Chinese Additive Anti-inflammatory Action for Aortopathy & Arteriopathy (5A) Registry protocol: rationale, design and methodology.

BACKGROUND: Acute aortic syndrome (AAS) is a life-threatening condition. Inflammation plays a key role in the pathogenesis, development and progression of AAS, and is associated with significant mortality and morbidity. Understanding the inflammatory responses and inflammation resolutions is essential for an appropriate management of AAS. METHOD: Thirty Chinese cardiovascular centers have collaborated to create a multicenter observational registry (named Chinese Additive Anti-inflammatory Action for Aortopathy & Arteriopathy [5A] registry), with consecutive enrollment of adult patients who underwent surgery for AAS that was started on Jan 1, 2016 and will be ended on December 31, 2040. Specially, the impact of inflammation and anti-inflammatory strategies on the early and late adverse events are investigated. Primary outcomes are severe systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), Sequential Organ Failure Assessment (SOFA) scores at 7 days following this current surgery. Secondary outcomes are SISR, 30-day mortality, operative mortality, hospital mortality, new-onset stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. DISCUSSION: The analysis of this multicenter registry will allow our better knowledge of the prognostic importance of preoperative inflammation and different anti-inflammatory strategies in adverse events after surgery for AAS. This registry is expected to provide insights into novel different inflammatory resolutions in management of AAS beyond conventional surgical repair. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04398992 (Initial Release: 05/19/2020).

The immunoproteasome subunit ß2i ameliorates myocardial ischemia/reperfusion injury by regulating Parkin-Mfn1/2-mediated mitochondrial fusion.

Mitochondrial dynamics are critical for maintaining mitochondrial morphology and function during cardiac ischemia and reperfusion (I/R). The immunoproteasome complex is an inducible isoform of the proteasome that plays a key role in modulating inflammation and some cardiovascular diseases, but the importance of immunoproteasome catalytic subunit ß2i (also known as LMP10 or MECL1) in regulating mitochondrial dynamics and cardiac I/R injury is largely unknown. Here, using ß2i-knockout (KO) mice and rAAV9-ß2i-injected mice, we discovered that ß2i expression and its trypsin-like activity were significantly attenuated in the mouse I/R myocardium and in patients with myocardial infarction (MI). Moreover, ß2i-KO mice exhibited greatly enhanced I/R-mediated cardiac dysfunction, infarct size, myocyte apoptosis and oxidative stress accompanied by excessive mitochondrial fission due to Mfn1/2 and Drp1 imbalance. Conversely, cardiac overexpression of ß2i in mice injected with recombinant adeno-associated virus 9 (rAAV9)-ß2i ameliorated cardiac I/R injury. Mechanistically, I/R injury reduced ß2i expression and activity, which increased the expression of the E3 ligase Parkin protein and promoted the degradation of mitofusin 1/2 (Mfn1/2), leading to excessive mitochondrial fission. In conclusion, our data suggest for the first time that ß2i exerts a protective role against cardiac I/R injury and that increasing ß2i expression may be a new therapeutic option for cardiac ischemic disease in clinical practice. Graphical abstract showing how the immunoproteasome subunit ß2i ameliorates myocardial I/R injury by regulating Parkin-Mfn1/2-mediated mitochondrial fusion.

Renal Artery Partial Occlusion After Aortic Dissection Is Associated With Impaired Renal Function in the Affected Kidney.

BACKGROUND: The renal artery is often involved in aortic dissection, leading to kidney ischaemia and renal dysfunction. However, some patients with aortic dissection with combined renal artery involvement do not show clinical renal dysfunction. This study aimed to analyse the relationship between renal artery involvement and renal function. METHODS: Data and images were collected from 79 patients (Group A), in Beijing Anzhen hospital between January 2015 and December 2017, who had type A aortic dissection, in order to analyse the relationship between renal artery involvement and serum creatinine. In order to further analyse the relationship between renal artery involvement and single kidney function, data from 27 patients (Group B) with aortic dissection from August 2018 to October 2018 were collected. Renal dynamic imaging was conducted, and clinical and image data were recorded. RESULTS: Results showed that patients with one partially occluded renal artery had higher variance of serum creatinine after surgery compared with patients with one false-lumen renal artery (5.8±22.7 µmol/L vs -18.7±22.7 µmol/L; p=0.003). The glomerular filtration rate of a single kidney that had a partially occluded renal artery was lower than that of a single kidney with a normal renal artery (37.77±9.57 vs 42.73±10.54; p=0.04). CONCLUSIONS: A partially occluded renal artery in aortic dissection was associated with impaired renal function after surgery, even though patients did not present high serum creatinine. More attention should be paid to those experiencing aortic dissection.

Surgical Treatment for Hypertrophic Obstructive Cardiomyopathy with Concomitant Mitral Valve Abnormalities: A Cohort of 26 Cases.

BACKGROUND: We sought to analyze the pathological characteristics of hypertrophic obstructive cardiomyopathy (HOCM) with concomitant mitral valve abnormalities and to discuss the surgical treatment strategies. METHODS: The clinical data of 26 HOCM patients treated from January 2014 to March 2016 were retrospectively analyzed. There were 19 males and 7 females with a mean age of 47 ± 16 years (range, 10-70 years). Echocardiography showed HOCM, systolic anterior motion of the mitral apparatus, and concomitant mitral regurgitation. Modified Morrow procedure with expanded resection area was performed in 21 patients. Concomitant mitral valvuloplasty was performed in 4 patients, coronary artery bypass grafting was performed in one patient, and aortic valve replacement was performed in one patient. Echocardiography was performed intraoperatively at postoperative 1 week and at postoperative 1 year to evaluate the left ventricular obstruction and the mitral regurgitation. RESULTS: The left ventricular outflow tract gradient, left ventricular outflow tract velocity, septal thickness, and mitral regurgitation area decreased significantly at postoperative 1 week and 1 year in comparison with the baseline (all P < .001). The postoperative mitral regurgitation and systolic anterior motion of the mitral apparatus were completely abolished or significantly relieved. Only one patient had moderate mitral regurgitation of 7 cm2 after the surgery. At postoperative 1 year, all patients were asymptomatic, and the quality of life was significantly improved. The New York Heart Association (NYHA) class was I-II. Echocardiography showed good anatomy and function of the mitral valve. CONCLUSIONS: Concomitant mitral valve abnormality is not uncommon in HOCM. Septal myectomy can adequately expand the left ventricular outflow tract and abolish mitral regurgitation and systolic anterior motion of the mitral apparatus. Concomitant mitral valvuloplasty is indicated for severe congenital abnormalities or secondary lesions of the mitral valve, and the outcomes are satisfactory.

Mechanical stretch-induced endoplasmic reticulum stress, apoptosis and inflammation contribute to thoracic aortic aneurysm and dissection.

Thoracic aortic aneurysm/dissection (TAAD) is characterized by excessive smooth muscle cell (SMC) loss, extracellular matrix (ECM) degradation and inflammation. In response to certain stimuli, endoplasmic reticulum (ER) stress is activated and regulates apoptosis and inflammation. Excessive apoptosis promotes aortic inflammation and degeneration, leading to TAAD. Therefore, we studied the role of ER stress in TAAD formation. A lysyl oxidase inhibitor, 3-aminopropionitrile fumarate (BAPN), was administrated to induce TAAD formation in mice, which showed significant SMC loss (α-SMA level). Excessive apoptosis (TUNEL staining) and ER stress (ATF4 and CHOP), along with inflammation, were present in TAAD samples from both mouse and human. Transcriptional profiling of SMCs after mechanical stress demonstrated the expression of genes for ER stress and inflammation. To explore the causal role of ER stress in initiating degenerative signalling events and TAAD, we treated wild-type (CHOP(+/+)) or CHOP(-/-) mice with BAPN and found that CHOP deficiency protected against TAAD formation and rupture, as well as reduction in α-SMA level. Both SMC apoptosis and inflammation were significantly reduced in CHOP(-/-) mice. Moreover, SMCs isolated from CHOP(-/-) mice were resistant to mechanical stress-induced apoptosis. Taken together, our results demonstrated that mechanical stress-induced ER stress promotes SMCs apoptosis, inflammation and degeneration, providing insight into TAAD formation and progression.

Association of the polymorphisms of MMP-9 and TIMP-3 genes with thoracic aortic dissection in Chinese Han population.

AIM: Thoracic aortic dissection (TAD) is the most common life-threatening disorder, and a shifted balance of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) is involved in TAD pathogenesis. The aim of this study was to evaluate the association of 4 single-nucleotide polymorphisms (SNPs) in MMP-9 and TIMP-3 genes with TAD risk in Chinese Han population. METHODS: A total of 206 Chinese patients with TAD and 180 controls were included in this study. Four SNPs (rs3918249, rs2274756, rs9609643 and rs8136803) were genotyped using high-throughput MALDI-TOF mass spectrometry. Allele and genotype association analyses were conducted using PLINK. RESULTS: All the 4 SNPs resulted in Hardy-Weinberg equilibrium in patients and controls. The G allele frequency for the MMP-9 SNP rs2274756 was significantly higher in female TAD patients than in female controls (P=0.0099). Moreover, after adjusting for traditional cardiovascular risk factors (sex, age, hypertension, dyslipidemia, diabetes and smoking habit), the rs2274756 polymorphism (odds ratio: 0.30; 95% confidence interval: 0.11 to 0.79, P=0.015) resulted in an independent susceptibility factor for TAD in females. No associations were found between the other SNPs and TAD. CONCLUSION: The results provide strong evidence for an association between MMP-9 SNP rs2274756 and female TAD risk in Chinese Han population.

A novel cleaning process for industrial production of xylose in pilot scale from corncob by using screw-steam-explosive extruder.

Steam explosion is the most promising technology to replace conventional acid hydrolysis of lignocellulose for biomass pretreatment. In this paper, a new screw-steam-explosive extruder was designed and explored for xylose production and lignocellulose biorefinery at the pilot scale. We investigated the effect of different chemicals on xylose yield in the screw-steam-explosive extrusion process, and the xylose production process was optimized as followings: After pre-impregnation with sulfuric acid at 80 °C for 3 h, corncob was treated at 1.55 MPa with 9 mg sulfuric acid/g dry corncob (DC) for 5.5 min, followed by countercurrent extraction (3 recycles), decoloration (activated carbon dosage 0.07 g/g sugar, 75 °C for 40 min), and ion exchange (2 batches). Using this process, 3.575 kg of crystal xylose was produced from 22 kg corncob, almost 90 % of hemicellulose was released as monomeric sugar, and only a small amount of by-products was released (formic acid, acetic acid, fural, 5-hydroxymethylfurfural, and phenolic compounds were 0.17, 1.14, 0.53, 0.19, and 1.75 g/100 g DC, respectively). All results indicated that the screw-steam-explosive extrusion provides a more effective way to convert hemicellulose into xylose and could be an alternative method to traditional sulfuric acid hydrolysis process for lignocellulose biorefinery.

Prognostic implication of residual inflammatory trajectories in acute type I aortic dissection: dual-center prospective cohort study.

BACKGROUND: Peripheral platelet-white blood cell ratio (PWR) integrating systemic inflammatory and coagulopathic pathways is a key residual inflammatory measurement in the management of acute DeBakey type I aortic dissection (AAD); however, trajectories of PWR in AAD is poorly defined. METHODS: Two AAD cohorts were included in two cardiovascular centers (2020-2022) if patients underwent emergency total arch replacement with frozen elephant trunk implantation. PWR data were collected over time at baseline and five consecutive days after surgery. Trajectory patterns of PWR were determined using the latent class mixed modelling (LCMM). Cox regression was used to determine independent risk factors. By adding PWR Trajectory, a user-friendly nomogram was developed for predicting mortality after surgery. RESULTS: Two hundred forty-six patients with AAD were included with a median follow-up of 26 (IRQ 20-37) months. Three trajectories of PWR were identified [cluster α 45(18.3%), ß105 (42.7%), and γ 96 (39.0%)]. Cluster γ was associated with higher risk of mortality at follow-up (crude HR, 3.763; 95% CI: 1.126-12.574; P =0.031) than cluster α. By the addition of PWR trajectories, an inflammatory nomogram, composed of age, hemoglobin, estimated glomerular filtration rate, and cardiopulmonary time was developed and internally validated, with adequate discrimination [the area under the receiver-operating characteristic curve 0.765, 95% CI: 0.660-0.869)], calibration, and clinical utility. CONCLUSION: Based on PWR trajectories, three distinct clusters were identified with short-term outcomes, and longitudinal residual inflammatory shed some light to individualize treatment strategies for AAD.

FL% is associated with the severity of acute DeBakey type I aortic dissection in patients undergoing frozen elephant trunk and total arch replacement.

Objectives: The diameter, area, and volume of the true lumen and false lumen (FL) have been measured in previous studies to evaluate the extent of DeBakey type I aortic dissection. However, these indicators have limitations because of the irregular shapes of the true and false lumens and the constant oscillation of intimal flap during systole and diastole. The ratio of arch lengths seems to be a more reliable indicator. FL% was defined as the ratio of the arch length of FL to the circumference of the aorta at the different levels of the aorta. The purpose of this article was to investigate whether FL% is a predictor of the severity of acute DeBakey type I aortic dissection in patients undergoing frozen elephant trunk (FET) and total arch replacement. Methods: In this retrospective observational study, we analyzed a total of 344 patients with acute DeBakey type I aortic dissection that underwent FET and total arch replacement at our center from October 2015 to October 2019. The patients were divided into two groups by cluster analysis according to the perioperative course. Binary logistic regression analyses were performed to determine whether FL% could predict the severity of acute DeBakey type I aortic dissection. The area under the receiver operating characteristic curve (AUROC) was used to assess the power of the multivariate logistic regression model for the severity of acute DeBakey type I aortic dissection. Results: The patients in the ultra-high-risk group (109 patients) had significantly more severe clinical comorbidities and complications than the patients in the high-risk group (235 patients). The ascending aortic FL% [odds ratio (OR), 11.929 (95% CI: 1.421-100.11); P = 0.022], location of initial tear [OR, 0.68 (95% CI: 0.47-0.98); P = 0.041], the degree of left iliac artery involvement [OR, 1.95 (95% CI: 1.15-3.30); P = 0.013], and the degree of right coronary artery involvement [OR, 1.46 (95% CI: 1.01-2.12); P = 0.045] on preoperative computed tomography angiography were associated with the severity of acute DeBakey type I aortic dissection. The AUROC value of this multivariate logistic regression analysis was 0.940 (95% CI: 0.914-0.967; P < 0.001). The AUROC value of ascending aortic FL% was 0.841 (95% CI: 0.798-0.884; P < 0.001) for the severity of acute DeBakey type I aortic dissection in patients undergoing FET and total arch replacement. Conclusions: Ascending aortic FL% was validated as an essential radiologic index for assessing the severity of acute DeBakey type I aortic dissection in patients undergoing FET and total arch replacement. Higher values of ascending aortic FL% were more severe.

Operative Mortality After Type A Aortic Dissection Surgery: Differences Based on Sex and Age.

Background: There is controversy regarding sex differences in short-term mortality in acute type A aortic dissection (ATAAD). Objectives: This study aimed to investigate the impact of sex differences on 30-day operative mortality after ATAAD surgery and to determine if other covariates modify the association. Methods: Consecutive patients (N = 5670) with surgically repaired ATAAD were identified from the multicenter China 5A study. The primary outcome was operative mortality. The age dependency was modeled using a cubic spline curve. Results: There were 1,503 females (26.5%) and 4,167 males (73.5%). Females were older and had a lower percentage of comorbidities compared with males. Females had higher mortality compared to males (10.2% vs 8.2%, P = 0.019); however, there was no difference after propensity analyses (adjusted OR: 1.334 [95% CI: 0.918-1.938]). There was an interaction with sex and age (P interaction = 0.035): older age was associated with higher odds of operative mortality among females (OR: 1.045 [95% CI: 1.029-1.061]) compared with males (OR: 1.025 [95% CI: 1.016-1.035]). The risk of mortality for males and females appears to diverge at 55 years of age (P interaction = 0.019): females under 55 years of age had similar odds to males (OR: 0.852 [95% CI: 0.603-1.205]) but higher odds when over 55 years (OR: 1.420 [95% CI: 1.096-1.839]) compared to males. Conclusions: Under the age of 55 years, females have similar odds of operative mortality compared with males; however, over the age of 55 years females have higher odds than males. Understanding differences in risk allows for individualized treatment strategies. (Additive Anti-inflammatory Action for Aortopathy & Arteriopathy; NCT04398992).

Anti-inflammatory response-based risk assessment in acute type A aortic dissection: A national multicenter cohort study.

Background: Early identification of patients at high risk of operative mortality is important for acute type A aortic dissection (TAAD). We aimed to investigate whether patients with distinct risk stratifications respond differently to anti-inflammatory pharmacotherapy. Methods: From 13 cardiovascular hospitals, 3110 surgically repaired TAAD patients were randomly divided into a training set (70%) and a test set (30%) to develop and validate a risk model to predict operative mortality using extreme gradient boosting. Performance was measured by the area under the receiver operating characteristic curve (AUC). Subgroup analyses were performed by risk stratifications (low versus middle-high risk) and anti-inflammatory pharmacotherapy (absence versus presence of ulinastatin use). Results: A simplified risk model was developed for predicting operative mortality, consisting of the top ten features of importance: platelet-leukocyte ratio, D-dimer, activated partial thromboplastin time, urea nitrogen, glucose, lactate, base excess, hemoglobin, albumin, and creatine kinase-MB, which displayed a superior discrimination ability (AUC: 0.943, 95 % CI 0.928-0.958 and 0.884, 95 % CI 0.836-0.932) in the derivation and validation cohorts, respectively. Ulinastatin use was not associated with decreased risk of operative mortality among each risk stratification, however, ulinastatin use was associated with a shorter mechanical ventilation duration among patients with middle-high risk (defined as risk probability >5.0 %) (ß -1.6 h, 95 % CI [-3.1, -0.1] hours; P = 0.048). Conclusion: This risk model reflecting inflammatory, coagulation, and metabolic pathways achieved acceptable predictive performances of operative mortality following TAAD surgery, which will contribute to individualized anti-inflammatory pharmacotherapy.

[Effects of thoracic endovascular repair in patients of type B aortic dissection].

OBJECTIVE: To retrospectively evaluate early and mid-term results of thoracic endovascular repair (TEVAR) of type B aortic dissection by the second generation of stent graft. METHODS: From January 2009 to January 2013, 383 acute, 43 sub-acute and 152 chronic patients with type B aortic dissection underwent TEVAR in our aortic center. The mean follow-up period was (27 ± 14) months. All clinical data were analyzed with SPSS 17.0. RESULTS: The 30-day mortality and morbidity were 0.35% and 1.2% respectively. The mid-term mortality and morbidity were 0.35% and 5.5%. Serious complications included retrograde type A dissection (n = 3), new tear at the distal end of stent (n = 26), endoleak (n = 3) and paraplegia (n = 0). The retreatment rate was 5.2% ( 6 patients were transformed to open operation and 24 patients underwent re-intervention). CONCLUSIONS: The early and mid-term results of thoracic endovascular repair (TEVAR) of type B aortic dissection by the second generation of stent graft showed lower mortality, no paraplegia and significant reduced endoleaks in comparison with the first generation stent graft. The new distal tear caused by the stent graft became the major complication. The design of the stent graft still need improvement.

Risk factor prediction of severe postoperative acute kidney injury at stage 3 in patients with acute type A aortic dissection using thromboelastography.

Objective: Perioperative blood transfusions and postoperative drainage volume not only are the commonly recognized risk factors for acute kidney injury (AKI) but also are indirect indicators of coagulopathy in patients with acute type A aortic dissection (ATAAD). However, standard laboratory tests fail to accurately reflect and assess the overall coagulopathy profile in patients with ATAAD. Thus, this study aimed to explore the association between the hemostatic system and severe postoperative AKI (stage 3) in patients with ATAAD using thromboelastography (TEG). Methods: We selected 106 consecutive patients with ATAAD who underwent emergency aortic surgery at Beijing Anzhen Hospital. All participants were categorized into the stage 3 and non-stage 3 groups. The hemostatic system was evaluated using routine laboratory tests and TEG preoperatively. We undertook univariate and multivariate stepwise logistic regression analyses to determine the potential risk factors for severe postoperative AKI (stage 3), with a special investigation on the association between hemostatic system biomarkers and severe postoperative AKI (stage 3). The receiver operating characteristic (ROC) curves were generated to assess the predictive ability of hemostatic system biomarkers for severe postoperative AKI (stage 3). Results: A total of 25 (23.6%) patients developed severe postoperative AKI (stage 3), including 21 patients (19.8%) who required continuous renal replacement therapy (RRT). Multivariate logistic regression analysis demonstrated that the preoperative fibrinogen level (OR, 2.02; 95% CI, 1.03 to 3.00; p = 0.04), platelet function (MA level) (OR, 1.23; 95% CI, 1.09 to 1.39; p = 0.001), and cardiopulmonary bypass (CPB) time (OR, 1.01; 95% CI, 1.00 to 1.02; p = 0.02) were independently associated with severe postoperative AKI (stage 3). The cutoff values of preoperative fibrinogen and platelet function (MA level) for predicting severe postoperative AKI (stage 3) were determined to be 2.56 g/L and 60.7 mm in the ROC curve [area under the curve (AUC): 0.824 and 0.829; p < 0.001]. Conclusions: The preoperative fibrinogen level and platelet function (measured by the MA level) were identified as potential predictive factors for developing severe postoperative AKI (stage 3) in patients with ATAAD. Thromboelastography could be considered a potentially valuable tool for real-time monitoring and rapid assessment of the hemostatic system to improve postoperative outcomes in patients.

Low preoperative serum fibrinogen level is associated with postoperative acute kidney injury in patients with in acute aortic dissection.

OBJECTIVE: Acute kidney injury (AKI) after cardiac surgery is associated with serious complication and high risk of mortality. The relationship between hemostatic system and the prognosis of patients with acute type A aortic dissection (ATAAD) has not been evaluated. The purpose of this study was to investigate the association between preoperative serum fibrinogen level and risk of postoperative AKI in patients with ATAAD. METHODS: A total of 172 consecutive patients undergoing urgent aortic arch surgery for ATAAD between April 2020 and December 2021 were identified from Beijing Anzhen Hospital aortic surgery database. The primary outcome was postoperative AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The univariate and multivariate logistic regression analysis were done to assess the independent predictors of risk for postoperative AKI. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive probabilities of risk factors for AKI. RESULTS: In our study, 51.2% (88/172) patients developed postoperative AKI. Multivariate logistic regression analysis identified low preoperative serum fibrinogen level (OR, 1.492; 95% CI, 1.023 to 2.476; p = 0.021) and increased body mass index (BMI) (OR, 1.153; 95% CI, 1.003 to 1.327; p = 0.046) as independent predictors of postoperative AKI in patients with ATAAD. A mixed effect analysis of variance modeling revealed that obese patients with low preoperative serum fibrinogen level had higher incidence of postoperative AKI (p = 0.04). The ROC curve indicated that low preoperative serum fibrinogen level was a significant predictor of AKI [area under the curve (AUC), 0.771; p < 0.001]. CONCLUSIONS: Low preoperative serum fibrinogen level and obesity were associated with the risk of postoperative AKI in patients with ATAAD. These data suggested that low preoperative serum fibrinogen level was preferred marker for predicting the postoperative AKI, especially in obese patients with ATAAD.

Contemporary use and outcome of Cabrol shunt in type A aortic dissection surgery: insight from China 5A study.

OBJECTIVE: Cabrol shunt has been introduced for surgical repair of type A aortic dissection (TAAD) without robust evidence supporting its routine preventive use. METHODS: Adult patients with TAAD from China 5A study were included if surgically repaired between 2016 and 2022. Primary outcome was operative mortality according to Society of Thoracic Surgeons criterion. Overall, we compared clinical outcomes in patients with and without Cabrol shunt, and subgroup analysis were further examined between Cabrol shunt and outcome among patients with or without root replacement. RESULTS: 3283 patients were finally identified for analysis, with median age of 51 (IQR 41-59) years, 2389 men, and 2201 treated with Cabrol shunt technique. Cabrol shunt-treated patients were more severely ill before surgery than those without Cabrol shunt. Overall, the rate of operative mortality was 6.6% (146/2201 in Cabrol shunt group and 71/1082 in non-Cabrol shunt group), with no association between Cabrol shunt and operative mortality (OR 1.012 (95% CI 0.754 to 1.357); p=0.938). Stratified by root replacement, Cabrol shunt was associated with similar risk of operative mortality either in patients without root replacement (OR 1.054 (0.747 to 1.487); p=0.764) or in patients with root replacement (OR 1.194 (0.563 to 2.536); p=0.644) (P interaction=0.765). Results were similar in multiple sensitivity analysis. CONCLUSION: Cabrol shunt was not associated with either a greatly lowered or an increased risk of operative mortality, regardless of aortic root replacement. Our study did not support the use of Cabrol shunt as a routine preventive strategy in the treatment of TAAD. TRIAL REGISTRATION NUMBER: NCT04398992.

Proximal vs Extensive Repair in Acute Type A Aortic Dissection Surgery.

BACKGROUND: This purpose of this study was to evaluate the impact of proximal vs extensive repair on mortality and how this impact is influenced by patient characteristics. METHODS: Of 5510 patients with acute type A aortic dissection from 13 Chinese hospitals (2016-2021) categorized by proximal vs extensive repair, 4038 patients were used for for model derivation using eXtreme gradient boosting and 1472 patients for model validation. RESULTS: Operative mortality of extensive repair was higher than proximal repair (10.4% vs 2.9%; odd ratio [OR], 3.833; 95% CI, 2.810-5.229; P < .001) with a number needed to harm of 15 (95% CI, 13-19). Seven top features of importance were selected to develop an alphabet risk model (age, body mass index, platelet-to-leucocyte ratio, albumin, hemoglobin, serum creatinine, and preoperative malperfusion), with an area under the curve of 0.767 (95% CI, 0.733-0.800) and 0.727 (95% CI, 0.689-0.764) in the derivation and validation cohorts, respectively. The absolute rate differences in mortality between the 2 repair strategies increased progressively as predicted risk rose; however it did not become statistically significant until the predicted risk exceeded 4.5%. Extensive repair was associated with similar risk of mortality (OR, 2.540; 95% CI, 0.944-6.831) for patients with a risk probability < 4.5% but higher risk (OR, 2.164; 95% CI, 1.679-2.788) for patients with a risk probability > 4.5% compared with proximal repair. CONCLUSIONS: Extensive repair is associated with higher mortality than proximal repair; however it did not carry a significantly higher risk of mortality until the predicted probability exceeded a certain threshold. Choosing the right surgery should be based on individualized risk prediction and treatment effect. (ClinicalTrials.gov no. NCT04918108.).

Acute Effects of Soleus Stretching on Ankle Flexibility, Dynamic Balance and Speed Performances in Soccer Players.

Most dynamic stretching protocols include the gastrocnemius muscle, but soleus stretches are often neglected, which is the key powerful muscle for the push-off (concentric) of all speed movements. The purpose of this study was to examine whether the added soleus stretch in a regular stretching protocol would have greater benefits for ankle flexibility, dynamic balance and functional performance. Fourteen healthy male soccer players received each of the stretching conditions (regular stretching only (Regular), regular stretching with soleus stretching (Soleus) and no stretching (Control)) randomly on different training days, with two-day separation. The ankle flexibility, standing heel-lift balance and speed performances were assessed following each stretching intervention. The active dynamic stretches were performed for 30 s with three repetitions on each of the three (Regular) and four (Soleus) muscles. One-way ANOVA with repeated measures (or the Friedman non-parametric test) was performed to determine any significant effect with alpha = 0.05. Our findings revealed that both the Regular and Soleus stretching groups showed an increased active range of ankle motion compared to the no-stretching control (Ps < 0.05). In the heel raise balance test, both stretching groups experienced a significant increase in maximum plantarflexion strength as well as resultant anterior−posterior and medial−lateral CoP excursions compared to the no-stretching control (Ps < 0.05). In the sprinting tasks, both the Soleus and Regular stretching groups induced faster linear and curved running times (Ps < 0.05). When comparing the two stretching groups, Soleus stretching led to better ankle flexibility, maximum plantarflexion strength and curved running time (Ps < 0.05). Thus, added stretches on the soleus muscles can provide further benefits to speed performances in soccer.

High-TSH Subclinical Hypothyroidism Is Associated With Postoperative Mortality in Acute Type A Aortic Dissection.

Background: Subclinical hypothyroidism can negatively affect the cardiovascular system and increase the risk of mortality, especially for individuals with thyroid-stimulating hormone (TSH) levels above 10 mU/L. We investigated the relationship between high-TSH subclinical hypothyroidism and postoperative mortality in acute type A aortic dissection (ATAAD) patients. Method: We enrolled 146 patients with ATAAD who underwent aortic surgery in Beijing Anzhen Hospital from July 2016 to November 2018. Thyroid hormone levels were obtained before surgery, and participants were divided into a ≥10mU/L TSH level group and a <10mU/L level group. Cox proportional hazard regression and subgroup analysis were conducted to examine the association of preoperative high-TSH subclinical hypothyroidism with postoperative mortality. Result: Participants with preoperative high-TSH (≥10mU/L) subclinical hypothyroidism tended to have longer hospitalization stays after surgery [16.0 (IQR 11.0-21.0) days vs 12.5 (IQR 8.0-16.0) days, P=0.001]. During the first 30 days after operation, 15 of 146 patients died (10.3%); during a median of 3.16 (IQR 1.76-4.56) years of follow-up, 24 patients died (16.4%). Cox proportional hazard regression showed that preoperative high-TSH subclinical hypothyroidism was independently associated with 30-day mortality (HR=6.2, 95% CI, 1.7-22.0, P=0.005) and postoperative mortality after adjusting for age, sex, BMI, hypertension, ejection fraction, diabetes and history of PCI (HR=3.4, 95% CI, 1.4-8.0, P=0.005). Conclusion: This study showed that preoperative high-TSH subclinical hypothyroidism was an independent predictor of postoperative mortality in ATAAD patients who underwent aortic surgery.

Prognostic Impact of Systemic Coagulation-Inflammation Index in Acute Type A Aortic Dissection Surgery.

Background: A novel hematologic parameter, systemic coagulation-inflammation (SCI) index reflecting inflammation and coagulation pathways could be easily obtained from clinically routine laboratory findings. We hypothesize that the SCI index has prognostic implication in predicting operative mortality for patients with acute type A aortic dissection (ATAAD). Objectives: This study aims to investigate the prognostic value of the SCI index and to establish an SCI-adding nomogram for mortality prediction in ATAAD patients. Methods: A total of 1,967 ATAAD patients surgically repaired were collected from 12 Chinese cardiovascular centers by the 5A (Additive Anti-inflammatory Action for Aortopathy & Arteriopathy [Multicenter Retrospective Study]) study III (2016-2020). SCI index was calculated as platelet count × fibrinogen/white blood cell count on admission. By adding SCI index, a nomogram was developed and evaluated for 90-day mortality prediction with conventional predictors via the Cox model with 10-fold cross-validation. Results: Patients were stratified with low SCI (<40), middle SCI (40-100), or high SCI (>100). The 90-day survival rates increased with SCI index (low 86.9%; [95% CI: 84.9%-89.0%], middle 92.7% [95% CI: 90.9%-94.9%], and high 96.4% [95% CI: 94.2%-98.6%]; log-rank P < 0.001). SCI index is independently associated with 90-day mortality (adjusted hazard ratio: 0.549; 95% CI: 0.424-0.710; P < 0.001). The addition of SCI index provided significantly incremental prognostic value to base model including age, serum creatinine, DeBakey class, and location of intimal entry (area under the curve: 0.677; 95% CI: 0.641-0.716 vs 0.724; 95% CI: 0.685-0.760; P = 0.002), which was confirmed by net reclassification improvement index (0.158; 95% CI: 0.065-0.235; P < 0.001) and integrated discrimination improvement index (0.070; 95% CI: 0.007-0.036; P < 0.001). Conclusions: SCI index is easily obtainable, performs moderately well as a predictor of short-term mortality in ATAAD patients, and may be useful for risk stratification in emergency settings. (Additive Anti-inflammatory Action for Aortopathy & Arteriopathy [Multicenter Retrospective Study] III NCT04918108).

Laboratory signatures differentiate the tolerance to hypothermic circulatory arrest in acute type A aortic dissection surgery.

OBJECTIVES: Our goal was to investigate whether laboratory signatures on admission could be used to identify risk stratification and different tolerance to hypothermic circulatory arrest in acute type A aortic dissection surgery. METHODS: Patients from 10 Chinese hospitals participating in the Additive Anti-inflammatory Action for Aortopathy & Arteriopathy (5A) study were randomly divided into derivation and validation cohorts at a ratio of 7:3 to develop and validate a simple risk score model using preoperative variables associated with in-hospital mortality using multivariable logistic regression. The performance of the model was assessed using the area under the receiver operating characteristic curve. Subgroup analyses were performed to investigate whether the laboratory signature-based risk stratification could differentiate the tolerance to hypothermic circulatory arrest. RESULTS: There were 1443 patients and 954 patients in the derivation and validation cohorts, respectively. Multivariable analysis showed the associations of older age, larger body mass index, lower platelet-neutrophile ratio, higher lymphocyte-monocyte ratio, higher D-dimer, lower fibrinogen and lower estimated glomerular filtration rate with in-hospital death, incorporated to develop a simple risk model (5A laboratory risk score), with an area under the receiver operating characteristic of 0.736 (95% confidence interval 0.700-0.771) and 0.715 (95% CI 0.681-0.750) in the derivation and validation cohorts, respectively. Patients at low risk were more tolerant to hypothermic circulatory arrest than those at middle to high risk in terms of in-hospital mortality [odds ratio 1.814 (0.222-14.846); odds ratio 1.824 (1.137-2.926) (P = 0.996)]. CONCLUSIONS: The 5A laboratory-based risk score model reflecting inflammatory, immune, coagulation and metabolic pathways provided adequate discrimination performances in in-hospital mortality prediction, which contributed to differentiating the tolerance to hypothermic circulatory arrest in acute type A aortic dissection surgery.Clinical Trials. gov number NCT04918108.