Bavaria Joseph E, Brinster Derek R, Gorman Robert C, Woo Y Joseph, Gleason Thomas, Pochettino Alberto
Division of Cardiothoracic Surgery, University of Pennsylvania Medical Center, Philadelphia 19104-4283, USA.
Ann Thorac Surg. 2002 Nov;74(5):S1848-52; discussion S1857-63. doi: 10.1016/s0003-4975(02)04128-0.
Acute type A dissections require surgery to prevent death from proximal aortic rupture or malperfusion. Most series over the past decade have reported a death rate in the range of 15% to 30%. The objective of this study is to examine the effect of an integrated surgical approach on the treatment of acute type A dissections.
From January 1994 to April 2002, 163 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion to replace the aortic arch; HCA established after 3 minutes of electroencephalographic silence in neuromonitored patients (60%) or after 45 minutes of cooling in patients who were not neuromonitored (40%); reinforcement of the residual arch tissue with a Teflon felt "neo-media;" cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension or replacement with a biological or mechanical valved conduit. When HCA times were greater than 50 minutes, antegrade cerebral perfusion is used. Since Februay 1999, BioGlue has been used as an anastomotic adjunct in the repair of type A dissections.
Mean age was 62 +/- 14 years, with 68% men and 15% with previous cardiac surgery. Seven percent of patients presented with a preoperative neurologic deficit, and 3% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9.8%. Excluding the patients with preoperative strokes (7%) and those with postoperative stroke (3%), the in-hospital death rate was 6.6%. In 6 patients, prompt changes in circulatory management consisting of switching cannulation sites or cross-clamp release with direct temporary aortic arch fenestration occurred when there were sudden changes in electroencephalogram during cooling.
A standardized approach to the treatment of acute type A dissections has improved outcomes. Our 55% mortality in patients with preoperative cerebral vascular accident (CVA) suggests that this group may be candidates for medical or delayed surgical treatment. Conversely, our 6.6% mortality rate for neurologically intact patients warrants aggressive and expeditious surgical intervention.
急性A型主动脉夹层需要手术治疗以预防因近端主动脉破裂或灌注不良导致的死亡。过去十年的大多数系列研究报告死亡率在15%至30%之间。本研究的目的是探讨综合手术方法对急性A型主动脉夹层治疗的效果。
从1994年1月至2002年4月，163例连续患者接受了急性A型主动脉夹层修复术。所有患者均采用如下综合手术管理：术中经食管超声心动图检查；采用逆行脑灌注的低温循环停搏（HCA）以置换主动脉弓；在神经监测患者中，脑电图沉默3分钟后（60%）或未进行神经监测的患者降温45分钟后（40%）建立HCA；用特氟龙毡“新中膜”加固残余主动脉弓组织；在HCA完成时将主动脉弓移植物插管以重新建立体外循环（顺行移植物灌注）；并用特氟龙毡“新中膜”重塑主动脉瓣窦段，以及将主动脉瓣重新悬吊或用生物或机械带瓣管道置换。当HCA时间超过50分钟时，采用顺行脑灌注。自1999年2月以来，BioGlue已被用作A型主动脉夹层修复术中的吻合辅助材料。
平均年龄为62±14岁，男性占68%，15%曾接受过心脏手术。7%的患者术前存在神经功能缺损，3%的患者在夹层修复术后发生了新的脑血管意外。住院死亡率为9.8%。排除术前中风患者（7%）和术后中风患者（3%），住院死亡率为6.6%。在6例患者中,降温期间脑电图突然变化时，迅速改变循环管理，包括更换插管部位或直接临时主动脉弓开窗释放交叉夹。
标准化的急性A型主动脉夹层治疗方法改善了治疗效果。我们对术前脑血管意外（CVA）患者55%的死亡率表明，该组患者可能适合药物治疗或延迟手术治疗。相反，我们对神经功能正常患者6.6%的死亡率表明需要积极、迅速的手术干预。
