Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
J Thorac Cardiovasc Surg. 2022 Dec;164(6):1698-1707.e3. doi: 10.1016/j.jtcvs.2020.12.113. Epub 2021 Jan 12.
Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients.
We queried our aortic database for consecutive patients who underwent ATAAD repair. Patients who underwent conservative repair (group 1) were compared with those who underwent extensive repair (group 2) using univariable and multivariable analysis.
From 1997 to 2019, 343 patients underwent ATAAD repair. Two hundred forty had conservative repair (root-sparing, hemiarch) whereas 103 had extensive repair (root replacement and/or total arch). Group 1 was older with more comorbidities such as hypertension, previous myocardial infarction, and renal dysfunction. Group 2 had more connective tissue disease (2.1% vs 12.6%; P < .01), aortic insufficiency, and longer intraoperative times. The incidence of individual postoperative complications was similar regardless of approach. A composite of major adverse events (operative mortality, myocardial infarction, stroke, dialysis, or tracheostomy) was higher in the conservative group (15.1% vs 5.9%; P = .03). Operative mortality was 5.6% and not different between groups. Ten-year survival was similar with either surgical approach. Ten-year cumulative risk of reintervention was greater in group 2 (5.6% vs 21% at 10 years; P < .01). In multivariable analysis, ejection fraction and diabetes were predictors of major adverse events but not extensive approach. Extensive approach was a predictor of late reoperation (odds ratio, 3.03 [95% confidence interval, 1.29-7.2]; P = .01).
A tailored conservative approach to ATAAD leads to favorable operative outcomes without compromising durability.
目前有无数种手术技术可用于修复急性 A 型主动脉夹层（ATAAD）。我们采用保留根部和半弓技术治疗高危患者、根部和全弓置换治疗低危患者的保守方法对结果进行了分析。
我们通过主动脉数据库查询连续接受 ATAAD 修复的患者。使用单变量和多变量分析比较行保守修复（第 1 组）和广泛修复（第 2 组）的患者。
1997 年至 2019 年，共有 343 例患者接受 ATAAD 修复。240 例行保守修复（保留根部、半弓），103 例行广泛修复（根部置换和/或全弓置换）。第 1 组年龄较大，合并症更多，如高血压、既往心肌梗死和肾功能不全。第 2 组结缔组织疾病（2.1% vs. 12.6%；P < 0.01）、主动脉瓣关闭不全和较长的手术时间更多。无论采用何种方法，单个术后并发症的发生率相似。保守组主要不良事件（手术死亡率、心肌梗死、卒中和透析或气管切开术）的发生率较高（15.1% vs. 5.9%；P = 0.03）。手术死亡率在两组之间无差异。两种手术方法的 10 年生存率相似。第 2 组的 10 年再干预累积风险较高（5.6% vs. 10 年时 21%；P < 0.01）。多变量分析显示，射血分数和糖尿病是主要不良事件的预测因素，但不是广泛手术的预测因素。广泛手术是晚期再次手术的预测因素（比值比，3.03 [95%置信区间，1.29-7.2]；P = 0.01）。
ATAAD 的定制保守方法可带来有利的手术结果，而不会降低耐久性。
