Lin Chun-Yu, Lee Kuang-Tso, Ni Ming-Yang, Tseng Chi-Nan, Lee Hsiu-An, Su I-Li, Ho Heng-Psan, Tsai Feng-Chun
Department of Cardiothoracic and Vascular Surgery Department of Cardiology Department of Anesthesiology, Chang Gung University, College of Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.
Medicine (Baltimore). 2018 Aug;97(35):e12165. doi: 10.1097/MD.0000000000012165.
Preoperative left ventricular dysfunction is a risk factor for postoperative mortality and morbidity in cardiovascular surgeries with cardiopulmonary bypass, including thoracic aortic surgery. Using a retrospective study design, this study aimed to clarify the short- and mid-term outcomes of patients who underwent acute type A aortic dissection (ATAAD) repair with reduced left ventricular function.Between July 2007 and February 2018, a total of 510 adult patients underwent surgical repair of ATAAD in a single institution. The patients were classified as having left ventricular ejection fraction (LVEF) <50% (low EF group, n = 86, 16.9%) and LVEF ≥50% (normal group, n = 424, 83.1%) according to transesophageal echocardiographic assessment at the operating room. Preoperative demographics, surgical information, and postoperative complication were compared between the two groups. Three-year survival was analyzed using the Kaplan-Meier actuarial method. Serial echocardiographic evaluations were performed at 1, 2, and 3 years postoperation.Demographics, comorbidities, and surgical procedures were generally homogenous between the 2 groups, except for a lower rate of aortic arch replacement in the low EF group. The averaged LVEFs were 44.3 ± 2.5% and 65.8 ± 6.6% among the low EF and normal groups, respectively. The patients with low EF had higher in-hospital mortality (23.3% versus 13.9%, P = .025) compared with the normal group. Multivariate analysis revealed that intraoperative myocardial failure requiring extracorporeal membrane oxygenation support was an in-hospital mortality predictor (odds ratio, 16.99; 95% confidence interval, 1.23-234.32; P = .034), as was preoperative serum creatinine >1.5 mg/dL. For patients who survived to discharge, the 3-year cumulative survival rates were 77.8% and 82.1% in the low EF and normal groups, respectively (P = .522). The serial echocardiograms revealed no postoperative deterioration of LVEF during the 3-year follow-up.Even with a more conservative aortic repair procedure, the patients with preoperative left ventricular dysfunction are at higher surgical risk for in-hospital mortality. However, once such patients are able to survive to discharge, the midterm outcome can still be promising.
术前左心室功能障碍是包括胸主动脉手术在内的体外循环心血管手术术后死亡率和发病率的危险因素。本研究采用回顾性研究设计，旨在阐明左心室功能降低的急性A型主动脉夹层（ATAAD）修复患者的短期和中期结局。
2007年7月至2018年2月，共有510例成年患者在单一机构接受了ATAAD手术修复。根据手术室经食管超声心动图评估，将患者分为左心室射血分数（LVEF）<50%（低EF组，n = 86，16.9%）和LVEF≥50%（正常组，n = 424，83.1%）。比较两组患者的术前人口统计学资料、手术信息和术后并发症。采用Kaplan-Meier精算方法分析3年生存率。术后1年、2年和3年进行系列超声心动图评估。
两组患者的人口统计学资料、合并症和手术方式总体相似，但低EF组主动脉弓置换率较低。低EF组和正常组的平均LVEF分别为44.3±2.5%和65.8±6.6%。与正常组相比，低EF患者的院内死亡率更高（23.3%对13.9%，P = 0.025）。多因素分析显示，术中需要体外膜肺氧合支持的心肌衰竭是院内死亡的预测因素（比值比，16.99；95%置信区间，1.23 - 234.32；P = 0.034），术前血清肌酐>1.5mg/dL也是如此。对于存活出院的患者，低EF组和正常组的3年累积生存率分别为77.8%和82.1%（P = 0.522）。系列超声心动图显示，在3年随访期间LVEF无术后恶化。
即使采用更保守的主动脉修复手术，术前左心室功能障碍的患者院内死亡的手术风险仍较高。然而，一旦这些患者能够存活出院，中期结局仍然可能较好。
