Asakura Toshihisa, Gojo S, Ishikawa M, Nishimura T, Imanaka K, Katogi T, Yokote Y, Kyo S
Department of Cardiovascular Surgery, Saitama Medical University, Saitama, Japan.
Kyobu Geka. 2007 Apr;60(4):297-302.
Coronary malperfusion due to acute type A aortic dissection (DAA) is a lethal complication. It is especially difficult to rescue the patients with left coronary malperfusion because of acute global myocardial infarction (AMI), even with successful surgical treatments, including the replacement of the ascending aorta and coronary artery bypass grafting (CABG). We review our experience and illustrate our approach to these critically ill patients. In addition, we classify the mechanism of malperfusion into 4 types based upon perioperative findings and discuss surgical management indivisually. From January 1990 to April 2005, a total of 260 patients were operated for DAA in our institution. Twenty (7.7%) patients, 11 men and 9 women were suffering from coronary malperfusion due to DAA. The mean age was 55 (range 28-72) years. The right coronary artery was involved in 9 patients, and the left in 11. All procedures such as graft replacement and CABG were done on an emergent or urgent basis. Hospital mortality rate of right coronary malperfusion was 22% (2/9 patients), and that related to left coronary malperfusion was 5/11 (45%). Assisting device was required in 9 cases, veno-arterial bypass (VAB) in 6 cases, left ventricular assist system (LVAS) in 1, left heart bypass (LHB) in 1, LHB+right heart bypass (RHB) in 1. We lost all patients using VAB. Only 3 patients supported with strong assist device survived. Aggressive myocardial resuscitation and early operation are the key factors in the management of these critically ill patients. But once severe myocardial infarction occurs, V-A bypass (percutaneous cardiopulmonary support) is useless in treating patients with DAA who develop severe heart failure. We recommend to implant stronger assist device including LVAS immediately before exacerbation of multiple organ failure. In conclusion, surgical management is not easy for emergency patients with DAA in association with myocardial ischemia. However, reasonable surgical results can be obtained with supplemental CABG and strong mechanical support of the left ventricle.
急性A型主动脉夹层（DAA）所致冠状动脉灌注不良是一种致命的并发症。由于急性全心肌梗死（AMI），抢救左冠状动脉灌注不良的患者尤为困难，即使成功进行了包括升主动脉置换和冠状动脉旁路移植术（CABG）在内的手术治疗也是如此。我们回顾了我们的经验，并阐述了我们对这些重症患者的治疗方法。此外，我们根据围手术期的发现将灌注不良的机制分为4种类型，并分别讨论手术管理。1990年1月至2005年4月，我院共有260例患者接受了DAA手术。20例（7.7%）患者，11例男性和9例女性，因DAA出现冠状动脉灌注不良。平均年龄为55岁（范围28 - 72岁）。9例患者右冠状动脉受累，11例左冠状动脉受累。所有诸如移植置换和CABG等手术均在急诊或紧急情况下进行。右冠状动脉灌注不良患者的医院死亡率为22%（2/9例患者），左冠状动脉灌注不良相关的死亡率为5/11（45%）。9例患者需要辅助装置，6例采用静脉 - 动脉旁路（VAB），1例采用左心室辅助系统（LVAS），1例采用左心旁路（LHB），1例采用LHB + 右心旁路（RHB）。使用VAB的患者全部死亡。仅3例接受强力辅助装置支持的患者存活。积极的心肌复苏和早期手术是这些重症患者管理的关键因素。但一旦发生严重心肌梗死，V - A旁路（经皮心肺支持）对发生严重心力衰竭的DAA患者治疗无效。我们建议在多器官功能衰竭加重前立即植入包括LVAS在内的更强力辅助装置。总之，对于合并心肌缺血的急诊DAA患者，手术管理并不容易。然而，通过补充CABG和对左心室的强力机械支持，可以获得合理的手术效果。
