梁盛华
中国医学科学院阜外医院 心血管外科
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.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2022
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.
Frontiers in cardiovascular medicine 2022
BACKGROUND:Abdominal aortic aneurysm (AAA) is potentially life threatening and characterized by immune-inflammatory cell infiltration and extracellular matrix degradation. Currently, pharmacotherapy mainly aims to control risk factors without reversion of the dilated aorta. This study analyzed the immune-inflammatory response and identified the immune-related hub genes of AAA.METHOD:Gene Expression Omnibus datasets (GSE57691, GSE47472 and GSE7084) were downloaded. After identification of GSE57691 differentially expressed genes (DEGs), weighted gene co-expression network analysis of the DEGs was performed. Through enrichment analysis of each module and screening in Immunology Database and Analysis Portal, immune-related hub genes were identified via protein-protein interaction (PPI) network construction and lasso regression. CIBERSORT was utilized to analyze AAA immune infiltration. The correlations between the immune-related hub genes and infiltrating immune cells were investigated. Receiver operating characteristic (ROC) curve analysis was performed to determine immune-related hub gene cutoff values, which were validated in GSE47472 and GSE7084.RESULT:In GSE57691, 1,018 DEGs were identified. Five modules were identified in the co-expression network. The blue and green modules were found to be related to immune-inflammatory responses, and 61 immune-related genes were identified. PPI and lasso regression analyses identified FOS, IL-6 and IL2RB as AAA immune-related hub genes. CIBERSORT analysis indicated significantly increased infiltration of naive B cells, memory activated CD4 T cells, follicular helper T cells, monocytes and M1 macrophages and significantly decreased infiltration of M2 macrophages in AAA compared with normal samples. IL2RB was more strongly associated with immune infiltration in AAA than were FOS and IL6. The IL2RB area under the ROC curve (AUC) value was > 0.9 in both the training and validation set, demonstrating its strong, stable diagnostic value in AAA.CONCLUSION:AAA and normal samples had different immune infiltration statuses. IL2RB was identified as an immune-related hub gene and a potential hub gene with significant diagnostic value in AAA.
Gene 2022
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.
Frontiers in cardiovascular medicine 2022
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.
Journal of vascular surgery 2022
Background:Frozen elephant trunk technique (FET) has been proven to provide an excellent landing zone for second-stage thoracoabdominal (TA) aortic repair. The aim of this study was to evaluate the impact of FET in TA aortic repair with normothermic iliac perfusion.Methods:From January 2008 to December 2019, 144 patients undergoing TA repair with normothermic iliac perfusion were enrolled in this study. Early and mid-term outcomes of patients with previous FET implantation (group A, n = 62) were compared with patients without previous FET implantation (group B, n = 82). The logistic regression analysis was performed to investigate the risk factors for adverse events, which were defined as early death, permanent stroke, permanent paraplegia, or permanent renal failure necessitating dialysis.Results:The proximal aortic clamp time and operating time was 14.26 ± 5.57 min and 357.40 ± 94.51 respectively in group A, which were both significantly shorter than that in group B (18.67 ± 5.24 min and 18.67 ± 5.24 min). The incidence of adverse event was significantly lower in group A than that in group B (9.7% vs. 25.6%, P = 0.027). There was no significant difference between two groups with regard to other complications or late outcomes. In addition, age >50 years, a Ccr < 90 ml/min/1.73 m2 and the operating time were identified as significant risk factors through logistic regression analysis for adverse events of TA repair.Conclusions:The FET technique simplifies the operative technique of proximal anastomosis, decreases the operating time and improves the early outcomes in TA repair, whereas does not provide a significant benefit with regard to late outcomes. Long-term follow-up and studies with larger sample sizes are necessary for further confirmation.
Frontiers in surgery 2022
This study aimed to compare clinical outcomes of patients treated by total arch replacement (TAR) with frozen elephant trunk (FET), aortic balloon occlusion (ABO) technique and hybrid arch repair (HAR). Between January 2017 and July 2019, 643 consecutive patients with aortic arch diseases were eligible for TAR, including 356 in conventional FET, 112 in ABO based on FET, and 175 in HAR. A retrospective cohort analysis of perioperative results was undertaken, performed with inverse probability weighting. The primary endpoint was composite endpoints included 30-day mortality, stroke, paraplegia, hemodialysis, reintubation, and intra-aortic balloon pump or extracorporeal membrane oxygenation support, and visceral dysfunction was secondary endpoint. Overall in-hospital mortality was 2.2% (FET = 2.5% vs ABO = 0 vs HAR = 2.9%, P= 0.210). Parallel early outcomes were demonstrated among three groups. ABO group was associated with significantly shorter circulatory arrest time (5, IQR 3-7 vs 16, IQR 14-18 minutes, P < 0.001), and a lower incidence of visceral dysfunction compared with FET group (25.1% vs 47.3%, P= 0.003). Patients receiving ABO suffered a significantly lower rate of prolonged ventilation (more than 72 hours; P= 0.014). Furthermore, a tendency toward decreasing composite endpoints was suggested in ABO (7.2%) compared with FET (15.5%, P= 0.061) and HAR (19.8%, P= 0.032). ABO technique obtains considerable early clinical outcomes for TAR compared with conventional FET and HAR, which could be a feasible and effective approach for patients with aortic arch diseases.
Seminars in thoracic and cardiovascular surgery 2021
OBJECTIVES:The goal of this study was to compare the early-to-midterm outcomes of patients treated with the frozen elephant trunk procedure with aortic balloon occlusion (FET-ABO) versus hybrid repair for aortic arch diseases.METHODS:Patients who underwent the FET-ABO (n = 134) and the hybrid procedure (n = 220) from 2017 to 2020 at our institution were analysed retrospectively. Early-to-midterm outcomes were compared using inverse probability weighting. Low-risk and high-risk subgroup analyses were performed according to the cut-off of the additive European System for Cardiac Operative Evaluation value of 6.RESULTS:The present study demonstrated similar 30-day mortality (3.7% vs 8.6%; P = 0.118) and adverse events between the FET-ABO and the hybrid groups. Fewer intraoperative red blood cell transfusions (0.54 ± 1.45 vs 1.26 ± 2.47 U; P = 0.001), decreased total hospital costs (P < 0.001) and considerable early-to-midterm survival [crude: hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.17-0.91; P = 0.030; adjusted: HR 0.35, 95% CI 0.13-0.91; P = 0.032) were obtained with the FET-ABO compared to the hybrid procedure. The inverse probability weighting method substantiated the foregoing results. Adjusted subgroup analyses suggested that the FET-ABO procedure had a trend towards improved survival in low-risk patients (HR 0.17, 95% CI 0.03-0.93; P = 0.041) and achieved outcomes comparable to those of the hybrid procedure in high-risk patients (HR 0.46, 95% CI 0.15-1.42; P = 0.176).CONCLUSIONS:The FET-ABO technique could be better promoted in hospitals lacking experience and equipment and could be more viable and cost-effective for selected patients compared with the hybrid procedure.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2021
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.
Journal of cardiothoracic surgery 2021
Background: Stanford type A aortic dissection (AAD) is a catastrophic disease. An immune infiltrate has been found within the aortic wall of dissected aortic specimens. The recall and activation of macrophages are key events in the early phases of AAD. Herein, the immune filtration profile of AAD was uncovered. Methods: Gene expression data from the GSE52093, GSE98770 and GSE153434 datasets were downloaded from the Gene Expression Omnibus (GEO). The differentially expressed genes (DEGs) of each dataset were calculated and then integrated. A protein-protein interaction (PPI) network was established with the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING), and the hub genes were identified in Cytoscape. Furthermore, gene ontology (GO) functional annotation and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis of hub genes were performed. Finally, we set GSE52093 and GSE98770 as the training set and GSE153434 as the validation set to assess immune infiltration in AAD using CIBERSORTx and analyzed the correlations between immune cells and hub genes in both the training and validation sets. Results: Sixty-one integrated DEGs were identified. The top 10 hub genes were selected from the PPI network, and 140 biological process (BP) terms and 12 pathways were enriched among the top 10 hub genes. The proportions of monocytes and macrophages were significantly higher in AAD tissues than in normal tissues. Notably, this result was consistent in the training set and the validation set. In addition, we found that among the hub genes, CA9, CXCL5, GDF15, VEGFA, CCL20, HMOX1, and SPP1 were positively correlated with CD14, a cell marker of monocytes, while CA9, CXCL5, GDF15, and VEGFA were positively correlated with CD68, a cell marker of macrophages in the training set. Finally, according to the results of the GO and KEGG analysis of hub genes, we found that the monocyte/macrophage-related genes were involved in immune-inflammatory responses through degradation of the extracellular matrix, endothelial cell apoptosis, hypoxia and the interaction of cytokines and chemokines. Conclusion: The monocyte-macrophage system plays a major role in immune-inflammatory responses in the development of AAD. Several hub genes are involved in this process via diverse mechanisms.
Frontiers in cardiovascular medicine 2021
