Association between cardiopulmonary bypass time and 90-day postoperative mortality in patients undergoing arch replacement with the frozen elephant trunk: a retrospective cohort study

Background:The aortic arch replacement and cardiopulmonary bypass(CPB)are both associated with the early mortality after cardiothoracic surgery.This study aimed to investigate the relationship between CPB time and 90-day post-operative mortality in patients undergoing aortic arch surgery using the frozen elephant trunk(FET)technique with selective ante-grade cerebral perfusion(SACP).Methods:We retrospectively reviewed data of 377 adult patients undergoing aortic arch surgery via FET with SACP from July 1,2017 to December 31,2018 at Beijing Anzhen Hospital.The baseline characteristics,intra-operative data,and post-operative data were collected.Univariate and multivariate Cox regression analyses were used to determine independent predictors of 90-day postoperative mortality.Results:The 90-day post-operative mortality was 13.53%.The 78.51%of patients were men.There were 318(84.35%)type A aortic dissections and 28(7.43%)aortic aneurysms.Among those,264(70.03%)were emergency operations.Median CPB time was 202.0(176.0,227.0)min.Multivariate Cox regression analysis revealed that CPB time was independently associated with 90-day post-operative mortality after adjusting confounding factors(hazard ratio:1.21/10 min increase in CPB time,95%confidence interval:1.15–1.27,P<0.001).Kaplan-Meier analysis based on CPB time tertiles revealed that the top tertile(median 236.0 min)was associated with reduced survival rate compared with middle and bottom tertiles(P<0.001).Each sub-group analysis based on the complexity of the underlying disease process showed similar associations between CPB time and 90-day post-operative mortality.Conclusions:CPB time remains a significant factor in determining 90-day post-operative mortality in patients undergoing aortic arch surgery using FET with SACP.Surgeons should be aware of the relationship between CPB time and 90-day post-operative mortality during operative procedures and avoid extended CPB time as far as possible.

Application of the "branch-first technique"in Sun's procedure

To the Editor:The branch-first technique has been reported in arch replacement for patients with arch lesions in order to provide total cerebral perfusion during the operation.A double "Y,"or modified three-branch graft, was used in this technique.Here we reported a branch-first technique combined with Sun's procedure using a "Y" shaped graft.

Branch-first Sun’s procedure:early experience in patients with aortic dissection and aortic aneurysm

Despite great progress in concepts and surgical technique,arch replacement remains a challenge for most cardiac surgery centers.The classic Sun’s procedure(total arch replacement using four-branched graft with stented elephant trunk implantation)has achieved good results in arch replacement in cases of type A aortic dissection and become the standard treatment for type A aortic dissection in our center.[1,2]The branch-first technique has been reported by some surgeons.In most cases,the three arch branches were reconstructed under cardiopulmonary bypass(CPB)or deep hypothermia circulatory arrest.We began applying the branch-first Sun’s procedure 1 year ago.131 The three arch branches were bypassed without CPB in most patients.The lowest temperature at circulatory arrest was also elevated.Here we report our early experience with branch-first Sun’s procedure in both elective and emergency settings.

Smoking history increases the risk of long-term mortality after thoracic endovascular aortic repair in patients with an uncomplicated type B dissection

Background:The preferred treatment for uncomplicated type B dissection(thoracic endovascular aortic repair[TEVAR]or medical)is still under debate.Since 2001,our center has performed TEVAR for uncomplicated type B dissection.Based on our data,5-and 10-year survival rates among patients with uncomplicated type B dissection after TEVAR were 96.5%and 83.0%,respectively.We,therefore,believe that TEVAR is preferable for uncomplicated type B dissections.This study analyzed the impact of a pre-operative smoking history on long-term survival after TEVAR in patients with uncomplicated type B dissections.Methods:From May 2001 to December 2013,data from 751 patients with type B dissections were collected and analyzed.Patients were divided into two groups(337 smoking patients and 414 non-smoking patients).The Kaplan-Meier method and log-rank test were used to compare survival curves of the two groups.Multivariable analyses using the Cox proportional hazards model were used to estimate the effects of smoking on survival rates.Results:The 5-and 10-year survival rates of non-smokers were 97.6%(95%confidence interval[CI],96.0%-99.2%)and 87.0%(95%CI,81.6%-92.7%),respectively,and 94.9%(95%CI,92.2%-97.7%)and 73.8%(95%CI,62.3%-87.5%)for smokers,respectively(Log-rank test,P=0.006).Multivariable analyses showed that smoking increased the risk of death during follow-up,2.1-fold when compared to non-smokers(P=0.039).Conclusion:A pre-operative smoking history increases long-term mortality rates after TEVAR in patients with uncomplicated type B dissections.

Debranching thoracic endovascular aortic repair combined with ascending aortic aortoplasty

Surgical treatment of aortic arch lesions is a challenge for cardiac surgeons because of the complexity of the technique.For high-risk patients who are not suitable to undergo traditional open arch replacement,debranching thoracic endovascular aortic repair (d-TEVAR) is often a good choice.Retrograde type A aortic dissection (RTAD) is a common and fatal complication after d-TEVAR,[1] and thus d-TEVAR is contraindicated in low-risk patients.Herein,we describe a modification of d-TEVAR with an aortoplasty of the ascending aorta using artificial blood vessels and the subsequent use as an anchoring zone to minimize the occurrence of RTAD.