Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany.
Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.
Eur J Cardiothorac Surg. 2024 Jul 1;66(1). doi: 10.1093/ejcts/ezae248.
Managing acute type A aortic dissection with coronary malperfusion is challenging. This study outlines our revascularization strategy for these patients.
Patients undergoing surgery for acute type A aortic dissection with coronary malperfusion and aortic root involvement from January 2000 to December 2021 were included. Patients were classified using the Neri classification for coronary dissection, including a novel 'Neri -' class (no coronary dissection). Patients undergoing revascularization either as a planned or as a bailout strategy due to persisting low cardiac output were compared additionally.
The cohort comprised 195 patients: 43 (22%) Neri -, 43 (22%) Neri A, 74 (38%) Neri B and 35 (18%) Neri C. Aortic root replacement was mainly performed in 25 Neri C patients (71%; P < 0.001). Concomitant bypass surgery was performed in 4 (9%) of Neri -, 5 (12%) of Neri A, 21 (28%) of Neri B and 32 (91%) of Neri C patients (P < 0.001). Thirty-day mortality was 42% with 21 (49%) Neri -, 12 (28%) Neri A, 30 (41%) Neri B and 19 (54%) Neri C patients (P = 0.087). Bailout revascularization was primarily performed in 11 Neri B patients (69%; P = 0.001) and associated with a higher 30-day mortality of 81% compared to 48% for planned revascularization (P = 0.042).
Postoperative outcomes in case of coronary malperfusion are poor, irrespective of the anatomic dissection pattern. The decision for concomitant bypass surgery is crucial but may be considered in Neri C patients combined with aortic root replacement. Bailout revascularization was most common in Neri B and showed dismal outcome.
急性 A 型主动脉夹层合并冠状动脉灌注不良的处理极具挑战性。本研究概述了我们对这些患者的血运重建策略。
纳入 2000 年 1 月至 2021 年 12 月期间因急性 A 型主动脉夹层合并冠状动脉灌注不良和主动脉根部受累而接受手术的患者。根据冠状动脉夹层的 Neri 分类对患者进行分类，包括一个新的“Neri-”类（无冠状动脉夹层）。由于持续低心输出量而计划或作为抢救策略进行血运重建的患者被进一步比较。
该队列包括 195 例患者：43 例（22%）为 Neri-，43 例（22%）为 Neri A，74 例（38%）为 Neri B，35 例（18%）为 Neri C。25 例 Neri C 患者（71%；P<0.001）主要行主动脉根部置换术。4 例（9%）Neri-、5 例（12%）Neri A、21 例（28%）Neri B 和 32 例（91%）Neri C 患者（P<0.001）行同期旁路手术。30 天死亡率为 42%，其中 21 例（49%）Neri-、12 例（28%）Neri A、30 例（41%）Neri B 和 19 例（54%）Neri C 患者（P=0.087）。11 例 Neri B 患者（69%）主要行抢救性血运重建（P=0.001），与计划性血运重建相比，30 天死亡率更高，为 81%（P=0.042）。
无论解剖学夹层模式如何，冠状动脉灌注不良的术后结果都很差。同期旁路手术的决定至关重要，但可考虑在 Neri C 患者中联合行主动脉根部置换术。抢救性血运重建最常见于 Neri B，结果不佳。
