Successful repair of acute type A aortic dissection during pregnancy at 16th gestational week with maternal and fetal survival: A case report and review of the literature

BACKGROUND Aortic dissection during pregnancy is a rare but life-threatening event for mothers and fetuses. It often occurs in the third trimester of pregnancy and the postpartum period. Most patients have connective tissue diseases such as Marfan syndrome. Thus, the successful repair of a sporadic aortic dissection with maternal and fetal survival in the early second trimester is extremely rare. CASE SUMMARY A 28-year-old woman without Marfan syndrome presented with chest pain at the 16th gestational week. Aortic computed tomographic angiography confirmed an acute type A aortic dissection (TAAD) with aortic arch and descending aorta involvement. Preoperative fetal ultrasound confirmed that the fetus was stable in the uterus. The patient underwent total arch replacement with a frozen elephant trunk using moderate hypothermic circulatory arrest with the fetus in situ. The patient recovered uneventfully and continued to be pregnant after discharge. At the 38^th gestational week, she delivered a healthy female infant by cesarean section. After 2.5 years of follow-up, the patient is uneventful and the child’s development is normal. CONCLUSION A fetus in the second trimester may have a high possibility of survival and healthy growth after aortic arch surgery.

Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

ObjectiveAcute 肾损害(AKI ) 经常发生在基于导管的 interventional 过程和增加死亡以后。然而，类型 B 尖锐大动脉的解剖(AAD ) 的 AKI 以前胸的 endovascular 动脉瘤修理(TEVAR ) 的含意仍然保持不清楚。这研究与类型 B AAD.MethodsBetween 2009 在病人在 TEVAR 前评估了 AKI 的发生，预言者，和在里面医院结果并且 2013， 76 个病人回顾地被评估从症状发作在 36 h 以内为类型 B AAD 收到了 TEVAR。病人被分类进 no-AKI 对 AKI 组，并且 AKI 的严厉进一步根据肾疾病被上演：在外科手术前的 AKI 的 TEVAR.ResultsThe 发生前改进全球结果标准是 36.8% 。在里面医院复杂并发症与 no-AKI 相比在有外科手术前的 AKI 的病人是显著地更高的(50.0% 对 4.2% 分别地；P &#x0003c；0.001 ) ，包括尖锐肾的失败(21.4% 对 0 分别地；P &#x0003c；0.001 ) ，并且他们与 AKI 的严厉增加了(P &#x0003c；0.001 ) 。身体温度和白血房间计数的最大的层次是以前显著地与最大的浆液 creatinine 有关铺平 TEVAR。Multivariate 分析在承认上显示出那收缩血压(或：1.023；95% CI：1.003-1.044；P = 0.0238 ) 并且双边的肾的动脉参与(或：19.076；95% CI：1.914-190.164；P = 0.0120 ) 外科手术前的 AKI.ConclusionsPreoperative AKI 的强壮的预言者经常与类型 B AAD 在病人被发生，并且与更高的在里面医院复杂并发症相关并且提高了煽动性的反应。承认和双边的肾的动脉参与上的收缩血压是为在 TEVAR 前的 AKI 的主要风险因素。

Predictors and in-hospital outcomes of preoperative acute kidney injury in patients with type A acute aortic dissection

BackgroundAcute 肾损害(AKI ) 在为尖锐大动脉的解剖(AAD ) 的外科以后是普通的并且增加在里面医院和长期的死亡。然而，很少数据与类型在病人在早外科手术前的 AKI 的临床、预示的关联上存在 AAD。我们试图在病人在在里面医院结果上决定外科手术前的 AKI 的发生和 AKI 的影响与打阿德梅索兹夫罗姆·梅 2009 到 2014 年 6 月，我们回顾地注册了为类型从症状发作和收到的开的外科在 48 h 以内进入我们的医院的 178 个病人 AAD。病人被划分成没有 AKI 和 AKI 组并且在 surgery.ResultsAKI 发生在 41 个病人(23.0%) 以前，根据 KDIGO 标准与 AKI 上演了严厉。在里面医院复杂并发症的发生在有与没有 AKI 相比的外科手术前的 AKI 的病人是显著地更高的(41.5% 对 9.5% ， P <；0.001 ) ，包括肾的梗塞(7.3% 对 0， P = 0.012 ) ，并且它与 AKI 严厉增加了(P 趋势 <；0.001 ) 。尽管没有重要差别被发现，没有 AKI，有 AKI 的病人与病人相比有更高的在里面医院死亡(14.6% 对 5.1% ， P = 0.079 ) 。Multivariate 分析显示那男性，承认上的心脏舒张的血压和双边的肾的动脉参与 AAD.ConclusionsEarly 是在有类型 A 的病人的外科手术前的 AKI 的独立预言者在外科前的 AKI 在有类型的病人是普通的 AAD，并且与增加的在里面医院复杂并发症被联系。男性，承认上的心脏舒张的血压和双边的肾的动脉参与是为外科手术前的 AKI 的主要预言者。

Development and validation of a nomogram for postoperative severe acute kidney injury in acute type A aortic dissection

BACKGROUND Postoperative acute kidney injury(AKI) is a major complication associated with increased morbidity and mortality after surgery for acute type A aortic dissection(AAAD). To the best of our knowledge, risk prediction models for AKI following AAAD surgery have not been reported. The goal of the present study was to develop a prediction model to predict severe AKI after AAAD surgery.METHODS A total of 485 patients who underwent AAAD surgery were enrolled and randomly divided into the training cohort(70%) and the validation cohort(30%). Severe AKI was defined as AKI stage Ⅲ following the Kidney Disease: Improving Global Outcomes criteria. Preoperative variables, intraoperative variables and postoperative data were collected for analysis. Multivariable logistic regression analysis was performed to select predictors and develop a nomogram in the study cohort. The final prediction model was validated using the bootstrapping techniques and in the validation cohort.RESULTS The incidence of severe AKI was 23.0%(n = 78), and 14.7%(n = 50) of patients needed renal replacement treatment.The hospital mortality rate was 8.3%(n = 28), while for AKI patients, the mortality rate was 13.1%, which increased to 20.5% for severe AKI patients. Univariate and multivariate analyses showed that age, cardiopulmonary bypass time, serum creatinine, and D-dimer were key predictors for severe AKI following AAAD surgery. The logistic regression model incorporated these predictors to develop a nomogram for predicting severe AKI after AAAD surgery. The nomogram showed optimal discrimination ability, with an area under the curve of 0.716 in the training cohort and 0.739 in the validation cohort. Calibration curve analysis demonstrated good correlations in both the training cohort and the validation cohort.CONCLUSIONS We developed a prognostic model including age, cardiopulmonary bypass time, serum creatinine, and D-dimer to predict severe AKI after AAAD surgery. The prognostic model demonstrated an effective predictive capability for severe AKI, which may help improve risk stratification for poor in-hospital outcomes after AAAD surgery.

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.

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease

Background： There are limited data on longer-term outcomes （〉5 years） for patients with unprotected left main coronary artery （ULMCA） disease who underwent percutaneous coronary intervention （PCI） in the drug-eluting stents （DES） era. This study aimed at comparing the long-term （〉5 years） outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting （CABG） and the predictors of adverse events. Methods： All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups. Results： Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses （DES = 465 vs. CABG = 457）. During the median follow-up of 7.1 years （interquartile range 5.3-8.2 years）, no difference was found between PCI and CABG in the occurrence of death （P = 0.282） and the composite endpoint of cardiac death, myocardial infarction （MI） and stroke （P = 0.294）. Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group （P = 0.014） in large part because of the significantly higher rate of repeat revascularization （P 〈 0.001）. PC/was correlated with the lower occurrence of stroke （P = 0.004）. Multivariate analysis showed ejection fraction （EF） （P = 0.012）, creatinine （P = 0.016）, and prior stroke （P = 0.03 l） were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age （P = 0.026） and EF （P = 0.002） were independent predictors in the CABG group. Conclusions： During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.

Antipsychotic Medications in Major Depression and the Association with Treatment Satisfaction and Quality of Life： Findings of Three National Surveys on Use of Psychotropics in China Between 2002 and 2012

Background： Optimizing treatment outcomes for depression requires understanding of how evidence-based treatments are utilized in clinical practice. Antipsychotic medications concurrent with antidepressant treatment are frequently used in major depression, but few studies have investigated trends and patterns of their use over time. This study aimed to examine the prescription patterns ofantipsychotic medications for major depression in China from 2002 to 2012 and their association with treatment satisfaction and quality of life （QOL）. Methods： A total of 3655 subjects with major depression treated in 45 Chinese psychiatric hospitals/centers nationwide were interviewed between 2002 and 2012. Patients＇ socio-demographic and clinical characteristics including psychopathology, medication side effects. satisfaction with treatment and QOL were recorded using a standardized protocol and data collection. Results： The frequency ofantipsychotic use was 24.9% in the whole sample; the corresponding figures were 17.1%, 20.3%, and 32.8% in 2002, 2006, and 2012, respectively （χ^2 = 90.3, df= 2, P 〈 0.001 ）. Multiple logistic regression analyses revealed that patients on concurrent antipsychotics had significantly more delusions or hallucinations, longer illness duration, greater side effects, and more likely to be treated as inpatients and in major hospitals （i.e., Level-Ⅲ hospital）. Antipsychotic use was associated with lower treatment satisfaction while there was no significant difference with respect to physical and mental QOL between the antipsychotic and nonantipsychotic groups. Conclusions： Concurrent antipsychotic use was found in about one in four treated depressed patients in China, which has increased over a 10-year period. Considering the association of drug-induced side effects and the lack of patients＇ and relatives＇ satisfaction with antipsychotic treatment, further examination of the rationale and appropriateness of the use of antipsychotics in depression is needed.

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.

"Cusp-overlap" technique simplifies the implantation of Chinese domestic transcatheter valve in transcatheter aortic valve implantation

Currently,transcatheter aortic valve implantation(TAVI)has become a feasible interventional technique for severe aortic stenosis in patients who deemed inoperable or are at high surgical risk.In China,the TAVI technique started from 2010.Until now two domestic devices J Valve(Jie Cheng Medical Technologies,Suzhou,China)and Venus AValve(Venus MedTech,Hangzhou,China)have been allowed access into the market in 2017,since then most centers began to set up TAVI programs.Venus A-Valve is the only transfemoral transcatheter valve in China which approximately has been implanted 4000 times,till VitaFlow(MicroPort,Shanghai,China)and SAPIEN 3(Edwards Lifesciences,Irvine,CA,USA)entered the market in China a few months ago.

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

To the Editor:For patients with acute DeBakey type laortic dissection,ascending aortic or hemiarch replacement can reduce the surgical time and save lives in critical situations.However,residual distal dissection increases the risk of dilatation,rupture,and death.[1] In contrast,total aortic arch replacement(TAR)with frozen elephant trunk(FET)implantation can minimize the need for re-intervention,[2] but may increase the risk of operative mortality,stroke,paraplegia,and other complications.Currently,the ques-tion of the optimal surgical strategy for acute DeBakey type I aortic dissection remains controversial owing to the scarcity of long-term follow-up data and the technical diversities among different institutions.