The Anzhen Risk Scoring System for Acute Type A Aortic Dissection:A Prospective Observational Study Protocol

Introduction:Acute type A aortic dissection(ATAAD)is a catastrophic disease with fatal outcomes.Malperfusion syndrome(MPS)is a serious complication of ATAAD,with an incidence of 20–40%.Many studies have shown that MPS is the main risk factor for poor ATAAD prognosis.However,a risk scoring system for ATAAD based on MPS is lacking.Here,we designed a risk scoring system for ATAAD to assess mortality through quantitative assessment of relevant organ malperfusion and subsequently develop rational treatment strategies.Methods and analysis:This was a prospective observational study.Patients’perioperative clinical data were col-lected to establish a database of ATAAD(N≥3000)and determine whether these patients had malperfusion complica-tions.The Anzhen risk scoring system was established on the basis of organ malperfusion by using a random forest survival model and a logistics model.The better method was then chosen to establish a revised risk scoring system.Ethics and dissemination:This study received ethical approval from the Ethics Committees of Beijing Anzhen Hospital,Capital Medical University(KS2019034-1).Patient consent was waived because biological samples were not collected,and no patient rights were violated.Findings will be disseminated at scientific conferences and in peer-reviewed publications.

Carotid versus axillary artery cannulation for descending aorta remodeling in type A acute aortic dissection

BACKGROUND Arterial cannulation sites for the surgical repair of type A aortic dissection(AAD)have evolved from right axillary artery(AA)cannulation to bilateral carotid artery(CA)based of femoral artery(FA)cannulation.Postoperative descending aorta remodeling is closely linked to the false lumen area ratio(FLAR),defined as false lumen area/aortic area,as well as to the incidence of renal replacement therapy(RRT).AIM To investigate the effect of the updated arterial cannulation strategy on descending aortic remodeling.METHODS A total of 443 AAD patients who received FA combined cannulation between March 2015 and March 2023 were included in the study.Of these,209 received right AA cannulation and 234 received bilateral CA cannulation.The primary outcome was the change in FLAR,as calculated from computed tomography angiography in three segments of the descending aorta:Thoracic(S1),upper abdominal(S2),and lower abdominal(S3).Secondary outcomes were the incidence of RRT and the serum inflammation response,as observed by the levels of high sensitivity C reaction protein(hs-CRP)and Interleukin-6(IL-6).RESULTS The postoperative/preoperative ratio of FLAR in S2 and S3 was higher in the AA group compared to the CA group(S2:0.80±0.08 vs 0.75±0.07,P<0.001;S3:0.57±0.12 vs 0.50±0.12,P<0.001,respectively).The AA group also had a significantly higher incidence of RRT(19.1%vs 8.5%,P=0.001;odds ratio:2.533,95%CI:1.427-4.493)and higher levels of inflammation cytokines 24 h after the procedure[hr-CRP:117±17 vs 104±15 mg/L;IL-6:129(103,166)vs 83(69,101)pg/mL;both P<0.001]compared to the CA group.CONCLUSION The CA cannulation strategy was associated with better abdominal aorta remodeling after AAD repair compared to AA cannulation,as observed by a greater change in FLAR and lower incidence of RRT.

Clinical profiles and outcomes of acute type A aortic dissection and intramural hematoma in the current era: lessons from the first registry of aortic dissection in China

Background::Acute type A aortic dissection(ATAAD)and acute type A intramural hematoma(ATAIMH)are life-threatening diseases with high mortality.To better understand their clinical features in the Chinese population,we analyzed the data from the first Registry of Aortic Dissection in China(Sino-RAD)to promote the understanding and management of the diseases.Methods::All patients with ATAAD and ATAIMH enrolled in Sino-RAD from January 1,2012 to December 31,2016 were involved.The data of patients’selection,history,symptoms,management,outcomes,and postoperation complications were analyzed in the study.The continuous variables were compared using the Student’s t test for normal distributions and the Mann-Whitney U test for non-normal distributions.Categorical variables were compared using the Chi-square test or Fisher exact test.Results::A total of 1582 patients with ATAAD and 130 patients with ATAIMH were included.The mean age of all patients was 48.4 years.Patients with ATAAD were significantly younger than patients with ATAIMH(48.9 years vs.55.6 years,P<0.001).For the total cohort,males were dominant,but the male ratio of patients with ATAAD was significantly higher compared to those with ATAIMH(P=0.01).The time range from the onset of symptom to hospitalization was 2.0 days.More patients of ATAIMH had hypertension than that of ATAAD(82.3%vs.67.6%,P<0.05).Chest and back pain were the most common clinical symptoms.Computerized tomography(CT)was the most common initial diagnostic imaging modality.84.7%received surgical treatment and in-hospital mortality was 5.3%.Patients with ATAAD mainly received surgical treatment(89.6%),while most patients with ATAIMH received medical treatment(39.2%)or endovascular repair(35.4%).Conclusions::Our study suggests that doctors should comprehensively use clinical examination and genetic background screening for patients with ATAAD and ATAIMH and further shorten the time range from symptoms onset to intervention,achieving early diagnosis and treatment,thereby reducing the mortality rate of patients with aortic dissection in China.We should standardize the procedures of aortic dissection treatment and improve people’s understanding.Meanwhile,the curing and transferring efficiency should also be improved.

Effect on surgery outcomes owing to the interval between onset of symptoms and surgery of patients with acute type A aortic dissection

Background:This study aimed to identify whether the interval from onset of symptoms to surgery affects the outcomes of surgery in patients with acute type A aortic dissection(AAAD).Methods:This study retrospectively examined 249 patients with AAAD who underwent Sun’s procedure.All patients were divided into 2 groups,hyperacute and acute,according to the interval from onset of symptoms to surgery.The primary endpoint was all-cause early mortality,and the secondary endpoint was early reoperation.Results:The surgery time,cardiopulmonary bypass time,clamp time,and selective cerebral perfusion time were not significantly different between the 2 groups.The intensive care unit length of stay and duration of mechanical ventilation of the 2 groups were 185.50hours versus 185.00hours(P=0.970)and 41.50hours versus 44.00hours(P=0.678),respectively.There were 52 early deaths:29 in the hyperacute group and 23 in the acute group(21.6%vs.20.0%,P=0.751).The incidence of reoperation was 0.7% and 0.9%(P>0.999),respectively.The incidence rates of postoperative acute heart failure(AHF),acute respiratory failure(ARF),nervous dysfunction,and acutekidney injury were37.3% versus 25.2%(P=0.041),51.5%versus51.3%(P=0.976),13.4% versus 7.0%(P=0.096),and 37.3% versus 37.4%(P=0.990),respectively.Multivariable analysis indicated that surgery in the hyperacute phase might be an independent risk factor for AHF(OR:1.765;95%CI:1.021–3.052;P=0.042).Conclusion:Surgery in the hyperacute phase of AAAD was associated with postoperative AHF.Therefore,early medical management or interventional therapy for complications before surgery performed by experienced surgeons is recommended,especially in the hyperacute phase.

Predictive value of age,creatinine,and ejection fraction(ACEF)score for in-hospital mortality and major adverse events in patients with acute type A aortic dissection

Background Patients with decreased cardiac and renal function,as well as old age suffer from poor outcomes when undergoing cardiac surgery.The aim of this study was to evaluate the association of age,creatinine and ejection fraction(ACEF)score with in-hospital prognosis of patients with the acute type A aortic dissection(ATAAD).Methods From September 2017 to June 2021,a total of 435 ATAAD patients undergoing open surgery repair were enrolled,and classified into low ACEF(ACEF score<0.91,n=286)and high ACEF group(ACEF score≥0.91,n=149)according to the optimal cutoff value of 0.91.Logistic regression analysis was performed to investigate the association between ACEF score with adverse events.Results Thirty-five(8.0%)patients were excluded and 94(21.6%)developed in-hospital major adverse clinical events(MACEs)during hospitalization.The in-hospital mortality in high ACEF group was significantly higher than in low ACEF group(13.4%vs.5.2%,P=0.003).The in-hospital MACE rate was also significantly higher in patients with high ACEF score(high ACEF group:27.5%vs.low ACEF group:18.5%,P=0.031).Multivariable logistic analysis revealed that ACEF score was an independent indicator for in-hospital mortality[odds ratio(OR):5.66,95%confidence interval(CI):1.43-22.48,P=0.014]and in-hospital MACEs(OR:3.44,95%CI:1.30-9.15,P=0.013).Conclusions Elevated ACEF score was an independent predictor for in-hospital mortality and MACEs in patients with ATAAD undergoing open surgery repair,which might provide additional risk stratification.

Perioperative Risk Factors for Post-operative Pneumonia after Type A Acute Aortic Dissection Surgery

Objective Type A acute aortic dissection(TAAAD)is a dangerous and complicated condition with a high death rate before hospital treatment.Patients who are fortunate to receive prompt surgical treatment still face high in-hospital mortality.A series of post-operative complications further affects the prognosis.Post-operative pneumonia(POP)also leads to great morbidity and mortality.This study aimed to identify the prevalence as well as the risk factors for POP in TAAAD patients and offer references for clinical decisions to further improve the prognosis of patients who survived the surgical procedure.Methods The study enrolled 89 TAAAD patients who underwent surgical treatment in Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan,Hubei province,China from December 2020 to July 2021 and analyzed the perioperative data and outcomes of these patients.Logistic regression analyses were used to identify the risk factors for POP.Results In the study,31.5%of patients developed POP.Patients with POP had higher proportions of severe oxygenation damage,pneumothorax,reintubation,tracheotomy,renal replacement therapy,arrhythmia,gastrointestinal bleeding,and longer duration of mechanical ventilation,fever,ICU stay,and length of stay(all with P<0.05).The in-hospital mortality was 2.3%.Smoking,preoperative white blood cells,and intraoperative transfusion were the independent risk factors for POP in TAAAD.Conclusion Patients who underwent TAAAD surgery suffered poorer outcomes when they developed POP.Furthermore,patients with risk factors should be treated with caution.

Endovascular stent-grafts for acute and chronic type B aortic dissection: comparison of clinical outcomes

Within the recent months, endovascular repair of aortic aneurysms has become a rather interesting alternative to patients considering open surgery. In the past, the procedure was typically and more solely reserved to a selected group of elderly patients with several co-morbidities.……

EFFECT OF ACUPUNCTURE ON PLASMA STRESS HORMONE LEVELS OF HYPOTHALAMUS-PITUITARY-ADRENAL AXIS IN TYPE II DIABETES WITH CONCURRENT ACUTE CEREBRAL INFARCTION PATIENTS

Objective: To observe the effect of acupuncture on the contents of stress hormones of the hypothalamus pituitary adrenal axis (HPA) in treatment of type II diabetes with concurrent acute cerebral infarction patients. Methods: 60 cases of inpatients were randomly and evenly divided into treatment group (conventional medication plus acupuncture) and control (conventional mediation) group. Plasma corticotropin releasing hormone (CRH), adrenocorticotropin hormone (ACTH) and corticosteroid (CS) contents before and after treatment were measured using radioimmunoassay (RIA) and compared with those of healthy subject group (n=30). Results: Plasma CRH, ACTH and CS levels in patients of both treatment group and control group at admission were significant higher than those of normal subject group (P<0.05). After treatment for 15～30 days, results showed that plasma CRH, ACTH and CS levels in both treatment and control groups lowered significantly in comparison with those of pre treatment (P<0.05 or 0.01); while those of treatment group were even more lower (being closer to the normal values) than those of control group (P<0.05 or 0.01). Conclusion: Acupuncture therapy can reduce the stress state of HPA in type II diabetes with concurrent acute cerebral infarction patients, i.e. regulate the neuroendocrine immunological net, which may be one of the mechanisms for acupuncture treatment of cerebral stroke.

Beyond the Usual Suspects (Aortic Dissection in Patients with Chronic Kidney Disease)

A comprehensive differential diagnosis is essential in the emergency department, even when patient presentations are atypical. Timely recognition of life-threatening conditions, such as aortic dissection, hinges on this critical diagnostic approach.

Comparison of Partial Upper Sternotomy Versus Median Sternotomy for Total Arch Replacement in Patients With Type A Aortic Dissection

Objective:Comparative studies of median sternotomy and partial upper sternotomy in total arch replacement for type A aortic dissection are rare,and the safety and benefits of partial upper sternotomy need further evaluation.This study aimed to explore the effectiveness and prognosis of partial upper sternotomy in total arch replacement among patients with type A aortic dissection.Methods:This is a retrospective study of patients who underwent total arch replacement for type A aortic dissection at the First Medical Center of Chinese People’s Liberation Army General Hospital between January 2016 and December 2019.They were grouped into the median sternotomy and partial upper sternotomy groups according to the different treatment methodologies.The intra-operative and prognostic indicators were compared between both groups.Results:Forty-nine patients were included:31 in the median sternotomy group and 18 in the partial upper sternotomy group.The partial upper sternotomy group had a shorter incision((9.0±0.8)cm vs.(25.5±1.3)cm,P=0.02)and smaller postoperative total drainage volume(885mL vs.1,820mL,P=0.03)than the median sternotomy group.The differences between the 2 groups with respect to other intra-operative indicators such as operation duration,cardiopulmonary bypass duration,aortic occlusion duration,hypothermic circulatory arrest duration,and intra-operative blood loss,and prognostic indicators such as red blood cell infusion,ventilator aid duration,cardiac intensive care unit stay,postoperative hospital stay,and postoperative complications were not significantly different(all P>0.05).Conclusions:The utilization of partial upper sternotomy in patients with type A aortic dissection resulted in a smaller incision and more aesthetically pleasing scar,along with reduced drainage volume compared to median sternotomy.

Impact of the COVID-19 pandemic on liver donation and transplantation:A review of the literature

The coronavirus disease 2019(COVID-19)pandemic has upended healthcare systems worldwide and led to an inevitable decrease in liver transplantation(LT)activity.During the first pandemic wave,administrators and clinicians were obliged to make the difficult decision of whether to suspend or continue a lifesaving procedure based on the scarce available evidence regarding the risk of transmission and mortality in immunosuppressed patients.Those centers where the activity continued or was heavily restricted were obliged to screen donors and recipients,design COVID-safe clinical pathways,and promote telehealth to prevent nosocomial transmission.Despite the ever-growing literature on COVID-19,the amount of high-quality literature on LT remains limited.This review will provide an updated view of the impact of the pandemic on LT programs worldwide.Donor and recipient screening,strategies for waitlist prioritization,and posttransplant risk of infection and mortality are discussed.Moreover,a particular focus is given to the possibility of donor-to-recipient transmission and immunosuppression management in COVID-positive recipients.

Altered gut microbiota composition in children and their caregivers infected with the SARS‑CoV‑2 Omicron variant

Background Gut microbiota alterations have been implicated in the pathogenesis of coronavirus disease 2019(COVID-19).This study aimed to explore gut microbiota changes in a prospective cohort of COVID-19 children and their asymptomatic caregivers infected with the severe acute respiratory syndrome coronavirus type 2(SARS-CoV-2)Omicron variant.Methods A total of 186 participants,including 59 COVID-19 children,50 asymptomatic adult caregivers,52 healthy children(HC),and 25 healthy adults(HA),were recruited between 15 April and 31 May 2022.The gut microbiota composition was determined by 16S rRNA gene sequencing in fecal samples collected from the participants.Gut microbiota functional profling was performed by using Phylogenetic Investigation of Communities by Reconstruction of Unobserved States(PICRUSt)software.Results The gut microbiota analysis of beta diversity revealed that the fecal microbial community of COVID-19 children remained far distantly related to HC.The relative abundances of the phyla Actinobacteria and Firmicutes were decreased,whereas Bacteroidetes,Proteobacteria,and Verrucomicrobiota were increased in COVID-19 children.Feces from COVID-19 children exhibited notably lower abundances of the genera Blautia,Bifdobacterium,Fusicatenibacter,Streptococcus,and Romboutsia and higher abundances of the genera Prevotella,Lachnoclostridium,Escherichia-Shigella,and Bacteroides than those from HC.The enterotype distributions of COVID-19 children were characterized by a high prevalence of enterotype Bacteroides.Similar changes in gut microbiota compositions were observed in asymptomatic caregivers.Furthermore,the microbial metabolic activities of KEGG(Kyoto Encyclopedia of Genes and Genomes)and COG(cluster of orthologous groups of proteins)pathways were perturbed in feces from subjects infected with the SARS-CoV-2 Omicron variant.Conclusion Our data reveal altered gut microbiota compositions in both COVID-19 children and their asymptomatic caregivers infected with the SARS-CoV-2 Omicron variant,which further implicates the critical role of gut microbiota in COVID-19 pathogenesis.