Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif.
Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif.
J Thorac Cardiovasc Surg. 2018 Jul;156(1):18-24.e3. doi: 10.1016/j.jtcvs.2018.01.096. Epub 2018 Feb 21.
To evaluate the effect of visceral, renal, or peripheral malperfusion on the outcome of acute type A aortic dissection.
We performed a retrospective review of the acute type A aortic dissection experience at Stanford Hospital between January 2005 and December 2015. Inverse probability weighting was used to account for differences between patients who experienced malperfusion syndromes and those who did not. Weighted logistic regression was used to evaluate in-hospital mortality, and midterm survival was assessed with the restricted mean survival time and weighted Cox regression. Reintervention was assessed with death as a competing risk.
There were 305 patients with type A dissection extending beyond the ascending aorta, and 82 (26.9%) presented with a malperfusion syndrome. In-hospital mortality in the malperfusion subgroup was no different compared with patients without malperfusion in weighted logistic regression, odds ratio, 1.50 (95% confidence interval, 0.65-3.47; P = .3). There was no difference in midterm survival using restricted mean survival time, -50.2 days (95% CI, -366.8 to 266.4; P = .8) in patients with malperfusion compared with patients without malperfusion at 8 years. Patients with malperfusion had an increased risk of interventions (12.5%) on aortic branches compared with patients without (5.7%) in weighted analysis at 10-years, hazard ratio, 3.06 (95% CI, 1.24-7.56; P = .02). The median time to reintervention on aortic branches was 2 days for patients with malperfusion compared with 230 days without malperfusion, P = .01.
Immediate operation for acute type A aortic dissection complicated by malperfusion is associated with good results.
评估内脏、肾脏或外周灌注不良对急性 A 型主动脉夹层结局的影响。
我们对斯坦福医院 2005 年 1 月至 2015 年 12 月间急性 A 型主动脉夹层的经验进行了回顾性分析。采用逆概率加权法来弥补灌注不良综合征患者与未发生灌注不良综合征患者之间的差异。采用加权逻辑回归评估院内死亡率，采用限制性平均生存时间和加权 Cox 回归评估中期生存率。采用死亡作为竞争风险来评估再次干预。
有 305 例主动脉夹层延伸至升主动脉以上，82 例（26.9%）表现为灌注不良综合征。在加权逻辑回归中，灌注不良亚组的院内死亡率与无灌注不良组无差异，比值比为 1.50（95%置信区间为 0.65-3.47；P=0.3）。采用限制性平均生存时间评估，灌注不良组与无灌注不良组在 8 年时的中期生存率无差异，分别为-50.2 天（95%CI，-366.8 至 266.4；P=0.8）。在加权分析中，与无灌注不良组相比，灌注不良组主动脉分支的介入风险（12.5%）增加，10 年时为 3.06（95%CI，1.24-7.56；P=0.02）。灌注不良组主动脉分支再干预的中位时间为 2 天，无灌注不良组为 230 天，P=0.01。
急性 A 型主动脉夹层伴灌注不良患者立即手术治疗效果良好。
