High preoperative bradykinin level is a risk factor for severe postoperative hypoxaemia in acute aortic dissection surgery.

NEW FINDINGS: What is the central question of this study? Hypoxaemia can lead to increased postoperative mortality in patients: what are the independent risk factors for severe hypoxaemia after acute Stanford type A aortic dissection? What is the main finding and its importance? Severe postoperative hypoxaemia was found in 36.4% of patients, and it was determined that high preoperative bradykinin levels and increased BMI were independent predictors of severe postoperative hypoxaemia in patients with acute Stanford type A aortic dissection. For obese patients with high preoperative bradykinin levels, more attention should be paid to preventing severe postoperative hypoxaemia. ABSTRACT: Severe hypoxaemia after cardiac surgery is associated with serious complications and a high risk of mortality. The purpose of this study is to investigate the independent risk factors of severe postoperative hypoxaemia in patients with acute Stanford type A aortic dissection. We collected 77 patients with acute Stanford type A aortic dissection who underwent surgical treatment. The primary outcome was severe postoperative hypoxaemia (PaO2 /FiO2  ≤ 100 mmHg), and a multivariate logistic regression analysis was performed to assess the independent predictors of risk for this. A mixed-effects analysis of variance model and a receiver operating characteristic (ROC) curve were generated to evaluate the predictive probabilities of risk factors for severe postoperative hypoxaemia. A total of 36.4% of patients developed severe postoperative hypoxaemia. The multivariate logistic regression analysis identified high preoperative bradykinin level (odds ratio (OR) = 55.918, P < 0.001) and increased body mass index (BMI; OR = 1.292, P = 0.032) as independent predictors of severe postoperative hypoxaemia in patients with acute Stanford type A aortic dissection. The mixed-effect analysis of variance model and ROC curve indicated that high preoperative bradykinin level and BMI were significant predictors of severe postoperative hypoxaemia (area under the ROC curve = 0.834 and 0.764, respectively). High preoperative bradykinin levels and obesity were independent risk factors for severe postoperative hypoxaemia in patients with acute Stanford type A aortic dissection. For obese patients with high levels of bradykinin before surgery, clinicians should actively take measures to block bradykinin-mediated inflammatory reactions.

Safety and efficacy of fibrinogen concentrate in aortic arch surgery involving moderate hypothermic circulatory arrest.

OBJECTIVE: Bleeding is a common complication of cardiac surgery, especially aortic arch surgery involving moderate hypothermic circulatory arrest. Fibrinogen concentrate has been increasingly used to treat coagulopathic bleeding in cardiac surgery, although its effectiveness and safety are unknown. The aim of this prospective study was to investigate the safety and efficacy of fibrinogen concentrate in patients with acute type A aortic dissection. METHODS: From July 2020 to August 2021, 84 patients with acute type A aortic dissection who underwent emergency aortic arch surgery involving MHCA and whose intraoperative fibrinogen level was less than 1.5 g/L were included in this study. Fifty-four patients who were supplemented with fibrinogen concentrate were included in the FC treatment group. Thirty patients were included in the non-FC treatment group. The primary endpoints included the required volumes of individual allogeneic blood products (RBCs, FFP, and PC), volumes of cumulative drainage within 24 and 48 h, and total volumes after infusion of FC, as well as reoperation rates due to bleeding. The secondary endpoint for the study was the incidence of serious adverse events from the infusion of FC to day 45. The serious adverse events defined for the evaluation of the safety of FC were death, pulmonary embolism and other thromboembolic or ischaemic events. The clinical data, routine laboratory tests and plasma fibrinogen levels were obtained at 5 time points. RESULTS: We observed rapid increases in the plasma fibrinogen level and subsequent improvement in haemostasis after the administration of fibrinogen concentrate. The mean fibrinogen level increased from 1.36 ± 0.75 g/L to 2.91 ± 0.76 g/L in the fibrinogen concentrate treatment group. The patients in the fibrinogen concentrate treatment group demonstrated lower volumes of cumulative postoperative drainage and transfused allogeneic blood products than the nonfibrinogen concentrate treatment group. There were no serious adverse events in the fibrinogen concentrate treatment group during hospitalization. CONCLUSION: Fibrinogen concentrate was effective at increasing the plasma fibrinogen level and significantly reduced the volumes of transfused allogeneic blood products and blood loss in patients with aortic arch surgery. There were no serious adverse events in the patients who received fibrinogen concentrate treatment. PERSPECTIVE STATE: The safety and efficacy of fibrinogen concentrate were investigated in acute type A aortic dissection patients with aortic arch surgery. Fibrinogen concentrate was effective at increasing the plasma fibrinogen level and significantly reduced the volumes of transfused allogeneic blood products and blood loss; there were no serious adverse events in the patients who received fibrinogen concentrate treatment.

The preoperative plasma histamine level as a possible protective biomarker for postoperative acute kidney injury.

Acute kidney injury (AKI) is a life-threatening complication of acute type A aortic dissection (ATAAD) patients. Increasing evidence suggests that histamine ameliorates the pathology of renal injury. However, data on the association between histamine levels and postoperative AKI in ATAAD patients are limited. The purpose of our study was to explore the incidence and independent risk factors of postoperative AKI, with special emphasis on the relationship between preoperative plasma histamine levels and the severity of postoperative ATAAD-AKI. This retrospective single-center study evaluated 160 patients with ATAAD admitted to the Beijing Anzhen Hospital aortic surgery database between April 2020 and December 2021. Univariate and multivariate logistic regression analyses were performed to determine the potential risk factors for postoperative ATAAD-AKI. A subgroup analysis was performed to investigate the association between preoperative plasma histamine levels and the severity of postoperative ATAAD-AKI or continuous renal replacement therapy (CRRT). ATAAD-AKI occurred in 84 of 160 patients (52.5%), including 32 with stage 1 (38.1%), 14 with stage 2 (16.7%), 38 with stage 3 (45.2%), and 34 (21.3%) received postoperative CRRT. The in-hospital mortality rate was 19.0% (16/84) in the AKI group and 2.6% (2/76) in the non-AKI group (P = .02). Preoperative lower plasma histamine levels (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.10-1.52; P = .004) were an important factor related to postoperative ATAAD-AKI in multivariate logistic regression analysis. Subgroup analysis revealed that low preoperative plasma histamine level was independently associated with postoperative ATAAD-AKI (stage 3) (OR, 1.38; 95% CI, 1.10-1.73; P = .005) and CRRT (OR, 1.44; 95% CI, 1.13-1.79; P = .008). Low preoperative plasma histamine level was an independent prognostic indicator of postoperative AKI in patients with ATAAD, especially for postoperative AKI (stage 3) and CRRT. Preoperative plasma histamine levels may serve as potential protective biomarkers of postoperative ATAAD-AKI.

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.

Short Term Prognosis of Renal Artery Stenosis Secondary to Acute Type B Aortic Dissection With TEVAR.

Objective: To determine the effect of renal artery stenosis (RAS) resulting from acute type B aortic dissection (ATBAD) with thoracic endovascular aortic repair (TEVAR) on early prognosis in patients with ATBAD. Methods: A total of 129 ATBAD patients in the National Acute Aortic Syndrome Database (AASCN) who underwent TEVAR between 2019 and 2020 were enrolled in our study. Patients were divided into two groups: the RAS group and the non-RAS group. Results: There were 21 RAS patients (16.3%) and 108 non-RAS patients (83.7%) in our cohort. No patient in our cohort died during the 1-month follow-up. There was no significant difference in preoperative creatinine clearance rate (CCr) between the two groups (90.6 ± 46.1 µmol/L in the RAS group vs. 78.7 ± 39.2 µmol/L in the non-RAS group, P = 0.303) but the RAS group had a significantly lower estimated glomerular filtration rate (eGFR) than the non-RAS group (83.3 ± 25.0 vs. 101.9 ± 26.9 ml/min, respectively; P = 0.028).One month after TEVAR, CCr was significantly higher (99.0 ± 68.1 vs. 78.5 ± 25.8 ml/min, P = 0.043) and eGFR (81.7 ± 23.8 vs. 96.0 ± 20.0 ml/min, P = 0.017) was significantly lower in the RAS group than in the non-RAS group. Conclusions: In ATBAD, RAS could result in acute kidney injury (AKI) in the early stage after TEVAR. The RAS group had a high incidence of hypertension. These results suggest that patients with RAS may need further treatment.

Does preoperative serum creatinine affect the early surgical outcomes of acute Stanford type A aortic dissection?

BACKGROUND: Acute Stanford type A aortic dissection is a lethal disease requiring surgery. Evidence regarding the effects of preoperative creatinine in mortality is limited, and few studies have evaluated the effect of postoperative dialysis treatment on it. METHODS: In this cohort study, we continuously recruited 632 surgical patients who were treated for acute type A aortic dissection in our hospital between January 2015 and May 2017. The preoperative level of serum creatinine was measured. All patients were followed up after surgery for 30 days to determine early mortality. RESULTS: The 30-day mortality after surgery increased with elevated levels of preoperative serum creatinine. Median (interquartile range) serum creatinine levels in survivors were 9.61 µmol/dL (7.28-12.62 µmol/dL) versus 13.41 µmol/dL (10.28-20.63 µmol/dL) in death (p < 0.01). Adjusted odds ratios for increasing per µmol/dL serum creatinine were 1.09 (95% confidence interval, 1.03-1.15). We also found that the effect of preoperative creatinine on 30-day mortality was diminished by dialysis treatment after surgery. CONCLUSION: Preoperative serum creatinine predicts outcome in patients undergoing surgery for Stanford type A aortic dissection, and postoperative dialysis treatment can reduce its hazard.

Moderate Hypothermic Circulatory Arrest Is Preferable During Cardiopulmonary Bypass.

The effect of temperature on cerebral injury during hypothermic circulatory arrest (HCA) has never been specifically studied. This study aimed to compare the effects of two different temperatures used for HCA on the degree of brain injury in pig models. Thirteen pigs were randomly assigned to a deep hypothermic circulatory arrest (DHCA) group (n = 5), moderate hypothermic circulatory arrest (MHCA) group (n = 5), or control group (n = 3). No significant differences in immunohistochemical assay results, including Bax, Bcl-2, and Caspase 3 staining, and a TUNEL assay, were observed between the DHCA and MHCA groups. Furthermore, no significant difference was found for biomarkers of brain injury (Soluble protein-100B) between the two experimental groups. Similarly, no significant difference was observed in the trend of changes in inflammatory factors, including tumor necrosis factor-α, interleukin (IL)-2, and IL-6, between the two groups (p > 0.05). However, coagulation factors, including FXI and FVII, were different between the DHCA and MHCA groups (p < 0.05). Therefore, it can be concluded that MHCA does not increase the risk of cerebral injury. Considering the adverse effects of DHCA on the coagulation system, MHCA is more suitable for current clinical practice.

Comparison of prognostic ability of perioperative myocardial biomarkers in acute type A aortic dissection.

Stanford type A aortic dissection (AD) is a lethal disease requiring surgery. Evidence regarding the prognostic ability of perioperative myocardiac markers on long-term outcome is limited.In this cohort study, we measured perioperative myocardiac markers level in 583 surgical patients with type A AD in our hospital between 2015 and 2017. All patients were followed up after surgery for a median period of 864 days to determine short- and long-term mortality.About one-fifth of patients has a positive preoperative myocardial markers, which was increased significantly after operation. Increase log10 post-creatine kinase MB isoenzyme (CK-MB) (hazard ratio [HR], 4.64; 95% confidence interval [CI] 1.89-11.43; P = .0008), log10 post-TnI (HR, 3.11; 95% CI 1.56-6.21; P = .0013), log10 post-Mb (HR, 3.00; 95% CI 1.40-6.43; P = .0048), log10 pre-CK-MB (HR,1.82; 95% CI 1.03-3.21; P = .0377), and upper tertile of post-CK-MB (HR,1.52; 95% CI 1.05-2.20; P = .0261) were the independent risk factor for 30 days mortality adjusted for potential confounders. None of cardiac markers was significantly associated with long-term outcome independent of other factors.Perioperative myocardiac predicts early outcome in type A AD patients undergoing surgery. Increasing perioperative myocardial markers do not appear to be a predictor for long-term all-cause mortality.

Protocol for creation of a risk scoring system for acute type A aortic dissection surgery.

Stanford type A aortic dissection is a kind of cardiovascular disease which seriously threatens human life and health. It has the characteristics of rapid onset, rapid progress and high mortality. Surgical treatment is a recognized treatment for type A aortic dissection. There are many disputed places in the actual clinical work about the timing, prognosis and methods of the operation. This study aims to establish an early mortality risk scoring system for acute Stanford A aortic dissection surgery patients. METHODS AND ANALYSIS: The structured data of patients with acute type A aortic dissection were collected. The primary outcome is death during hospitalization. Secondary outcomes will include re-operation and related complications. A risk scoring system of patients with acute type A aortic dissection undergoing surgical treatment will be established. Prospective data will be used to validate the risk stratification ability and accuracy of the model in operative risk prediction.

Increased risk for the development of postoperative severe hypoxemia in obese women with acute type a aortic dissection.

BACKGROUND: The purpose of this study is to identify the risk factors for postoperative severe hypoxemia after surgery for acute type A aortic dissection. METHODS: This was a single-center retrospective study including 112 consecutive patients undergoing urgent aortic arch surgery for acute type A aortic dissection between December 2016 and April 2017 at Beijing Anzhen Hospital. RESULTS: Multivariate logistic regression analysis identified female (OR, 12.978; 95% CI, 3.332 to 50.546; p < 0.001) and increased body mass index (OR, 1.473; 95% CI, 1.213 to 1.789; p < 0.001) as independent predictors of postoperative severe hypoxemia in patients with acute type A aortic dissection. CONCLUSIONS: Obesity and female were independent risk factors for postoperative severe hypoxemia in patients with acute type A aortic dissection. More attention should be paid to preventing postoperative severe hypoxemia in obese women with acute type A aortic dissection.

Deep Hypothermic Circulatory Arrest Does Not Show Better Protection for Vital Organs Compared with Moderate Hypothermic Circulatory Arrest in Pig Model.

BACKGROUND: Continued debates exist regarding the optimal temperature during hypothermic circulatory arrest in aortic arch repair for patients with type A aortic dissection. This study seeks to examine whether the use of moderate hypothermic circulatory arrest in a pig model provides comparable vital organ protection outcomes to the use of deep hypothermic circulatory arrest. METHODS: Thirteen pigs were randomly assigned to 30 minutes of hypothermic circulatory arrest without cerebral perfusion at 15°C (n = 5), 25°C (n = 5), and a control group (n = 3). The changes in standard laboratory tests and capacity for protection against apoptosis in different vital organs were monitored with different temperatures of hypothermic circulatory arrest management in pig model to determine which temperature was optimal for hypothermic circulatory arrest. RESULTS: There were no significant differences in the capacity for protection against apoptosis in vital organs between 2 groups (p > 0.05, respectively). Compared with the moderate hypothermic circulatory arrest group, the deep hypothermic circulatory arrest group had no significant advantages in terms of the biologic parameters of any other organs (p > 0.05). CONCLUSIONS: Compared with deep hypothermic circulatory arrest, moderate hypothermic circulatory arrest is a moderate technique that has similar advantages with regard to the levels of biomarkers of injury and capacity for protection against apoptosis in vital organs.

Cardiopulmonary bypass time is an independent risk factor for acute kidney injury in emergent thoracic aortic surgery: a retrospective cohort study.

BACKGROUND: Thoracic aortic surgery and cardiopulmonary bypass are both associated with development of postoperative acute kidney injury. In this study, we undertook to investigate the relationship between cardiopulmonary bypass time and postoperative acute kidney injury in patients undergoing thoracic aortic surgery for acute DeBakey Type I aortic dissection. METHODS: All patients receiving thoracic aortic surgery for acute DeBakey Type I aortic dissection in Beijing Anzhen hospital from December 2015 to April 2017 were included. Cardiopulmonary bypass time was recorded during surgery. Acute kidney injury was defined based on the Kidney Disease Improving Global Outcomes criteria. A total of 115 consecutive patients were eventually analyzed. RESULTS: The overall incidence of acute kidney injury was 53.0% (n = 61). The average age was 47.8 ± 10.7 years; 74.8% were male. Mean cardiopulmonary bypass time was 211 ± 56 min. In-hospital mortality was 7.8%. Multivariate logistic regression revealed that cardiopulmonary bypass time was independently associated with the occurrence of postoperative acute kidney injury after adjust confounding factors (odds ratio = 1.171; 95% confidence interval: 1.002-1.368; P = 0.047). CONCLUSIONS: Cardiopulmonary bypass time is independently associated with an increased hazard of acute kidney injury after thoracic aortic surgery for acute DeBakey Type I aortic dissection. Further understanding of the mechanism of this association is crucial to the design of preventative strategies.

Iatrogenic aortic dissection during percutaneous coronary intervention: A case report and review of the literature.

A 64-year-old female complaining of unrelieved chest pain for 2 days was admitted to the Emergency Room of the Beijing Anzhen Hospital, Beijing, China. After definitive diagnosis, a percutaneous coronary intervention was implemented, but immediately after embedding the stent in the distal area of the right coronary artery, an acute coronary and aortic dissection was found. Cardiologists immediately gave the patient conservative management. At the same time, another smaller stent was immediately embedded in the proximal area of the right coronary artery and plunged into the ascending aorta by 2 mm, with the intention of covering the tear of the dissection. Repeated coronary angiography showed that a 40% stricture of the distal right coronary artery remained and less contrast agent had been extravasated. The patient was then transferred to the Department of Cardiac Surgery and received emergency surgery consisting of right coronary artery bypass grafting and ascending aorta replacement. The patient remained in the intensive care unit for 18 days after the surgery. The patient recovery was acceptable and she was discharged with a small amount of bilateral hydrothorax, moderate malnutrition oedema and iron deficiency anaemia.

Changes in coagulation factor XII and its function during aortic arch surgery for acute aortic dissection-a prospective observational study.

BACKGROUND: Changes in the intrinsic coagulation pathway during aortic arch surgery in patients with acute aortic dissection (AAD) have not yet been reported. The aim of this study is to describe the changes in intrinsic coagulation factor XII, explore its function and find a new target for the treatment of coagulopathy during surgery. METHODS: Eighty-eight patients undergoing emergent surgery for AAD were enrolled. Changes in the intrinsic and extrinsic coagulation pathways were evaluated at 5 different timepoints during the perioperative period by measuring intrinsic coagulation factor XII, extrinsic coagulation factor VII and some intrinsic upstream stimulating factors. The 88 patients were also divided into two groups according to whether reoperation for coagulopathy was required after surgery. RESULTS: Both coagulation factors XII and VII demonstrated a significant and similar change during the perioperative period. These factors decreased significantly during hypothermia circulation arrest (P<0.001) and recovered to normal levels by 24 hours after surgery. Among the intrinsic upstream stimulating factors, bradykinin (BK) demonstrated a similar changing trend with coagulation factors XII and VII, while other stimulating factors did not. However, compared with factor VII, factor XII demonstrated a greater decline during surgery. The proportion of decline of factor XII from anesthesia induction to hypothermia circulation arrest was 42%, whereas the proportion of decline of factor VII during the same period was 20% (P<0.001). Moreover, factor VII recovered to preoperative levels 4 hours after surgery with a relatively faster speed (P<0.001) while factor XII had not recovered (P=0.010). The independent t-test and Wilcoxon test showed that coagulation factor XII levels during hypothermia circulation arrest (P=0.002), total dosage of fibrinogen (P=0.027), total dosage of packed red blood cells (PRBCs) (P=0.006) and total dosage of fresh frozen plasma (FFP) (P=0.022) during the perioperative period were significantly different between the patients who did or did not require reoperation for coagulopathy. Multivariable logistic regression analysis suggested that the factor XII level during hypothermia circulation arrest was an independent risk factor for reoperation for coagulopathy [odds ratio (OR): 1.342, 95% confidence interval (CI): 1.058-1.570; P=0.012]. CONCLUSIONS: Factor XII levels are more influenced by surgery and require a longer period of time to recover to preoperative levels compared with factor VII, and the level of factor XII during hypothermia circulation arrest might be an independent risk factor for reoperation for coagulopathy. Therefore, supplementation of coagulation factor XII and its upstream stimulating factors might be a promising therapeutic modality in the future.

Low preoperative fibrinogen level is risk factor for neurological complications in acute aortic dissection.

Aortic arch surgery in patients with acute aortic dissection is frequently complicated by neurological complications and coagulopathy. However, the relationship between the coagulation system and neurological complications in patients with acute aortic dissection has not been clarified. Thus, the aim of this study was to investigate the relationship between the coagulation system and neurological complications in patients with acute aortic dissection.From September 2014 to January 2016, a total of 126 patients with acute type A aortic dissection were enrolled. Perioperative characteristics and standard laboratory tests upon admission were analyzed using univariate and multivariate logistic regression analysis in this study. The primary outcome was the correlation between the coagulation system and neurological complications.Univariate logistic regression analysis showed that the neurological complications (+) group underwent more serious and complicated postoperative outcomes. Multivariable logistic regression analysis revealed serum creatinine level (OR, 1.049; 95% CI, 1.011-1.089; P = .01), white blood cell counts (OR, 1.581; 95% CI, 1.216-2.057; P = .001) and fibrinogen concentration upon admission (OR, 0.189; 95% CI, 0.060-0.596; P = .004) as predictors of neurological complications. However, we found that there was no association between the coagulation system and in-hospital mortality.Low preoperative fibrinogen level is the preferred marker for predicting clinical neurological complications in patients with acute type A aortic dissection treated with surgical repair.

[Clinical analysis of pregnancy and postpartum cardiovascular complications in Marfan syndrome].

OBJECTIVE: To investigate the management of pregnancy and cardiovascular complications in women with Marfan syndrome (MFS). METHODS: From October 1994 to September 2006, 30 patients with MFS undergoing cardiovascular surgery were studied retrospectively. RESULTS: In the labor of 46 offsprings given birth by 30 women, 5 cases (11%) were performed elective cesarean section because of the existence of aortic complication, and 12 (26%) were diagnosed as MFS. The gestation in two patients was terminated due to deterioration of aortic abnormalities during their third trimester, and they received surgical treatment with Bentall procedure. Two developed acute aortic dissection during labor and post delivery respectively. With the manipulation of anticoagulation peripartum, one who had the implantation with mechanical prosthesis went through pregnancy and delivery uneventfully. The average duration between delivery and cardiovascular surgery was (15 +/- 9) years. CONCLUSIONS: Vaginal delivery can be done safely in patients with the MFS who do not have or have mild cardiovascular system abnormalities, aortic dissection, or other important cardiac abnormalities, cesarean section should be the preferred method of delivery. Women with MFS are at increased risk for dissection and congestive heart failure during pregnancy and should be counseled before pregnancy about these risks, as well as the inheritance of the condition.

Iatrogenic acute aortic dissection induced by off-pump coronary artery bypass grifting: A case report and review of the literature.

RATIONALE: Iatrogenic acute aortic dissection (IAAD) induced by cardiac surgery is a fatal complication, with 0.04% of therapeutic procedures and worse outcomes than spontaneous aortic dissection. PATIENTS CONCERNS: A 64-year-old male complaining of intermittent chest tightness for 4 years received an off-pump coronary artery bypass grifting (OPCABG) and IAAD was found during surgery. DIAGNOSIS: Unstable angina, coronary artery triple vessel lesion, IAAD. INTERVENTIONS: An ascending aorta replacement surgery was implemented immediately and extracorporeal membrane oxygenation (ECMO) was applied during surgery. The patient suffered from oliguria symptoms and began to receive continuous renal replacement therapy (CRRT) after surgery. What was worse, osteofascial compartment syndrome (OCS) was also confirmed the day after surgery. OUTCOMES: The CRRT and ECMO were both removed and the condition of the right leg was also stable. But the patient passed away because of uncontrollable sepsis 18 days after the surgery. LESSONS: OPCABG is clearly the riskiest type of surgery associated with IAADs in cardiac surgical procedures, which should be considered with great concern. Whether ECMO should be used postoperatively in IAAD patients is still a controversial subject, due to some fatal complications linked with it.

Consumption coagulopathy in acute aortic dissection: principles of management.

BACKGROUND: The effect of acute aortic dissection itself on coagulopathy or surgery-related coagulopathy has never been specifically studied. The aim of the present study was to perioperatively describe consumption coagulopathy in patients with acute aortic dissection. METHODS: Sixty-six patients with acute type A aortic dissection were enrolled in this study from January 2015 to September 2016. Thirty-six patients with thoracic aortic aneurysms were used as a control group during the same period. Consumption coagulopathy was evaluated using standard laboratory tests, enzyme-linked immunosorbent assay and thromboelastograghy at five perioperative time-points. RESULTS: A significant reduction in clotting factors and fibrinogen was observed at the onset of acute aortic dissection. Enzyme-linked immunosorbent assay and thromboelastograghy also revealed a persistent systemic activation of the coagulation system and the consumption of clotting factors. In contrast, although platelet counts were consistently low, we did not find that platelet function was more impaired in the acute aortic dissection group than the control group. CONCLUSIONS: After surgery, clotting factors and fibrinogen were more impaired than platelet function. Thus, we proposed that hemostatic therapy should focus on the rapid and sufficient supplementation of clotting factors and fibrinogen to improve consumption coagulopathy in patients with acute aortic dissection.

Innominate artery aneurysm, how to solve it?

We herein describe our *These authors contributed equally to this work. experience with a congenital innominate artery aneurysm (IAA) that was managed with a simple surgical procedure. A 44-year-old woman was admitted for chest distress. Computed tomography angiography showed a 3.6-cm IAA arising from the aortic arch and compressing the trachea. A median sternotomy was performed with the patient under general anesthesia, and the IAA was found to involve the origin of the innominate artery and the bifurcation of the right subclavian artery and common carotid artery; however, the aorta was intact. An 8-mm Dacron graft was anastomosed to the ascending aorta and distal end of the IAA without cardiopulmonary bypass. The postoperative course was uneventful, and repeat computed tomography angiography revealed no evidence of recurrence 6 months postoperatively. We also herein present a literature review of this rare clinical condition.