Association of carotid duplex ultrasonography screening with stroke and mortality among patients undergoing coronary artery bypass grafting.

OBJECTIVE: Selection criteria for carotid duplex ultrasonography screening (DUS) before coronary artery bypass grafting (CABG) is primarily based on limited observational analysis, and the risks associated with carotid artery stenosis (CAS) detected by this approach to preoperative DUS are uncertain. This study aimed to determine the association of carotid DUS with stroke and mortality among patients undergoing CABG. METHODS: Adult patients with coronary artery disease who underwent isolated CABG or CABG with concomitant valvular or congenital procedure were identified. CHA2DS2-VASc score was assessed before CABG, and patients were recorded as high risk if they had a score of 3 or higher. The primary outcomes were stroke and all-cause mortality. Secondary outcomes included ischemic stroke, non-ischemic stroke, transient ischemic attack, and cardiovascular mortality. RESULTS: Among 8958 patients who underwent CABG, 70.9% (n = 6347) received carotid DUS preoperatively (low-risk, 57.3%; high-risk, 42.7%). In the low-risk cohort, there was no significant difference in the risk of stroke (20.7 per 1000 patient-years for CAS vs 13.1 per 1000 patient-years for no CAS; adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 0.78-1.68) or mortality (20.5 per 1000 patient-years for CAS vs 16.8 per 1000 patient-years for no CAS; aHR, 1.33; 95% CI, 0.97-1.83) at 15 years. In the high-risk cohort, CAS was associated with significantly higher risks of stroke at 30 days (433.2 vs 279.5 per 1000 patient-years; aHR, 1.92; 95% CI, 1.00-3.70) and mortality at 15 years (38.4 vs 32.7 per 1000 patient-years; aHR, 1.25; 95% CI, 1.01-1.57) compared with no CAS. CONCLUSIONS: CAS did not impact the incidence of stroke or mortality in the low-risk cohort who underwent CABG. However, in the high-risk cohort, CAS was associated with a significant increase in the risks of 30-day stroke and 15-year mortality, indicating selective carotid DUS is necessarily recommended for these patients.

Surgical treatment patterns and clinical outcomes of type B aortic dissection involving the aortic arch.

OBJECTIVE: In the present report, we have described the outcomes of endovascular repair, hybrid arch repair, and open surgical repair for type B dissection involving the aortic arch (B1-2, D). METHODS: Cases of endovascular repair, hybrid arch repair, and open surgical repair performed between January 2015 and December 2019 for aortic dissection designated as B1-2, D by the Society for Vascular Surgery/Society of Thoracic Surgeons classification were retrospectively analyzed. The primary end point was all-cause mortality at follow-up. The secondary end points included early mortality, early morbidities, and aortic-related late events. Kaplan-Meier curves were created to analyze survival from all-cause mortality and freedom from aortic-related late events in the endovascular, hybrid, and open groups. Propensity score matching and stratification (stratified by proximal dissection extension: B1, D and B2, D) were performed as sensitivity analyses to compare the outcomes among the three treatment patterns after controlling for major confounders. RESULTS: The present study included 151 patients (men, 79.5%; mean age, 47.3 ± 10.5 years), with 72 (47.7%) in the endovascular group, 46 (30.5%) in the hybrid group, and 33 (21.8%) in the open group. No significant difference was noted in early mortality between the endovascular, hybrid, and open groups (1.4% vs 2.2% vs 3.0%; P = .791). The incidence of early endoleak was significantly greater (33.3% vs 13.0% vs 6.1%; P = .002) and the incidence of renal function deterioration was less (4.2% vs 26.1% vs 24.2%; P = .001) after endovascular repair vs hybrid arch repair and open surgery. After a median follow-up of 40.0 months (range, 0-84.0 months), no significant differences were found in all-cause mortality (5.6% vs 4.3% vs 3.0%; P = 1.0), aortic-related late events (16.7% vs 15.2% vs 12.1%; P = .834), or late endoleak (9.7% vs 4.3% vs 6.1%; P = .630) after endovascular, hybrid, and open surgery. The propensity score matching and stratification analyses displayed consistent outcomes for early mortality, all-cause mortality, and aortic-related late events among the three groups. CONCLUSIONS: The mid- to long-term outcomes after endovascular repair, hybrid arch repair, and open surgical repair for type B dissection involving the aortic arch (B1-2, D) were favorable and comparable in selected patients. Extensive experience and multidisciplinary teamwork are prerequisites for individualized strategies for repair of B1-2, D.

A novel classification, management and long-term outcomes of coronary artery involvement in acute aortic dissection.

BACKGROUND: To introduce a new and simple classification and management of coronary artery involvement in aortic dissection and report results. METHODS: Coronary artery involvement was classified into two types according to the integrity of coronary intima: simple lesion (type S) and complex lesion (type C). Complex lesions were treated by CABG and simple lesions were treated by ostial repair or reimplantation. Data were collected and analyzed retrospectively. RESULTS: From January 2010 to December 2019, 267 consecutive patients were enrolled in the study, and among them complex lesions occurred in 27 patients (11.1%) and simple lesions was found in 240 patients(89.9%). Eleven untreated vessels with simple lesion were found to be involved again in the same operation and treated by CABG. The two type groups had comparable operative mortality (type S vs. type C, 9.6% vs. 18.5%, P = 0.28). 221 patients received follow-up with a median duration of 52 months. The overall survival rates at 1, 5, and 10 years postoperatively were 88.9%, 85.7%, and 79.8% in type S group and 79.2%, 79.2%, and 79.2% in type C group, respectively (P = 0.47). For the patients who received CABG and survived at discharge, radiographic follow-up with a median duration of 28 (IQR 7-55.5) months showed the freedom from occlusion of vein graft at 1, 5, and 10 years postoperatively were 87.5%, 70.0%, 28.0%. CONCLUSIONS: According to the new classification, two types of lesions could be treated by corresponding methods with satisfactory early and long-term results. Unrepaired coronary artery was at a risk of re-involvement. Vein graft onto arteries without atherosclerosis still had a high occlusion rate.

Association of the bovine aortic arch and bicuspid aortic valve with thoracic aortic disease.

BACKGROUND: Both bicuspid aortic valve (BAV) and bovine aortic arch (BA) are considered as markers of thoracic aortic disease (TAD). But the association between them is not yet clear. This study aimed to explore the potential association of BAV and BA with TAD. METHODS: The study involved 449 participants who underwent their first aortic valve replacement in Fuwai Hospital from June 2017 to March 2018. All patients underwent multidetector computed tomography and echocardiography before surgery. The clinical characteristics were recorded to analyze the association between BAV, BA, and TAD. The univariate and multivariate logistic regression analyses were applied to identify the risk factors for TAD. RESULTS: BA accounted for 79.8% of the arch variants and was the most common aortic arch branching variant. BAV was present in 52.6% of the patients with BA and 38.1% of the patients with normal arch (NA). Among the 185 patients in the BAV subgroup, 50 had BA and 135 had NA. No significant differences were found in BAV anatomical phenotype, aortopathy phenotype, and valve function between BA and NA. The multivariate analysis showed that the presence of BAV and male sex were the risk predictors of TAD. BA was not a risk factor for TAD in either univariate or multivariate analysis. CONCLUSIONS: The proportion of BAV in patients with BA was significantly higher than that of NA, but the BAV phenotype and aortopathy were not related to BA. BAV was a risk factor for TAD, whereas BA was not associated with TAD.

Enhancing surfactin production in B. velezensis Bs916 combined cumulative mutagenesis and expression key enzymes.

Surfactin is a lipopeptide which has attracted massive attention due to its versatile bioactive properties, although it has less commercial application due to its low yield in wild strains. The B. velezensis Bs916 has enable commercial production of surfactin due to its outstanding capacity to synthesize lipopeptides and amenable to genetically engineering. In this study, 20 derivatives with high surfactin production were obtained firstly by transposon mutagenesis and knockout techniques, and the surfactin yield of the derivative H5 (△GltB) was increased approximately 7-folds, reaching to 1.48 g/L. The molecular mechanism of high yielding surfactin in △GltB was investigated by the transcriptomic and KEGG pathway analysis. The results indicated that △GltB enhanced its ability to synthesize surfactin mainly by promoting transcription of the srfA gene cluster and inhibiting degradation of some key precursors such as fatty acid. Secondly, we obtained a triple mutant derivative BsC3 by cumulative mutagenesis of the negative genes GltB, RapF, and SerA, and it could increase the surfactin titer by twofold, reaching to 2.98 g/L. Thirdly, we achieved overexpression of two key rate-limiting enzyme genes, YbdT, and srfAD, and the derivative BsC5 which further increased the surfactin titer by 1.3-fold, reaching to 3.79 g/L. Finally, the yield of surfactin by derivatives was significantly increased under the optimal medium, particularly the BsC5 increased the surfactin titer to 8.37 g/L. To the best of our knowledge, this is one of the highest yields that have been reported. Our work may pave way for large scale production of surfactin by B. velezensis Bs916. KEY POINTS: • Elucidation of the molecular mechanism of surfactin high-yielding transposon mutant. • Genetically engineering of B. velezensis Bs916 surfactin titer to 8.37 g/L for large scale preparation.

Elevated AST/ALT (De Ritis) Ratio is a Risk Factor of Drainage Volume after Aortic Arch Surgery.

BACKGROUND: To examine the correlation between the preoperative elevated aspartate aminotransferase (AST)/alanine transaminase (ALT) (De Ritis) ratio and the drainage volume in patients after aortic arch surgery. METHODS: This retrospective cohort study was conducted from January 2017 to December 2018. The exposure factor was the preoperative AST/ALT ratio and the primary outcome was the total amount of the drainage volume. The optimal AST/ALT ratio cutoff value was determined by the maximum Youden index. Accordingly, we defined the ratio ≥0.92 as a high AST/ALT ratio and <0.92 as a low AST/ALT ratio. Based on the median drainage volume of all participants, we dichotomized the study population: patients with a total drainage volume of 1670 mL or more were classified into high-output group (HOPG) and the remaining patients were classified into the low-output group (LOPG). Univariable and multivariable logistic regression analyses were conducted to investigate the correlation between the elevated AST/ALT ratio and drainage volume. RESULTS: 425 participants were enrolled. 213 participants were divided into the LOPG and the others were in the HOPG. 244 participants were divided into the low AST/ALT ratio group. In the univariable logistic regression analysis, the odds ratio (OR) and 95% condifence interval (CI) for the large drainage volume in participants with elevated AST/ALT ratio were 1.810 and 1.226-2.670 (p = 0.003). After adjustments with the confounders, multivariable logistic regression analysis showed an elevated AST/ALT ratio was significantly associated with the total amount of drainage volume (OR = 1.725, 95% CI 1.115-2.669, p = 0.014). CONCLUSIONS: Preoperative elevated AST/ALT ratio is an independent risk factor for the pericardial and mediastinal drainage volume in patients undergoing aortic arch surgery. It might represent a novel marker for individual risk assessment for cardiac surgery.

Does methylprednisolone provide protective effect in total aortic arch replacement requiring hypothermia circulatory arrest and selective cerebral perfusion?

BACKGROUND: Glucocorticoids (GC)were applied in total aortic arch replacement (TAAR) at various dosages in many centers, but with limited evidence. METHODS: The retrospective study was aimed to evaluate whether methylprednisolone was associated with better postoperative outcomes in patients undergoing TAAR. Patients undergoing TAAR with moderate hypothermia and selective cerebral perfusion between 2017.1 to 2018.12 in Fuwai hospital were classified into three groups according to doses of methylprednisolone given in the surgery: large-GC group (1500-3000 mg); medium-GC group (500-1000 mg) and no-GC group (0 mg). Postoperative outcomes were compared among three groups. Multivariable analysis was performed to identify the association of methylprednisolone with outcomes. RESULTS: Three hundred twenty-eight patients were enrolled. Two hundred twenty-eight were in the large-GC group, 34 were in the medium-GC group, and 66 were in the no-GC group. The incidences of major adverse outcomes in large-GC, medium-GC and no-GC groups were 22.8%, 17.6% and 18.2%, respectively, with no statistical difference. A significant difference was observed in post-cardiopulmonary bypass (CPB) fresh frozen plasma (FFP) transfusion (p < .001) and chest drainage volume (p < .001). Multivariable analysis demonstrated that methylprednisolone was not associated with better outcomes (p = .455), while large doses of methylprednisolone were significantly associated with excessive chest drainage (over 2000 mL) [OR (99% CI) 4.282 (1.66-11.044), p < .001] and excessive post-CPB FFP transfusion (over 400 mL) [OR (99% CI) 2.208 (1.027-4.747), p = .008]. CONCLUSIONS: Large doses of methylprednisolone (1500-3000 mg) did not show a protective effect in TAAR with moderate hypothermia arrest plus selective cerebral perfusion and might increase postoperative bleeding and FFP transfusion.

The impact of prophylactic ascending aorta replacement on the long-term prognosis of zone 0 hybrid arch repair.

OBJECTIVES: To investigate the impact of prophylactic zone 0 replacement with prosthetic grafts on the long-term prognosis and perioperative safety of zone 0 hybrid arch repair (HAR) when zone 0 is neither dilated nor pathologic. METHODS: We retrospectively reviewed 115 patients whose zone 0 aorta was neither dilated nor pathologic and who underwent zone 0 HAR from January 2009 to December 2020 and divided then into two groups depending on whether zone 0 was replaced, with 46 patients in the no-replacement group and 69 patients in the replacement group. Inverse probability of treatment weighting (IPTW) was used to balance the baseline difference, and outcomes were compared after IPTW adjustment. The primary end points were overall survival and adverse aortic events (AAEs). The secondary end points were early composite adverse events and other perioperative complications. Subgroup analysis was performed by age, diagnosis, zone 0 maximum diameter and risk stratification. RESULTS: The 5-year IPTW-adjusted overall survival rate was 84% in the no-replacement group 90% in the replacement group (P = .61). With death as a competing risk, the IPTW-adjusted cumulative incidence of AAEs at 5 and 10 years was 23% and 41% in the no-replacement group, and 14% and 25% in the replacement group, respectively (subdistribution hazard ratio [sHR], 0.56; 95% confidence interval [CI], 0.23-1.39; P = .23). Considering proximal complications alone, the replacement group exhibited lower 5-year (3% vs 18%) and 10-year (6% vs 36%) cumulative incidences of proximal complications (sHR, 0.11; 95% CI, 0.01-0.91; P = .04) after IPTW adjustment. A subgroup analysis demonstrated that the benefits of zone 0 replacement in decreasing AAEs were observed in those aged 60 years or less (sHR, 0.15; 95% CI, 0.03-0.75; P = .02) and those with type B aortic dissection (sHR, 0.24; 95% CI, 0.07-0.82; P = .02). Additionally, zone 0 replacement did not increase early composite adverse event morbidity (9% vs 21%; P = .08) or early mortality (7% vs 6%; P = .87). CONCLUSIONS: Although zone 0 was neither dilated nor pathologic, prophylactic zone 0 replacement in zone 0 HAR significantly decreased the incidence of proximal complications, without impairing perioperative safety. Additionally, this strategy was associated with benefits in reducing AAEs in younger patients and patients with type B aortic dissection. Thus, prophylactic zone 0 replacement should be considered for reconstructing a stable proximal landing zone in zone 0 HAR.

Outcomes of one-staged procedures to treat aortic coarctation complicated by cardiac anomalies.

OBJECTIVE: One-staged surgical treatment of aortic coarctation combined with cardiac anomalies is challenging. We aim to evaluate the feasibility of bilateral aortofemoral bypass technique in one-staged surgery treating coractation by comparing surgical outcomes with catheter intervention plus stent (hybrid). METHODS: Between January 2012 and December 2017, 50 patients underwent one-staged surgical procedures to treat coarctation and repair concomitant cardiac anomalies, like aortic root dilatation, cardiac valvular disease and so on. Among them, 30 patients underwent bilateral aortofemoral bypass and 20 patients underwent hybrid procedure to treat coarctation. We retrospectively analyzed the data of these patients and compared the early and late results. RESULTS: All the baseline clinical characteristics were comparable between groups except that the mean age of bypass group was 39.5 ± 14.0 years which was older than hybrid group (27.9 ± 8.5 years, P = 0.002). Technical success was achieved in all patients, with no hospital death or other severe complications. Immediately after surgery, in bypass and hybrid group, the mean upper-limb systolic blood pressure decreased from 159.4 to 119.7 mmHg and 148.4 to 111.6 mmHg, the median peak systolic gradient decreased from 68.0 to 10 mmHg and 46.5 to 10 mmHg respectively (P = 0.09). And the mean upper-lower limbs gradient decreased from 21.7 to 5.9 mmHg and 21.0 to 2.7 mmHg respectively (P = 0.104). The mean follow-up time was 76.92 ± 18.7 in bypass group and 85.4 ± 20.6 months in hybrid group. There were 4 late deaths in bypass group (one died of gastrointestinal bleeding, one died of pulmonary embolism and the other two died of heart failure caused by mechanical prosthetic valve dysfunction). The follow-up peak systolic gradient and other blood pressure parameters showed stable and no differences between two groups. CONCLUSIONS: The bilateral aortofemoral bypass surgery is a safe and effective method which can be used in one-staged surgical strategy to treat coarctation complicated by cardiac anomalies and can be an alternative to the hybrid method.

Visceral protection in total arch replacement for aortic dissection: Effect of lower body hypothermia.

OBJECTIVE: Optimal hypothermia strategy for total arch replacement in acute type A aortic dissection (ATAAD) is unclear. A higher temperature during circulatory arrest might reduce tolerance to ischemia for visceral organs. We sought to investigate the effect of hypothermia on visceral protection. METHODS: From January 2010 to December 2019, 1138 consecutive patients underwent total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. The data were retrospectively collected and analyzed. Visceral organ injury and visceral-related adverse outcomes were defined as acute renal failure or spinal cord injury or both. Multivariate logistic regression analysis and multivariate linear regression model were used. RESULTS: The mean age of patient was 46.9 ± 10.0 years, with a male preponderance (79.6%). Operative mortality was 6.1% (69 patients). Spinal cord injury occurred in 55 (4.8%) patients and 133 (11.7%) patients had acute renal failure. In the multivariate logistic regression model, neither bladder temperature (odds ratio [OR] 0.971, 95% confidence interval [CI] 0.922-1.024, p = .278) nor circulatory arrest duration (OR 1.017, 95% CI 0.987-1.047, p = .267) significantly associated with visceral-related adverse outcomes. Female, lower limb malperfusion, age, cardiopulmonary bypass (CPB) duration and preoperative serum creatinine level were independent risk factors of visceral-related outcomes. There was a significant negative correlation between bladder temperature and CPB duration in multiple linear regression model (ß = -3.67, p < .0001). CONCLUSIONS: Bladder temperature had no effect on outcomes related to visceral protection under the premise of short circulatory arrest duration, but female gender, lower limb malperfusion, age, CPB duration, and preoperative serum creatinine level were independent risk factors. Bladder temperature negatively correlated to CPB duration.

Proliferative Vascular Smooth Muscle Cells Stimulate Extracellular Matrix Production via Osteopontin/p38 MAPK Signaling Pathway.

INTRODUCTION: Extracellular matrix disorder and cellular phenotype transformation are the major histopathological features associated with ascending aortic aneurysms. Rare studies have investigated the relationship between cellular phenotype transformation and the abnormalities of the matrix constituents. In this study, we investigated whether the cellular phenotype transformation resulted in the extracellular matrix disorder. METHODS: Aortic samples were obtained from 20 patients undergoing operations for ascending aortic aneurysms. Control aortic samples were obtained from 15 patients who underwent coronary artery bypass graft. The protein levels of osteopontin (OPN), collagen, and elastin were examined using Western blot, and quantitative reverse transcriptase-PCR was used to analyze the mRNA expression of collagen and elastin. In vitro experiment, vascular smooth muscle cells (VSMCs) were treated with recombinant human OPN (rh-OPN) or p38 MAPK inhibitor (SB203580) to investigate whether OPN and p38 MAPK regulated the expression of collagen and elastin. RESULTS: The protein level of OPN and collagen III increased in ascending aortic aneurysm samples, compared with controls (p < 0.05). There was no difference in the protein level of elastin between aneurysm tissues and the controls. VSMCs treated with rh-OPN increased the collagen III and elastin protein level and mRNA expression (p < 0.05). Cells treated with SB203580 decreased the collagen III and elastin protein level and mRNA expression (p < 0.05). Furthermore, VSMCs incubated with SB203580 reduced the rh-OPN-induced production of collagen III and elastin (p < 0.05). CONCLUSION: OPN, the proliferative VSMCs maker, increased the expression of extracellular matrix. OPN/p38 MAPK signaling pathways may protect against ascending aortic aneurysm progression.

Isolated True Subclavian Aneurysm without Aberrant Subclavian Artery or Coarctation of Descending Aorta.

OBJECTIVE: Isolated true subclavian artery aneurysm (SAA) without aberrant subclavian artery or coarctation of descending aorta is a rare peripheral aneurysm. Herein, the experience of our medical center in the treatment of this disease is presented. METHODS: The Division operative log was queried to identify cases of SAA repair between January 2012 and September 2019 that were not associated with coarctation of the aorta or the presence of an aberrant subclavian artery. A total of 22 cases were identified. The characteristics, treatment and clinical outcomes of these cases were assessed. RESULTS: The mean age of patients was 53.5 ± 14.3 years and 14 patients were male (63.6%). Half of the cases were attributed to atherosclerotic degeneration. The clinical symptoms of aneurysms were varied, including asymptomatic, pulsatile mass of supraclavicular fossa, local pain, upper limb embolism, Horner's syndrome and hoarseness. Aneurysms were located on the right in 17 cases, on the left in 3 cases and on both sides in 2 cases. Fifteen (68%) patients underwent an intervention, of which 11 (50%) underwent an open surgical repair, and 4 (18%) underwent endovascular repair. The mean diameter of the aneurysms was 39.5 ± 20.7 mm in the open surgery group, and 24.0 ± 4.7 mm in the endovascular group. The follow-up duration ranged from 2 months to 12 years. One patient died of cardiogenic disease in the untreated group. Patients undergoing open operative repair had 100% patency of the reconstruction. In the endovascular group, one patient had stent occlusion 2 years after the operation. CONCLUSIONS: The most common cause of isolated subclavian aneurysm without aberrant subclavian artery or coarctation of descending aorta is atherosclerosis. The clinical symptoms of aneurysms are varied, and the aneurysms tend to occur on the right side. Based on the anatomical conditions of SAAs, open surgery and endovascular repair can be used for treatment.

[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.

[Outcomes after Surgical Repair of Thoracoabdominal Aortic Aneurysm with Distal Aortic Dissection:DeBakey Type â versus Type â ¢].

Objective To evaluate the early and mid-term results after surgical repair of thoracoabdominal aortic aneurysm(TAAA)in patients with DeBakey typeⅠor Ⅲ aortic dissection. Methods The clinical data of 130 patients who underwent TAAA repair for chronic DeBakey typeⅠ(groupⅠ, n=47)or type Ⅲ(group Ⅲ, n=83)aortic dissections in our center between January 2009 and December 2017 were retrospectively analyzed.Early postoperative results,midterm survival,and re-interventions were compared between these two groups. Results The 30-day mortality rate was 6.9%(n=9)in the overall cohort,with no statistic difference between groupⅠand group Ⅲ(10.6% vs. 4.8%;χ2=0.803, P=0.370).The incidence of major adverse events(38.3% vs. 51.8%;χ2=2.199, P=0.138),5-year actuarial survival rate [(81.7±5.9)% vs.(87.2±4.2)%;χ2=0.483, P=0.487],and 5-year actuarial freedom from all reinterventions [(84.5±6.7)% vs.(85.5±4.8)%;χ2=0.010, P=0.920] showed no significant differences between these two groups. Conclusions The early and mid-term outcomes after surgical repair of TAAA are similar for DeBakey typeⅠ and type Ⅲ patients.However,studies with larger sample sizes are still required.

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.

Continuous-Flow Electrosynthesis of Benzofused S-Heterocycles by Dehydrogenative C-S Cross-Coupling.

Reported herein is the synthesis of benzofused six-membered S-heterocycles by intramolecular dehydrogenative C-S coupling using a modular flow electrolysis cell. The continuous-flow electrosynthesis not only ensures efficient product formation, but also obviates the need for transition-metal catalysts, oxidizing reagents, and supporting electrolytes. Reaction scale-up is conveniently achieved through extended electrolysis without changing the reaction conditions and equipment.

Catalyst- and Supporting-Electrolyte-Free Electrosynthesis of Benzothiazoles and Thiazolopyridines in Continuous Flow.

A catalyst- and supporting electrolyte-free method for electrochemical dehydrogenative C-S bond formation in continuous flow has been developed. A broad range of N-arylthioamides have been converted to the corresponding benzothiazoles in good to excellent yields and with high current efficiencies. This transformation is achieved using only electricity and laboratory grade solvent, avoiding degassing or the use of inert atmosphere. This work highlights three advantages of electrochemistry in flow, which is (i) a supporting electrolyte-free reaction, (ii) an easy scale-up of the reaction without the need for a larger reactor and, (iii) the important and effective impact of having a good mixing of the reaction mixture, which can be achieved effectively with the use of flow systems. This clearly improves the reported methods for the synthesis of benzothiazoles.

Single Stage Hybrid Repair for DeBakey Type I Aortic Dissection in High Risk Patients.

OBJECTIVES: To evaluate the efficacy of the less invasive hybrid zone 0 (Z0) total aortic arch repair (HAR, ascending repair + complete debranching + thoracic endovascular aortic repair [TEVAR]) without deep hypothermic circulatory arrest in management of DeBakey type I aortic dissection (IAD). The adverse outcome was defined as a single composite endpoint comprising peri-operative mortality, permanent neurological deficit, and renal failure necessitating haemodialysis at discharge. METHODS: A retrospective review of prospectively collected data was conducted of 120 consecutive patients (mean EuroSCORE = 11.6%) with IAD undergoing HAR (urgent/emergency, n = 97, 80.8%) involving reconstruction of the ascending aorta (zone 0) and total arch exclusion with TEVAR during a 7.5 year period. Multivariable analysis of 27 potential pre-operative and intra-operative risk factors was performed to examine the early composite endpoint and short and long-term overall mortality. RESULTS: The total early (30 day or in hospital) mortality was 9.2% (n = 11). The incidence of the composite endpoint was 11.7% (n = 14). On multivariable analysis, malperfusion syndromes were predictors of the composite endpoint (odds ratio [OR], 4.789; 95% CI 1.362-16.896; p = .015), and previous cerebrovascular accident (OR, 13.74; 95% CI 2.330-81.039; p = .004) and myocardial ischaemia time (OR, 1.038; 95% CI 1.015-1.061; p = .001) predicted short and long-term overall mortality. The overall survival was 84.7% during a median follow up of 3.4 years. Freedom from late aortic adverse events was 93.1% at 5 years, including secondary aortic intervention and endoleak. The maximum diameters of the true lumen increased significantly in stented thoracic (14.4 ± 6.5 mm to 29.7 ± 5.3 mm, p < .001), lower thoracic (14.2 ± 6 mm to 21.6 ± 7.2 mm, p < .001) and abdominal (11.7 ± 4.8 mm to 17.4 ± 4.1 mm, p < .001) aorta. Complete thrombosis of the peri-stent false lumen was achieved in 88.2% of CT scans (82/93) performed a mean of 12 ± 17 months (median 5 months; 25-75% quartile, 2-12 months) post-operatively. CONCLUSIONS: IAD was treated safely and durably by Z0 HAR, and peri-operative mortality and morbidity were not substantially higher despite the older age and high risk of patients.

Acute Kidney Injury After Total Arch Replacement Combined With Frozen Elephant Trunk Implantation: Incidence, Risk Factors, and Outcome.

OBJECTIVES: Acute kidney injury (AKI) is common after thoracic aortic surgery and is a significant predictor of morbidity and mortality. Total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation has been reported to produce satisfactory clinical outcomes, whereas several features of the surgical procedure may induce postoperative AKI. The authors aimed to clarify the incidence of and risk factors for postoperative AKI and the association of AKI with short-term outcomes. DESIGN: This study was a retrospective analysis of a prospectively collected cohort. A multivariate logistic regression model was used to identify predictors of postoperative AKI. SETTING: Single center. PARTICIPANTS: Clinical data were analyzed for 553 consecutive patients who underwent TAR combined with FET implantation between 2013 and 2016. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Postoperative AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Postoperative AKI occurred in 77.6% of the whole cohort. Patients in stage 3 AKI were associated with a higher incidence of major adverse events and in-hospital and 90-day mortality (p < 0.001, p < 0.05, p < 0.01, respectively). In the multivariate analysis, male sex (odds ratio [OR] 1.94; 95% confidence interval [95% CI] 1.22-3.18; p = 0.005); older age (per 10 years) (OR 1.37; 95% CI 1.14-1.67; p = 0.001); elevated body mass index (per 5 kg/m2) (OR 1.41; 95% CI 1.08-1.87; p = 0.01); and prolonged cardiopulmonary bypass duration (per 30 minutes) (OR 1.17; 95% CI 1.01-1.37; p = 0.03) were identified as independent predictors of postoperative AKI. CONCLUSION: TAR combined with FET implantation carries a high-risk for postoperative AKI compared with other types of thoracic aortic surgeries. Cardiopulmonary bypass duration was identified as the only modifiable predictor of AKI, and patients may benefit from moderate hypothermic circulatory arrest instead of deep hypothermic circulatory arrest.

Copper-Catalyzed Intramolecular Oxidative Amination of Unactivated Internal Alkenes.

A copper-catalyzed oxidative amination of unactivated internal alkenes has been developed. The Wacker-type oxidative alkene amination reaction is traditionally catalyzed by a palladium through a mechanism involving aminopalladation and ß-hydride elimination. Replacing the precious and scarce palladium with a cheap and abundant copper for this transformation has been challenging because of the difficulty associated with the aminocupration of internal alkenes. The combination of a simple copper salt, without additional ligand, as the catalyst and Dess-Martin periodinane as the oxidant, promotes efficiently the oxidative amination of allylic carbamates and ureas bearing di- and trisubstituted alkenes leading to oxazolidinones and imidazolidinones. Preliminary mechanistic studies suggested a hybrid radical-organometallic mechanism involving an amidyl radical cyclization to form the key C-N bond.