Aortic Arch-Clamping Technique in Hemiarch Replacement Without Circulatory Arrest.

The open anastomosis technique has become more popular since it was first used in hemiarch replacement; however, hypothermic circulatory arrest is unavoidable. This institution performed a novel surgical technique called the arch-clamping technique. It has been used in the treatment of patients with ascending aortic aneurysm extending to the proximal aortic arch and avoids the use of hypothermic circulatory arrest. Thirty patients had a hemiarch replacement with the arch-clamping technique from 2021 to 2022; all of them were discharged uneventfully.

Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections.

OBJECTIVES: To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections. STUDY DESIGN: We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors. RESULTS: Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/µL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%). CONCLUSIONS: In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.

Perfusion management of arch-clamping technique in total arch replacement with frozen elephant trunk.

A technique called arch-clamping was used at our institute to ensure perfusion of the lower body and brain during total arch replacement with frozen elephant trunk (TAR and FET). The aortic arch clamp is inserted between the left common carotid artery and the left subclavian artery after inserting the stented elephant trunk into the true lumen of the descending aorta during the procedure, and then clamps the aorta and graft together as the distal anastomotic edge of the aorta. After the arch clamp was in place, lower body perfusion was resumed through the femoral artery was resumed and time to circulatory arrest was reduced to approximately 4 min. Cardiopulmonary bypass (CPB) flow was gradually restored to full rate. Thereafter, the left carotid artery anastomosis was completed and rewarming began. Finally, during the rewarming period, other branches of the aortic arch and ascending aorta were reconstructed. In this paper, we describe the perfusion management strategy, discuss intraoperative monitoring parameters, and examine the feasibility of the technique from a perfusion perspective.

Spinal Cord Protection of Aorto-Iliac Bypass in Open Repair of Extent II and III Thoracoabdominal Aortic Aneurysm.

BACKGROUND: Spinal cord injury (SCI) is one of the serious complications of thoracoabdominal aortic aneurysm (TAAA) repair. Cardiopulmonary bypass (CPB) and left heart bypass (LHB) are well-established extracorporeal circulatory assistance methods to increase distal aortic perfusion and prevent spinal cord ischaemia in TAAA repair. Aorto-iliac bypass, a new surgical adjunct offering distal aortic perfusion without the need of complex perfusion skills, was developed as a substitute for CPB and LHB. However, its spinal cord protective effect is unknown. METHODS: The perioperative data of 183 patients who had elective open Crawford extent II and III TAAA repair at our aortic centre from July 2011 to May 2019 were retrospectively analysed. Spinal cord protection was compared between the aorto-iliac bypass group (n=106) and the extracorporeal circulatory assistance group (n=77 [65 CPB, 12 LHB]), and the risk factors for SCI in these patients were explored. RESULTS: Eleven (11) patients had postoperative SCI: five (6.5%) in the extracorporeal circulatory assistance group (four with CPB and one with LHB), and six (5.7%) in the aorto-iliac bypass group. The incidence of SCI was 6.0% (11/183 cases). There was no difference between the aorto-iliac bypass group and the extracorporeal circulatory assistance group (p=1.0), while operation time, proximal aortic clamp time, intercostal artery clamp time, and length of intensive care unit stay were all increased in the latter group. Multivariate logistic regression analysis showed that cerebrospinal fluid pressure (odds ratio [OR] 1.270; 95% confidence interval [CI] 1.092-1.478 [p=0.002]) and lowest haemoglobin on the first postoperative day (OR 0.610; 95% CI 0.416-0.895 [p=0.011]) were the independent predictors of SCI in TAAA repair. CONCLUSIONS: Spinal cord protection of aorto-iliac bypass is comparable to that of CPB and LHB in open TAAA repair.

Blood Transfusion and Acute Kidney Injury After Total Aortic Arch Replacement for Acute Stanford Type A Aortic Dissection.

AIM: To evaluate the effect of packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelet concentrate (PC) transfusions on acute kidney injury (AKI) in patients with acute Stanford type A aortic dissection (ATAAD) with total arch replacement (TAR). METHOD: From December 2015 to October 2017, 421 consecutive patients with ATAAD undergoing TAR were included in the study. The clinical data of the patients and the amount of pRBCs, FFP, and PC were collected. Acute kidney injury was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Logistic regression was used to identify whether pRBCs, FFP, and platelet transfusions were risk factors for KDIGO AKI, stage 3 AKI, and AKI requiring renal replacement therapy (RRT). RESULTS: The mean ± standard deviation age of the patients was 47.67±10.82 years; 77.7% were men; and the median time from aortic dissection onset to operation was 1 day (range, 0-2 days). The median transfusion amount was 8 units (range, 4-14 units) for pRBCs, 400 mL (range, 0-800 mL) for FFP, and no units (range, 0-2 units) for PC. Forty-one (41; 9.7%) patients did not receive any blood products. The rates of pRBC, PC, and FFP transfusions were 86.9%, 49.2%, and 72.9%, respectively. The incidence of AKI was 54.2%. Considering AKI as the endpoint, multivariate logistic regression showed that pRBCs (odds ratio [OR], 1.11; p<0.001) and PC transfusions (OR, 1.28; p=0.007) were independent risk factors. Considering KDIGO stage 3 AKI as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.15; p<0.001), PC transfusion (OR, 1.28; p<0.001), a duration of cardiopulmonary bypass (CPB) ≥293 minutes (OR, 2.95; p=0.04), and a creatinine clearance rate of ≤85 mL/minute (OR, 2.12; p=0.01) were independent risk factors. Considering RRT as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.12; p<0.001), PC transfusion (OR, 1.33; p=0.001), a duration of CPB ≥293 minutes (OR, 3.79; p=0.02), and a creatinine clearance rate of ≤85 mL/minute (OR, 3.34; p<0.001) were independent risk factors. CONCLUSIONS: Kidney Disease: Improving Global Outcomes-defined stage AKI was common after TAR for ATAAD. Transfusions of pRBCs and PC increased the incidence of AKI, stage 3 AKI, and RRT. Fresh frozen plasma transfusion was not a risk factor for AKI.

Management of acute type A aortic dissection during COVID-19 outbreak: Experience from Anzhen.

OBJECTIVES: We seek to report our management protocol and early outcomes of acute type A aortic dissection (ATAAD) repair during the early phase of coronavirus disease 2019 (COVID-19). METHODS: From January 23 to April 30, 2020, we performed ATAAD repair for 33 patients, including three with pregnancy-related TAADs. Confirmation of COVID-19 depended on the results of two nucleic acid tests and pulmonary computed tomography scan. Based on testing results and hemodynamic stability, patients were triaged to an isolated intensive care unit or negative pressure operating room for emergency surgery. RESULTS: Mean age 50.2 ± 13.3 years and 20 were male (60.1%) and 8 patients were febrile (>37.3°C; 24.2%) and 17 were lymphopenic (51.5%). No patient was excluded from COVID-19 infection preoperatively. Extensive aortic repair with total arch replacement (TAR) was performed in 24 (72.7%), and limited proximal repair in 9 patients (27.3%). Cardiopulmonary bypass and cross-clamp times averaged 177 ± 34 and 88 ± 20 min for TAR, and 150 ± 30 and 83 ± 18 min for hemiarch, respectively. The mean operation time was 410 ± 68.3 min. Operative mortality was 6.1% (2/33). Complications included reintubation in four (12.1%), acute kidney failure in two (6.1%), and cerebral infarction in one (3.0%). No paraplegia nor re-exploration for bleeding occurred. COVID-19 was excluded in 100% eventually. No nosocomial infection occurred. Nor did any patient/surgical staff develop fever or test positive during the study period. CONCLUSIONS: The results of this study show that our management protocol based on testing results and hemodynamic stability in patients with ATAAD during the COVID-19 pandemic was effective and achieved favorable early surgical outcomes.

Insulin-like growth factor-binding protein 3 inhibits angiotensin II-induced aortic smooth muscle cell phenotypic switch and matrix metalloproteinase expression.

NEW FINDINGS: What is the central question of this study? Insulin-like growth factor 1 and its major binding protein insulin-like growth factor binding protein 3 (IGFBP3) are involved in collagen deregulation in several cardiovascular diseases: what is the role of IGFBP3 in thoracic aortic dissection and does it regulate aortic smooth muscle cells' phenotypic switch? What is the main finding and its importance? IGFBP3 inhibits aortic smooth muscle cells' phenotypic switch from a contractile to a synthetic phenotype, decreases matrix metalloproteinase 9 activation and suppresses elastin degradation. These findings provide a better understanding of the pathogenesis of thoracic aortic dissection. ABSTRACT: Thoracic aortic dissection (TAD) is characterized by aortic media degeneration and is a highly lethal disease. An aortic smooth muscle cell (AoSMC) phenotypic switch is considered a key pathophysiological change in TAD. Insulin-like growth factor binding protein 3 (IGFBP3) was found to be downregulated in aortic tissues of TAD patients. The present work aimed to study the function of IGFBP3 in AoSMCs' phenotypic switch and matrix metalloproteinase (MMP) expression. We established a mouse model of TAD by angiotensin (Ang) II infusion to ß-aminopropionitrile-administrated mice, and found decreased IGFBP3 expression accompanied by aortic dilatation and elastin degradation in vivo. Further, mouse (m)AoSMCs were isolated from mouse thoracic aorta and treated with Ang II. Ang II induced downregulation of IGFBP3 in vitro. To further study the function of IGFBP3, primary mAoSMCs were infected with adenovirus expressing IGFBP3 followed by Ang II induction. Enforced upregulation of IGFBP3 decreased MMP9 expression and activation as well as increasing tissue inhibitor of metalloproteinase (TIMP) 1 expression in Ang II-induced mAoSMCs. No difference was observed in MMP2 and TIMP3 expression. IGFBP3 suppressed subsequent Ang II-induced elastin degradation in vitro. IGFBP3 inhibited Ang II-induced mAoSMCs' phenotypic switch as evidenced by increased smooth muscle actin α-2 (ACTA2) and myosin heavy chain 11 (MYH11) expression and decreased secreted phosphoprotein 1 (SPP1) and vimentin expression. Taken together, the present study demonstrates the role of IGFBP3 in preserving AoSMCs' contractile state and reducing MMP9 activation and thus promoting elastic fibre synthesis, which provides a better understanding of the pathogenesis of TAD.

Relationship Between Renal Function and Renal Artery Involvement in Acute Debakey Type I Aortic Dissection.

BACKGROUND: The aim of this study was to analyse the differences in renal function among various types of renal artery involvement in acute Debakey Type I aortic dissection. METHODS: From January 2016 to January 2018, 304 consecutive patients with acute Debakey type I aortic dissection with renal artery involvement were included. According to computed tomography angiography (CTA) findings, renal artery involvement on one side can be classified into four types: type A, in which a large intimal tear is near the renal artery orifice; type B, the orifice of the renal artery originates entirely from the false lumen; type C, the orifice of the renal artery originates entirely from the true lumen; and type D, a renal artery dissection is observed. All patients underwent aortic repair. RESULTS: The average age was 46.98±10.64 years. The types of bilateral renal artery involvement were as follows: AB type, four patients (1.32%); AC type, 38 patients (12.50%); AD type, three patients (0.99%); BB type, 13 patients (4.28%); BC type, 140 patients (46.05%); BD type, four patients (1.32%); CC type, 76 patients (25.00%); and CD type, 26 patients (8.55%). One-way ANOVA showed that there was no significant difference in serum creatinine (P = .57) and creatinine clearance rate (P = .08) between the groups. A statistically significant difference in age, gender, body mass index, hypertension history and aortic dissection onset time also was not observed (P > .05). The overall incidence of KDIGO acute kidney injury (AKI) was 49.67%. There was no significant difference in AKI incidence between different types of renal artery involvement after aortic surgery (P = .39). For patients needing renal replacement therapy, CTA showed that enhancement of renal cortex in the arterial phase was low and the boundary between the cortex and medulla was unclear in bilateral kidneys. CONCLUSION: The types of renal artery involvement did not affect renal function in the acute phase.

Efficacy of Total Aortic Arch Replacement Combined with Frozen Elephant Trunk in Aortic Reoperation.

BACKGROUND The aim of this study was to estimate the long-term efficacy of total aortic arch replacement combined with the frozen elephant trunk (TAR+FET) technique for aortic disease following a prior cardiac surgery procedure. MATERIAL AND METHODS We performed TAR+FET for 118 patients for major vessel disease following a prior cardiac procedure with median sternotomy incision. All patients were divided into 5 groups: in group A, the prior major procedure was aortic valve replacement (AVR); in group B, the prior major procedure was isolated ascending aorta replacement; in group C, the prior major procedure was aortic root replacement; in group D, the prior major procedure was aortic arch replacement or intervention; and in group E, the prior major procedure was 'other' cardiac operative procedure. The long-term follow-up visit results were estimated using the Kaplan-Meier method. RESULTS The 30-day mortality rate after the operation was 13.6% (16/118) - 2 died in group A, 1 in group B, 8 in group C, 4 in group D, and 1 in group E. Follow-up visits were completed in 99% of patients. The mean follow-up time was 47.6±36.3 months and 12 patients had died by follow-up, so the total long-term survival rate was 76.3%. One-year survival rates of the 5 groups were 85% (group A), 93.8% (group B), 82.3% (group C), 50% (group D), and 50% (group E), respectively. Five-year survival rates of the 5 groups were 85%, 93.8%, 80.6%, 50%, and 50%, respectively. CONCLUSIONS The TAR+FET technique is feasible and efficacious for aortic reoperation in patients who previously underwent cardiac surgery since the short-term mortality in patients with recurrent aortic arch disease after cardiac surgery is not high.

Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.

BACKGROUND: Geriatric patients commonly present to the ED after a fall. Recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric fall guidelines. This study applied a theoretical domains framework (TDF) approach to systematically investigate barriers and enablers in the provision of guideline-based care to ED geriatric fall patients. METHODS: From June to September 2017, semistructured interviews of staff ED physicians practising in Ontario, Canada, were conducted and analysed. An interview guide based on the TDF was used to capture 14 domains influencing provision of guideline-based care. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs and evidence of strong beliefs that would influence provision of guideline-based care. RESULTS: Eleven interviews were conducted with practising ED physicians. Thirty belief statements were identified across 13 relevant TDF domains (all except Optimism). Prominent themes included lack of knowledge, paucity of evidence, heterogeneous self-perceived skills, perceived increased time and workload, importance of allied health support, inconsistently available allied health workers, lack of positive reinforcement, emotions negatively impacting these clinical encounters and support for memory aids. Overall, ED physicians were supportive of guideline implementation, and believe it will lead to better outcomes for geriatric fall patients. CONCLUSION: This study identified important barriers and enablers to provision of guideline-based care in geriatric ED fall patients. Based on these findings, future implementation of guidelines nationally and internationally should focus on improving knowledge and training on guidelines, improving positive reinforcement for guideline-appropriate management, greater allied health support and further research to support guidelines.

One-Stage Repair of Adult Aortic Coarctation and Concomitant Cardiac Diseases: Ascending to Abdominal Aorta Extra-Anatomical Bypass Combined with Cardiac Surgery.

BACKGROUND: To evaluate one-stage repair with ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery for adult aortic coarctation (COA) concomitant with cardiac diseases. METHODS: Between February 2009 and September 2016, 24 consecutive patients (79.17% male, mean age 36.04±13.67years) with COA and concomitant cardiac diseases underwent one-stage repair (ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery). Two (2) patients who underwent off-pump coronary artery surgery combined with ascending to abdominal aorta bypass did not require cardiopulmonary bypass. Twenty-two (22) patients underwent one-stage repair under cardiopulmonary bypass. RESULTS: No in-hospital mortality was observed. There was a significant reduction in baseline systolic blood pressure from 159.80±23.58 to 127.0±6.86mmHg. Mean upper-lower limb blood gradient pressure decreased significantly from 37.80±8.73 to 11.47±2.12mmHg after surgery. Two (2) patients required prolonged mechanical ventilation for respiratory dysfunction. One patient needed temporary continuous renal replacement therapy. No re-exploration for bleeding and gastrointestinal complications was needed. There was no postoperative paraplegia or permanent neurological abnormalities. Grafts were patent for all patients and no graft-related complications were observed in the hospital. Median follow-up was 41.50 months (interquartile range [IQR] 16.75-64.50 months) and 6-year survival was 76.39%. Median number of antihypertensive drugs was 0 (IQR 0-1), which was a significant reduction compared with preoperative drugs (2, IQR 1-3). CONCLUSIONS: Ascending to abdominal extra-anatomical aorta bypass combined with cardiac surgery is a safe and effective one-stage repair technique for patients with COA concomitant with cardiac diseases.

Comparability of a short food frequency questionnaire to assess diet quality: the DISCOVER study.

This study aims to assess comparability of a short food frequency questionnaire (SFFQ) used in the Determinants of Suicide: Conventional and Emergent Risk Study (DISCOVER Study) with a validated comprehensive FFQ (CFFQ). A total of 127 individuals completed SFFQ and CFFQ. Healthy eating was measured using Healthy Eating Score (HES). Estimated food intake and healthy eating assessed by SFFQ was compared with the CFFQ. For most food groups and HES, the highest Spearman's rank correlation coefficients between the two FFQs were r > .60. For macro-nutrients, the correlations exceeded 0.4. Cross-classification of quantile analysis showed that participants were classified between 46% and 81% into the exact same quantiles, while 10% or less were misclassified into opposite quantiles. The Bland-Altman plots showed an acceptable level of agreement between the two dietary measurement methods. The SFFQ can be used for Canadian with psychiatric disorders to rank them based on their dietary intake.

Aorta-Iliac Bypass in Thoracoabdominal Aortic Aneurysm Repair in Young Chinese Patients.

BACKGROUND: Many surgical methods of thoracoabdominal aortic aneurysm repair (TAAAR) have been introduced over the past several decades, with varying degrees of success. We developed an aorta-iliac bypass technique to treat thoracoabdominal aortic aneurysm (TAAA) in young Chinese patients. The aim of this study is to evaluate the results of this technique intraoperatively and postoperatively. METHODS: From June 2014 to March 2015, 28 patients underwent TAAAR using aorta-iliac bypass technique. A four-branched tetrafurcate graft was used. Two branches of the graft are sutured to bilateral common iliac arteries in an end-to-side fashion. The trunk of the graft was sutured to the proximal descending aorta in an end-to-end fashion. Then aorta-iliac bypass was established, and the lower extremities, viscera organ and spinal cord (SC) obtained perfusion from proximal descending aorta via the bypass graft. The thoracic and abdominal aorta were clamped in a staged fashion. The patent segmental arteries (SAs), and visceral arteries (coeliac trunk, superior mesenteric arteries, and renal arteries) were reattached sequentially. Evoked potential (EP) monitoring was adopted to assess the SC ischaemia throughout the procedure. The postoperative outcomes and follow-up results of this technique were evaluated. RESULTS: There was no in-hospital mortality. Complications included acute kidney dysfunction and pulmonary haemorrhage in one case (3.6%) each. The SAs were reattached in all cases. The EP wave disappeared after proximal descending aorta was clamped, and gradually recovered after the patent SAs reattached. The median follow-up after operation was eight months (range, 1-10 months). There was no delayed neurologic deficit or late death. CONCLUSIONS: Thoracoabdominal aortic aneurysm repair using aorta-iliac bypass may be a simple and safe choice for young Chinese patients with thoracoabdominal aortic aneurysms.

[Effect of aorta-iliac bypass total thoracoabdominal aorta aneurysm repair to spinal cord function].

OBJECTIVE: To evaluate the effect of aorta-iliac bypass total thoracoabdominal aorta aneurysm repair to spinal cord function. METHODS: This was a prospective study. From June 2014 to April 2015, 31 patients underwent total thoracoabdominal aorta aneurysm repair were treated with aorta-iliac bypass technique. There were 23 male and 8 female patients with a mean age of (36±12) years. A 4-branched tetrafurcate graft was used. The aorta-iliac bypass was established, then distal descending aorta was perfused in a retrograde fashion via bypass graft. Thoracic and abdominal aorta were replaced in a staged fashion. Evoked potentials (EP) monitoring was adopted to assess the spinal cord ischemia throughout the procedure. The intraoperative evoked potentials results, clinical outcomes and follow-up results of this technique were evaluated. RESULTS: The EP wave disappeared after proximal descending aorta clamped and gradually recovered after the patent segmental arteries reattached. Motor evoked potentials disappeared for (56±18) minutes, somatosensory evoked potentials disappeared for (50±19) minutes. The EP wave was restored to normal at the end of operation in all cases. The somatosensory evoked potentials remained unchanged in 2 cases (false negative). One case died after operation. There were acute kidney dysfunction in 3 cases, and pulmonary haemorrhage in 1 case. No spinal cord injure occurred. The median follow-up after operation was 8 months (ranging from 1 to 11 months). There was no delayed neurologic deficit or relative death. CONCLUSIONS: There is a transient function loss of spinal cord during the aorta-iliac bypass total thoracoabdominal aorta aneurysm repair. But the process is reversible. The technique of the aorta-iliac bypass is practicable.

Is Previous Cardiac Surgery a Risk Factor for Short and Mid-term Mortality Following Total Aortic Arch Replacement in Patients with Stanford Type A Aortic Dissection?

BACKGROUND: The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. METHODS: Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test. RESULTS: The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p<0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test). CONCLUSIONS: PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection.

Risk factors for prolonged mechanical ventilation after total aortic arch replacement for acute DeBakey type I aortic dissection.

BACKGROUND: EuroSCORE II is an objective risk scoring model. The aim of this study was to assess the performance of EuroSCORE II in the prediction of prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection and evaluate the risk factors for prolonged mechanical ventilation. METHODS: Between February 2009 to February 2012, data from 240 patients who underwent total aortic arch replacement for acute DeBakey type I aortic dissection were collected retrospectively. Mechanical ventilation after the surgery longer than 48 hours was defined as postoperative prolonged mechanical ventilation. EuroSCORE II was applied to predict prolonged mechanical ventilation. A C statistic (receiver operating characteristic curve) was used to test discrimination of the model. Calibration was assessed with a Hosmer-Lemeshow goodness-of-fit statistic. Multiple logistic regression analysis was used to identify the final risk factors of prolonged mechanical ventilation. RESULTS: The overall mortality was 10%. The mean length of mechanical ventilation after total aortic arch replacement was 42.72 ± 51.45 hours. Total 74 patients needed prolonged mechanical ventilation. EuroSCORE II showed poor discriminatory ability (C statistic 0.52) and calibration (Hosmer-Lemeshow, p<0.05) in predicting prolonged mechanical ventilation. On multivariate analysis, independent risk factors for postoperative prolonged mechanical ventilation were age ≥ 48.5 years (p<0.001, OR=3.85), preoperative leukocyte count ≥ 13.5 × 109/L (p<0.001, OR=4.05) and symptom onset before the surgery less than one week (p=0.002, OR=3.75). CONCLUSIONS: EuroSCORE II could not predict prolonged mechanical ventilation following total aortic arch replacement for acute DeBakey type I aortic dissection. Preoperative high level of leukocyte, age and surgical period from symptom onset are risk factors for prolonged mechanical ventilation.

Can EuroSCORE II predict the mortality and length of intensive care unit stay after total aortic arch replacement with stented elephant trunk implantation for DeBakey type I aortic dissection?

BACKGROUND: EuroSCORE is a widely used objective risk scoring model. OBJECTIVE: The aim of this study was to evaluate the validation of EuroSCORE II for predicting in-hospital mortality and length of intensive care unit (ICU) stay after total aortic arch replacement with stented elephant trunk implantation for DeBakey Type I aortic dissection. PATIENTS AND METHODS: Between February 2009 and February 2012, data from 384 consecutive patients, who underwent aortic surgery using total aortic arch replacement with stented elephant trunk implantation, were collected retrospectively. EuroSCORE II was applied to predict mortality and length of ICU stay. The C-statistic was used to test discrimination of the model. Calibration was assessed with the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: The in-hospital mortality was 8.07%. The mean length of ICU stay was 3.06 days. A total of 75 patients remained at ICU for 5 days or more and 42 patients for 7 days or more. EuroSCORE II did not show good discriminatory ability in predicting mortality and length of ICU stay. The C-statistic of predicting mortality, ICU stay for 5 days or more, and ICU stay for 7 days or more were 0.49, 0.56, and 0.52, respectively. The calibration was poor for predicting mortality (p < 0.001), ICU stay for 5 days or more (p < 0.001), and ICU stay for 7 days or more (p < 0.001). CONCLUSION: Although EuroSCORE II is the newest risk model for cardiac surgery, it is not accurate when it is applied for thoracic aortic surgery. A new risk evaluating system specially designed for aortic surgery should be developed in the future.

Redo Total Aortic Arch Replacement in Patients with Aortic Dissection After Open-Heart Surgery and Long-Term Follow-Up Results.

INTRODUCTION: The objectives of this study were to investigate the main treatment strategies and long-term follow-up results of aortic dissection surgery after open-heart surgery (ADSOHS) and to analyze the risk factors that cause ADSOHS. METHODS: One hundred thirty-seven patients with ADSOHS hospitalized in our hospital from January 2009 to December 2018 were selected as the research object. Long-term follow-up results, complications, mortality, and changes of cardiac function before and after operation were used to explore the value of Sun's operation. RESULTS: The length of stay in intensive care unit of these 137 patients ranged from 9.5 to 623.75 hours (average of 76.41±97.29 hours), auxiliary ventilation time ranged from 6.0 to 259.83 hours (average of 46.16±55.59 hours), and hospital stay ranged from six to 85 days (average of 25.06±13.04 days). There were seven cases of postoperative low cardiac output, 18 cases of coma and stroke, and six cases of transient neurological dysfunction. A total of 33 patients died; 19 patients died during the perioperative period, 18 died during Sun's operation and one died during other operation; and 14 patients died during follow-up (January 2021), 12 cases of Sun's operation and two cases of other operations. CONCLUSION: ADSOHS treatment strategy is of high application value, and the risk of neurological complications and mortality is low. The main risk factors are postoperative low cardiac output, coma, stroke, and transient neurological dysfunction. The extracorporeal circulation time is relatively long. Short- and long-term follow-up effects are good, and it is worthy of clinical promotion.

A machine learning-based probabilistic computational framework for uncertainty quantification of actuation of clustered tensegrity structures.

Clustered tensegrity structures integrated with continuous cables are lightweight, foldable, and deployable. Thus, they can be used as flexible manipulators or soft robots. The actuation process of such soft structure has high probabilistic sensitivity. It is essential to quantify the uncertainty of actuated responses of the tensegrity structures and to modulate their deformation accurately. In this work, we propose a comprehensive data-driven computational approach to study the uncertainty quantification (UQ) and probability propagation in clustered tensegrity structures, and we have developed a surrogate optimization model to control the flexible structure deformation. An example of clustered tensegrity beam subjected to a clustered actuation is presented to demonstrate the validity of the approach and its potential application. The three main novelties of the data-driven framework are: (1) The proposed model can avoid the difficulty of convergence in nonlinear Finite Element Analysis (FEA), by two machine learning methods, the Gauss Process Regression (GPR) and Neutral Network (NN). (2) A fast real-time prediction on uncertainty propagation can be achieved by the surrogate model, and (3) Optimization of the actuated deformation comes true by using both Sequence Quadratic Programming (SQP) and Bayesian optimization methods. The results have shown that the proposed data-driven computational approach is powerful and can be extended to other UQ models or alternative optimization objectives.

Early and long-term outcomes of young adult patients ≤30 years old with acute type A aortic dissection.

OBJECTIVES: The aim of this study was to investigate the early and long-term outcomes after total arch replacement (TAR) and frozen elephant trunk (FET) implantation in adult patients ≤30 years with acute type A aortic dissection (ATAAD). METHODS: All young adult patients (≤30 years) with ATAAD who underwent TAR and FET between 2009 and 2017 were enrolled. The end points were major organ morbidity and mortality, aortic-related events and reoperation. RESULTS: The mean age of all 83 patients was 25.9 (standard deviation, 3.3) years. The in-hospital mortality was 9.64% (8/83), and 9 (10.8%) patients required re-exploration for bleeding. The aortic-related events risk was 42.7% (32/75) and the aortic reoperation risk was 17.3% (13/75). Overall survival was 85.5% [95% confidence interval (CI), 75.9-91.5%] at 5 years and 75.9% (95% CI, 63.3-84.7%) at 10 years. The cumulative incidence of aortic-related events was 35% (95% CI, 24-47%) at 5 years and 58% (95% CI, 36-75%) at 10 years; the cumulative reoperation rate was 15% (95% CI, 7.9-24%) at 5 years and 17% (95% CI, 9.2-27%) at 10 years. Marfan syndrome significantly increased the aortic-related events (P = 0.036) and reoperation (P = 0.041) risks. CONCLUSIONS: Despite extensive repair in young ATAAD patients, the late aortic dilatation and reoperation risk remain high. The TAR and FET procedures achieved satisfactory early outcomes and reduced late aortic dilatation and reoperation in young patients compared with other records. Close follow-up and aggressive early reintervention are essential for patients with aortic-related risk factors early in life.