Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.
Eur J Cardiothorac Surg. 2013 Feb;43(2):389-96. doi: 10.1093/ejcts/ezs342. Epub 2012 Jun 7.
The objective of this study was to report long-term results and incidence of reoperations after surgery for acute type A dissection.
All 232 consecutive patients who underwent surgery for acute type A aortic dissection from 1972 to April 2011 were included. Patient, procedural and follow-up information was obtained from hospital records.
Mean age was 57.9 years (standard deviation 13.4 years), 64% were male. In 157 patients, the native aortic valve was preserved, 75 underwent aortic valve replacement (valved conduit 49, aortic allograft 16, mechanical prosthesis 8 and bioprosthesis 2). Thirty-, 60- and 90-day mortalities were 18.1% (n = 42), 19.8% (n = 46) and 21.6% (n = 50), and decreased over time. Thirty-day mortality in the period 2007-11 was 12.5%. During follow-up of hospital survivors (mean duration 7.2 years, range 0.2-25.7 years), 64 patients died. Risk factors for 30-day mortality were preoperative resuscitation and longer cardiopulmonary bypass time. The use of circulatory arrest and biological glue was associated with a lower 30-day mortality. Actuarial survival was 53.4% (95% confidence interval [CI] 45.8-61.0%) after 10 and 29.3% (95% CI 29.9-48.7%) after 15 years. Late survival was comparable for patients with preserved native valves versus patients with various types of valve replacement. Forty-three patients underwent 47 reoperations; for aortic valve insufficiency in 17 patients (12 native valve, 5 allograft), recurrent aortic dissections or aneurysms in 27 and other cardiac operations in 3 . Actuarial freedom from aortic valve reoperation at 10 years was 85.6% for patients with a preserved native aortic valve, 84.8% after allograft implantation and 100% after prosthetic replacement (Tarone-Ware test P = 0.13). Aortic valve preservation in patients presenting with severe aortic insufficiency was associated with an increased risk of aortic valve reoperation.
Acute type A dissection in the current era is associated with a decreasing acceptable operative mortality risk and has a satisfactory long-term survival for hospital survivors. These factors were both involved were associated with a lower 30-day mortality. A substantial proportion of patients will require reoperations on the aortic valve or the aorta.
本研究旨在报告急性 A 型夹层手术后的长期结果和再手术发生率。
纳入 1972 年至 2011 年 4 月期间因急性 A 型主动脉夹层而行手术的 232 例连续患者。从病历中获取患者、手术和随访信息。
平均年龄为 57.9 岁（标准差 13.4 岁），64%为男性。157 例患者保留了原生主动脉瓣，75 例接受了主动脉瓣置换术（带瓣管道 49 例，主动脉同种异体移植 16 例，机械假体 8 例，生物假体 2 例）。30 天、60 天和 90 天的死亡率分别为 18.1%（n=42）、19.8%（n=46）和 21.6%（n=50），且呈下降趋势。2007-11 年期间的 30 天死亡率为 12.5%。在住院幸存者（平均随访时间 7.2 年，范围 0.2-25.7 年）的随访中，有 64 例患者死亡。30 天死亡率的危险因素是术前复苏和更长的体外循环时间。使用停循环和生物胶与 30 天死亡率降低相关。术后 10 年和 15 年的累积生存率分别为 53.4%（95%可信区间[CI]45.8-61.0%）和 29.3%（95% CI 29.9-48.7%）。晚期生存率在保留原生瓣膜的患者和接受各种类型瓣膜置换术的患者之间无差异。43 例患者接受了 47 次再手术；17 例（12 例为原生瓣膜，5 例为同种异体移植）因主动脉瓣关闭不全，27 例因复发性主动脉夹层或动脉瘤，3 例因其他心脏手术。术后 10 年保留原生主动脉瓣的患者主动脉瓣再手术的累积无事件率为 85.6%，同种异体移植术后为 84.8%，假体置换术后为 100%（Tarone-Ware 检验 P=0.13）。在出现严重主动脉瓣关闭不全的患者中保留主动脉瓣与主动脉瓣再手术风险增加相关。
在当前时代，急性 A 型夹层的手术死亡率风险较低，且住院幸存者的长期生存率令人满意。这些因素都与较低的 30 天死亡率相关。相当一部分患者需要对主动脉瓣或主动脉进行再次手术。
