Department of Cardiovascular Surgery, FuWai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
Eur J Cardiothorac Surg. 2019 Feb 1;55(2):345-350. doi: 10.1093/ejcts/ezy269.
Acute Type A aortic dissection exhibits poor in-hospital outcomes after emergency surgery. Evaluation of risk predictors for in-hospital major adverse outcomes (MAO) is key to reducing the mortality rate and improving the quality of care.
We enrolled 70 patients who presented with postoperative MAO and 195 patients who recovered well. Through univariate and multivariate analyses, clinical characteristics were compared between the patients in the 2 groups.
In-hospital mortality was 6.4% in this series. The patients in the MAO group were older and had a higher frequency of coronary artery involvement by dissection (60.0% vs 21.0%) (P < 0.05). Preoperatively, when compared to the group of patients without MAO, the patients in the MAO group were more likely to have a neurological deficit (18.6% vs 9.7%) and, to a certain extent, lower limb symptoms encompassing visceral and renal malperfusion (20.0% vs 8.2%) (P < 0.05). Compared to patients with MAO, patients without MAO experienced longer duration from initial onset of symptoms to surgery and had an ascending aorta with a larger diameter. In patients with MAO, the average durations of cardiopulmonary bypass (CPB), cardiac arrest and hypothermic circulatory arrest were much longer than those in patients with no MAO (all P < 0.001). Multivariate analysis showed that in-hospital adverse outcomes were associated with older age [odds ratio (OR) = 1.047 (1.008-1.087), P < 0.05], presentation of lower limb symptoms prior to surgery [OR = 2.905 (1.109-7.608), P < 0.05] and long CPB duration [OR = 1.011 (1.005-1.018), P < 0.01]. When patients with acute Type A aortic dissection experienced a duration from symptom onset to surgery [OR = 0.993 (0.987-0.999), P < 0.05] or had an ascending aorta with a large diameter [OR = 0.942 (0.892-0.995), P < 0.05], the number of postoperative adverse events decreased significantly.
At a centre that has a large caseload, where practitioners can become proficient through experience as well as training, good outcomes can be dependably produced in patients with acute Type A aortic dissection and without malperfusion syndromes. For patients presenting with these risk features, MAO need to be anticipated, and the incidence of a composite end point of major adverse events remains unsatisfactory.
急性A型主动脉夹层患者在急诊手术后的院内预后较差。评估院内主要不良结局（MAO）的风险预测因子是降低死亡率和改善护理质量的关键。
我们纳入了 70 例术后发生 MAO 的患者和 195 例恢复良好的患者。通过单因素和多因素分析，比较了两组患者的临床特征。
本研究系列中院内死亡率为 6.4%。MAO 组患者年龄较大，且夹层累及冠状动脉的发生率较高（60.0%比 21.0%）（P<0.05）。术前，与无 MAO 组相比，MAO 组患者更易发生神经功能缺损（18.6%比 9.7%），且下肢症状在一定程度上包括内脏和肾灌注不良（20.0%比 8.2%）（P<0.05）。与无 MAO 组患者相比，有 MAO 组患者从发病到手术的时间更长，升主动脉直径更大。在 MAO 组中，体外循环（CPB）、心脏骤停和低温循环停止的平均时间明显长于无 MAO 组（均 P<0.001）。多因素分析显示，院内不良预后与年龄较大（比值比[OR]=1.047（1.008-1.087），P<0.05）、术前下肢症状（OR=2.905（1.109-7.608），P<0.05）和 CPB 时间较长（OR=1.011（1.005-1.018），P<0.01）有关。当急性 A 型主动脉夹层患者从发病到手术的时间[OR=0.993（0.987-0.999），P<0.05]或升主动脉直径较大[OR=0.942（0.892-0.995），P<0.05]时，术后不良事件的数量显著减少。
在一个经验丰富且培训完善的中心，对于无灌注综合征的急性 A 型主动脉夹层患者，可以取得良好的治疗效果。对于具有这些风险特征的患者，应预期 MAO 的发生，且主要不良事件复合终点的发生率仍不理想。
