OBJECTIVE: This study aims to compare aortic morphology between repaired coarctation patients and controls, and to identify aortic morphological risk factors for hypertension and cardiovascular events (CVEs) in coarctation patients.
METHODS: Repaired coarctation patients with computed tomography angiography (CTA) or magnetic resonance angiography (MRA) were included, followed-up and compared with sex-matched and age-matched controls. Three-dimensional aortic shape was reconstructed using patients\' CTA or MRA, or four-dimensional flow cardiovascular magnetic resonance in controls, and advanced geometrical characteristics were calculated and visualised using statistical shape modelling. In patients, we examined the association of geometrical characteristics with (1) baseline hypertension, using multivariable logistic regression; and (2) cardiovascular events (CVE, composite of aortic complications, coronary artery disease, ventricular arrhythmias, heart failure hospitalisation, stroke, transient ischaemic attacks and cardiovascular death), using multivariable Cox regression. The least absolute shrinkage and selection operator (LASSO) method selected the most informative multivariable model.
RESULTS: Sixty-five repaired coarctation patients (23 years (IQR 19-38)) were included, of which 44 (68%) patients were hypertensive at baseline. After a median follow-up of 8.7 years (IQR 4.8-15.4), 27 CVEs occurred in 20 patients. Aortic arch dimensions were smaller in patients compared with controls (diameter p<0.001, wall surface area p=0.026, volume p=0.007). Patients had more aortic arch torsion (p<0.001) and a higher curvature (p<0.001). No geometrical characteristics were associated with hypertension. LASSO selected left ventricular mass, male sex, tortuosity and age for the multivariable model. Left ventricular mass (p=0.014) was independently associated with CVE, and aortic tortuosity showed a trend towards significance (p=0.070).
CONCLUSIONS: Repaired coarctation patients have a smaller aortic arch and a more tortuous course of the aorta compared with controls. Besides left ventricular mass index, geometrical features might be of importance in long-term risk assessment in coarctation patients.

OBJECTIVE: To describe the incidence of acute aortic dissection in a clearly defined population, to assess onset symptoms and admission biochemical marker levels and to analyse variables potentially associated to mortality.
METHODS: Medical records and CT angiograms of all patients hospitalised for acute aortic dissection in the Stockholm County during the 5-year period 2012-2016 were reviewed. The patients were followed until date of death or until 31 December 2020. The annual incidence was determined. Associations between clinical and biochemical variables and 30-day mortality, respectively, were analysed using multivariable logistic regression models.
RESULTS: A total of 344 patients were included. The mean annual incidence of acute aortic dissection was 4.1 per 100 000. Median age was 67 years (range 24-91) and 34% (n=118) were women. Type A dissection was predominant; 220 patients (64%) had type A and 124 (36%) had type B. Painless dissection was more common in type A than in type B (18% vs 15%, p=0.003). Type A dissection patients also more commonly had elevated plasma troponin T (44% vs 21%, p<0.001) and thrombocytopenia (26% vs 15%, p=0.010) than type B dissection patients on admission. Overall, 30-day mortality was 28% in type A and 11% in type B (p<0.001). Both painless dissection (OR 4.30, 95% CI 1.80 to 10.28, p=0.001) and elevated troponin T (OR 3.78, 95% CI 2.01 to 7.12, p<0.001), respectively, were associated with increased 30-day mortality in all acute aortic dissection patients. Thrombocytopenia was associated with elevated 30-day mortality only in patients with type A (OR 3.09, 95% CI 1.53 to 6.21, p=0.002).
CONCLUSIONS: Nearly two-thirds of acute aortic dissection patients had type A. Levels of troponin T and platelets, respectively, paired with presence or absence of typical symptoms may become useful adjuncts in risk stratification of patients with acute aortic dissection.

OBJECTIVE: Cabrol shunt has been introduced for surgical repair of type A aortic dissection (TAAD) without robust evidence supporting its routine preventive use.
METHODS: Adult patients with TAAD from China 5A study were included if surgically repaired between 2016 and 2022. Primary outcome was operative mortality according to Society of Thoracic Surgeons criterion. Overall, we compared clinical outcomes in patients with and without Cabrol shunt, and subgroup analysis were further examined between Cabrol shunt and outcome among patients with or without root replacement.
RESULTS: 3283 patients were finally identified for analysis, with median age of 51 (IQR 41-59) years, 2389 men, and 2201 treated with Cabrol shunt technique. Cabrol shunt-treated patients were more severely ill before surgery than those without Cabrol shunt. Overall, the rate of operative mortality was 6.6% (146/2201 in Cabrol shunt group and 71/1082 in non-Cabrol shunt group), with no association between Cabrol shunt and operative mortality (OR 1.012 (95% CI 0.754 to 1.357); p=0.938). Stratified by root replacement, Cabrol shunt was associated with similar risk of operative mortality either in patients without root replacement (OR 1.054 (0.747 to 1.487); p=0.764) or in patients with root replacement (OR 1.194 (0.563 to 2.536); p=0.644) (P interaction=0.765). Results were similar in multiple sensitivity analysis.
CONCLUSIONS: Cabrol shunt was not associated with either a greatly lowered or an increased risk of operative mortality, regardless of aortic root replacement. Our study did not support the use of Cabrol shunt as a routine preventive strategy in the treatment of TAAD.
BACKGROUND: NCT04398992.

We present the case of a 38-year-old male with a diagnosis of Stanford A aortic dissection and associated coarctation of the thoracic aorta. Acute dissection associated with coarctation of the aorta is a rare problem and difficult to manage surgically. Establishing a cardiopulmonary bypass (CPB) with adequate flows is the main objective of the procedure; optimal cannulation ensures the protection of cerebral and visceral organs. We successfully performed aortic valve re-implantation surgery (T. David Surgery), replacement of the ascending aorta and aortic arch, as well as debranching of the supra-aortic trunks. The cannulation technique was axillary and femoral to guarantee flows through the coarctation area.
Presentamos el caso de un varón de 38 años con diagnóstico de disección de aorta Stanford A y coartación de aorta torácica asociada. La disección aguda asociada a la coartación de la aorta es un problema raro y difícil de manejar quirúrgicamente. Establecer un bypass cardiopulmonar con flujos adecuados es el principal objetivo del procedimiento; una canulación óptima asegura la protección de órganos cerebrales y viscerales. Realizamos con éxito una cirugía de reimplante de válvula aórtica (cirugía de T. David), reemplazo de la aorta ascendente y del arco aórtico, además de debranching de los troncos supraaórticos. La técnica de canulación fue axilar y femoral para garantizar flujos a través de la zona de coartación.

Percutaneous coronary intervention (PCI) of the ostium of the left circumflex artery (LCx) is technically challenging. The aim of this study was to compare long-term clinical outcomes of ostial PCI located in the LCx versus the left anterior descending artery (LAD) in a propensity-matched population.
Consecutive patients with a symptomatic isolated \'de novo\' ostial lesion of the LCx or LAD treated with PCI were included. Patients with a stenosis of >40% in the left main (LM) were excluded. A propensity score matching was performed to compare both groups. The primary endpoint was target lesion revascularisation (TLR); other endpoints included target lesion failure and an analysis of the bifurcation angles.
From 2004 to 2018, 287 consecutive patients with LAD (n=240) or LCx (n=47) ostial lesions treated with PCI were analysed. After the adjustment, 47 matched pairs were obtained. The mean age was 72±12 years and 82% were male. The LM-LAD angle was significantly wider than the LM-LCx angle (128°±23° vs 108°±24°, p=0.002). At a median follow-up of 5.5 (IQR 1.5-9.3) years, the rate of TLR was significantly higher in the LCx group (15% vs 2%); with an HR of 7.5, 95% CI 2.1 to 26.4, p<0.001. Interestingly, in the LCx group, TLR-LM occurred in 43% of the TLR cases; meanwhile, no TLR-LM involvement was found in the LAD group.
Isolated ostial LCx PCI was associated with an increase in the rate of TLR compared with ostial LAD PCI at long-term follow-up. Larger studies evaluating the optimal percutaneous approach at this location are needed.

暂无摘要。

Inflammation is a hallmark of the initial development and progression of aortic dissection. This study aimed to investigate the value of preoperative inflammatory biomarkers in predicting aorta-related adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection.
We included all patients who underwent TEVAR for type B aortic dissection between November 2016 and November 2020 in this single-center, retrospective cohort study. Patients were divided into two groups: the AAEs group (n = 75) and the non-AAEs group (n = 126). Preoperative inflammatory biomarkers were recorded, including neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic immune inflammation index (SII), and systemic inflammatory response index (SIRI). Patients were followed-up for the development of AAEs. Prediction accuracy of inflammatory biomarkers for AAEs were evaluated using the area under the receiver operating characteristic curves.
This study included 201 patients, of whom 80.0% were men, with a mean age of 59.1 ± 12.5 years. A total of 75 patients developed AAEs after TEVAR. The AUCs of NLR, MLR, PLR, SII, and SIRI for AAEs were.746,.782,.534,.625 and.807, respectively. Age and SIRI were independent risk factors for the AAEs after TEVAR (HR 3.264, p <.001; HR 4.281, p <.001, respectively). Survival analysis revealed significantly lower AAE-free status in patients with preoperative SIRI > = 4 (p <.001).
Increased preoperative SIRI and age are independent risk factors for AAEs after TEVAR in type B aortic dissection.

UNASSIGNED: To investigate the function of C/EBPα in the development of aortic dissection (AD) and the underlying mechanism.
UNASSIGNED: Aortic vascular smooth muscle cells (VSMCs) were isolated, cultured, and identified from AD rats. Then, C/EBPα and PIK3C2A were knockdown or overexpressed by siRNA or plasmid transfection, respectively. Rapamycin or 3-MA was utilized to stimulate and restrain autophagy of VSMCs, respectively. Western blot was used to evaluate the expression levels of C/EBPα, PIK3C2A, LC3, Beclin-1, p62, MMP-2, MMP-9, α-SMA, SM-MHC, and OPN. The pathological status of aortic ring was evaluated by stretch stress, and ChIP assay was used to analyze the binding between C/EBPα and PIK3C2A. C/EBPα shRNA was injected into tail vein to observe the effect of C/EBPα knockdown in vivo on phenotype, autophagy of aortic vascular tissue by immunohistochemical staining and Western blot.
UNASSIGNED: The protein levels of C/EBPα, PIK3C2A, MMP-2, MMP-9, and LC3 in the aorta of AD rats were all upregulated significantly. C/EBPα and rapamycin promoted notable upregulation of the synthesized proteins (OPN), PIK3C2A, matrix metalloproteinases, LC3, and Beclin-1 in VSMCs, while suppressed contractile proteins (α-SMA and SM-MHC) and p62. The opposite results were observed in the C/EBPα-knockdown VSMCs, PIK3C2A-knockdown VSMCs, or VSMCs treated with 3-MA. C/EBPα, PIK3C2A, and LC3 were dramatically upregulated by the stimulation of 3 g and 5 g stretch stress. The downregulated contractile proteins, upregulated synthetic proteins, activated autophagy, and aggravated pathological state in 5 g stretch stress-treated aortic rings were significantly reversed by the knockdown of C/EBPα. ChIP results indicated that there was a binding site for C/EBPα in the promoter of PIK3C2A. C/EBPα also downregulated α-SMA level and upregulated OPN levels in AD rats in vivo.
UNASSIGNED: Our data indicated that during the development of AD, C/EBPα regulated the transition of VSMC phenotype and extracellular matrix remodeling by activating autophagy through regulating the transcriptional activity of PIK3C2A promoter.

UNASSIGNED: To compare the efficacy of the percutaneous presuture technique (PPST) and the femoral artery incision technique (FAIT) under local anesthesia in the treatment of endovascular aortic repair (EVAR) for patients with uncomplicated type B aortic dissection (uTBAD).
UNASSIGNED: Two hundred and ninety-five patients diagnosed with uTBAD who underwent EVAR under local anesthesia from June 2017 to December 2021 were consecutively and randomly selected for retrospective analysis. The PPST was performed in 178 cases and the FAIT was performed in 117 cases. The clinical characteristics and surgical and postoperative data from the two groups were analyzed.
UNASSIGNED: There were no significant differences in clinical characteristics between the two groups (p > 0.05). The operative time of the PPST group was significantly shorter than that of the FAIT group (46 (33, 58) versus 72 (67.5, 78.0) minutes, p < 0.001), as was the operative approach procedure time (6 (4.5, 9.0) versus 38 (36.5, 43.5) minutes, p < 0.001), and length of postoperative hospital stay (5.19 ± 2.26 versus 8.33 ± 3.76 days, p < 0.001). There were fewer postoperative approach-related procedural complications in the PPST group than in the FAIT group (2 versus 12, p < 0.001); similarly, the average frequency of postoperative wound disinfection was significantly lower in the PPST group (1.08 ± 0.39 versus 3.31 ± 0.91 times, p < 0.05). Obesity was identified as an independent risk factor for postoperative approach-related procedural complications (OR, 22.26; 95% CI, 4.74-104.49; p < 0.001).
UNASSIGNED: The PPST has comparable safety and efficacy to the FAIT in EVAR under local anesthesia. It can shorten the length of hospital stay, reduce operation time, lower the risk of wound-related complications, reduce the frequency of postoperative wound disinfection, and hasten postoperative recovery. It can therefore be used as a first-line surgical technique in EVAR of uTBAD under local anesthesia, especially in obese patients.

BACKGROUND: Perioperative coagulopathy and intractable bleeding are severe complications in acute type A aortic dissection (ATAAD) repair surgery. Mediastinal packing with delayed sternal closure (DSC) is a commonly adapted technique to stabilize the hemorrhagic tendency. This retrospective study aims to investigate the early and late outcomes and risk factors in patients who underwent DSC procedure during ATAAD repair surgery.
METHODS: This study investigated 704 consecutive patients who underwent ATAAD repair at this institution between January 2007 and September 2020. These patients were dichotomized into the DSC (n = 109; 15.5%) and primary sternal closure (PSC) groups (n = 595; 84.5%). The clinical features, surgical information, postoperative complications, 5-years cumulative survival, and freedom from reoperation rates were compared. A multivariate logistic regression analysis was used to identify the independent risk factors for patients who underwent DSC.
RESULTS: The DSC group showed a higher rate of hemopericardium and preoperative malperfusion, and was associated with longer cardiopulmonary bypass and aortic clamping times and a higher rate of intraoperative extracorporeal membrane oxygenation (ECMO) support. The DSC group showed higher blood transfusion volumes and rate of reexploration for bleeding after surgery. However, the in-hospital mortality rates (17.4% vs. 13.3%; P = 0.249), 5-year survival rates (66.9% vs. 68.2%; P = 0.635), and freedom from reoperation rates (89.1% vs. 82.5%; P = 0.344) were comparable between the DSC and PSC groups. Multivariate analysis revealed that hemopericardium, preoperative malperfusion, and intraoperative ECMO support were risk factors for implementing DSC.
CONCLUSIONS: DSC is an efficient life-saving technique to stabilize patients with intractable bleeding after undergoing ATAAD repair surgery, which leads to acceptable short- and long-term outcomes. Patients who were at risk for intractable bleeding should have early decision-making for implementing DSC.