The impact of antiplatelet therapy on the descending thoracic aorta fate and long-term prognosis of extensive repaired type A aortic dissection.

OBJECTIVES: To evaluate the impact of antiplatelet therapy on the long-term descending thoracic aorta (DTA) fate and prognosis of extensive repaired type A aortic dissection (TAAD). METHODS: 1147 eligible TAAD patients from January 2010 to December 2019 were stratified into non-antiplatelet (n = 754) and antiplatelet groups (n = 393). The primary end points were overall survival, and DTA remodelling, including false lumen (FL) thrombosis and aortic redilation. The secondary end points were DTA reintervention or rupture and major bleeding events (MBEs). RESULTS: The 5-year overall survival rates were 95.6% and 94.3% in the non-antiplatelet and antiplatelet groups (P = 0.53), respectively. In the stent covering segment, the 1-year FL complete thrombosis rates were 92.1% and 92.4% in the non-antiplatelet and antiplatelet groups (P = 0.27), respectively, while in the stent uncovering segment, the 5-year FL complete thrombosis rates were 47.1% and 56.5% in the non-antiplatelet and antiplatelet groups (P = 0.12), respectively. Antiplatelet therapy was not an independent predictor of aortic redilation at the pulmonary artery bifurcation (ß±SE = -0.128 ± 0.203, P = 0.53), diaphragm (ß±SE = 0.143 ± 0.152, P = 0.35) or coeliac artery (ß±SE = 0.049 ± 0.136, P = 0.72) levels. With death as a competing risk, the cumulative incidences of DTA reintervention or rupture at 5 years were 4.6% and 4.0% in the non-antiplatelet and antiplatelet groups (sHR = 0.85, 95% CI, 0.49∼1.19; P = 0.58), respectively, and the 5-year cumulative incidences of MBEs were 2.1% and 2.3% in the non-antiplatelet and antiplatelet groups (sHR = 0.82, 95% CI, 0.56∼2.67; P = 0.62), respectively. CONCLUSIONS: Antiplatelet therapy did not impact long-term DTA FL thrombosis, redilation, reintervention or rupture, MBEs or overall survival on extensive repaired TAAD. Thus, antiplatelet therapy can be administered as indicated on extensive repaired TAAD.

Early Obliterated Cabrol Shunt: Culprit of Aortopulmonary Fistula in Large Pseudoaneurysm after Bentall Procedure.

Aortopulmonary fistula secondary to a large pseudoaneurysm after a Bentall procedure is a rare but complex complication. Herein, we report a case of Cabrol shunt obliteration and pseudoaneurysm formation three months after a Bentall procedure. The patient also presented with congestive heart failure due to an aortopulmonary fistula six years later. Surgery was successfully performed to repair the dehiscence of the biliteral coronary ostia and the aortopulmonary fistula, and to replace the ascending aorta. Postoperatively, the patient recovered uneventfully.

Reconsideration and surgical technique report of root repair management of acute Stanford type A aortic dissection.

Currently, there is a lack of expert consensus and clinical guidelines about the treatment strategy for aortic roots in patients with acute Stanford type A aortic dissection with aortic sinuses less than 45 mm in diameter and without combined connective tissue disorder. The physiological aortic sinus plays a key role in the protection of the aortic valve and cardiac function. Thus, we invented a "watching without dealing with" technique of aortic root repair to preserve the aortic sinus as much as possible. This technique could simplify the operation and improve the patient's prognosis, which is worth learning and promoting.

The impact of prophylactic ascending aorta replacement on the long-term prognosis of zone 0 hybrid arch repair.

OBJECTIVES: To investigate the impact of prophylactic zone 0 replacement with prosthetic grafts on the long-term prognosis and perioperative safety of zone 0 hybrid arch repair (HAR) when zone 0 is neither dilated nor pathologic. METHODS: We retrospectively reviewed 115 patients whose zone 0 aorta was neither dilated nor pathologic and who underwent zone 0 HAR from January 2009 to December 2020 and divided then into two groups depending on whether zone 0 was replaced, with 46 patients in the no-replacement group and 69 patients in the replacement group. Inverse probability of treatment weighting (IPTW) was used to balance the baseline difference, and outcomes were compared after IPTW adjustment. The primary end points were overall survival and adverse aortic events (AAEs). The secondary end points were early composite adverse events and other perioperative complications. Subgroup analysis was performed by age, diagnosis, zone 0 maximum diameter and risk stratification. RESULTS: The 5-year IPTW-adjusted overall survival rate was 84% in the no-replacement group 90% in the replacement group (P = .61). With death as a competing risk, the IPTW-adjusted cumulative incidence of AAEs at 5 and 10 years was 23% and 41% in the no-replacement group, and 14% and 25% in the replacement group, respectively (subdistribution hazard ratio [sHR], 0.56; 95% confidence interval [CI], 0.23-1.39; P = .23). Considering proximal complications alone, the replacement group exhibited lower 5-year (3% vs 18%) and 10-year (6% vs 36%) cumulative incidences of proximal complications (sHR, 0.11; 95% CI, 0.01-0.91; P = .04) after IPTW adjustment. A subgroup analysis demonstrated that the benefits of zone 0 replacement in decreasing AAEs were observed in those aged 60 years or less (sHR, 0.15; 95% CI, 0.03-0.75; P = .02) and those with type B aortic dissection (sHR, 0.24; 95% CI, 0.07-0.82; P = .02). Additionally, zone 0 replacement did not increase early composite adverse event morbidity (9% vs 21%; P = .08) or early mortality (7% vs 6%; P = .87). CONCLUSIONS: Although zone 0 was neither dilated nor pathologic, prophylactic zone 0 replacement in zone 0 HAR significantly decreased the incidence of proximal complications, without impairing perioperative safety. Additionally, this strategy was associated with benefits in reducing AAEs in younger patients and patients with type B aortic dissection. Thus, prophylactic zone 0 replacement should be considered for reconstructing a stable proximal landing zone in zone 0 HAR.

Early and Midterm Outcomes of Type II Hybrid Arch Repair for Complex Aortic Arch Pathology.

Background: The hybrid arch repair (HAR) is an appealing surgical option in the management of aortic arch diseases. The aim is to evaluate the short and mid-term outcomes of type II HAR involving replacement of the ascending aorta, arch debranching, and zone 0 stent graft deployment in diverse arch pathologies. Methods: 200 patients with various diffuse aortic pathologies involving the arch were enrolled between 2016 and 2019. Complex arch diseases included acute type A dissection (n = 129, 64.5%), acute type B dissection (n = 16, 8.0%), aortic arch aneurysm (n = 42, 21.0%) and penetrating arch ulcer (n = 13, 6.5%). Mortality, morbidity, survival and re-intervention were analyzed. Results: The overall 30-day mortality rate was 8.0% (16/200). Stroke was present in 3.5% (7/200) of the general cohort and spinal cord injury was occurred in 3.0% (6/200). Multivariable logistic analysis showed that cardiac malperfusion and CPB time were the risk factors associated with 30-day mortality. The mean follow-up duration was 25.9 months (range 1-57.2 months), and the 3-year survival rate was 83.1%. On Cox regression analysis, age, diabetes, cardiac malperfusion and CPB time predicted short and mid-term overall mortality. A total of 3 patients required reintervention during the follow-up due to the thrombosis of epiaortic artificial vessels (n = 1), anastomotic leak at the site of the proximal ascending aorta (n = 1) and the type I endoleak (n = 1). Conclusions: Type II HAR was performed with satisfactory early and mid-term outcomes in complex aortic arch pathologies.

Cannulation strategy in frozen elephant trunk for type A aortic dissection: double arterial cannulation approach.

OBJECTIVES: The goal of this study was to compare clinical outcomes of double arterial cannulation (DAC), axillary cannulation and femoral cannulation in patients undergoing frozen elephant trunk for type A aortic dissection. METHODS: Between 2015 and 2020, the study included 488 patients and was divided into 3 groups: 171 in the DAC group, 217 in the axillary group and 100 in the femoral group. Overall survival was the primary end point and clinical outcomes were analysed after inverse probability weighting. RESULTS: A total of 43 patients died during the follow-up period. DAC group presented higher percentages of coeliac trunk, renal and iliac artery malperfusion, but early outcomes and overall survival did not differ among groups. Subgroup analyses suggested that in patients requiring cardiopulmonary bypass duration ≥180 min, DAC approach was associated with a tendency to improved overall survival compared with axillary [hazard ratio (HR): 0.35, 95% confidence interval (CI): 0.14-0.90, P = 0.029) and femoral cannulation (HR: 0.38, 95% CI: 0.14-1.03, P = 0.058). Inverse probability weighting adjustment (axillary as reference: HR: 0.34, 95% CI: 0.13-0.86, P = 0.022; femoral as reference: HR: 0.33, 95% CI: 0.11-0.90, P = 0.030) and multivariable Cox proportional hazards model (covariates including age, gender, acute dissection, any organ malperfusion and deep hypothermic circulatory arrest) confirmed this result. CONCLUSIONS: DAC approach was commonly used in patients with branch artery malperfusion and clinical outcomes did not differ compared with axillary and femoral cannulation. It provides a flexible and effective option with adequate perfusion for cases with various dissection-involved statuses and prolonged cardiopulmonary bypass duration.

Hybrid Technique on the Total Arch Replacement for Type A Aortic Dissection: 12-year Clinical and Radiographical Outcomes From a Single Center.

Objective: Hybrid total arch replacement (HTAR) was an alternative for type A aortic dissection (TAAD). This study aimed to evaluate the clinical and radiographical outcomes of HTAR for TAAD and to evaluate the clinical outcomes of performing this procedure under mild hypothermia. Methods: A total of 209 patients who underwent HTAR for TAAD were retrospectively analyzed and stratified into mild (n = 48) and moderate (n = 161) hypothermia groups to evaluate the effects of mild hypothermia on the clinical outcomes. Long-term clinical outcomes were evaluated by the overall survival and adverse aortic events (AAEs). A total of 176 patients with preoperative and at least one-time postoperative aortic computed tomography angiography in our institute were included for evaluating the late aortic remodeling (aortic diameter and false lumen thrombosis). Results: The median follow-up period was 48.3 (interquartile range [IQR] = 28.4-73.7) months. The overall survival rate was 88.0, 83.2, and 77.1% at the 1, 5, and 10 years, respectively, and in the presence of death as a competing risk, the cumulative incidence of AAEs was 4.8, 9.9, and 12.1% at the 1, 5, and 10 years. The aortic diameters were stable in the descending thoracic and abdominal aorta (P > 0.05 in all the measured aortic segments). A total of 100% complete false lumen thrombosis rate in the stent covered and distal thoracic aorta were achieved at 1 year (64/64) and 4 years (18/18), respectively after HTAR. The overall composite adverse events morbidity and mortality were 18.7 and 10.0%. Mild hypothermia (31.2, IQR = 30.2-32.0) achieved similar composite adverse events morbidity (mild: 14.6 vs. moderate: 19.9%, P = 0.41) and early mortality (mild: 10.4 vs. moderate: 9.9%, P = 1.00) compared with moderate hypothermia (median 27.7, IQR = 27-28.1) group, but mild hypothermia group needed shorter cardiopulmonary bypass (mild: 111, IQR = 93-145 min vs. moderate: 136, IQR = 114-173 min, P < 0.001) and aortic cross-clamping (mild: 45, IQR = 37-56 min vs. moderate: 78, IQR = 54-107 min, P < 0.001) time. Conclusion: Hybrid total arch replacement achieved desirable early and long-term clinical outcomes for TAAD. Performing HTAR under mild hypothermia was as safe as under moderate hypothermia. After HTAR for TAAD, dissected aorta achieved desirable aortic remodeling, presenting as stable aortic diameters and false lumen complete thrombosis. In all, HTAR is a practical treatment for TAAD.

Postoperative Hepatic Dysfunction After Frozen Elephant Trunk for Type A Aortic Dissection.

Background: This study was aimed to investigate the incidence, risk factors, and outcomes of patients with postoperative hepatic dysfunction (PHD) after frozen elephant trunk (FET) for type A aortic dissection (TAAD). Method: A retrospective study was performed with 492 patients who underwent FET for TAAD between 2015 and 2019. Independent risk factors for PHD were determined by multivariate mixed-effect logistic analysis with surgeon-specific factor as a random effect. Results: The incidence of PHD was 25.4% (n = 125) in our cohort. Patients with PHD presented higher early mortality (10.4 vs. 1.1%, p < 0.001), rates of acute kidney injury (42.4 vs. 12.8%, p < 0.001), and newly required dialysis (23.2 vs. 3.0%, p < 0.001) compared with those without PHD. Moreover, with the median follow-up period of 41.3 months, the survival curve was worse in patients with PHD compared with no PHD group (log-rank p < 0.001), whereas it was similar after excluding patients who died within 30 days (log-rank p = 0.761). Multivariable analyses suggested that PHD was predicted by preoperative aspartate transferase [odds ratio (OR), 1.057; 95% confidence intervals (CI), 1.036-1.079; p < 0.001], celiac trunk malperfusion (OR, 3.121; 95% CI, 1.008-9.662; p = 0.048), and cardiopulmonary bypass time (OR, 1.014; 95% CI, 1.005-1.023; p = 0.003). Retrograde perfusion (OR, 0.474; 95% CI, 0.268-0.837; p = 0.010) was associated with a reduced risk of PHD. Celiac trunk malperfusion was an independent predictor for PHD but not associated with early mortality and midterm survival. Conclusions: PHD was associated with increased early mortality and morbidity, but not with late death in midterm survival. PHD was predicted by preoperative aspartate transferase, celiac trunk malperfusion, and cardiopulmonary bypass (CPB) time, and retrograde perfusion was associated with a reduced risk of PHD.

Risk factor analysis of clinical outcomes of total aortic arch replacement and frozen elephant trunk with aortic balloon occlusion.

BACKGROUND: Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 min, which increases the surgical risk. We invented an aortic balloon occlusion (ABO) technique that requires 5 min of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study. METHODS: This retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of ABO group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during in-hospital stay were also recorded. RESULTS: The 30-day mortality rates were similar between ABO group (4.6%) and conventional group (7.8%, P = 0.241). Multivariate analysis showed ABO reduced postoperative acute kidney injury (23.1% vs. 35.7%, P = 0.013) and hepatic injury (12.3% vs. 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs. 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge. CONCLUSIONS: The ABO achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay.

Impact of body mass index on early and mid-term outcomes after surgery for acute Stanford type A aortic dissection.

BACKGROUND: Obesity is dramatically increasing worldwide, and more obese patients may develop aortic dissection and present for surgical repair. The study aims to analyse the impact of body mass index (BMI) on surgical outcomes in patients with acute Stanford type A aortic dissection (ATAAD). METHODS: From January 2017 to June 2019, the clinical data of 268 ATAAD patients in a single centre were retrospectively reviewed. They were divided into three groups based on the BMI: normal weight (BMI 18.5 to < 25 kg/m2, n = 110), overweight (BMI 25 to < 30 kg/m2, n = 114) and obese (BMI ≥30 kg/m2, n = 44). RESULTS: There was no statistical difference among the three groups in terms of the composite adverse events including 30-day mortality, stroke, paraplegia, renal failure, hepatic failure, reintubation or tracheotomy and low cardiac output syndrome (20.9% vs 21.9% vs 18.2% for normal, overweight and obese, respectively; P = 0.882). No significant difference was found in the mid-term survival among the three groups. The proportion of prolonged ventilation was highest in the obese group followed by the overweight and normal groups (59.1% vs 45.6% vs 34.5%, respectively; P = 0.017). Multivariable logistic regression analysis suggested that BMI was not associated with the composite adverse events, while BMI ≥30 kg/m2 was an independent risk factor for prolonged ventilation (OR 2.261; 95% CI 1.056-4.838; P = 0.036). CONCLUSIONS: BMI had no effect on the early major adverse outcomes and mid-term survival after surgery for ATAAD. Satisfactory surgical outcomes can be obtained in patients with ATAAD at all weights.

Type II hybrid arch repair versus total arch replacement with frozen elephant trunk: a propensity score-matched analysis.

OBJECTIVES: The aim of this study was to evaluate the objective outcomes of type II hybrid arch repair (HAR) and total arch replacement with frozen elephant trunk (TAR with FET). METHODS: Data from 528 patients who underwent aortic arch repair from January 2017 to June 2019 were collected, which consisted of 175 type II HAR and 353 TAR with FET. The propensity score-matched analysis identified a subgroup of 90 pairs. Perioperative data and mid-term follow-up results were assessed. RESULTS: There was no significant difference in the composite adverse events (type II HAR, 20.6%, 36/175 vs TAR with FET, 17.8%, 63/353, P = 0.450). Multivariable logistic analysis of the 528 patients showed that the procedure type (type II HAR or TAR with FET) was not associated with composite adverse events, 30-day mortality or stroke. The 3-year survival rates were 84.8% in the type II HAR group and 90.1% in the TAR with FET group (P = 0.12). The 3-year reintervention-free rates in the type II HAR and TAR with FET groups were 98.7% and 96.5% (P = 0.22), respectively. After matching, no significant difference was found in the incidence of composite adverse events or the 3-year survival and reintervention-free rates. CONCLUSIONS: No significant clinical differences were found in the early and mid-term outcomes of type II HAR and TAR with FET. The long-term outcomes remain to be investigated. Careful patient selection for individualized approaches is the key to taking full advantage of the 2 surgical procedures.

Outcome of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement.

BACKGROUND: There are limited data regarding the clinical outcomes of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement (AVR). We aimed to analyze outcomes of reoperative aortic root or ascending aorta replacement after prior AVR. METHODS: Eighty patients with prior AVR underwent reoperative aortic root or ascending aorta replacement in our hospital. The indications were root or ascending aortic aneurysm in 36 patients, root or ascending aortic dissection in 37, root false aneurysm in 2, prosthesis valve endocarditis (PVE) with root abscess in 2, Behçet's disease (BD) with root destruction in 3 patients. An elective surgery was performed in 63 patients and an emergent surgery in 17. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test. RESULTS: The operative techniques included ascending aorta replacement in 14 patients, ascending aorta replacement with AVR in 3, prosthesis-sparing root replacement (PSRR) in 35, Bentall procedure in 24, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/80). A composite of adverse events occurred in 5 patients, including 1 operative death, 2 stroke and 3 renal failure necessitating hemodialysis. The mean follow-up was 35.5±22.1 months. Five late deaths occurred. The Kaplan-Meier survival at 1 year, 3 years and 6 years were 97.5%, 91.1% and 84.1%, respectively. Aortic events developed in 3 patients. The freedom from aortic events at 1-year, 3-year, and 6-year were 100%, 96.3% and 88.9%, respectively. There were no differences in survival and freedom from aortic events between the elective group and the emergent group. CONCLUSIONS: Reoperative aortic root or ascending aorta replacement after prior AVR could be performed to treat the root or ascending pathologies after AVR, with satisfactory early and midterm outcomes.

Characteristics of organ cysts and their association with type A aortic dissection.

OBJECTIVE: We aimed to evaluate the incidence of organ cysts in patients with type A aortic dissection (TAAD) to assess the association between organ cysts and TAAD. METHODS: Between January 2018 and December 2018, all patients with TAAD undergoing aortic surgery at our center were enrolled into the study; patients undergoing isolated coronary artery bypass grafting at our center were selected as the control group. Baseline differences between the 2 groups were adjusted using propensity-score matching. The incidence of organ cysts was compared between the 2 groups in total and matched cohorts. RESULTS: We enrolled 290 patients with TAAD and 293 patients with coronary artery disease (control group). The incidence of all organ cysts, liver cysts, renal cysts, and other organ cysts, was significantly higher in the TAAD group than in the control group (50.0% vs. 35.5%, p<0.001; 24.5% vs. 10.2%, p<0.001; 33.4% vs. 24.9%, p=0.023; and 6.2% vs. 1.5%, p=0.005; respectively). Among the 191 propensity score-matched patient pairs, the incidence of organ cysts, liver cysts, renal cysts, and other organ cysts was also significantly higher in the TAAD group than in the control group (57.6% vs. 30.9%, p<0.001; 28.8% vs. 11.0%, p<0.001; 39.3% vs. 19.9%, p<0.001; and 8.4% vs. 1.0%, p=0.001; respectively). The incidence of cysts with single-organ and multiple-organ involvement was also significantly higher in the TAAD group than in the control group (34.0% vs. 20.4%, p=0.003; and 23.6% vs. 10.5%, p=0.001). CONCLUSION: Our results show a higher incidence of organ cysts in patients with TAAD which is indicative of a common pathogenetic pathway between organ cysts and aortic dissection.

Mitral valve repair with artificial chordae replacement in children: a single-center experience.

OBJECTIVES: To summarize the experience of mitral valve (MV) repair with artificial chordae replacement in children, and analyze early and intermediate outcomes. METHODS: From January 2011 to May 2019, all patients (< 18 years) who received MV repair with artificial chordae replacement were retrospectively reviewed. Freedom from MV reoperation, MV dysfunction, moderate or severe MR were estimated by the Kaplan-Meier curve and log-rank test. RESULTS: A total of 30 patients were included in this study. According to our definition, 15 patients had simple lesions and 15 patients had complex lesions. During 36 months' follow-up (range 3-97 months), two patients received MV reoperation and seven patients developed MV dysfunction, including six patients with moderate or severe MR and one patient with mitral stenosis. Freedom from MV reoperation at 1, 5 and 8 years were 100%, 91.3% and 91.3%, respectively. And freedom from MV dysfunction at 1, 3 and 5 year were 96.0%, 77.1% and 61.8%, respectively. Five-year freedom from MV dysfunction showed significant differences between patients with simple lesions and patients with complex lesions (100% vs 32.7%, log-rank P = 0.008), and between patients aged less than 12 years and patients aged more than 12 year (33.5% vs 90.0%, log-rank P = 0.025). CONCLUSION: The early and intermediate outcomes of mitral valve repair with artificial chordae replacement were acceptable in children, and the outcomes were optimal in patients with simple lesions, and patients aged more than 12 years.

Clinical Outcome of Patients with Transposition of the Great Arteries and Intramural Coronary Artery.

To review the early and intermediate outcomes of patients with transposition of the great arteries (TGA) and intramural coronary artery (IMCA) who underwent arterial switch operation (ASO) at our center. Among 450 patients with TGA who underwent an ASO between 2010 and 2018, 26 (5.8%) patients were identified with IMCA. The left coronary artery was intramural in 21 of 26 patients. We adopted coronary transfer using double coronary buttons with unroofed intramural course for all 26 patients. Early mortality for patients with IMCA was 3 of 26 (11.5%) compared with 10 of 424 (2.4%) for those without IMCA (p = 0.007). Six patients suffered major adverse events, including extracorporeal membrane oxygenation support in 3 patients, delayed sternal closure in 6 patients. The follow-up was available for all 23 survivors, with the mean follow-up period of 73.5 ± 28.7 months. There was no late death and reinterventions, and all patients were asymptomatic at last follow-up. One patient exhibited moderate neopulmonary regurgitation, and 1 patient presented with distal stenosis of the right pulmonary artery. Coronary transfer using double coronary buttons with unroofed intramural course was a good option for patients with TGA and IMCA. With this technique, ASO could be performed with optimal early and intermediate outcomes.

Safety and durability of single-stage type I hybrid total aortic arch repair for extensive aortic arch disease: early- and long-term clinical outcomes from a single center and our 10-year of experience.

BACKGROUND: Single-stage type I hybrid total aortic arch repair is a surgical treatment for extensive aortic arch disease, but the clinical outcomes were distinguishing. The purposes of this study were to share our experience and evaluate the perioperative safety and long-term durability. METHODS: Thirty-six patients who underwent single-stage type I hybrid total aortic arch repair in Fuwai Hospital between January 2010 and June 2020 were respectively reviewed. Early primary endpoint was defined as early composite adverse events, including mortality, multiple organ dysfunction syndrome (MODS), unplanned reoperation, stroke, paraplegia, acute renal failure (ARF) necessitating continuous renal replacement therapy (CRRT), respiratory failure and stents related complications. Long-term endpoints included late mortality, late aortic related reintervention and late adverse aortic events. When evaluating the early- and long-term outcomes, all patients were stratified into two subgroups by age (65 years). RESULTS: All patients acquired technical success. Early composite adverse events rate was 11.1% (4/36), in-hospital mortality was 8.3% (3/36). Average follow-up period was 48.0±35.3 months. Overall survival rate was 83.3% and 51.9% at 5 and 10 years respectively. Late aortic related reintervention occurred at one (3.0%, 1/33) patient and this patient died after reintervention. Overall freedom from adverse aortic events was 79.2% and 47.5% at 5 and 10 years respectively. Significant difference was not observed between the elderly and young subgroups, no matter in early- and long-term outcomes. CONCLUSIONS: Single-stage type I hybrid total aortic arch repair has achieved desirable outcomes in our center, which does not increase perioperative risk in the elderly patients, meanwhile, also acquire acceptable durability in the young patients. In conclusion, this surgery is a practical mini-invasive treatment for extensive aortic arch disease with strict and limited indications.

Secondary Open Arch Operation After Prior Thoracic Endovascular Aortic Repair.

BACKGROUND: Many patients required secondary open arch operation due to new aortic pathologies or complications after thoracic endovascular aortic repair (TEVAR). In this study, we investigated the outcome of secondary open arch operation after prior TEVAR. METHODS: Fifty-seven consecutive patients underwent secondary open arch operation after prior TEVAR. The major indications were retrograde type A aortic dissection (n = 24), proximal new aortic dissection (n = 8), and type Ⅰa endoleak (n = 16). An elective operation was performed in 35 patients and an emergent operation in 22. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test. The survival was also analyzed with the Cox analysis. RESULTS: The in-hospital mortality was 7.0% (4 of 57). The mean follow-up time was 32.2 ± 19.7 months. Five late deaths occurred. The overall survival at 1 year, 3 years, and 6 years was 89.5%, 84.6%, and 79.9%, respectively. Aortic events developed in 7 patients. Freedom from aortic events after the operation at 1 year, 3 years, and 6 years was 94.2%, 83.0%, and 77.8%, respectively. There were no differences in survival and freedom from aortic events between the elective group and the emergent group. The Cox analysis identified additional coronary artery bypass grafting and hypothermic circulatory arrest as independent factors predicting survival. CONCLUSIONS: Secondary open arch operation could be performed to treat the arch pathologies after TEVAR with acceptable early and midterm outcomes.

Early outcomes of hybrid type II arch repair versus total arch replacement with frozen elephant trunk in acute DeBakey type I aortic dissection: a propensity score-matched analysis.

OBJECTIVES: The aim was to evaluate the short-term outcomes of hybrid type II arch repair (HAR) and total arch replacement with frozen elephant trunk (TAR with FET) for acute DeBakey type I aortic dissection patients. METHODS: From January 2017 to June 2019, the clinical data of acute DeBakey type I aortic dissection patients in a single centre were retrospectively reviewed; there were 92 cases of HAR and 268 cases of TAR with FET, with 56 pairs by propensity score matching. RESULTS: After matching, the composite end points including 30-day mortality, stroke, paraplegia, renal failure, hepatic failure, reintubation or tracheotomy and low cardiac output syndrome were comparable (21.4%, 12/56 in the HAR group vs 21.4%, 12/56 in the TAR with FET group, P = 1.000). The rate of acute kidney injury (AKI) was significantly lower in the HAR group (58.9%, 33/56 vs 80.4%, 45/56, P = 0.031). The distribution of AKI stage according to the Kidney Disease Improving Global Outcomes criteria was different (P = 0.039), with more patients suffering from high-grade AKI in the TAR with FET group. Multivariable logistic analysis showed that the procedure type (HAR or TAR with FET) was not an independent predictor of composite adverse events or stroke. HAR was identified as a protective factor against AKI (odds ratio 0.485, 95% confidence interval 0.287-0.822; P = 0.007). CONCLUSIONS: In the treatment of acute DeBakey type I aortic dissection, no significant differences were found in early outcomes between the 2 groups, but HAR was associated with a significantly lower incidence of AKI.

Clinical features and surgical outcomes of type A intramural hematoma.

BACKGROUND: Data on the clinical features and surgical outcomes of type A intramural hematoma (IMH) in Chinese patients are very limited. We aimed to present the surgical experiences on type A IMH in our center, and report early and late outcomes. METHODS: From February 2012 to April 2018, 106 consecutive patients underwent open surgery for type A IMH at our hospital. We adopted emergent operation for patients with cardiac tamponade or other severe complications, and recommended initial medical treatment followed by elective surgery for stable patients. The composite endpoints included operative mortality, permanent nerve damage (stroke, paraplegia), and new-onset renal failure necessitating hemodialysis. Risk factors for operative mortality and the composite endpoints were identified using univariable and multivariable logistic regression model analysis. The survival and freedom from aortic events were analyzed using a Kaplan-Meier surviving curve and a log-rank test. RESULTS: Except 1 patient receiving emergent surgery (within 24 hours from onset) because of cardiac tamponade and cerebral malperfusion, all patients received initial medical treatment and delayed surgery. Two patient developed pericardial tamponade while waiting for surgery, and then received emergent surgery. Preoperative conversion to aortic dissection (AD) was noted in no patient. The operative techniques included ascending aorta replacement in 9 patients, hemiarch replacement in 18 patients, total arch replacement (TAR) with frozen elephant trunk (FET) in 45 patient and hybrid aortic arch repair in 34 patients. The mean cardiopulmonary bypass (CPB) time and cross-clamp time were 138.7±41.6 and 79.3±27.8 min, respectively. The operative mortality was 1.9% (2/106). And the composite endpoints occurred in 7 patients. Multivariable logistic regression analysis showed CPB time ≥200 min and chronic kidney disease were risk factors for the composite endpoints. The follow-up data were available in 97 survivors, with the mean follow-up time of 30.8±16.2 months. Three patients died and 5 patients developed aortic events during the follow-up. The overall survival at 1-, 3- and 5-year were 97.0%, 95.3%, and 79.4%, respectively. And freedom from aortic events at 1-, 3- and 5-year were 97.7%, 95.3% and 89.4%, respectively. CONCLUSIONS: Our strategy had got low mortality and excellent mid-term survival in patients with type A IMH. Therefore, our strategy was suitable for the surgical repair of type A IMH in Chinese population.