Zhu Qi-Yuan, Lv Xiao-Shuo, Li Shou-Ming, Li Xiao-Nan, Zhang Wei, Xue Jin-Rong, Zhang Zuo, Uimonen Mikko, Mennander Ari, Zhao Hong-Lei
Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.
Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China.
J Thorac Dis. 2024 Dec 31;16(12):8709-8723. doi: 10.21037/jtd-2024-2048. Epub 2024 Dec 28.
Acute type A aortic dissection (ATAAD) requires emergency surgery, but the choice of primary surgery remains controversial. It is believed that simple ascending aorta replacement may lead to higher postoperative survival rate, while the Sun procedure [frozen elephant trunk (FET) + total arch replacement (TAR)] performed in the first stage may obtain better long-term results. The study aimed to compare the outcome of ATAAD patients who underwent the Sun procedure with those without TAR + FET.
Data of 452 patients with ATAAD admitted to Beijing Anzhen Hospital for surgical treatment from August 1, 2020, to August 16, 2022, were collected and analyzed. Patients with the Sun procedure (n=344) were compared to those without the Sun procedure (n=108). The two groups of patients were matched using propensity score matching (PSM), and the risk factors of poor prognosis were analyzed.
The average postoperative follow-up period was 976±414 days, and the loss of follow-up rate was 0. The postoperative 30-day mortality rates were 12.56% and 5.38% in the Sun procedure group and the non-Sun procedure group after PSM matching, respectively (P=0.06). Multivariate logistic regression analysis showed that postoperative cardiogenic shock, postoperative cerebral malperfusion syndrome (MPS), postoperative spinal MPS, and need for continuous renal replacement therapy (CRRT) were independent risk factors for postoperative 30-day death. The 3-year survival rates were 85.02% and 91.40% in the Sun procedure group and the non-Sun procedure group after PSM matching, respectively (P=0.12). According to multivariate cox regression analysis, the independent risk factors associated with postoperative midterm death were consistent with those associated with 30-day postoperative death that pointed out by logistic regression. The incidence of spinal MPS after the Sun procedure was higher than that in the non-Sun procedure group (P=0.003). At 3-year follow-up, the probability of no distal aortic events (DAEs) was 97.17% and 91.59%, in the Sun procedure group and non-Sun procedure group, respectively, representing a significant difference (P=0.02). Multivariate Cox regression showed that Marfan syndrome and non-Sun procedure were risk factors for DAEs. Fine-Gray analysis also produced results similar to multifactor cox regression analysis, that Marfan syndrome and non-Sun procedure were risk factors for DAEs.
There was no significant difference in postoperative mortality between the Sun procedure group and the non-Sun procedure group. The incidence of spinal MPS in the Sun procedure group was higher than that in the non-Sun procedure group, while the incidence of DAEs in the Sun procedure group was lower than that in non-Sun procedure group.
急性A型主动脉夹层（ATAAD）需要紧急手术，但初次手术方式的选择仍存在争议。人们认为单纯升主动脉置换可能导致更高的术后生存率，而一期进行孙氏手术[冰冻象鼻术（FET）+全弓置换术（TAR）]可能会获得更好的长期效果。本研究旨在比较接受孙氏手术的ATAAD患者与未接受TAR+FET手术患者的结局。
收集并分析了2020年8月1日至2022年8月16日在北京安贞医院接受手术治疗的452例ATAAD患者的数据。将接受孙氏手术的患者（n=344）与未接受孙氏手术的患者（n=108）进行比较。两组患者采用倾向得分匹配（PSM）进行匹配，并分析预后不良的危险因素。
术后平均随访时间为976±414天，失访率为0。PSM匹配后，孙氏手术组和非孙氏手术组术后30天死亡率分别为12.56%和5.38%（P=0.06）。多因素logistic回归分析显示，术后心源性休克、术后脑灌注不良综合征（MPS）、术后脊髓MPS以及需要持续肾脏替代治疗（CRRT）是术后30天死亡的独立危险因素。PSM匹配后，孙氏手术组和非孙氏手术组的3年生存率分别为85.02%和91.40%（P=0.12）。根据多因素cox回归分析，与术后中期死亡相关的独立危险因素与logistic回归指出的术后30天死亡相关危险因素一致。孙氏手术后脊髓MPS的发生率高于非孙氏手术组（P=0.003）。在3年随访时，孙氏手术组和非孙氏手术组无远端主动脉事件（DAE）的概率分别为97.17%和91.59%，差异有统计学意义（P=0.02）。多因素Cox回归显示，马方综合征和非孙氏手术是DAE的危险因素。精细灰色分析也得出了与多因素cox回归分析相似的结果，即马方综合征和非孙氏手术是DAE的危险因素。
孙氏手术组和非孙氏手术组术后死亡率无显著差异。孙氏手术组脊髓MPS的发生率高于非孙氏手术组，而孙氏手术组DAE的发生率低于非孙氏手术组。
