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 收集 2011 年 1 月至 2017 年 6 月在武汉同济医院收治的 10 例妊娠合并主动脉夹层的临床资料,回顾性分析其临床特点、治疗方案及母(胎)儿结局。 结果 10 例患者中,大部分(8 例)为初产妇,且大部分在孕晚期(6 例)和产褥期(4 例)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-2 聚体(D-dimmer)、CPR 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+冠脉搭桥术,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 例存活。 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 cases of pregnancy complicated with aortic dissection in Wuhan Tongji Hospital from January 2011 to June 2017 were collected. The clinical characteristics, treatment protocols and outcomes of mother and fetus were analyzed retrospectively. Results In 10 patients, the majority (8 cases) for primipara, and most of them are in the late stages of pregnancy (6 cases) and puerperal (4 cases), Among them, 1 patients 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: 90/60mmHg, right upper limb blood pressure: 150/90mmHg).the major clinical manifestations were severe chest and back pain which happened suddenly, with D-2 dimer (D-dimmer)、CPR increased which may be associated with inflammatory reaction. All patients were diagnosed by Thoracoabdominal aortic CTA, including 5 cases of Stanford type A dissection, 5 cases of Stanford type B dissection. In 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 cases of Endovascular graft exclusion for thoracic aortic stent graft, 2 cases underwent BENTALL operation, 1 patients with BENTALL + total aortic arch replacement + vascular thoracic aortic stent graft, 1 cases underwent BENTALL operation combined with Endovascular graft exclusion for thoracic aortic stent graft, 1 cases underwent BENTALL+ coronary artery bypass grafting, 1 cases 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. 9 cases were single birth, among them 5 newborn cases occurred severe asphyxia, 4 cases occurred mild asphyxia. Finally, 3 neonates died due to severe complications, and the remaining 6 survived. Conclusion the ratio of pregnancy with Stanford type A aortic dissection occurred 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 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

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