Cuntao Yu

Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: Experience with 107 patients

OBJECTIVE In patients with acute type A dissection, it is controversial whether to use a more aggressive strategy with extended aortic replacement to improve long-term outcome or to use a conventional strategy with limited ascending aortic or hemiarch replacement to circumvent a life-threatening situation. METHODS Between April 2003 and June 2007, 107 patients (17 women, 90 men; mean age, 45 +/- 11 years; range, 17-78 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Computed tomography was performed to evaluate the residual false lumen in the descending aorta during follow-up. RESULTS Thirty-day mortality was 3.74% (4/107 patients), and in-hospital mortality was 4.67% (5/107 patients). Spinal cord injury was observed in 3 patients (1 patient with left lower-extremity paraparesis and 2 patients with paraplegia). Cerebral infarction was observed in 3 patients, ventilator support exceeding 5 days was required in 9 patients, and rebleeding was observed in 4 patients. During a mean follow-up of 35 +/- 14 months, 3 patients died and 3 patients were lost to follow-up. On postoperative computed tomography, complete thrombus formation was observed around the stented elephant trunk in 95% of patients (95/100) and at the diaphragmatic level in 69% of patients (69/100). CONCLUSION Low morbidity and mortality were achieved using total arch replacement combined with stented elephant trunk implantation. These encouraging surgical results and postoperative outcomes favor this more aggressive procedure for acute type A dissection.

Treatment of complex coarctation and coarctation with cardiac lesions using extra-anatomic aortic bypass

BACKGROUND Coarctation of the aorta with cardiac lesions or complex coarctation is a formidable challenge for cardiac surgeons. Extra-anatomic bypass allows simultaneous intracardiac repair or an alternative approach for patients with complex coarctation. METHODS Between July 1997 and March 2008, 43 patients with coarctation of the aorta underwent extra-anatomic bypass grafting, including 10 ascending-to-descending aorta bypasses and 33 ascending aorta-to-infrarenal abdominal aorta bypasses. Forty patients had additional cardiovascular disorders and concomitant procedures performed including aortic valve replacement, mitral valve replacement, coronary artery bypass grafting, closure of ventricular septal defect and patent ductus arteriosus, ascending aorta repair, and the Bentall procedure. The other three patients had complex coarctation of the aorta, including a long-segment coarctation in two cases, and descending aortic aneurysm in one. RESULTS Two patients died perioperatively: one due to air embolism during the cardiopulmonary bypass; one due to septic shock. There were no late deaths. Complications included laparotomy for mechanical ileus in one and re-exploration for bleeding in one case. There were no strokes or paraplegia and no grafted-related complication during follow-up period. Systolic blood pressure dropped from 160 +/- 27 mm Hg before surgery to 114 +/- 16 mm Hg postoperatively. Only two patients with mild hypertension postoperatively needed oral medicine. CONCLUSIONS Extra-anatomic aortic bypass via median sternotomy or median sternotomy-laparotomy can be performed with low morbidity and mortality. It is a preferable single-stage approach for patients with concomitant complex coarctation and cardiovascular disorders.

Hybrid total arch repair without deep hypothermic circulatory arrest for acute type A aortic dissection (R1).

OBJECTIVE To investigate the surgical outcomes of hybrid total arch repair without deep hypothermic circulatory arrest for patients with acute Stanford type A aortic dissection. METHODS Retrospective review of clinical data of patients with acute Stanford type A aortic dissection who underwent surgical repair at our institution between November 2009 and December 2011 identified 21 patients who underwent hybrid total arch repair without deep hypothermic circulatory arrest. The in-hospital and follow-up data were investigated. Postoperative serial computed tomography angiography was used to evaluate the fate of true and false lumen in arch and descending aorta. RESULTS Mean follow-up was 13.8 months (range, 3 to 21 months). The 1- and 12-month survival rates (by Kaplan-Meier analysis) were 95.2% (95% confidence interval, 86.2%-100%) and 90.5% (95% confidence interval, 78.0%-100%), respectively. No endograft caudal migration occurred. One patient with type I endoleak was successfully resolved during operation. There was no late rupture or paraplegia. CONCLUSIONS Hybrid total arch repair without deep hypothermic circulatory arrest offers a promising alternative to risk reduction of complications during the postoperative period and late adverse events resulting from false lumen enlargement in the arch and descending aorta.

Lung biopsy findings in previously inoperable patients with severe pulmonary hypertension associated with congenital heart disease

BACKGROUND Congenital heart disease with near-systemic pulmonary arterial pressures, previously thought to have irreversible pulmonary vascular disease (PVD), has been successfully corrected at our institution recently. Whether the PVD is reversible remains unknown. This study aimed to examine the nature of the pulmonary arterial vessels in these selective patients. METHODS All patients with congenital heart disease and severe pulmonary hypertension (PH) were selected using Diagnostic-treatment to undergo radical repair (n=49). Lung biopsy specimens were obtained during operation. The nature of PVD was determined by Heath-Edwards classification system. All specimens were quantitatively analyzed by calculating percentage media wall area, percentage media wall thickness and arteriole density. RESULTS Transcutaneous oxygen saturation of all selected patients increased significantly after Diagnostic-treatment (P<0.001). There were no operative deaths. Mean pulmonary artery pressure and pulmonary vascular resistance regressed significantly postoperatively (P<0.001). The incidence of postoperative PH was 59.2% (29/49). Of 49 selected patients with severe PH, 38 (77.6%) showed grade I change, 5 (10.2%) showed grade II change, 4 (8.2%) showed grade III change and only 2 (4%) showed grade IV change with plexiform lesion. The percentage media wall area, percentage media wall thickness and arteriole density were significantly increased in patients associated with PH than in normal subjects (P<0.001). Follow-up data showed the reversal of PVD in these 2 patients with plexiform lesions. CONCLUSIONS The PVD in these selective patients with congenital heart disease and severe PH using a Diagnostic-treatment-and-Repair strategy is generally reversible and these patients are operable in current era.

Repair of Chronic Type B Dissection With Aortic Arch Involvement Using a Stented Elephant Trunk Procedure

BACKGROUND A conventional single-stage procedure, staged procedures, or debranching of the supraaortic vessels, followed by immediate transfemoral stenting of the aortic arch, have been introduced to treat chronic type B dissection with aortic arch involvement. The best method for surgical repair of chronic type B dissection with aortic arch involvement alone or concomitant with proximal aortic lesions is not known. METHODS Between October 2003 and December 2008, 19 patients underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion through a median sternotomy. Thirteen patients had proximal aortic lesions. Postoperative computed tomography was used to evaluate thrombosis and absorption of the false lumen. RESULTS Concomitant proximal aortic lesions were repaired in all patients. Thirty-day mortality was 5.26% (1/19). There was one late death at a mean follow-up of 36 +/- 12 months. There was no spinal cord injury or visceral malperfusion. One patient with Marfan syndrome with chronic dissection underwent thoracoabdominal aortic replacement 6 months later. Obliteration of the false lumen around the stented elephant trunk was observed in 16 patients (94.1%, 16/17) during follow-up. CONCLUSIONS This technique is safe, effective, and economical. Replacement of aortic arch dissection and thrombosis of the dissected descending aorta was achieved simultaneously. Concomitant proximal aortic lesions were repaired. Favorable surgical outcomes and postoperative results using this technique were obtained in patients with chronic type B dissection with aortic arch involvement alone or concomitant with proximal aortic lesions.

Total Arch Replacement with Stented Elephant Trunk Technique: A Proposed Treatment for Complicated Stanford Type B Aortic Dissection

Abstract  Objectives: The treatment of Stanford type B aortic dissections involving the arch or associated with proximal aortic aneurysms remains a surgical challenge. We report our results with total arch replacement with the stented elephant trunk (SET) procedure for these complicated Stanford type B aortic dissections. Methods: Between December 2003 and June 2008, 31 patients were admitted for complicated type B dissection (12 acute, 19 chronic). The mean age at operation was 44.3 ± 10.6 years (range: 22‐68 years). The surgeries were performed by using total arch replacement combined with SET implantation. Enhanced computed tomography (CT) was performed before discharge as well as 3 months and annually to evaluate the condition of the graft and the residual false lumen. Results: The procedure was successful in all but two patients; two patients died of multiple organ failure following surgery. No paraplegia was observed after surgery. Follow‐up was completed in 27 of 29 patients and the mean follow‐up period was 18.4 ± 12.3 months (range: 6‐54 months). During follow‐up CT scans, thrombus formation was observed in the descending aortic false lumen excluded by the stented graft in most patients. One patient died during follow‐up while two patients with Marfan syndrome underwent successful operations for replacement of the remaining descending and abdominal aorta. Conclusion: Total arch replacement with the SET procedure has emerged as a viable option for complicated type B dissections and is associated with low morbidity and mortality. At mid‐term follow‐up, most patients have either thrombosed or have had no further increase in the false lumen of the descending aorta.

Acute Kidney Injury after Total Arch Replacement Combined With Frozen Elephant Trunk Implantation: Incidence, Risk Factors, and Outcome

OBJECTIVES Acute kidney injury (AKI) is common after thoracic aortic surgery and is a significant predictor of morbidity and mortality. Total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation has been reported to produce satisfactory clinical outcomes, whereas several features of the surgical procedure may induce postoperative AKI. The authors aimed to clarify the incidence of and risk factors for postoperative AKI and the association of AKI with short-term outcomes. DESIGN This study was a retrospective analysis of a prospectively collected cohort. A multivariate logistic regression model was used to identify predictors of postoperative AKI. SETTING Single center. PARTICIPANTS Clinical data were analyzed for 553 consecutive patients who underwent TAR combined with FET implantation between 2013 and 2016. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: Postoperative AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Postoperative AKI occurred in 77.6% of the whole cohort. Patients in stage 3 AKI were associated with a higher incidence of major adverse events and in-hospital and 90-day mortality (p < 0.001, p < 0.05, p < 0.01, respectively). In the multivariate analysis, male sex (odds ratio [OR] 1.94; 95% confidence interval [95% CI] 1.22-3.18; p = 0.005); older age (per 10 years) (OR 1.37; 95% CI 1.14-1.67; p = 0.001); elevated body mass index (per 5 kg/m2) (OR 1.41; 95% CI 1.08-1.87; p = 0.01); and prolonged cardiopulmonary bypass duration (per 30 minutes) (OR 1.17; 95% CI 1.01-1.37; p = 0.03) were identified as independent predictors of postoperative AKI. CONCLUSION TAR combined with FET implantation carries a high-risk for postoperative AKI compared with other types of thoracic aortic surgeries. Cardiopulmonary bypass duration was identified as the only modifiable predictor of AKI, and patients may benefit from moderate hypothermic circulatory arrest instead of deep hypothermic circulatory arrest.

Morphological features of the thoracic aorta and supra-aortic branches in patients with acute Type A aortic dissection in China

OBJECTIVES This study aimed to investigate the morphological characteristics of the dissected thoracic aorta and brachiocephalic arteries within the Chinese population. METHODS A retrospective analysis of computed tomography scans of 387 patients with acute Type A aortic dissection was carried out. The dimensions of the thoracic aorta at multiple levels and other imaging characteristics were studied. RESULTS The patients with a maximum diameter ≥55 mm accounted for less than one-third of the population. Among those without Marfan syndrome (MFS) (n = 349), only 114 (32.8%) patients had a maximal aortic diameter ≥ 55 mm, whereas among those with MFS (n = 38), 20 (78.9%) had a maximal aortic diameter ≥ 45 mm. The predicted maximum aortic diameter is 88.46 - 0.81 × height (cm) + 63.02 × body surface area (m2) + 5.50 × (if diabetes, 1, if not, 0) - 6.63 × (if hypertension, 1, if not, 0). A positive correlation was established between a circular false lumen and the probability that brachiocephalic arteries were involved by dissection. The size ratio of false lumen to true lumen was greater in the circumferential group when compared with the crescent group. The independent predictors for the circumferential false lumen were age, atherosclerosis and smoking. CONCLUSIONS Herein, the morphological characteristics of the thoracic aorta among Chinese patients with acute Type A aortic dissection were described. The currently recommended criteria for prophylactic aorta surgery were applied to most patients with MFS but not to those without MFS within the Chinese population. Furthermore, the shape of the false lumen was identified as a putative risk factor that might affect the prognosis of the patients.

In-hospital major adverse outcomes of acute Type A aortic dissection

OBJECTIVES Acute Type A aortic dissection exhibits poor in-hospital outcomes after emergency surgery. Evaluation of risk predictors for in-hospital major adverse outcomes (MAO) is key to reducing the mortality rate and improving the quality of care. METHODS We enrolled 70 patients who presented with postoperative MAO and 195 patients who recovered well. Through univariate and multivariate analyses, clinical characteristics were compared between the patients in the 2 groups. RESULTS In-hospital mortality was 6.4% in this series. The patients in the MAO group were older and had a higher frequency of coronary artery involvement by dissection (60.0% vs 21.0%) (P < 0.05). Preoperatively, when compared to the group of patients without MAO, the patients in the MAO group were more likely to have a neurological deficit (18.6% vs 9.7%) and, to a certain extent, lower limb symptoms encompassing visceral and renal malperfusion (20.0% vs 8.2%) (P < 0.05). Compared to patients with MAO, patients without MAO experienced longer duration from initial onset of symptoms to surgery and had an ascending aorta with a larger diameter. In patients with MAO, the average durations of cardiopulmonary bypass (CPB), cardiac arrest and hypothermic circulatory arrest were much longer than those in patients with no MAO (all P < 0.001). Multivariate analysis showed that in-hospital adverse outcomes were associated with older age [odds ratio (OR) = 1.047 (1.008-1.087), P < 0.05], presentation of lower limb symptoms prior to surgery [OR = 2.905 (1.109-7.608), P < 0.05] and long CPB duration [OR = 1.011 (1.005-1.018), P < 0.01]. When patients with acute Type A aortic dissection experienced a duration from symptom onset to surgery [OR = 0.993 (0.987-0.999), P < 0.05] or had an ascending aorta with a large diameter [OR = 0.942 (0.892-0.995), P < 0.05], the number of postoperative adverse events decreased significantly. CONCLUSIONS At a centre that has a large caseload, where practitioners can become proficient through experience as well as training, good outcomes can be dependably produced in patients with acute Type A aortic dissection and without malperfusion syndromes. For patients presenting with these risk features, MAO need to be anticipated, and the incidence of a composite end point of major adverse events remains unsatisfactory.

Surgery for Type B Dissection Using a Short-Stented Elephant Trunk Procedure

BACKGROUND Stent grafting is a very important treatment for type B dissection. Some patients are unsuitable for endograft repair because of inadequate proximal and/or distal fixation zones. We reviewed our experience of proximal descending thoracic replacement combined with short-stented elephant trunk implantation for type B dissection for patients without adequate fixation zones for endografts. METHODS Twenty-one patients with type B dissection (10 acute, 11 chronic) underwent this procedure between August 2003 and December 2007. After replacement of the proximal descending thoracic aorta, a short-stented elephant trunk was implanted into the residual descending thoracic aorta. The residual false lumen was evaluated post-operatively using computed tomography (CT) scans. RESULTS There were no in-hospital deaths. One death was observed during a mean follow-up of 69 ± 15 months. One patient with preoperative shock suffered paraparesis but recovered postoperatively. One patient had paraplegia and was lost to follow-up. Cerebral hemorrhage was observed in 1 patient, but he recovered. Thrombus obliteration of the false lumen around the stented elephant trunk was observed in 19 patients (95%) and at the diaphragmatic level in 17 patients (85%) during follow-up. CONCLUSION Replacement of the proximal descending thoracic aorta combined with short-stented elephant trunk implantation was a suitable alternative for type B dissection for patients without adequate fixation zones for endografts (particularly for young subjects). This procedure allowed enlargement of the true lumen, re-establishment of the true lumen, induction of thrombosis of the false lumen, and shrinkage of the aorta. Injury to the spinal cord, however, was an intractable problem.