Kyo S, Takamoto S, Omoto R, Matsumura M, Kimura S, Neya K, Adachi H, Yokote Y
Department of Surgery, Saitama Medical School, Japan.
Herz. 1992 Dec;17(6):377-89.
In the past eight years until July 1992, 92 patients were admitted in the acute state of aortic dissection within two weeks from the onset of symptoms. 41 were diagnosed as Stanford type A and 51 were type B by transthoracic and transesophageal echography, computer tomography, and surgery. Sensitivity of transesophageal echography to detect the intimal flap and the false lumen was 97.6% in patients with Stanford type A and 100% in patients with Stanford type B. The surgical decision making has been mostly depending on the transesophageal echographic diagnosis. When the intimal flap was detected in the ascending aorta (Stanford type A) surgery was performed in emergency regardless of any evidence of rupture, cardiac tamponade, and severe aortic regurgitation. When the aortic dissection was detected only in the descending aorta (Stanford type B) the main course of therapeutic strategy in our institute was medical treatment. Surgery was performed on 37 patients of type A and nine patients of type B with mortality of 18.9% and 55.5% respectively. Four patients of type A and 42 patients of type B were treated medically with a mortality of 75.0% and 2.2% respectively. The relatively large leakages from the anastomosis of the aortic clamp site were repaired secondarily in two patients, and fenestration of the superior mesenteric artery was performed on one patient due to ischemia of the small intestine depending on the intraoperative direct scanning of color flow mapping. Coronary artery involvement of dissection was strongly suspected in two patients by intraoperative transesophageal echography and aortocoronary bypass grafting was performed on these patients. Perfusion problems was encountered in five of 37 patients with type A aortic dissection (13.5%) during cardiopulmonary bypass. Intraoperative transesophageal echography could clearly detect the hemodynamic changes in the descending aorta resulting from inadequate perfusion which was useful for the management of perfusion control during cardiopulmonary bypass. Secondary repair of the aortic arch was required due to ischemia of the aortic arch vessels in two patients after the primary surgery. The extension of the dissection into the aortic arch vessels can be promptly diagnosed with the combination of transesophageal echography and transcutaneous echography. In conclusion, transesophageal Doppler echography is the most rapid diagnostic tool for decision making in acute aortic dissection, and intraoperative transesophageal echo can provide useful information to resolve the perfusion difficulties during cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 400 WORDS)
在截至1992年7月的过去八年中，92例患者在症状发作两周内以急性主动脉夹层状态入院。经胸和经食管超声心动图、计算机断层扫描及手术检查，41例被诊断为斯坦福A型，51例为B型。经食管超声心动图检测内膜瓣和假腔的敏感性在斯坦福A型患者中为97.6%，在B型患者中为100%。手术决策大多依赖于经食管超声心动图诊断。当在升主动脉检测到内膜瓣（斯坦福A型）时，无论有无破裂、心脏压塞及严重主动脉瓣关闭不全的证据，均进行急诊手术。当仅在降主动脉检测到主动脉夹层（斯坦福B型）时，我院治疗策略的主要方法是内科治疗。37例A型患者和9例B型患者接受了手术，死亡率分别为18.9%和55.5%。4例A型患者和42例B型患者接受内科治疗，死亡率分别为75.0%和2.2%。两名患者因主动脉夹闭部位吻合口相对较大的渗漏而进行了二次修复，一名患者因小肠缺血根据术中彩色血流图直接扫描进行了肠系膜上动脉开窗术。两名患者术中经食管超声心动图强烈怀疑夹层累及冠状动脉，并对其进行了主动脉冠状动脉旁路移植术。37例A型主动脉夹层患者中有5例（13.5%）在体外循环期间出现灌注问题。术中经食管超声心动图可清晰检测到因灌注不足导致的降主动脉血流动力学变化，这对体外循环期间的灌注控制管理很有用。两名患者在初次手术后因主动脉弓血管缺血需要进行主动脉弓二次修复。经食管超声心动图和经皮超声心动图联合应用可迅速诊断夹层向主动脉弓血管的扩展。总之，经食管多普勒超声心动图是急性主动脉夹层决策中最快速的诊断工具，术中经食管超声可提供有用信息以解决体外循环期间的灌注困难。（摘要截选至400字）
