Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
J Thorac Cardiovasc Surg. 2024 Mar;167(3):882-892.e2. doi: 10.1016/j.jtcvs.2022.04.051. Epub 2022 Jul 14.
The study objective was to determine the impact of malperfusion syndrome on in-hospital mortality and midterm survival after emergency aortic arch reconstruction for acute type A aortic dissection.
This was an observational study of aortic surgeries from 2010 to 2018. All patients with acute type A aortic dissection undergoing open aortic arch reconstruction were included. Patients were dichotomized by the presence or absence of malperfusion syndrome and were analyzed for differences in short-term postoperative outcomes, including morbidity and in-hospital mortality. Kaplan-Meier survival estimation and multivariable Cox analysis were performed to identify variables associated with survival.
A total of 467 patients undergoing aortic arch reconstruction for acute type A aortic dissection were identified, of whom 332 (71.1%) presented without malperfusion syndrome and 135 (28.9%) presented with malperfusion syndrome. Patients with malperfusion syndrome had higher in-hospital mortality (21.5% vs 5.7%) than patients without malperfusion syndrome. After multivariable adjustment, malperfusion syndrome was associated with worse survival (hazard ratio, 2.43, 95% confidence interval, 1.61-3.66, P < .001) compared with patients without malperfusion syndrome. The predicted risk of mortality increased as the number of malperfused vascular beds increased. Patients with coronary malperfusion syndrome and neuro-malperfusion syndrome had reduced survival compared with the rest of the cohort (P < .05).
Malperfusion syndrome is associated with higher in-hospital mortality and reduced survival for patients with acute type A aortic dissection, with the risk of mortality increasing as the number of malperfused vascular beds increases. Coronary malperfusion syndrome and neuro-malperfusion syndrome may represent a high-risk subgroup of patients presenting with acute type A aortic dissection complicated by malperfusion syndrome. Finally, malperfusion syndrome may benefit from immediate surgical intervention to restore true lumen perfusion, as opposed to operative delay.
本研究旨在探讨急性 A 型主动脉夹层患者行急诊主动脉弓重建术后，发生灌注不良综合征对院内死亡率和中期生存的影响。
本研究为回顾性队列研究，纳入了 2010 年至 2018 年期间行开放主动脉弓重建术的急性 A 型主动脉夹层患者。根据是否存在灌注不良综合征，将患者分为两组，并分析两组患者短期术后结局的差异，包括发病率和院内死亡率。采用 Kaplan-Meier 生存估计和多变量 Cox 分析确定与生存相关的变量。
共纳入 467 例接受主动脉弓重建术治疗的急性 A 型主动脉夹层患者，其中 332 例（71.1%）患者无灌注不良综合征，135 例（28.9%）患者存在灌注不良综合征。存在灌注不良综合征的患者院内死亡率（21.5% vs. 5.7%）高于无灌注不良综合征的患者。多变量调整后，与无灌注不良综合征的患者相比，灌注不良综合征与较差的生存相关（风险比，2.43；95%置信区间，1.61-3.66；P<0.001）。随着灌注不良的血管床数量的增加，预测的死亡率风险增加。存在冠状动脉灌注不良综合征和神经灌注不良综合征的患者与队列其余患者相比，生存率降低（P<0.05）。
灌注不良综合征与急性 A 型主动脉夹层患者的院内死亡率升高和生存时间缩短相关，且随着灌注不良的血管床数量的增加，死亡率风险增加。冠状动脉灌注不良综合征和神经灌注不良综合征可能代表了伴有灌注不良综合征的急性 A 型主动脉夹层患者的一个高风险亚组。最后，灌注不良综合征可能受益于立即进行手术干预以恢复真腔灌注，而不是延迟手术。
