Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
Virginia Cardiac Services Quality Initiative, Falls Church, Virginia.
Ann Thorac Surg. 2019 Sep;108(3):708-713. doi: 10.1016/j.athoracsur.2019.02.065. Epub 2019 Apr 2.
Limited prior studies suggest patients with acute type A aortic dissection (ATAAD) and prior cardiac surgery are at increased risk for major complications compared with those without a prior sternotomy. We sought to investigate the impact of prior cardiac surgery on ATAAD outcomes across a multicenter regional consortium.
Patients undergoing surgical intervention for ATAAD in a regional Society of Thoracic Surgeons database between 2002 and 2017 were stratified by prior cardiac surgery (reoperative) status. Demographics, operative characteristics, outcomes and cost data were compared by univariate analysis. Multivariable regression models assessed risk-adjusted impact of reoperative status on outcomes.
A total of 1,332 patients underwent surgery for ATAAD, of whom 138 (10.4%) were reoperations. Reoperative patients were older (63 vs. 58 years, p < 0.01) with more comorbidities. These patients had longer median cardiopulmonary bypass times (218 vs 177 minutes, p < 0.01) and increased blood product utilization; however rates of aortic arch, root, and valve procedures were similar. On unadjusted analysis operative mortality was higher in reoperative patients (28% vs 15%, p < 0.01) with a longer total length of stay (13 vs 10 days, p = 0.02). Reoperative patients exhibited a trend toward decreased mortality at high-volume centers (25.7% vs 37.9%, p = 0.19). After risk adjustment reoperative status remained associated with mortality (odds ratio, 2.1; p < 0.01) as well as composite morbidity-mortality (odds ratio, 2.2; p < 0.01).
In this multicenter cohort undergoing repair of ATAAD prior cardiac surgery was associated with an increased morbidity and mortality. Centralization to high-volume centers and emerging technologies may improve outcomes in this high-risk population.
有限的既往研究表明，与未行胸骨切开术的患者相比，急性 A 型主动脉夹层（ATAAD）和既往心脏手术的患者发生主要并发症的风险增加。我们试图调查多中心区域联盟中既往心脏手术对 ATAAD 结果的影响。
在 2002 年至 2017 年期间，在区域胸外科医师协会数据库中接受 ATAAD 手术治疗的患者根据既往心脏手术（再次手术）状态进行分层。通过单变量分析比较人口统计学、手术特征、结果和成本数据。多变量回归模型评估再次手术状态对结果的风险调整影响。
共有 1332 例患者接受了 ATAAD 手术，其中 138 例（10.4%）为再次手术。再次手术患者年龄较大（63 岁比 58 岁，p<0.01），合并症更多。这些患者的中位体外循环时间更长（218 分钟比 177 分钟，p<0.01），血液制品用量增加；然而，主动脉弓、根部和瓣膜手术的比例相似。在未调整分析中，再次手术患者的手术死亡率更高（28%比 15%，p<0.01），总住院时间更长（13 天比 10 天，p=0.02）。再次手术患者在高容量中心死亡率呈下降趋势（25.7%比 37.9%，p=0.19）。风险调整后，再次手术状态与死亡率（比值比，2.1；p<0.01）以及复合发病率-死亡率（比值比，2.2；p<0.01）仍然相关。
在本多中心队列中，ATAAD 修复术前行心脏手术与发病率和死亡率增加相关。向高容量中心集中和新兴技术的应用可能会改善这一高危人群的结局。
