中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

妊娠合并主动脉夹层的外科治疗

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目的 总结妊娠合并主动脉夹层的发病特点、妊娠期管理,探讨合理的诊疗方案。 方法 回顾性分析 2011 年 1 月至 2017 年 6 月武汉同济医院收治的 10 例妊娠合并主动脉夹层患者的临床资料,年龄 25.2(21~29)岁。 结果 10 例患者中,8 例为初产妇;5 例在孕晚期,4 例在产褥期发病,其中 1 例患者有妊娠期高血压,且左右上肢血压明显异常(初始接诊时:左上肢血压 90/60 mm Hg,右上肢血压 150/90 mm Hg)。临床表现主要为突发剧烈胸背疼痛,伴 D-二聚体、C-反应蛋白(CRP)升高,可能与炎性反应相关;所有患者均经胸腹主动脉 CTA 确诊,其中 5 例为 Stanford A 型夹层,5 例为 Stanford B 型夹层,10 例患者中 1 例患者因拒绝手术,最终夹层破裂死亡、胎死腹中,其余 9 例均接受手术治疗,3 例行胸主动脉覆膜支架腔内隔绝术,2 例行 Bentall 术,1 例行 Bentall 术+全主动脉弓血管置换术+胸主动脉覆膜支架腔内隔绝术,1 例行 Bentall 术+胸主动脉覆膜支架腔内隔绝术,1 例行 Bentall+冠状动脉旁路移植术,1 例行胸腹主动脉血管置换术;其中 1 例行胸主动脉覆膜支架腔内隔绝术因术后重症感染死亡,其余 8 例康复出院。9 例夹层患者均为单胎分娩,9 例新生儿中有 5 例出现新生儿重度窒息,4 例轻度窒息。最终 3 例新生儿因严重并发症死亡,余 6 例生存。 结论 妊娠期合并主动脉夹层发生 Stanford A 型的比率远高于普通人群,胎儿发生宫内窒息的可能性较大,但经过积极有效的手术及围手术期处理,可以有效挽救母(胎)儿生命。

Objective To summarize the characteristics and management of pregnancy complicated with aortic dissection, and to explore the reasonable diagnosis and treatment plan. Methods The clinical data of 10 patients of pregnancy complicated with aortic dissection in Wuhan Tongji Hospital from January 2011 to June 2017 were collected. Their age was 25.2 (21-29) years. Results In the 10 patients, the majority (8 patients) were primipara, and most of them were in the late stages of pregnancy (5 patients) and puerperal (4 patients). Among them, 1 patient had gestational hypertension, and the blood pressure of the left and right upper extremities was significantly abnormal (initial blood pressure: left upper limb blood pressure: 90/60 mm Hg, right upper limb blood pressure: 150/90 mm Hg). The major clinical manifestations were severe chest and back pain which happened suddenly, with D-dimmer and C-creative protein increased which may be associated with inflammatory reaction. All patients were diagnosed by thoracoabdominal aortic CTA, including 5 patients of Stanford type A dissection and 5 patients of Stanford type B dissection. In the 10 patients, 1 patient refused surgery and eventually died of aortic rupture with the death of fetus before birth. And the remaining 9 patients underwent surgical treatment, 3 patients of endovascular graft exclusion for thoracic aortic stent graft, 2 patients underwent Bentall operation, 1 patient with Bentall + total aortic arch replacement + vascular thoracic aortic stent graft, 1 patient with Bentall operation combined with endovascular graft exclusion for thoracic aortic stent graft, 1 patient with Bentall + coronary artery bypass grafting, 1 patient of thoracoabdominal aortic vascular replacement. Among them, 1 patient underwent endovascular graft exclusion for thoracic aortic stent graft died of severe postoperative infection, and the remaining 8 patients were discharged from hospital. Nine patients were single birth, among them 5 newborn patients had severe asphyxia, 4 patients had mild asphyxia. Finally, 3 neonates died of severe complications, and the remaining 6 survived. Conclusion The ratio of pregnancy with Stanford type A aortic dissection is far higher than in the general population, the possibility of fetal intrauterine asphyxia is larger, but through active and effective surgical and perioperative treatment, we can effectively save the life of mother and fetus.

关键词: 主动脉夹层; 妊娠; Stanford 分型; 外科治疗; 母胎结局

Key words: Aortic dissection; pregnancy; Stanford type; surgical therapy; maternal outcome and fetal outcome

引用本文: 郭倩男, 李魁, 朱硕, 谭德才, 熊田辛, 朱桂枝, 郑智, 潘友民, 王海灏, 李军. 妊娠合并主动脉夹层的外科治疗. 中国胸心血管外科临床杂志, 2018, 25(11): 956-961. doi: 10.7507/1007-4848.201801043 复制

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1. Huisman CM, Zwart JJ, Roos-Hesselink JW, et al. Incidence and predictors of maternal cardiovascular mortality and severe morbidity in The Netherlands: a prospective cohort study. PLoS One, 2013, 8(2): e56494.
2. Immer FF, Bansi AG, Immer-Bansi AS, et al. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg, 2003, 76(1): 309-314.
3. Smok DA. Aortopathy in pregnancy. Semin Perinatol, 2014, 38(5): 295-303.
4. Collins D. Aetiology and management of acute cardiac tamponade. Crit Care Resusc, 2004, 6(1): 54-58.
5. Yang G, Peng W, Zhao Q, et al. Aortic dissection in women during the course of pregnancy or puerperium: a report of 11 cases in central south China. Int J Clin Exp Med, 2015, 8(7): 11607-11612.
6. Wong CK, Chan PH, Siu CW. Letter by Wong et al regarding article, "pregnancy and the risk of aortic dissection or rupture: A cohort-crossover analysis". Circulation, 2017, 135(12): e780-e781.
7. Sawlani N, Shroff A, Vidovich MI. Aortic dissection and mortality associated with pregnancy in the United States. J Am Coll Cardiol, 2015, 65(15): 1595-1604.
8. Coulon C. Thoracic aortic aneurysms and pregnancy. Presse Med, 2015, 44(11): 1126-1135.
9. Li Y, Yang N, Duan W, et al. Acute aortic dissection in China. Am J Cardiol, 2012, 110(7): 1056-1061.
10. 刘亚欣. 主动脉夹层患者临床特征与预后分析. 中国协和医科大学. 2008.
11. European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J, 2011, 32(24): 3147-3197.
12. 徐革. 血浆D-二聚体和纤维蛋白原降解产物在急性脑梗死患者中的检测意义. 河北医学, 2014, 24(1): 28-31.
13. 李大主, Sharma Ranjit, 曾秋棠, 等. 树突状细胞激活介导的炎性反应与主动脉夹层. 中国急救医学, 2004, 24(4): 21-22.
14. Giannakoulas G, Giannoglou G, Soulis J, et al. A computational model to predict aortic wall stresses in patients with systolic arterial hypertension. Med Hypotheses, 2005, 65(6): 1191-1195.
15. Jayaram A, Carp HM, Davis L, et al. Pregnancy complicated by aortic dissection: caesarean delivery during extradural anaesthesia. Br J Anaesth, 1995, 75(3): 358-360.
16. Trimarchi S, Nienaber CA, Rampoldi V, et al. Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg, 2005, 129(1): 112-122.