College of Medicine, Drexel University, Philadelphia, Pennsylvania.
Department of Internal Medicine, Richmond University Medical Center, Staten Island, New York.
Ann Thorac Surg. 2020 Nov;110(5):1476-1483. doi: 10.1016/j.athoracsur.2020.01.083. Epub 2020 Mar 7.
Patients with acute type A aortic dissection (ATAAD) present with heterogeneous involvement of the aortic root complex. Despite this variation, the aortic root can usually be preserved the majority of the time by Teflon (WL Gore, Newark, DE) inlay patch reconstruction of the dissected sinuses of Valsalva (SOV). In this study, we report the long term anatomic, functional, and clinical outcomes associated with the preserved SOV after surgery for ATAAD.
From 2002-2017, of 776 emergency ATAAD operations at a single institution, 558 (71.9%) underwent valve resuspension with SOV preservation. Echocardiography reports were reviewed to obtain postoperative SOV dimensions. Cumulative incidence of SOV dilation ≥ 4 5mm was calculated using the Fine-Gray method with death as a competing risk. Repeated-measures linear mixed effects model was used to determine risk factors for SOV growth over time.
During the follow-up period, 62 of 558 (11.1%) patients developed SOV diameter ≥ 45 mm. Cumulative incidence of SOV dilation ≥ 45 mm at 1, 5, and 10 years was 5.5%, 12.4%, and 18.9% respectively. In a multivariable Cox regression model, preoperative SOV diameter ≥ 45 mm was associated with a hazard ratio of 14.11 (95% confidence interval 7.03-31.62) for postoperative SOV dilation ≥ 45 mm. In a repeated-measures linear mixed effects model, preoperative and discharge SOV diameter were significant predictors of SOV dilation. Postoperative time course was also identified as significant indicating growth over time.
The preserved sinuses of Valsalva after surgery for ATAAD may be prone to progressive dilatation over time. Closer echocardiographic surveillance may be warranted in these patients.
急性 A 型主动脉夹层（ATAAD）患者的主动脉根部复合体受累情况各异。尽管存在这种差异，但通过 Teflon（WL Gore，Newark，DE）镶嵌补丁重建夹层的瓦氏窦（SOV），大多数情况下仍可保留主动脉根部。在这项研究中，我们报告了手术后保留的 ATAAD 患者 SOV 的长期解剖学、功能和临床结果。
在一家医疗机构，2002 年至 2017 年间，776 例急性 ATAAD 手术中，558 例（71.9%）进行了瓣叶悬吊和 SOV 保留。回顾超声心动图报告以获取术后 SOV 尺寸。使用 Fine-Gray 方法计算 SOV 扩张≥45mm 的累积发生率，死亡为竞争风险。使用重复测量线性混合效应模型确定 SOV 随时间增长的危险因素。
在随访期间，558 例患者中有 62 例（11.1%）发生 SOV 直径≥45mm。SOV 扩张≥45mm 的 1、5 和 10 年累积发生率分别为 5.5%、12.4%和 18.9%。在多变量 Cox 回归模型中，术前 SOV 直径≥45mm 与术后 SOV 扩张≥45mm 的风险比为 14.11（95%置信区间 7.03-31.62）。在重复测量线性混合效应模型中，术前和出院时的 SOV 直径是 SOV 扩张的显著预测因子。术后时间过程也被确定为显著，表明随时间的增长。
ATAAD 手术后保留的 SOV 可能会随着时间的推移而逐渐扩张。这些患者可能需要更密切的超声心动图监测。
