中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

急性主动脉 A 型夹层主动脉根部处理技术的近远期效果分析

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目的 比较急性主动脉 A 型夹层累及主动脉根部的各种处理方式的早期和远期结果。 方法 收集 2010 年 1 月 1 日至 2015 年 12 月 31 日期间,阜外医院急性主动脉 A 型夹层并累及主动脉根部的手术患者 673 例的临床资料,男 512 例、女 161 例,平均年龄(48.80±11.22)岁。主动脉瓣交界悬吊组共 403 例,其中男 287 例、女 116 例,平均年龄(50.61±9.95)岁。单纯升主动脉置换组 95 例,男 76 例、女 19 例,平均年龄(49.83±12.21)岁。主动脉根部置换组 175 例,男 149 例、女 26 例,平均年龄(44.07±11.99)岁。比较三组患者的术前主动脉瓣反流、术中指标、术后主动脉瓣反流等指标差异。 结果 591 例(87.8%)患者不同程度的主动脉瓣交界受累,主动脉瓣交界悬吊组,升主动脉置换组,主动脉根部置换组的交界轻度、中度、重度受累的比例分别为 31.7%、52.4%、15.9%,87.4% 、12.6% 、0.0%,23.4%、56.0%、20.6%,三组差异有统计学意义(P<0.01)。三组的主动脉窦直径分别为(39.06±5.11)mm、(38.27±4.41)mm和(50.39±6.22)mm,三组差异有统计学意义(P<0.01)。三组院内死亡率差异无统计学意义(12.2%vs. 13.7% vs. 9.7%,P=0.58)。三组 5 年生存率差异无统计学意义( 83.06% vs. 81.27% vs. 83.05%,P=0.85),三组 5 年免于中量及以上主动脉瓣反流比例差异无统计学意义( 95.2% vs. 98.6% vs. 100%,P=0.07)。三组均无再次行主动脉根部干预。 结论 本中心主动脉瓣交界悬吊、升主动脉置换、主动脉根部置换术近远期结果满意。但是主动脉瓣交界悬吊组主动脉瓣中量反流的发生率较高,若要评价其超长期疗效还需要进一步研究。

Objective To compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute type A aortic dissection, including aortic valve (AV) resuspension, isolated supracoronary ascending aorta replacement, and aortic root replacement procedure (Bentall). Methods All patients who underwent acute Type A aortic dissection repair between January 2010 and December 2015 in Fuwai Hospital were retrospectively analyzed in our study. There were 673 patients with 512 males and 161 females at mean age of 48.80±11.22 years. There were 403 patients as an AV resuspension group (287 males and 116 females at average age of 50.61±9.95 years), 95 patients as an isolated supracoronary ascending aorta replacement group (76 males and 19 females at average of 49.83±12.21 years), and 175 patients as an AV resuspension group (149 males and 26 females at average of 44.07±11.99 years). The differences of preoperative aortic insufficiency, intraoperative variables and postoperative aortic insufficiency were compared in the three groups. Results Five hundred ninety-one patients (87.8%) had aortic valve commissure involved. The proportion of mild degree, moderate degree, and severe degree among the three groups were statistically significant (31.7%, 52.4%, 15.9%; 87.4%, 12.6%, 0.0%; 23.4%, 56.0%, 20.6%; P < 0.01). The diameter of aortic sinus in the three groups was 39.06±5.11 mm, 38.27±4.41 mm, 50.39±6.22 mm, respectively, with a statistical difference ( P< 0.01). The duration of surgery, cardiopulmonary bypass time, aorta cross-clamp time were also statistically significant (P < 0.01). The in-hospital mortality was 11.73% in the whole group. There was no difference among the three groups (12.2% vs. 13.7% vs. 9.7%, P=0.58). Five-year survival rate was similar (83.06% vs. 81.27% vs. 83.05%, P=0.85). The 5-year free from over moderate aortic insufficiency rate were 95.2%, 98.6% and 100% respectively, with no statistical difference (P=0.07). There was no re-do operation for aortic root diseases in the whole group. Conclusion According to aortic root processing strategy in our center, AV resuspension, isolated supracoronary ascending aorta replacement, and aortic root replacement can achieve satisfactory results. However, there is higher incidence of aortic insufficiency through AV resuspension. Further study is needed to evaluate its efficacy.

关键词: 主动脉夹层; 主动脉根部; 主动脉瓣; 死亡率

Key words: Aortic dissection; aortic root; aortic valve; mortality

引用本文: 丘俊涛, 于存涛, 罗新锦, 刘燊, 姜文翔, 吴进林, 张良. 急性主动脉 A 型夹层主动脉根部处理技术的近远期效果分析. 中国胸心血管外科临床杂志, 2018, 25(11): 949-955. doi: 10.7507/1007-4848.201801041 复制

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1. Mészáros I, Mórocz J, Szlávi J, et al. Epidemiology and clinicopathology of aortic dissection. Chest, 2000, 117(5): 1271-1278.
2. Pacini D, Di Marco L, Fortuna D, et al. Acute aortic dissection: epidemiology and outcomes. Int J Cardiol, 2013, 167(6): 2806-2812.
3. Fann JI, Glower DD, Miller DC, et al. Preservation of aortic valve in type A aortic dissection complicated by aortic regurgitation. J Thorac Cardiovasc Surg, 1991, 102(1): 62-73.
4. Mazzucotelli JP, Deleuze PH, Baufreton C, et al. Preservation of the aortic valve in acute aortic dissection: long-term echocardiographic assessment and clinical outcome. Ann Thorac Surg, 1993, 55(6): 1513-1517.
5. Westaby S, Katsumata T, Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg, 1997, 64(4): 1108-1112.
6. 陈伟丹. 保留主动脉瓣主动脉根部置换术的研究进展. 中国胸心血管外科临床杂志, 2012, 19(2): 189-192.
7. Yacoub MH, Gehle P, Chandrasekaran V, et al. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg, 1998, 115(5): 1080-1090.
8. 李良鹏, 黄福华, 苏存华, 等. 部分主动脉根部重建术在急性 Stanford A 型主动脉夹层的应用. 中国胸心血管外科临床杂志, 2017, 24(7): 506-511.
9. Booher AM, Isselbacher EM, Nienaber CA, et al. The IRAD classification system for characterizing survival after aortic dissection. Am J Med, 2013, 126(8): 730.
10. Yu CT. The considerations of surgical treatment strategies of acute type a aortic dissection. J Thorac Cardiovasc Surg, 2016, 152(3): 935-937.
11. Westaby S, Saito S, Katsumata T. Acute type A dissection: conservative methods provide consistently low mortality. Ann Thorac Surg, 2002, 73(3): 707-713.
12. Pacini D, Settepani F, De Paulis R, et al. Early results of valve-sparing reimplantation procedure using the Valsalva conduit: a multicenter study. Ann Thorac Surg, 2006, 82(3): 865-871.
13. Ergin MA, McCullough J, Galla JD, et al. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg, 1996, 10(10): 840-844.
14. Halstead JC, Spielvogel D, Meier DM, et al. Composite aortic root replacement in acute type A dissection: time to rethink the indications? Eur J Cardiothorac Surg, 2005, 27(4): 626-632.
15. Sabik JF, Lytle BW, Blackstone EH, et al. Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg, 2000, 119(5): 946-962.
16. Goldfinger JZ, Halperin JL, Marin ML, et al. Thoracic aortic aneurysm and dissection. J Am Coll Cardiol, 2014, 64(16): 1725-1739.
17. Movsowitz HD, Levine RA, Hilgenberg AD, et al. Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair. J Am Coll Cardiol, 2000, 36(3): 884-890.
18. Goda M, Imoto K, Suzuki S, et al. Risk analysis for hospital mortality in patients with acute type a aortic dissection. Ann Thorac Surg, 2010, 90(4): 1246-1250.
19. Kazui T, Washiyama N, Bashar AH, et al. Surgical outcome of acute type A aortic dissection: analysis of risk factors. Ann Thorac Surg, 2002, 74(1): 75-81.
20. Olsson C, Hillebrant CG, Liska J, et al. Mortality in acute type A aortic dissection: validation of the Penn classification. Ann Thorac Surg, 2011, 92(4): 1376-1382.
21. Bavaria JE, Brinster DR, Gorman RC, et al. Advances in the treatment of acute type A dissection: an integrated approach. Ann Thorac Surg, 2002, 74(5): S1848-S1852.
22. 刘正琴, 吴树明, 山东大学, 等. A 型主动脉夹层术后常见神经系统并发症的系列研究. 中国胸心血管外科临床杂志, 2017, 24(3): 211-216.
23. Schoenrath F, Laber R, Maralushaj M, et al. Survival, neurologic injury, and kidney function after surgery for acute type A aortic dissection. Thorac Cardiovasc Surg, 2016, 64(2): 100-107.
24. Casselman FP, Tan ES, Vermeulen FE, et al. Durability of aortic valve preservation and root reconstruction in acute type A aortic dissection. Ann Thorac Surg, 2000, 70(4): 1227-1233.
25. Kunihara T, Neumann N, Kriechbaum SD, et al. Long-term outcome of aortic root remodeling for patients with and without acute aortic dissection. Circ J, 2017, 81(12): 1824-1831.
26. Kirsch M, Soustelle C, Houël R, et al. Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg, 2002, 123(2): 318-325.
27. von Segesser LK, Lorenzetti E, Lachat M, et al. Aortic valve preservation in acute type A dissection: is it sound? J Thorac Cardiovasc Surg, 1996, 111(2): 381-390.
28. Castrovinci S, Pacini D, Di Marco L, et al. Surgical management of aortic root in type A acute aortic dissection: a propensity-score analysis. Eur J Cardiothorac Surg, 2016, 50(2): 223-229.
29. Gunn TM, Stamou SC, Kouchoukos NT, et al. Techniques of proximal root reconstruction and outcomes following repair of acute type A aortic dissection. Aorta (Stamford), 2016, 4(2): 33-41.