Objective Acute type A aortic dissection associated pregnancy severely threatens the lives of both the mother and her ferus.We retrospectively reviewed our clinical experience with this life-threatening condition in six cases.Methods Between January 2007 and February 2012,6 women with acute type A aotic dissection associated pregnancy were treated by our group,with an average of 3 1 years (range 24 -37 weeks)and a mean gestation weeks of 24.5 (range,12 -38 weeks ).The etiology was Marfan syndrome in 4 cases and gestational hypertension in 2.The pathology was the modified Stanford type A3S in I case,A2C in 2 and A3C in 3.- Five patients were treated surgically and 1 medically.Surgical operations were performed under hypothermic cardiopulmonary bypass or deep hypothermic circulatory arrest,including Bentall procedure in 1case,Bentall + Sun's procedure in 2,ascending aortic replacement + Sun's procedure in 2.Results The woman treated medically and her fetus died from aortic rupture 9 days after admission.The cardiopulmonary bypass and cross clamp time and circulatory arrest time averaged 167 rninites(range,75 -210 minites) and 98 minites(range,83 - 145 minites) and 23.5minites(range,19 -27 minutes),respectively.Five patients treaed surgically survived the operation.Three fetuses survived rand two fetuses died.After a mean follow-up of 2.2 years (range,1 - 3.5 years ),5 patients were doing well.CT angiogram detected nonmal aortic and valvular structures,with no signs of distal dilation.Three babies were normal in development and neurocognitive functios.Conclusion Palients with aortic dissection associated with pregnancy should be operated on ugently and medical treatment carries high risks of aortic rupture and maternal and fetal death.Methods of surgical repair,peffusion techniques and delivery should be chosen based on the underlying aortic pathology and gestational age,so as to maximize the safety of the mother and her baby.

Objective To summarize the experience of surgical repair for Stanford type A aortic dissection after cardiac surgery.Methods From February 2009 to December 2011,11 patients who underwent previous cardiac surgery accepted the aortic surgery for Stanford type A aortic dissection.There were 8 males and 3 females.The range of age was from 29 to 64 years,the mean age was(52.27±9.90) years.In these patients,one patient had underwent ventrical septal defect,one patient atrial septal defect,nine patients aortic valve replacement.The interval between the two operations was 1-26 years.The types of aortic dissection was A1S(4 patients),A1C(1 patient),A2S(1 patient),A2C(4 patients),A3C(1 patient).All the patients underwent aortic surgery for aortic dissection.Results The time of cardiopulmonary bypass was 75-409 minutes,the mean value was(185.36± 99.67) minutes.Aortic cross clamp time was 37-203 minutes,the mean value was (84.09± 48.36) minutes.Total six patients needed deep hypothermia and selective cerebral perfusion time was 8-32 minutes.The mean value was(17.71 ± 9.48) minutes.One patient dead in the hospital and the mortality was 9％.The morbidity was 27％.Ten patients followed up 16-45 months.No aortic rupture,paraplegia and death were observed in follow-up time.Conclusion The delayed Stanford type A aortic dissection after cardiac surgery should be attached great importance and always need emergency surgery to save patients' life.The technique is demanding and risk is great for surgeons and patients.For the patients who suffered aortic valve disease combined with dilation of ascending aorta larger than 4.5 cm,the ascending aorta also should be repaired while aortic valve replacement is performed,which could avoid delayed aortic dissection in the future.

Objective To evaluate the risk factors of Sun' s procedure for acute Stanford A type aortic dissection involving aortic arch.Methods Between February 2009 to February 2012,data from 233 patients who underwent Sun' s procedure for acute Stanford type A aortic dissection involving aortic arch were collected retrospectively.All the risk factors related to mortality were analyzed by univariate statistical analysis.Significant univariate variables were entered into multiple logistic analysis.Results Total 23 patients died in the hospital and the mortality was 9.87 ％.Univariate analysis showed that age,limb ischemia,and cardiopulmonary bypass longer than 268 minutes were risk factors for mortality.After these factors were entered into multiple logistic regression analysis,multiple logistic regression showed that age(P =0.017,OR =1.062),cardiopulmonary by pass time longer than 268 minutes(P =0.001,OR =6.150) were final independent risk factors for mortality.ConclusionAge and cardiopulmonary bypass time longer than 268 minutes were final independent risk factors for mortality.Longer cardiopulmonary bypass time should be avoided.

Objective EuroSCORE is a widely used objective risk scoring model.The aim of this study was to evaluate the validation of EuroSCORE Ⅱ in predicting mid-term survival after total aortic arch replacement with stented elephant trunk implantation(sun' s procedure) for Stanford Type A aortic dissection.Methods Total 90 patients entered the study randomly.All the patients underwent aortic surgery using total aortic arch replacement with stented elephant trunk implantation (Sun's procedure).The patients were divided into three groups based on the predicting mortality by EuroSCORE Ⅱ.Ggroup 1:0 ＜:P ≤ 5 ％,Group 2:5 ％ ＜ P ≤ 10％,Group 3:P ＞ 10％.Kaplan-Meier method was used to evaluate the long term survival of three groups.Receiver operating characteristic curve was used to test discrimination of the EuroSCORE.Calibration was assessed with a Hosmer-Lemeshow goodness-offit statistic.Results 87 patients were followed umil October,2013.The mean follow-up time was(33.32 ± 11.11) months.Total 5 patients died during the follow-up time.Three patients died in group 1,2 patients died in group 2 and 1 in group 3.There was no statistical difference for the mid-term survival rate between 3 groups (P =0.054).Conclusion Although EuroSCORE Ⅱ is the newest risk model for cardiac surgery,it is not accurate when it is applied for predicting mid-term survival after aortic surgery.A new risk evaluating system specially designed for aortic surgery should be developed in the future.

Objective To establish the risk scoring system in predicting prolonged intensive care unit(ICU) stay after Sun' s procedure(total aortic arch replacement with stented elephant trunk implantation) for Stanford type A aortic dissection.Accumulate experience in establishing the mathematical model in predicting the prognosis of Chinese people undergoing aortic surgery.Methods Between February 2009 and February 2012,data from 384 consecutive patients in Bejing Anzhen Hospotal,who underwent aortic surgery using Sun' s procedure,were collected retrospectively.Lengths of ICU stay longer than 7 days was defined as prolonged ICU stay.All the factors related to prolonged ICU stay were entered into univariate analysis.Then the variables with statistical difference were entered into multiple logistic analysis.The mathematical model was established based on the logistic analysis.The C-statistic was used to test discrimination of the model.Calibration was assessed with the Hosmer-Lemeshow goodness-of-fit statistic.Results The in-hospital mortality was 8.07％.The mean length of ICU stay was 3.06 days.42 patients stayed in ICU for 7 days or more.Logistic regression identified that preoperative stroke history(P =0.001,0R =9.40,regression coefficient =2.24),creatinine clearance ≤ 50 ml/min (P =0.03,OR =2.91,regression coefficient =1.07) surgical period from symptom onset shorter than 1 week (P =0.003,OR =2.89,regression coefficient =1.06),combining with coronary artery bypass grafting(P =0.03,OR =3.14,regression coefficient =1.15) were final independent risk factor for prolonged ICU stay.Simple logistic score were defined as:stroke history 22 points,creatinine clearance ≤50 ml/min 11 points,surgical period from symptom onset shorter than 1 week 11 points,combining with coronary artery bypass grafting 12 points.Additive score was defined as:stroke history 9 points,surgical period from symptom onset shorter than 1 week 3 points,creatinine clearance≤50 ml/min 11 points 3 points,combining with coronary artery bypass grafting 3 points.C statistic (receiver operating characteristic curve) for logistic algorithm was 0.72 and for additive model was 0.71.However,Hosmer Lemeshow goodness-of-fit was good (P ＞ 0.05) for logistic algorithm,was poor for additive model(P ＜ 0.05).Conclusion Using logistic regression to establish a scoring system predicting the prognosis of aortic surgery is feasible.The predicting model utilizing regression coefficient is accurate and is convenient for clinical using.Additive algorithm is not accurate and should be abandoned.

Objective The aim of this study was to evaluate whether the reoperation is the risk factor for mortality after Sun's procedure(Total aortic arch replacement + frozen elephant trunk) for Stanford type A aortic dissection involving aortic arch.Methods Between February 2009 to February 2012,data from 383 patients who underwent Sun's procedure for Stanford type A aortic dissection involving aortic arch were collected retrospectively.35 patients had history of cardiac surgery.Of these patients,16 patients had underwent Bentall procedure,7 patients ascending aortic replacement,4 patients Wheat surgery,4 patients aortic valve replacement,2 patents Bentall combined with mitral valve replacement or plasty,1 patient bivalve replacement,1 patient atrial septal defect repair,1 patient coronary artery surgery.All the risk factors related to mortality were analyzed by univariate statistical analysis.Significant univariate variables were entered into multiple logistic analysis.Results Total 31 patients died in the hospital and the mortality was 8.07％.Of the 35 patients with history of cardiac surgery,3 patients died and the mortality was 8.33％.Univariate analysis showed that symptom onset before surgery less than 1 week,preoperative limb ischemia,combining with coronary artery surgery and cardiopulmonary bypass time longer than 300 minutes in the operative were risk factors for mortality.After these factors were entered into multiple logistic regression analysis,the result showed that symptom onset before surgery less than 1 week (P =0.038,OR =2.43),cardiopulmonary bypass time longer than 300 minutes(PP ＜0.001,OR =12.05) were final independent risk factors for mortality.Reoperation was not the independent risk factor for mortality.The intensive care unit and mechanical ventilation length of reoperation group was (2.09 ± 1.89) days and(30.09 ±33.42) hours respectively,while that of primary group was(2.71 ±3.01) days (P =0.25) and(33.86 ±40.98) hours(P =0.61) respectively.The incidence of postoperative bleeding of reoperation group was 3.03％,while that of primary group was 1.88％ (P =0.50).Conclusion Reoperation was not the independent risk factor for mortality after Sun's procedure for Stanford type A aortic dissection involving aortic arch and the morbidity was also not higher than primary surgery.For these patients,sun' s procedure should be advocated.

Objective To study the mechanisms of levofloxacin,thymopentin combined with decoction of four noble drugs for treatment of patients with severe pulmonary tuberculosis and offer a new therapeutic strategy for treatment of the disease.Methods A total of 100 patients with severe pulmonary tuberculosis admitted to Qinghai Fourth People's Hospital from November 2013 to January 2016 were enrolled,and they were divided into a research group (50 patients) and a control group (50 patients) by random number table.The patients in two groups were treated with 2HRZE/4HR standardized therapy program.The patients in the research group were additionally treated with levofloxacin (0.5 g orally taken,1 times a day),thymopentin (1 mg intravenous injection,once a day) combined with decoction of four noble drugs (ginseng 9 g,poria 9 g,atractylodes 9 g,and licorice 6 g,all the above ingredients were immersed in 400 mL water and boiled to 100 mL,one dose orally taken daily and it was equally divided into 2 parts,one part taken in the morning and the remaining part taken in the evening).Four months after treatment,the changes of indexes of immune functions [total lymphocyte count (LY),CD4+,CD8+,and CD4+/CD8+ ratio],blood coagulation indexes [prothrombin time (PT),activated partial thromboplastin time (APTT),thrombin time (TT),D-dimer,and plasma fibrinogen (Fib)],pulmonary function indexes [forced vital capacity (FVC),peak expiratory flow rate (PEF),forced expiratory maximum volume in 1 second (FEV1),and mean maximum expiratory flow (MMEF)] and blood gas analysis indexes [arterial partial pressure of carbon dioxide (PaCO2),arterial partial pressure of oxygen (PaO2),pulse oxygen saturation (SpO2),and oxygenation index (PaO2/FiO2)] and the therapeutic effects were observed in the two groups.Results After treatment,the CD8+,TT,PT,Fib,D-Dimer and PaCO2 of two groups were decreased significantly than those before treatment (all P ＜ 0.05);while the LY,CD4+,CD4+/CD8+ ratio,FEV1,FVC,PEF,MMEF,APTT,PaO2,SpO2 and PaO2/FiO2 of two groups were all increased significantly than those before treatment (all P ＜ 0.05).The changes of the study group were more obvious than those of the control group [LY (109/L):1.79 ± 0.19 vs.1.45 ± 0.16,CD4+:0.40 ± 0.03 vs.0.33 ± 0.03,CD8+:0.20 ± 0.01 vs.0.23 ± 0.02,CD4+/CD8+ ratio:2.10 ± 0.23 vs.1.67 ± 0.20,FEV1:0.269 ± 0.004 vs.0.198 ± 0.003,FVC:(3.78 ± 0.41)％ vs.(3.14 ± 0.39)％,PEF (L/s):3.68 ± 0.26 vs.3.05 ± 0.23,MMEF (L/s):0.96 ± 0.06 vs.0.74 ± 0.05,PaO2 (mmHg,1 mmHg =0.133 kPa):95.11 ± 7.68 vs.85.23 ± 7.01,PaCO2 (mmHg):31.76± 3.26 vs.46.28±4.36,SpO2:0.96±0.08 vs.0.91 ±0.07,PaO2/FiO2 (mmHg):310.58± 11.12 vs.285.01 ± 10.76,TT (s):15.64± 1.25 vs.18.82 ± 1.54,PT (s):12.69 ± 1.01 vs.14.28 ± 1.21,APTT (s):29.01 ± 2.02 vs.25.21 ± 1.80,Fib (mg/L):233.46 ± 15.61 vs.286.27 ± 18.14,D-Dimer (μg/L):210.88 ± 14.13 vs.256.39 ± 16.47,all P ＜ 0.05].After combined treatment,the sputum negative conversion rate [94％ (47/50) vs.60％ (30/50)],the total efficiency [88％ (44/50) vs.64％ (32/50)] and the focus absorption rate [86％ (43/50) vs.60％ (30/50)] of research group were significantly higher than those of the control group (all P ＜ 0.05).Conclusions The combination of levofloxacin,thymopentin and decoction of four noble drugs on the bases of 2HRZE/4HR standardized therapy for treatment of patients with severe pulmonayr tuberculosis can help to regulate acid-base balance,improve the hypoxia condition and lung function,elevate the immune function and increase the blood circulation in the body to improve clinical efficacy.

OBJECTIVETo observe the difference in the therapeutic effects on infantile herpetic angina among the treatments with western medication, acupuncture and the combined therapy of acupuncture and western medication.

METHODSOne hundred and twenty children of herpetic angina were randomized into a western medication group, an acupuncture group and a combined therapy group, 40 cases in each one. Besides the basic treatment with symptomatic support, in the western medication group, ribavirin granules were prescribed for oral administration, 10 mg/kga day, three times a day, for 3 days. In the acupuncture group, acupuncture was applied at Fengchi (GB 20), Hegu (LI 4), Quchi (LI 11), Xiaguan (ST 7), Jiache (ST 6), Dicang (ST 4), Shaoshang (LU 11) and Shangyang (LI 1), once a day, for 3 days. In the combined therapy group, the treatments as the western medication group and the acupuncture group were used, in which, the oral administration with ribavirin granules and acupuncture were adopted for 3 days. The clinical therapeutic effects were compared after treatment and the follow-up visit was conducted since the 4th day at the end of treatment to compare the antifebrile time, herpes relieving time and the use frequency of ibuprofen oral liquid in the children among the three groups.

RESULTSAfter treatment, the total effective rate was 95.0% (39/40) in the combined therapy group, was 62.5% (25/40) in the western medication group and was 80.0% (32/40) in the acupuncture group. The result in the combined therapy group was better than those in the acupuncture group and the western medication group, indicating the significant differences (both<0.05). The antifebrile time and the herpetic relief time in the combined therapy group were earlier than those in the acupuncture group and the western medication group, indicating the significant differences (both<0.05). The use frequency of ibuprofen oral liquid in the combined therapy group was lower than those in the acupuncture group and the western medication group, indicating the significant difference (both<0.05).

CONCLUSIONSThe combined therapy with acupuncture and western medication relieve fever and herpes much more quickly and reduces the use frequency of ibuprofen oral liquid as compared with the simple use of acupuncture or western medication in the treatment of infantile herpetic angina, which achieve the much better therapeutic effects.

Objective:To study the risk factors of massive bleeding in patients with acute Stanford type A aortic dissection undergoing moderate hypothermic circulatory arrest repair.Methods:From January 2016 to October 2017, 486 consecutive patients with acute type A aortic dissection were included in the study. All operations were performed with moderate hypothermic circulatory arrest. The basic clinical data of patients were collected retrospectively. Massive bleeding was defined according to definition of Universal Definition of Perioperative Bleeding(UDPB) 4 class and the Blood Conservation Using Antifibrinolytics in a Randomized Trial(BART). Significant variables in univariate analysis were included in multivariate logistic regression analysis. Results:Thirty-four patients(7.00%) died in hospital. A total of one hundred and eighty-seven patients(38.48%) fulfilled criteria of the definition of BART massive bleeding. Forty-five patients(9.26%), 8 patients(1.65%), 114 patients(23.46%), 147 patients(30.25%) and 172 patients(35.39%) were in grade 0, grade 1, grade 2 and grade 4, respectively. With BART as the end point, the result of multivariate logistic regression showed that female gender( OR=3.32, P<0.001), anemia( OR=2.24, P=0.04), clearance creatine≤85 ml/min( OR=1.93, P=0.01), D-dimer level(every 500 ng/ml increase, OR=1.02, P=0.003), cardiopulmonary bypass(CPB) time( OR=1.01, P<0.001), total arch replacement(TAR, OR=2.40, P=0.02) were independent risk factors for massive bleeding, and the time from onset to operation( OR=0.86, P=0.01) was protective factor. With UDPB 4 class as the end point, multivariate logistic regression showed that creatinine clearance≤85 ml/min( OR=2.05, P=0.001), CPB time( OR=1.01, P=0.04) were independent risk factors for massive bleeding. The time from anset to operation( OR=0.85, P=0.002) and Bentall procedure( OR=0.65, P=0.04) were the protective factors. Conclusion:Massive bleeding was more common in acute Stanford type A aortic dissection. Female gender, poor preoperative renal function, high D-dimer level, early time accepting surgical operation and long CPB were independent risk factors. For high-risk patients, simple and effective surgical methods should be taken to reduce the risk of bleeding.

ObjectiveTo explore the surgical techniques and clinical experiences in treating thoracoabdominal aorta dissecting aneurysm following Sun's procedure.MethodsFrom June 2009 to May 2011,thoracoabdominal aorta replacement was performed in thirteen patients with thoracoabdominal aorta dissecting aneurysm following Sun's procedure in Beijing Anzhen Hospital.Among which,eleven were male,and two were female with a mean age 39.3 years (28 -58 years).All cases were Stanford A aortic dissection,and were underwent Sun's Procedure.The pathogeny of the dissection,ten were Marfan's syndrome,and three were hypertension.Thoracoabdominal aorta dissecting aneurysms were all Crawford type Ⅱ,with the diameter( 5.78 ± 1.00 )cm (4.0 -8.0 cm).All the procedures were performed through combined thoracoabdominal incision via the retroperitoneal approach.And thoracoabdominal aorta was replaced by a tetrafurcate graft with short-time interval circulatory arrest.24 - 30 mm tetrafurcate grafts were selected in all patients.The main graft of the tetrafurcate graft was anastomosed to the elephant truck stent graft.Visceral arteries were joined into a patch and were anastomosed to the other end of the main graft.T6 to T12 intercostal arteries were reconstructed by an 8 mm sidearm.Another 8 mm sidearm was anastomosed to the left renal artery.Both 10 mm sidearms were anastomosed to iliac arteries.Among which,seven were underwent by profound hypothermia with circulatory arrest,and six were underwent off pump with normal temperature.ResultsNo early death.Twelve patients were cured and discharged from hospital.Seven patients were underwent profound hypothermia with circulatory arrest.Among which,one patient had paraplegia,sepsis,pseudomembranous colitis,respiratory failure,and died on 102-day after operation.Another one patient had neurological dysfunction and was cured after six-day's dehydrated treatment.The UFCT showed that the tetrafurcate graft was unobstructed,no distortion,no pseudoaneurysms in all patients.The branch to intercostal arteries was obstructed in three cases,but there were no spinal cord ischemia complications.The mean duration of follow-up was (9.6 ±2.1 ) months (range,1 -24 months),with a follow-up rate of 100％.All the tetrafurcate graft were very well,no obstruction,no distortion and no pseudoaneurysms.There were no cerebral,spiral cord and abdominal viscera ischemia complications in all patients.ConclusionThoracoabdominal aorta replacement after Sun's procedure is simple,and it is helpful to reduce complications.Following Sun's procedure,using tetrafurcate graft with short-time interval circulatory arrest and off pump technique in thoracoabdominal aorta replacement is simple,and it is helpful to reduce complications.