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.

Is obstructive sleep apnoea associated with hypoxaemia and prolonged ICU stay after type A aortic dissection repair? A retrospective study in Chinese population.

BACKGROUND: Although obstructive sleep apnoea (OSA) is prevalent among patients with aortic dissection, its prognostic impact is not yet determined in patients undergoing major vascular surgery. We aimed to investigate the association of OSA with hypoxaemia and with prolonged intensive care unit (ICU) stay after type A aortic dissection (TAAD) repair. METHODS: This retrospective study continuously enrolled 83 patients who underwent TAAD repair from January 1 to December 31, 2018. OSA was diagnosed by sleep test and defined as an apnoea hypopnea index (AHI) of ≥ 15/h, while an AHI of > 30/h was defined severe OSA. Hypoxaemia was defined as an oxygenation index (OI) of < 200 mmHg. Prolonged ICU stay referred to an ICU stay of > 72 h. Receiver operating characteristic curve analysis was performed to evaluate the predictive value of postoperative OI for prolonged ICU stay. Multivariate logistic regression was performed to assess the association of OSA with hypoxaemia and prolonged ICU stay. RESULTS: A total of 41 (49.4%) patients were diagnosed with OSA using the sleep test. Hypoxaemia occurred postoperatively in 56 patients (67.5%). Postoperatively hypoxaemia developed mostly in patients with OSA (52.4% vs. 83.0%, p = 0.003), and particularly in those with severe OSA (52.4% vs. 90.5%, p = 0.003). The postoperative OI could fairly predict a prolonged ICU stay (area under the receiver-operating characteristic curve, 0.72; 95% confidence intervals [CI] 0.60-0.84; p = 0.002). Severe OSA was associated with both postoperative hypoxaemia (odds ratio [OR] 6.65; 95% CI 1.56-46.26, p = 0.008) and prolonged ICU stay (OR 5.58; 95% CI 1.54-20.24, p = 0.009). CONCLUSIONS: OSA was common in patients with TAAD. Severe OSA was associated with postoperative hypoxaemia and prolonged ICU stay following TAAD repair.

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.

Repair of Type Ia Endoleaks Involving the Distal Arch Using Left Subclavian Artery-Left Common Carotid Artery Transposition with a Stented Elephant Trunk.

BACKGROUND: Type Ia endoleaks are common after thoracic endovascular aortic repair (TEVAR). However, the repair of type Ia endoleaks involving the distal arch is challenging because of the presence of the interventional endografts, potential damage to the aortic arch vessels, and the location and size of the aneurysmal body. We retrospectively reviewed our experience of the surgical treatment of type Ia endoleaks with distal arch involvement using left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition with a stented elephant trunk. METHODS: Sixteen patients (male = 16; mean age, 47 ± 9 years, range 31-63 years) with type Ia endoleaks involving the distal arch underwent LSCA-LCCA transposition with a stented elephant trunk from July 2010 to July 2018. TEVAR failure occurred in 12 patients, re-TEVAR was performed in two patients, hybrid aortic arch repair in one patient, and the chimney technique in one patient. RESULTS: There were no in-hospital deaths. Fourteen patients required mechanical ventilation for <24 h and one for <48 h. One patient required reintubation after mechanical ventilation for 19 h and continuous renal replacement therapy because of renal failure. One patient received pericardial drainage, and recurrent laryngeal nerve injury occurred in one patient. Three patients died during follow-up. CONCLUSIONS: The LSCA-LCCA transposition with a stented elephant trunk can produce satisfactory results in patients with a type Ia endoleak involving the distal arch. Using this technique, it is possible to exclude the aneurysm sac distal to the LCCA origin and seclude the failed interventional endograft. These encouraging outcomes suggested that this technique could be a suitable surgical treatment for this type of lesion.

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.

Distal Arch Aneurysm Repair Using Left Subclavian Artery Transposition With Stented Elephant Trunk in the Hybrid Repair Era.

BACKGROUND: Hybrid aortic arch repair is an invasive approach to the surgical management of distal aortic arch aneurysm. The complications associated with hybrid aortic arch repair, such as stroke and endoleaks, are not uncommon and late reintervention is frequent. We retrospectively reviewed our experience of distal aortic arch aneurysm repair using the stented elephant trunk procedure with left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition in the hybrid repair era. METHODS: Between May 2009 and September 2016, 19 patients with distal aortic arch aneurysm underwent LSCA-LCCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All patients were males with a median age of 51±14 (range 20-69) years. RESULTS: There were no in-hospital deaths. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurologic deficits were observed in any patients prior to hospital discharge. One patient underwent concomitant thoracic endovascular aortic repair after this technique. One case required reoperation due to bleeding. One patient required debridement due to poor wound healing. During a mean follow-up of 33±21months, one patient died. CONCLUSIONS: Satisfactory results were obtained in suitable patients undergoing surgery for distal aortic arch aneurysm using LSCA-LCCA transposition with stented elephant trunk implantation in the hybrid repair era. The straightforward nature of the surgical approach, with avoidance of the complications related to hybrid aortic arch repair and reduction of late re-intervention favours this technique for treating distal aortic arch aneurysm.

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.

Acute Ischemic Pancreatitis Secondary to Aortic Dissection.

BACKGROUND: Acute ischemic pancreatitis secondary to aortic dissection is very rare with an unclarified mechanism. We retrospectively reviewed 6 such cases in our center and present their outcomes herein. METHODS: Between February 2009 and April 2017, 6 patients (male = 2 and female = 4; mean age, 58 ± 8 years [range, 47-70 years]) with acute aortic dissection associated with pancreatitis were admitted to our center. There were 3 type A and 3 type B dissections. One patient developed renal dysfunction and visceral organ ischemia, and 1 developed renal failure and ischemia of the lower extremity. Five patients had a history of hypertension, and 1 had diabetes mellitus. RESULTS: After aggressive medical treatment, 5 patients survived the acute phase of aortic dissection and acute ischemic pancreatitis. Surgery was required in 4 patients and thoracic endovascular aortic repair in 1 patient. There were no severe postoperative complications, and all 5 were discharged. One patient with acute type B dissection refused treatment and died from multiple organ failure. No complications or deaths occurred in the postoperative follow-up period. CONCLUSIONS: Acute ischemic pancreatitis after aortic dissection is a very unusual complication. The potential for this concomitant diagnosis should always be considered during the diagnostic stages. There is no clear consensus regarding the management of aortic dissection associated with acute pancreatitis.

Repair of Distal Aortic Arch Aneurysms by Left Subclavian Artery Transposition with Stented Elephant Trunk Implantation.

BACKGROUND: Repair of distal aortic arch aneurysms remains technically challenging using conventional open surgery due to its location. Several techniques, including a conventional prosthetic graft replacement and a hybrid technique, were introduced to manipulate this lesion. We retrospectively reviewed our experience with left subclavian artery (LSCA) transposition with stented elephant trunk implantation for repair of distal aortic arch aneurysms. METHODS: From May 2009 to December 2014, 9 men (mean age 55 ± 16 years) with distal aortic arch aneurysms underwent LSCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with antegrade selective cerebral perfusion via a median sternotomy. One case had a history of endovascular abdominal aortic repair. RESULTS: There was no in-hospital death. The mean time of mechanical ventilation and intensive care unit stay was 22 ± 9 and 53 ± 17 hr, respectively. No severe complications occurred in this group. All patients survived and were discharged. No patient died during the follow-up period. Postoperative computed tomography revealed good patency of the anastomotic site between the LSCA and the left common carotid artery. CONCLUSIONS: Satisfactory surgical results and follow-up outcomes were achieved by simultaneous repair of proximal aortic lesions and complete seal of the lesion involving the distal aortic arch and proximal descending aorta using LSCA transposition with implantation of a stented elephant trunk. Encouraging outcomes favor this technique for distal aortic arch aneurysm.

Hybrid Operation for Descending Aortic Pathologies Involving Distal Aortic Arch.

Background A combined endovascular and debranching hybrid procedure was performed for descending aortic pathologies involving the distal aortic arch. We reviewed our results of this procedure to summarize clinical experiences. Methods From April 2009 to April 2013, 36 patients (21 males and 15 females) underwent the hybrid operation. Hospital stay and complications were closely monitored after operation. Follow-up CT scan was performed at postoperative 3 months and 12 months. Results The hospital stay ranged from 7 to 25 (15.1 ± 5.0) days. The mean age at operation was 67.6 ± 4.8 years (range: 60-79 years). In-hospital mortality and stroke rates were 2.8% (1/36) and 2.8% (1/36). At a mean follow-up of 22 months (4-52 months), the mortality was 0% (0/35). All remaining 35 patients returned to normal life. During the follow-up period, one patient required secondary endovascular reintervention for a type 1 distal endovascular leak. Conclusion Hybrid repair for descending aortic pathologies involving the distal arch proves to be effective and safe at midterm follow-up with acceptable surgical risks and satisfactory results.

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.

One-Stage Repair of Acute Type B Dissection With Ascending Thoracic Aortic Dilatation Using a Stented Elephant Trunk Procedure.

BACKGROUND: Acute type B dissection with ascending thoracic aortic dilatation (ATAD) is very common, but remains surgically challenging with the use of the conventional single-stage procedure via median sternotomy or lateral thoracotomy. We report our experience with repair of acute type B dissection with ATAD using a one-stage stented elephant trunk procedure. METHODS: We retrospectively reviewed the medical records of 16 patients (13 males and 3 females) with acute type B dissection with ATAD who underwent ascending thoracic aortic reconstruction combined with a stented elephant trunk procedure under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion between February 2009 and February 2013. ATAD included ascending aortic aneurysm in four patients, ascending aortic enlargement + aortic regurgitation in three, and ascending aortic aneurysm + aortic root aneurysm in nine. Lower limb ischemia occurred in one case. RESULTS: There was no in-hospital mortality. Drainage of the pericardial sac was indicated for two patients with pericardial effusion. The median durations of ventilator support and intensive care unit stay were 25 ± 18 and 48 ± 7 hours, respectively. Lower limber ischemia was alleviated after implantation of a stented elephant trunk. One patient received thoracoabdominal aortic replacement during follow-up and encountered no postoperative complications. CONCLUSIONS: Satisfactory surgical results and follow-up outcomes can be achieved using the proposed one-stage stented elephant trunk procedure for acute type B dissection with ATAD.

Repair of type A dissection with mitral regurgitation using total arch replacement with mitral valve surgery.

BACKGROUND: Mitral regurgitation (MR) is very rare in patients with type A dissection. We retrospectively reviewed our experience of total arch replacement (TAR) with mitral valve surgery for type A dissection with MR. METHODS: From November 2009 to October 2012, 14 patients with type A dissection (chronic = 11; acute = 3) with MR underwent TAR combined with mitral valve surgery under hypothermic cardiopulmonary bypass with selective cerebral perfusion. The Bentall procedure was performed in 11 patients, aortic valve replacement (AVR) in one patient, coronary artery bypass grafting (CABG) in three patients, and tricuspid valvuloplasty (TVP) in one patient. RESULTS: Thirty-day mortality was 7.1% (1/14). One patient died after transfer to another hospital secondary to renal failure. Low cardiac output syndrome was observed in three patients (21.4%, 3/14), one of whom underwent left ventricular assist device implantation. Continuous renal replacement therapy was performed in four cases (28.6%, 4/14). Two patients underwent reoperation during follow-up period: One patient had mitral paravalvular leakage and the other dilatation of the thoracoabdominal aorta. CONCLUSIONS: Repair of type A dissection with MR can be performed in a single operation. Combined TAR and mitral valve surgery is a much bigger and more complex operation associated with high morbidity.

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.

Human cytomegalovirus infection is associated with essential hypertension in Kazakh and Han Chinese populations.

BACKGROUND: We aimed to study the association between cytomegalovirus (CMV) infection and hypertension in Kazakh and Han populations from Xinjiang Province, China. MATERIAL/METHODS: We analyzed data on 800 Kazakhs (467 hypertension patients and 333 healthy control participants) and 800 Hans (482 hypertension patients and 318 healthy control participants) aged 18-84 years old. ELISA and real-time quantitative PCR coupled with restriction fragment length polymorphism analysis were applied for determining CMV infection and glycoprotein B (gB) genotypes, respectively. RESULTS: Serologic evidence of CMV infection was obtained for 95.4% and 90.1% of the Kazakhs and Hans, respectively. The CMV seroprevalence rates among the Kazakh and Han participants with hypertension were 96.8% and 89.8%, respectively. Multiple logistic regression analyses revealed statistically significant independent associations between CMV seropositivity and hypertension in Kazakh males and between CMV antibody titers and hypertension in Hans; significant relationships also existed between CMV antibody titers and blood pressure in Hans. In Kazakhs, 3 CMV gB genotypes were identified: gB2 and genotype mixtures gB1+gB2 and gB2+gB3. In Hans, 4 CMV gB genotypes were identified: gB1, gB2, gB1+gB2, and gB2+gB3. Of the 4 studied genotypes, gB2+gB3 showed a significant independent association with hypertension in Kazakh females. CONCLUSIONS: CMV infection is associated with essential hypertension in Kazakh males and Hans in Xinjiang. CMV seropositivity is associated with hypertension in Kazakh males, and CMV antibody titers are associated with blood pressure and hypertension in Han males and females. Moreover, the CMV gB2+gB3 genotype mixture is associated independently with essential hypertension in Kazakh females.

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.

Ginsenoside Rg3 decreases breast cancer stem-like phenotypes through impairing MYC mRNA stability.

Breast cancer stem cells (BCSCs) are responsible for breast cancer metastasis, recurrence and treatment resistance, all of which make BCSCs potential drivers of breast cancer aggression. Ginsenoside Rg3, a traditional Chinese herbal medicine, was reported to have multiple antitumor functions. Here, we revealed a novel effect of Rg3 on BCSCs. Rg3 inhibits breast cancer cell viability in a dose- and time-dependent manner. Importantly, Rg3 suppressed mammosphere formation, reduced the expression of stemness-related transcription factors, including c-Myc, Oct4, Sox2 and Lin28, and diminished ALDH(+) populations. Moreover, tumor-bearing mice treated with Rg3 exhibited robust delay of tumor growth and a decrease in tumor-initiating frequency. In addition, we found that Rg3 suppressed breast cancer stem-like properties mainly through inhibiting MYC expression. Mechanistically, Rg3 accelerated the degradation of MYC mRNA by enhancing the expression of the let-7 family, which was demonstrated to bind to the MYC 3' untranslated region (UTR). In conclusion, our findings reveal the remarkable suppressive effect of Rg3 on BCSCs, suggesting that Rg3 is a promising therapeutic treatment for breast cancer.

Treatment of aortic root aneurysm and mitral valve pathology through a single aortotomy.

BACKGROUND: Aortic root aneurysms combined with lesions of the mitral valve requires synchronous operations. The conventional approach is to treat the two lesions through separate aortic and atrial incisions. METHODS: From May 2009 to August 2012, 28 transaortic mitral valve operations were performed. There were 23 males and five females, the age ranged from 18 to 75 years, mean 41 ± 16 years. The operative procedures included Bentall+MVR in 20 patients, Bentall+MVP in three patients, Bentall+total arch replacement+stent elephant trunk+MVP in one patient, Bentall+total arch replacement+stent elephant trunk+MVR in two patients, Bentall+MVP+CABG in two patients. Follow-up was completed for all patients, with a mean follow-up period of 22 ± 10 months and a maximum of 42 months. RESULTS: Transaortic mitral valve surgery was successful for all patients. There was a reoperation in two patients for bleeding. In the MVP group, there was mild regurgitation in two cases before discharge, without further development during the follow-up. In the MVR group, there was paravalvular leakage in one patient three months later, which required repair. There were no deaths in the hospital and the follow-up period, and no valve-associated complication during the follow-up period. The heart function of all patients during the follow-up period was Level I-II (NYHA). CONCLUSION: Transaortic mitral valve operation is a feasible surgical approach to treat patients with aortic root aneurysms combined with mitral valve lesions.

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

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

Aortic regurgitation caused by Behçet's disease: surgical experience during an 11-year period.

BACKGROUND AND AIM OF THE STUDY: Aortic regurgitation (AR) caused by Behçet's disease is a rare clinical condition and surgical experience is limited. Many patients undergoing simple aortic valve replacement (AVR) required a second or third operation as a result of prosthetic valve dehiscence. We analyze our experience with surgical management for AR in Behçet's disease during an 11-year period. METHODS: From April 1997 through December 2008, 10 male patients (mean age, 38.4 ± 6.9 years) with AR caused by Behçet's disease underwent surgical treatment. The primary procedures were AVR in seven cases and aortic root replacement in three (two Bentall, one Cabrol). The duration of follow-up was 5.3 ± 3.6 years. RESULTS: In the seven patients with simple AVR, valve dehiscence occurred in six after an interval of 2.9 ± 1.7 months, necessitating 11 reoperations (four redo AVRs, one redo redo-AVR, four aortic root replacements, and two heart transplants) with one early death. In aortic root replacement patients, two Bentall patients survived and required no reintervention, and the Cabrol patient died from electromechanical uncoupling one year postoperatively. Of the seven survivors, the definite procedure was aortic root replacement in four cases, heart transplantation in two, and AVR in one. CONCLUSIONS: The rate of valve dehiscence was high after isolated AVR in patients with AR caused by Behçet's disease. At the first operation, aortic root replacement should be the procedure of choice, preferably with a homograft. Heart transplantation might be a feasible alternative to aortic root replacement in selected patients.