The Etiological Heterogeneity of Bicuspid Aortopathy between Ascending and Root Morphotype.

BACKGROUND: Valve-related hemodynamics and intrinsically regulated matrix proteases are 2 determined pathogenetic factors associated with medial elastin degeneration in bicuspid aortopathy. This study analyzed the association between elastic fiber deterioration and the 2 pathogenetic factors in ascending and root morphotypes, aiming to elucidate the etiological heterogeneity between the 2 morphotypes. METHODS: Four-dimensional flow cardiac magnetic resonance was used to measure the regional wall shear stress (WSS) on the ascending aorta, and matrix metalloproteinase (MMP) expression was assessed by immunoblotting. After histopathology analysis of aortic tissue, we assessed whether elevated regional WSS and increased MMP expression corresponded with medial elastin thinning. RESULTS: Increased regional WSS corresponded with medial elastin thinning in both morphotypes. Increased expression of different MMP isoforms corresponded with medial elastin degeneration in bicuspid aortopathy. The significantly increased expression of MMP-2 corresponded with a decrease of elastic fiber thickness in the ascending morphotype (P = .046), whereas elastic fiber thinning was associated with high levels of MMP-3 expression (P = .012) in the root morphotype. No association was observed between regional WSS and MMP expression. CONCLUSION: There is no difference in the effect of valve-related hemodynamics between ascending and root morphotype, and MMPs are not involved in the process of elastic fiber degeneration induced by increased WSS. The increased expression of different MMP isoforms was observed in the context of elastic fiber degeneration between the 2 morphotypes, implying that heterogeneity between them is revealed in the different intrinsic pathway of medial elastin degradation.

[Risk Factors for Acute Renal Failure after Thoracoabdominal Aortic Aneurysm Surgery].

Objective To investigate the risk factors associated with acute renal failure (ARF) after thoracoabdominal aortic aneurysm (TAAA) surgery. Methods A total of 156 patients underwent TAAA repair between January 2009 and December 2017. Renal failure was defined based on the Kidney Disease Improving Global Outcomes criteria. The patients were divided into ARF group and non-ARF group based on the presence/absence of postoperative ARF. The risk factors of ARF were analyzed by univariate analysis and multivariate logistic analysis. Results The subjects included 111 males and 45 females aged (40.4±10.9) years (range:19-65 years). The surgical reasons included aortic dissection (n=130,83.3%),aneurysm (n=22,14.1%),and pseudoaneurysm (n=4,2.6%). The degrees of repair included Crawford extent I in 6 patients (3.8%),extent Ⅱ in 128 patients (82.1%),extent Ⅲ in 20 patients (12.8%),and extent Ⅳ in 2 patients(1.3%). There were 3 patients presented with aortic rupture and 6 patients received emergent operations. Nine patients (5.8%) died within 30 days after surgery,and 8 patients (5.1%) suffered from permanent paraplegia. Thirty-six patients (23.1%) had ARF after surgery,and 18 of them needed dialysis. Multivariate logistic analysis showed that smoking (OR =2.637,95%CI=1.113-6.250,P=0.028),packed red blood cell usage in operation (≥6 U) (OR =5.508,95%CI=2.144-11.930,P=0.000),reoperation for bleeding (OR=3.529,95%CI=1.298-9.590,P=0.013) were independent risk factors for ARF after TAAA repair. Conclusion Smoking,packed red blood cell usage in operation (≥6 U),reoperation for bleeding are the independent risk factors of ARF after TAAA surgery.

Surgical treatment for Kommerell's diverticulum associated with aortic dissection involving aortic arch.

OBJECTIVE: Kommerell diverticulum with aortic dissection involving aortic arch is a rare but troublesome condition. The purpose of this study is to summarize the experience and strategy of surgical treatment. METHOD: From November 2015 to January 2018, seven consecutive patients underwent surgical treatment in our institution. Three patients with acute type A aortic dissection and one patient with acute type B aortic dissection received total arch replacement and frozen elephant trunk (FET) implantation through median sternotomy. Three patients with chronic type B aortic dissection underwent total aortic arch and descending aorta replacement through median sternotomy and lateral thoracotomy. RESULT: There were seven male patients whose median age was 42.3 ± 11.7 (from 14 to 54) years old. There was no perioperative death in this study. One patient had postoperative critical illness polyneuropathy and required prolonged mechanical ventilation (485 hours) and recovered finally. Follow up was completed for all seven patients with a median follow-up time of 7 (3-46) months. One patient with type A dissection developed aneurysm of the descending aorta distal to the FET and received reintervention. No clinical events and abnormal computed tomography manifestations were found in the other seven patients. CONCLUSION: Total arch replacement and FET through single median incision is a reliable method for Kommerell diverticulum associated with acute dissection involving arch. For Kommerell diverticulum associated with chronic type A or B aortic dissection involving aortic arch, graft replacement by double or single incision is safe and appropriate.

[Early and Midterm Results of Thoracoabdominal Aortic Aneurysm Repair in Patients with Marfan Syndrome].

Objective To evaluate the early and midterm results of surgical repair of thoracoabdominal aortic aneurysm(TAAA)in patients with Marfan syndrome(MFS). Methods The clinical data of patients with MFS undergoing TAAA repair in Fuwai Hospital between January 2009 and December 2017 were retrospectively analyzed.These patients were divided into two groups:MFS group(n=58)and non-MFS group(n=98).The baseline data,early postoperative results,and midterm follow-up outcomes were compared between these two groups. Results MFS patients were significantly younger(32 years old vs. 45 years old,t=9.603,P=0.000)and more frequently had a history of aortic aneurysm or dissection(19% vs. 0,χ 2=19.996,P=0.000)than non-MFS patients.However,the proportions of males and smokers were significantly lower when compared with non-MFS patients(55.2% vs. 80.6%,χ 2=11.489,P=0.001;13.8% vs. 46.9%,χ 2=17.686,P=0.001).There was no significant difference in proportion of emergency operation,prophylactic cerebrospinal fluid drainage,operation time,intra-operative circulation management,and intra-operative blood transfusion(all P>0.05).The 30-day mortality rate was significantly lower in MFS group than in non-MFS group(0 vs. 9.2%, [Formula: see text]=5.034,P=0.025). Conclusions For patients with MFS,TAAA repair provides lower 30-day mortality and comparative middle-term survival.However,the re-intervention rate is higher among MFS patients,highlighting the importance of close follow-up.

Intercostal Artery Reconstruction: The Simple and Effective Technique on Spinal Cord Protection during Thoracoabdominal Aortic Replacement.

BACKGROUND: To retrospectively analyze the role of intercostal artery reconstruction in the spinal cord protection for patients undergoing extensive thoracoabdominal aortic aneurysm repair. METHODS: From August 2007 to 2014, thoracoabdominal aortas (Crawford II) of 81 consecutive patients with mean age 39.4 ± 10.32 years were repaired. Seventy-three of these patients (90.12%) were diagnosed with aortic dissection in our group, 25 (30.86%) with Stanford type A dissection and 48 (59.26%) with Stanford B aortic dissection. All 25 patients with type A dissection have previously undergone surgical procedures which include Bentall's procedures in 11 cases, ascending aortic replacement in 6 cases, and total aortic arch replacement in 8 cases. All procedures were performed under profound hypothermia with interval cardiac arrest after making a thoracoabdominal incision. Extracorporeal circulation was instituted with 2 arterial cannulae and a single venous cannula in the right atrium. T6-T12 intercostal arteries and L1 and L2 lumbar arteries were formed to a neo-intercostal artery in place and were connected to an 8 mm branch for maintaining spinal cord blood perfusion. Visceral arteries were joined into a patch and anastomosed to the end of the main graft. The left renal artery was anastomosed to an 8 mm branch or joined to the patch. The other 10 mm branches were anastomosed to iliac arteries. RESULTS: With 100% follow-up, early mortality was 7.4%. Six deaths were recorded; 1 patient died of cerebral hemorrhage, 3 of renal failure, 1 of heart failure because of myocardial infarction, and the last one died from the rupture of celiac artery dissection. The rate of postoperative spinal cord deficits was 3.7%, 2 patients with paraplegia and 1 patient with paraparesis. None had bladder or rectum dysfunction. Neo-intercostal arteries were clogged in 12 patients within follow-up period and formed pseudoaneurysm in 2 patients with Marfan syndrome. The mean survival time in this group was 54.22 ± 3.03 months (95% confidence interval 44.37-59.90 months) with survival rate of 92.37% after 1 year, 89.02% after 2 years, and 85.54% after 5 years. All patients were free from spinal cord deficits. CONCLUSIONS: Intercostal artery reconstruction is an effective technique for spinal cord protection in patients with the thoracoabdominal aortic repair. It can achieve favorable results and avoid spinal cord deficits with long-term follow-up.

[Stented elephant trunk and femoral artery bypass grafting surgery for extended aneurysmal dilation of Stanford A aortic dissection or aortic aneurysm].

OBJECTIVES: To summarize the clinical experience of stented elephant trunk with femoral artery bypass grafting procedure to treat severe aneurysmal dilation of Stanford A aortic dissection or aortic aneurysm. To study the surgical indication and surgical strategy of chronic Stanford A aortic dissection and aneurysmal dilation, also to summarize the early follow-up results. METHODS: From February 2006 to November 2011, 19 patients with Stanford A aortic dissection or aortic aneurysm with extented aneurysmal dilation (megaaorta) received stented elephant trunk with femoral artery bypass grafting procedure. There were 3 acute cases and 16 chronic cases with 14 male patients and 5 female patients. Average age of this group was (42 ± 8) years and average body weight was (70 ± 15) kg. One patient was aortic aneurysm and all the other were Stanford A aortic dissection. Eight patients were Mafan's syndrome. Ascending aorta replacement or Bentall's operation was done first and total arch replacement and stented elephant trunk operation was done under deep hypothermia and circulatory arrest. After the patient was weaned from cardiopulmonary bypass, bypass from ascending aorta to femoral artery was done subcutaneously using the 10 mm graft in the same femoral incision. RESULTS: There was no operative mortality. One patient had chylothorax which recovered with medical treatment and one patient got paraplegia after surgery. The cardiopulmonary bypass time was (176 ± 42) minutes, aortic cross clamping time was (88 ± 25) minutes and deep hypothermia and low flow rate time was (23 ± 8) minutes. The blood pressure of the lower extremities were normal after operation. Follow-up time was (22 ± 19) months. All patients survived. False lumen closure rate at the stent level was 100%. CT scan at 3 to 6 months after operation showed no obvious dilation of the descending aorta. Two patient successfully received second stage operation of total (subtotal) thoracoabdominal aorta replacement. CONCLUSIONS: Stented elephant trunk and aorta to femoral artery bypass is a safe procedure to treat aortic dissection or aortic aneurysm with extended aneurysmal dilation. This procedure can effectively increase the blood supply of the lower extremities due to small true lumen of the descending aorta, and may decrease the speed of dilation of the false lumen. It is also a practical procedure to lay the foundation for the second stage operation of normothemia thoracoabdominal aorta replacement.

[Risk analysis for hospital mortality after operations for type A aortic dissection].

OBJECTIVE: To analyze the risk factors for hospital mortality after operations for type A aortic dissection. METHODS: Totally 766 consecutive patients (586 male and 180 female patient, aged (45±12) years, ranging from 16 to 78 years), who underwent surgery for type A aortic dissection from January 2001 to December 2010, were studied retrospectively. Preoperative and operation related clinic factors were analyzed by univariate analysis, followed by Logistic regression model, to identify the risk factors of hospital mortality. RESULTS: Overall, 37 patients (4.8%) died during hospitalization. On univariate analysis, significant risk factors for hospital mortality were male, acute status, renal dysfunction, cardiac dysfunction, cardiopulmonary bypass time, duration of operation, volume of blood transfusion, re-operation for bleeding (χ2=4.008-27.093, P<0.05). On Logistic regression model, independent risk factors were acute status (OR=2.784, 95%CI: 1.166-6.649, P=0.021), renal dysfunction (OR=6.285, 95%CI: 1.738 - 22.723, P=0.005), cardiac dysfunction (OR=3.052, 95%CI: 1.083-8.606, P=0.035), re-operation for bleeding (OR=3.690, 95%CI: 1.262-10.791, P=0.017), volume of blood transfusion (OR=1.033, 95%CI: 1.008-1.058, P=0.010). Additionally, male (OR=0.387, 95%CI: 0.177-0.848, P=0.018) was protective factor, and alternatively, female was indeed one of the independent risk factors for hospital mortality. CONCLUSION: Female, acute status, renal dysfunction, cardiac dysfunction, re-operation for bleeding, volume of blood transfusion were independent risk factors for hospital mortality after operations for type A aortic dissection.

Characteristics of organ cysts and their association with type A aortic dissection.

OBJECTIVE: We aimed to evaluate the incidence of organ cysts in patients with type A aortic dissection (TAAD) to assess the association between organ cysts and TAAD. METHODS: Between January 2018 and December 2018, all patients with TAAD undergoing aortic surgery at our center were enrolled into the study; patients undergoing isolated coronary artery bypass grafting at our center were selected as the control group. Baseline differences between the 2 groups were adjusted using propensity-score matching. The incidence of organ cysts was compared between the 2 groups in total and matched cohorts. RESULTS: We enrolled 290 patients with TAAD and 293 patients with coronary artery disease (control group). The incidence of all organ cysts, liver cysts, renal cysts, and other organ cysts, was significantly higher in the TAAD group than in the control group (50.0% vs. 35.5%, p<0.001; 24.5% vs. 10.2%, p<0.001; 33.4% vs. 24.9%, p=0.023; and 6.2% vs. 1.5%, p=0.005; respectively). Among the 191 propensity score-matched patient pairs, the incidence of organ cysts, liver cysts, renal cysts, and other organ cysts was also significantly higher in the TAAD group than in the control group (57.6% vs. 30.9%, p<0.001; 28.8% vs. 11.0%, p<0.001; 39.3% vs. 19.9%, p<0.001; and 8.4% vs. 1.0%, p=0.001; respectively). The incidence of cysts with single-organ and multiple-organ involvement was also significantly higher in the TAAD group than in the control group (34.0% vs. 20.4%, p=0.003; and 23.6% vs. 10.5%, p=0.001). CONCLUSION: Our results show a higher incidence of organ cysts in patients with TAAD which is indicative of a common pathogenetic pathway between organ cysts and aortic dissection.

Treatment of complex coarctation and coarctation with cardiac lesions using extra-anatomic aortic bypass.

BACKGROUND: Coarctation of the aorta with cardiac lesions or complex coarctation is a formidable challenge for cardiac surgeons. Extra-anatomic bypass allows simultaneous intracardiac repair or an alternative approach for patients with complex coarctation. METHODS: Between July 1997 and March 2008, 43 patients with coarctation of the aorta underwent extra-anatomic bypass grafting, including 10 ascending-to-descending aorta bypasses and 33 ascending aorta-to-infrarenal abdominal aorta bypasses. Forty patients had additional cardiovascular disorders and concomitant procedures performed including aortic valve replacement, mitral valve replacement, coronary artery bypass grafting, closure of ventricular septal defect and patent ductus arteriosus, ascending aorta repair, and the Bentall procedure. The other three patients had complex coarctation of the aorta, including a long-segment coarctation in two cases, and descending aortic aneurysm in one. RESULTS: Two patients died perioperatively: one due to air embolism during the cardiopulmonary bypass; one due to septic shock. There were no late deaths. Complications included laparotomy for mechanical ileus in one and re-exploration for bleeding in one case. There were no strokes or paraplegia and no grafted-related complication during follow-up period. Systolic blood pressure dropped from 160 +/- 27 mm Hg before surgery to 114 +/- 16 mm Hg postoperatively. Only two patients with mild hypertension postoperatively needed oral medicine. CONCLUSIONS: Extra-anatomic aortic bypass via median sternotomy or median sternotomy-laparotomy can be performed with low morbidity and mortality. It is a preferable single-stage approach for patients with concomitant complex coarctation and cardiovascular disorders.

[Clinical application of stented elephant trunk technique for complicated Stanford type B aortic dissection].

OBJECTIVE: To summarize the experience of the application of stented elephant trunk procedure in the treatment of the patients with complicated Stanford type B aortic Dissection. METHODS: Between January 2004 and March 2009, 33 patients (27 male and 6 female) underwent stented elephant trunk implantation in the descending aorta for complicated type B dissection. Right auxiliary artery cannulation was routinely used for cardiopulmonary bypass and selected cerebral perfusion. The stented elephant trunk was implanted through the aortic arch under hypothermic circulatory arrest. Complications were recorded to evaluate the immediate and mid-term results. RESULTS: Cardiopulmonary bypass time was 174 +/- 29 min, and average selective cerebral perfusion and lower body arrest time was 24 +/- 9 min. The in-hospital mortality was 6.0% (2/33). No paraplegia was observed after surgery. During follow-up CT-scans thrombus formation was observed within the descending aortic false lumen excluded by the stented graft in the acute and chronic aortic dissections. There was one death during follow-up. CONCLUSIONS: The stented elephant trunk procedure could be an effective treatment for complicated type B dissection; it also could close the false lumen of the descending aorta and in preventing expansion of the descending aorta.

[Chronic Debakey I aortic dissection in Marfan syndrome and hypertensive patients with modified stented elephant trunk surgery: a post-operative CT assessment].

OBJECTIVE: To assess the outcome of stented elephant trunk surgery for chronic DebakeyIaortic dissection in Marfan syndrome and hypertension patients by CT. METHODS: Between 2003 and 2008, 54 patients underwent the modified stented elephant trunk procedure and total arch replacement for chronic DebakeyIaortic dissection. Twenty-two patients were made a diagnosis of Marfan syndrome and the other 32 patients of hypertension. Aortic evolvement was evaluated with CT angiography by calculating the diameter ratios between the stent graft/true lumen and the aorta at the same level. RESULTS: CT study one year after discharge showed no difference in the diameter ratios of the stent and aorta at the carina level between groups (0.84 +/- 0.16 vs 0.80 +/- 0.23, P = 0.472), but had significant difference before and after surgery (0.29 +/- 0.16 vs 0.72 +/- 0.21, P < or = 0.001). And significant difference occurred at the different periods after discharge (0.72 +/- 0.21 vs 0.81 +/- 0.20, 0.81 +/- 0.20 vs 0.77 +/- 0.20, P < or = 0.001). The residual false lumen in the proximal descending aorta reached complete thrombosis in 59% of Marfan and 78% of hypertension. CONCLUSION: The modified stented elephant trunk technique is effective for closing the false lumen in the proximal descending aorta of chronic DebakeyIaortic dissection in Marfan syndrome and hypertension patients.

[Aortic valve preservation and root reconstruction in Marfan syndrome].

OBJECTIVE: To explore the experiences of aortic valve preservation and root reconstruction in patients with Marfan syndrome. METHODS: From July 2003 to Dec 2007, 22 patients with Marfan syndrome were treated by aortic valve preservation and root reconstruction. There were 12 male and 10 female, the age ranged from 10 to 57 years old with a mean of (28 +/- 10) years. The operation procedures included reimplantation technique in 9 patients, remodeling technique in 8 patients, and patch technique in 2 patients. In addition, reimplantation technique + total aorta replacement in 1 patient, remodeling technique + "aortic arch replacement + stent-elephant trunk" in 1 patient, patch technique + "aortic arch replacement + stent-elephant trunk" in 1 patient. The patients were followed-up by 17 to 64 months with a mean of (46 +/- 16) months. RESULTS: No in-hospital and follow-up period death occurred. There was one reexploration for bleeding 1 d postoperative. No valve-related complication occurred during the follow-up. At the end of follow-up, no aortic regurgitation was demonstrate in 16 patients, but mild regurgitation in 4 patients, moderate regurgitation in 1 patient and severe regurgitation in 1 patient. Two patients with moderate and severe aortic regurgitation need reoperation 1 year postoperative. CONCLUSION: The early and mid-term results of aortic valve preservation and root reconstruction operations in Marfan syndrome were favorable.

[Surgical repair of ruptured sinus of Valsalva aneurysm to right atrium].

OBJECTIVES: To summarize the experience of surgical repair of ruptured sinus of Valsalva aneurysm to right atrium and to compare the difference between through right atrium repair and transaortic combined with right atrium approach. METHODS: Between January 2004 and December 2009, 53 patients with ruptured sinus of Valsalva aneurysm to right atrium underwent surgical repair. There were 35 male and 18 female, aged from 15 to 63 with a mean of (33 ± 9) years. Repair through right atrium had undergone in 40 patients (group I), while transaortic combined with right atrium approach in 13 patients (group II). Surgical results between the two group and group were compared in cardiopulmonary bypass time, clamp aorta time, mechanical ventilation time, ICU time and postoperative stay time. RESULTS: There were no significant differences between two groups in cardiopulmonary bypass time [(86 ± 29) min vs. (96 ± 30) min], clamp aorta time [(59 ± 29) min vs. (71 ± 25) min], mechanical ventilation time [(9 ± 4) h vs. (16 ± 23) h], ICU time [(35 ± 23) h vs. (35 ± 23) h], postoperative stay time [(7.1 ± 0.9) d vs. (7.7 ± 2.8) d] (P > 0.05). Follow-up was performed from 1 to 64 months, with a mean of (32 ± 21) months. There was no death during follow up. One needed operation due to severe aortic valve regurgitation. One combined with coronary artery disease used medication. Heart function (NYHF) of the other patients were I and II degree during follow up. CONCLUSIONS: Surgical repair of ruptured sinus of Valsalva aneurysm to right atrium shows good result. There is no significant difference between through right atrium repair and transaortic combined with right atrium approach.

Different therapeutic modalities for aortic arch disease combined with Kommerell's diverticulum: single-center experience with nine cases.

BACKGROUND: Aortic arch disease with Kommerell's diverticulum is an uncommon but troublesome condition, and there are a variety of therapeutic modalities for treating this. We retrospectively analyzed cases who underwent open surgery to summarize different situations and approaches. METHODS: From November 2015 to January 2019, nine patients underwent operation for the mentioned disorder. Four patients with aortic dissection received total arch replacement. Two patients suffering from type B aortic dissection (TBAD) have accepted graft replacement from ascending aorta (aAO) to descending aorta. Two patients with true aneurysm and congenital malformation underwent graft bypass from aAO to descending aorta. One patient had graft replacement of descending aorta. RESULTS: There were nine (eight males and one female) patients with median age of 45 (from 14 to 54) years. The 30-day mortality was 11.1% (1 patient) due to refractory respiratory failure caused by compression of bronchus. One patient had complication of peripheral neuropathy and recovered eventually. Eight patients were followed-up for a median period of 20 [9-46] months. All patients were alive and had no long-term complications except one patient who received re-intervention due to delayed dilation of downstream aorta. CONCLUSIONS: Treatment for different arch lesions with Kommerell's diverticulum should follow corresponding indications. Open surgery is the preferred choice and detailed therapeutic strategy depends on the extension of aneurysm, classification and phase of dissection. Stenting might cause airway compression when right-sided arch and vascular ring exist.

[Extraanatomic aortic bypass grafting for the treatment of complex aortic coarctation].

OBJECTIVE: To review the experience of extraanatomic aortic bypass grafting for the treatment of complex aortic coarctation. METHODS: From July 1997 to July 2008, 48 consecutive patients (median age 30 years; range 10 to 58 years) with complex aortic coarctation underwent extraanatomic aortic bypass grafting. Indications include: (1) coarctation with intracardiac anomaly (n = 28); (2) coarctation with ascending aortic aneurysm (n = 1); (3) adult coarctation with calcification of local aortic wall (n = 7); (4) coarctation with hypoplasia aortic arch (n = 4); (5) long or multiple coarctation segment (n = 4); (6) coarctation with poststenotic aneurysm (n = 1); and (7) recurrent coarctation (n = 3). Routing of the grafts was:ascending-to-posterior pericardial descending aorta (n = 37); ascending-to-infrarenal abdominal aorta (n = 9); left subclavian artery-to-descending aorta(n = 2). Concomitant cardiac operations were performed in 31 patients (65%) using cardiopulmonary bypass; procedures included: aortic valve replacement in 16; mitral valve repair or replacement in 9; Bentall procedures in 6; patent ductus arteriosus closure in 5; ascending aortic replacement or plasty in 4; ventricular septal defect closure in 3 and coronary artery bypass surgery in 2. RESULTS: There was no operative death. One patient died of septic shock 39 days postoperatively. Two patients received laparotomy because of mechanical ileus shortly after the ascending-to-subrenal abdominal aortic bypass. Mean systolic blood pressure gradient between upper and lower extremities decreased from (65 +/- 27) mm Hg preoperatively to (14 +/- 11) mm Hg postoperatively (P < 0.05). During a mean follow-up of 28.9 months, there were no late deaths or graft-related complications. Residual mild hypertension were observed in five patients. CONCLUSION: Extraanatomic aortic bypass is an attractive treatment option for complex aortic coarctation in adults and adolescents. It can be performed with low morbidity and mortality. The midterm results is favorable.

[Midterm outcome of one stage total or subtotal aortic replacement].

OBJECTIVE: To summarize the experience of one-stage total and subtotal aortic replacement for aneurysm evolving the entire aorta and show the midterm results of the operation. METHODS: From February 2004 to July 2008, 22 patients (17 men and 5 women, age ranged from 19 to 47 years old) underwent one-stage total or subtotal aortic replacement under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. Seven patients received subtotal aortic replacement (from the aortic valve to the abdominal aorta). Fifteen patients underwent total aortic replacement (from the aortic valve to the aortic bifurcation). Patients were opened with a mid-sternotomy and a thoracoabdominal incision. First, the ascending aorta was replaced; following which the aortic arch was reconstructed. Finally, the thoracoabdominal aorta was fully replaced. RESULTS: Thirty-day mortality was 4.5% (1/22). One patient died of multiple organ failure 11 days postoperatively. Two patients had cerebral infarction secondary to embolism. Spinal neurological deficits didn't occur. Twenty-one patients survived the operation and were followed up for 3 to 56 months (35.0 +/- 16.9 months). There was no late death. One patient received aortic valve replacement due to aortic valve regurgitation one year after David and total aortic replacement. CONCLUSION: One-stage total and subtotal aortic replacement is an effective operation for aneurysm evolving the whole length of the aorta with acceptable mortality and morbidity. Midterm follow-up showed satisfactory results.

[Further development of pulmonary artery after Glenn procedure: effect of different antegrade pulmonary blood flows on cyanotic congenital heart defects].

OBJECTIVE: To compare the effect of different antegrade pulmonary blood flow on the further development of pulmonary artery after Glenn procedure in cyanotic congenital heart defects (CHD) patients. METHODS: Between October 2000 and December 2006, 132 CHD patients with decreased pulmonary artery blood flow underwent bidirectional Glenn shunt, among them 18 patients received intraoperative lung biopsy. Patients were divided into two groups according to their different sources of antegrade pulmonary blood flow: antegrade arterial blood flow group (n = 33) and antegrade venous blood flow group (n = 99). The percutaneous oxygen saturation (SpO2), hemoglobin (Hb) concentration, and hemotocrit (Hct) value were examined and recorded before and after operation. The diameters of left pulmonary artery (LPA) and right pulmonary artery (RPA) were measured with two-dimensional echocardiography and the results were used to calculate the pulmonary artery index (PAI). The method of half-quantitative morphometric technique and an image analyzer were used to measure the following indicators of pulmonary microvessels: the percentage of media thickness (MT%), the percentage of media section area (MS%), vascular numbers of per square centimeter (VPSC), and mean alveolar number (MAN). RESULTS: Before the operation, obvious cyanosis was found in both groups, while SpO2, Hct, and Hb were not significantly different (P > 0.05). LPA, RPA, and PAI were not significantly different between two groups (P > 0.05). The MT% and MS% in antegrade venous blood flow group were significantly less than those in antegrade arterial blood flow group (P < 0.05), but VPSC and MAN were not significantly different (P > 0.05). After Glenn procedure, hypoxia and cyanosis were remarkably improved in both two groups. There was a significantly negative correlation between SpO2 and Hct (r = -0.49, P < 0.01) or Hb (r = -0.196, P < 0.01 ). The PAI increased by 22% in antegrade arterial blood flow group and 44% in antegrade venous blood flow group (P < 0.05). The diameters of LPA and RPA in antegrade venous blood flow group were significantly larger than those in antegrade arterial blood flow group (P < 0.05) and the growth of RPA in antegrade arterial blood flow group was not significant. CONCLUSION: A better pulmonary artery growth occurs in the patients of pulmonary stenosis after Glenn shunt than in those of pulmonary atresia, and it contributes to an earlier completion of Fontan procedure.

[Lung pathology of complex congenital heart defect with diminished pulmonary blood flow but without aortopulmonary collateral artery and patent ductus arteriosus in infants and young children].

OBJECTIVE: The development of pulmonary vascular bed is strongly flow-dependent. Abnormal pulmonary blood flow leads to pulmonary pathological changes. This study aimed to observe the pathological changes of small pulmonary arteries and alveoli in complex congenital heart defect with diminished pulmonary blood flow but without aortopulmonary collateral artery (APCA) and patent ductus arteriosus (PDA) in infants and young children. METHODS: Autopsy pulmonary specimens obtained from 5 children who died of non-cardiovascular diseases were used as the control group (age: 4-18 months). Fifty-six children (age: 4-36 months) with complex congenital heart defect with diminished pulmonary blood flow but without APCA and PDA served as the study group, including 34 cases of tetralogy of Fallot, 7 cases of double outlet right ventricle with pulmonary stenosis, 9 cases of single ventricle with pulmonary stenosis, 4 cases of tricuspid atresia with pulmonary stenosis and 2 cases of complete atrioventricular septal defect with pulmonary stenosis. Pulmonary specimen sections were stained by hematoxylin-eosin and Weigert-Van Gieson. Percentage of media thickness (MT%), percentage of media section area (MS%), number of small arterial per square centimeter (APSC), mean alveolar number (MAN), mean linear intercept (MLI), proportion of parenchyma area in total area (PPA%) and alveolar to small arterial ratio per unit area (AAR) were measured by morphologic quantitative analysis. RESULTS: MT% (10.93+/-2.87% vs 15.08+/-2.51%), MS% (18.97+/-5.56% vs 25.04+/-3.87%) and APSC (202.43+/-67.45 vs 441.69+/-65.29) decreased significantly in the study group compared with the control group (P<0.01). The internal diameter of small pulmonary artery (80.26+/-21.57 microm vs 58.53+/-10.29 microm; P<0.05), AAR (46.59+/-14.43 vs 34.46+/-4.98; P<0.01) and MLI (144.98+/-44.87 microm vs 108.39+/-20.76 microm; P<0.05) increased significantly compared with the control group. CONCLUSIONS: The media of small pulmonary arteries becomes thinner, the lumen of small pulmonary arteries becomes larger, and the number of small arterial per square centimeter and the mean alveolar number are reduced in infants and young children with complex congenital heart defect with diminished pulmonary blood flow but without APCA and PDA.

Morphological features of the thoracic aorta and supra-aortic branches in patients with acute Type A aortic dissection in China.

OBJECTIVES: This study aimed to investigate the morphological characteristics of the dissected thoracic aorta and brachiocephalic arteries within the Chinese population. METHODS: A retrospective analysis of computed tomography scans of 387 patients with acute Type A aortic dissection was carried out. The dimensions of the thoracic aorta at multiple levels and other imaging characteristics were studied. RESULTS: The patients with a maximum diameter ≥55 mm accounted for less than one-third of the population. Among those without Marfan syndrome (MFS) (n = 349), only 114 (32.8%) patients had a maximal aortic diameter ≥ 55 mm, whereas among those with MFS (n = 38), 20 (78.9%) had a maximal aortic diameter ≥ 45 mm. The predicted maximum aortic diameter is 88.46 - 0.81 × height (cm) + 63.02 × body surface area (m2) + 5.50 × (if diabetes, 1, if not, 0) - 6.63 × (if hypertension, 1, if not, 0). A positive correlation was established between a circular false lumen and the probability that brachiocephalic arteries were involved by dissection. The size ratio of false lumen to true lumen was greater in the circumferential group when compared with the crescent group. The independent predictors for the circumferential false lumen were age, atherosclerosis and smoking. CONCLUSIONS: Herein, the morphological characteristics of the thoracic aorta among Chinese patients with acute Type A aortic dissection were described. The currently recommended criteria for prophylactic aorta surgery were applied to most patients with MFS but not to those without MFS within the Chinese population. Furthermore, the shape of the false lumen was identified as a putative risk factor that might affect the prognosis of the patients.

P38 mitogen-activated protein kinase inhibition attenuates pulmonary inflammatory response in a rat cardiopulmonary bypass model.

OBJECTIVE: Cardiopulmonary bypass (CPB) produces an inflammatory response associated with pulmonary dysfunction. P38 mitogen-activated protein kinase (P38MAPK) have been shown to mediate pulmonary inflammatory response after CPB, we examined the effect of SB203580, a specific p38 MAPK inhibitor, on CPB-induced pulmonary inflammatory response. METHODS: Sprague-Dawley rats (n=54) were randomized into three groups (each n=18): (1) S group, rats underwent sham CPB; (2) CPB group, rats underwent CPB; (3) SB group, rats underwent CPB plus pretreatment with SB203580 (10 mg/kg, i.v., 30 min before CPB). The lung samples were collected after 10 min, 60 min, and 150 min lung reperfusion (each n=6) in CPB group and SB group, and after 70 min, 120 min, and 210 min observation in S group as the control. RESULTS: The level of lung phospho-IkappaBalpha, nuclear factor (NF)-kappaB activity and activating protein (AP)-1 activity in CPB group was increased than S group. CPB resulted in increased pulmonary tissue tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta expression and production, increased pulmonary inflammatory response. The in vivo administration of SB203580 prevented up-regulation of lung-phosphorylated p38 MAP kinase, decreased pulmonary tissue level of proinflammatory cytokines expression and production, and reduced lung inflammation. CONCLUSIONS: These findings suggested that (1) p38 MAP kinase activation is one of the important aspects of the signaling event that mediate the release of TNF-alpha and IL-1beta and contributes to CPB-induced pulmonary inflammatory response, (2) SB203580 selectively inhibiting p38 MAP kinase activation efficaciously reduces pulmonary inflammatory response after CPB, and (3) p38 MAP kinase influence the activation of NF-kappaB in the lung during and after CPB.