Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
Ann Thorac Surg. 2019 Apr;107(4):1174-1180. doi: 10.1016/j.athoracsur.2018.09.065. Epub 2018 Nov 13.
This study reviewed our experience with coronary artery (CA) malperfusion secondary to type A aortic dissection.
Between 2002 and 2017, 76 patients presented with CA malperfusion, with a dissection flap limited to the aorta in the region of the coronary ostium (type A lesion) in 26 (34%), with a dissection flap involving the CA itself (type B lesion) in 32 (42%), or with complete avulsion of the CA (type C lesion) in 18 (24%).
Ostial repair was successfully performed in 23 type A patients (88%), in 20 type B patients (63%), and in no type C patient (0%). CA bypass grafting was performed when antegrade cardioplegia could not be applied in all 18 type C patients (100%) and in 5 type B patients (16%) because of a primary entry at the coronary ostium and in 7 patients (type A: 3 patients [12%], type B: 4 patients [13%]) with evidence of CA disease (p < 0.001). Perioperative mortality in patients with CA malperfusion was high (18 patients [24%]), but there was no difference in short-term (p = 0.153) or long-term survival (log-rank p = 0.542). Also, a landmark analysis showed equal survival of discharged patients with and without CA malperfusion (log-rank p = 0.645).
We recommend CA bypass grafting in patients with type C lesions or in patients with underlying CA disease for optimal delivery of cardioplegia and ostial pledgetted suture repair in patients with type A lesions or type B lesions when the administration of antegrade cardioplegia is successful.
本研究回顾了我们在主动脉夹层继发冠状动脉（CA）灌注不良方面的经验。
2002 年至 2017 年，76 例患者出现 CA 灌注不良，其中 26 例（34%）夹层瓣局限于主动脉冠状动脉口区域（A型病变），32 例（42%）夹层瓣累及 CA 本身（B 型病变），18 例（24%）CA 完全撕脱（C 型病变）。
23 例 A 型患者（88%）、20 例 B 型患者（63%）成功进行了口部修复，而无 C 型患者（0%）成功进行了口部修复。由于在所有 18 例 C 型患者（100%）和 5 例 B 型患者（16%）中无法应用顺行心脏停搏液，且由于冠状动脉口原发性入口和 7 例患者（A 型：3 例[12%]，B 型：4 例[13%]）存在 CA 疾病证据，因此进行了 CA 旁路移植术（p<0.001）。CA 灌注不良患者的围手术期死亡率较高（18 例[24%]），但短期（p=0.153）和长期生存率（对数秩检验 p=0.542）无差异。此外，标志分析显示，有无 CA 灌注不良的出院患者的生存率相等（对数秩检验 p=0.645）。
我们建议在 C 型病变患者中进行 CA 旁路移植术，在 A 型病变或 B 型病变患者中存在 CA 疾病时，应在成功应用顺行心脏停搏液的情况下进行 CA 旁路移植术，对于优化心脏停搏液的输送和冠状动脉口填塞缝合修复。
