MicroRNA-19b-3p dysfunction of mesenchymal stem cell-derived exosomes from patients with abdominal aortic aneurysm impairs therapeutic efficacy.

Senescence of vascular smooth muscle cells (VSMCs) contributes to the formation of abdominal aortic aneurysm (AAA). Although mesenchymal stem cell exosomes (MSC-EXO) have been confirmed to restrict the development of AAA, their biological activity depends largely on the physiological state of the MSCs. This study aimed to compare the effects of adipose-derived MSC-EXO from healthy donors (HMEXO) and AAA patients (AMEXO) on senescence of VSMCs in AAA and explore the underlying mechanisms. An ApoE-/- mouse model of AAA was used to investigate the therapeutic effects of HMEXO, AMEXO or miR-19b-3p-AMEXO on AAA development. This in vitro model of AAA was established by treating VSMCs with Ang II (Angiotensin II). The senescence of VSMCs was determined by senescence-associated ß-galactosidase (SA-ß-gal) staining. The morphology of mitochondria in VSMCs was examined by MitoTracker staining. HMEXO exhibited superior capacity compared with AMEXO to inhibit VSMC senescence and attenuate AAA formation in Ang II-treated ApoE-/- mice. In vitro, both AMEXO and HMEXO inhibited Ang II-induced VSMC senescence via downregulation of mitochondrial fission. Notably, compared with HMEXO, the ability of AMEXO to inhibit VSMC senescence was significantly decreased. miRNA sequencing and the expression of miR-19b-3p was significantly decreased in AMEXO compared with HMEXO. Luciferase assay suggested that MST4 (Mammalian sterile-20-like kinase 4) is a potential target of miR-19b-3p. Mechanistically, miR-19b-3p in HMEXO ameliorated VSMC senescence by inhibiting mitochondrial fission via regulation of the MST4/ERK/Drp1 signaling pathway. Overexpression of miR-19b-3p in AMEXO improved their beneficial effect on AAA formation. Our study reveals that MSC-exosomal miR-19b-3p exerts protective effects against Ang II-induced AAA and VSMC senescence via regulation of the MST4/ERK/Drp1 pathway. The pathological state of AAA patients alters the miRNA components of AMEXO and impairs their therapeutic benefits.

Aortic balloon occlusion simplifies dissected thoracoabdominal aortic aneurysm repair after frozen elephant trunk.

Here, we report a case of a dissected thoracoabdominal aortic aneurysm repair after frozen elephant trunk implantation, using aortic balloon occlusion technique to simplify the proximal anastomosis and avoid deep hypothermic circulatory arrest.

A comparison of single and double arterial cannulation for cardiopulmonary bypass for acute type A aortic surgery: A single center, retrospective observational study.

Background: Acute type A aortic dissection (ATAAD) is a cardiovascular emergency and has high mortality and morbidity. We retrospectively compared the effects on outcomes of single arterial cannulation via axillary artery (AAC) with double arterial cannulation via axillary and femoral artery (DAC) in patients who underwent cardiopulmonary bypass (CPB) for ATAAD.Methods: Between January 2017 and May 2021, four hundred 29 patients who underwent aortic arch repair with circulatory arrest for ATAAD were divided into AAC group (n = 283) and DAC group (n = 146). The propensity score-matched (PSM) analysis were performed to compare the characteristics and outcomes of the groups.Results: After PSM (n = 137 in each), the DAC group had a longer duration of CPB (229 vs 244, p = 0.011), aortic cross-clamp time (121 vs 149, p < 0.001), durations of Intensive Care Unit (ICU) stay (7 vs 8, p = 0.014) and hospital stay (19 vs 25, p < 0.001) compared with AAC group. The incidences of dialysis (21% vs. 31%, p = 0.073), postoperative stroke (9% vs 15%, p = 0.143), ECMO support (2% vs 7%, p = 0.077), in-hospital mortality (7% vs 14%, p = 0.071) and follow-up mortality (10% vs 19%, p = 0.059) showed no significant difference between two groups. Multivariate logistic regression analysis showed postoperative ECMO (OR: 16.69, 95% CI: 1.78-156.29; p = 0.014) or stroke (OR: 11.34, 95% CI: 2.64-48.72; p < 0.001) were associated with in-hospital mortality. Univariate Cox regression results showed stroke history (OR: 4.61, 95% CI: 1.90-11.16; p = 0.001), aortic valvuloplasty (OR: 0.21, 95% CI: 0.07-0.59; p = 0.003), postoperative ALT day1 (OR: 1.00, 95% CI: 1.00-1.00; p = 0.008), ECMO (OR: 16.30, 95% CI: 4.78-55.61; p < 0.001), tracheotomy (OR: 3.78, 95% CI: 1.08-13.20; p = 0.037), postoperative stroke (OR: 4.61, 95% CI: 1.90-11.16; p < 0.001) and re-exploration for bleeding (OR: 3.52, 95% CI: 1.01-12.27; p = 0.048) were associated to follow-up mortality.Conclusions: For surgical treatment of ATAAD with CPB when compared to double axillary and femoral artery, single axillary cannulation was associated with shorter durations of CPB and ACC as well as ICU and hospital stays but no with significant difference in mortality.

Therapeutic management of acute type A aortic intramural hematoma.

OBJECTIVES: The proper therapeutic management for acute type A aortic intramural hematoma (IMH) is still controversial. The purpose of this study was to compare the outcomes following emergency surgery or conservative treatment for patients with this disease. METHODS: From January 2015 to December 2018, 124 consecutive patients were diagnosed with an acute type A aortic IMH and were included in this study. According to our surgical indications, they were divided into two groups: an operation group (OG) and a conservative treatment group (CG). RESULTS: Of 124 patients, 83 (66.9%) patients accepted emergency surgery and 41 (33.1%) patients accepted strict conservative treatment. There were no differences between these two groups in early mortality and complications. However, the late mortality of patients in the CG was significantly higher than for patients in the OG. A maximum aortic diameter in the ascending aorta and aortic arch ≥ 45 mm and maximum thickness of IMH in the same section ≥ 8 mm were risk factors for IMH related death in patients undergoing conservative treatment. CONCLUSIONS: The mortality associated with emergency surgery for patients with acute type A aortic IMH was satisfactory. In clinical centers with well-established surgical techniques and postoperative management, emergency surgical treatment may provide a better outcome than medical treatment for patients with acute type A aortic IMH.

Alpha-actin-2 mutations in Chinese patients with a non-syndromatic thoracic aortic aneurysm.

BACKGROUND: Aortic aneurysms and/or dissection (AADs) in the aorta are a leading cause of human morbidity and mortality. To date, data on non-syndromic thoracic AADs (TAADs) have been mainly derived from Caucasians, and the genetic basis of TAADs remains to be elucidated. In this study, we assessed gene mutations in a Chinese population with TAADs. METHODS: A cohort of 68 non-syndromic familial TAAD Chinese patients was screened for the most common TAAD-causing genes (ACTA2, MYH11, TGFBR1, TGFBR2, and SMAD3) using high-resolution melting (HRM) analysis. Thereafter, 142 unrelated non-syndromic sporadic cases were recruited and further analyzed using HRM analysis to estimate the prevalence of disease-causing mutations in these candidate genes. RESULTS: Two novel ACTA2 mutations (N117I and L348R) were identified in each familial TAAD proband separately, and an additional novel ACTA2 mutation (Y168N) was identified in one patient with sporadic TAADs. In contrast, none of the three mutations occurred in 480 control subjects. Also, no other gene mutations were identified in this cohort of Chinese TAAD patients. CONCLUSIONS: The current study identified three novel ACTA2 mutations in Chinese TAAD patients, and these mutations represented the most predominant genes responsible for non-syndromic TAADs. In addition, HRM analysis was shown to be a sensitive and high-throughput method for screening gene mutations.

Bowel ischemia caused by a giant thrombus in the ascending aorta. A case report.

Although an ascending aortic thrombus is a rare condition, it can cause serious complications of thromboembolism. Here we present a rare case of a patient who was hospitalized due to ileal arteries embolization caused by emboli from a giant thrombus in the ascending aorta. After 10 days anti-coagulation therapy, we performed a surgery to replace the ascending aorta containing the strip organized thrombus with a synthetic graft. During two years of postoperative follow-up, no recurrence of aortic thrombosis was found. Although the exact cause of this thrombus remains unclear, we believe that it is important to perform a surgery as soon as the presence of an ascending aortic thrombus is confirmed, which could help preventing the major recurrent embolic events.

The safety and prognostic evaluation of subsequent aortic surgery after thoracic endovascular aortic repair: a retrospective cohort study.

Background: Thoracic endovascular aortic repair (TEVAR) is a widely employed clinical procedure for treating various aortic pathologies. However, some patients require subsequent surgical interventions post-TEVAR, particularly due to life-threatening complications such as aortic dissection. This study aimed to evaluate the safety and prognosis associated with additional aortic surgeries following TEVAR. Methods: A retrospective analysis was conducted on 21 patients who underwent aortic surgery after TEVAR at Guangdong Provincial People's Hospital between September 2016 and August 2020. By compiling and reviewing perioperative data, we assessed surgical-related complications and survival rates. Results: Among the 21 patients, 95.2% were male, with an average age of 53 years. Preoperative comorbidities included hypertension in 15 individuals, abdominal aortic aneurysm in one patient, and coronary heart disease in two patients. The primary complications of TEVAR were stent leakage and retrograde aortic dissection, with the latter being the predominant type in subsequent aortic surgeries. The mean duration of aortic clamping during surgery was 130.0 minutes, with a deep hypothermic circulatory arrest time of 8.5 minutes. Postoperatively, two patients suffered in-hospital mortality, one developed renal dysfunction, four required re-entry into the operating room for further treatment, and the average length of hospital stay was 20 days. Following discharge, 14.3% of patients experienced complications, with central nervous system symptoms being the most prevalent. Kaplan-Meier survival analysis indicated a 5-year survival rate of 85.7%. Conclusions: Aortic surgical intervention following TEVAR is a safe therapeutic approach that can improve patient prognosis. However, meticulous management of the perioperative period is crucial for reducing the risk of complications and improving survival rates. This study provides valuable insights into aortic surgery post-TEVAR, but large-scale research is needed to validate these findings.

Case report: Acute right ventricular dysfunction after surgery in a pregnant patient with congenital heart disease and aortic dissection.

Pregnant women with aortic dissection are hemodynamically outmost complex patients. The two major diagnoses that should be considered in pregnant patients with congenital heart disease (CHD) and acute type A aortic dissection presenting with postoperative right ventricular dysfunction are pulmonary thromboembolism and right ventricular infarction. We present a rare case of postoperative right ventricular dysfunction in pregnant women with CHD and acute aortic dissection, which was diagnosed by pulmonary computed tomography angiography and treated by percutaneous coronary intervention.

Inclusion of interleukin-6 improved the performance of postoperative acute lung injury prediction for patients undergoing surgery for thoracic aortic disease.

Background: We studied acute lung injury (ALI) in thoracic aortic disease (TAD) patients and investigated the predictive effect of interleukin-6 (IL-6) in acute lung injury after thoracic aortic disease. Methods: Data on 188 TAD patients, who underwent surgery between January 2016 to December 2021 at our hospital, were enrolled in. We analyzed acute lung injury using two patient groups. Patients with No-ALI were 65 and those with ALI were 123. Univariate logistic, LASSO binary logistic regression model and multivariable logistic regression analysis were performed for acute lung injury. Results: Preoperative IL-6 level was lower (15.80[3.10,43.30] vs. 47.70[21.40,91.60] pg/ml, p < 0.001) in No-ALI group than in ALI group. The cut-off points, determined by the ROC curve, were preoperative IL-6 > 18 pg/ml (area under the curve: AUC = 0.727). Univariate logistic regression analysis showed 19 features for TAD appeared to be early postoperative risk factors of acute lung injury. Using LASSO binary logistic regression, 19 features were reduced to 9 potential predictors (i.e., Scrpost + PLTpost + CPB > 182 min + D-dimerpost + D-dimerpre + Hypertension + Age > 58 years + IL6 > 18 pg/ml + IL6). Multivariable logistic regression analysis showed that Postoperative creatinine, CPB > 182 min and IL-6 > 18 pg/ml were early postoperative risk factors for ALI after TAD, and the odds ratios (ORs) of postoperative creatinine, CPB > 182 min and IL-6 > 18 pg/ml were 1.006 (1.002-1.01), 4.717 (1.306-19.294) and 2.96 (1.184-7.497), respectively. When postoperative creatinine, CPB > 182 min and IL-6 > 18 pg/ml (AUC = 0.819), the 95% confidence interval [CI] was 0.741 to 0.898. Correction curves were nearly diagonal, suggesting that the nomogram fit well. The DCA curve was then drawn to demonstrate clinical applicability. The DCA curve showed that the threshold probability of a patient is in the range of 30% to 90%. Conclusions: The inclusion of interleukin-6 demonstrated good performance in predicting ALI after TAD surgery.

Risk factors for early death after surgery in patients with acute Stanford type A aortic dissection: A systematic review and meta-analysis.

BACKGROUND: There are many risk factors related to early death after surgery among patients with acute Stanford type A aortic dissection (ATAAD) that have been analyzed in previous studies, but no evidence-based study has been conducted to confirm these risk factors. AIMS: The aims of this study were to investigate risk factors for early death after surgery in patients with ATAAD via systematic review and meta-analysis and assess evidence-based strategies for preventing adverse events. METHODS: The protocol for this study was prospectively registered with PROSPERO (CRD 42022332772). The authors systematically searched PubMed, Ovid, Scopus, Web of Science and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines from database construction to May 2021. Studies that met the selection criteria were determined by two independent researchers, and the odds ratios (ORs) and 95% confidence intervals (95% CIs) were reported for the risk factors and were pooled using Stata 15.0. RESULTS: A total of 23 studies including 5510 patients met the inclusion criteria, and 10 risk factors were analyzed in this meta-analysis. The preoperative risk factors for early death after surgery in patients with ATAAD were age [(OR: 1.03, 95% CI (1.01, 1.06)], male sex [(OR: 1.43, 95% CI (1.06, 1.92)], shock [(OR: 1.91, 95% CI (1.06, 3.45)], malperfusion [(OR: 3.45, 95% CI (2.24, 5.31)] and cardiac tamponade [(OR: 3.89, 95% CI (1.17, 12.98)]. CONCLUSION: Patients with ATAAD who have an older age, male sex, shock, malperfusion and cardiac tamponade have a higher risk for early death after surgery. However, more highly homogenous studies are needed to demonstrate these results. Clinical staff should pay more attention to these factors and take individual actions to reduce mortality after surgery in patients with ATAAD.

Ascending aortic volume: A feasible indicator for ascending aortic aneurysm elective surgery?

Diameter-based criterion have been widely adopted for preventive surgery of ascending thoracic aortic aneurysm (ATAA). However, recent and growing evidence has shown that diameter-based methods may not be sufficient for identifying patients who are at risk of an ATAA. In this study, fluid-structure interaction (FSI) analysis was performed on one-hundred ATAA geometries reconstructed from clinical data to examine the relationship between hemodynamic conditions, ascending aortic volume (AAV), ascending aortic curvature, and aortic ratios measured from the reconstructed 3D models. The simulated hemodynamic and biomechanical parameters were compared among different groups of ATAA geometries classified based on AAV. The ATAAs with enlarged AAV showed significantly compromised hemodynamic conditions and higher mechanical wall stress. The maximum oscillatory shear index (OSI), particle residence time (PRT) and wall stress (WS) were significantly higher in enlarged ATAAs compared with controls (0.498 [0.497, 0.499] vs 0.499 [0.498, 0.499], p = 0.002, 312.847 [207.445, 519.391] vs 996.047 [640.644, 1573.140], p < 0.001, 769.680 [668.745, 879.795] vs 1072.000 [873.060, 1280.000] kPa, p < 0.001, respectively). Values were reported as median with interquartile range (IQR). AAV was also found to be more strongly correlated with these parameters compared to maximum diameter. The correlation coefficient between AAV and average WS was as high as 0.92 (p < 0.004), suggesting that AAV might be a feasible risk identifier for ATAAs. STATEMENT OF SIGNIFICANCE: Ascending thoracic aortic aneurysm is associated with the risk of dissection or rupture, creating life-threatening conditions. Current surgical intervention guidelines are mostly diameter based. Recently, many studies proposed to incorporate other morphological parameters into the current clinical guidelines to better prevent severe adverse aortic events like rupture or dissection. The purpose of this study is to gain a better understanding of the relationship between morphological parameters and hemodynamic parameters in ascending aortic aneurysms using fluid-solid-interaction analysis on patient-specific geometries. Our results suggest that ascending aortic volume may be a better indicator for surgical intervention as it shows a stronger association with pathogenic hemodynamic conditions.

The role of surgeon's intuition for acute type A aortic dissection in an era of evidence-based medicine: a prospective cohort study.

Background: Intuition may play a role in clinical practice. This prospective cohort study aimed to explore whether surgeons' intuition is valid in predicting the operative mortality of acute type A aortic dissection (ATAAD). Methods: After admission (before surgery), attending surgeons were asked to rate the mortality on a scale of 1 to 10, with 1 to 3 representing unlikely, 4-6 possible, and 7-10 very likely. The area under the curve (AUC) of receiver operating characteristic (ROC) analysis was performed to assess the accuracy of prediction models. Results: A significantly higher Surgeon's Score [5.0 (2.0, 8.0) vs. 8.0 (7.0, 10.0)] was observed in the mortality group, compared to the survival group. The odds ratio (OR) for Surgeon's Score was 1.32 [95% confidence interval (CI): 1.09-1.66, P=0.009]. Least absolute shrinkage and selection operator (LASSO) regression picked the following variables as significant predictors for early mortality of ATAAD: Surgeon's Score, Penn classification, age, aortic regurgitation, coronary artery disease, chronic obstructive pulmonary disease, platelet count, and ejection fraction. The AUC for the German Registry for Acute Aortic Dissection Type A (GERAADA) score and Surgeon's Score were 0.740 (95% CI: 0.625-0.854), and 0.710 (95% CI: 0.586-0.833), respectively. The combined model of GERAADA score and Surgeon's Score yielded an AUC of up to 0.761 (95% CI: 0.638-0.884). Conclusions: Intuition certainly has a place alongside evidence-based medicine. The duet of intuition and statistics-based scoring systems allows us to make more accurate predictions, potentially resulting in more rational clinical decisions.

Construction of multifunctional hydrogel with metal-polyphenol capsules for infected full-thickness skin wound healing.

Damaged skin cannot prevent harmful bacteria from invading tissues, causing infected wounds or even severe tissue damage. In this study, we developed a controlled-release antibacterial composite hydrogel system that can promote wound angiogenesis and inhibit inflammation by sustained releasing Cu-Epigallocatechin-3-gallate (Cu-EGCG) nano-capsules. The prepared SilMA/HAMA/Cu-EGCG hydrogel showed an obvious inhibitory effect on Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus). It could also promote the proliferation and migration of L929 fibroblasts. In vivo full-thickness infected wound healing experiments confirmed the angiogenesis and inflammation regulating effect. Accelerate collagen deposition and wound healing speed were also observed in the SilMA/HAMA/Cu-EGCG hydrogel treated group. The findings of this study show the great potential of this controlled-release antibacterial composite hydrogel in the application of chronic wound healing.

Natural history of isolated abdominal aortic dissection: A prospective cohort study.

Objectives: Isolated abdominal aortic dissection (IAAD) is extremely rare, with its optimal treatment and intervention timing remaining poorly understood. We aimed to study the natural history of IAAD and facilitate better clinical decision. Methods: Consecutive patients admitted to our institution from January 2016 to April 2021 were enrolled and followed up prospectively. All-cause death was taken as the primary endpoint. Results: A total of 68 patients with IAAD were included. The mean age at presentation was 61.2 ± 14.8 (Range: 26.0, 93.0) years and 55 (80.9%) were male. A total of 38 (55.9%) patients were treated conservatively, 27 (39.7%) received endovascular aneurysm repair (EVAR), and 3 (4.4%) underwent open surgery. After a mean follow-up of 2.4 years (Range: 0.1, 5.5), 9 (13.2%) patients died, 8 of whom (21.0%) were treated conservatively and 1 EVAR (3.7%). Compared with EVAR/open surgery, patient treated conservatively had a much worse survival (p = 0.043). There was no significant difference between different IAAD aortic sizes regarding mortality (p = 0.220). Patients with completely thrombosed false lumen fared improved survival rate, followed by partial thrombosis and patency, respectively, although not significantly (p = 0.190). No significant difference was observed between male and female concerning survival rate (p = 0.970). Patients without symptoms had a significantly improved survival (p = 0.048). Conclusion: On the basis of patients' preference and surgeons' experience, a more aggressive treatment regimen for IAAD should be considered, with EVAR being the first choice, especially for those with persistent symptoms and patent false lumen, regardless of sex, age, or aortic size.

Single-cell analysis of graft-infiltrating host cells identifies caspase-1 as a potential therapeutic target for heart transplant rejection.

Aims: Understanding the cellular mechanisms underlying early allograft rejection is crucial for the development of effective immunosuppressant strategies. This study aims to investigate the cellular composition of graft-infiltrating cells during the early rejection stage at a single-cell level and identify potential therapeutic targets. Methods: A heterotopic heart transplant model was established using enhanced green fluorescent protein (eGFP)-expressing mice as recipients of allogeneic or syngeneic grafts. At 3 days post-transplant, eGFP-positive cells infiltrating the grafts were sorted and subjected to single-cell RNA-seq analysis. Potential molecular targets were evaluated by assessing graft survival and functions following administration of various pharmacological inhibitors. Results: A total of 27,053 cells recovered from syngrafts and allografts were classified into 20 clusters based on expression profiles and annotated with a reference dataset. Innate immune cells, including monocytes, macrophages, neutrophils, and dendritic cells, constituted the major infiltrating cell types (>90%) in the grafts. Lymphocytes, fibroblasts, and endothelial cells represented a smaller population. Allografts exhibited significantly increased proportions of monocyte-derived cells involved in antigen processing and presentation, as well as activated lymphocytes, as compared to syngrafts. Differential expression analysis revealed upregulation of interferon activation-related genes in the innate immune cells infiltrating allografts. Pro-inflammatory polarization gene signatures were also enriched in these infiltrating cells of allografts. Gene profiling and intercellular communication analysis identified natural killer cells as the primary source of interferon-γ signaling, activating inflammatory monocytes that displayed strong signals of major histocompatibility complexes and co-stimulatory molecules. The inflammatory response was also associated with promoted T cell proliferation and activation in allografts during the early transplant stages. Notably, caspase-1 exhibited specific upregulation in inflammatory monocytes in response to interferon signaling. The regulon analysis also revealed a significant enrichment of interferon-related motifs within the transcriptional regulatory network of downstream inflammatory genes including caspase-1. Remarkably, pharmacological inhibition of caspase-1 was shown to reduce immune infiltration, prevent acute graft rejection, and improve cardiac contractile function. Conclusion: The single-cell transcriptional profile highlighted the crucial role of caspase-1 in interferon-mediated inflammatory monocytes infiltrating heart transplants, suggesting its potential as a therapeutic target for attenuating rejection.

Does the weekend effect exist for acute type A aortic dissection?-a retrospective case-control study.

Background: The weekend effect refers to the mortality difference for patients admitted/operated on weekends compared to those on weekdays. The study aimed to provide new evidence on the impact of the weekend effect on acute type A aortic dissection (ATAAD). Methods: Primary endpoints were operative mortality, stroke, paraplegia, and continuous renal replacement therapy (CRRT). A meta-analysis of current evidence on the weekend effect was first conducted. Analyses based on single-center data (retrospective, case-control study) were further performed. Results: A total of 18,462 individuals were included in the meta-analysis. The pooled results showed that mortality was not significantly higher for ATAAD on weekends compared to that on weekdays [odds ratio (OR): 1.16, 95% CI: 0.94-1.43]. The single-center cohort included 479 patients, which also showed no significant differences in primary and secondary outcomes between the two groups. The unadjusted OR for weekend group over weekday group was 0.90 (95% CI: 0.40-1.86, P=0.777). The adjusted OR for weekend group was 0.94 (95% CI: 0.41-2.02, P=0.880) controlling for significant preoperative factors, and 0.75 (95% CI: 0.30-1.74, P=0.24) controlling for significant preoperative and operative factors altogether. In PSM matched cohort, the operative mortality was still comparable between the weekend group [10 (7.2%)] and weekday group [9 (6.5%)] (P=1.000). No significant survival difference was observed between the two groups (P=0.970). Conclusions: The weekend effect was not found to be applicable to ATAAD. However, clinicians should be cautious of the weekend effect as it is disease-specific and may vary across healthcare systems.

Early and midterm results of valve-sparing aortic root reconstruction with a bovine pericardium patch for patients with acute type a aortic dissection.

Objectives: We evaluated the feasibility, effectiveness, and safety of valve-sparing aortic root reconstruction with a bovine pericardium patch for patients with acute type A aortic dissection (ATAAD). Methods: From January 2016 to January 2021, 895 consecutive patients with ATAAD received surgical treatment at our hospital. After applying our exclusion criteria, 508 patients were included in this research. Based on the attending surgeon's judgment and preference, 192 patients underwent our novel surgical novel surgical technique of valve-sparing aortic root reconstruction (repair group [RG]) and 316 patients underwent the Bentall procedure (Bentall group [BG]). Results: In the RG, the early mortality rate was 4.2% (8/192). In the BG, the early mortality rate was 5.1% (16/316). There were no significant differences between groups. The incidence of postoperative renal failure in the BG was significantly higher than that in the RG. The mean follow-up time was 2.93 years (standard deviation, ±1.38 years). There were no significant differences between groups regarding ATAAD-related mortality and reoperation. In the RG, the rate of freedom from aortic root reoperation at 5 years was 98.2%, and the grade of aortic regurgitation 6 months later was significant less than that before surgery, and it did not worsen during later follow-up. Conclusions: Valve-sparing aortic root reconstruction with a bovine pericardium patch can be successfully performed for selected patients with ATAAD and is associated with low in-hospital and late mortality rates and low root reoperation rates during early and midterm follow-up.

Aortic Balloon Occlusion Technique Does Not Improve Peri-Operative Outcomes for Acute Type A Acute Aortic Dissection Patients With Lower Body Malperfusion.

Background: The management of malperfusion is vital to improve the outcomes of surgery for acute type A acute aortic dissection (ATAAD). Open arch repair under hypothermic circulatory arrest with selective antegrade cerebral perfusion (HCA/sACP) is safe and efficient but associated with inevitable hypothermia and ischemia-reperfusion injury. The aortic balloon occlusion (ABO) technique is shown to be organ protective by allowing higher temperature and shorter circulatory arrest time. In this study, we aimed to evaluate the safety and efficacy of this new technique for ATAAD patients with lower body malperfusion. Methods: Between January 2013 and November 2020, 355 ATAAD patients with lower body malperfusion who underwent arch repair in our institute were enrolled. The patients were divided into 2 groups: ABO group (n = 85) and HCA/sACP group (n = 271). Propensity score matching was performed to correct baseline differences. Results: Using the propensity score matching, 85 pairs were generated. Circulatory arrest time was significantly lower in the ABO group compared with the HCA/sACP group (median, 8 vs. 22 min; p < 0.001). The incidence of in-hospital mortality (10.6 vs. 12.9%; p = 0.812), stroke (7.1 vs. 7.1%; p = 1.000), dialysis (25.9 vs. 32.9%; p = 0.183), hepatic dysfunction (52.9 vs. 57.6%; p = 0.537), tracheostomy (4.7 vs. 2.4%; p = 0.682), paraplegia (1.2 vs. 4.7%; p = 0.368) were comparable between ABO and HCA/sACP groups. Other outcomes and major adverse events were comparable. The multivariable logistic analysis did not recognize ABO technique protective against any major adverse outcomes. Conclusions: For ATAAD patients with lower body malperfusion, the ABO technique allows the performance of arch repair with frozen elephant trunk (FET) under higher temperature and shorter circulatory arrest time. However, ABO technique did not improve perioperative outcomes. Future studies are warranted to evaluate the efficacy of this technique.

Coronary Malperfusion Secondary to Acute Type A Aortic Dissection: Surgical Management Based on a Modified Neri Classification.

Background: Coronary malperfusion (CM) secondary to acute type A aortic dissection (ATAAD) is considered rare but has a high mortality rate. This study examined the incidence, management, and outcomes of patients with CM secondary to ATAAD and proposes a modified Neri classification. Methods: Between 2015 and 2020, out of 1018 patients who underwent surgical repair for ATAAD, 137 presented with CM, including 68 (49.6%), 43 (31.3%), and 15 (10.9%) with Neri types A, B, and C, respectively, and 11 (8.0%) with coronary orifice intimal tear (COIT), which we consider a novel category. Results: The occurrence rate of CM was 13.4%. CM was associated with higher in-hospital mortality (18.2% vs. 7.8%, p < 0.001). For Neri type A (98.5%) and most type B lesions (72.1%), coronary repair was adequate. Coronary artery bypass grafting (CABG) was necessary for type B patients unsuited for repair (23.2%) and for all type C patients (100%). Repair of COIT was possible (45.5%). The in-hospital mortality rates differed significantly among the four lesion groups (p = 0.006). Conclusions: The occurrence of CM secondary to ATAAD may be more frequent than previously reported. Surgical management based on lesion classification achieved acceptable outcomes. Repair was adequate for Neri type A and most type B lesions. Other type B and type C lesions could be treated by CABG. Coronary orifice intimal tear is a unique set of lesions, for which orifice repair was also possible.