Parish Landi M, Gorman Joseph H, Kahn Sophia, Plappert Theodore, St John-Sutton Martin G, Bavaria Joseph E, Gorman Robert C
Department of Surgery, Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA 19036, USA.
Eur J Cardiothorac Surg. 2009 Jun;35(6):941-5; discussion 945-6. doi: 10.1016/j.ejcts.2008.12.047. Epub 2009 Feb 23.
Elective ascending aortic replacement is recommended to prevent acute type A aortic dissection when any segment of the proximal aorta is greater than 5.5 cm. However, little data exist that meticulously describe the size of the ascending aorta at multiple levels in patients who suffer acute type A dissections. We sought to definitively characterize the size distribution of the proximal aorta in this patient population.
Preoperative transesophageal echocardiography was used to measure the diameter of the proximal aorta at the aortic annulus, in the sinus segment, at the sinotubular junction and in the ascending aorta in 177 non-Marfan patients with tricuspid aortic valves who presented to one institution over a 10-year period with an acute type A dissection. Predicted aortic diameters for each patient based on the individual's age, gender and body size were also calculated at all four aortic positions using previously published regression equations derived from a large cohort of normal patients.
Sixty patients were female (33.9%; aged 67+/-12 years) and 117 were male (66.1%; aged 60+/-17 years). Sixty-two percent of all patients had maximum aortic diameters less than 5.5 cm at time of dissection and 42% of patients had maximum aortic diameters less than 5.0 cm. Over 20% of all patients had maximal aortic dimensions of less than 4.5 cm. In women, 12% of the dissected aortas had a maximal dimension less than 4.0 cm.
The majority of patients with acute type A aortic dissection present with aortic diameters <5.5 cm and thus do not fall within current guidelines for elective ascending aortic replacement. Methods other than size measurement of the ascending aorta are needed to identify patients at risk for dissection. Aggressive medical management of patients with ascending aortic diameters over 4 cm is warranted. Preventative replacement of the ascending aorta at 4.5 cm should be considered especially at high volume aortic surgery centers and patients having cardiac surgery for other indications.
当升主动脉近端任何节段直径大于5.5 cm时，建议行择期升主动脉置换术以预防急性A型主动脉夹层。然而，关于急性A型主动脉夹层患者多个层面升主动脉大小的详细数据较少。我们试图明确该患者群体近端主动脉的大小分布特征。
对177例非马凡综合征、三尖瓣主动脉瓣且在10年期间因急性A型主动脉夹层就诊于某一机构的患者，术前采用经食管超声心动图测量主动脉瓣环、窦部、窦管交界及升主动脉处近端主动脉的直径。还使用先前从一大群正常患者得出的回归方程，在所有四个主动脉位置计算每位患者基于其年龄、性别和体型的预测主动脉直径。
60例为女性（33.9%；年龄67±12岁），117例为男性（66.1%；年龄60±17岁）。所有患者中，62%在夹层时最大主动脉直径小于5.5 cm，42%患者最大主动脉直径小于5.0 cm。超过20%的患者最大主动脉尺寸小于4.5 cm。在女性中，12%的夹层主动脉最大尺寸小于4.0 cm。
大多数急性A型主动脉夹层患者的主动脉直径<5.5 cm，因此不符合当前择期升主动脉置换的指南标准。需要升主动脉大小测量以外的方法来识别有夹层风险的患者。对于升主动脉直径超过4 cm的患者，积极的药物治疗是必要的。尤其在高容量主动脉手术中心以及因其他指征行心脏手术的患者中，应考虑在主动脉直径达4.5 cm时预防性置换升主动脉。
