Introduction Aortic dissection (AD) is a life-threatening cardiovascular emergency with a high mortality rate, and acute Stanford Type A AD is the most dangerous form, often requiring surgical intervention. Factors contributing to the progression of AD include increased heart rate, blood pressure and the rate of ventricular contraction (dP/dt). While heart rate control is a cornerstone of preoperative management for AD per existing guidelines, the recommended target (eg, ≤60 bpm in American Heart Association 2010) is consensus-driven (Level C) and thus not grounded in high-level evidence. The ESCORT (Efficacy and Safety of preoperative Controlling heart Rate in patients with acute Type A aortic dissection) trial is designed to address this critical gap by providing high-level evidence from a randomised controlled trial to define the optimal preoperative heart rate target.Methods and analysis The study is a multicentre, single-blind, RCT involving adult patients diagnosed with acute (Stanford Type A) AD, scheduled for aortic arch prosthetic vascular replacement and elephant trunk stent implantation surgery. 680 patients will be randomised into two groups: low heart rate target group (55–65 beats per minute) and standard heart rate target group (75–85 beats per minute). The intervention involves protocol-directed medication to achieve the target heart rates, with esmolol as the primary recommended agent. The primary outcome measure is the rate of major adverse cardiovascular event within 30 days after surgery, and secondary outcomes include various clinical, economic and biochemical measures.Discussion The ESCORT study is the large-scale RCT to investigate the optimal preoperative heart rate control in patients with acute type A AD. The results of this study have the potential to fill the evidence gap in current clinical guidelines and provide evidence-based support for clinical management. The findings may influence the standard of care by either endorsing lower heart rate targets or providing alternative guidance for managing heart rate in this high-risk patient population. The study’s results will be disseminated through publications and presentations at both national and international conferences, ensuring that the results are accessible to the medical community and relevant patient organisations.Ethics and dissemination This study, including the study protocol (version 1.3, 3 December 2022), was approved by the Ethics Committee of Fuwai Hospital, CAMS and PUMC (approval number: 2022-1886). Additional approvals were obtained from the ethics committees of participating subcentres (approval numbers are listed in the main text). The findings will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences.Trial registration number ChiCTR2300067811.

To the Editor: Total aortic arch replacement (TAR) is a surgical procedure associated with significant perioperative risks, leading to a higher rate of mortality and neurologic complications. Ascending aortic or hemiarch replacement is associated with less complicated procedures, which can be used to effectively resect the proximal intimal tear and potentially improve the survival rates in these patients.[1] Hybrid aortic repair, combining open-chest surgery and stent placement has been effectively used in patients with an aortic arch aneurysm.[2] Although a hybrid technique is often followed, only a limited number of studies with a small number of cases have investigated the application of this procedure for the treatment of type I aortic dissection.[1,2] This study aimed to evaluate the early and mid-term safety and efficacy of the hybrid technique in this cohort by analyzing a large sample size. The study was approved by the Ethics Committee of Fuwai Hospital (No. 2015025) and complied with the Declaration of Helsinki. The study group obtained written informed consent from each patient before they participated in the study. The clinical data were collected during January 2010 and December 2016 from Fuwai Hospital. Patients were divided into two groups depending on the surgical techniques; the frozen elephant trunk (FET) group involved 815 (86.9%) patients who performed traditional TAR combined with FET; also, the hybrid group included 122 (13.1%) patients with hybrid TAR. The exclusion criteria for the hybrid procedure were as follows: (i) the patients’ age <50 years and (ii) the patients who had severe compression for the true lumen of the descending aorta caused by the false lumen. The definition of the composite complication included new-onset kidney failure, operative death, and persistent nerve system damage. Our patients were followed up by standardized forms during telephone or face-to-face interview. For the surgery techniques in the FET group, the clamp was removed after deep hypothermic circulatory arrest (DHCA), and the aortic arch was transected proximal to the left subclavian artery, then three brachiocephalic vessels were separately clamped. FET stent graft was implanted directly into the true lumen of the descending aorta, the distal end of a tetrafurcate graft was anastomosed to the distal end of the aortic arch, which incorporating FET stent graft. The left common carotid artery, the innominate artery, and the left subclavian artery were then respectively conducted. Finally, the artificial vessel was anastomosed to the ascending aorta [Figure 1A]. For the hybrid group, the aortic cross-clamp was used between the opening of the innominate artery and the left common carotid artery after the nasopharyngeal temperature lowered to 28°C, then the ascending aorta were removed. The tetrafurcate graft was then sutured to the aortic arch, subsequently sutured to the innominate artery and ascending aorta. The other two branches were sutured to the left common artery, and the left subclavian artery. The cardiopulmonary bypass (CPB) was discontinued, then the guiding wire and sheath were advanced retrogradely, the stent was implanted, and the proximal part was anchored to the artificial vessel [Figure 1B].Figure 1: Surgery techniques in the Frozen elephant trunk (FET) group and the hybrid group. (A) After deep hypothermic circulatory arrest (DHCA) was instituted, the clamp on ascending aorta was removed and the aortic arch was transected proximal to the left subclavian artery, then three brachiocephalic vessels were separately clamped. FET stent graft was implanted into the true lumen of the descending aorta under direct vision. The distal end of a tetrafurcate graft was anastomosed to the distal end of the aortic arch, incorporating the stented graft. Anastomoses of the left common carotid artery, left subclavian artery, and innominate artery were then conducted. Finally, the proximal end of the artificial vessel was anastomosed to the ascending aorta. (B) After nasopharyngeal temperature was lowered to 28°C, the aortic cross-clamp was used between the opening of the innominate artery and the left common carotid artery, ascending aorta were removed. The distal end of a tetrafurcate graft was then sutured to the proximal aortic arch, subsequently the innominate artery and the proximal end of the graft to the ascending aorta. The other two branches were sequentially anastomosed with the left common artery, left subclavian artery. Then the guiding wire and sheath were advanced retrogradely, the stent was implanted and the proximal part was anchored to the artificial vessel to complete the arch repair.Statistical analyses were performed using SAS 9.4 software (SAS Institute Inc., Cary, NC, USA). Continuous variables were analyzed using a t-test or rank-sum test, whereas classification variables were analyzed using a Chi-square test and Fisher exact test. All tests were two-sided, with a confidence level of α = 0.05; a P value < 0.05 was considered statistically significant. There were 109 pairs of patients selected from the two groups by using a 1:1 matched pair design. The composite of complications and post-operative death were analyzed by the Multivariable logistic models for the two groups. The Kaplan-Meier analysis was used to estimate post-operative survival. The patients’ average age in the hybrid group was 61.3 years, which was significantly higher than the FET group (61.3 vs. 46.7 years, P < 0.001). Cardiac malperfusion and aortic valve insufficiency were more frequently observed in the FET group (9.3% vs. 3.3% and 14.4% vs. 4.9%). The other clinical manifestations had no significant differences between the two groups [Supplementary Table 1, https://links.lww.com/CM9/A593]. The average diameter and the length of the stent were 30.3 ± 6.4 and 190.5 ± 25.5 mm, respectively. There were no significant differences in combined surgical procedures after propensity score matching between the two groups, but time of surgery, cross-clamping, and CPB were shorter in the hybrid group (P < 0.05) [Supplementary Table 2, https://links.lww.com/CM9/A593]. The early mortality had no significant difference between the two groups (9.0% vs. 10.7%, P = 0.577). There was no spinal cord injury in the hybrid group, having a lower incidence of post-operative renal and liver insufficiency in the hybrid group (P = 0.013, P = 0.022, and P = 0.014, respectively) after matching. Additional information is displayed in Supplementary Table 3, https://links.lww.com/CM9/A593. We followed up 778 patients for an average of 36.8 months; 28 (3.6%) patients underwent redo surgery and 40 (5.1%) died. For the patients who performed redo surgery, 19 (76%) underwent thoracoabdominal aortic replacement, five (20%) received ascending aorta anastomosis surgery, and one (4%) underwent root replacement in the FET group. One underwent repeat root replacement, and two underwent ascending aorta anastomosis surgery in the hybrid group. After propensity score matching, the post-operative 1-, 3-, and 5-year survival rates were 80.7%, 76.9%, and 74.6% in the FET group, respectively, and 87.9%, 86.3%, and 82.2% in the hybrid group, respectively (P = 0.086) [Supplementary Figure 1, https://links.lww.com/CM9/A593]. It was previously demonstrated that the hybrid procedure can be implemented for the treatment of true aortic arch aneurysms, pseudoaneurysms, and other aortic lesions under normal temperature.[3] The intravascular placement of stents on zone 0 of the native aorta would increase the risk of dissection, especially when the diameter of the ascending aorta is higher than 40 mm.[4] Hybrid TAR in our group eliminated those risks, due to the placement of the stent on the graft. However, the type Ia endoleaks are often inevitable because of the incomplete apposition of the stent-grafts to the lesser curvature of the aortic arch, resulting in a bird beak defect.[5] Besides, nine cases of type I endoleak were noted in our cohort; these endoleaks resolved without any further intervention, as shown by imaging evaluation 3 months post-surgery. Our results showed a better trend for total mortality rate and the composite of complications in the hybrid group, although those differences were not statistically significant. Furthermore, the hybrid technique had less interfere on the liver and kidney function, which reduced the incidence of post-operative liver and kidney dysfunction. The association between DHCA and the risk of stroke has been controversial in the literature.[6] In our center, we carried out moderate hypothermia to avoid potential damage from DHCA in the hybrid group. Because DHCA can increase CPB time and usage of blood products, both of which might cause neurologic injury. Placing a longer stent in the dissected descending aorta could effectively promote remodeling of distal false lumens but may increase the risk of spinal cord ischemia (SCI).[7] Our results showed that there was no paraplegia in the hybrid group, although longer coverage of descending aorta was observed in the hybrid group compared with the FET group. Although we exactly did not know why a lower SCI occurred in the hybrid group than the FET group, we observed a lower CPB time and less usage of blood products, both of which might had protection for SCI. To conclude, the one-stage hybrid arch repair is associated with acceptable early and mid-term morbidity and mortality rates, offering more options for patients with DeBakey type I aortic dissection, but the long-term clinical outcome still need to be explored. Conflicts of interest None.

AimsVarious kinds of surgical strategies and prostheses have been advocated to improve short-term and long-term outcomes in type A aortic dissection (TAAD). Large-scale repair of the pathological aorta is hard to generalize due to complex procedures. We aimed to investigate the performance, effectiveness and safety of a novel Sutureless Integrated Stented (SIS) graft prosthesis in TAAD patients undergoing total arch replacement (TAR) and frozen elephant trunk (FET) implantation surgery.MethodsAll patients admitted to Fuwai Hospital were prospectively screened. Urgent or scheduled surgery was arranged for eligible patients. The primary endpoint was operative mortality. Key secondary endpoints included stroke, spinal cord injury, unexpected aortic reoperation, and 1-year survival. Discharged patients were followed up with computed tomography angiography and transthoracic echocardiography at 3 months, 6 months, and 1 year after surgery. Performance, effectiveness and safety analyses were performed in those patients.ResultsBetween August 1 and September 3, 2020, ten TAAD patients were enrolled in this study and successfully implanted with the SIS graft prosthesis. The median (IQR) age was 56.50 (43.75, 66.75) years (range from 31 to 75), and seven patients were male (70.0%). All patients underwent ascending aorta replacement + TAR + FET and additional procedures when necessary. The median (IQR) operation time, cardiopulmonary bypass time and cross clamp time were 270.50 (218.50, 312.50), 110.00 (88.00, 125.75), 69.50 (51.25, 82.75) min, respectively. Of note, the median (IQR) circulatory arrest time was 9.00 (8.00, 9.00) min (range from 4 to 12). The median (IQR) lowest nasopharyngeal temperature was 26.75 (25.98, 27.67) °C. Follow-up was 100% completed. During the 1-year follow-up, no patients died, no severe adverse events occurred, and rate of freedom from aortic reintervention was 100%.ConclusionsThe SIS graft prosthesis was implanted in a novel sutureless way, which simplified the surgical procedure, shortened the circulatory arrest time and avoided deep hypothermia. The preliminary clinical outcomes and follow-up outcomes demonstrated the effectiveness and safety of this prosthesis. A large-scale trial is being conducted to further assess these findings.

Objective: The duration of hypothermic circulatory arrest (HCA) is one of the important factors affecting the prognosis of arch surgery, which is still controversial. The purpose of this study was to investigate the effect of HCA duration on early prognosis in type A aortic dissection (TAAD) patients who underwent arch surgery in our center.Methods: All consecutive patients who underwent surgical treatment for TAAD in Fuwai Hospital from January 2013 to December 2018 were included in this study and divided into four quartile groups based on HCA time. Baseline characteristics, perioperative indicators, and early mortality were statistically analyzed by propensity score matching (PSM) and restricted cubic spline (RCS) method. Perioperative adverse events were confirmed according to the American STS database and Penn classification.Results: About 1,018 consecutive patients (mean age 49.11 ± 1.4 years, male 74.7%) with TAAD treated surgically were eventually included in this study. After PSM, with the prolongation of HCA time, the surgical mortality rates of group [2,15], (15,18], (18,22], and (22,73] were 4.1, 6.6, 7.8, and 10.9% with p = 0.041, respectively. As shown in RCS, the mortality rate increased sharply after the HCA time exceeded 22 min. And from the subgroup analysis, the HCA time of 22 min or less was associated with better clinical outcomes (OR 2.09, 95%CI 1.25–3.45, p = 0.004).Conclusions: The early mortality increases significantly with the duration of HCA time when arch surgery was performed. And multiple systems throughout the body can be adversely affected.

Objective: To examine the early outcome of valve sparing aortic root replacement with reimplantation technique (David procedure) with partial upper sternotomy. Methods: From April 2016 to April 2020, 31 patients underwent valve sparing aortic root replacement under partial upper sternotomy at Vascular Surgery Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. There were 28 males and 3 females, aging (44±13) years (range: 11 to 65 years). Preoperative aortic regurgitation was found greater than moderate in 15 patients, moderate in 6 patients and less than moderate in 10 patients. The diameter of aortic annulus was (26±3) mm (range: 21 to 34 mm), the diameter of aortic sinus was (51±6) mm (range: 41 to 68 mm), the diameter of ascending aorta was (43±8) mm (range: 26 to 62 mm). The preoperative ejection fraction was (65±4) % (range: 59% to 72%) and left ventricular end-diastolic diameter was (55±6) mm (range: 42 to 68 mm). All cases were treated with David Ⅰ procedure, including simple David procedure in 26 patients, David+ascending aorta and partial aortic arch replacement in 3 patients, David+thoracic endovascular aortic repair in 1 patient, David+stent elephant trunk implantation in 1 patient. Results: The operation time, cardiopulmonary bypass time and aortic cross-clamping time were (330±58) minutes (range: 214 to 481 minutes), (138±23) minutes (range: 106 to 192 minutes) and (108±17) minutes (range: 82 to 154 minutes), respectively. There were no death and serious complications (stroke, myocardial infarction, renal insufficiency, severe infection, etc.). The postoperative drainage volume within 24 hours was (314±145) ml (range: 130 to 830 ml). The intubation time was (14±3) hours (range: 8 to 21 hours), and the ICU time was (M(QR)) 2.1(1.5) days (range: 1.0 to 5.0 days). Eight patients had no blood transfusion, the proportion of red blood cell use was 9.7% (3/31), plasma use was 22.6% (7/31), and platelet use was 71.0% (22/31). The postoperative left ventricular ejection fraction was (62±4)% (range: 54% to 69%), and left ventricular end-diastolic diameter was (48±4) mm (range: 39 to 56 mm). After operation, aortic regurgitation was significantly improved, with no more than moderate regurgitation, small to moderate regurgitation in 3 patients, minor regurgitation in 3 patients, micro regurgitation in 12 patients and no regurgitation in 13 patients. The follow-up period was 3.5(6.1) months (range: 2.0 to 39.0 months). Echocardiographic follow-up data were obtained in 26 cases, including moderate regurgitation in 1 patient, small to moderate regurgitation in 9 patients, minor regurgitation in 5 patients, micro regurgitation in 6 patients and no regurgitation in 5 patients. There were no major adverse cardiovascular events and aortic events during the follow-up period. No patient was reoperated for aortic regurgitation. Conclusion: Valve sparing aortic root replacement under partial upper sternotomy is safe and feasible, and the early result is satisfactory.

Due to better postoperative convalescence and quality of life, experienced centers focus on minimally invasive surgical techniques and approaches, but this approach is not routinely performed for valve-sparing root replacement procedures. The purpose of this study was to assess the safety and feasibility of valve-sparing root replacement via partial upper sternotomy. Between January 2016 and April 2021, 269 patients underwent a valve-sparing root replacement procedure, and partial upper sternotomy was performed in 52 patients. The clinical outcomes of the partial upper sternotomy (PUS) and complete sternotomy (CS) groups, including mortality, degree of aortic insufficiency, blood loss and consumption of blood products, postoperative complications, and hospitalization expenses, were compared. The Kaplan–Meier method was used to assess the degree of aortic regurgitation. Propensity score matching was performed as a sensitivity analysis. There was only one in-hospital death (in the CS group, p = 1) and no postoperative moderate to severe aortic insufficiency in either group. The blood loss and consumption of blood products in the PUS group were also lower than in the CS group, especially for plasma use. Regarding the need for re-exploration because of bleeding, acute kidney injury, pericardial pleural effusion, drainage volume within the first 24 h, mechanical ventilation time, and arrhythmia, the two groups were comparable. Patients in the CS group showed a longer ICU time (74.20 ± 47.21 vs. 50.9 30.16 h, p = 0.001) and higher hospitalization expenses (135,649.52 ± 29,992.21 vs. 123,380.15 ± 27,062.82 yuan, p < 0.001). None of the patients died or reoperated during the follow-up. Freedom from moderate or severe aortic insufficiency remained comparable after matching (p = 0.97). Minimally invasive valve-sparing aortic replacement via partial upper sternotomy can be safely performed in selected patients.

Background To evaluate the efficacy and safety of ascending aortoiliac bypass surgery for one-stage repair of adult coarctation of the aorta (CoA) and concomitant cardiac disease. Methods From March 2012 to October 2018, 51 consecutive CoA patients were treated with ascending aorta to bilateral iliac artery bypass concomitant with and cardiac surgerical procedures performed for a variety of reasons. A Y-shaped graft was used for the bypass procedure. We evaluated early outcomes, including postoperative death, systolic blood pressure and differences between upper and lower limb blood pressure. Results The average age was 41 years and 64.7% of patients were men. Simultaneous cardiac procedures included aortic valve replacement, ventricular septal defect repair, Bentall procedures and Wheat procedures. No deaths occurred in the early postoperative period. Three patients had delayed healing at the site of the abdominal lower quadrant incisions. The average systolic pressure in the upper limb and the average difference between the upper- and lower-limb blood pressure decreased significantly after surgery (162.7 ± 13.4 mmHg vs 128.4 ± 6.7 mmHg, P = .000; 69.6 ± 15.6 mmHg vs 8.7 ± 7.6 mmHg, P = .000, respectively); The systolic blood pressure in the lower limb increased after bypass surgery (93.1 ± 6.2 mmHg vs 119.6 ± 7.7 mmHg, P = .000). The follow-up rate was 100%, with an average follow-up time of 61 months. Six patients (11.8%) had graft stenosis or occlusion. Three patients (5.9%) underwent endovascular embolectomy. Conclusions In our small series, ascending aortoiliac bypass for one-stage repair of CoA with concomitant cardiac lesions appears safe and efficacious in effectively reduceing differences between upper and lower limb systolic blood pressure. Further study with larger sample size and longer follow-up is needed.

Pulmonary artery aneurysm (PAA) is a relatively rare disease. The symptoms are usually nonspecific and often identified due to coughing or dyspnea. Pericardial tamponade caused by the PAA dissection or rupture is the most common cause of death, so active surgical treatment is recommended. The surgical reports in the literature are handful. Here we report three cases, all of whom were admitted due to exertional dyspnea. PAAs were observed from the main to the left and/or the right pulmonary artery. All three cases received PAA resection and artificial graft replacement with good outcomes.

目的 探讨一期Ⅱ型杂交全主动脉弓修复术治疗不同年龄Stanford A型主动脉夹层患者的有效性.方法 回顾性分析2016年1月至2018年12月于阜外医院行杂交全主动脉弓修复术的126例A型主动脉夹层患者的临床资料,其中男78例(61.9％)、女48例(38.1％),平均年龄(61.8±6.9)岁.患者按年龄分为高龄组(≥60岁,n=82)及非高龄组(＜60岁,n=44).对两组患者的术前、术中及术后资料进行分析比较.结果 高龄组患者与非高龄组患者年龄差异有统计学意义[(65.9±4.1)岁vs.(54.3±4.1)岁,P＜0.010],其它术前基线资料差异无统计学意义.术后早期死亡共6例(4.8％),术后卒中3例(2.4％),截瘫患者2例(1.6％).共植入支架194枚,平均直径(33.6±1.8)mm,平均长度(199.0±6.7) mm.非高龄组患者呼吸机使用时间[(31.9±41.7)h vs.(61.0±89.2)h,P=0.043]及重症监护室停留时间[(77.8±51.4)hvs.(143.1±114.4)h,P＜0.001]均明显短于高龄组.两组患者院内死亡率、再手术率及术后生存率方面差异无统计学意义(P＞0.05).随访1～ 43 (22.6±10.8)个月,3例失访.术后支架段假腔完全血栓化104例(82.5％),内漏11例(9.2％).结论 杂交全主动脉弓修复术治疗Stanford A型主动脉夹层早中期效果满意,非高龄组与高龄组患者早期治疗效果相当,中期随访结果非高龄组优于高龄组.

Objective To analyze the characteristics of changes in diameters of ascending aorta and false lumen in patients with acute type-A aortic dissection, hereby to determine the risk factors of preoperative dissection rupture. Methods Between January 2010 and December 2016, a total of 794 patients with acute type A dissection were selected. The total diameters of aortic sinus, ascending aorta and the proximal arch as well as the diameter of the false lumen were measured in aortic enhanced CT images. And the competitive risk analysis was used to determine the independent risk factors for dissection rupture. Results 90 patients (11.3％) died of rupture before surgical treatment. The mean age of all patients was 52.2 years. The mean interval time from onset to endpoint was 90.9 h in the rupture group, which was shorter than that in the surgery group (119.7 h,P=0.058). More patients in the rupture group manifested with syncope than in the surgery group (11.1％ vs 1.3％, P<0.001). The preoperative shock in the rupture group was significantly higher than in the surgery group (7.8％vs 2.7％, P=0.021). The average diameter of the ascending aorta was 48.6 mm, and it was significantly greater in the rupture group than in the surgery group (50.0 mm vs 47.3 mm, P=0.003). The average diameter of the false lumen of the ascending aorta was 28.0 mm, which was significantly greater in the rupture group than in the surgery group (34.3 mm vs 22.4 mm, P<0.001). The average ratio of false lumen diameter/true lumen diameter of the ascending aorta was 2.9; it was significantly greater in the rupture group than in the surgery group (3.4 vs 2.5, P<0.001). The preoperative rupture rate increased with the diameter of the false lumen;For a diameter of the false lumen of≥31 mm, the degree of dominance ratio was the maximum under the premise of statistical significance with a rupture rate of 20％ (64/320), while the rupture rate was 6.82％(32/474) for a diameter of the false lumen of <31 mm. When the false lumen/true lumen ratio was ≥3.38, the degree of dominance ratio reached the maximum value under the premise of statistical significance. A multivariate regression analysis showed that a diameter of ascending aorta of <45 mm , the diameter of the false lumen (OR=1.04, 95％CI 1-1.10;P=0.041) and false lumen/true lumen ratio ≥4 (OR=1.24, 95％CI 1.06-5.28;P=0.029) were closely associated with preoperative rupture. Conclusions The rupture of acute type-A dissection is closely correlated to the diameter of false lumen of ascending aorta and false lumen/true lumen ratio. When the total diameter of ascending aorta is <45 mm, the risk of dissection rupture is closely associated with the diameter of false lumen and false lumen/true lumen ratio.

OBJECTIVE:The study objective was to determine whether hybrid aortic repair yields superior outcomes compared with the conventional surgical approach for DeBakey type I aortic dissection. METHODS:A retrospective analysis of patients with DeBakey type I dissection admitted to Fuwai Hospital between January 2010 and December 2016 showed that 815 patients (86.9%) underwent open total arch replacement with frozen elephant trunk (frozen elephant trunk group) and 122 (13.1%) underwent hybrid aortic arch repair without deep hypothermic circulatory arrest (hybrid group). We selected 109 pairs of patients for propensity score matching. Outcomes included early postoperative death, a composite of complications, dissected aorta remodeling, long-term survival, and freedom from reoperation. RESULTS:Early mortality and complication rates were lower in the hybrid group, but the difference was not statistically significant (9.2% vs 17.4%, P = .073; 15.6% vs 25.7%, P = .066). The rates of postoperative renal insufficiency was significantly lower in the hybrid group than in the frozen elephant trunk group (22.9% vs 38.5%, P = .013); liver insufficiency and paraplegia were significantly lower in the hybrid group than in the frozen elephant trunk group (20.2% vs 33.9%, P = .022; 0% vs 6.4%, P = .014). After matched, the 1-year, 3-year, and 5-year survivals were 87.6%, 86.3%, and 82.2%, respectively, in the hybrid group and 80.7%, 76.5%, and 74.6% (P = .071), respectively, in the frozen elephant trunk group. CONCLUSIONS:Hybrid aortic arch repair is a viable alternative treatment for patients with DeBakey type I aortic dissection, which improves outcomes and promotes remodeling of the dissected thoracic aorta.

Objective To study the effect of percutaneous femoral venous cannulation in aortic valve replacement (AVR) through upper hemisternotomy. Methods This was a retrospective study of 65 consecutive AVR patients through upper hemisternotomy between May 2012 and January 2017 at Fuwai Hospital. The patients were divided into femoral vein group (n = 26) and right auricle group (n = 39). Outcomes of the two groups were compared to study the effects of different cannulation methods. Results There was no in -hospital death in the two groups. There was a reoperation for bleeding in the femoral vein group, but no complications at the catheter site and no thrombosis in the femoral vein or pulmonary embolism happened. In the right auricle group, there was an intraoperative convertion to conventional sternotomy due to perivalvular leakage. No other severe complications were observed in both groups. There was no significant difference in cardiopulmanary bypass time, aortic cross-clamp time, operation time, mechanical ventilation time, length of ICU stay, hospitalization costs, length of postoperative hospital stay, blood loss and blood transfusion rate between the two groups. Conclusions Percutaneous femoral venous cannulation is safe and feasible in AVR through upper hemisternotomy. This method is a useful alternative to the right auricle cannulation for patients whose right auricle is difficult to expose or those who are concerned about the cosmetic result.

Objective Conventional technique with deep hypothermia circulatory arrest (DHCA) during extensive thoracoabdominal aortic aneurysm (TAAA) repair often complicated with high mortality and neurologi-cal complications, the optimal strategy for improving outcomes after TAAA repair remains unclear. We evalu-ated the protective effect of arterial bypass with normothermia technique during repair of extensive TAAAs. Methods From January 2005 to June 2017, a total of 190 patients with Crawford extend Ⅱ/Ⅲ underwent extensive thoracoabdominal aortic aneurysm (TAAA) repair and either with arterial bypass plus normothermia technique (group A) or with deep hypothermia circulatory arrest (group B). In group A, 75 patients (55 men;age 40.7years; 54 patients (72％) with dissection) underwent arterial bypass procedure. In group B, 115 pa-tients with DHCA procedure (87 men; age 38.8 years; 99 patients (66.1％) with dissection). The outcomes were compared by operative death (in-hospital death or death within 30 days of surgery) and permanent neu-rological complications (includes permanent stroke, paraplegia and cerebral hemorrhage). Results The opera-tive death occurred in 1 patient (1.3％) and 9 patients (7.8％) in group A and group B (P=0.045), respectively. The permanent neurological complications occurred in 5 patients (6.7％) and 19 patients (16.7％) in group A and group B (P=0.044), respectively. Gastrointestinal dysfunction occurred in 1 patient (1.3％) in group A and in 12 patients (10.5％) in group B (P=0.015), respectively, but there were no differences in occurrence of postoperative paraplegia, stroke and cerebral hemorrhage respectively between two groups (4 patients (5.4％) vs. 9 patients (7.8％), P=0.506; 1 patients (1.3％) vs. 7 patients (6.1％), P=0.111 and 1 patients (1.3％) vs. 3patients (2.6％), P=0.483). Multivariable analysis indicated that permanent neurological complications (OR:13.50,95％CI:3.48-52.36,P=0.000), DHCA(OR:15.85,95％CI:2.64-95.13, P=0.003),postoperative re-nal insufficiency (OR:8.47,95％CI:2.12-33.89,P=0.003)、gastrointestinal dysfunction (OR:15.11,95％CI:3.454-66.10,P=0.000)were independent predictors for early mortality. The overall postoperative survival rate between group A and B was 98.5％ vs. 90％,96.3％ vs. 90％ and 96.3％ vs. 83％ at 3 years, 5 years and 10 years respectively; there were no significant differences between two groups for survival rate (P=0.460). Con-clusions Arterial bypass with normothermia technique improved the early outcomes with lower risk of opera-tive death and permanent neurological complications in patients who had repair of extensive TAAAs.

Objective To investigate predictors for mortality among patients with Stanford type A acute aortic dissection (AAD) and to establish a predictive model to estimate risk of in-hospital mortality. Methods A total of 999 patients with Stanford type A AAD enrolled between 2010 and 2015 in our hospital were included for analysis. There were 745 males and 254 females with a mean age of 49.8±12.0 years. There were 837 patients with acute dissection and 182 patients (18.22％) were preoperatively treated or waiting for surgery in the emergency department and 817 (81.78％) were surgically treated. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality. Significant risk factors for in-hospital death were used to develop a prediction model. Results The overall in-hospital mortality was 25.93％. In the multivariable analysis, the following variables were associated with increased in-hospital mortality: increased age (OR=1.04, 95％ CI 1.02 to 1.05, P＜0.000 1), acute aortic dissection (OR=2.49, 95％ CI 1.30 to 4.77, P=0.006 1), syncope (OR=2.76, 95％ CI 1.15 to 6.60, P=0.022 8), lower limbs numbness/pain (OR=7.99, 95％ CI 2.71 to 23.52, P=0.000 2), type Ⅰ DeBakey dissection (OR=1.72, 95％ CI 1.05 to 2.80, P=0.030 5), brachiocephalic vessels involvement (OR=2.25, 95％ CI 1.20 to 4.24, P=0.011 7), acute liver insufficiency (OR=2.60, 95％ CI 1.46 to 4.64, P=0.001 2),white blood cell count (WBC)>15×109 cells/L (OR=1.87, 95％ CI 1.21 to 2.89, P=0.004 9) and massive pericardial effusion (OR=4.34, 95％ CI 2.45 to 7.69, P＜0.000 1). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed. Conclusion Different clinical manifestations and imaging features of patients with Stanford type A AAD predict the risk of in-hospital mortality. This model can be used to assist physicians to quickly identify high risk patients and to make reasonable treatment decisions.

OBJECTIVES The aim of this study is to evaluate the safety and efficacy of thoraco-abdominal aortic aneurysm repair with normothermic iliac perfusion. METHODS One hundred and ninety patients who underwent aortic replacement for the Crawford type II thoraco-abdominal aortic aneurysm between January 2005 and June 2017 were assigned to 2 groups: normothermic iliac perfusion (group A, n = 75) and deep hypothermic circulatory arrest (group B, n = 115). We selected 58 pairs of patients for propensity score matching. We analysed early operative death, a composite of complications and mid-term survival. RESULTS After propensity score matching, no early operative death occurred in group A (0.0%), and group B had 4 cases of early operative death (6.9%), with a statistically significant difference (P = 0.047). The composite of complications was reported in 11 patients in group A (21.0%) and in 21 patients in group B (36.2%) (P = 0.038). Age >50 years [odds ratio (OR) 6.50, 95% confidence interval (CI) 2.32-16.36; P = 0.020], deep hypothermia (OR 12.13, 95% CI 1.64-23.13; P = 0.003) and chronic renal insufficiency (OR 8.21, 95% CI 2.34-43.33; P < 0.001) were independent risk factors for early operative death. The 3-year, 5-year and 7-year survival rates were 98.3%, 98.3% and 86.9% in group A and 86.9%, 86.9% and 86.9% in group B, respectively (P = 0.471). The 7-year cumulative incidence function rates for reintervention were 0.026% in group A and 0.048% in group B (P = 0.625). CONCLUSIONS Normothermic iliac perfusion provides a viable alternative for thoraco-abdominal aortic aneurysm repair, which reduced early operative death and composited complications.

This study explored the periodic changes in the onset of aortic dissection in a single center in northern China, with the goal to improve predictability and prevention. We collected the clinical data of 1121 patients from Hebei Province treated for acute aortic dissection at Fuwai Hospital between January 2010 and December 2016. The patterns of aortic dissection during different periods of each day, each month, and each quarter of a year were analyzed. Variations in the number of cases were summarized for weekdays, weekends, and different periods of a day in each season. We compared the differences in gender, age, body mass index, Marfan syndrome, hypertension, and the type of aortic dissection during different time periods and different seasons. In the study, 774 patients (69.1%) with type A aortic dissection and 347 patients (30.9%) with type B aortic dissection were included. The average age of 1121 patients was 51.4 +/- 12.0 years. Overall, the peak period for the onset of aortic dissection in a day was between 13:00 and 18:00. There was no statistically significant difference in the number of cases between weekdays and weekend (P = 0.94). Most cases occurred in winter (30.9%); the rate of onset was the lowest in summer (16.6%). No statistically significant difference was observed between male and female patients in terms of variations during different periods of a day (P = 0.45) and seasons (P = 0.12). In conclusion, aortic dissection displayed circadian and seasonal patterns in northern China. Onset of the disease peaked between 13:00 and 18:00 in a day. Winter was the peak season for the onset of acute aortic dissection, regardless of sex, type of dissection and age.

Objective By analyzing the early- and mid-term clinical results of type Ⅱ hybrid arch repair for the treatment of aortic A aortic dissection, the efficacy of hybridization technique in the application of type A aortic dissection was evaluated systematically. Methods We retrospectively studied the records of patients with DeBakey type I dissection who were admitted to the Beijing Fuwai hospital between January 2010 and December 2016. 122 continuous patients underwent hybrid aortic arch repair without deep hypothermic circulatory arrest, the landing zone of stent was located in ascending aorta (Zone 0) . All patients were followed up by clinic or telephone review, aortic computed tomography (CT) were checked before surgery and discharge time. All patients were reviewed by CT during 3-6 month after first discharge and once per year during follow up thereafter. Results The average age of all patients was (61±7) years, male patients accounted for 66.4%, patients with acute dissection accounted for 85.2%, there were 39 patients (32%) with different degree of preoperative poor organ perfusion. A total of 154 stents were implanted in 122 patients, sinus plasty was performed in 26 patients (21.3%) , valvuloplasty was performed in 39 patients (32%) , coronary bypass surgery was performed in 9 patients (7.4%) . The average time of cardiopulmonary bypass (CPB) time was (135.3±38.9) minutes, cross clamp time was (58.3±27.8) minutes, 117 patients (95.9%) were completed under non-stop circulation. There were 11 cases of early death (9%) , 19 cases of complex complication (15.6%) , and 28 cases of postoperative renal insufficiency (23%) . No cerebral infarction or paraplegia occurred after operation, 3 patients (2.5%) developed temporary spine cord paralysis. Multiple regression analysis showed that postoperative renal insufficiency (OR: 12.75, 95%CI: 1.77-38.30, P=0.034) and postoperative gastrointestinal insufficiency (OR: 24.03, 95%CI: 2.26-55.61, P=0.008) were the independent risk factors of death for all patients. Operative duration (OR: 2.36, 95%CI: 0.58-2.33, P=0.030) , postoperative renal insufficiency (OR: 20.18, 95%CI: 4.93-82.67, P<0.001) and postoperative gastrointestinal insufficiency (OR: 11.54, 95%CI: 2.29-58.08, P=0.003) were the independent risk factors of composited complication. Average follow-up time was 32.9±25.2 months. There were 92 cases of complete thrombus formation of false lumen in stent (86.8%) , 14 cases of partial thrombus formation (13.2%) , there were 9 cases of thoracic segment tumor like dilation (8.5%) , 9 cases of abdominal segment tumor like dilation (8.5%) . During follow up period, 7 cases died (6.6%) . The survival rates of 3, 5 and 7 years after operation were 94.7%, 91% and 91%, respectively, reintervention rate was 2.8% (3 cases) , the free from reoperation rates of 3, 5 and 7 years after operation were 98%, 92.4% and 92.4%, respectively. Conclusions This single-stage hybrid arch procedure offers an alternative approach to type A dissection and associated with acceptable early and midterm major morbidity and mortality. However, given the high rate of renal dysfunction, more attention is required for further application. Key words: Hybrid aortic repair; Aortic dissection; Deep hypothermic circulatory arrest

目的探索可吸收性心包膜填补材料（GM042）预防心包粘连的效果及其安全性。方法将80例实施心脏手术且预计3年内需再次手术的患者随机分为两组:试验组,40例,年龄（1.79±1.72）岁;对照组,40例,年龄（1.63±1.52）岁。两组最终纳入患者共73例:试验组36例,男23例、女13例;对照组37例,男20例、女17例。试验组在手术时使用GM042填补心包膜缺损部位,对照组不使用。评价GM042的可操作性、安全性及减轻心包粘连的作用。结果试验组术前与术后半年的临床检查指标差异无统计学意义,未见GM042明显相关不良反应。GM042在术中可操作性良好;再次手术时试验组粘连评分低于对照组（P＜0.05）,且心表心包膜肥厚、心表面钙化及心表结构可见度均优于对照组（P＜0.05）。结论 GM042在心外科手术中具有防粘连效果,符合临床安全性要求,适用于需再次手术的患者。

Objective: To investigate the clinical indication of cardiac implantable electronic devices (CIED) lead retraction between surgical and trans-venous approaches in patients with CIED infection, and to explore the principles for surgical CIED retraction. <br> Methods: A total of 59 consecutive patients with CIED infection treated in our hospital from 2002-01 to 2014-04 were retrospectively studied. The patients were divided into 2 groups: Surgical group, n=10 and Trans-venous group, n=49. The clinical characteristics and prognosis were analyzed and compared between 2 groups. <br> Results: There were no real differences in gender and age between 2 groups. The patients in Trans-venous group mainly suffered from pocket infection (41/49), while in Surgical group mainly had infective endocarditis or lead vegetation (7/10), P<0.05. Surgical group had the longer time of CIED implantation than Trans-venous group (12.1 ± 7.3) years vs (9.2 ± 6.9) years, P<0.05. There were 6/10 patients in Surgical group received other cardiac procedure at meanwhile and 2 patients had epicardial lead implantation. No death occurred in either group. Surgical group presented less procedural complication and tricuspid regurgitation than those in Trans-venous group, P<0.05. <br> Conclusion: CIED lead retraction can be electively performed by trans-venous approach, it may work as the ifrst choice in clinicl practice. The surgical lead retraction was suitable for the following patients:①with extra large vegetation which may cause pulmonary embolism,②with dififculty for trans-venous lead retraction,③combining with other cardiac diseases which need operation at meanwhile and④with tricuspid valve malfunction incurred by infective endocarditis.