Dougenis D, Daily B B, Kouchoukos N T
Division of Cardiothoracic Surgery, Washington University School of Medicine, and the Heart Center, Missouri Baptist Medical Center, BJC Health System, St. Louis, USA.
Ann Thorac Surg. 1997 Oct;64(4):986-92. doi: 10.1016/s0003-4975(97)00626-7.
Reoperations on the aortic root and the ascending aorta are being performed with increasing frequency and remain a challenging problem.
Eighty-one patients (age range, 14 to 78 years) underwent reoperations on the aortic root or the ascending aorta during a 14.5-year interval ending October 1996. The previous operations were aortic valve procedure (28%), coronary artery bypass grafting (25%), aortic root replacement (24%), ascending aortic replacement (19%), and miscellaneous (5%). Twenty-two patients (27%) had had two or more previous operations. The principal indications for reoperation were true or false aneurysm (35%), acute or chronic dissection (28%), and malfunction of an aortic valve substitute (27%). The reoperations performed were aortic root replacement (composite graft, allograft, or autograft) in 48 patients and graft replacement of the ascending aorta in 33 patients. Concomitant procedures included aortic arch replacement in 43 patients (55%) and coronary artery bypass grafting in 33 patients (41%).
The 30-day mortality rate was 8.6% (7 patients). It was 8.3% for aortic root replacement and 9.1% for ascending aorta replacement (p > 0.05). Using stepwise multivariate logistic regression analysis of 23 variables, preoperative functional class III/IV (p = 0.047) and duration of cardiopulmonary bypass (p = 0.007) were significant independent predictors of early death. The mean duration of follow-up was 3.6 years. The 1-year, 5-year, and 10-year survival rates were 89%, 81%, and 69%, respectively. Freedom from reoperation on the heart or ascending aorta was 98%, 92%, and 69%, respectively. Reoperation for false aneurysm (p = 0.050) and the presence of coexisting coronary artery disease requiring bypass grafting (p = 0.010) were the only significant predictors of late mortality.
Reoperations on the aortic root and the ascending aorta can be accomplished with acceptable early mortality and satisfactory long-term results. More frequent resection of the aneurysmal or dissected segments of the ascending aorta and aortic root at the initial operation may reduce the need for subsequent reoperation.
主动脉根部和升主动脉再次手术的频率日益增加，仍然是一个具有挑战性的问题。
在截至1996年10月的14.5年期间，81例患者（年龄范围14至78岁）接受了主动脉根部或升主动脉的再次手术。先前的手术包括主动脉瓣手术（28%）、冠状动脉旁路移植术（25%）、主动脉根部置换术（24%）、升主动脉置换术（19%）以及其他手术（5%）。22例患者（27%）曾接受过两次或更多次先前手术。再次手术的主要指征为真性或假性动脉瘤（35%）、急性或慢性主动脉夹层（28%）以及主动脉瓣置换物功能障碍（27%）。实施的再次手术包括48例患者的主动脉根部置换术（复合移植物、同种异体移植物或自体移植物）和33例患者的升主动脉移植物置换术。同期手术包括43例患者（55%）的主动脉弓置换术和33例患者（41%）的冠状动脉旁路移植术。
30天死亡率为8.6%（7例患者）。主动脉根部置换术的死亡率为8.3%，升主动脉置换术的死亡率为9.1%（p>0.05）。对23个变量进行逐步多因素逻辑回归分析，术前功能分级III/IV（p=0.047）和体外循环时间（p=0.007）是早期死亡的显著独立预测因素。平均随访时间为3.6年。1年、5年和10年生存率分别为89%、81%和69%。心脏或升主动脉再次手术的无复发生存率分别为98%、92%和69%。假性动脉瘤再次手术（p=0.050）以及存在需要旁路移植术的并存冠状动脉疾病（p=0.010）是晚期死亡的唯一显著预测因素。
主动脉根部和升主动脉再次手术可取得可接受的早期死亡率和满意的长期效果。在初次手术时更频繁地切除升主动脉和主动脉根部的动脉瘤或夹层段可能会减少后续再次手术的需求。
