Department of Cardio-Thoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
Department of Cardio-Thoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
Ann Thorac Surg. 2023 Jun;115(6):1396-1402. doi: 10.1016/j.athoracsur.2022.06.041. Epub 2022 Jul 21.
The effect of an "aggressive" approach on the aortic root in acute type A aortic dissection (ATAAD) remains insufficiently explored.
Retrospective analysis was conducted between 1992 and 2020 of a single-center, prospective cohort of consecutive patients aged ≥18 years diagnosed with ATAAD. Patients were divided into 2 groups: aortic root replacement (ARR; prosthetic or valve-sparing root replacement, n = 141) and conservative root approach (CRA; root sparing of partially dissected root, n = 90; and supracoronary ascending replacement in nondissected root, n = 68). Inverse probability weighting was used to compare patients with different preoperative characteristics. Mean follow-up was 5.1 (0-21) years in ARR and 7.1 (0-25) years in CRA.
The frequency of ARR increased over the years, with 19% and 78% of patients undergoing ARR in the earliest and most recent periods, respectively. Early mortality decreased over the years, despite a more aggressive approach, and remained lower in ARR. CRA was associated with a higher hazard of late mortality (hazard ratio, 1.38; 95% CI, 1.12-1.68; P = .001) and reintervention (hazard ratio, 2.08; 95% CI, 1.44-3.56; P = .001). After CRA, new-onset aortic valve insufficiency was a common cause of reintervention.
Over the years, there was a gradual increase in the root replacement approach in ATAAD. Root replacement was associated with better long-term survival and fewer reinterventions compared with the conservative approach, whereas the in-hospital mortality decreased during these years. Hence, aggressive root replacement is safe and may be applied in ATAAD with good long-term clinical results, without increased hospital mortality.
急性 A 型主动脉夹层（ATAAD）中主动脉根部的“激进”处理效果仍未得到充分探索。
回顾性分析了 1992 年至 2020 年间在一家单中心前瞻性连续患者队列中诊断为 ATAAD 的年龄≥18 岁的患者。患者分为 2 组：主动脉根部置换术（ARR；人工或保留瓣膜的根部置换术，n=141）和保守根部处理（CRA；部分撕裂根部保留，n=90；非撕裂根部升主动脉置换术，n=68）。使用逆概率加权法比较了不同术前特征的患者。ARR 的平均随访时间为 5.1（0-21）年，CRA 为 7.1（0-25）年。
ARR 的频率逐年增加，最早和最近时期分别有 19%和 78%的患者接受 ARR。尽管采用了更激进的方法，但近年来早期死亡率有所下降，ARR 组的死亡率仍然较低。CRA 与晚期死亡率（风险比，1.38；95%置信区间，1.12-1.68；P=.001）和再次干预（风险比，2.08；95%置信区间，1.44-3.56；P=.001）的风险增加相关。CRA 后，新发主动脉瓣关闭不全是再次干预的常见原因。
近年来，ATAAD 中根部置换术的应用逐渐增加。与保守方法相比，根部置换术与更好的长期生存率和更少的再次干预相关，而在此期间住院死亡率下降。因此，激进的根部置换术是安全的，并且可能在 ATAAD 中具有良好的长期临床效果，而不会增加住院死亡率。
