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.

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.

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.

Inflammatory risk stratification individualizes anti-inflammatory pharmacotherapy for acute type A aortic dissection

The systemic benefits of anti-inflammatory pharmacotherapy vary across cardiovascular diseases in clinical practice.We aimed to evaluate the application of artificial intelligence to acute type A aortic dissection(ATAAD)patients to determine the optimal target population who would benefit from urinary trypsin inhibitor use(ulinastatin).Patient characteristics at admission in the Chinese multicenter 5A study database(2016-2022)were used to develop an inflammatory risk model to predict multiple organ dysfunction syndrome(MODS).

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.

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.

MiR-551b-5p Contributes to Pathogenesis of Vein Graft Failure via Upregulating Early Growth Response-1 Expression

Background： Vein graft failure （VGF） is a serious complication of coronary artery bypass graft, although the mechanism remains unclear. The study aimed to investigate the effects of microRNAs （miRNAs） on the endothelial dysfunction involved in VGF. Methods： Human umbilical vein endothelial cells （HUVECs） were subjected to mechanical stretch stimulation to induce endothelial dysfunction. Genome-wide transcriptome profiling was performed using the Human miRNA OneArray＂ V4 （PhalanxBio Inc., San Diego, USA）. The miRNA-messenger RNA （mRNA） network was investigated using gene ontology and Kyoto Encyclopedia of Genes and Genomes. The miR-55 1b-5p mimic and inhibitor were applied to regulate miR-55 lb-5p expression in the HUVECs. The 5-ethynyl-2＇-deoxyuridine assay, polymerase chain reaction （PCR）, and Western blotting （WB） were used to assess HUVECs proliferation, mRNA expression, and protein expression, respectively. The vein graft model was established in early growth response （Egr）-I knockout （KO） mice and wide-type （WT） C57BL/6J mice for pathological and immunohistochemical analysis. Endothelial cells isolated from the veins of WT and Egr-1 KO mice were subjected to mechanical stretch stimulation; PCR and WB were conducted to confirm the regulatory effect of Egr- 1 on Intercellular adhesion molecule （loam-1）. One-way analysis of variance and independent t-test were performed for data analysis. Results： Thirty-eight rniRNAs were differentially expressed in HUVECs after mechanical stretch stimulation. The bioinforrnatics analysis revealed that Egr-1 might be involved in VGF and was a potential target gene of miR-551b-5p. The mechanical stretch stimulation increased miR-55 1b-5p expression by 2.93 ± 0.08 told （t= 3.07, P 〈 0.05）, compared with the normal HUVECs. Transfection with the miR-551b-5p mimic or inhibitor increased expression of miR-551b-5p by 793.1 ± 171.6 fold （t = 13.84, P 〈 0.001） or decreased by 26.3% ± 2.4% （t= 26.39, P 〈 0.05） in the HUVECs, respectively. HUVECs proliferation and EGR-I mRNA expression were significantly suppressed by inhibiting miR-551b-5p expression （P 〈 0.05）. The lumens of the vein grafts in the Egr-1 KO mice were wider than that in the WT mice. lcam-I expression was suppressed significantly in the Egr-1 KO vein grafts （P 〈 0.05）. Conclusions： Increased miR-55 1b-5p expression leads to endothelial dysfunction by upregulating Egr-1 expression. EGR-1 KO can improve the function of a grafted vein through suppressing loam-1.