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Background: The risk of coronary artery disease (CAD) in different valve dysfunction has been unclear. Methods: We reviewed patients, who underwent valve heart surgery and coronary angiography from 2008 to 2021, at our center. Results: A total of 7,932 patients were included in the present study, and 1,332 (16.8%) had CAD. The mean age of the study cohort was 60.5±7.9 years, and 4,206 (53.0%) were male. CAD was 21.4% in aortic disease, 16.2% in mitral valve disease, 11.8% in isolated tricuspid valve disease, and 13.0% in combined aortic and mitral valve disease. Patients with aortic stenosis were older than those with regurgitation (63.6±7.4 years vs. 59.5±8.2 years, P < 0.001), and the CAD risks also were higher (28.0% vs. 19.2%, P < 0.001). The age difference was minimal (60.6±8.2 years vs. 59.5±6.7 years, P = 0.002) between patients with mitral valve regurgitation and stenosis, but the risks of CAD were twice high in regurgitation (20.2% vs. 10.5%, P < 0.001). When the type of valve impairment was not considered, non-rheumatic etiology, advanced age, male sex, hypertension, and diabetes were independent predictors of CAD. Conclusion: In patients undergoing valve surgery, the prevalence of CAD was influenced by conventional risk factors. Importantly, CAD also was associated with the type and etiology of valve diseases.

An integrated battery system, which integrates solar power and rechargeable battery in the same unit, is recognized as a propective solution for the shortage and inefficiency of power energy. Herein, a hybrid S/N719 dye cathode is proposed in the rechargeable Li-S battery to realize the photo-assisted charging battery system. Specifically, the photo-charge contribution reduces the charge voltage of the sulfur cathode by 0.12 V and accelerates the charge process under light illumination, showing the great potential in saving electric energy and expediting fast-charge capacity of Li-S battery.

The midterm clinical outcomes of patients with latent left ventricular outflow tract (LVOT) obstruction who undergo septal myectomy are unclear. Therefore, this study aimed to evaluate the clinical outcomes of patients with latent LVOT obstruction who underwent septal myectomy.We studied 34 patients with hypertrophic cardiomyopathy (HCM) and latent LVOT obstruction who underwent septal myectomy in 2011-2019 at Anzhen Hospital. After 2:1 propensity score matching, the study cohort included 34 patients with latent LVOT obstruction and 68 patients with resting LVOT obstruction.Compared to patients with resting LVOT obstruction, patients with latent LVOT obstruction had a thinner interventricular septal thickness (18.2 ± 3.2 mm vs. 20.4 ± 5.6 mm; p = .01), while the proportion of moderate or severe mitral regurgitation was significantly higher (26.5% vs. 5.9%; p = .003). Moreover, the proportion of mitral valve procedures (26.5% vs. 5.9%; p = .004) was significantly higher in patients with latent LVOT obstruction. However, there was no intergroup difference in cardiovascular death (5.9% vs. 1.5%, p = .26). Furthermore, the 5-year survival rates after sudden cardiac death (100.0% vs. 91.7%; p = .26) and cardiovascular death (95.5% vs. 89.0%; p = .32) were similar between HCM patients with latent versus resting LVOT obstruction.Midterm clinical outcomes were similar and excellent in a matched cohort of HCM patients with latent versus resting LVOT obstruction after septal myectomy.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with a higher prevalence of postoperative atrial fibrillation in patients who underwent cardiac surgery. However, whether OSA is a risk factor for postoperative atrial fibrillation after septal myectomy remains unclear. We hypothesized that OSA was associated with postoperative atrial fibrillation after septal myectomy. METHODS: A total of 99 patients with hypertrophic obstructive cardiomyopathy who underwent septal myectomy were included in our manuscript. Polysomnography was performed in all patients, and the heart rhythm was continuously monitored during the perioperative period. RESULTS: In the present study, 25 (25.3%) patients developed postoperative atrial fibrillation after septal myectomy. The prevalence of postoperative atrial fibrillation was significantly higher in patients with OSA and increased with the worsening severity of OSA. Notably, the apnea-hypoxia index was significantly higher in patients with postoperative atrial fibrillation among the different OSA groups. In receiver operating characteristic analysis, the area under the curve for the apnea-hypopnea index was 0.785 (95% CI: 0.684–0.887, P

BACKGROUND: Hypertrophic cardiomyopathy (HCM) with extreme interventricular septal thickness (IVST) is associated with a higher incidence of adverse cardiovascular events. However, the results of these patients who underwent septal myectomy are unclear. METHODS: We studied 47 HCM patients with IVST ≥30 mm who underwent septal myectomy between 2011 and 2018 in Anzhen Hospital. After a 2:1 propensity score matching, the study cohort included 141 patients and 94 patients with IVST

Background Type 2 diabetes mellitus is common in cardiovascular disease. It is associated with adverse clinical outcomes for patients who had undergone coronary artery bypass and valve operations. The aim of this study was to evaluate the impact of type 2 diabetes mellitus on the midterm outcomes of patients with hypertrophic cardiomyopathy who underwent septal myectomy. Methods We retrospectively analyzed the data of 67 hypertrophic cardiomyopathy patients with type 2 diabetes mellitus who underwent septal myectomy from two medical centers in China from 2011 to 2018. A propensity score–matched cohort of 134 patients without type 2 diabetes mellitus was also analyzed. Results During a median follow-up of 28.0 (interquartile range: 13.0–3.0) months, 9 patients died. The cause of death of all of these patients was cardiovascular, particularly sudden cardiac death in 3 patients. Patients with type 2 diabetes mellitus had a higher rate of sudden cardiac death (4.5% vs. 0.0%, p = 0.04). The Kaplan–Meier survival analysis revealed that the rates of predicted 3-year survival free from cardiovascular death (98.1% vs. 95.1%, p = 0.14) were similar between the two groups. However, the rates of predicted 3-year survival free from sudden cardiac death (100% vs. 96.7%, p = 0.01) were significantly higher in hypertrophic cardiomyopathy patients without type 2 diabetes mellitus than in those with type 2 diabetes mellitus. Furthermore, after adjustment for age and sex, only N-terminal pro-brain natriuretic peptide (hazards ratio: 1.002, 95% confidence interval: 1.000–1.005, p = 0.02) and glomerular filtration rate ≤ 80 ml/min (hazards ratio: 3.23, 95% confidence interval: 1.34–7.24, p = 0.047) were independent risk factors for hypertrophic cardiomyopathy patients with type 2 diabetes mellitus. Conclusions Hypertrophic cardiomyopathy patients with and without type 2 diabetes mellitus have similar 3-year cardiovascular mortality after septal myectomy. However, type 2 diabetes mellitus is associated with higher sudden cardiac death rate in these patients. In addition, N-terminal pro-brain natriuretic peptide and glomerular filtration rate ≤ 80 ml/min were independent risk factors among hypertrophic cardiomyopathy patients with type 2 diabetes mellitus.

With the sharing economy boom, there is a notable increase in the number of car-sharing corporations, which provided a variety of travel options and improved convenience and functionality. Owing to the similarity in the travel patterns of the urban population, car-sharing system often faces the problem of imbalance in the number of shared cars within the spatial distribution, especially during the rush hours. There are many challenges in redressing this imbalance, such as insufficient data and the large state space. In this study, we propose a new reward method called Double P (Picking & Parking) Bonus (DPB). We model the research problem as a Markov Decision Process (MDP) problem and introduce Deep Deterministic Policy Gradient, a state-of-the-art reinforcement learning framework, to find a solution. The results show that the rewarding mechanism embodied in the DPB method can indeed guide the users’ behaviors through price leverage, increase user stickiness, and cultivate user habits, thereby boosting the service provider’s long-term profit. In addition, taking the battery power of the shared car into consideration, we use the method of hierarchical reinforcement learning for station scheduling. This station scheduling method encourages the user to place the car that needs to be charged on the charging post within a certain site. It can ensure the effective use of charging pile resources, thereby rendering the efficient functioning of shared cars.

OBJECTIVES To study the perioperative outcomes and long-term survival rates in patients undergoing thoracic endovascular aortic repair (TEVAR) for uncomplicated type B dissection. METHODS A total of 751 patients with uncomplicated type B dissection who underwent TEVAR at our centre between May 2001 and December 2013 were retrospectively reviewed. The mean age of all patients (619 males and 132 females) was 52.8 ± 10.9 years. The follow-up period ranged from 1 to 170 months (median 70 months). RESULTS Five patients died during the perioperative period (mortality rate 0.7%). Four patients (0.5%) developed retrograde type A dissection. Two patients (0.3%) developed paraplegia and 1 patient developed incomplete paralysis (0.1%). There were no postoperative cerebral infarctions. The 5- and 10-year survival rates were 96.5% [95% confidence interval (CI) 95.0–98.0%] and 83.0% (95% CI 77.9–88.4%), respectively. The 5- and 10-year reintervention rates were 4.6% (95% CI 3.0–6.2%) and 7.9% (95% CI 5.3–10.5%), respectively. CONCLUSIONS Although the application of TEVAR for patients with uncomplicated dissection is still under debate, many patients who have undergone TEVAR have benefitted substantially from the treatment. Our data showed that TEVAR had low mortality and complication rates both in the short- and long-term follow-up periods. TEVAR may be considered as a first choice for patients with uncomplicated type B dissection.

Melastoma dodecandrum, the only creeping species in the Melastoma genus, serves as a medicinal herb in southeast China. It belongs to the huge family Melastomataceae, which contains over 5000 species worldwide. In this study, we used next-generation sequencing to determine the complete chloroplast genome sequences of M. dodecandrum, which is a circular molecule of 156,611 bp in length. After annotation, we identified 131 putative genes in total, comprised of 85 protein-coding genes, 38 transfer RNA genes and 8 ribosomal RNA genes. Genome structure, GC content, repeat sequences and codon usage were investigated to gain a comprehensive understanding of this genome. Furthermore, we conducted comparative genome analyses between the M. dodecandrum genome and that of four other Melastomataceae species. Additionally, a phylogenetic analysis was performed based on available chloroplast genomes of Melastomataceae species and several Myrtaceae species, revealing the taxonomic relationships between M. dodecandrum and related species. In conclusion, our study represents the first look into the complete chloroplast genome of M. dodecandrum, providing abundant information for further studies such as species identification, taxonomy and phylogenetic resolution of Melastomataceae species.

Transition metal oxides (TMOs) have gained enormous research interests as negative materials of next generation lithium-ion batteries due to their higher energy density, lower cost, and better eco-friendliness. However, they are prone to low electronic conductivities and dramatic volume change during charge/discharge and there is also a great challenge in realizing TMO electrodes with satisfactory LIB performances. In this study, for the first time, amorphous nickel-boride (Ni-B) was introduced into porous NiCo2O4 nanospheres by an in situ solution growth route to overcome the existing issues. The coated Ni-B component could not only function as anchors for NiCo2O4 nanospheres to suppress the severe volume expansion but could also act as effective electron-conducting bridges to promote fast electron/charge transfer. Furthermore, the existence of abundant mesopores centered at ∼6.5 nm in this composite could effectively suppress the severe volume variations in the lithiation/delithiation process. As expected, the NiCo2O4@Ni-B composites delivered a high reversible capacity of 1221 mA h g-1 at 0.2 A g-1 and 865 mA h g-1 at 0.5 A g-1 over 500 cycles; more impressively, at the high rate of 5 A g-1, a capacity of 648 mA h g-1 could be also obtained, showing its good rate capability. As a result, these results demonstrated an effective and facile way to design conversion-type negative electrode materials with superior lithium storage properties.

BACKGROUND The incidence of obstructive sleep apnea (OSA) is significantly higher in patients who undergo coronary artery bypass grafting (CABG). OSA is correlated with a higher incidence of postoperative complications in patients undergoing CABG. However, whether OSA is associated with a decrease in renal function and a higher incidence of dialysis after CABG remains unclear. METHODS Data from 178 consecutive patients who underwent isolated CABG at Anzhen Hospital between June 2019 and June 2020 were analyzed. Polysomnography was performed in all the patients. RESULTS A total of 142 (79.8%) patients were diagnosed with OSA, 78 with mild OSA, and 64 with moderate-to-severe OSA. Compared to patients without OSA, the level of creatinine was significantly increased, and the level of estimated glomerular filtration rate (eGFR) was decreased in patients with OSA. In addition, the percentage of patients undergoing dialysis during the perioperative period increased with the severity of OSA (0.0% vs. 2.6% vs. 18.8%, P=0.02). Multiple linear regression analysis showed that age (β=-0.29, P

Background This study aimed to evaluate the clinical outcomes of one-staged hybrid procedure for aortic lesions involving the distal aortic arch. Methods We retrospectively studied 99 consecutive patients who underwent the hybrid procedure (thoracic endovascular aortic repair combined with supra-arch branch vessel bypass) in our center between April 2009 and January 2020 for lesions involving the distal aortic arch. Results Median age was 64.0 (57.0-69.0) years, and 83 (83.8%) patients were male. There were five deaths in the perioperative period (three due to cerebral infarction and two due to intimal rupture). During the median follow-up of 41.0 months, 20 patients died, three had endoleak, one had a newly formed intimal tear, and two had femoral artery pseudoaneurysm. The 5- and 10-year survival rates of the total population were 72.2% and 48.8%, respectively. Additionally, there was no difference in the 5-year survival rate among the four groups according to different pathologies (Type B aortic dissection, aortic ulcer, aortic aneurysm, aortic pseudoaneurysm: 74.7%, 78.2%, 61.1%, and 75.5%, respectively, p = .58). Furthermore, there was no difference in the 5- and 10-year survival rates between the two groups according to the different bypass methods (right axillary artery [RAA]-left axillary artery [LAA] vs. RAA-LAA-left common carotid artery: 74.1% vs. 68.9%, p = .38). Conclusions Although one-staged hybrid procedure has fewer complications in high-risk patients with lesions involving the distal aortic arch, the long-term survival rate is not optimistic.

Recent studies have revealed that neural combinatorial optimization (NCO) has advantages over conventional algorithms in many combinatorial optimization problems such as routing, but it is less efficient for more complicated optimization tasks such as packing which involves mutually conditioned action spaces. In this paper, we propose a Recurrent Conditional Query Learning (RCQL) method to solve both 2D and 3D packing problems. We first embed states by a recurrent encoder, and then adopt attention with conditional queries from previous actions. The conditional query mechanism fills the information gap between learning steps, which shapes the problem as a Markov decision process. Benefiting from the recurrence, a single RCQL model is capable of handling different sizes of packing problems. Experiment results show that RCQL can effectively learn strong heuristics for offline and online strip packing problems (SPPs), outperforming a wide range of baselines in space utilization ratio. RCQL reduces the average bin gap ratio by 1.83% in offline 2D 40-box cases and 7.84% in 3D cases compared with state-of-the-art methods. Meanwhile, our method also achieves 5.64% higher space utilization ratio for SPPs with 1000 items than the state of the art., Comment: 16 pages, 5 figures, 3 tables. Accepted to Knowledge-Based Systems, 2022

Background Obstructive sleep apnea (OSA) is a common disease associated with worse structural and functional impairment of the heart in patients with hypertrophic obstructive cardiomyopathy (HOCM). Hypothesis The presence and severity of OSA can decrease the right ventricular ejection fraction (RVEF) in patients with HOCM. Methods In total, 151 consecutive patients with a confirmed diagnosis of HOCM at Fuwai Hospital between September 2017 and September 2018 were included. Polysomnography and cardiac magnetic resonance imaging were performed in all patients. Results Overall, 84 (55.6%) patients were diagnosed with OSA. The RVEF significantly decreased with the severity of OSA (none, mild, moderate‐severe: 46.1 ± 8.2 vs 42.9 ± 7.5 vs 41.4 ± 7.4, P = .009). The apnea‐hypopnea index (AHI) was significantly high in patients with RVEF40%, RVEF40%, those with RVEF

Additional file 3: Table S2. Baseline patient characters in unmatched cohort.

Additional file 1: Table S1. Relative multivariable imbalance L1 and Summary of unbalanced covariates.

The aim of this study was to evaluate the effect of 3-dimensional (3D) printing in treatment of hypertrophic obstructive cardiomyopathy (HOCM) and its roles in doctor-patient communication.3D-printed models were constructed preoperatively and postoperatively in seven HOCM patients received surgical treatment. Based on multi-slice computed tomography (CT) images, regions of disorder were segmented using the Mimics 19.0 software (Materialise, Leuven, Belgium). After generating an STL-file (StereoLithography file) with patients' data, the 3D printer (Objet350 Connex3, Stratasys Ltd., USA) created a 3D model. The pre- and post-operative 3D-printed models were used to make the surgical plan preoperatively and evaluate the outcome postoperatively. Meanwhile, a questionnaire was designed for patients and their relatives to learn the effectiveness of the 3D-printed prototypes in the preoperative conversations.The heart anatomies were accurately printed with 3D technology. The 3D-printed prototypes were useful for preoperative evaluation, surgical planning, and practice. Preoperative and postoperative echocardiographic evaluation showed left ventricular outflow tract (LVOT) obstruction was adequately relieved (82.71±31.63 to 14.91±6.89 mmHg, P0.001), the septal thickness was reduced from 21.57±4.65 to 17.42±5.88 mm (P0.001), and the SAM disappeared completely after the operation. Patients highly appreciated the role of 3D model in preoperative conversations and the communication score was 9.11±0.38 points.A 3D-printed model is a useful tool in individualized planning for myectomies and represent a useful tool for physician-patient communication.

Background: Percutaneous transluminal septal myocardial ablation (PTSMA) and modified Morrow septal myectomy (MMSM) are two invasive strategies used to relieve obstruction in patients with hypertrophic cardiomyopathy (HCM). This study aimed to determine the clinical outcome of these two strategies. Methods: From January 2011 to January 2015, 226 patients with HCM were treated, 68 by PTSMA and 158 by MMSM. Both ultrasonic cardiograms and heart functional class were recorded before, after operations and in the follow-up. Categorical variables were compared using Chi-square or Fisher’s exact tests. Quantitative variables were compared using the paired samples t-test. Results: Interventricular septal thickness was significantly reduced in both groups (21.27 ± 4.43 mm vs. 18.72 ± 4.13 mm for PTSMA, t = 3.469, P < 0.001, and 21.83 ± 5.03 mm vs. 16.57 ± 3.95 mm for MMSM, t = 10.349, P < 0.001, respectively). The left ventricular outflow tract (LVOT) pressure gradient (PG) significantly decreased after the operations in two groups (70.30 ± 44.79 mmHg vs. 39.78 ± 22.07 mmHg for PTSMA, t = 5.041, P < 0.001, and 74.58 ± 45.52 mmHg vs. 13.95 ± 9.94 mmHg for MMSM, t = 16.357, P < 0.001, respectively). Seven patients (10.29%) in the PTSMA group required a repeat operation in the follow-up. Eight (11.76%) patients were evaluated for New York Heart Association (NYHA) III/IV in the PTSMA group, which was significantly more than the five (3.16%) in the same NYHA classes for the MMSM group at follow-up. Less than 15% of patients in the PTSMA group and none of the patients in the MMSM group complained of chest pain during follow-up. Conclusions: Both strategies can not only relieve LVOT PG but also improve heart function in patients with HCM. However, MMSM might provide a more reliable reduction in gradients compared to PTSMA. Key words: Hypertrophic Cardiomyopathy; Myectomy; Percutaneous Transluminal Septal Myocardial Ablation

Transition metal oxides (TMOs) have gained enormous research interests as negative materials of next generation lithium-ion batteries due to their higher energy density, lower cost, and better eco-friendliness. However, they are prone to low electronic conductivities and dramatic volume change during charge/discharge and there is also a great challenge in realizing TMO electrodes with satisfactory LIB performances. In this study, for the first time, amorphous nickel-boride (Ni-B) was introduced into porous NiCo2O4 nanospheres by an in situ solution growth route to overcome the existing issues. The coated Ni-B component could not only function as anchors for NiCo2O4 nanospheres to suppress the severe volume expansion but could also act as effective electron-conducting bridges to promote fast electron/charge transfer. Furthermore, the existence of abundant mesopores centered at ∼6.5 nm in this composite could effectively suppress the severe volume variations in the lithiation/delithiation process. As expected, the NiCo2O4@Ni-B composites delivered a high reversible capacity of 1221 mA h g-1 at 0.2 A g-1 and 865 mA h g-1 at 0.5 A g-1 over 500 cycles; more impressively, at the high rate of 5 A g-1, a capacity of 648 mA h g-1 could be also obtained, showing its good rate capability. As a result, these results demonstrated an effective and facile way to design conversion-type negative electrode materials with superior lithium storage properties.

With the boom of sharing economy, more and more car-sharing corporations sprout up, providing more travel options and convenience. Due to similar travel patterns of urban dwellers, the car-sharing system results in an imbalance of shared cars in spatial distribution, especially during the rush hours. To redress this imbalance faces many challenges, such as insufficient data and the enormous state space. In this study, we propose a new reward method called Double P (Picking & Parking) Bonus (DPB). We model the research problem as a Markov Decision Process (MDP) problem and introduce Deep Deterministic Policy Gradient, a state-of-the-art reinforcement learning framework, to find a solution. The results show that the rewarding mechanism embodied in the DPB method can indeed guide the users' behaviors through price leverage, increase user stickiness, cultivate user habits, and thus boost the service provider's long-term profit.

Melastoma dodecandrum, the only creeping species in the Melastoma genus, serves as a medicinal herb in southeast China. It belongs to the huge family Melastomataceae, which contains over 5000 species worldwide. In this study, we used next-generation sequencing to determine the complete chloroplast genome sequences of M. dodecandrum, which is a circular molecule of 156,611 bp in length. After annotation, we identified 131 putative genes in total, comprised of 85 protein-coding genes, 38 transfer RNA genes and 8 ribosomal RNA genes. Genome structure, GC content, repeat sequences and codon usage were investigated to gain a comprehensive understanding of this genome. Furthermore, we conducted comparative genome analyses between the M. dodecandrum genome and that of four other Melastomataceae species. Additionally, a phylogenetic analysis was performed based on available chloroplast genomes of Melastomataceae species and several Myrtaceae species, revealing the taxonomic relationships between M. dodecandrum and related species. In conclusion, our study represents the first look into the complete chloroplast genome of M. dodecandrum, providing abundant information for further studies such as species identification, taxonomy and phylogenetic resolution of Melastomataceae species. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s12298-019-00651-x) contains supplementary material, which is available to authorized users.

The study was conducted to evaluate the surgical results in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent either classic Morrow septal myectomy or modified procedure. The modified Morrow septal myectomy has gained interest as a new treatment for patients with drug-refractory symptoms of HOCM; however, its benefits in comparison to the classic procedure are unknown. In all, 236 symptomatic HOCM patients underwent surgical treatment from January 2006 to January 2015. Among them, 86 patients were treated by the classic Morrow myectomy and 150 patients via the modified procedure. Septal thickness, maximal left ventricular outflow tract (LVOT) pressure gradient (PG), and the presence of a permanent pacemaker were recorded after operation and follow-up The left ventricular septal thickness (22.1 ± 11.9 vs 17.1 ± 4.0 mm for classic procedure, and 22.3 ± 4.4 vs 16.1 ± 3.5 mm for modified procedure; P

To compare the efficacies of endoscopic harvesting saphenous vein as sequential graft by pedicled and scheltoned technique.From June 2013 to December 2013, a total of 93 patients undergoing coronary artery bypass with endoscopic vein harvesting in shank were recruited. Saphenous veins were harvested by pedicled method in group A (n =46) and scheltoned method in group B (n =47). Harvesting method was decided by a random number for each patient. Saphenous veins were used as sequential grafts during off-pump coronary artery bypass. Inter-group comparisons were made in time for harvesting, time for repairing, venous injuries and perioperative effect of saphenous vein. The postoperative follow-up period was 30 days. Early failure of saphenous vein graft was evaluated with coronary computed tomography (CT) angiography.All saphenous veins in shank were harvested successfully. No significant difference existed in vein length. In groups A and B, average time for harvesting was (21. 7 ± 5. 6) and (27. 4 ± 6. 4) min (P0. 05) and time for repairing (7. 2 ± 2. 7) and (10. 6± 4. 4) min respectively (P0. 05). No severe injury resulted in non-using of saphenous in both groups. The repair rates of saphenous vein were 10. 9% and 38. 3% respectively (P0. 05). For each repaired saphenous vein, the average number of locations was (1. 6 ± 0. 5) and (3. 1 ± 1. 0) sites respectively (P0. 05). All patients were discharged uneventfully. There was no perioperative onset of myocardial infarction or malignant arrhythmia. For groups A and B, 89. 1% and 93. 6% were followed up for 1 month post-operation. No angina, myocardial infarction or heart failure occurred. For groups A and B, 32 and 37 cases were re-examined on CT coronary angiography and all saphenous vein grafts maintained patency.Pedicled method is more safe and reliable for endoscopic saphenous vein harvesting. It can ensure the quality of sequential graft, shorten harvesting time and reduce the risks of vein injury.

To the Editor: We report two cases of arch replacement combined with frozen elephant trunk implantation procedure using the collared anastomosis technique for giant arch and thoracic aorta dilatation. A 62-year-old hypertensive female patient was admitted because of endoleak after thoracic endovascular aortic repair (TEVAR). The patient underwent TEVAR procedure because of Stanford type B aortic dissection 5 years ago. The proximal diameter of the stent graft was 50 mm. Another patient was a 52-year-old man suffering from arch and thoracic aneurysm. The diameter of the aneurysm was 52 mm. The ascending aorta and aortic valve of the two patients were normal. Aortic arch replacement and frozen elephant trunk implantation were performed. We developed the one-stage open procedure for arch pathology and obtained satisfactory results.[1] However, the diameters of the thoracic aorta were larger than the diameter of the frozen elephant trunk, resulting in difficulty in suture placement. As such, frozen elephant trunk procedure with a four-branched hybrid graft is suitable for such implantation case. However, the four-branched hybrid graft is still unavailable in China. As such, we made one using a four-branched graft, a hollow graft patch, and a frozen elephant trunk during cooling. The steps were as follows: (1) Deploying the frozen elephant trunk out of the body; (2) anastomosing the graft and the frozen elephant trunk together (hybrid graft); (3) trimming a hollow graft patch; (4) suturing the graft patch at the joint of the hybrid graft; and (5) binding the frozen elephant trunk as previously mentioned [Figure 1a]. Figure 1 The hybrid graft we made using a four-branched graft, a hollow graft patch, and a frozen elephant trunk (a). The collar of the hybrid graft, the wall of the proximal aneurysm, and the proximal part of the previously implanted stent graft were anastomosed ... The endoleak can result in the persistent expansion of the aorta and is reported to be an important factor of aortic rupture. Sac enlargement was reported as the key cause of endoleak.[2] For the first case, the stent graft implanted 5 years ago had a diameter of 50 mm and adhered to the aortic wall rigidly. As such, we left it in the aorta instead of pulling it out. The proximal naked part of the stent graft was trimmed, and then the frozen elephant trunk was deployed inside the previous stent graft. Then, the collar of the hybrid graft, the wall of the proximal aneurysm, and the proximal part of the previously implanted stent graft were anastomosed together as a “sandwich” [Figure 1b]. For the second case, the frozen elephant trunk of the hybrid graft was deployed inside the thoracic aorta, and then the collar of the hybrid graft and the wall of the proximal aneurysm were anastomosed together. No endoleak was detected during postoperative computed tomography at 6 months. In aorta surgery, size matching between the graft and the wall of the aneurysm is important. An unmatched size would result in bleeding because of undistributed tension. For our two cases, the size of the graft did match the size of the thoracic aorta well. With this technique, the two patients were discharged from the hospital without any complication. The collared anastomosis technique has several advantages. First, the collared anastomosis technique reduced the tension of the stoma. Second, the collared anastomosis technique decreased the difficulty in suture placement. Finally, the collared anastomosis technique excluded the space between the frozen elephant trunk and previous stent graft or thoracic aorta. The collared anastomosis technique could be an option for patients who have giant arch and thoracic aorta dilatation.