Publications by authors named "Wei-Guo Ma"

97 Publications

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

BMC Cardiovasc Disord 2021 09 6;21(1):421. Epub 2021 Sep 6.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.

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.
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http://dx.doi.org/10.1186/s12872-021-02226-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8422665PMC
September 2021

Does preoperative dual antiplatelet therapy affect bleeding and mortality after total arch repair for acute type A dissection?

Interact Cardiovasc Thorac Surg 2021 Aug 30. Epub 2021 Aug 30.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.

Objectives: Data are scarce and mixed regarding the impact of preoperative dual antiplatelet therapy (DAPT) on the surgical outcomes of acute type A aortic dissection (ATAAD). We seek to evaluate the impact of DAPT on bleeding-related events and early- and mid-term mortality after total arch replacement and frozen elephant trunk in such patients.

Methods: This study comprised 48 ATAAD patients on preoperative DAPT and 418 without DAPT (the whole series, i.e. unmatched cohort), from which 45 matched pairs were selected by propensity score (matched cohort). Bleeding-related events (reoperation for bleeding, bleeding of ≥1500 ml within the first 12 h postoperatively or transfusion of ≥10 units of red blood cell or use of recombinant activated factor VII), operative mortality and mid-term survival were compared in the unmatched and matched cohorts. The impact of preoperative DAPT was evaluated with multivariable analysis.

Results: In the unmatched cohort, bleeding of ≥1500 ml/12 h postoperatively was more common in the DAPT group (18.8% vs 8.4%, P = 0.020); operative mortality was 9.7%, which did not differ with DAPT (12.5% vs 9.3%, P = 0.48). Nor did bleeding-related events (54.2% vs 43.5%, P = 0.16) differ significantly between 2 groups. In the matched cohort, neither were drainage of ≥1500 ml/12 h (20% vs 6.7%, P = 0.063) and bleeding-related events (53.3% vs 42.2%, P = 0.30), nor operative mortality (13.8 vs 8.9%, P = 0.50) and mid-term survival (79.3% vs 76.4%, P = 0.93) significantly different between 2 groups. DAPT was not identified as a predictor for operative mortality [odd ratio (OR) 0.97, 95% confidence interval (CI) 0.31-3.08; P = 0.96; adjusted OR 1.28, 95% CI 0.22-7.20; P = 0.78] and bleeding-related events (OR 1.50, 95% CI 0.76-2.95; P = 0.24; adjusted OR 2.03, 95% CI 0.80-3.66; P = 0.14).

Conclusions: In patients with ATAAD undergoing total arch replacement and frozen elephant trunk, although preoperative DAPT led to more postoperative bleeding, it did not increase bleeding-related events nor operative mortality nor mid-term death. The results of this study imply that for patients with ATAAD, emergency surgical repair, even if as extensive as total arch repair, should not be contraindicated or delayed simply because of ongoing DAPT.
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http://dx.doi.org/10.1093/icvts/ivab226DOI Listing
August 2021

Is there a one-size-fits-all technique for calcified ascending aorta in coronary artery bypass grafting?

Ann Thorac Surg 2021 Aug 11. Epub 2021 Aug 11.

Department of Cardiac Surgery Beijing Anzhen Hospital Capital Medical University, 2 Anzhen Road, Beijing, 100029, China.

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http://dx.doi.org/10.1016/j.athoracsur.2021.07.029DOI Listing
August 2021

Effects of Decompressive Cervical Surgery on Blood Pressure in Cervical Spondylosis Patients With Hypertension: A Time Series Cohort Study.

Int J Spine Surg 2021 Aug 15;15(4):683-691. Epub 2021 Jul 15.

Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China.

Background: The blood pressure of cervical spondylosis (CS) patients with hypertension often returns to normal after decompressive cervical surgery (DCS). However, the effect of DCS on the blood pressure of patients with CS has not been rigorously studied.

Methods: We recruited 50 consecutive CS patients with hypertension from 2014-2017 and investigated the changes in blood pressure after DCS using a time series design. Ambulatory blood pressure monitoring (ABPM) was performed at 3 and 0 days before DCS and at 30 and 90 days after DCS. The primary outcome was mean 24-hour systolic blood pressure (SBP). Secondary outcomes included mean 24-hour diastolic blood pressure (DBP), office blood pressure, and the percentage of patients on antihypertensive medication. Paired test was used for assessing the changes in blood pressure over time and a McNemar test was used for comparison among different medication groups.

Results: The mean 24-hour SBP did not vary significantly among 4 time points (134.5 ± 14.7, 132.8 ± 14.7, 131.5 ± 13.3, and 133.2 ± 14.6, respectively; = .42). The mean 24-hour DBP showed a similar trend. However, mean office SBP/DBP decreased significantly from 142.5/82.0 mm Hg before surgery to 127.3/76.6 mm Hg after surgery (both < .01). The corresponding percentage of patients on antihypertensive medication decreased significantly, from 84% to 54% ( < .01).

Conclusions: This study confirmed previous findings of reduction in office blood pressure associated with DCS among CS patients with hypertension. However, this was not confirmed by multiple-time series of 24-hour ABPM.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/8090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375702PMC
August 2021

Identification of Blood miR-216a, miR-377 and Their Target Genes ANGPTL4, GAP-43 and Serum of PPARG as Biomarkers for Diabetic Peripheral Neuropathy of Type 2 Diabetes.

Clin Lab 2021 Apr;67(4)

Background: Diabetic peripheral neuropathy (DPN) is one of the most common and complex chronic complications of diabetes, but it is clinically lacking effective means for early diagnosis and early treatment. MicroRNA, in the occurrence and development of the disease, has an important regulatory role. Its role in diabetes has been reported more. However, specific research on microRNA in DPN is rare.

Methods: Based on the results of bioinformatics screening, miR-377 and miR-216a, their respective target molecules growth association protein 43 (GAP-43) and angiopoietin-like 4 protein (ANGPTL4), and related pathways peroxisome proliferator activated receptor gamma (PPARG) and chemerin were tested by RT-qPCR and ELISA in blood samples of DPN to analyze the correlation between these differentially expressed molecules and clinico-pathological factors of DPN.

Results: In this study, we found that miR-377, miR-216a, GAP-43, ANGPTL4, and PPARG were significantly differentially expressed genes for DPN. The correlation analysis showed that they were closely related to the clinical indicators of DPN suggesting that they may be involved in the development of DPN. In addition, receiver operating characteristic (ROC) curves generated for miR216a, miR377, ANGPTL4, GAP43, PPARG revealed that they can be used as new molecular diagnostic markers of DPN.

Conclusions: miR-216a, miR-377, ANGPTL4, GAP-43, and PPARG could potentially be biomarkers of DPN.
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http://dx.doi.org/10.7754/Clin.Lab.2020.191220DOI Listing
April 2021

Impact of Sleep Duration on Depression and Anxiety After Acute Ischemic Stroke.

Front Neurol 2021 26;12:630638. Epub 2021 Mar 26.

Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

Abnormal sleep duration predicts depression and anxiety. We seek to evaluate the impact of sleep duration before stroke on the occurrence of depression and anxiety at 3 months after acute ischemic stroke (AIS). Nationally representative samples from the Third China National Stroke Registry were used to examine cognition and sleep impairment after AIS (CNSR-III-ICONS). Based on baseline sleep duration before onset of stroke as measured by using the Pittsburgh Sleep Quality Index (PSQI), 1,446 patients were divided into four groups: >7, 6-7, 5-6, and <5 h of sleep. Patients were followed up with the General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) for 3 months. Poststroke anxiety (PSA) was defined as GAD-7 of ≥5 and poststroke depression (PSD) as PHQ-9 of ≥5. The association of sleep duration with PSA and PSD was evaluated using multivariable logistic regression. The incidences of PSA and PSD were 11.2 and 17.6% at 3 months, respectively. Compared to a sleep duration of >7 h, 5-6 h, and <5 h of sleep were identified as risk factors of PSA [odds ratio (OR), 1.95; 95% confidence interval (CI), 1.24-3.07; < 0.01 and OR, 3.41; 95% CI, 1.94-6.04; < 0.01) and PSD (OR, 1.47; 95% CI, 1.00-2.17; = 0.04 and OR, 3.05; 95% CI, 1.85-5.02; < 0.01), while 6-7 h of sleep was associated with neither PSA (OR, 1.09; 95% CI, 0.71-1.67; = 0.68) nor PSD (OR, 0.92; 95% CI, 0.64-1.30; = 0.64). In interaction analysis, the impact of sleep duration on PSA and PSD was not affected by gender ( = 0.68 and = 0.29, respectively). Sleep duration of shorter than 6 h was predictive of anxiety and depression after ischemic stroke.
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http://dx.doi.org/10.3389/fneur.2021.630638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032928PMC
March 2021

Limited vs. extended repair for acute type I aortic dissection: long-term outcomes over a decade in Beijing Anzhen Hospital.

Chin Med J (Engl) 2021 Apr 6;134(8):986-988. Epub 2021 Apr 6.

Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital of Capital Medical University, Beijing 100029, China.

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http://dx.doi.org/10.1097/CM9.0000000000001416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078232PMC
April 2021

New Proximal Anastomosis Technique for Calcified Ascending Aorta in Coronary Artery Bypass Grafting.

Ann Thorac Surg 2021 Mar 6. Epub 2021 Mar 6.

Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China, 100029.

To deal with calcified ascending aorta during CABG, we describe an alternative technique to create a clampless proximal anastomosis using a Foley catheter and polypropylene suture. In 30 patients, the number of distal anastomoses averaged 3.1 ± 0.7, and mean time of proximal anastomosis was 18.9 ± 1.3 minutes, respectively. Neither early nor late death occurred. Stroke occurred in 2 high-risk patients. At mean 1.6 ± 0.5 years of follow-up, 1 patient sustained recurrent angina, and graft patency was 93%. These favorable outcomes show that this alternative technique is a safe and effective approach to calcified ascending aorta in CABG.
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http://dx.doi.org/10.1016/j.athoracsur.2021.01.076DOI Listing
March 2021

Optimization of the total arch replacement technique: Left subclavian perfusion with sequential aortic reconstruction.

J Thorac Cardiovasc Surg 2021 Jun 4;161(6):e447-e451. Epub 2020 Dec 4.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.

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http://dx.doi.org/10.1016/j.jtcvs.2020.11.110DOI Listing
June 2021

Does the 45 mm Size Cutoff for Ascending Aortic Replacement Predict Better Early Outcomes in Bicuspid Aortic Valve?

Thorac Cardiovasc Surg 2021 Jan 19. Epub 2021 Jan 19.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.

Background:  The aim of this study is to test if the newly proposed 45 mm size criterion for ascending aortic replacement (AAR) in bicuspid aortic valve (BAV) patients undergoing aortic valve replacement (AVR) is predictive of improved early outcomes.

Methods:  Data of 306 BAV patients with an aortic diameter of ≥45 mm undergoing AVR alone or with AAR were retrospectively analyzed. Patients were divided into groups of AVR + AAR ( = 220) and AVR only ( = 86) based on if surgery was performed according to the 45 mm criterion. End point was early adverse events, including 30-day and in-hospital mortality, cardiac events, acute renal failure, stroke, and reoperation for bleeding. Cox regression was used to assess if conformance to 45 mm criterion could predict fewer early adverse events.

Results:  AVR + AAR group had significantly higher postoperative left ventricular ejection fraction (LVEF) (0.59 ± 0.09 vs. 0.55 ± 0.11,  = 0.006) and longer cardiopulmonary bypass (CPB) time (128 vs. 111 minutes,  = 0.002). Early adverse events occurred in 45 patients (14.7%), which was more prevalent in the AVR-only group (22.1% vs. 11.8%,  = 0.020). Conformance to the 45 mm criterion predicted lower rate of early adverse events (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.28-0.98,  = 0.042). After adjustment for gender, age, AAo diameter, sinuses of Valsalva diameter, preoperative LVEF, Sievers subtypes, BAV valvulopathy, and CPB and cross-clamp times, conformance to the 45 mm size criterion still predicted lower incidence of early adverse events (HR: 0.37, 95% CI: 0.15-0.90,  = 0.028).

Conclusions:  This study shows that conformance to 45 mm size cutoff for preemptive AAR during aortic valve replacement in patients with BAV was not associated with increased risk for adverse events and may improve early surgical outcomes.
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http://dx.doi.org/10.1055/s-0040-1722197DOI Listing
January 2021

Unraveling the Mysteries of Cerebral Malperfusion in Type A Aortic Dissection.

Ann Thorac Surg 2021 08 23;112(2):509-510. Epub 2020 Dec 23.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, 2 Anzhen Rd, Beijing 100029, China. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2020.11.037DOI Listing
August 2021

Incidental para-ureteral aggressive angiomyxoma: a rare case report and literature review.

BMC Urol 2020 Nov 10;20(1):182. Epub 2020 Nov 10.

Department of Urology, Karamay Central Hospital, Karamay, 834000, Xinjiang, China.

Background: Aggressive angiomyxoma (AA) is a rare tumor that typically occurs in the pelvis and perineum, most commonly in women of reproductive age. However, no para-ureteral AA has been reported according to the literature. Case presentation We herein describe the first case of para-ureteral AA. A 62-year-old male presented to our institute in March 2017 with a para-ureteral mass that was 15 mm in diameter incidentally. No symptom was observed and laboratory analysis was unremarkable. Magnetic resonance and computed tomography imaging showed a non-enhancing mass abutting the left ureter without causing obstruction. Laparoscopic resection of the mass was performed without injury to the ureter. Pathologic and immunohistochemical results were consistent with AA. Till now, no recurrence was noticed.

Conclusions: We reported a rare case of para-ureteral AA, along with a literature review. Early diagnosis, proper surgical plan and long-term close follow-up is recommended for its high risk of recurrence and malignant potential.
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http://dx.doi.org/10.1186/s12894-020-00755-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653999PMC
November 2020

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

J Card Surg 2021 May 16;36(5):1659-1664. Epub 2020 Sep 16.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.

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.
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http://dx.doi.org/10.1111/jocs.15041DOI Listing
May 2021

Is the frozen elephant trunk technique justified for chronic type A aortic dissection in Marfan syndrome?

Ann Cardiothorac Surg 2020 May;9(3):197-208

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.

Background: Chronic type A aortic dissection (cTAAD) in Marfan syndrome (MFS) is rare. Surgical experience is limited and the role of frozen elephant trunk (FET) technique remains undefined. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and FET technique for cTAAD in MFS.

Methods: The clinical data of sixty-eight patients with MFS undergoing FET and TAR for cTAAD were analyzed.

Results: Mean age was 35.8±9.7 years and thirty-nine were male (57.4%). Operative mortality was 10.3% (7/68). Stroke occurred in one (1.5%), re-exploration for bleeding in five (7.3%), low cardiac output in four (5.9%), and acute renal failure in two (2.9%). Follow-up was complete in 100% (61/61) at mean 7.3±4.0 years. The false lumen was obliterated in 73.5% across FET and 50.0% in unstented descending aorta (DAo). Distal dilation occurred in twenty patients, six of whom underwent thoracoabdominal aortic replacement, one abdominal aortic replacement and one thoracic endovascular aortic repair (TEVAR). Late death occurred in five. At ten years, 59.8% were free from distal aortic dilation, and the incidences were 23.2% for death, 14.4% for distal reoperation, and 62.4% for reoperation-free survival. Predictors for operative mortality were extra-anatomic bypass [odds ratio (OR), 229.592; P=0.036], preoperative maximal size (DMax) of aortic sinuses (mm) (OR, 1.134; P=0.032) and cardiopulmonary bypass (CPB) time (minute) (OR, 1.061; P=0.041). Risk factors for aortic dilatation included patent false lumen at diaphragmatic hiatus [hazard ratio (HR), 5.374; P=0.008], preoperative DMax (mm) of proximal DAo (HR, 1.068; P=0.001) and renal arteries (HR, 1.102; P=0.005) which also predicted distal reoperation (HR, 1.149; P=0.001). The time from onset to operation (day) (HR, 1.002; P=0.004) and CPB time (minute) (HR, 1.032; P=0.036) predicted late death.

Conclusions: This study shows that the TAR and FET technique is a safe and durable approach to cTAAD in patients with MFS. The operation should be performed as early as possible to optimize clinical outcomes.
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http://dx.doi.org/10.21037/acs.2020.03.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298250PMC
May 2020

Perioperative Chemotherapy on Survival in Patients With Upper Urinary Tract Urothelial Carcinoma Undergoing Nephroureterectomy: A Population-Based Study.

Front Oncol 2020 21;10:481. Epub 2020 Apr 21.

Department of Urology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.

To estimate the stage-specific impact of perioperative chemotherapy on survival for upper urinary tract urothelial carcinoma (UTUC) patients treated with nephroureterectomy (NU). Overall, 7,278 UTUC patients treated with NU from 2004 to 2015 were identified within the SEER database. Kaplan-Meier plots were used to elucidate overall survival (OS) and cancer-specific survival (CSS) rates. Multivariable Cox regression analyses were used to test the impact of chemotherapy on survival rates, after stratifying according to pathological stage. Chemotherapy was performed in 17.3% of patients and in 5.7, 11.5, 25.4, and 51.3% of patients with, respectively, pT1, pT2, pT3, and pT4 disease ( < 0.001). In multivariable analyses, perioperative chemotherapy was associated with a lower OS in pT2 patients and a lower CSS in pT1 disease (both < 0.05), while predisposed to a higher OS in pT3 and pT4 patients (both < 0.01). Moreover, perioperative chemotherapy was prone to a higher OS or CSS in pN+ disease compared to no chemotherapy (both < 0.01). Perioperative chemotherapy was more frequently performed in locally advanced UTUC patients. The beneficial effect of chemotherapy on OS was evident in pT3/pT4 and pN+ patients. In addition, a clear CSS benefit was observed in patients who received chemotherapy for pN+ UTUC, while perioperative chemotherapy may reduce CSS for pT1 and OS for pT2 patients following NU.
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http://dx.doi.org/10.3389/fonc.2020.00481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186446PMC
April 2020

Aortic dissection during pregnancy and postpartum in patients with Marfan syndrome: a 21-year clinical experience in 30 patients.

Eur J Cardiothorac Surg 2020 08;58(2):294-301

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China.

Objectives: Pregnancy-related aortic dissection (AoD) in Marfan syndrome is a lethal catastrophe. Due to its rarity and limited clinical experience, there is no consensus regarding the optimal management strategy. We seek to present our 21-year experience in such patients , focusing on management strategies and early and late outcomes.

Methods: Between 1998 and 2019, we managed 30 pregnant women with Marfan syndrome (mean age 30.7 ± 4.3 years) who sustained AoD at a mean of 28.3 ± 8.8 weeks of gestation (GWs). AoD was acute in 21 (70%), type A (TAAD) in 24 (80%) and type B (TBAD) in 6 (20%). Fourteen TAADs (58.3%, 14/24) and 2 TBADs (33.3%, 2/6) occurred in the third trimester or postpartum. The maximal aortic size was < 45 mm in 26.7% (8/30; 3 TAADs, 5 TBADs). Management strategy was based on the types of dissection and GWs (i.e. surgical versus medical treatment, surgery or delivery first).

Results: TAADs were treated medically in 1 and surgically in 23. The timing of delivery and surgery were caesarean first at 35.4 ± 6.1 GWs in 7 (29.2%), followed by surgery after mean 46 days; single-stage C-section and surgery at 32.0 ± 5.0 GWs in 10 (41.7%); and surgery first at 18.0 ± 5.8 GWs in 6 (25%), followed by C-section after 20 days. Maternal and foetal mortality were 28.6% (2/7) and 14.3% (1/7), 10.0% (1/10) and 20.0% (2/10) and 16.7% (1/6) and 83.3% (5/6), respectively. Five TBADs (83.3%) were managed with C-section followed by surgery in 2 and medical treatment in 3. The respective maternal and foetal mortality were 50% (1/2) and 100% (2/2) and 33.3% (1/3) and 33.3% (1/3), respectively. One TBAD was managed surgically first followed by C-section, resulting in maternal survival and foetal death. Follow-up was complete in 95.8% (23/24) at 3.7 ± 2.9 years. Four late deaths occurred and reoperation was performed in 1 patient. Maternal and foetal survival were 64.3% and 54.1% at 6 years, respectively.

Conclusions: Management of AoD in pregnant women with Marfan syndrome should be based on types of dissection (surgical versus medical) and gestational age (delivery or surgery first), which largely determine maternal and foetal survival. Aortic repair should be considered prior to conception in women with Marfan syndrome even at diameters smaller than recommended by current guidelines.
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http://dx.doi.org/10.1093/ejcts/ezaa048DOI Listing
August 2020

Extended repair for acute type A aortic dissection: long-term outcomes of the frozen elephant trunk technique beyond 10 years.

J Cardiovasc Surg (Torino) 2020 Jun 18;61(3):292-300. Epub 2020 Feb 18.

Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital of Capital Medical University, Beijing, China.

Background: Long-term data are scarce regarding the efficacy of extended repair for acute type A aortic dissection (ATAAD) using the frozen elephant trunk and total arch replacement (FET + TAR) technique. We seek to evaluate our single-center experience with the FET + TAR technique in patients with ATAAD, focusing on early and long-term survival and reoperation.

Methods: The early and long-term outcomes of FET + TAR were analyzed for 518 patients with ATAAD operated on between April 2003 and December 2012. Mean age 46.2±10.5 years and 426 were male (82.2%). The mean time from symptomatic onset to surgery was 4.8±3.7 days. Malperfusion occurred in 66 (12.7%) and Marfan syndrome (MFS) in 51 (9.8%). Bentall procedure was performed in 153 (29.5%), aortic cusp resuspension in 82 (15.8%), root remodeling (uni- or bi-Yacoub) in 19 (3.7%), ascending aortic replacement in 22 (4.2%) and extra-anatomic bypass in 15 patients (2.9%). The times of cardiopulmonary bypass (CPB), cross-clamp and selective antegrade cerebral perfusion were 201±50, 112±34, and 26±10 minutes, respectively.

Results: Operative mortality rate was 7.5% (39/518). Spinal cord injury occurred in 2.5% (13/518), stroke in 2.9% (15/518), re-exploration for bleeding in 2.5% (13/518) and acute kidney injury in 4.6% (24/518). Early reintervention with thoracic endovascular aortic repair (TEVAR) was performed in 3 (0.6%). Follow-up was complete in 98.7% (473/479) at mean 9.0±4.8 years (range 0.2-16.2). Late death occurred in 74, distal dilation in 31 and distal new entry in 9 patients. Late reoperation was performed in 31 patients, including TEVAR in 12, thoracoabdominal aortic replacement in 9, abdominal aortic replacement in 2, and anastomotic leak repair in 5. Survival and freedom from distal reoperation were 77.3% (95% confidence interval [CI] 72.9-81.1%) and 69.8% (95% CI 63.4-75.3%), and 92.9% (95% CI 89.9-95.0%) and 92.9% (95% CI 89.9-95.0%) at 10 and 15 years, respectively. Competing risks analysis showed that at 12 years, the incidence was 28.0% for death, 8.5% for distal reoperation, and 63.5% of patients were alive without reoperation. Multivariable analyses found that CPB time (in minutes) (odds ratio [OR], 1.011; 95% CI 1.006-1.017; P<0.001) and malperfusion syndrome (binary) (OR 2.291; 95% CI 1.283-6.650; P=0.011) were predictive of operative mortality, while multiple malperfusion predicted late death (hazard ratio, HR 6.815; 95% CI 2.447-18.984; P<0.001). Risk factors for late death and distal reoperation included MFS (HR, 1.824; 95% CI 1.078-3.087; P=0.025) and malperfusion (HR, 1.787; 95% CI 1.042-3.064; P=0.035).

Conclusions: In this large series of patients with ATAAD, the FET + TAR technique has achieved favorable early and long-term survival and freedom from reoperation up to 15 years. Marfan syndrome and malperfusion syndrome were risk factors for early and late mortality and distal reoperation. This study adds long-term evidence supporting the use of the FET + TAR technique in patients with ATAAD involving the arch and descending aorta.
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http://dx.doi.org/10.23736/S0021-9509.20.11293-XDOI Listing
June 2020

Total arch replacement and frozen elephant trunk for aortic dissection in aberrant right subclavian artery.

Eur J Cardiothorac Surg 2020 07;58(1):104-111

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.

Objectives: Aortic dissection (AoD) in the presence of an aberrant right subclavian artery (ARSA) is very rare. Clinical experience is limited, and there is no consensus regarding the optimal management strategy. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and frozen elephant trunk (FET) technique as an approach to AoD in patients with ARSA by retrospectively analysing our single-centre experience.

Methods: From 2009 to 2017, we performed TAR + FET for 22 patients with ARSA sustaining AoD (13 acute, 59.1%). The mean age was 46.0 years [standard deviation (SD) 8.3], and 19 patients were male (86.4%). ARSA orifice was dilated in 15 (68.2%) patients, and a Kommerall diverticulum was diagnosed in 13 (59.1%) patients with a mean diameter of 21.8 mm (SD 7.7; range 15-40). Surgery was performed via femoral and right/left carotid cannulation under hypothermic circulatory arrest at 25°C. The ARSA was reconstructed using a separate branched graft.

Results: ARSA was closed proximally by ligation in 16 (72.7%) patients, direct suture in 4 (18.2%) patients and both in 2 (9.1%) patients. Operative mortality was 13.6% (3/22). Type Ib endoleak occurred in 1 (4.5%) patient at 8 days. Follow-up was complete in 100% at mean 4.2 years (SD 2.0), during which 3 late deaths and 1 reintervention for type II endoleak occurred. Survival was 81.8% and 76.4% at 3 and 5 years, respectively. Freedom from reoperation was 89.2% up to 8 years. In competing risks analysis, the incidence was 22.1% for death, 10.8% for reoperation and 67.1% for event-free survival at 5 years. The false lumen, ARSA orifice and Kommerall diverticulum were obliterated in 100%. Grafts were patent in 100%. No patients experienced cerebral ischaemia and upper extremity claudication. Hypothermic circulatory arrest time (min) was sole predictor for death and aortic reintervention (hazard ratio 1.168, 95% confidence interval 1.011-1.348; P = 0.034).

Conclusions: The TAR and FET technique is a safe and efficacious approach to AoD in patients with ARSA. Modifications of routine TAR + FET techniques are essential to successful repair, including femoral and right/left carotid artery cannulation, ligation of ARSA on the right side of the trachea and ARSA reconstruction with a separate graft.
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http://dx.doi.org/10.1093/ejcts/ezaa029DOI Listing
July 2020

Chronologic and Climatic Factors of Acute Aortic Dissection: Study of 1642 Patients in Two Continents.

Ann Thorac Surg 2020 08 28;110(2):575-581. Epub 2019 Dec 28.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China; Aortic Institute at Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut.

Background: The purpose of this study was to examine whether chronologic and climatic factors and lunar phases affect the onset of acute aortic dissection (AAD).

Methods: The frequencies of AAD were analyzed with regard to the chronologic and climatic factors and lunar phases on the day when AAD occurred for 1642 patients with AAD from two aortic referral centers in the United States and China.

Results: Mean age of patients was 51.6 ± 13.1 years, and 1260 (76.7%) were men. Dissection was type A in 1125 patients (68.5%) and type B in 517 (31.5%). Early mortality rate was 11.6% (190 of 1642), including 89 aortic ruptures before operation and 101 operative deaths. There was a winter peak in occurrence (33.6%, P < .01) with a relative risk of 1.519. In a week, the frequency was highest on Wednesday (15.5%) and Monday (15.2%), and lowest on Sunday (12.8%). Month-specific incidence was significantly inversely correlated to the mean temperature (rho = -0.650, P = .022) and directly correlated to the atmospheric pressure (rho = 0.706, P = .001). The proportion of type A dissection was significantly higher in the full moon phase compared with type B dissection (73.7% vs 66.9%, P = .012).

Conclusions: Acute aortic dissection exhibits significant chronologic variation in the frequency of occurrence, with a peak in winter and on Wednesdays, and nadir in summer and on Sundays. The incidence is significantly correlated to the mean temperature and atmospheric pressure. The proportion of type A dissection is higher in the full moon phase. These results are important for understanding the mechanisms involved in triggering AAD events and helpful for improving disease prevention and patient care.
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http://dx.doi.org/10.1016/j.athoracsur.2019.11.013DOI Listing
August 2020

Conservative arch management versus aggressive arch reconstruction for type A intramural hematoma.

Ann Cardiothorac Surg 2019 Sep;8(5):551-555

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.

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http://dx.doi.org/10.21037/acs.2019.07.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785489PMC
September 2019

Can Frozen Elephant Trunk Cure Type I Dissection Confined to Thoracic Aorta in Marfan Syndrome?

Ann Thorac Surg 2020 04 5;109(4):1174-1182. Epub 2019 Sep 5.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and the Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China. Electronic address:

Background: This study sought to evaluate the long-term impact of frozen elephant trunk (FET) on the distal aorta of patients with Marfan syndrome (MFS) who had type I dissection confined to the thoracic aorta (above the diaphragmatic hiatus).

Methods: Between 2003 and 2016, 42 patients with MFS (Ghent or revised Ghent criteria) (age 33.3 ± 8.9 years; 27 men; 64.3%) sustaining type I dissection above the diaphragmatic hiatus involving the aortic arch (22 acute; 52.4%) underwent total arch replacement and FET. Dissection extended distally to the mid-descending aorta in 32 (76%) and to above the diaphragmatic hiatus in 10 (24%) patients. Operative mortality was 4.8% (2 of 42). Follow-up was 100% at 6.3 ± 3.0 years.

Results: Maximal aortic sizes at the mid-descending aorta, diaphragmatic hiatus, renal arteries, and largest segment of abdominal aorta were 22.8, 21.1, 19.1, and 19.9 mm preoperatively and 23.1, 22.0, 19.8, and 22.4 mm on the latest computed tomographic angiography. Dilation and complete remodeling of the distal aorta occurred in 10.0% (4 of 40) and 90% (36 of 40) of patients, respectively. One late death occurred, and 3 distal reoperations were performed. Preoperative abdominal aortic maximal aortic size was predictive of distal dilatation (mm) (hazard ratio, 1.78; P = .021) and reoperation (≥25 mm vs <25 mm) (hazard ratio, 12.88; P = .037). At 10 years, freedom from dilation, reoperation, and death were 69.8%, 78.1%, and 90.0%, respectively. At 8 years, the rates of death, reoperation, and reoperation-free survival were 10%, 11%, and 79%, respectively.

Conclusions: The FET technique has a positive remodeling impact on type I dissection confined to the thoracic aorta in patients with MFS. This study adds evidence supporting the safety and durability of this extended approach for type I aortic dissection in MFS.
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http://dx.doi.org/10.1016/j.athoracsur.2019.07.051DOI Listing
April 2020

Surgical repair of cervical aortic arch: An alternative classification scheme based on experience in 35 patients.

J Thorac Cardiovasc Surg 2020 06 18;159(6):2202-2213.e4. Epub 2019 Jun 18.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China.

Objective: Cervical aortic arch (CAA) is rare and difficult to repair. Clinical experience is limited. We report the surgical techniques and midterm outcomes in 35 patients with CAA based on an alternative classification scheme.

Methods: Of 35 patients with CAA, 30 (85.7%) had left-sided aortic arch and 5 had (14.3%) right-sided aortic arch (all 5 had a vascular ring). Mean age was 34.2 ± 13.1 years, 23 were female (65.7%), and 18 were asymptomatic (51.4%). Surgical access and procedure were chosen according to an alternative classification scheme that is based on the presence or absence of vascular ring and relationship of descending aorta to the side of the aortic arch. In the left-sided aortic arch group, aortic arch reconstruction though median sternotomy was performed in 15 patients, and distal arch and descending thoracic aortic replacement via left thoracotomy in 15 patients. In the right-sided aortic arch group, ascending-to-descending aortic bypass was done via median sternotomy in 2 patients and right thoracotomy in 1, and distal arch and descending thoracic aortic replacement via right thoracotomy in 2 patients.

Results: Neither death nor spinal cord injury occurred. Left recurrent laryngeal nerve injury, prolonged ventilation, and reexploration for bleeding occurred in 1 each. In 11 patients with coarctation, the upper-lower limb gradient decreased significantly postoperatively (from 34.0 ± 12.7 to 10.2 ± 2.7 mm Hg; P < .01). The diseased aortic segment was excluded in 34 patients, except 1 with residual aneurysm in the proximal descending thoracic aorta. Follow-up was complete in 100% at mean 4.4 ± 2.0 years. No late death, limb ischemia, or stroke occurred. Endovascular repair was performed in 1 patient, and ascending aortic dilation occurred in 1 patient. The residual aorta remained nondilated in 33 patients. Aortic grafts were patent in 100%, with no anastomotic leak or pseudoaneurysm. At 6 years, the incidences of death, aortic events, and event-free survival were 0%, 6.5%, and 93.5%, respectively.

Conclusions: Open repair of CAA can achieve favorable early and midterm outcomes. Surgical accesses and procedures should be chosen based on type of CAA, anatomic variations and associated anomalies. Our alternative categorization scheme of CAA is intuitive and comprehensive, which may facilitate classification and surgical decision making.
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http://dx.doi.org/10.1016/j.jtcvs.2019.03.143DOI Listing
June 2020

Surgical repair of graft aneurysm following ascending-to-abdominal aortic bypass.

J Vasc Surg Cases Innov Tech 2019 Jun 25;5(2):183-186. Epub 2019 May 25.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China.

Graft aneurysm after ascending aorta to abdominal aorta bypass is a rare complication of repair of coarctation of the aorta. We present a case of an aneurysm measuring 75 mm in diameter at the midportion of the prosthetic graft in a 33-year-old man. To prevent aneurysm rupture, redo ascending-to-abdominal aortic bypass was performed through an upper ministernotomy and upper midline laparotomy. No postoperative complications occurred. The patient was successfully discharged on postoperative day 6. Although ascending-to-abdominal aortic bypass can achieve long-term patency, the prosthetic graft still has the rare risk of aneurysm formation, as highlighted in this case. Early diagnosis and timely management of this rare complication are essential in preventing aneurysm rupture.
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http://dx.doi.org/10.1016/j.jvscit.2018.12.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536852PMC
June 2019

Frozen elephant trunk does not increase incidence of paraplegia in patients with acute type A aortic dissection.

J Thorac Cardiovasc Surg 2020 04 14;159(4):1189-1196.e1. Epub 2019 Apr 14.

Liverpool Centre for Cardiovascular Science, Thoracic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom. Electronic address:

Objective: We seek to assess the safety of total arch replacement with frozen elephant trunk for acute type A aortic dissection in respect to the risks of operative mortality, stroke, and paraplegia using an international multicenter registry (ARCH).

Methods: The ARCH Registry database from 37 participating centers was analyzed between 2000 and 2015. Patients who underwent emergency surgery for acute type A aortic dissection treated by total arch replacement with or without frozen elephant trunk were included. Operative mortality, permanent neurologic deficits, and spinal cord injury were primary end points. These end points were analyzed using univariate and hierarchical multivariate regression analyses, as well as conditional logistic regression analysis and post hoc propensity-score stratification.

Results: A total of 11,928 patients were enrolled in the ARCH database, of which 6180 were managed with total arch replacement. A comprehensive analysis was performed for 978 patients who underwent total aortic arch replacement for acute type A aortic dissection with or without frozen elephant trunk placement. In propensity-score matching, there were no significant differences between total arch replacement and frozen elephant trunk in terms of permanent neurologic deficits (11.9% vs 10.1%, P = .59) and spinal cord injury (4.0% vs 6.3%, P = .52) For patients included in the post hoc propensity-score stratification, frozen elephant trunk was associated with a statistically significantly lower mortality risk (odds ratio, 0.47; P = .03).

Conclusions: The use of frozen elephant trunk for acute type A aortic dissection does not appear to increase the risk of paraplegia in appropriately selected patients at experienced centers. The exact risk factors for paraplegia remain to be determined.
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http://dx.doi.org/10.1016/j.jtcvs.2019.03.097DOI Listing
April 2020

Acute Aortic Dissection in Young Adult Patients: Clinical Characteristics, Management, and Perioperative Outcomes.

J Invest Surg 2020 Mar 25;33(3):211-217. Epub 2019 Mar 25.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China.

Acute aorta dissection (AD) is a fatal emergency, however, studies addressing the clinical characteristics, management, and outcome of acute AD in young adult patients aged under 45 years in China are very few. A retrospective study including 490 patients with acute AD as the final diagnosis was conducted. Patients' demographics, clinical characteristics, medical history, and laboratory and diagnostic imaging findings were retrieved from medical records. The median age of young adult patients with acute AD was 38 years old with an interquartile range from 33 to 41. Male and smoker constituted 84.49% and 50.61% of the cohort, respectively. Hypertension was found in 54.49%, while Marfan syndrome was seen in 4.29% of the patients. Abrupt onset of chest or back pain was the most common symptoms (85.31%), while altered consciousness, coma and oliguria were less reported. Most patients (89.39%) were managed with surgical interventions. Typical complications (central nervous system complications, spinal cord ischemia, myocardial ischemia/infarction, mesenteric ischemia/infarction and acute renal failure) were seen in a small portion of treated patients during perioperative period. For in-hospital mortality there were 24 (∼5%) cases recorded. Correlation analysis indicated that perioperative complications were associated with the length of cardiopulmonary bypass (CPB) ( < 0.0001), and mortality after surgery correlated history of prior cardiac surgery ( = 0.043). CPB and prior cardiac surgery were associated with perioperative complications and mortality after surgery, respectively. The findings are valuable to the further refinement of diagnosis and surgical management of patients with acute aortic dissection.
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http://dx.doi.org/10.1080/08941939.2018.1489916DOI Listing
March 2020

Renal malperfusion affects operative mortality rather than late death following acute type A aortic dissection repair.

Asian J Surg 2020 Jan 14;43(1):213-219. Epub 2019 Mar 14.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China. Electronic address:

Objective: The aim of our study was to assess how much renal malperfusion increases the risk of early and late mortality in patients with acute type A aortic dissection (ATAAD) undergoing surgical repair.

Methods: This study included 218 patients with ATAAD undergoing surgical repair using the total arch replacement and frozen elephant trunk technique. Mean age was 47.8 ± 10.7 years and 170 were male (78.0%). Based on clinical symptoms and computed tomographic angiography (CTA) findings, 48 patients were diagnosed with preoperative renal malperfusion (22.0%). Clinical data were compared between two groups. The impact of renal malperfusion on operative and late mortality were evaluated with Cox regression.

Results: Patients with renal malperfusion experienced significantly higher incidences of persistent postoperative acute kidney injury (AKI; 10/48, 20.8% vs 7/170, 4.1%; p < 0.001) and transient AKI (10/48, 20.8% vs 8/170, 4.7%; p = 0.001) as well as operative mortality (22.9%, 11/48 vs 8.3%, 14/170; p = 0.023). Five-year survival was significantly lower in the renal malperfusion group (72.9% vs 87.0%, p = 0.003). Renal malperfusion was the risk factor for operative mortality (hazard ratio, HR, 2.74; 95% CI, 1.07-6.99; p = 0.035) and overall mortality (HR, 2.64; 95% CI, 1.23-5.67; p = 0.013) but did not predict late death (HR, 2.46; 95% CI, 0.65-9.35; p = 0.187).

Conclusion: Renal malperfusion increases the risk of operative mortality by 3 times but did not affect late death in patients undergoing acute type A dissection repair.
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http://dx.doi.org/10.1016/j.asjsur.2019.02.004DOI Listing
January 2020

Fate of distal aorta after frozen elephant trunk and total arch replacement for type A aortic dissection in Marfan syndrome.

J Thorac Cardiovasc Surg 2019 Mar 24;157(3):835-849. Epub 2018 Aug 24.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China. Electronic address:

Objective: The use of the frozen elephant trunk technique for type A aortic dissection in Marfan syndrome is limited by the lack of imaging evidence for long-term aortic remodeling. We seek to evaluate the changes of the distal aorta and late outcomes after frozen elephant trunk and total arch replacement for type A aortic dissection in patients with Marfan syndrome.

Methods: Between 2003 and 2015, we performed frozen elephant trunk + total arch replacement for 172 patients with Marfan syndrome suffering from type A aortic dissection (94 acute; 78 chronic). Mean age was 34.6 ± 9.3 years, and 121 were male (70.3%). Early mortality was 8.1% (14/172), and follow-up was complete in 98.7% (156/158) at a mean of 6.2 ± 3.3 years. Aortic dilatation was defined as a maximal diameter of greater than 50 mm or an average growth rate of greater than 5 mm/year at any segment detected by computed tomographic angiography. Temporal changes in the false and true lumens and maximal aortic size were analyzed with linear mixed modeling.

Results: After surgery, false lumen obliteration occurred in 86%, 39%, 26%, and 21% at the frozen elephant trunk, unstented descending aorta, diaphragm, and renal artery, respectively. The true lumen expanded significantly over time at all segments (P < .001), whereas the false lumen shrank at the frozen elephant trunk (P < .001) and was stable at distal levels (P > .05). Maximal aortic size was stable at the frozen elephant trunk and renal artery (P > .05), but grew at the descending aorta (P = .001) and diaphragm (P < .001). Respective maximal aortic sizes before discharge were 40.2 mm, 32.1 mm, 31.6 mm, and 26.9 mm, and growth rate was 0.4 mm/year, 2.8 mm/year, 3.6 mm/year, and 2.6 mm/year. By the latest follow-up, distal maximal aortic size was stable in 63.5% (99/156), and complete remodeling down to the mid-descending aorta occurred in 28.8% (45/156). There were 22 late deaths and 23 distal reoperations. Eight-year incidence of death was 15%, reoperation rate was 20%, and event-free survival was 65%. Preoperative distal maximal aortic size (mm) predicted dilatation (hazard ratio, 1.11; P < .001) and reoperation (hazard ratio, 1.07; P < .001). A patent false lumen in the descending aorta predicted dilatation (hazard ratio, 3.88; P < .001), reoperation (hazard ratio, 3.36; P = .014), and late death (hazard ratio, 3.31; P = .045).

Conclusions: The frozen elephant trunk technique can expand the true lumen across the aorta, decrease or stabilize the false lumen, and stabilize the distal aorta in patients with Marfan syndrome with type A aortic dissection, thereby inducing favorable remodeling in the distal aorta. This study adds long-term clinical and radiologic evidence supporting the use of the frozen elephant trunk technique for type A dissection in Marfan syndrome.
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http://dx.doi.org/10.1016/j.jtcvs.2018.07.096DOI Listing
March 2019

Decision-making algorithm for ascending aortic aneurysm: Effectiveness in clinical application?

J Thorac Cardiovasc Surg 2019 05 14;157(5):1733-1745. Epub 2018 Nov 14.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn. Electronic address:

Objective: The risk of rupture and dissection in ascending thoracic aortic aneurysms increases as the aortic diameter exceeds 5 cm. This study evaluates the clinical effectiveness of a specific algorithm based on size and symptoms for preemptive surgery to prevent complications.

Methods: A total of 781 patients with nondissecting ascending thoracic aortic aneurysms who presented electively for evaluation to our institution from 2011 to 2017 were triaged to surgery (n = 607, 77%) or medical observation (n = 181, 24%) based on a specific algorithm: surgery for large (>5 cm) or symptomatic aneurysms. A total of 309 of 781 patients did not undergo surgery. Of these, 128 (16%) had been triaged to prompt repair but did not undergo surgery for a variety of reasons ("surgery noncompliant and overwhelming comorbidities" group). Another 181 patients (24%) were triaged to medical management ("medical" group).

Results: In the "surgery noncompliant and overwhelming comorbidities" versus the "medical" group, mean aortic diameters were 5 ± 0.5 cm versus 4.45 ± 0.4 cm and aortic events (rupture/dissection) occurred in 17 patients (13.3%) versus 3 patients (1.7%), respectively (P < .001). Later elective surgeries (representing late compliance in the "surgery noncompliant and overwhelming comorbidities group" or onset of growth or symptoms in the "medical" group) were conducted in 21 patients (16.4%) versus 15 patients (8.3%) (P = .04), respectively. Death ensued in 20 patients (15.6%) versus 6 patients (3.3%) (P < .001), respectively. In the "surgery noncompliant and overwhelming comorbidities" group, 7 of 20 patients died of definite aortic causes compared with none in the "medical" group.

Conclusions: Patients with ascending thoracic aortic aneurysms who did not follow surgical recommendations experienced substantially worse outcomes compared with medically triaged candidates. The specific algorithm based on size and symptoms functioned effectively in the clinical setting, correctly identifying both at-risk and safe patients.
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http://dx.doi.org/10.1016/j.jtcvs.2018.09.124DOI Listing
May 2019

Frozen elephant trunk with modified arch reconstruction and left subclavian transposition for chronic type A dissection.

J Thorac Dis 2018 Sep;10(9):5376-5383

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing 100029, China.

Background: Several methods of arch vessel reconstruction, such as (island) and branched graft techniques, have been proposed to treat aortic arch pathologies during total arch replacement (TAR). We seek to review our experience with modified en bloc technique and left subclavian (LSCA)-left carotid artery (LCCA) transposition in TAR and frozen elephant trunk (FET) procedure for chronic type A aortic dissection (CTAAD).

Methods: From September 2010 to September 2016, 35 consecutive patients with CTAAD underwent modified arch reconstruction with LSCA-LCCA transposition during TAR and FET procedure. Computed tomographic angiography (CTA) was performed during follow-up.

Results: In-hospital mortality was 5.7% (2/35). No neurological deficit or spinal cord injury occurred. Re-exploration for bleeding and continuous renal replacement therapy were required in 2 patients each (5.7%). Follow-up was complete in 100% for a mean duration of 4.1±1.8 years (range, 0.5-6.7 years). One patient experienced a transient stroke and thoracoabdominal aortic replacement was performed in 1. There were 2 late non-cardiac deaths. Survival was 87.9% (95% CI, 70.7-95.3%) at 6 years. At 6 years, the incidence was 3% for reoperation, 12% for late death, and 85% of patients were alive without reoperation. The anastomosis between the LSCA and LCCA was patent in 100%.

Conclusions: Acceptable early and mid-term outcomes were achieved for patients with chronic type A dissection using technique with LSCA-LCCA transposition during TAR and FET procedure. This technique may be an alternative approach to chronic type A dissection in selected patients.
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http://dx.doi.org/10.21037/jtd.2018.08.140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196179PMC
September 2018

Distal Stent Graft-Induced New Entry After TEVAR of Type B Aortic Dissection: Experience in 15 Years.

Ann Thorac Surg 2019 03 4;107(3):718-724. Epub 2018 Nov 4.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Bejing, China. Electronic address:

Background: Experience is limited with distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of type B dissection (TBAD). We report the management strategy and outcomes in such patients.

Methods: Clinical data were analyzed for 95 patients (age, 53.2 ± 10.9 years; 82 men) who presented with distal SINE after TEVAR for TBAD.

Results: Follow-up was 100% for 7.2 ± 3 years after primary TEVAR. Distal SINE occurred at a mean of 2.7 ± 2.4 years. Re-TEVAR was performed for 78, with routine stent grafts in 64 and a more tapered graft in 14. Three patients were managed surgically and 14 medically. Two patients died after re-TEVAR. During follow-up at 5.8 ± 2.9 years, late death occurred in 19 patients, 7 with medical therapy and 12 with re-TEVAR. Distal SINE recurred in 11 at 3.5 ± 1.7 years after re-TEVAR. Reintervention significantly improved survival up to 8 years compared with medical therapy (88.3% vs 63.5%, p = 0.001). In 64 patients with routine stent grafts, mortality was 24%, distal SINE recurred in 20%, and recurrence-free survival was 56% at 6 years. Neither death nor recurrence of SINE occurred in 14 patients with a more tapered stent graft. Predictors for distal SINE after primary TEVAR were stent graft length (hazard ratio, 0.984; p = 0.037) and chronic phase (hazard ratio, 1.725; p = 0.049).

Conclusions: In TBAD patients with distal SINE after TEVAR, reintervention with re-TEVAR could improve long-term survival significantly. Recurrence of distal SINE was high after re-TEVAR using routine stent grafts. More tapered stent grafts may be helpful in preventing the recurrence of distal SINE.
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http://dx.doi.org/10.1016/j.athoracsur.2018.09.043DOI Listing
March 2019
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