Shi Yi, Dun Yaojun, Guo Hongwei, Liu Yanxiang, Zhang Bowen, Qian Xiangyang, Yu Cuntao, Sun Xiaogang
Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
J Thorac Dis. 2020 Aug;12(8):3964-3975. doi: 10.21037/jtd-20-748.
Data on the clinical features and surgical outcomes of type A intramural hematoma (IMH) in Chinese patients are very limited. We aimed to present the surgical experiences on type A IMH in our center, and report early and late outcomes.
From February 2012 to April 2018, 106 consecutive patients underwent open surgery for type A IMH at our hospital. We adopted emergent operation for patients with cardiac tamponade or other severe complications, and recommended initial medical treatment followed by elective surgery for stable patients. The composite endpoints included operative mortality, permanent nerve damage (stroke, paraplegia), and new-onset renal failure necessitating hemodialysis. Risk factors for operative mortality and the composite endpoints were identified using univariable and multivariable logistic regression model analysis. The survival and freedom from aortic events were analyzed using a Kaplan-Meier surviving curve and a log-rank test.
Except 1 patient receiving emergent surgery (within 24 hours from onset) because of cardiac tamponade and cerebral malperfusion, all patients received initial medical treatment and delayed surgery. Two patient developed pericardial tamponade while waiting for surgery, and then received emergent surgery. Preoperative conversion to aortic dissection (AD) was noted in no patient. The operative techniques included ascending aorta replacement in 9 patients, hemiarch replacement in 18 patients, total arch replacement (TAR) with frozen elephant trunk (FET) in 45 patient and hybrid aortic arch repair in 34 patients. The mean cardiopulmonary bypass (CPB) time and cross-clamp time were 138.7±41.6 and 79.3±27.8 min, respectively. The operative mortality was 1.9% (2/106). And the composite endpoints occurred in 7 patients. Multivariable logistic regression analysis showed CPB time ≥200 min and chronic kidney disease were risk factors for the composite endpoints. The follow-up data were available in 97 survivors, with the mean follow-up time of 30.8±16.2 months. Three patients died and 5 patients developed aortic events during the follow-up. The overall survival at 1-, 3- and 5-year were 97.0%, 95.3%, and 79.4%, respectively. And freedom from aortic events at 1-, 3- and 5-year were 97.7%, 95.3% and 89.4%, respectively.
Our strategy had got low mortality and excellent mid-term survival in patients with type A IMH. Therefore, our strategy was suitable for the surgical repair of type A IMH in Chinese population.
关于中国患者A型壁内血肿（IMH）临床特征及手术结果的数据非常有限。我们旨在介绍本中心治疗A型IMH的手术经验，并报告早期和晚期结果。
2012年2月至2018年4月，我院连续106例患者接受了A型IMH的开放手术。对于有心包填塞或其他严重并发症的患者，我们采用急诊手术；对于病情稳定的患者，建议先进行初始药物治疗，然后择期手术。复合终点包括手术死亡率、永久性神经损伤（中风、截瘫）以及需要血液透析的新发肾衰竭。使用单变量和多变量逻辑回归模型分析确定手术死亡率和复合终点的危险因素。采用Kaplan-Meier生存曲线和对数秩检验分析生存情况及无主动脉事件生存率。
除1例因心包填塞和脑灌注不良在发病24小时内接受急诊手术的患者外，所有患者均接受了初始药物治疗和延迟手术。2例患者在等待手术期间发生心包填塞，随后接受了急诊手术。无患者术前转为主动脉夹层（AD）。手术方式包括9例升主动脉置换、18例半弓置换、45例带冰冻象鼻（FET）的全弓置换（TAR）和34例杂交主动脉弓修复。平均体外循环（CPB）时间和主动脉阻断时间分别为138.7±41.6分钟和79.3±27.8分钟。手术死亡率为1.9%（2/106）。7例患者出现复合终点。多变量逻辑回归分析显示CPB时间≥200分钟和慢性肾脏病是复合终点的危险因素。97例幸存者有随访数据，平均随访时间为30.8±16.2个月。随访期间3例患者死亡，5例患者发生主动脉事件。1年、3年和5年的总生存率分别为97.0%、95.3%和79.4%。1年、3年和5年的无主动脉事件生存率分别为97.7%、95.3%和89.4%。
我们的策略在A型IMH患者中死亡率低，中期生存率良好。因此，我们的策略适用于中国人群中A型IMH的手术修复。
