating-heart or non-beating-heart conditions. However, the risk of cerebral air embolism (i.e., stroke) is a concern in the beating-heart approach. This study aimed to compare the outcomes of beating- and non-beating-heart approaches in robot-assisted ASD repair. METHODS: From 2010 to 2019, a total of 45 patients (mean age, 43.4±14.6 years; range, 19-79 years) underwent ASD repair using the da Vinci robotic surgical system. Twenty-seven of these cases were performed on a beating heart (beating-heart group, n=27) and the other cases were performed on an arrested or fibrillating heart (non-beating-heart group, n=18). Cardiopulmonary bypass (CPB) was achieved via cannulation of the femoral vessels and the right internal jugular vein in all patients. RESULTS: Complete ASD closure was verified using intraoperative transesophageal echocardiography in all patients. Conversion to open surgery was not performed in any cases, and there were no major complications. All patients recovered from anesthesia without any immediate postoperative neurologic symptoms. In a subgroup analysis of isolated ASD patch repair (beating-heart group: n=22 vs. non-beating-heart group: n=5), the operation time and CPB time were shorter in the beating-heart group (234±38 vs. 253±29 minutes, p=0.133 and 113±28 vs. 143±29 minutes, p=0.034, respectively). CONCLUSION: Robot-assisted ASD repair can be safely performed with the beating-heart approach. No additional risk in terms of cerebral embolism was found in the beating-heart group.

Changes in aortic growth rate and factors influencing aneurysmal dilatation after uncomplicated acute type B aortic dissection.

OBJECTIVES: The aim of this study was to evaluate changes in aortic growth rate and factors influencing aneurysmal dilatation after uncomplicated acute type B aortic dissection (ABAD). METHODS: Medically treated patients with uncomplicated ABAD between September 2004 and January 2020 were retrospectively reviewed. Diameters of 6 different sites in the descending aorta were measured and aortic growth rate was calculated according to the time interval. Factors associated with aneurysmal changes were also investigated. RESULTS: This study enrolled a total of 105 patients who underwent >2 serial computed tomography with a mean follow-up duration of 35.4 (12.1-77.4) months. The mean overall growth rates of the proximal descending thoracic aorta (DTA), mid-DTA, distal DTA, proximal abdominal aorta, maximal DTA and maximal abdominal aorta were 0.6 (1.9), 2.9 (5.2), 2.1 (4.0), 1.2 (2.2), 3.3 (5.6) and 1.4 (2.5) mm/year, respectively. The growth rate was higher at the early stage. It decreased over time. Growth rates of proximal DTA, mid-DTA, distal DTA, proximal abdominal aorta, maximal DTA, and maximal abdominal aorta within 3 months after dissection were 1.3 (9.6), 12.6 (18.2), 7.6 (11.7), 5.9 (7.5), 16.7 (19.8) and 6.8 (8.9) mm/year, respectively. More than 2 years later, they were 0.2 (0.6), 1.6 (1.6), 1.2 (1.3), 0.9 (1.4), 1.7 (1.9) and 1.2 (1.7) mm/year, respectively. Factors associated with aneurysmal changes after uncomplicated ABAD included an elliptical true lumen (odds ratio = 3.16; 95% confidence interval: 1.19-8.41; P = 0.021) and a proximal entry >10 mm (odds ratio = 3.08; 95% confidence interval: 1.09-8.69; P = 0.034) on initial computed tomography imaging. CONCLUSIONS: The aortic growth rate was higher immediately after uncomplicated ABAD but declined eventually. Patients with an elliptical true lumen and a large proximal entry might be good candidates for early endovascular intervention after uncomplicated ABAD.

Can preoperative features predict residual false lumen remodelling after tear-oriented limited resection for acute type I dissection?

OBJECTIVES: Our goal was to identify the preoperative findings in computed tomography correlated with the postoperative changes of the false lumen (FL) remaining in the descending thoracic aorta following tear-oriented surgery for acute type I dissection. METHODS: Patients who underwent ascending +/- partial arch replacement, with available preoperative and postoperative late (>1 year) CT scans, were included. Preoperative cross-sectional parameters were measured by the semi-automated centreline method at the level of the anastomosis. The parameters of the patients who presented positive remodelling of the proximal descending thoracic aorta were compared with those of the patients who did not in the late images. RESULTS: Among the included 101 patients, positive remodelling of the proximal descending thoracic aorta was observed in 46.5%, of which 76.6% extended downwards to the middle descending thoracic aorta. In the univariable analysis, an FL area ratio <50% (P < 0.001), a circumferential ratio of dissection <50% (P = 0.028), an FL width <20 mm (P = 0.008) at the distal anastomotic zone and not leaving residual arch branches having patent false lumens (P = 0.005) correlated with positive remodelling. The number of fulfilled above-mentioned features revealed a better correlation, which was stronger in patients without Marfan syndrome and in those older than 50 years. CONCLUSIONS: The cross-sectional extent of dissection at the presumed distal anastomotic zone is associated with descending thoracic aorta positive remodelling following tear-oriented replacement for acute type I aortic dissection. Considering the anatomical features in determining the extent of aortic replacement, some of the non-Marfan elderly patients can be spared from aggressive total arch replacement with the frozen elephant trunk technique.

Influence of Ipsilateral Graft Inflow to Arteriovenous Fistula for Hemodialysis in Coronary Bypass Surgery.

In coronary artery bypass grafting (CABG) for patients on hemodialysis, there has been concern about "coronary steal". This study aims to evaluate the influence of using an in situ internal thoracic artery (ITA) ipsilateral to a preexisting arteriovenous fistula (AVF) in dialysis-dependent patients undergoing CABG. Between 2004 and 2018, dialysis-dependent patients with AVFs who underwent CABG were enrolled. According to the locational relationship of AVFs and in situ ITA grafts, the patients were divided into the ipsilateral group (n = 22) and the contralateral group (n = 21). Inverse probability weighting analysis was used to estimate and compare the late clinical outcomes. The late cardiac-related adverse events were not significantly different between the two groups: "major adverse cardiovascular and cerebrovascular events (MACCE)" (p = 0.090), "composite outcome of recurrent angina and coronary re-intervention" (p = 0.600). The in situ ITA graft of CABG on the ipsilateral side to AVF was not a significant risk factor for MACCE or the composite outcome of recurrent angina and coronary re-intervention. There was no statistically significant difference in the graft patency between the groups. Therefore, it might not be necessary to avoid using an in situ ITA on the ipsilateral side of an upper-arm AVF for optimal coronary artery bypass grafting in dialysis-dependent patients.