Midterm clinical results of Sun's procedure with median resternotomy / 中华胸心血管外科杂志

Objective:To summarize the clinical data of Sun's procedure(total aortic arch replacement with frozen elephant trunk technique) in the treatment of complex aortic arch disease after previous cardiac surgery.Methods:From January 1, 2018 to December 31, 2020, a total of 55 patients underwent resternotomy Sun's procedure in the Aortic Surgery Center of Beijing Anzhen Hospital, including 41 males and 14 females, with a mean age of(45.4±12.7) years old, were retrospectively analyzed. The indications of primary cardiac surgery included type A aortic dissection, aortic root or ascending aortic aneurysm, heart valve surgery, and coronary heart disease. Indications for reoperation included residual aortic dissection larger than 55 mm in diameter, aortic aneurysm dilation, new type A aortic dissection, anastomotic leakage with symptoms, and pseudoaneurysm. All the operations were performed under general anesthesia and median resternotomy, total aortic arch replacement with the stented elephant trunk implantation and were performed by anterograde unilateral or bilateral cerebral perfusion.Results:There was no intraoperative death, and the postoperative mortality was 9.1%(5/55). The causes of death were 2 cases of low cardiac output, 1 case of respiratory failure, 1 case of cerebral complications, and 1 case of gastrointestinal bleeding. Except death, there were 2 cases of postoperative cerebral complications(2/50, 4%), 5 cases of spinal cord injury(transient paraplegia)(5/50, 10%), the median duration of ventilator use was 17 hours(14-42 h). Other postoperative complications included respiratory insufficiency requiring ventilatory support longer than 48 hours(8/50, 16%), renal insufficiency requiring temporary dialysis(2/50, 4%). The follow-up time was(25.9±11.2) months(10-47 months), during which 1 case died due to cerebral complication, 4 cases underwent total thoracoabdominal aorta replacement, and 1 case underwent anastomotic leakage repair.Conclusion:It is safe and effec to perform Sun's procedure(total aortic arch replacement with frozen elephant trunk technique) in the treatment of complex arch disease after previous cardiac surgery.

A Case Report of Partial Aortic Arch Replacement for Traumatic Aortic Arch Injury / 日本心臓血管外科学会雑誌

A 79-year-old woman presented to our hospital with high energy trauma. Enhanced CT revealed injury to the aortic arch. The left carotid artery was pulled out due to extension force and a drawing out lesion formed. Cardiopulmonary bypass was established with cannulation of the right femoral artery and the right atrium, and systemic cooling was started. We opened the aortic arch with deep hypothermic circulatory arrest, and detected a 10 mm drawing out lesion at the bottom of the left carotid artery. Aortic arch was transected at the distal of the left carotid artery to exclude the drawing out lesion, and partial arch replacement was performed. The patient's postoperative course was uneventful, and she was discharged from our hospital without any complication.

An elephant trunk stent graft strayed into the false lumen leading to a death during the Sun's operation: A case report / 中南大学学报(医学版)

Type A aortic dissection (AD) is a critical and severe disease with high mortality. The Sun's operation is a standard surgical method for this kind of disease at present. For the procedure, an elephant trunk stent is inserted into the true lumen of the descending aorta and the aortic arch is replaced. A patient was admitted to the First Hospital of Lanzhou University due to sudden chest and back pain for 6 days. Computed tomography angiography (CTA) showed type A AD. Ascending aorta replacement, Sun's operation, and ascending aorta to right femoral artery bypass grafting were performed. After surgery, the patient's condition was worsened. The digital subtraction angiography (DSA) showed the elephant trunk stent was inserted into the false lumen of AD, leading to the occlusion of the large blood vessel at the distal part of the abdominal aorta and below. Although we performed intima puncture and endovascular aortic repair, the patient was still dead.

Clinical effects of type Ⅱ hybrid aortic arch repair for type A aortic dissection in elderly and non-elderly patients / 中国胸心血管外科临床杂志

@#Objective    To discuss the efficacy of type Ⅱ hybrid aortic arch repair for type A aortic dissection in patients of different age groups. Methods    We retrospectively analyzed the clinical data of 126 patients with type A aortic dissection admitted to the Fuwai Hospital between January 2016 and December 2018, including 78 (61.9%) males and 48 (38.1%) females, with an average age of 61.8±6.9 years. The patients were divided into an elderly group (≥60 years, n=82) and a non-elderly group (<60 years, n=44). The preoperative, intraoperative and postoperative data of patients in the two groups were compared. Results    The age between the elderly and non-elderly group was significantly different (65.9±4.1 years vs. 54.3±4.1 years, P<0.010), and no significant difference was found between the two groups in other preoperative baseline data. There were 6 (4.8%) patients of early death, 3 (2.4%) patients of stroke and 2 (1.6%) patients of paralysis. A total of 194 stents were implanted, and the average dimeter of the stents was 33.6±1.8 mm and the average length was 199.0±6.7 mm. The non-elderly group had shorter mechanical ventilation time (31.9±41.7 h vs. 61.0±89.2 h, P=0.043) and ICU stay time (77.8±51.4 h vs. 143.1±114.4 h, P<0.001) than the elderly group. There was no significant difference in in-hospital mortality rate, reoperation rate or survival rate between the two groups (P>0.05). Follow-up time was 1-43 (22.6±10.8) months, and 3 patients were lost. There were 104 (82.5%) patients of complete thrombus formation of false lumen in stent and endoleak was reported in 11 (9.2%) patients. Conclusion    Type Ⅱ hybrid aortic arch repair offers an alternative approach to acute type A aortic dissection with acceptable early and mid-term clinical effects. The non-elderly patients have a similar early treatment effect to the elderly patients, but have a better mid-term outcome.

Utility of the Isolation Technique for Total Arch Replacement in Patients with a Shaggy Aorta / 日本心臓血管外科学会雑誌

Introduction : Prevention of embolic stroke is the key issue to perform aortic arch replacement in patients with a shaggy aorta. The aim of this study is to report the utility of the isolation technique for total arch replacement in patients with a shaggy aorta. Methods : Clinical results of seven patients (71.7 years old, all men) with a shaggy aorta who underwent total arch replacement between January 2017 and November 2018 were retrospectively reviewed. The operative indications were a distal arch or proximal descending aortic aneurysm in 6 patients and a thrombus inside brachiocephalic artery in one. A cerebral perfusion was established by inserting a cannula directly into all supra-aortic branches before starting systemic perfusion. Result : Utilizing the isolation technique with clamping of all branches in 4 patients and the functional isolation technique with clamping of two branches in 3, total arch replacement was performed in all patients (operation time : 513 min, selective cerebral perfusion time : 162 min). No operative death was observed and no newly developed stroke was encountered. Conclusion : The isolation technique is a useful method to prevent stroke during total arch replacement in patients with a shaggy aorta.

Association between cardiopulmonary bypass time and 90-day postoperative mortality in patients undergoing arch replacement with the frozen elephant trunk: a retrospective cohort study / 中华医学杂志(英文版)

Background@#The aortic arch replacement and cardiopulmonary bypass (CPB) are both associated with the early mortality after cardiothoracic surgery. This study aimed to investigate the relationship between CPB time and 90-day post-operative mortality in patients undergoing aortic arch surgery using the frozen elephant trunk (FET) technique with selective ante-grade cerebral perfusion (SACP).@*Methods@#We retrospectively reviewed data of 377 adult patients undergoing aortic arch surgery via FET with SACP from July 1, 2017 to December 31, 2018 at Beijing Anzhen Hospital. The baseline characteristics, intra-operative data, and post-operative data were collected. Univariate and multivariate Cox regression analyses were used to determine independent predictors of 90-day postoperative mortality.@*Results@#The 90-day post-operative mortality was 13.53%. The 78.51% of patients were men. There were 318 (84.35%) type A aortic dissections and 28 (7.43%) aortic aneurysms. Among those, 264 (70.03%) were emergency operations. Median CPB time was 202.0 (176.0, 227.0) min. Multivariate Cox regression analysis revealed that CPB time was independently associated with 90-day post-operative mortality after adjusting confounding factors (hazard ratio: 1.21/10 min increase in CPB time, 95% confidence interval: 1.15–1.27, P < 0.001). Kaplan-Meier analysis based on CPB time tertiles revealed that the top tertile (median 236.0 min) was associated with reduced survival rate compared with middle and bottom tertiles (P < 0.001). Each sub-group analysis based on the complexity of the underlying disease process showed similar associations between CPB time and 90-day post-operative mortality.@*Conclusions@#CPB time remains a significant factor in determining 90-day post-operative mortality in patients undergoing aortic arch surgery using FET with SACP. Surgeons should be aware of the relationship between CPB time and 90-day post-operative mortality during operative procedures and avoid extended CPB time as far as possible.

Successful Reversal of Delayed Postoperative Paraplegia Complicating Emergency Total Arch Replacement for Type A Dissection / 日本心臓血管外科学会雑誌

We report a rare case of paraplegia after emergency total arch replacement for type A acute aortic dissection. A 52-year-old man was referred to our hospital for acute aortic dissection. Contrast-enhanced computed tomography showed a type A aortic dissection extending from the aortic root into the right iliac arteries. The true lumen of the descending and abdominal aorta was collapsed and blood flow to the right lower limb had decreased. Large entry and re-entry tears were revealed in the ascending and distal arch aorta, respectively. His preoperative consciousness was clear, hemodynamics were stable, and there was no evidence of paraplegia or paraparesis. Extracorporeal circulation was established by femoral artery and right atrium cannulation. Total arch replacement was performed under moderate hypothermic circulatory arrest (lowest bladder temperature : 21.9°C). The postoperative course was uneventful and he was extubated 6 h postoperatively. Postoperative hemodynamic parameters were stable, the mean blood pressure was maintained at around 70 mmHg, and limb movements were confirmed at that time. Although there was no abnormality of lower limb movement until the following morning, paraplegia occurred about 17 h after surgery. While maintaining a mean blood pressure of over 90 mmHg, urgent cerebrospinal drainage was immediately performed and combined with steroid treatment and a continuous infusion of naloxone. The neurological defect was resolved immediately after cerebrospinal drainage, and neurological function steadily improved through rehabilitation. He was discharged 20 days after surgery with no neurological defects. Late paraplegia after total replacement for type A acute aortic dissection is a rare complication. From our experience, it is suggested that early diagnosis and treatment are important for improving paraplegia.

Early- and mid-term results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion / 中国胸心血管外科临床杂志

@#Objective    To investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral antegrade cerebral perfusion (MHCA+UACP). Methods    We retrospectively analyzed the clinical data of 146 patients who underwent emergent aortic arch replacement using MHCA+UACP in our institution from January 2008 to June 2018. There were 111 males and 35 females aged 60.3±7.2 years. According to different surgical approaches, patients were divided into two groups: a total arch replacement (TAR) group (n=104) and a semi arch replacement (SAR) group (n=42). Right axillary artery was cannulated for cardiopulmonary bypass (CPB) and cerebral perfusion. Core temperature at the onset of MHCA was 23.4±1.4 ℃. UACP was initiated at 18-22 ℃ with the flow of 5-10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of 50–60 mm Hg. Results    CPB time was 235.0±42.0 min. Aortic clamp time was 154.0±29.0 min. Circulatory arrest (CA) time was 48.1±13.0 min. The CPB time and CA time of the TAR group were longer than those of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological dysfunction (PND), temporary neurological dysfunction (TND), acute kidney injury (AKI) requiring dialysis and delayed extubation (mechanical ventilation time > 72 hours). Overall incidence of PND and TND was 2.7% and 6.8%, respectively. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate or incidence of complications was found between the two groups. The average follow-up was 63.0±33.1 months. The 5-year survival rate was 72.6% in the TAR group and 85.5% in the SAR group. Conclusion    Emergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.

A Case of Completely Thoracoscopic Surgery for Chylothorax after Ascending Aorta and Aortic Arch Replacement / 日本心臓血管外科学会雑誌

A 66-year-old woman attended our hospital for ascending aortic aneurysm. She was admitted with sudden back pain and acute aortic dissection of Stanford type B was revealed by computed tomography. We performed replacement of the ascending aorta and aortic arch with the frozen elephant trunk technique. The left pleural drainage fluid turned cloudy white after diet initiation on postoperative day 2. We diagnosed chylothorax with biochemical analysis and stopped oral intake completely, but the drainage increased to 3,700 ml/day. On postoperative day 8, completely thoracoscopic ligation of thoracic duct was performed. The drainage decreased immediately after the procedure. She could start meals on postoperative day 12 and was discharged on postoperative day 22. We conclude that a completely thoracoscopic ligation of thoracic duct for persistent chylothorax after aortic surgery can lead to early resolution.

Optimized selective arterial perfusion approach in total aortic arch replacement of stanford type a aortic dissection / 第二军医大学学报

Objective To explore the curative effect of optimized selective arterial perfusion approach in the total aortic arch replacement of the Stanford type A aortic dissection. Methods From Sep. 2016 to Oct. 2017, 31 Stanford A aortic dissection patients received total aortic arch replacement with cardiopulmonary bypass of optimized selective arterial perfusion approach (O-CPB group, 25 males and 6 females, aged [50.87±9.08] years old) in our hospital. And 60 Stanford A aortic dissection patients, who underwent total aortic arch replacement with cardiopulmonary bypass of traditional approach in our hospital from Jan. 2015 to Oct. 2017, were included as control (T-CPB group, 52 males and 8 females, aged [48.38±12.46] years old). The perioperative blood biochemistry parameters and clinical data were compared between the two groups. Multivariate logistic regression was used to analyze the risk factors for postoperative 30-day mortality. Results Compared with the T-CPB group, the O-CPB group had significantly shorter extracorporeal circulation time, circulatory arrest time and operation time ([206.90±39.92] min vs [276.37±29.92] min, [5.03±1.54] min vs [21.73±6.67] min and [396.68±58.57] min vs [469.28±69.77] min, all P0.01). The blood consumption volume and ICU detention time were significantly less in the O-CPB group versus the T-CPB group ([1 401±738] mL vs [1 705±580] mL and [5.94±2.45] d vs [7.42±3.53] d, both P0.05). The postoperative blood lactate and C-reactive protein concentrations in the O-CPB group were significantly lower than those in the T-CPB group ([6.10±3.80] mmol/L vs [8.11±4.51] mmol/L and [72.13±22.86] mg/L vs [84.78±17.07] mg/L; P0.05, P0.01). The patients in the O-CPB group were awake earlier than those in the T-CPB group ([3.32±1.11] h vs [4.14±1.59] h, P0.05). The absolute value of postoperative Richmond agitation-sedation scale (RASS) score of the O-CPB and T-CPB groups were 1.23±1.06 and 2.15±1.30, respectively, and the difference was statistically significant (P0.01). In O-CPB group, the oxygenation index was significantly higher and mechanical ventilation time was significantly shorter versus the T-CPB group ([234.42±79.51] mmHg vs [183.10±77.26] mmHg and [50.19±37.63] h vs [70.12±40.84] h; P0.01, P0.05; 1 mmHg＝0.133 kPa). There was no significant difference in the postoperative 30-day mortality rate between the O-CPB and T-CPB groups (6.45% [2/31] vs 11.67% [7/60], P0.05). Multivariate logistic regression showed that circulatory arrest time≥31 min and blood consumption volume≥1 390 mL were independent risk factors of postoperative 30-day mortality of Stanford A aortic dissection patients undergoing total aortic arch replacement, with OR (95% CI) being 1.517 (1.153-1.995) and 1.006 (1.002-1.010), respectively. Conclusion With bilateral antegrade selective cerebral perfusion and moderate hypothermia perfusion in lower body, the optimized selective arterial perfusion approach needs shorter circulatory arrest time, and less blood consumption compared with cardiopulmonary bypass of traditional approach. Moreover, it has a good protective effect on the brain and lung during total aortic arch replacement of Stanford type A aortic dissection.

A Case of Stanford Type A Acute Aortic Dissection after Surgery for Esophageal Cancer / 日本心臓血管外科学会雑誌

A 76-year-old man with a history of total esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer was transferred to our hospital because of consciousness disorder. It became an emergency operation on diagnosis of Stanford type A acute aortic dissection on enhanced CT. Because CT showed the retrosternal gastric tube ran along the right side of the body of the sternum through the back side of the manubrium, we opted for skin and the suprasternal incision on the left side from center. We could perform total aortic arch replacement without the damage of the gastric tube except that the right side of the operative view was slightly poor. We did not recognize digestive organ symptoms such as postoperative passage disorders nor mediastinitis. The patient was discharged from our hospital on postoperative day 24.

Effect of Edaravone Combining Ulinastatin on Brain Protection in Patients of Type A Aortic Dissection After Total Arch Replacement / 中国循环杂志

Objective: To observe the effect of edaravone combining ulinastatin on brain protection in patients of type A aortic dissection (AAD) after total arch replacement. Methods: A total of 60 AAD patients with total arch replacement in our hospital from 2014-09 to 2016-01 were prospectively studied. Based on peri-operative application of edaravone and ulinastatin, the patients were divided into 2 groups: EU group: 1) the patients received ulinastatin 300000 U/8h and edaravone 0.5mg/Kg/12h from administration to 3 days post-operation, 2) during cardiopulmonary bypass, the patients received ulinastatin 300000 U/2h and edaravone 0.5mg/Kg; Control group, the patients had no such treatment.n=30 in each group. The following items were observed:①operative condition;②blood levels of speciifc brain injury markers as S-100 and neuron speciifc enolase (NSE) at different time points: beginning of surgery (T0), opening aorta clamp (T1), right after cardiopulmonary bypass (T2), entering ICU (T3), 24h post-operation (T4) and 3 days post-operation (T5); ③post-operative condition. Results:①Durations of operation, cardiopulmonary bypass, cardiac arrest and bilateral antegrade selective cerebral perfusion (BACP), the frequency of BACP and UACP (unilateral antegrade selective cerebral perfusion), the lowest rectal temperature and blood levels of S-100, NSE at T0 were similar between 2 groups.②Compared with Control group, EU group had decreased S-100 and NSE from T1 to T5,P0.05. Conclusion: Edaravone combining ulinastatin had brain protective effect in AAD patients after total arch replacement;it may reduce blood speciifc brain injury markers while the clinical signiifcance should be further investigated.

A Case of Symptomatic Mural Thrombus in the Ascending Thoracic Aorta / 日本心臓血管外科学会雑誌

Fifty-two-year-old man who suffered from headache and left neck pain was brought to a nearby hospital by ambulance. Anisocoria and disorder in the field of view of the left eye were observed. Emergency brain MRA showed obstruction of the left internal carotid artery. The patient was transported to our hospital for emergency surgery for suspected acute type A aortic dissection on CT scan. Operative findings revealed a thrombus attached to the ascending aorta continued to left common carotid artery. Thrombectomy for left carotid artery and partial arch replacement were performed. The patient was discharged in good condition on the 16th postoperative day. We encountered a very rare mural thrombus in the ascending aorta.

Surgical Treatment for 32 Cases of Marfan's Syndrome / 中国医师杂志

Objective To observe the operative outcomes of Marfan's syndrome.Methods Collecting 32 cases of Marfan's syndrome operated in our hospital and analyzing the changes of cardiac function between preoperation and 6～12 months postoperation. Results There were 29 cases of Bentall(replacement of the ascending aortic with flap valve canal) operation, 3 cases of them were Bentall with total aortic arch replacement; two case were replaced the mitral valve in the homochronous operation; 3 cases died from the Bentall operation,other 3 cases were lost to follow up. The size of left ventricle(LV), left ventricular ejection fraction(LVEF), left ventricular end-diastolic volume index (LVEDVI) and left ventricular end-systolic volume index(LVESVI) were remarkable improved in postoperation. Conclusions Surgical treatment is an effective way for the cardiovascular lesions of Marfan's syndrome.