Lenos Aristidis, Bougioukakis Petros, Irimie Vadim, Zacher Michael, Diegeler Anno, Urbanski Paul P
Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany.
Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
Eur J Cardiothorac Surg. 2015 Sep;48(3):491-6. doi: 10.1093/ejcts/ezu454. Epub 2014 Dec 11.
The study was conducted to evaluate our results of acute aortic dissection repair taking into account the impact of surgical experience in aortic surgery.
Between August 2002 and March 2013, 162 consecutive patients (mean age: 63 ± 14 years) underwent surgery for acute type A aortic dissection. All patients were operated on by one of the clinic's attending surgeons with wide experience in cardiac surgery (at least 2000 procedures performed personally), however about one-half of the patients (75 patients, 46%) were operated by the aortic team (AT) surgeons with profound experience in complex aortic pathologies. All perioperative data were collected prospectively and retrospective statistical analysis was performed using uni- and multivariate analyses to identify predictors for surgical adverse outcome (AO) containing in-hospital and/or 90-day mortality and new permanent neurological and organ dysfunctions.
AO was observed in 36 patients (22.2%) including in-hospital mortality in 22 (13.6%). Multivariate logistic regression analysis identified surgery not performed by the AT as the strongest predictor for AO (odds ratio: 14.1; 95% confidence interval: 3.5-55.6; P < 0.0001) followed by any malperfusion, myocardial infarction and creatinine level. Two groups were built according to the surgery performed by the AT (Group AT) or by the surgeons not on the AT (Group No-AT). The comparison of the groups showed no relevant differences regarding the preoperative characteristics, especially compromised consciousness, malperfusion and extent of dissection. Yet, the outcomes in Group AT vs No-AT were significantly different presenting AO: 8.0 vs 34.5% (P < 0.0001), in-hospital mortality: 4.0 vs and 21.8% (P < 0.001), new permanent neurological deficit: 2.7 vs 11.5% (P = 0.03), even if valve-sparing repairs and complete arch replacements were much more frequent in Group AT. The groups also differed considerably in regard to cannulation and perfusion management, which might play a decisive role in surgical outcome.
Aortic repair in acute type A dissection, when performed by highly specialized aortic surgeons, offers not only much better outcomes but also provides significantly higher rate of curative albeit valve-sparing aortic repairs. Patient-centred care in referral aortic centres with surgery performed by specialized teams should be striven for to improve surgical results in acute aortic dissection surgery.
本研究旨在评估急性主动脉夹层修复的结果，并考虑主动脉手术经验的影响。
2002年8月至2013年3月期间，162例连续患者（平均年龄：63±14岁）接受了急性A型主动脉夹层手术。所有患者均由该诊所具有丰富心脏手术经验（个人至少完成2000例手术）的主治医生之一进行手术，然而，约一半的患者（75例，46%）由在复杂主动脉病变方面具有深厚经验的主动脉团队（AT）外科医生进行手术。前瞻性收集所有围手术期数据，并进行回顾性统计分析，采用单因素和多因素分析来确定手术不良结局（AO）的预测因素，包括住院和/或90天死亡率以及新的永久性神经和器官功能障碍。
36例患者（22.2%）出现AO，其中22例（13.6%）住院死亡。多因素逻辑回归分析确定非AT团队进行的手术是AO的最强预测因素（比值比：14.1；95%置信区间：3.5 - 55.6；P < 0.0001），其次是任何灌注不良、心肌梗死和肌酐水平。根据AT团队（AT组）或非AT团队的外科医生进行的手术分为两组。两组术前特征比较无显著差异，尤其是意识障碍、灌注不良和夹层范围。然而，AT组与非AT组的结局在AO方面有显著差异：8.0%对34.5%（P < 0.0001），住院死亡率：4.0%对21.8%（P < 0.001），新的永久性神经功能缺损：2.7%对11.5%（P = 0.03），即使保留瓣膜修复和全弓置换在AT组更为常见。两组在插管和灌注管理方面也有很大差异，这可能对手术结局起决定性作用。
急性A型夹层的主动脉修复由高度专业化的主动脉外科医生进行时，不仅能提供更好的结局，而且能显著提高治愈性保留瓣膜主动脉修复的比例。应努力在转诊主动脉中心以患者为中心进行护理，并由专业团队进行手术，以改善急性主动脉夹层手术的结果。
