Prognostic Value of Left Ventricular Longitudinal Function and Myocardial Fibrosis in Patients With Ischemic and Non-Ischemic Dilated Cardiomyopathy Concomitant With Type 2 Diabetes Mellitus: A 3.0 T Cardiac MR Study.

BACKGROUND: Poorly controlled type 2 diabetes mellitus (T2DM) is known to result in left ventricular (LV) dysfunction, myocardial fibrosis, and ischemic/nonischemic dilated cardiomyopathy (ICM/NIDCM). However, less is known about the prognostic value of T2DM on LV longitudinal function and late gadolinium enhancement (LGE) assessed with cardiac MRI in ICM/NIDCM patients. PURPOSE: To measure LV longitudinal function and myocardial scar in ICM/NIDCM patients with T2DM and to determine their prognostic values. STUDY TYPE: Retrospective cohort. POPULATION: Two hundred thirty-five ICM/NIDCM patients (158 with T2DM and 77 without T2DM). FIELD STRENGTH/SEQUENCE: 3T; steady-state free precession cine; phase-sensitive inversion recovery segmented gradient echo LGE sequences. ASSESSMENT: Global peak longitudinal systolic strain rate (GLPSSR) was evaluated to LV longitudinal function with feature tracking. The predictive value of GLPSSR was determined with ROC curve. Glycated hemoglobin (HbA1c) was measured. The primary adverse cardiovascular endpoint was follow up every 3 months. STATISTICAL TESTS: Mann-Whitney U test or student's t-test; Intra and inter-observer variabilities; Kaplan-Meier method; Cox proportional hazards analysis (threshold = 5%). RESULTS: ICM/NIDCM patients with T2DM exhibited significantly lower absolute value of GLPSSR (0.39 ± 0.14 vs. 0.49 ± 0.18) and higher proportion of LGE positive (+) despite similar LV ejection fraction, compared to without T2DM. LV GLPSSR was able to predict primary endpoint (AUC 0.73) and optimal cutoff point was 0.4. ICM/NIDCM patients with T2DM (GLPSSR < 0.4) had more markedly impaired survival. Importantly, this group (GLPSSR < 0.4, HbA1c ≥ 7.8%, or LGE (+)) exhibited the worst survival. In multivariate analysis, GLPSSR, HbA1c, and LGE (+) significantly predicted primary adverse cardiovascular endpoint in overall ICM/NIDCM and ICM/NIDCM patients with T2DM. CONCLUSIONS: T2DM has an additive deleterious effect on LV longitudinal function and myocardial fibrosis in ICM/NIDCM patients. Combining GLPSSR, HbA1c, and LGE could be promising markers in predicting outcomes in ICM/NIDCM patients with T2DM. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: 5.

Dynamic changes in cardiac morphology, function, and diffuse myocardial fibrosis duration of diabetes in type 1 and type 2 diabetic mice models using 7.0 T CMR and echocardiography.

Background: Diabetes mellitus (DM) is associated with an increased risk of cardiovascular disease (CVD). Hence, early detection of cardiac changes by imaging is crucial to reducing cardiovascular complications. Purpose: Early detection of cardiac changes is crucial to reducing cardiovascular complications. The study aimed to detect the dynamic change in cardiac morphology, function, and diffuse myocardial fibrosis(DMF) associated with T1DM and T2DM mice models. Materials and methods: 4-week-old C57Bl/6J male mice were randomly divided into control (n=30), T1DM (n=30), and T2DM (n=30) groups. A longitudinal study was conducted every 4 weeks using serial 7.0T CMR and echocardiography imaging. Left ventricular ejection fraction (LV EF), tissue tracking parameters, and DMF were measured by cine CMR and extracellular volume fraction (ECV). Global peak circumferential strain (GCPS), peak systolic strain rate (GCPSSR) values were acquired by CMR feature tracking. LV diastolic function parameter (E/E') was acquired by echocardiography. The correlations between the ECV and cardiac function parameters were assessed by Pearson's test. Results: A total of 6 mice were included every 4 weeks in control, T1DM, and T2DM groups for analysis. Compared to control group, an increase was detected in the LV mass and E/E' ratio, while the values of GCPS, GCPSSR decreased mildly in DM. Compared to T2DM group, GCPS and GCPSSR decreased earlier in T1DM(GCPS 12W,P=0.004; GCPSSR 12W,P=0.04). ECV values showed a significant correlation with GCPS and GCPSSR in DM groups. Moreover, ECV values showed a strong positive correlation with E/E'(T1DM,r=0.757,P<0.001;T2DM, r=0.811,P<0.001). Conclusion: The combination of ECV and cardiac mechanical parameters provide imaging biomakers for pathophysiology, early diagnosis of cardiac morphology, function and early intervention in diabetic cardiomyopathy in the future.

Debranching Thoracic Endovascular Aortic Repair Combined with Ascending Aortic Banding: Analysis of a New Surgical Procedure.

BACKGROUND: To analyze the clinical effect of debranching thoracic endovascular aortic repair combined with ascending aortic banding. METHODS: The clinical data of patients who underwent a debranching thoracic endovascular aortic repair combined with ascending aortic banding at Anzhen Hospital (Beijing, China) between January 2019 and December 2021 were reviewed to evaluate the occurrence and outcomes of postoperative complications. RESULTS: A total of 30 patients underwent a debranching thoracic endovascular aortic repair combined with ascending aortic banding. There were 28 male patients (93.3%) with an average age of 59.9 ± 11.8 years. Twenty-five patients underwent simultaneous surgery and five patients had staged surgery. Postoperatively, two patients developed complete paraplegia (6.7%), three patients developed incomplete paraplegia (10%), two patients developed cerebral infarction (6.7%), and one patient developed femoral artery thromboembolism (3.3%). No patient died during the perioperative period, and one patient (3.3%) died during the follow-up period. None of the patients underwent retrograde type A aortic dissection during the perioperative and postoperative follow-up periods. CONCLUSIONS: Banding the ascending aorta with a vascular graft to restrict its movement and to serve as the proximal anchoring area of the stent graft can reduce the risk of retrograde type A aortic dissection.

A retrospective study of thoracic endovascular aortic repair timing in patients with uncomplicated type B dissection who have a smoking history.

Objective: To determine the optimal timing of thoracic endovascular aortic repair (TEVAR) for patients with uncomplicated type B dissections who have a smoking history. Methods: Data from 308 consecutive patients with uncomplicated type B dissections, who have a smoking history and onset-to-TEVAR time within 90 days, were analyzed. The patients were divided into two groups: Acute and subacute phases. Univariate and multivariate regression analyses were performed. Smooth curve fitting and threshold analysis were performed to characterize the relationship between the onset-to-TEVAR time and follow-up deaths. Results: There were no significant differences between the two groups. Smooth curve fitting and threshold effect analysis showed that if early TEVAR was performed within 9.4 days from onset, there was better long-term survival and there was no significant difference after 9.4 days. Conclusion: By studying the relationship between onset-to-TEVAR time and all-cause mortality, we found that early TEVAR may have a lower all-cause mortality rate during follow-up in uncomplicated type B dissection patients who have a smoking history and within 90 days from onset.

Thoracic endovascular aortic repair (TEVAR) to retrieve a stented elephant trunk graft entrapped in the false lumen of dissection patients.

A stented elephant trunk graft entrapped in the false lumen during Sun's procedure (total arch replacement combined with stented elephant trunk implantation) is a serious complication with an extremely high mortality rate. This article describes a case of a patient who was successfully saved with the use of thoracic endovascular aortic repair.

Sun's total arch replacement and stent elephant trunk with modified branch-first technique for patients with Stanford type A aortic dissection.

BACKGROUND: Stanford type A aortic dissection (STAAD) is a critical cardiovascular disease, and surgical procedure is the first-choice treatment. The classical surgical procedure still leads to a high mortality rate and neurological complications. In this study, we introduce a new modified Sun's procedure and investigate the association between the branch-first technique and the postoperative outcomes of patients with STAAD. METHODS: A total of 108 consecutive patients with STAAD who underwent arch replacement and stent elephant trunk procedure at Beijing Anzhen Hospital between July, 2017 and November, 2018 were included in the analysis. The patients were divided into two groups: the branch-first group and the classic group. The branch-first group and the classic group comprised 24 patients (22.2%) and 84 patients (77.8%), respectively. RESULTS: Patients in the branch-first group had a significantly shorter cardiopulmonary bypass (CPB) duration (172.4±29.9 vs. 194.9±47.4 min; P=0.035), Intensive care unit (ICU) stay [17.0 (14.6-38.2) vs. 42.1 (19.7-87.2) hours; P<0.001], and mechanical ventilation time [15.5 (11.9-40.0) vs. 19.0 (17.0-45.6) hours; P=0.018] than patients in the classic group. The branch-first was associated with a reduction in postoperative neurological complications in all models. CONCLUSIONS: The benefits of the branch-first technique, including lower CPB duration, better bilateral cerebral perfusion, and higher nasopharyngeal temperature during hypothermic arrest, contributed to a shortened recovery time for patients after surgery.

Corrigendum: Association Between D-dimer and Early Adverse Events in Patients With Acute Type A Aortic Dissection Undergoing Arch Replacement and the Frozen Elephant Trunk Implantation: A Retrospective Cohort Study.

[This corrects the article DOI: 10.3389/fphys.2019.01627.].

Smoking history increases the risk of long-term mortality after thoracic endovascular aortic repair in patients with an uncomplicated type B dissection.

BACKGROUND: The preferred treatment for uncomplicated type B dissection (thoracic endovascular aortic repair [TEVAR] or medical) is still under debate. Since 2001, our center has performed TEVAR for uncomplicated type B dissection. Based on our data, 5- and 10-year survival rates among patients with uncomplicated type B dissection after TEVAR were 96.5% and 83.0%, respectively. We, therefore, believe that TEVAR is preferable for uncomplicated type B dissections. This study analyzed the impact of a pre-operative smoking history on long-term survival after TEVAR in patients with uncomplicated type B dissections. METHODS: From May 2001 to December 2013, data from 751 patients with type B dissections were collected and analyzed. Patients were divided into two groups (337 smoking patients and 414 non-smoking patients). The Kaplan-Meier method and log-rank test were used to compare survival curves of the two groups. Multivariable analyses using the Cox proportional hazards model were used to estimate the effects of smoking on survival rates. RESULTS: The 5- and 10-year survival rates of non-smokers were 97.6% (95% confidence interval [CI], 96.0%-99.2%) and 87.0% (95% CI, 81.6%-92.7%), respectively, and 94.9% (95% CI, 92.2%-97.7%) and 73.8% (95% CI, 62.3%-87.5%) for smokers, respectively (Log-rank test, P = 0.006). Multivariable analyses showed that smoking increased the risk of death during follow-up, 2.1-fold when compared to non-smokers (P = 0.039). CONCLUSION: A pre-operative smoking history increases long-term mortality rates after TEVAR in patients with uncomplicated type B dissections.

Tirofiban Promotes the Proliferation of Human Umbilical Vein Endothelial Cells In Vitro Via Enhanced Vascular Endothelial Growth Factor Expression.

BACKGROUND: In the design and development of small-caliber artificial blood vessels, endothelialization is a key issue, but it is not well understood at present. Some studies have used vascular endothelial growth factor (VEGF) sustained-release methods to promote endothelial cell proliferation. However, this method is not ideal. This study has used drugs to induce endothelial cells to produce VEGF. This method in turn functions to promote cell proliferation and promote the endothelialization of artificial blood vessels. This study aimed to investigate the effect of the antiplatelet drug tirofiban on endothelial cell proliferation in vitro. METHODS: In this study, human umbilical vein endothelial cells (HUVECs) were used to determine the effect of tirofiban-stimulated cell proliferation. Analysis of cell proliferation, assayed by the Cell Counting Kit-8 assay, showed that the number of cells was increasingly higher than in the absence of tirofiban. It was also observed that heparin enhanced the tirofiban effect. The cell VEGF expression at different time points after tirofiban addition was detected by western blot analysis. RESULTS: The absorbance values of the experimental (1 µg/mL tirofiban) and the control groups (0 tirofiban) were 1.74 (SD, 0.03) and 1.51 (SD, 0.07) (P < .001), respectively, after 4 days of culture under the same conditions. The amount of VEGF produced by HUVECs gradually increased after treatment with tirofiban, reached a peak at 2 hours, and was 1.3-fold greater than the control group (P = .034). Compared with the tirofiban-only group, the absorbance value of the tirofiban and 10 µg/mL of heparin group was significantly increased (P < .001). CONCLUSIONS: Tirofiban promoted the proliferation of HUVECs by promoting the synthesis of VEGF in HUVECs. Heparin enhanced tirofiban activity in promoting HUVEC proliferation.

Association between cardiopulmonary bypass time and 90-day post-operative mortality in patients undergoing arch replacement with the frozen elephant trunk: a retrospective cohort study.

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 post-operative 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.

Analysis of perioperative outcome and long-term survival rate of thoracic endovascular aortic repair in uncomplicated type B dissection: single-centre experience with 751 patients.

OBJECTIVES: To study the perioperative outcomes and long-term survival rates in patients undergoing thoracic endovascular aortic repair (TEVAR) for uncomplicated type B dissection. METHODS: A total of 751 patients with uncomplicated type B dissection who underwent TEVAR at our centre between May 2001 and December 2013 were retrospectively reviewed. The mean age of all patients (619 males and 132 females) was 52.8 ± 10.9 years. The follow-up period ranged from 1 to 170 months (median 70 months). RESULTS: Five patients died during the perioperative period (mortality rate 0.7%). Four patients (0.5%) developed retrograde type A dissection. Two patients (0.3%) developed paraplegia and 1 patient developed incomplete paralysis (0.1%). There were no postoperative cerebral infarctions. The 5- and 10-year survival rates were 96.5% [95% confidence interval (CI) 95.0-98.0%] and 83.0% (95% CI 77.9-88.4%), respectively. The 5- and 10-year reintervention rates were 4.6% (95% CI 3.0-6.2%) and 7.9% (95% CI 5.3-10.5%), respectively. CONCLUSIONS: Although the application of TEVAR for patients with uncomplicated dissection is still under debate, many patients who have undergone TEVAR have benefitted substantially from the treatment. Our data showed that TEVAR had low mortality and complication rates both in the short- and long-term follow-up periods. TEVAR may be considered as a first choice for patients with uncomplicated type B dissection.

Association Between D-dimer and Early Adverse Events in Patients With Acute Type A Aortic Dissection Undergoing Arch Replacement and the Frozen Elephant Trunk Implantation: A Retrospective Cohort Study.

Objective: In the present study, we investigated the associations between D-dimer levels at admission and early adverse events in patients with acute type A aortic dissection undergoing arch replacement and the frozen elephant trunk (FET). Methods: We retrospectively analyzed data of patients with acute type A aortic dissection undergoing aortic arch surgery and FET from July 2017 to December 2018 at Beijing Anzhen Hospital. D-dimer levels were evaluated within 24 h of admission. Multivariate Cox regression analysis was used to determine independent predictors of early postoperative adverse events. Results: A total of 347 patients were included in the study. The average age of the patients was 48.07 ± 10.56 years, with male predominance (79.25%). The incidence of 90-day postoperative adverse events was 18.7%, consisting of 14.7% mortality and 4.0% permanent neurological dysfunction (PND). The median D-dimer level was 1.95 ug/ml (interquartile range, 0.77-3.16 ug/ml). Multivariable Cox regression analysis revealed that D-dimer level was independently associated with 90-day postoperative adverse events after adjustment for confounding factors (hazard ratio = 1.19 per 10 ug/ml increase in D-dimer, 95% confidence interval: 1.01-1.41; P = 0.039). Kaplan-Meier analysis revealed that the highest tertile (median 6.27 ug/ml) had more 90-day postoperative adverse events compared with the median and lowest tertiles (P = 0.0014). Sub-analysis found that the association remained unchanged. Conclusion: Increased D-dimer levels at admission were associated with 90-day postoperative adverse events in patients with acute type A aortic dissection undergoing arch replacement and FET. These results may help clinicians optimize the risk evaluation and perioperative clinical management to reduce early adverse events. Key Question: Explore the relationship between D-dimer and early outcomes in patients with aortic dissection with arch replacement. Key Findings: Increased D-dimer at admission was associated with adverse events in patients with aortic dissection with arch surgery. Take-Home Message: The high-risk patients deserve close medical monitoring.