IntroductionReintubation is an adverse postoperative complication in patients with Type A aortic dissection (AAD) that correlates to poor outcomes. This study aims to employ machine learning algorithms to establish a practical platform for the prediction of reintubation.MethodsA total of 861 patients diagnosed with AAD and undergoing surgical procedures, 688 patients as training and testing cohort from a single center, and 173 patients as validation cohort from four centers were enrolled. The least absolute shrinkage and selection operator (LASSO) was used for screening risk variables associated with reintubation for subsequent model construction. Subsequently, seven machine-learning models were built. The model with the best discrimination and calibration performance was used to predict reintubation. Finally, the SHapley Additive exPlanation (SHAP) was employed to explain the prediction model.ResultsReintubation was performed in 107 patients (12.43%). The LASSO analysis identified re-admission to the intensive care unit (ICU), continuous renal replacement therapy, length of stay in the ICU, and duration of invasive mechanical ventilation as significant risk factors for reintubation. The XGBoost model was selected as the final prediction model due to its better performance than other models, with the AUC, sensitivity, and specificity of 0.969, 0.8889, and 0.8611 in the testing cohort. SHAP values demonstrated the effects of individual features on the overall model. Finally, a web calculator was developed based on XGBoost model for the clinical use.ConclusionWe have developed and validated a high-performing risk prediction model for postoperative reintubation in patients with AAD. It can provide valuable guidance to clinicians in predicting reintubation and in developing timely preventative measures.

BACKGROUND: Recent studies show that hyperactivation of mTOR (mammalian target of rapamycin) signaling plays a causal role in the development of thoracic aortic aneurysm and dissection. Modulation of PP2A (protein phosphatase 2A) activity has been shown to be of significant therapeutic value. In light of the effects that PP2A can exert on the mTOR pathway, we hypothesized that PP2A activation by small-molecule activators of PP2A could mitigate AA progression in Marfan syndrome (MFS). METHODS: Two distinct mouse models of MFS underwent daily oral administration of small-molecule activators of the PP2A compound DT-061 to assess its therapeutic potential. Echocardiography was performed to monitor the growth of the aortic root and ascending aorta. Histological evaluation was performed to assess alterations in the vascular wall. RNA-sequencing, Western blot, and immunostaining were performed to decipher the underlying mechanisms by which DT-061 suppresses AA progression. RESULTS: PP2A activity decreased, while mTOR activity increased in both human and mouse aortas with MFS. Concordantly, oral administration of DT-061 increased PP2A activation, reducing aortic expansion in Marfan mice. DT-061 treatment also mitigated medial hypertrophy, elastin breakdown, and extracellular matrix deterioration in the ascending aorta, along with decreased metalloproteinase activities. Mechanistic studies suggest that DT-061 suppresses mTOR signaling and smooth muscle cell dedifferentiation, contributing to its effects on thoracic aortic aneurysm and dissection progression. CONCLUSIONS: These studies demonstrate a pathological role of PP2A activity loss in the cause of MFS and implicate that activation of PP2A may serve as a novel therapeutic strategy to limit MFS progression, including aortic aneurysm formation.

Cardiovascular, metabolic, and immune disorders intersect through inflammasome signaling, motivating the development of a unified framework for cardiovascular risk across obesity, diabetes, infection, and autoimmunity. We first outline inflammasome architecture and activation, highlighting cryo-EM evidence that NEK7 licenses NLRP3 assembly, the coupling of priming to ion-flux and oligomerization, and cross-talk with the non-canonical caspase-4/5/11 pathway that feeds forward into IL-1β/IL-18 maturation and pyroptosis. In metabolic disease, lipotoxicity, mitochondrial ROS, oxidized lipids, and crystalline cholesterol converge on NLRP3 across adipose, myeloid, and vascular compartments, driving endothelial dysfunction, plaque growth, and adverse cardiac remodeling. Immune system diseases further amplify cardiovascular injury: population-level data link autoimmunity to heightened CVD risk, while AIM2- and NLRP3-dependent axes accelerate atherogenesis and destabilize plaques, particularly in clonal hematopoiesis and after acute infectious or ischemic insults. Translationally, anti-inflammatory trials validate this biology—IL-1β blockade lowered recurrent events in CANTOS, and low-dose colchicine reduced events in chronic coronary disease—yet heterogeneity of benefit and safety signals underscores the need for precise patient selection and timing. We propose a path forward that mirrors disease chronology: dampen priming, selectively inhibit assembly, and modulate effectors (IL-1 pathway or pyroptosis). Collectively, this review integrates mechanism and medicine to position inflammasomes as actionable hubs linking metabolic dysfunction, immune dysregulation, and cardiovascular disease, and charts priorities for precise, durable prevention and therapy.

Behcet's disease (BD) is a multisystem inflammatory disease that is characterized by oral aphthosis, genital aphthosis, ocular lesions, and cutaneous lesions. Although BD rarely affects the cardiovascular system, its symptoms can be shown as aortic regurgitation (AR), which requires surgical intervention. Due to the special pathogenesis of BD, a low preoperative diagnosis rate and a high incidence of serious complications, such as perivalvular leakage, valve detachment, and pseudoaneurysm after prosthetic valve replacement, surgical treatment of BD with severe AR has a poor prognosis. In recent years, new surgical strategies have been developed to improve treatment efficacy for this disease. This article reviews and summarizes the evolution of surgical techniques for BD with AR and aims to provide a reference for optimizing surgical strategies, improving perioperative management, and assisting prognosis in patients suffering from BD with severe AR.

BackgroundType A aortic dissection (TAAD) is a cardiovascular emergency condition with high mortality rate. Hybrid total aortic arch replacement using endovascular graft for the descending aorta repair results in favorable outcomes and has been recommended as an alternative procedure for the higher-risk category patients. Our institution started applying the upper ministernotomy incision technique for the hybrid procedures back in 2018.MethodsWe collected patients who underwent hybrid total arch replacement (HTAR) via ministernotomy (96) and total arch replacement with frozen elephant trunk (TAR + FET) procedures (99), between 2018 and 2021. The baseline information, intraoperative and postoperative characteristics have been compared. Kaplan-Meier analysis was used for survival evaluation. Cox regression were applied to identify the independent predictor of mortality.ResultsThe baseline characteristics between the two patient groups were compared and found similar, except that RBC counts were higher (p = 0.038) and the ascending aorta diameter was smaller (P = 0.019) in the “HTAR” group relative to the “TAR + FET” group. The cardiopulmonary bypass time (P < 0.001), the aortic cross clamp time (P < 0.001), the operation duration (P = .029), ICU (P = 0.037) and postoperative hospital stay (P = 0.002) were shorter in the “HTAR” group. The “HTAR” group exhibited also significantly lower levels of intraoperative transfusion (all <0.001) characteristics than the “TAR + FET” group. The hospital mortality and 1-year mortality revealed similar patterns in both groups.ConclusionHTAR via ministernotomy have similar short term prognosis, and also reduced the ICU and postoperative hospital stay. In all, The application of the ministernotomy technique in HTAR was safe and technically feasible and may benefit individual patients as well as hospitals in general.

Sade and colleagues 1 Sade R.M. Carpenter A.J. D’Amico T.A. et al. Unethical studies on transplantation in cardiothoracic surgery journals. Ann Thorac Surg. 2021; 112: 1746-1752https://doi.org/10.1016/j.athoracsur.2021.07.070 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar ,2 Sade R.M. Carpenter A.J. D’Amico T.A. et al. Unethical studies on transplantation in cardiothoracic surgery journals. J Thorac Cardiovasc Surg. 2021; 162: 1647-1653https://doi.org/10.1016/j.jtcvs.2021.07.061 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar copublished an article titled “Unethical Studies on Transplantation in Cardiothoracic Surgery Journals” in the 2 most respected journals in the field of cardiothoracic surgery. Subsequently, we collected some feedback from a group of cardiothoracic transplant surgeons in China. The immediate response from these colleagues was actually a simple question: “Should scientific journals become political battlefields?” Unethical Studies on Transplantation in Cardiothoracic Surgery JournalsThe Annals of Thoracic SurgeryVol. 112Issue 6PreviewExecuted prisoners have been a source of organs for transplantation in several countries; for example, Taiwan, Singapore, and China.1 Taiwan and Singapore have long since stopped the practice, but China has not. Taking organs by coercive methods has been documented in some countries, such as India and Egypt,2 but unlike China, this practice is illegal and subject to criminal prosecution in those jurisdictions. Full-Text PDF China’s Opaque Wall of SecrecyThe Annals of Thoracic SurgeryVol. 115Issue 4PreviewWe are grateful to Dong and colleagues1 for addressing several issues in our paper on the Chinese transplant system.2 We appreciate that many Chinese thoracic transplant surgeons want to make their system better, as we stated in our paper: “One of the most unfortunate consequences of the ongoing use of executed prisoner organs is the damage to the international reputations and standings of those transplant surgeons in China who are dedicated to high ethical standards in their practices and are making vigorous and honest efforts to establish a transparent and trustworthy system.” We have no reason to doubt that this statement describes the authors of the present letter, but also understand the motivation for Chinese thoracic transplant surgeons to present their system in the best light, highlighting organ donations in their country as transparent, fair, and traceable, despite the direct and indirect evidence to the contrary from the several scholarly sources that we cited. Full-Text PDF

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Sade and colleagues1Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.J Thorac Cardiovasc Surg. 2021; 162: 1647-1653Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,2Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.Ann Thorac Surg. 2021; 112: 1746-1752Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar copublished an article in December 2021 in Journal of Thoracic and Cardiovascular Surgery and Annals of Thoracic Surgery. Over the subsequent weeks we conducted a brief survey of a group of cardiothoracic transplant experts in China via telephone calls and social media platforms. The aim of the survey was to collect feedback from these targeted readers. Although we fully understood that this article was not endorsed either by the journals or by their parent professional organizations, the immediate response from our Chinese colleagues was actually a very simple question: Should scientific journals become political battlefields? Indeed, few would disagree that Sade and colleagues are internationally recognized experts in the field of thoracic surgery. We have learned a lot from their previous seminal publications on ethics. During our current survey, almost each and every Chinese surgeon noticed that Sade and colleagues1Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.J Thorac Cardiovasc Surg. 2021; 162: 1647-1653Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,2Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.Ann Thorac Surg. 2021; 112: 1746-1752Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar begin by listing Taiwan as among the few "countries" (together with Singapore and China) that allowed taking organs from executed prisoners for transplantation. In the Central Picture of the article (available only in the Journal of Thoracic and Cardiovascular Surgery version), Taiwan was not included in the map of China.1Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.J Thorac Cardiovasc Surg. 2021; 162: 1647-1653Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar As an old saying goes, "the devil is in the details." We trust that Sade and colleagues are not politically biased and they are definitely knowledgeable enough to understand the long-existing One China Policy, which has been officially acknowledged over the past 5 decades by nearly all global organizations, including the United Nations and the World Health Organization (WHO), and by more than 180 countries, including the United States of America. Honestly speaking, we believe Sade and colleagues may not realize their inadvertent oversight could lead to misunderstandings. Nonetheless, the sensitivity and the importance of such a fundamental issue should not be underestimated. Occupying a commanding position, Sade and colleagues1Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.J Thorac Cardiovasc Surg. 2021; 162: 1647-1653Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,2Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.Ann Thorac Surg. 2021; 112: 1746-1752Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar further indiscriminately criticized the entire transplantation system in the People's Republic of China. Their claims were mainly based on an unconvincing report by The China Tribunal, which was not supported by reliable objective evidence. For instance, the record of organ donors and transplantation procedures in China provided in this report was highly inaccurate. It was quoted that "The Tribunal assesses as credible numbers of operations between 60,000 and 90,000 per annum in the years 2000-2014."1Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.J Thorac Cardiovasc Surg. 2021; 162: 1647-1653Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,2Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.Ann Thorac Surg. 2021; 112: 1746-1752Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In fact, before 2005 heart transplantation in mainland China was still largely in its learning curve phase (only 70 cases over 5 years, whereas cases from Hong Kong, Macau, and Taiwan were not included).3Sun Y.F. Wang Z.W. Zhang J. Cai J. Shi F. Dong N.G. Current status of and opinions on heart transplantation in China.Curr Med Sci. 2021; 41: 841-846https://doi.org/10.1007/s11596-021-2444-9Crossref PubMed Scopus (6) Google Scholar The total number of heart transplantations over the next 10 years (2005-2014) was just 1398, despite an increase year by year from 68 in 2005 to 324 in 2014.3Sun Y.F. Wang Z.W. Zhang J. Cai J. Shi F. Dong N.G. Current status of and opinions on heart transplantation in China.Curr Med Sci. 2021; 41: 841-846https://doi.org/10.1007/s11596-021-2444-9Crossref PubMed Scopus (6) Google Scholar Indeed, the annual number of heart transplantations in mainland China has steadily increased from 279 in 2015 to 679 in 2019 and 557 in 2020 (Figure 1).3Sun Y.F. Wang Z.W. Zhang J. Cai J. Shi F. Dong N.G. Current status of and opinions on heart transplantation in China.Curr Med Sci. 2021; 41: 841-846https://doi.org/10.1007/s11596-021-2444-9Crossref PubMed Scopus (6) Google Scholar The progress of lung transplantation programs in China has been similar over the same timeframe (Figure 2).4Wu B. Hu C. Chen W. He J. Jiang G. Zhang J. et al.China lung transplantation developing: past, present and future.Ann Transl Med. 2020; 8: 41https://doi.org/10.21037/atm.2019.10.26Crossref PubMed Google Scholar Taken together, even if the numbers of all abdominal organ transplantation procedures are summed, the overestimated volume of "60,000 and 90,000 per annum in the years 2000-2014"1Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.J Thorac Cardiovasc Surg. 2021; 162: 1647-1653Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,2Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.Ann Thorac Surg. 2021; 112: 1746-1752Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar is far from trustable. It is a blatant violation of scientific ethics to produce hypothetical statements with subjective conjecture and unsubstantiated data reported by The China Tribunal. Such an attitude is an arrogant insult and slander to more than 5000 Chinese citizens who selflessly choose to become voluntary organ donors for the health of others every year.Figure 2The annual numbers of lung transplantation procedures in mainland China, 2015-2020 (cases from Hong Kong, Macau, and Taiwan were not included). The corresponding yearly total amount is shown on top of each bar, including 8 and 7 heart–lung transplantation operations in 2019 and 2020, respectively.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The missing key word here is trust. Sade and colleagues do not believe the fact that, starting from January 1, 2015, "nonconsenting prisoners as the source of organs for transplantation" has been legally prohibited in China. They do not believe that the organ donation system is transparent or that the origins of all organs have been traceable since that date. In fact, the China Organ Transplant Response System is responsible for allocating donated organs based on medical criteria, such as the clinical urgency of the recipient and organ matching results, in accordance with relevant organ allocation policies in China. The allocation process prohibits human intervention and is overseen by multiple governmental agencies to ensure its transparency, fairness, and traceability.3Sun Y.F. Wang Z.W. Zhang J. Cai J. Shi F. Dong N.G. Current status of and opinions on heart transplantation in China.Curr Med Sci. 2021; 41: 841-846https://doi.org/10.1007/s11596-021-2444-9Crossref PubMed Scopus (6) Google Scholar, 4Wu B. Hu C. Chen W. He J. Jiang G. Zhang J. et al.China lung transplantation developing: past, present and future.Ann Transl Med. 2020; 8: 41https://doi.org/10.21037/atm.2019.10.26Crossref PubMed Google Scholar, 5Huang J.F. Wang H.B. Zheng S.S. Liu Y.F. Shi B.Y. Shen Z.Y. et al.The new era of organ transplantation in China.Chin Med J. 2016; 129: 1891-1893https://doi.org/10.4103/0366-6999.187865Crossref PubMed Scopus (13) Google Scholar, 6Hu X.J. Dong N.G. Liu J.P. Li F. Sun Y.F. Wang Y. Status on heart transplantation in China.Chin Med J. 2015; 128: 3238-3242https://doi.org/10.4103/0366-6999.170238Crossref PubMed Scopus (9) Google Scholar, 7Shi B.Y. Liu Z.J. Yu T. Development of the organ donation and transplantation system in China.Chin Med J. 2020; 133: 760-765https://doi.org/10.1097/CM9.0000000000000779Crossref PubMed Scopus (17) Google Scholar A nationwide system known as the Green Channel of Human Organ Transport, which utilizes high-speed trains and commercial flights, has been developed in China.4Wu B. Hu C. Chen W. He J. Jiang G. Zhang J. et al.China lung transplantation developing: past, present and future.Ann Transl Med. 2020; 8: 41https://doi.org/10.21037/atm.2019.10.26Crossref PubMed Google Scholar,7Shi B.Y. Liu Z.J. Yu T. Development of the organ donation and transplantation system in China.Chin Med J. 2020; 133: 760-765https://doi.org/10.1097/CM9.0000000000000779Crossref PubMed Scopus (17) Google Scholar Moreover, China submits organ transplantation data annually to the WHO, in accordance with relevant regulations. After inspecting the China Organ Transplant Response System, Dr Jose Nunez, a WHO officer who oversees global organ transplantation, commented that "China's organ transplant reform has achieved remarkable results in a short period of time, and China's experience can serve as a model for the entire Asian region and the world".8Specialists hail China's progress in organ donation, transplant.https://www.chinadaily.com.cn/a/201912/09/WS5dedb0e0a310cf3e3557ccfd.htmlDate: 2019Date accessed: December 26, 2021Google Scholar China is a developing country. The health care system in a country that is home to almost one-fifth of the global population remains to be refined, and the development of organ transplant programs is no exception. We agree that there is scope for further improvement. Sade and colleagues1Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.J Thorac Cardiovasc Surg. 2021; 162: 1647-1653Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,2Sade R.M. Carpenter A.J. D'Amico T.A. Drake D.H. Entwistle III, J.W. Ray S. et al.Unethical studies on transplantation in cardiothoracic surgery journals.Ann Thorac Surg. 2021; 112: 1746-1752Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar recognized that cardiothoracic transplant surgeons in China "are dedicated to high ethical standards in their practices and are making vigorous and honest efforts to establish a transparent and trustworthy system." Many of us are proud to be international members of The Society of Thoracic Surgeons and The American Association for Thoracic Surgery. We deeply appreciate the continued help and support from our colleagues worldwide and we are keen to learn from them and exchange scientific knowledge with them through publications in international referred academic journals.3Sun Y.F. Wang Z.W. Zhang J. Cai J. Shi F. Dong N.G. Current status of and opinions on heart transplantation in China.Curr Med Sci. 2021; 41: 841-846https://doi.org/10.1007/s11596-021-2444-9Crossref PubMed Scopus (6) Google Scholar, 4Wu B. Hu C. Chen W. He J. Jiang G. Zhang J. et al.China lung transplantation developing: past, present and future.Ann Transl Med. 2020; 8: 41https://doi.org/10.21037/atm.2019.10.26Crossref PubMed Google Scholar, 5Huang J.F. Wang H.B. Zheng S.S. Liu Y.F. Shi B.Y. Shen Z.Y. et al.The new era of organ transplantation in China.Chin Med J. 2016; 129: 1891-1893https://doi.org/10.4103/0366-6999.187865Crossref PubMed Scopus (13) Google Scholar, 6Hu X.J. Dong N.G. Liu J.P. Li F. Sun Y.F. Wang Y. Status on heart transplantation in China.Chin Med J. 2015; 128: 3238-3242https://doi.org/10.4103/0366-6999.170238Crossref PubMed Scopus (9) Google Scholar, 7Shi B.Y. Liu Z.J. Yu T. Development of the organ donation and transplantation system in China.Chin Med J. 2020; 133: 760-765https://doi.org/10.1097/CM9.0000000000000779Crossref PubMed Scopus (17) Google Scholar,9Wu B. Huang M. Jiao G. Hu C. Yang Y. Chen J.Y. et al.Lung transplantation during the outbreak of coronavirus disease 2019 in China.J Thorac Cardiovasc Surg. 2022; 163: 326-335Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Whereas cardiothoracic transplant surgeons in China keep elevating the bar to a new height of excellence for the better care of our patients, we always wholeheartedly welcome kind advice from international experts. Once again, we wish to emphasize that there is nothing personal in this letter against Sade and colleagues. However, we are strongly against political prejudice and regional discrimination. We sincerely hope that some of our colleagues in Western countries take off their tinted glasses and acknowledge the progress occurring in this part of the world. Finally, as a humble reminder to Sade and colleagues, we would like to recall an ancient (approximately 239 BC) Chinese idiom about a man who used a boat to cross a river. It so happened that his sword fell into the water. Immediately, he cut a mark on the side of the boat and assured himself that "this is where I have dropped my sword." When the boat came to its destination and stopped, the man plunged into the stream at the point indicated by the incised mark in an attempt to retrieve his lost sword. Unfortunately, this man did not understand that the boat had moved on, but the sword had not. On the contrary, our colleagues worldwide can consciously recognize the fact that progress of organ transplantation in China is on the right track and keeps advancing forward. Deeds always speak louder than words. Unethical studies on transplantation in cardiothoracic surgery journalsThe Journal of Thoracic and Cardiovascular SurgeryVol. 162Issue 6PreviewExecuted prisoners have been a source of organs for transplantation in several countries; for example, Taiwan, Singapore, and China.1 Taiwan and Singapore have long since stopped the practice, but China has not. Taking organs by coercive methods has been documented in some countries, such as India and Egypt,2 but unlike China, this practice is illegal and subject to criminal prosecution in those jurisdictions. Full-Text PDF Reply from authors: The boat, the sword, and the opacity of Chinese transplant dataThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 3PreviewWe are grateful to Dong and colleagues1 for addressing several issues in our paper on the Chinese transplant system.2 We appreciate that many Chinese thoracic transplant surgeons want to make their system better, as we stated in our paper: "One of the most unfortunate consequences of the ongoing use of executed prisoner organs is the damage to the international reputations and standings of those transplant surgeons in China who are dedicated to high ethical standards in their practices and are making vigorous and honest efforts to establish a transparent and trustworthy system." We have no reason to doubt that this statement describes the authors of the present letter but also understand the motivation for Chinese thoracic transplant surgeons to present their system in the best light, highlighting organ donations in their country as transparent, fair, and traceable, despite the direct and indirect evidence to the contrary from the several scholarly sources that we cited. Full-Text PDF

Protein phosphatase 2A (PP2A), a crucial serine/threonine phosphatase, has recently been reported to play an important role in cardiovascular disease. Previous studies have hinted that PP2A is involved in atherosclerosis formation, but the associated mechanisms remain poorly understood. In this study, we investigate the role of PP2A in the pathogenesis of atherosclerosis. In human atherosclerotic coronary arteries, we found that the expression and activity of PP2A decreased significantly when compared to non-atherosclerotic arteries. Additional experiments demonstrated that pharmacological inhibition of PP2A aggravated atherosclerosis of ApoE−/− mice. Considering the central role of macrophages in atherosclerosis, mice with conditional knockout of the PP2A-Cα subunit in myeloid cells were produced to investigate the function of PP2A in macrophages. Results showed that PP2A deficiency in myeloid cells aggravated atherosclerotic lesions in mice. in vitro experiments indicated that PP2A-deficient macrophages had an enhanced ability of lipid uptake and foam cell formation. Mechanistically, the deficiency of the PP2A in macrophages led to an increase in the phosphorylation level of p38, which contributed to the elevated expression of scavenger receptor CD36, a key factor involved in lipoprotein uptake. Our data suggest that PP2A participates in the pathophysiological process of atherosclerosis. The decrease of PP2A expression and activity in macrophages is a crucial determinant for foam cell formation and the initiation of atherosclerosis. Our study may provide a potential novel approach for the treatment of atherosclerosis.

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The selection of the second graft conduit remains a matter of debate. To address this point, the Arterial Revascularization Trial (ART) was performed, but this large randomized controlled trial did not prove the benefit of bilateral internal thoracic artery (BITA) graft over single internal thoracic artery (SITA) graft with regard to all-cause mortality, myocardial infarction, or stroke at postoperative 10 years, and a subgroup analysis showed no interaction according to age.1Taggart D.P. Benedetto U. Gerry S. Altman D.G. Gray A.M. Lees B. et al.Bilateral versus single internal-thoracic-artery grafts at 10 years.N Engl J Med. 2019; 380: 437-446Crossref PubMed Scopus (307) Google Scholar Here, Navia and colleagues2Navia D. Espinoza J. Vrancic M. Piccinini F. Camporrotondo M. Dorsa A. et al.Bilateral internal thoracic artery grafting in elderly patients: any benefit in survival?.J Thorac Cardiovasc Surg. October 3, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar report their single-center retrospective observational study comparing the BITA graft with the SITA graft in patients aged 70 years or greater undergoing coronary artery bypass grafting surgery (CABG) from 2001 to 2018. They adopted propensity score–matched technique and found the use of BITA graft improved 10-year survival, with similar postoperative morbidity in patients at this age. They are to be congratulated on the important and meaningful results; however, there are a number of points worth discussing. First, the assessment workflow for the choice of BITA graft or SITA graft before the operation wasn't mentioned in the study, and it is unclear whether the factors like coronary anatomy and severity of culprit vessel were considered. The latter one has been shown to be an important predictor of the graft patency and survival after CABG.3Bakaeen F.G. Ravichandren K. Blackstone E.H. Houghtaling P.L. Soltesz E.G. Johnston D.R. et al.Coronary artery target selection and survival after bilateral internal thoracic artery grafting.J Am Coll Cardiol. 2020; 75: 258-268Crossref PubMed Scopus (40) Google Scholar Moreover, among their cohort of 1300 patients, patients in the SITA cohort were older with more comorbidities, such as previous renal failure, hypertension, peripheral artery disease, urgency, and low ejection fraction, suggesting that the SITA graft might be used preferentially in greater-risk patients. Second, a recent meta-analysis of randomized controlled trials showed the use of radial artery (RA) compared with SVG was associated with a lower risk of a composite of cardiovascular outcomes among patients undergoing CABG.4Gaudino M. Benedetto U. Fremes S. Ballman K. Biondi-Zoccai G. Sedrakyan A. et al.Association of radial artery graft vs saphenous vein graft with long-term cardiovascular outcomes among patients undergoing coronary artery bypass grafting: a systematic review and meta-analysis.JAMA. 2020; 324: 179-187Crossref PubMed Scopus (84) Google Scholar In addition, a recent publication from Royse and colleagues5Royse A.G. Bellomo R. Royse C.F. Clarke-Errey S. Boggett S. Kelly T. et al.Radial artery versus bilateral mammary composite Y coronary artery grafting: 15-year outcomes.Ann Thorac Surg. October 15, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar reported that postoperative survival was not different between RA and right internal thoracic artery when using as the second arterial conduit joined to the left internal thoracic artery (LITA) via a Y graft for total arterial revascularization. However, in the present study, there was a mixed population in the SITA graft group, which included LITA plus RA with or without saphenous vein (SVG) in 80% of the patients and LITA plus SVG in the remaining patients.2Navia D. Espinoza J. Vrancic M. Piccinini F. Camporrotondo M. Dorsa A. et al.Bilateral internal thoracic artery grafting in elderly patients: any benefit in survival?.J Thorac Cardiovasc Surg. October 3, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Therefore, we are concerned about the difference of outcomes between the BITA and SITA graft groups was derived from these 20% of patients with LITA plus SVG. If the authors can provide an additional subgroup analysis, it would have better clarified the significance of their findings. Finally, they matched 243 pairs by propensity score; given that there were only 332 patients in the SITA group, this represents more than a 27% loss from the population of interest that could result in decreased generalizability and accuracy of the results. Furthermore, the propensity-matched patients in the study were more like the SITA group than the BITA group, so external validity for the greater BITA cohort is in question. Bilateral internal thoracic artery grafting in elderly patients: Any benefit in survival?The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 2PreviewThe purpose of the present study was to compare survival outcomes in propensity score–matched patients aged 70 years or greater receiving a bilateral internal thoracic artery graft with patients receiving a single internal thoracic artery graft. Full-Text PDF Bilateral internal thoracic artery grafting in elderly patients makes sense indeedThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 2PreviewWe thank Sun and colleagues for their important comments on our recent article. As we stated, we adopted bilateral internal thoracic artery (BITA) grafting in elderly patients in our routine practice in 2003 in more than 95% of our patients with multivessel coronary artery disease and focused on the therapeutic influence of this approach in patients older than age 70 years in our report.1 We are fully aware that the length of the study period could have influenced the final results; however, that would be the expected evolution of a department trying to provide and adapt the best therapeutic approach in coronary surgery over time. Full-Text PDF

Lamelas and Alnajar1Lamelas J. Alnajar A. Early outcomes for surgical minimally invasive SAPIEN 3 transcatheter mitral valve replacement.Ann Thorac Surg. 2021; 112: 494-500Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar reported their experience of transcatheter mitral valve replacement (TMVR) in mitral annular calcification (MAC) with balloon-expandable S3 SAPIEN (Edwards Lifesciences, Irvine, CA); a total of 16 patients were included with outstanding early outcomes: the 30-day and 1-year mortality rate was 12.5% and 36.2%, respectively. One patient had mild left ventricular outflow tract obstruction (LVOTO), a moderate to severe paravalvular leak was noted in 2 patients and 2 patients received new pacemaker implementation.1Lamelas J. Alnajar A. Early outcomes for surgical minimally invasive SAPIEN 3 transcatheter mitral valve replacement.Ann Thorac Surg. 2021; 112: 494-500Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The rate of transcatheter heart valve thrombosis after TMVR is potentially higher than that observed after transcatheter aortic valve replacement.2Pagnesi M. Moroni F. Beneduce A. et al.Thrombotic risk and antithrombotic strategies after transcatheter mitral valve replacement.JACC Cardiovasc Interv. 2019; 12: 2388-2401Crossref PubMed Scopus (29) Google Scholar Therefore, an anticoagulation-based antithrombotic strategy should be considered after TMVR. In the present study, Lamelas and associates provided the information on postoperative anticoagulant therapy, but the data of postoperative transcatheter heart valve thrombosis was missing. It will be more helpful if transcatheter heart valve thrombosis was reported and analyzed as the secondary endpoint. Secondly, not like the case for TMVR valve-in-valve in mitral position, the annulus of MAC is difficult to be conformed to a relatively symmetrical round shape without much impact on surrounding structures, including conduction system, circumflex coronary artery, and aortic valve. Therefore, new complete heart block and paravalvular leak after TMVR were quite common.3von Ballmoos M.C.W. Kalra A. Reardon M.J. Complexities of transcatheter mitral valve replacement (TMVR) and why it is not transcatheter aortic valve replacement (TAVR).Ann Cardiothorac Surg. 2018; 7: 724-730Crossref PubMed Scopus (29) Google Scholar Is there any experience the authors can share to assess the risk of these postoperative morbidities? And once they occurred, what strategies should the surgeon follow? Finally, LVOTO is a frailty problem specific to TMVR valve-in-MAC. Prior publications suggested the rate of LVOTO after TMVR valve-in-MAC ranges from 9.3% to 39.7% despite careful case selection.4Yoon S.H. Whisenant B.K. Bleiziffer S. et al.Outcomes of transcatheter mitral valve replacement for degenerated bioprostheses, failed annuloplasty rings, and mitral annular calcification.Eur Heart J. 2019; 40: 441-451Crossref PubMed Scopus (235) Google Scholar In the present report, the LVOTO rate (6.25%) was lower than previous reports. Given the significant morbidity and mortality associated with LVOTO, the surgical experience of Dr Lamelas’s team should be encouraged. However, if the authors could provide the standard definition of LVOTO used in the study, along with the skills they adopted to prevent LVOTO in TMVR, their results will be more convincing. Early Outcomes for Surgical Minimally Invasive SAPIEN 3 Transcatheter Mitral Valve ReplacementThe Annals of Thoracic SurgeryVol. 112Issue 2PreviewLimited surgical options are available for patients with extensive mitral annular calcification. Several reports have shown the feasibility of surgical mitral valve replacement (MVR) using a transcatheter aortic valve in the mitral position (MVR-TAVR). This study reviewed 30-day and 1-year outcomes of a minimally invasive approach for MVR-TAVR. Full-Text PDF Outcomes to Consider in the Surgical Implantation of Transcatheter Valves in Patients With Mitral Annular CalcificationThe Annals of Thoracic SurgeryVol. 112Issue 6PreviewWe would like to thank Wang and Hu1 for their interest in our work and for taking the time to provide helpful feedback. Their letter notes the lack of postoperative valve thrombosis (vT) data in our study.2 While we agree that transcatheter valves may have higher rates of vT and should be investigated, the primary objective of our retrospective study was assessment of mortality, which did not include a systematic evaluation of high-resolution imaging techniques. However, we did observe a lack of major thromboembolic events or clinical episodes of vT. Full-Text PDF

IMPORTANCE Angiotensin II is significantly associated with the pathogenesis of acute aortic dissection. Angiotensin II type 1 receptor agonistic autoantibodies (AT1-AAs) can mimic the effect of angiotensin II. OBJECTIVE To investigate the association between AT1-AAs and all-cause and cause-specific mortality risk in patients with acute aortic dissection. DESIGN, SETTING, AND PARTICIPANTS A total of 662 patients with clinically suspected aortic dissection from 3 medical centers inWuhan, China, were enrolled in this cohort study from August 1, 2014, to July 31, 2016. Of these, 315 patients were included in the 3-year follow-up study. Follow-up was mainly performed via telephone interviews and outpatient clinic visits. Data analysis was conducted from March 1 toMay 31, 2020. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were all-cause mortality, death due to aortic dissection, and late aortic-related adverse events. RESULTS The full study cohort included 315 patients with AAD (mean [SD] age, 56.2 [12.7] years; 230 men [73.0%]). Ninety-two patients (29.2%) were positive for AT1-AAs. The mortality of AT1-AA-positive patients was significantly higher than that of AT1-AA-negative patients (40 [43.5%] vs 37 [16.6%]; P <.001). The mortality risk in AT1-AA-positive patients was always significantly higher than that in AT1-AA-negative patients in patients with both type A and type B dissection. Multivariable analysis showed that the risk of AT1-AA-positive patients for type A dissection was significantly higher than that of AT1-AA-negative patients (odds ratio [OR], 1.88; 95% CI, 1.12-3.13; P =.02). The Cox proportional hazards regression model showed a significant increase of all-cause mortality risk (OR, 2.27; 95% CI, 1.44-3.57; P <.001) and late aortic-related adverse events (OR, 1.58; 95% CI, 1.062.36; P =.03) among AT1-AA-positive patients during the follow-up period compared with AT1-AA-negative patients. CONCLUSIONS AND RELEVANCE This cohort study first detected AT1-AAs in patients with acute aortic dissection. The presence of AT1-AAs was associated with significantly higher all-cause and cause-specific mortality during a follow-up period of 3 years. The antibodiesmay be a risk factor for aortic dissection.

Mesenchymal stem cells (MSCs) have been proven capable of differentiating into endothelial cells (ECs) and increasing vascular density in mouse ischemia models. However, the therapeutic potential of MSCs in neointimal hyperplasia after vascular injury is still not fully understood. In this study, we proposed that sustained release of miR-217 inhibitor encapsulated by nanoparticles in MSCs can enhance the therapeutic effects of MSCs on alleviating neointimal hyperplasia in a standard mouse wire injury model. We intravenously administered MSCs to mice with injured arteries and examined neointimal proliferation, endothelial differentiation and senescence. We demonstrated that MSCs localized to the luminal surface of the injured artery within 24 h after injection and subsequently differentiated into endothelial cells, inhibited neointimal proliferation and migration of vascular smooth muscle cells. Transfection of MSCs with poly lactic-co-glycolic acid nanoparticles (PLGA-NP) encapsulating an miR-217 agomir abolished endothelial differentiation as well as the therapeutic effect of MSCs. On the contrary, silencing of endogenous miR-217 improved the therapeutic efficacy of MSCs. Our study provides a new strategy of augmenting the therapeutic potency of MSCs in treatment of vascular injury.

We were pleased to read the insightful letter by Condello and colleagues.1 Optimal timing for mitral valve surgery in asymptomatic degenerative mitral regurgitation requires serial monitoring for a decline in left ventricular (LV) function. When measurements are near a threshold for surgical intervention, the use of biomarkers is warranted.2 We agree with their comment that strain analysis of myocardial tissue can allow us to find an index of early or latent LV dysfunction much earlier than conventional 2-dimensional ultrasonography.

Background Transcatheter aortic valve replacement (TAVR) has gained increasing acceptance for patients with aortic disease. Both transfemoral (TF-TAVR) and transapical (TA-TAVR) approach were widely adopted while their performances are limited to a few studies with controversial results. This meta-analysis aimed to compare the mortality and morbidity of complications between TF- versus TA-TAVR based on the latest data. Methods Electronic databases were searched until April 2021. RCTs and observational studies comparing the outcomes between TF-TAVR versus TA-TAVR patients were included. Heterogeneity assumption was assessed by an I 2 test. The pooled odds ratios(OR) or mean differences with corresponding 95% confidence intervals (CI) were used to evaluate the difference for each end point using a fixed-effect model or random-effect model based on I 2 test. Results The meta-analysis included 1 RCT and 20 observational studies, enrolling 19,520 patients (TF-TAVR, n = 11,986 and TA-TAVR, n = 7,534). Compared with TA-TAVR, TF-TAVR patients showed significantly lower rate of postoperative in-hospital death (OR = 0.67, 95% CI 0.59–0.77, P < 0.001) and 1-year death (OR = 0.53, 95% CI 0.41–0.69, P < 0.001). Incidence of major bleeding and acute kidney injury were lower and length of hospital stay was shorter, whereas those of permanent pacemaker and major vascular complication were higher in TF-TAVR patients. There were no significant differences between TF-TAVR versus TA-TAVR for stroke and mid-term mortality. Conclusions There were fewer early deaths in patients with transfemoral approach, whereas the number of mid-term deaths and stroke was not significantly different between two approaches. TF-TAVR was associated with lower risk of bleeding, acute kidney injury as well as shorter in-hospital stay, but higher incidence of vascular complication and permanent pacemaker implantation.

BACKGROUNDTranscatheter aortic valve replacement (TAVR) has gained increasing acceptance for patients with aortic disease. A rare but fatal complication prosthetic valve endocarditis (PVE) could greatly influence the clinical outcomes of TAVR. This meta-analysis aims to pin down the predictors of PVE in TAVR patients.METHODSWe performed a systematic search for studies that reported the incidence and risk factors of PVE after TAVR. Data on studies, patients, baseline characteristics, and procedural characteristics were abstracted. Crude risk ratios (RRs) and 95% confidence intervals for each predictor were calculated by the use of random-effects models. Heterogeneity assumption was assessed by an I2 test.RESULTSWe obtained data from 8 studies that included 68,805 TAVR patients, of whom 1,256 (1.83%) were diagnosed with PVE after TAVR. 280 patients died within the 30-days of PVE diagnosis and the pooled in-hospital mortality was 22.3%. The summary estimates indicated an increased risk of PVE after TAVR for males (RR 1.53, P = .0001); for patients with orotracheal intubation (RR 1.65, P = .01), new pacemaker implantation (RR 1.46, P = .003), and residual aortic regurgitation (≥2 grade) (RR 1.62, P = .05); while older age (RR 0.97, P = .0007) and implantation of a self-expandable valve (RR 0.74, P = .02) were associated with a lower risk of PVE after TAVR.CONCLUSIONClinical characteristics and peri- procedure factors including age, male sex, valve type, orotracheal intubation, pacemaker implantation, and residual regurgitation were proven to be associated with the occurrence of PVE-TAVR. Clinicians should pay particular attention to PVE when treating TAVR patients with these predictors.

BACKGROUND The optimal prosthesis for aortic valve replacement (AVR) with concomitant coronary artery bypass grafting (CABG) is controversial. We investigated postoperative outcomes in these patients with a biological prosthesis or mechanical prosthesis. METHODS A retrospective cohort analysis was performed of 2485 patients aged 50 to 69 years who underwent AVRDCABG in Hubei province hospitals from 2002 to 2018. The median follow-up duration was 6.5 years (interquartile range, 0-15.8 years). Propensity score matching for 18 baseline characteristics yielded 346 patient pairs between bioprosthetic and mechanical prosthetic groups. End points were death, stroke, major bleeding event, and reoperation. RESULTS No differences in survival, stroke, or overall reoperation rates were observed between the bioprosthetic and mechanical valve groups. The 15-year cumulative incidence of reoperation due to prosthesis failure/dysfunction was higher in the bioprosthetic group (hazard ratio [HR], 2.72; 95% confidence interval [CI], 1.26-5.88; P = .011), whereas the 15-year cumulative incidence of reoperation due to coronary artery disease progression/bypass failure was similar between 2 groups (HR, 0.76; 95% CI, 0.37-1.57; P = .459). Mechanical valves were associated with a higher 15-year cumulative incidence of major bleeding events compared with bioprosthetic valves (HR, 1.92; 95% CI, 1.16-3.19; P = .012). CONCLUSIONS Long-term survival, overall reoperation, or stroke incidence was comparable among the 2 groups, while patients with a mechanical valve showed a greater likelihood of major bleeding events. Regarding the limited durability of bioprosthetic valves, a larger sample size monitored for 15 or more years will be necessary to determine the optimal aortic valve prosthesis for patients aged 50 to 69 years undergoing concurrent AVR and CABG. (Ann Thorac Surg 2022;113:100-8) (c) 2022 by The Society of Thoracic Surgeons

A subclavian-superior vena cava arteriovenous fistula is usually acquired and secondary to trauma or operations, while congenital causes are very rare. A congenital arteriovenous fistula leads to congestive heart failure soon after birth and is typically diagnosed in early infancy. We present an unusual case of a 21-year-old female suffering from new-onset heart failure at 20 years old who was diagnosed with a congenital arteriovenous fistula from the right subclavian artery to the superior vena cava (RSA-to-SVC) with stenosis at the proximal initial site of the fistula. The patient successfully underwent transcatheter occlusion for the fistula and had a significant improvement in symptoms at the 3-month follow-up. An RSA-to-SVC fistula is a very rare congenital disorder that can lead to shunt-related heart failure. If there is an indication for closure, as with the patient presented, percutaneous device closure can be considered a reasonable option.