Murashita T, Kunihara T, Shiiya N, Aoki H, Myojin K, Yasuda K
Department of Cardiovascular Surgery, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, 060-8648, Sapporo, Japan.
Eur J Cardiothorac Surg. 2001 Nov;20(5):967-72. doi: 10.1016/s1010-7940(01)00923-x.
In repair of acute type A aortic dissection, the type of proximal repair of the ascending aorta has been of great interest; however, very few reports are available regarding this issue in chronic aortic dissection. The surgical strategies for proximal repair in chronic dissection may not the same as those for acute dissection. We reviewed our 10-year experience of both acute and chronic type A aortic dissections in order to elucidate the validity of valve preservation and the long-term results of aortic regurgitation (AR).
From 1990 to 1999, 93 patients (55 acute and 38 chronic dissections) underwent operation for type A aortic dissection. Five Marfan patients were included in each group. The degree of AR was evaluated by echocardiography before and after (at hospital discharge and late follow-up) operation.
In acute type A aortic dissection (n=55), 16 patients had AR grade II or greater (29%), of whom seven had AR grade III (13%). In 29 patients, dissection was found below the sinotubular junction (STJ) and 14 patients had AR grade II or greater (48%). The aortic valve was replaced in four patients (7%), of whom three had Marfan's syndrome. Only one non-Marfan patient required aortic valve replacement because of valve stenosis. In those whose aortic valve was preserved (n=51), three patients still had AR grade II at hospital discharge, while at late follow-up, AR had deteriorated to grade III in two of them, although no reoperation has been required so far. In chronic type A aortic dissection (n=38), 14 patients had AR grade II or greater (37%), of whom 11 had AR grade III or greater (29% vs. 13% in acute dissection; P=0.051). In 15 patients, dissection was found below the STJ and 12 patients had AR grade II or greater (80% vs. 48% in acute dissection; P=0.043). The aortic valve was replaced in eight patients (21% vs. 7% in acute dissection; P=0.051), including three Marfan patients. Of those whose aortic valve was preserved (n=30), two patients required reoperation for severe AR. The freedom from postoperative AR grade III or greater was 89% at 5 years for operative survivors with acute dissection and 92% for those with chronic dissection, respectively.
This retrospective study suggests that preservation of the aortic valve in acute type A aortic dissection is feasible in non-Marfan patients regardless of the degree of AR. In chronic dissection, aortic root replacement needs to be considered when the degree of AR is greater than moderate because of a dilated STJ and/or annulus. In both acute and chronic dissections, satisfactory mid- to long-term results with a low incidence of reoperation were obtained in those whose aortic valve was preserved.
在急性A型主动脉夹层修复术中，升主动脉近端修复的方式备受关注；然而，关于慢性主动脉夹层这一问题的报道却非常少。慢性夹层近端修复的手术策略可能与急性夹层不同。我们回顾了10年来急性和慢性A型主动脉夹层的治疗经验，以阐明保留瓣膜的有效性及主动脉瓣反流（AR）的长期结果。
1990年至1999年，93例患者（55例急性夹层和38例慢性夹层）接受了A型主动脉夹层手术。每组纳入5例马凡综合征患者。术前及术后（出院时和晚期随访）通过超声心动图评估AR程度。
在急性A型主动脉夹层（n = 55）中，16例患者AR分级为II级或更高（29%），其中7例为AR III级（13%）。29例患者的夹层位于窦管交界（STJ）下方，14例患者AR分级为II级或更高（48%）。4例患者（7%）进行了主动脉瓣置换，其中3例患有马凡综合征。仅一名非马凡综合征患者因瓣膜狭窄需要进行主动脉瓣置换。在保留主动脉瓣的患者（n = 51）中，3例患者出院时仍为AR II级，而在晚期随访时，其中2例患者的AR恶化至III级，尽管目前尚未进行再次手术。在慢性A型主动脉夹层（n = 38）中，14例患者AR分级为II级或更高（37%），其中11例为AR III级或更高（29%，急性夹层为13%；P = 0.051）。15例患者的夹层位于STJ下方，12例患者AR分级为II级或更高（80%，急性夹层为48%；P = 0.043）。8例患者（21%，急性夹层为7%；P = 0.051）进行了主动脉瓣置换，包括3例马凡综合征患者。在保留主动脉瓣的患者（n = 30）中，2例患者因严重AR需要再次手术。急性夹层手术存活者术后5年无AR III级或更高的比例为89%，慢性夹层为92%。
这项回顾性研究表明，在非马凡综合征患者的急性A型主动脉夹层中，无论AR程度如何，保留主动脉瓣都是可行的。在慢性夹层中，当AR程度大于中度且STJ和/或瓣环扩张时，需要考虑进行主动脉根部置换。在急性和慢性夹层中，保留主动脉瓣的患者均获得了满意的中长期结果，再次手术发生率较低。
