Objectives: 1) To present a case of a patient with aortic dissection. 2) To show how the case arrived to its plausible diagnosis. 3) To discuss other illnesses discovered in the case. Case Summary This is a case of a 54-year old, female, Filipino, Catholic, who presented with severe chest pain, substernal in location, with pain intensity of 8/10 associated with diaphoresis and dyspnea leading to fainting spells. Initial impression was cardiogenic shock secondary to Non-ST elevated myocardial infarction. On physical examination, the patient was drowsy and in cardio-respiratory distress. She had symmetrical chest expansion and no retractions were noted. Clear breath sounds were noted in all lung fields. She had an adynamic precordium with normal rate and regular rhythm, however with distant heart sounds. There was no murmur, heave or thrill appreciated. Vital signs at the emergency room showed a blood pressure of 110/80 which eventually became 80/50 mmH, respiratory rate of 22 cycles per minute, heart rate of 80-100 beats per minute and was febrile. Patient was scheduled for a stat coronary angiography, however on further reassessment, repeat ECG showed resolution of the inferolateral wall ischemia but this could not explain her fluctuating blood pressure. When the patient underwent the scheduled bedside 2D echo, a moderate cardiac tamponade was discovered with a 4.5 cm aortic dissection. With these findings, patient underwent aortic repair, graft insertion with evacuation of hematoma. She was discharged stable and with no recurrence of chest pain.
Cardiac Tamponade ; Aortic Dissection

Humans ; Aortic Dissection ; Aorta

Aortic Dissection/complications* ; Aortic Rupture/etiology* ; Humans

Aortic Dissection ; Aortic Aneurysm, Thoracic ; Humans ; Models, Theoretical

Humans ; Aortic Dissection/surgery* ; Aortic Rupture/surgery* ; Death ; Treatment Outcome

Aortic Dissection/surgery* ; Aortic Aneurysm, Thoracic/surgery* ; Blood Vessel Prosthesis Implantation ; Endovascular Procedures ; Humans ; Treatment Outcome

Objective: Near-infrared spectroscopy (NIRS) is widely used for intraoperative cerebral oxygen saturation monitoring in patients with acute type A aortic dissection. This study aimed to investigate the correlation between NIRS-derived oxygen saturation and risk of postoperative stroke. Methods: This study included 193 patients with acute type A aortic dissection undergoing emergency surgery and elective unilateral cerebral perfusion via the right axillary artery at the Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China, from 2018 to 2020. NIRS was used for intraoperative cerebral oxygen saturation monitoring, and the basal values and the lowest values of cerebral oxygen saturation during deep hypothermic circulatory arrest (DHCA) were recorded. The patients were divided into no-stroke group (n=178, 92.2%) and stroke group (n=15, 7.8%) according to the absence or presence of postoperative stroke. The differences in preoperative, operative and postoperative clinical differences between the two groups were compared, and the relationship between the lowest cerebral oxygen saturation value and the change in cerebral oxygen saturation value ((base-lowest)/basal) and postoperative stroke were analyzed. Results: The proportion of preoperative atrial fibrillation (6.7% vs. 0.6%, P=0.026), and the proportion of preoperative hypotension (26.7% vs. 9.0%, P=0.031) were significantly higher in the stroke group than no-stroke group. There were no differences in the surgical approach between the two groups. Cardiopulmonary bypass (CPB) time ((256.1±84.8) h vs.(217.8±58.4) h, P=0.020), postoperative mechanical ventilation time ((139.3±172.8) h vs. (35.6±45.6) h, P<0.001) were significantly longer in stroke group as compared to no-stroke group. Incidence of postoperative tracheotomy (20.0% vs. 1.1%, P<0.001), acute kidney injury (73.3% vs. 30.3%, P=0.001) and continuous renal replacement therapy (46.7% vs. 11.8%, P<0.001) as well as mortality (20.0% vs. 5.1%, P=0.022) were significantly higher in the stroke group than in non-stroke group. There was no significant difference in the basal NIRS value and the lowest NIRS value during DHCA between the two groups. Patients in the stroke group had a significantly greater intraoperative change rate of right NIRS as compared to no-stroke group (15.2%±15.7% vs. 9.2%±7.0%, P=0.006). Conclusions: NIRS is valuable for monitoring cerebral oxygen saturation during acute type A aortic dissection surgery, and the rate change of NIRS during operation correlates significantly with postoperative stroke.
Aortic Dissection/surgery* ; Humans ; Monitoring, Intraoperative/methods* ; Oxygen ; Oxygen Saturation ; Spectroscopy, Near-Infrared/methods* ; Stroke

OBJECTIVE: To explore whether the differentiation of vascular stem cells (VSC) into smooth muscle cells (SMC) in aortic dissection (AD) is dysregulated, and to verify the role of Notch3 pathway in this process. METHODS: Aortic tissues were obtained from AD patients undergoing aortic vascular replacement and heart transplant donors at Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital Affiliated to Southern Medical University. VSC were isolated by enzymatic digestion and c-kit immunomagnetic beads. The cells were divided into normal donor-derived VSC group (Ctrl-VSC group) and AD-derived VSC group (AD-VSC group). The presence of VSC in the aortic adventitia was detected by immunohistochemical staining, and VSC was identified by stem cell function identification kit. The differentiation model of VSC into SMC established in vitro was induced by transforming growth factor-β1 (10 μg/L) for 7 days. They were divided into normal donor VSC-SMC group (Ctrl-VSC-SMC group), AD VSC-SMC group (AD-VSC-SMC group) and AD VSC-SMC+Notch3 inhibitor DAPT group (AD-VSC-SMC+DAPT group,DAPT 20 μmol/L was added during differentiation induction). The expression of contractile marker Calponin 1 (CNN1) in SMC derived from aortic media and VSC were detected by immunofluorescence staining. The protein expressions of contractile markers α-smooth muscle actin (α-SMA), CNN1 as well as Notch3 intracellular domain (NICD3) in SMC derived from aortic media and VSC were detected by Western blotting. RESULTS: Immunohistochemical staining showed there was a population of c-kit-positive VSC in the adventitia of aortic vessels, and VSC from both normal donors and AD patients had the ability to differentiate into adipocytes and chondrocytes. Compared with normal donor vascular tissue, the expressions of SMC markers α-SMA and CNN1 of tunica media contraction in AD were down-regulated (α-SMA/β-actin: 0.40±0.12 vs. 1.00±0.11, CNN1/β-actin: 0.78±0.07 vs. 1.00±0.14, both P < 0.05), while the protein expression of NICD3 was up-regulated (NICD3/GAPDH: 2.22±0.57 vs. 1.00±0.15, P < 0.05). Compared with Ctrl-VSC-SMC group, the expressions of contractile SMC markers α-SMA and CNN1 were down-regulated in AD-VSC-SMC group (α-SMA/β-actin: 0.35±0.13 vs. 1.00±0.20, CNN1/β-actin: 0.78±0.06 vs. 1.00±0.07, both P < 0.05), the protein expression of NICD3 was up-regulated (NICD3/GAPDH: 22.32±1.22 vs. 1.00±0.06, P < 0.01). Compared with AD-VSC-SMC group, the expressions of contractile SMC markers α-SMA, CNN1 were up-regulated in AD-VSC-SMC+DAPT group (α-SMA/β-actin: 1.70±0.07 vs. 1.00±0.15, CNN1/β-actin: 1.62±0.03 vs. 1.00±0.02, both P < 0.05). CONCLUSIONS Dysregulation of VSC differentiation into SMC occurs in AD, while inhibition of Notch3 pathway activation can restore the expression of contractile proteins in VSC-derived SMC in AD.
Humans ; Actins ; Platelet Aggregation Inhibitors ; Signal Transduction ; Aortic Dissection ; Cell Differentiation ; Myocytes, Smooth Muscle ; Stem Cells

Endovascular treatment of Stanford type B aortic dissection (type B dissection) has been widely used. There will be complications such as aortic dilatation, which will lead to poor prognosis of some patients. With more in-depth researches, it was found that there was a possible correlation between the prognosis of type B dissection and tears, such as the increasing of aortic diameter would be faster with longer tears, and the location of the tear will affect the thrombosis of the false lumen. Studies on hemodynamics have also found that different characteristics of tears of aortic dissection can cause changes in the pressure, blood flow rate and blood capacity in the true and false lumens recently. The hemodynamic changes can be used to predict the prognosis of type B dissection. The main characteristics of tears included the size, position, number of tears, residual tears and stent graft induced new entry. Describing the effect of tear characteristics on the development of type B dissection, can provide the basis for the clinical treatment and further research of type B dissection.
Humans ; Aortic Dissection/surgery* ; Hemodynamics ; Prognosis ; Blood Vessel Prosthesis Implantation/adverse effects* ; Thrombosis/etiology* ; Endovascular Procedures/adverse effects* ; Aortic Aneurysm, Thoracic/surgery* ; Stents/adverse effects* ; Treatment Outcome

Objectives: To compare the short-term outcomes of branched stentgrafts for left subclavian artery (LSA) revascularization or partial LSA coverage without reconstruction in the treatment of type B aortic dissection with proximal tear close to LSA. Methods: A total of 125 type B aortic dissection patients were treated with thoracic endovascular aortic repair (TEVAR) in Xinqiao Hospital of the Army Medical University from January 2019 to March 2021. Their medical records were reviewed and the outcomes were followed up. According to the different treatment methodologies, the patients were divided into complete LSA coverage with reconstruction group (n=25) and partial LSA coverage without reconstruction group (n=100). The data of baseline characteristics, clinical outcomes, and incidence of postoperative in-hospital adverse events were collected and compared between the two groups. The adverse events during one-year follow-up were also compared between the two groups. Kaplan-Meier analysis and log-rank test were used to compare the cumulative survival rates between groups. Results: Compared with partial LSA coverage group, distance of proximal tear to LSA((8.69±2.32)mm vs. (13.77±1.71) mm) was shorter, in-hospital expenses[175 400(166 000-189 900) yuan vs. 143 700 (138 100-151 800) yuan] was higher, average length of stent [200.00 mm vs. 150.00 (150.00-150.00) mm] and operation time [155.00 (140.00-170.00) min vs. 95.00 (80.00-100.00) min] were longer, and volumes of contrast agent [300.00 (200.00-300.00) ml vs. 200.00 (200.00-300.00) ml] (P<0.05) were higher for patients in the complete LSA coverage with reconstruction group. The incidence of post-operative fever was significantly higher in complete LSA coverage with revascularization group than that in partial LSA partial coverage with reconstruction group (56% vs. 25%, P=0.003). There was no significant difference in the incidences of all-cause death, stroke, endoleak, paraplegia, and LSA branch vessel occlusion between the two groups during follow-up. Kaplan-Meier analysis showed that there was no significant difference in the cumulative survival rates between the two groups (log-rank test: P=0.572 5). Conclusion: The TEVAR with complete LSA revascularization or partial LSA coverage without reconstruction for type B aortic dissection close to LSA are safe and effective with high success rates. There is no significant difference between these two techniques in short-term outcomes.
Aortic Dissection/surgery* ; Aortic Aneurysm, Thoracic/surgery* ; Blood Vessel Prosthesis Implantation/methods* ; Endovascular Procedures/methods* ; Humans ; Retrospective Studies ; Stents ; Subclavian Artery/surgery* ; Time Factors ; Treatment Outcome