Isselbacher E M, Cigarroa J E, Eagle K A
Cardiac Unit, Massachusetts General Hospital, Boston 02114.
Circulation. 1994 Nov;90(5):2375-8. doi: 10.1161/01.cir.90.5.2375.
Cardiac tamponade frequently complicates acute proximal aortic dissection and is one of the most common causes of death from aortic dissection. Well-defined strategies for the management of acute aortic dissection now exist; however, little is known about how best to manage the hemopericardium that may complicate it.
Using a computer-based review, we retrospectively identified 10 patients presenting to our hospital over a 13-year period who were diagnosed with both aortic dissection and cardiac tamponade. All 10 had proximal dissections. Three of the 10 presented as the sudden onset of fatal electromechanical dissociation, 6 presented with hypotension, and 1 was normotensive on presentation. Of the 7 hypotensive or normotensive patients diagnosed with cardiac tamponade, 4 underwent successful pericardiocentesis while awaiting surgery. At time intervals of 5 to 40 minutes after their pericardiocenteses, 3 of the 4 patients experienced sudden onset of electromechanical dissociation and death; the fourth patient survived and underwent surgical repair. Of the 3 hypotensive or normotensive patients who had either no pericardiocentesis or an unsuccessful pericardiocentesis, all 3 underwent successful surgical repair and survived.
In this study, patients with an aortic dissection complicated by cardiac tamponade have an early mortality of 60%. While 3 of the 10 died from electromechanical dissociation immediately upon presentation, the 3 other deaths all occurred shortly after successful pericardiocentesis, a procedure undertaken to stabilize them. While the number of patients in this series is small, the observations do raise the possibility that in patients with cardiac tamponade complicating aortic dissection pericardiocentesis could be harmful rather than beneficial. Possible mechanisms for why the performance of pericardiocentesis might destabilize such patients are proposed.
心脏压塞常使急性近端主动脉夹层病情复杂化，是主动脉夹层最常见的死亡原因之一。目前已有明确的急性主动脉夹层治疗策略；然而，对于如何最佳处理可能并发的心包积血，人们知之甚少。
通过计算机检索，我们回顾性确定了13年间我院收治的10例同时诊断为主动脉夹层和心脏压塞的患者。所有10例均为近端夹层。10例中有3例表现为致命性电机械分离的突然发作，6例表现为低血压，1例就诊时血压正常。在7例诊断为心脏压塞的低血压或血压正常患者中，4例在等待手术期间成功进行了心包穿刺。在进行心包穿刺后的5至40分钟内，4例患者中有3例突然出现电机械分离并死亡；第4例患者存活并接受了手术修复。在3例未进行心包穿刺或心包穿刺不成功的低血压或血压正常患者中，所有3例均成功进行了手术修复并存活。
在本研究中，并发心脏压塞的主动脉夹层患者早期死亡率为60%。10例中有3例就诊时即死于电机械分离，另外3例死亡均发生在成功进行心包穿刺（旨在稳定病情的操作）后不久。尽管本系列患者数量较少，但这些观察结果确实增加了这样一种可能性，即对于并发主动脉夹层的心脏压塞患者，心包穿刺可能有害而非有益。文中提出了心包穿刺可能使此类患者病情不稳定的潜在机制。
