Attia Rizwan, Young Christopher, Fallouh Hazem B, Scarci Marco
Department of Cardiac Surgery, St Thomas' Hospital, London, UK.
Interact Cardiovasc Thorac Surg. 2009 Nov;9(5):868-71. doi: 10.1510/icvts.2009.211854. Epub 2009 Aug 3.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with acute aortic intramural haematoma (IMH) is open surgical repair superior to conservative management. IMH is defined as a clinical condition related to but pathologically distinct from aortic dissection. In this potentially lethal entity, there is haemorrhage into the aortic media in the absence of an intimal tear. Altogether more than 204 papers were found using the reported search terms, from which six systematic reviews represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. IMH represents 17% of all dissections, whereas in postmortem studies this condition is found in 4-13%. The 30-day mortality of IMH is 24% (36% with type A and 12% with type B IMH; P<0.05). With surgical repair, 30-day mortality of type A IMH was 14% for patients treated surgically and 36% for patients treated medically with a P-value of 0.02. Survival at 1, 2, 3, 5 and 10 years was respectively: 81+/-21%, 87+/-8%, 83+/-6%, 65+/-22% and 44+/-14%. In contrast, with 8% mortality associated with medical treatment, prognosis of type B IMH is more favourable without surgical intervention, the latter associated with a 30-day mortality of 33% (P<0.05). Symptomatic patients and those with rapid progression or overt dissection during follow-up need emergent surgery. Ascending aortic diameter of >50 mm or subadventitial haematoma thickness of >12 mm should be considered as the candidates for early surgery. Although IMH seems to have an improved prognosis over aortic dissection, survivors of IMH are at significant risk for progressive aortic abnormalities, including aortic rupture, aneurysm, and ulceration. We conclude that surgical treatment of aortic IMH involving the ascending aorta with open distal replacement of ascending aorta results in lower mortality and longer survival compared to conservative management. IMH affecting the descending aorta can be managed with medical or endovascular interventional approach. In this latter group, serial imaging of the aorta is recommended, as aneurysm formation is not uncommon.
根据结构化方案撰写了一篇心脏外科的最佳证据主题。所探讨的问题是：在急性主动脉壁内血肿（IMH）患者中，开放手术修复是否优于保守治疗。IMH被定义为一种与主动脉夹层相关但在病理上不同的临床病症。在这个潜在致命的病症中，在没有内膜撕裂的情况下，主动脉中膜发生出血。使用报告的检索词共找到204多篇论文，其中六项系统评价代表了回答该临床问题的最佳证据。这些论文的作者、期刊、发表日期和国家、研究的患者群体、研究类型、相关结局和结果都列成了表格。IMH占所有夹层的17%，而在尸检研究中，这种病症的发现率为4% - 13%。IMH的30天死亡率为24%（A型为36%，B型为12%；P<0.05）。对于手术修复，A型IMH患者手术治疗的30天死亡率为14%，保守治疗的为36%，P值为0.02。1年、2年、3年、5年和10年的生存率分别为：81±21%、87±8%、83±6%、65±22%和44±14%。相比之下，B型IMH保守治疗死亡率为8%，不进行手术干预预后更有利，手术干预的30天死亡率为33%（P<0.05）。有症状的患者以及随访期间病情快速进展或出现明显夹层的患者需要紧急手术。升主动脉直径>50mm或外膜下血肿厚度>12mm应被视为早期手术的候选者。尽管IMH的预后似乎比主动脉夹层有所改善，但IMH幸存者仍有发生主动脉进行性异常的重大风险，包括主动脉破裂、动脉瘤和溃疡。我们得出结论，与保守治疗相比，对累及升主动脉的主动脉IMH进行开放手术，行升主动脉远端置换，可降低死亡率并延长生存期。影响降主动脉的IMH可采用药物或血管内介入方法治疗。对于后一组患者，建议对主动脉进行系列影像学检查，因为动脉瘤形成并不少见。
