Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan Health System, Ann Arbor, Mich.
Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy.
J Thorac Cardiovasc Surg. 2017 Apr;153(4):S74-S79. doi: 10.1016/j.jtcvs.2016.12.029. Epub 2017 Jan 9.
Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time.
One thousand seven hundred thirty-two patients undergoing surgery for type A aortic dissection were identified from the International Registry of Acute Aortic Dissection Interventional Cohort Database. Patients were divided into time tertiles (T) (T1: 1996-2003, T2: 2004-2010, and T3: 2011-2016).
Frequency of valve sparing procures increased (T1: 3.9%, T2: 18.6%, and T3: 26.7%; trend P < .001). Biologic valves were increasingly utilized (T1: 35.6%, T2; 40.6%, and T3: 52.0%; trend P = .009), whereas mechanical valve use decreased (T1: 57.6%, T2: 58.0%, and T3: 45.4%; trend P = .027) for aortic valve replacement. Adjunctive cerebral perfusion use increased (T1: 67.1%, T2: 89.5%, and T3: 84.8%; trend P < .001), with increase in antegrade cerebral techniques (T1: 55.9%, T2: 58.8%, and T3: 66.1%; trend P = .005) and hypothermic circulatory arrest (T1: 80.1%, T2: 85.9%, and T3: 86.8%; trend P = .030). Arterial perfusion through axillary cannulation increased (T1: 18.0%, T2: 33.2%, and T3: 55.7%), whereas perfusion via a femoral approach diminished (T1: 76.0%, T2: 53.3%, and T3: 30.1%) (both P values < .001). Hemiarch replacement was utilized more frequently (T1: 27.0%, T2: 63.3%, and T3: 51.7%; trend P = .001) and partial arch was utilized less frequently (T1: 20.7%, T2: 12.0%, and T3: 8.4%; trend P < .001), whereas complete arch replacement was used similarly (P = .131). In-hospital mortality significantly decreased (T1: 17.5%, T2: 15.8%, and T3: 12.2%; trend P = .017).
There have been significant changes in operative strategy over time in the management of type A aortic dissection, with more frequent use of valve-sparing procedures, bioprosthetic aortic valve substitutes, antegrade cerebral perfusion strategies, and hypothermic circulatory arrest. Most importantly, a significant decrease of in-hospital mortality was observed during the 20-year timespan.
随着心胸外科技术的进步，我们对急性 A 型主动脉夹层手术治疗策略的变化进行了研究。
从国际急性 A 型主动脉夹层干预队列登记数据库中确定了 1732 名接受 A 型主动脉夹层手术的患者。患者分为时间三分位组（T）（T1：1996-2003 年，T2：2004-2010 年，T3：2011-2016 年）。
保留瓣膜手术的比例逐渐增加（T1：3.9%，T2：18.6%，T3：26.7%；趋势 P<0.001）。生物瓣的使用逐渐增加（T1：35.6%，T2：40.6%，T3：52.0%；趋势 P=0.009），而机械瓣的使用减少（T1：57.6%，T2：58.0%，T3：45.4%；趋势 P=0.027）用于主动脉瓣置换。辅助性脑灌注的使用增加（T1：67.1%，T2：89.5%，T3：84.8%；趋势 P<0.001），顺行性脑技术的使用增加（T1：55.9%，T2：58.8%，T3：66.1%；趋势 P=0.005）和低温循环停止（T1：80.1%，T2：85.9%，T3：86.8%；趋势 P=0.030）。腋动脉插管的动脉灌注增加（T1：18.0%，T2：33.2%，T3：55.7%），而经股动脉途径的灌注减少（T1：76.0%，T2：53.3%，T3：30.1%）（均 P 值<0.001）。半弓置换术的应用更为频繁（T1：27.0%，T2：63.3%，T3：51.7%；趋势 P=0.001），部分弓置换术的应用减少（T1：20.7%，T2：12.0%，T3：8.4%；趋势 P<0.001），而全弓置换术的应用则相似（P=0.131）。住院死亡率显著降低（T1：17.5%，T2：15.8%，T3：12.2%；趋势 P=0.017）。
在 A 型主动脉夹层的管理中，手术策略在 20 年的时间内发生了重大变化，更多地采用了保留瓣膜的手术、生物瓣主动脉瓣替代品、顺行性脑灌注策略和低温循环停止。最重要的是，在这 20 年期间，住院死亡率显著下降。
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