急性A型主动脉夹层脑灌注不良患者的外科治疗：国际急性主动脉夹层注册研究结果。
Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection.
机构信息
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
出版信息
J Thorac Cardiovasc Surg. 2021 May;161(5):1713-1720.e1. doi: 10.1016/j.jtcvs.2019.11.003. Epub 2019 Nov 15.
BACKGROUND
The strategy for intervention remains controversial for patients presenting with type A aortic dissection (TAAAD) and cerebral malperfusion with neurologic deficit.
METHODS
Surgically managed patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection were evaluated to determine the incidence and prognosis of patients with cerebral malperfusion.
RESULTS
A total of 2402 patients underwent surgical repair of TAAAD. Of these, 362 (15.1%) presented with cerebral malperfusion (CM) and neurologic deficits, and 2040 (84.9%) patients had no neurologic deficits at presentation. Patients with CM were more less likely to present with chest pain (66% vs 86.5%; P < .001) and back pain (35.9% vs 44.4%; P = .008). Patients with CM were more likely to present with syncope (48.4% vs 10.1%; P < .001), peripheral malperfusion (52.7% vs 38.0%; P < .001), and shock (16.2% vs 4.1%; P < .001). There was no difference in the incidence of Marfan syndrome (2.8% vs 3.0%; P = .870) or history of known aortic aneurysm (11.7% vs 13.9%; P = .296). Patients with CM were more likely to have a DeBakey I (63.8% vs 47.1%; P < .001) and a pericardial effusion (53.8% vs 40.6; P < .001) on presentation. There was no difference in total arch replacement (21.3% for CM vs 19.5% for no CM; P = .473). Patients with CM had an increased incidence of postoperative cerebrovascular accident (17.5% vs 7.2%; P < .001) and acute kidney injury (28.3% vs 18.1%; P < .001). In-hospital mortality was greater in patients with CM (25.7% vs 12.0%; P < .001).
CONCLUSIONS
Fifteen percent of patients with TAAAD presented with CM and neurologic deficits. Despite the fact that this subset of the population was older and more likely to present with peripheral malperfusion, cardiac tamponade, and in shock, in-hospital survival was noted in nearly 75% of the patients. Surgeons may continue to offer lifesaving surgery for TAAAD to this critically ill cohort of patients with acceptable morbidity and mortality.
背景
对于出现 A 型主动脉夹层（TAAAD）和伴有神经功能缺损的脑灌注不良的患者，干预策略仍存在争议。
方法
对国际急性主动脉夹层注册中心接受手术治疗的 TAAAD 患者进行评估，以确定伴有脑灌注不良和神经功能缺损患者的发病率和预后。
结果
共有 2402 例 TAAAD 患者接受了手术修复。其中，362 例（15.1%）出现脑灌注不良（CM）和神经功能缺损，2040 例（84.9%）患者就诊时无神经功能缺损。CM 患者胸痛的可能性较小（66% vs 86.5%；P<0.001）和背痛（35.9% vs 44.4%；P=0.008）。CM 患者更可能出现晕厥（48.4% vs 10.1%；P<0.001）、外周灌注不良（52.7% vs 38.0%；P<0.001）和休克（16.2% vs 4.1%；P<0.001）。马凡综合征的发生率无差异（2.8% vs 3.0%；P=0.870）或已知主动脉瘤病史（11.7% vs 13.9%；P=0.296）。CM 患者更可能为 DeBakey I 型（63.8% vs 47.1%；P<0.001）和出现心包积液（53.8% vs 40.6%；P<0.001）。全主动脉弓置换术的发生率无差异（CM 组为 21.3%，无 CM 组为 19.5%；P=0.473）。CM 患者术后脑血管意外（17.5% vs 7.2%；P<0.001）和急性肾损伤（28.3% vs 18.1%；P<0.001）的发生率更高。CM 患者住院死亡率更高（25.7% vs 12.0%；P<0.001）。
结论
15%的 TAAAD 患者出现 CM 和神经功能缺损。尽管这部分人群年龄较大，更有可能出现外周灌注不良、心脏压塞和休克，但近 75%的患者存活。外科医生可能会继续为这一危重病群患者提供挽救生命的手术治疗，其发病率和死亡率是可以接受的。
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