Brown James A, Arnaoutakis George J, Kilic Arman, Gleason Thomas G, Aranda-Michel Edgar, Sultan Ibrahim
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida.
J Card Surg. 2020 Sep;35(9):2331-2337. doi: 10.1111/jocs.14819. Epub 2020 Jul 11.
Within the spectrum of acute aortic syndromes, intramural hematoma (IMH) is a distinct lesion that is characterized by crescentic or circumferential thickening of the aortic wall in the absence of an intimal defect. The reported incidence of IMH among all type A acute aortic syndromes ranges from 3.5% to 28.3%. As compared with acute aortic dissection, IMH is a disease of the elderly, and it tends to have reduced rates of malperfusion syndromes, aortic insufficiency, and root dilation, yet also tends to have increased rates of pericardial effusion, cardiac tamponade, and periaortic hematoma. With respect to natural history, IMH may progress to classic dissection, frank rupture, or aneurysmal dilation; yet, IMH may also regress and be completely resorbed. However, studies disagree over the rates of progression or regression; as such, few studies agree on the short-term and long-term prognosis associated with IMH. American and European guidelines advocate emergent surgery for all acutely presenting type A IMH. At a minimum, supracoronary replacement of the aorta with hemiarch reconstruction is the preferred extent of operative repair to reduce rates of long-term reintervention for disease progression. However, valve and/or root procedures may be necessary proximally, while total arch reconstruction or hybrid procedures for the descending aorta may be necessary distally. Much remains unknown for IMH, including the ideal extent of aortic repair, risk-stratification for elderly patients, and the optimal treatment paradigm for stable, uncomplicated IMH. As such, IMH remains a diagnostic and therapeutic challenge for the cardiovascular surgeon.
在急性主动脉综合征范围内，壁内血肿（IMH）是一种独特的病变，其特征是主动脉壁呈新月形或环形增厚，而不存在内膜缺损。据报道，在所有A型急性主动脉综合征中，IMH的发病率在3.5%至28.3%之间。与急性主动脉夹层相比，IMH是一种老年人疾病，其灌注不良综合征、主动脉瓣关闭不全和根部扩张的发生率往往较低，但心包积液、心脏压塞和主动脉周围血肿的发生率往往较高。就自然病程而言，IMH可能进展为典型夹层、明显破裂或动脉瘤样扩张；然而，IMH也可能消退并完全吸收。然而，关于进展或消退率的研究存在分歧；因此，很少有研究就与IMH相关的短期和长期预后达成共识。美国和欧洲的指南主张对所有急性发作的A型IMH进行急诊手术。至少，采用半弓重建的升主动脉置换术是手术修复的首选范围，以降低疾病进展导致的长期再次干预率。然而，近端可能需要进行瓣膜和/或根部手术，而远端可能需要进行全弓重建或降主动脉杂交手术。关于IMH仍有许多未知之处，包括主动脉修复的理想范围、老年患者的风险分层以及稳定、无并发症的IMH的最佳治疗模式。因此，IMH仍然是心血管外科医生面临的诊断和治疗挑战。
