Rylski Bartosz, Branchetti Emanuela, Bavaria Joseph E, Vallabhajosyula Prashanth, Szeto Wilson Y, Milewski Rita K, Desai Nimesh D
Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa; Heart Center, University of Freiburg, Freiburg, Germany.
Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
J Thorac Cardiovasc Surg. 2014 Sep;148(3):944-8.e1. doi: 10.1016/j.jtcvs.2014.05.050. Epub 2014 May 22.
The current guidelines for ascending aortic replacement were determined from already dissected aorta diameters. Previous computed tomography-based work on humans who underwent imaging before and directly after aortic dissection onset has shown an average 30% increase in the ascending aortic diameter with acute dissection. The present investigation evaluated the incidence of predissection ascending aortic dilatation in acute type A dissection.
From 2002 to 2013, 495 patients presented with acute type A aortic dissection to 1 center. Of these cases, 343 were non-Marfan, nonbicuspid with spontaneous dissection etiology. In those with available preoperative computed tomography angiograms (n = 83) or transesophageal echocardiograms (n = 260), the predissection ascending aorta diameters were modeled from the dissected aorta diameters by subtraction of the average diameter increase rate.
Altogether 343 patients were included (age, 62 years; range, 53-73; 64% men). The median modeled predissection ascending diameter was 3.7 cm (first quartile, 3.3; third quartile, -4.1). Of the 343 patients, 334 (97%) and 315 (92%) had an ascending diameter before dissection onset of <5.5 cm and <5.0 cm, respectively. More than 60% of women and 70% of men had a nondilated ascending aorta before type A dissection onset. The median predissection ascending aortic diameter did not differ between women and men (3.7 cm; first quartile, 3.4; third quartile, 4.2; vs 3.7 cm; first quartile, 3.3; third quartile, 4.1; P = .810).
More than 60% of patients with spontaneous, non-Marfan, nonbicuspid, type A dissection will have a nondilated ascending aorta before dissection onset. Only 3% would meet the criteria for elective ascending replacement to prevent aortic dissection. Additional research on the genetic and biochemical predictors of aortic dissection is essential.
目前升主动脉置换术的指南是根据已解剖的主动脉直径制定的。先前基于计算机断层扫描对主动脉夹层发作前后进行成像的人体研究表明，急性夹层发作时升主动脉直径平均增加30%。本研究评估了急性A型夹层发作前升主动脉扩张的发生率。
2002年至2013年，495例急性A型主动脉夹层患者就诊于1个中心。其中，343例为非马凡综合征、非二叶式且病因是自发性夹层。在那些有术前计算机断层扫描血管造影（n = 83）或经食管超声心动图（n = 260）的患者中，通过减去平均直径增加率，从已解剖的主动脉直径推算出夹层发作前升主动脉直径。
共纳入343例患者（年龄62岁；范围53 - 73岁；64%为男性）。推算出的夹层发作前升主动脉直径中位数为3.7 cm（第一四分位数，3.3；第三四分位数，4.1）。在343例患者中，分别有334例（97%）和315例（92%）在夹层发作前升主动脉直径<5.5 cm和<5.0 cm。超过60%的女性和70%的男性在A型夹层发作前升主动脉未扩张。女性和男性夹层发作前升主动脉直径中位数无差异（3.7 cm；第一四分位数，3.4；第三四分位数，4.2；对比3.7 cm；第一四分位数，3.3；第三四分位数，4.1；P = 0.810）。
超过60%的自发性、非马凡综合征、非二叶式A型夹层患者在夹层发作前升主动脉未扩张。只有3%的患者符合择期升主动脉置换以预防主动脉夹层的标准。对主动脉夹层的遗传和生化预测因素进行更多研究至关重要。
