Girdauskas Evaldas, Kuntze Thomas, Borger Michael A, Falk Volkmar, Mohr Friedrich-Wilhelm
Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany.
J Thorac Cardiovasc Surg. 2009 Dec;138(6):1363-9. doi: 10.1016/j.jtcvs.2009.04.059. Epub 2009 Sep 5.
Patients who have type A dissection with preoperative malperfusion syndromes are believed to be at extremely high surgical risk. Our aim was to evaluate perioperative and long-term results of patients with preoperative malperfusion.
A total of 276 patients (174 men; mean age 59.5 +/- 13.4 years) underwent surgery for acute type A dissection between October 1994 and January 2008. Preoperative malperfusion syndromes were diagnosed in 93 (33.7%) patients (group I) and involved coronary circulation in 41 (15%) patients, central nervous system in 39 (14%) patients, limb ischemia in 32 (11.6%) patients, and mesenteric circulation in 8 (3%) patients. Postoperative results were compared between patients with preoperative malperfusion and those without this complication (group II, n = 183).
In-hospital mortality was 29.0% in group I versus 13.6% in group II (P = .002). The postoperative intensive care unit stay was longer (11.4 +/- 9.7 vs 7.7 +/- 6.9 days; P = .04) in the malperfusion group. A total of 6 (75%) patients with mesenteric malperfusion died. Long-term follow-up (range, 1-122 months postoperatively) was available in 100% of survivors. One-year and 5-year overall survivals were 49.8% +/- 11.8% and 41.8% +/- 12.6% in group I versus 70.4% +/- 7.6% and 56% +/- 10.4% in group II (P = .005). Cox regression analysis identified preoperative malperfusion as a significant risk factor for long-term mortality after surgery for type A dissection (hazard ratio, 1.7; 95% confidence intervals, 1.2-3.1).
Preoperative malperfusion is a significant risk factor influencing perioperative and long-term survival after surgery for acute type A dissection. Percutaneous interventional procedures and delayed surgery should be considered in patients with clinically apparent mesenteric malperfusion because of the dismal prognosis of immediate surgical therapy.
患有A型夹层且术前存在灌注不良综合征的患者被认为手术风险极高。我们的目的是评估术前存在灌注不良患者的围手术期及长期结果。
1994年10月至2008年1月期间，共有276例患者（174例男性；平均年龄59.5±13.4岁）接受了急性A型夹层手术。93例（33.7%）患者（I组）被诊断为术前存在灌注不良综合征，其中41例（15%）累及冠状动脉循环，39例（14%）累及中枢神经系统，32例（11.6%）累及肢体缺血，8例（3%）累及肠系膜循环。比较术前存在灌注不良患者与无此并发症患者（II组，n = 183）的术后结果。
I组住院死亡率为29.0%，II组为13.6%（P = .002）。灌注不良组术后重症监护病房停留时间更长（11.4±9.7天对7.7±6.9天；P = .04）。共有6例（75%）肠系膜灌注不良患者死亡。100%的幸存者获得了长期随访（术后1至122个月）。I组1年和5年总生存率分别为49.8%±11.8%和41.8%±12.6%，II组分别为70.4%±7.6%和56%±10.4%（P = .005）。Cox回归分析确定术前灌注不良是A型夹层手术后长期死亡的重要危险因素（风险比，1.7；95%置信区间，1.2 - 3.1）。
术前灌注不良是影响急性A型夹层手术后围手术期及长期生存的重要危险因素。对于临床上明显存在肠系膜灌注不良的患者，由于立即手术治疗预后不佳，应考虑采用经皮介入治疗和延迟手术。
