Rylski Bartosz, Milewski Rita K, Bavaria Joseph E, Vallabhajosyula Prashanth, Moser William, Szeto Wilson Y, Desai Nimesh D
Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa; Heart Center Freiburg University, Freiburg, Germany.
Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
J Thorac Cardiovasc Surg. 2014 Dec;148(6):2981-5. doi: 10.1016/j.jtcvs.2014.05.093. Epub 2014 Jul 19.
To present the outcomes of routinely performed hemiarch replacement in patients with acute type A aortic dissection.
From 1993 to 2013, among 629 patients with acute type A dissection, 534 patients (85%) underwent hemiarch, 63 patients (10%) underwent hemiarch and antegrade thoracic stent grafting, 26 patients (4%) underwent total arch, and 6 patients (1%) underwent isolated ascending replacement. Patients with hemiarch replacement comprised the study population. Median follow-up was 4.1 years (first quartile, 1.9; third quartile, 7.8) (2462 patient years).
In-hospital mortality was 12% (66 out of 534 patients). Survival was 80% ± 2%, 68% ± 3%, and 51% ± 3%, and 84% ± 3%, 65% ± 4%, and 41% ± 6% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .375). Freedom from distal aortic reintervention was 97% ± 1%, 90% ± 2%, and 85% ± 3% and 99% ± 1%, 97% ± 2%, and 90% ± 5% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .046). Seven patients (1.3%) required reintervention for aortic arch aneurysm and 25 patients (5%) required reintervention for descending aortopathy. The success rate for distal reintervention performed electively or urgently was 92% (24 out of 26 patients). Marfan syndrome (odds ratio, 3.43; P = .046) and DeBakey type I dissection (odds ratio, 2.49; P = .048) were independent predictors of distal aortic reintervention.
Aggressive hemiarch replacement in acute type A dissection can be performed with low mortality and low aortic arch reoperation rate. Resection of all dissected aortic wall tissue decreases, but does not eliminate, the risk of later adverse aortic events.
介绍对急性A型主动脉夹层患者常规进行半弓置换的结果。
1993年至2013年期间，在629例急性A型夹层患者中，534例（85%）接受了半弓置换，63例（10%）接受了半弓置换及顺行性胸段支架植入，26例（4%）接受了全弓置换，6例（1%）接受了单纯升主动脉置换。接受半弓置换的患者构成研究人群。中位随访时间为4.1年（第一四分位数，1.9；第三四分位数，7.8）（2462患者年）。
住院死亡率为12%（534例患者中的66例）。在DeBakey I型和II型患者中，1年、5年和10年的生存率分别为80%±2%、68%±3%和51%±3%，以及84%±3%、65%±4%和41%±6%（对数秩检验P = 0.375）。DeBakey I型和II型患者在1年、5年和10年时免于远端主动脉再次干预的比例分别为97%±1%、90%±2%和85%±3%，以及99%±1%、97%±2%和90%±5%（对数秩检验P = 0.046）。7例（1.3%）患者因主动脉弓瘤需要再次干预，25例（5%）患者因降主动脉病变需要再次干预。择期或急诊进行的远端再次干预成功率为92%（26例患者中的24例）。马凡综合征（优势比，3.43；P = 0.046）和DeBakey I型夹层（优势比，2.49；P = 0.048）是远端主动脉再次干预的独立预测因素。
对急性A型夹层进行积极的半弓置换可以实现低死亡率和低主动脉弓再次手术率。切除所有夹层的主动脉壁组织可降低但不能消除后期主动脉不良事件的风险。
