Vázquez Muñiz C A, Delgado Osorio H
Department of Internal Medicine, University District Hospital, San Juan, Puerto Rico.
Bol Asoc Med P R. 1997 Oct-Dec;89(10-12):161-6.
Acute dissection of the thoracic aorta has a very poor prognosis unless promptly diagnosed and treated. The clinical presentation, diagnosis and management of 16 patients was reviewed.
We identified 12 patients from the Puerto Rico Medical Center and 4 patients from the "Centro Cardiovascular de Puerto Rico y del Caribe" whose diagnosis was made from January 1991 to December 1995. Medical records and autopsy reports were reviewed.
Of the 16 patients, 10 [62%] were males, 10 [62%] were 60 years old or older [range 25 to 85 years], and 15 [93%] had a past history of hypertension although only 6 [38%] were found with an initial blood pressure of 140/90 or higher. Chest pain was the initial symptom in 13 [81%]. Of these 46% [6/13] described it as oppressive, with radiation to back or neck in 38% [5/13]. In none a neurological abnormality was the initial presentation. No physical sign was present in more than 40% of patients. One patient had a diastolic murmur suggestive of aortic regurgitation but none had a pericardial rub or a neurologic deficit. The electrocardiogram showed left ventricular hypertrophy in 35% but none had changes compatible with an acute Q wave infarction. The chest radiography was compatible with dissection in all in whom it was done [8/8]. Computerized tomography of the chest was diagnostic in 6 of 8 patients [sensitivity 75%]. Aortography had a sensitivity of 80% [4/5]. Trans-thoracic echocardiogram was diagnostic in 3 of 4 patients [75% sensitivity]. Transesophageal echocardiogram had a 100% sensitivity [2/2]. In 8 patients [50%] the correct diagnosis was made by postmortem examination, all of whom died within 24 hours of Emergency Room's evaluation. Of those properly diagnosed 5 died without being surgically intervened. Only one survived surgery [1/3] Overall mortality was 93%. The most common pathological finding was Type A dissection in 14 [88%]. Cardiac tamponade was found in 9 [56%]. Hemothorax was found in 6 [38%]. Aortic valve insufficiency was reported in 20% and coronary artery involvement in 28%.
The dismal prognosis traditionally associated with acute dissection of the thoracic aorta remains unchanged. Prompt diagnosis based on high clinical suspicion. followed by expeditious medical and surgical treatment are fundamental to change the natural course of this condition.
除非及时诊断和治疗，胸主动脉急性夹层预后极差。回顾了16例患者的临床表现、诊断及治疗情况。
我们确定了来自波多黎各医疗中心的12例患者和来自“波多黎各及加勒比心血管中心”的4例患者，其诊断时间为1991年1月至1995年12月。查阅了病历和尸检报告。
16例患者中，10例（62%）为男性，10例（62%）年龄在60岁及以上（年龄范围25至85岁），15例（93%）有高血压病史，尽管仅6例（38%）初始血压≥140/90。胸痛是13例（81%）患者的初始症状。其中46%（6/13）描述为压迫性疼痛，38%（5/13）放射至背部或颈部。无一例以神经功能异常为初始表现。超过40%的患者无体征。1例患者有提示主动脉反流的舒张期杂音，但均无心包摩擦音或神经功能缺损。心电图显示35%患者有左心室肥厚，但均无符合急性Q波梗死的改变。所有进行胸部X线检查的患者（8/8）结果均与夹层相符。胸部计算机断层扫描在8例患者中的6例具有诊断价值（敏感性75%）。主动脉造影敏感性为80%（4/5）。经胸超声心动图在4例患者中的3例具有诊断价值（敏感性75%）。经食管超声心动图敏感性为100%（2/2）。8例患者（50%）经尸检确诊，均在急诊室评估后24小时内死亡。在那些被正确诊断的患者中，5例未接受手术干预死亡。仅1例手术存活（1/3）。总体死亡率为93%。最常见的病理发现是14例（88%）为A型夹层。9例（56%）发现心包填塞。6例（38%）发现血胸。20%报告有主动脉瓣关闭不全，28%有冠状动脉受累。
传统上与胸主动脉急性夹层相关的预后不佳情况仍未改变。基于高度临床怀疑进行快速诊断，随后迅速进行药物和手术治疗是改变该病自然病程的关键。
