A型壁内血肿的治疗结果与管理
Outcomes and management of type A intramural hematoma.
作者信息
Sandhu Harleen K, Tanaka Akiko, Charlton-Ouw Kristofer M, Afifi Rana O, Miller Charles C, Safi Hazim J, Estrera Anthony L
机构信息
Department of Cardiothoracic and Vascular Surgery, Clinical Science Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
出版信息
Ann Cardiothorac Surg. 2016 Jul;5(4):317-27. doi: 10.21037/acs.2016.07.06.
BACKGROUND
Initial optimal management of acute type A aortic dissection (ATAAD) with intramural hematoma (ATAIMH) remains controversial, especially between centers in the Eastern vs. Western worlds. We examined the literature and our experience to report outcomes after repair of ATAIMH.
METHODS
We reviewed the hospital, follow-up clinic records and online mortality databases for all patients who presented to our center for open repair of ATAAD between 1999 and 2014. Preoperative characteristics, early and long-term outcomes were compared between classic ATAAD vs. ATAIMH. Survival was analyzed using Kaplan-Meier and log-rank statistics.
RESULTS
Of the 523 repaired ATAAD, 101 patients (19%) presented with IMH and 422 (81%) had classic dissection. ATAIMH were significantly older (64.8±12.9 vs. 56.8±14.6 years; P<0.001), more commonly females (39% vs. 26%; P=0.010), had poor baseline renal function (i.e., glomerular filtration rate) (P<0.017), more retrograde dissections (27% vs. 8.3%; P<0.001), and less distal malperfusion (5% vs. 15%; P<0.001). Age greater than 60 years, female sex, retrograde dissection, and Marfan syndrome were strongly correlated with ATAIMH. Time to repair for ATAIMH was longer (median, 55.3 vs. 9.8 hours; P<0.001) with one death in ATAIMH within three days of presentation (0.9% vs. 6%; P=0.040). In all, 30-day mortality in ATAIMH was not different from classic ATAAD (12% vs.16%; P=0.289). A significantly lower incidence of postoperative dialysis in ATAIMH was noted (10% vs. 19%; P=0.034). When adjusted for age and renal function, late survival was improved with IMH (P<0.039).
CONCLUSIONS
ATAIMH continues to be associated with significant morbidity and mortality, comparable to classic aortic dissection. A multidisciplinary management approach involving aggressive medical management and risk stratification for timely surgical intervention, along with genetic profiling, is recommended for optimal care. Long-term monitoring is mandatory to assess compliance to medical therapy and recognition of evolving complications.
背景
急性A型主动脉夹层合并壁内血肿（ATAIMH）的初始最佳治疗方案仍存在争议，尤其是在东西方不同中心之间。我们查阅了相关文献并结合自身经验，报告ATAIMH修复术后的结果。
方法
我们回顾了1999年至2014年间在本中心接受ATAAD开放修复手术的所有患者的医院病历、随访门诊记录及在线死亡率数据库。比较经典ATAAD与ATAIMH患者的术前特征、早期和长期结果。采用Kaplan-Meier法和对数秩检验分析生存率。
结果
在523例接受修复的ATAAD患者中，101例（19%）表现为IMH，422例（81%）为经典夹层。ATAIMH患者年龄显著更大（64.8±12.9岁 vs. 56.8±14.6岁；P<0.001），女性更常见（39% vs. 26%；P=0.010），基线肾功能（即肾小球滤过率）较差（P<0.017），逆行夹层更多（27% vs. 8.3%；P<0.001），远端灌注不良更少（5% vs. 15%；P<0.001）。年龄大于60岁、女性、逆行夹层和马凡综合征与ATAIMH密切相关。ATAIMH的修复时间更长（中位数，55.3小时 vs. 9.8小时；P<0.001），有1例ATAIMH患者在就诊后三天内死亡（0.9% vs. 6%；P=0.040）。总体而言，ATAIMH的30天死亡率与经典ATAAD无差异（12% vs. 16%；P=0.289）。ATAIMH术后透析发生率显著更低（10% vs. 19%；P=0.034）。调整年龄和肾功能后，IMH患者的晚期生存率有所提高（P<0.039）。
结论
ATAIMH仍然与显著的发病率和死亡率相关，与经典主动脉夹层相当。建议采用多学科管理方法，包括积极的药物治疗、及时手术干预的风险分层以及基因分析，以实现最佳治疗。必须进行长期监测，以评估药物治疗的依从性并识别不断演变的并发症。
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