Al-Tawil Mohammed, Salem Mohamed, Friedrich Christine, Diraz Shirin, Broll Alexandra, Rezahie Najma, Schoettler Jan, de Silva Nora, Puehler Thomas, Cremer Jochen, Haneya Assad
Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, 24118 Kiel, Germany.
J Clin Med. 2023 Oct 20;12(20):6659. doi: 10.3390/jcm12206659.
Acute type A aortic dissection (ATAAD) continues to be a subject of active research due to its high mortality rates and associated complications. Cerebral malperfusion in ATAAD can have a devastating impact on patients' neurological function and overall quality of life. We aimed to explore the risk profile and prognosis in ATAAD patients presenting with preoperative imaging signs of cerebral malperfusion (PSCM).
We obtained patient data from our Aortic Dissection Registry, which included 480 consecutive ATAAD cases who underwent surgical repair between 2001 and 2021. Primary endpoint outcomes included the in-hospital and 30-day mortality, postoperative new neurological deficit, mechanical ventilation hours, and intensive care unit (ICU) length of stay.
Of the total cohort, 82 patients (17.1%) had PSCM. Both groups had similar distributions in terms of age, sex, and body mass index. The patients in the PSCM group presented with a higher logistic EuroSCORE (47, IQR [31, 64] vs. 24, IQR [15, 39]; < 0.001) and a higher portion of patients with a previous cardiac surgery (7.3% vs. 2.0%; = 0.020). Intraoperatively, the bypass, cardioplegia, and aortic cross-clamp times were similar between both groups. However, the patients in the PSCM group received significantly more intraoperative packed red blood cells, fresh frozen plasma, and platelets transfusions ( < 0.05). Following the surgery, the patients who presented with PSCM had markedly longer ventilation hours (108.5 h, IQR [44, 277] vs. 43 h, IQR [16, 158], < 0.001) and a significantly longer ICU length of stay (7 days, IQR [4, 13] vs. 5 days, IQR [2, 11]; = 0.013). Additionally, the patients with PSCM had significantly higher rates of postoperative new neurological deficits (35.4% vs. 19.4%; = 0.002). In the Cox regression analysis, PSCM was associated with significantly poorer long-term survival (hazard ratio (HR) 1.75, 95%CI [1.20-2.53], = 0.003). Surprisingly, hypertension was shown as a protective factor against long-term mortality (HR: 0.59, 95%CI [0.43-0.82], = 0.001).
PSCM in ATAAD patients is linked to worse postoperative outcomes and poorer long-term survival, emphasizing the need for early recognition and tailored management.
急性A型主动脉夹层（ATAAD）因其高死亡率及相关并发症，仍是积极研究的课题。ATAAD中的脑灌注不良会对患者的神经功能和整体生活质量产生毁灭性影响。我们旨在探讨术前有脑灌注不良影像学征象（PSCM）的ATAAD患者的风险特征和预后。
我们从主动脉夹层登记处获取患者数据，其中包括2001年至2021年间连续接受手术修复的480例ATAAD病例。主要终点结局包括住院期间和30天死亡率、术后新发神经功能缺损、机械通气时间以及重症监护病房（ICU）住院时长。
在整个队列中，82例患者（17.1%）有PSCM。两组在年龄、性别和体重指数方面分布相似。PSCM组患者的逻辑欧洲心脏手术风险评估系统（EuroSCORE）更高（47，四分位间距[IQR][31, 64] 对比 24，IQR[15, 39]；P < 0.001），且既往有心脏手术史的患者比例更高（7.3% 对比 2.0%；P = 0.020）。术中，两组的体外循环、心脏停搏和主动脉阻断时间相似。然而，PSCM组患者术中接受的浓缩红细胞、新鲜冰冻血浆和血小板输注量显著更多（P < 0.05）。术后，有PSCM的患者机械通气时间明显更长（108.5小时，IQR[44, 277] 对比 43小时，IQR[16, 158]，P < 0.001），ICU住院时长显著更长（7天，IQR[4, 13] 对比 5天，IQR[2, 11]；P = 0.013）。此外，有PSCM的患者术后新发神经功能缺损的发生率显著更高（35.4% 对比 19.4%；P = 0.002）。在Cox回归分析中，PSCM与显著更差的长期生存率相关（风险比[HR] 1.75，95%置信区间[CI][1.20 - 2.53]，P = 0.003）。令人惊讶的是，高血压被证明是长期死亡率的保护因素（HR：0.59，95%CI[0.43 - 0.82]，P = 0.001）。
ATAAD患者的PSCM与更差的术后结局和更差的长期生存率相关，强调了早期识别和针对性管理的必要性。
