Bayamin Karama, Power Adam, Chu Michael W A, Dubois Luc, Valdis Matthew
Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada.
Division of Vascular Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada.
J Card Surg. 2022 Nov;37(11):3827-3834. doi: 10.1111/jocs.16872. Epub 2022 Aug 21.
Malperfusion syndrome (MPS) is associated with the highest mortality and major morbidity risk in patients with acute Type A aortic dissection (TAAD). The timing of the open proximal aortic repair in the presence of MPS remains debatable given variability in clinical presentation and different local treatment algorithms. This paper provides an up to date and comprehensive overview of published outcomes and available techniques for addressing malperfusion in the setting of acute TAAD.
We have reviewed published data from the major aortic dissection registries including the International Registry of Acute Aortic Dissection, the German Registry for Acute Aortic Dissection In Type A, and the Nordic Consortium for Acute Type A Aortic Dissection, as well as the most up to date literature involving malperfusion in the setting of acute TAAD. This data highlights unique strategies that have been adopted at aortic centers internationally to address malperfusion in this setting pre-, intra-, and postoperatively, which are summarized here and may be of great clinical benefit to other centers treating this disease with more traditional methods.
The review of the available data has definitively shown an increased mortality up to 43% and morbidity in patients presenting with MPS in the setting of acute TAAD. More specifically, preoperative MPS has been shown to be an independent predictor of mortality with mesenteric malperfusion associated with the worst mortality outcomes from 70% to 100%. Addressing MPS pre or intraoperatively is associated with significantly reduced mortality outcomes down to 4%-13%.
Adapting a dynamic and easily accessible diagnostic method for the comprehensive assessment of different forms of malperfusion (dynamic/static) and incorporating it within the surgical plan is the first step toward early diagnosis and prevention of malperfusion related complications.
在急性A型主动脉夹层（TAAD）患者中，灌注不良综合征（MPS）与最高的死亡率及主要发病风险相关。鉴于临床表现的变异性和不同的局部治疗方案，存在MPS时进行主动脉近端开放修复的时机仍存在争议。本文对已发表的关于急性TAAD中处理灌注不良的结果及可用技术进行了最新且全面的综述。
我们回顾了来自主要主动脉夹层登记处的已发表数据，包括国际急性主动脉夹层登记处、德国A型急性主动脉夹层登记处、北欧急性A型主动脉夹层联盟，以及涉及急性TAAD中灌注不良的最新文献。这些数据突出了国际上主动脉中心在术前、术中和术后处理这种情况下的灌注不良所采用的独特策略，在此进行总结，可能对其他采用更传统方法治疗该疾病的中心具有重大临床益处。
对现有数据的综述明确显示，在急性TAAD背景下出现MPS的患者死亡率高达43%，发病率也有所增加。更具体地说，术前MPS已被证明是死亡率的独立预测因素，肠系膜灌注不良与最差的死亡率结果相关，从70%到100%不等。在术前或术中处理MPS可使死亡率显著降低至4% - 13%。
采用一种动态且易于获取的诊断方法来全面评估不同形式的灌注不良（动态/静态），并将其纳入手术计划，是早期诊断和预防灌注不良相关并发症的第一步。
