Hemoadsorption of Rivaroxaban and Ticagrelor during Acute Type A Aortic Dissection Operations

Objective: To analyze the results of hemoadsorption in patients with cardiac surgery to thoracic aortic surgery, who had been loaded beforehand with either Factor Xa inhibitor rivaroxaban or P2Y12 receptor antagonist ticagrelor.Methods: We investigated 21 of 171 consecutive patients (median age 71 [interquartile range 62, 76] years) who underwent emergency cardiac operations for acute type A aortic dissection between 2014 and 2020. These patients were pretreated with rivaroxaban (n = 9) or ticagrelor (n = 12). In ten of 21 cases (since 2017), we installed a hemoadsorber into the heart–lung machine and compared the results to eleven patients done without hemoadsorber before that time.Results: The operation time was significantly shorter in the adsorber group (286 ± 40 min vs. 348 ± 79 min; p = 0.045). The postoperative 24-hour drainage volume was significantly lower after adsorption (p <0.001; 482 ± 122 ml vs. 907 ± 427 ml) and no rethoracotomy had to be performed (compared to two rethoracotomies [18.9%] among patients without adsorber use). Also, patients without hemoadsorption required significantly more platelet transfusions (p = 0.049).Conclusions: In patients with acute type A aortic dissection who were pretreated with rivaroxaban and ticagrelor, the intraoperative use of CytoSorb hemoadsorption during cardiopulmonary bypass is reported for the first time. The method was found to be effective to prevent from bleeding and to improve the outcome in aortic dissection.     

Aortic Root Reconstruction with TachoSil Fibrin Sealant Patch in Acute Type A Aortic Dissection

Purpose: We propose a novel technique for reconstruction of the dissected aortic root with the use of TachoSil fibrin sealant patch.Methods: Patients with acute type A aortic dissection involving the aortic root were included. Appropriately prepared TachoSil fibrin sealant patch was placed between the dissected layers of the aortic root to achieve their durable fusion. Thus, the false lumen was eliminated, and the anatomical and functional structure of the aortic wall was restored.Results: In all, 13 patients mean aged 57 ± 10.3 years underwent surgery for acute type A aortic dissection with the use of TachoSil fibrin sealant patch. All patients survived the surgery. The mean follow-up time was 30.8 ± 16.4 months. Follow-up computed tomography angiography (CTA) scans confirmed no aortic root dissection in all patients.Conclusions: This technique ensures durable restoration of the aortic wall structure, eliminates the secondary aortic valve regurgitation, and allows for the preservation of patients’ native aortic valve.     

Impact of Transapical Aortic Cannulation for Acute Type A Aortic Dissection

Objective: Early and mid-term result of transapical aortic (TAA) cannulation technique was evaluated compared with femoral artery (FA) cannulation in Acute Type A Aortic Dissection(AAAD).Methods: From January 2000 to October 2013, 80 consecutive patients with AAAD were underwent the ascending aortic replacement at Nagasaki Kouseikai Hospital. These patients were divided into two groups according to the cannulation site, FA cannulation (n = 34) and TAA cannulation (n = 46). Early and mid-term outcomes were compared between two groups.Result: Preoperative patient characteristics were almost comparable between groups. The time from skin incision to starting cardiopulmonary bypass (CPB) was significantly shorter in the TAA group (45 ± 16 vs 23 ± 5.1 min; P <0.001). There were no significant differences in post-operative cerebral infarction in two groups (17% versus 11%; P = NS). The operative mortality rate was 8.8% in FA group and 4.3% in TAA group (P = NS). During follow up (mean, 6.8 years), survival at 3 years and 5 years was 77.4% and 71.9% in TAA group and 76.3% and 73.8% in FA group, respectively.Conclusion: The postoperative morbidity and mortality between the two groups were almost the same. TAA cannulation for acute Type A aortic dissection is faster, easy and safe with acceptable early and mid-term outcome.     

Risk Factors for Hypoxemia After Surgery for Acute Type A Aortic Dissection

Purpose Postoperative hypoxemia is a frequent complication of surgery for acute type A aortic dissection. We tried to determine the factors associated with postoperative hypoxemia. Methods Between 1997 and 2003, 114 patients underwent surgery for acute type A aortic dissection. Multivariate logistic regression analysis was done to identify the independent predictors of postoperative hypoxemia, defined by an arterial partial oxygen/inspired oxygen fraction (PaO₂/FiO₂) ratio of 200 or lower. Results The overall in-hospital mortality was 6.1% (7 of 114 patients), being 5.2% in the hypoxemia group and 6.9% in the non-hypoxemia group. The ventilation time and intensive care unit stay were significantly longer in the hypoxemia group than in the non-hypoxemia group (P = 0.0044, P = 0.038, respectively). Logistic regression identified the following variables as predictors for postoperative hypoxemia: body mass index ≥25 (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.1–15.01; P < 0.001), preoperative PaO₂/FiO₂ ratio ≤300 (OR, 2.6; 95% CI, 1.09–6.13; P = 0.031), and the volume of transfused blood (OR, 1.08; 95% CI, 1.01–1.18; P = 0.037). Conclusions Initiating early treatment for hypoxemia and reducing the volume of blood transfused intraoperatively may improve the postoperative clinical course of obese patients with preoperative hypoxemia.     

急性A型主动脉夹层手术主动脉断端加固方法的改进

目的改进急性主动脉夹层手术中对主动脉断端加固处理的方法,探讨该方法的有效性。方法华西医院胸心血管外科在主动脉夹层手术中对主动脉夹层断端加固方法在传统＂三明治＂法的基础上进行了改良,2006年1月至2008年12月对28例急性A型主动脉夹层患者采用改良主动脉夹层断端加固法施行手术。其中10例用外膜向内翻转折迭加固断端,另18例在夹层中（内外膜之间）和内膜内侧放置条形毛毡或心包条,缝线加其固定加固夹层断端;并观察吻合口出血情况和术后早期转归。结果全组患者无出血并发症;手术死亡2例,1例为术中、术后出现严重低心排血量综合征,另1例于术后1周死于多器官功能衰竭。术后仅2例患者出现苏醒延迟,其他均无神经系统并发症,无胸骨和手术切口相关并发症。26患者经治疗后痊愈出院。结论改良主动脉断端加固方法除了能达到加固夹层断端的目的外,还可以很清楚地发现吻合口上的出血点,从而施行有效的缝合止血。该方法实施方便、有效,值得在临床推荐应用。     

妊娠期急性Stanford A型主动脉夹层的诊断与治疗

目的 总结妊娠期急性Stanford A型主动脉夹层（acute type A aortic dissection,AAAD） 患者的诊治经验。 方法 回顾性分析2008年5月至2010年7月首都医科大学附属北京安贞医院3例妊娠期AAAD患者（年龄分别为：30岁、32岁、35岁） 经手术治疗的临床资料。1例剖宫产后3 d行Sun’s手术 （全主动脉弓置换＋降主动脉支架置入手术）,胎儿宫内死亡;1例行剖宫产、子宫切除术后立即实施Bentall＋Sun’s手术成功;1例先行剖宫产,保留子宫同期行升主动脉置换＋Sun’s手术。 结果 3例孕妇顺利恢复,病例2及病例3 的胎儿亦顺利恢复。术后6个月进行随访,CT （computerized tomographic） 检查提示主动脉夹层假腔血栓机化形成。3例产妇术后恢复佳,2例存活婴儿发育正常。 结论 妊娠期AAAD的治疗原则为：首先及时准确地诊断至关重要;其次保证母体血流动力学平稳;第三应保证止血确切;最后,多种方法联合应用对保证母体及胎儿的良好预后非常重要。     

Transit-Time Flow Measurement of Saphenous Vein Graft Used for Surgery of Acute Type A Aortic Dissection with Coronary Malperfusion

Purpose: Transit-time flow measurement (TTFM), consisting of pulsatility index (PI), mean graft flow, and diastolic filling, is mainly used as a bypass assessment for coronary artery disease (CAD). However, little was known about TTFM in the case of coronary malperfusion (CMP). This study aimed to clarify the difference in the results of TTFM between two different diseases.Methods: Between 2010 and 2020, 138 patients underwent aortic surgery and coronary artery bypass grafting (CABG) with vein grafts. Patients were divided into two groups: CMP (n = 26) and CAD (n = 27). Their results were compared. The primary endpoints were the results of TTFM. Secondary endpoints were the relation between TTFM and mortality, morbidity, and short-term patency in each group.Results: The PI in the CMP group was significantly higher than the other group (4.7 ± 2.9 vs. 3.4 ± 1.9, p = 0.04). There was no statistical significance in the other two elements. In both groups, the short-term graft patency, mortality, and morbidity but for cardiac tamponade did not significantly change depending on the TTFM results.Conclusions: Patients with CMP tended to have a higher PI than those with CAD. With additional CABG for aortic dissection, insufficient TTFM results did not necessarily mean poor short-term graft patency, complications, or case mortality.     

Acute aortic dissections with entry tear in the arch: A report from the International Registry of Acute Aortic Dissection

Objective

To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch.

Late Complications Following Surgery for Type A Acute Aortic Dissection Using Gelatin-Resorcin-Formaldehyde Glue: Report of Two Cases

Gelatin-resorcin-formaldehyde (GRF) glue has been widely applied during operations for acute aortic dissection (AAD). At our institution, GRF glue was applied in 40 patients who underwent surgical procedures for AAD from 1995, two of whom needed a reoperation because of the development of a redissection and/or a pseudoaneurysm at the anastomotic sites. The operative findings and histological examinations suggested that the application of GRF glue during the initial operations might be related to the development of a redissection and/or a pseudoaneurysm.     

Extensive Arch Repair with a Novel Two-Branched Stent Graft in Acute Type A Aortic Dissection

Purpose: In this study, we compared the early results between the extensive arch repair with a novel two-branched stent graft (TSG) and the traditional technique.Methods: Between 2013 July and 2015 March, 63 acute type A aortic dissection (ATAAD) patients from four cardiac centers with indications for extensive arch repair were included in this study. Finally, 28 patients were involved in the traditional procedure (TP) group (23 males with the age of 49.75 ± 9.26 years) and 35 patients were involved in the TSG group (29 males with the age of 53.82 ± 8.17 years).Results: The operation was successful in all patients. The selective cerebral perfusion time, total operation time, and chest drainage within 24 hours after the operation in the TSG group were significantly less than those in the TP group (P ≤0.05). The mean follow-up time was 11.17 ± 1.74 months in the TP group and 11.94 ± 4.29 months in the TSG group. No statistical differences were found in aortic diameter, false lumen diameter, and true lumen diameter at the diaphragmatic level during the follow-up.Conclusion: Our technique with a novel TSG simplified the extensive arch repair procedure and was an effective way for the treatment of ATAAD.     

不同主动脉断端加固方法在急性Stanford A型主动脉夹层手术中的应用

目的总结不同主动脉断端加固方法在主动脉夹层手术中的应用及其效果。方法2012年1月至2013年5月,共有95例主动脉夹层在南京医科大学附属南京医院接受手术治疗。根据主动脉断端的加固方法不同,将其中72例患者（23例Bentall手术患者未纳入本研究）分为3组,A组：23例,男18例、女5例,年龄（48．67±9．23）岁,其中主动脉壁内外均使用毛毡条行“三明治”加固;B组：11例,男8例、女3例,年龄（48．00±9．17）岁,仅主动脉内膜内侧使用心包条加固;C组：38例,男29例、女9例,年龄（49．20±8．57）岁,主动脉断端不进行任何加固,与人工血管直接吻合。分析并比较3组患者的术后转归情况。结果术后住院死亡8例[其中A组1例（4．35％,1／23）,C组7例（18．42％,7／38）],住院死亡率11．11％。1例（A组）死于创面广泛渗血,最后出现弥散性血管内凝血;3例（均为C组）死于术后针眼、吻合口广泛渗血,循环不能维持;4例（均为C组）术后三尖瓣重度反流,继发严重低心排血量综合征,最终导致多脏器功能衰竭而死亡。术后严重并发症包括肾功能衰竭5例,呼吸功能不全7例,严重脑梗死致偏瘫1例,轻瘫3例,延迟苏醒2例,下肢缺血坏死1例。术后胸腔引流量C组最多,A组胸腔引流量与B组比较差异无统计学意义。随访64例,随访时间1～6个月。随访期间无死亡。5例肾功能衰竭患者中只有1例定期行血液透析治疗,其余4例患者肾功能均恢复正常;1例脑梗死患者肢体功能部分恢复,可以拄拐行走;3例轻瘫患者肢体功能均恢复正常。结论主动脉夹层断端的吻合质量异常重要,术中可根据具体情况选择合适的加固方式;使用毛毡条行“三明治”加固可以减少吻合口渗血,预防吻合口撕裂所致急性心肌梗死的发生,降低术后死亡率;若主动脉夹层剥离累及冠状动脉开口,需同期行冠状动脉旁路移植术。     

Malperfusion in acute type A aortic dissection: An update from the Nordic Consortium for Acute Type A Aortic Dissection

Objectives

To evaluate the effect of preoperative malperfusion on 30-day and late mortality and postoperative complications using data from the Nordic Consortium for Acute Type A Aortic Dissection (ATAAD) registry.