升主动脉及主动脉弓疾病的外科治疗：技术改进与疗效提升

Surgical management of ascending and aortic arch disease: refined techniques with improved results.

作者信息

Stowe C L, Baertlein M A, Wierman M D, Rucker M, Ebra G

机构信息

Florida Heart Institute, Orlando, USA.

出版信息

Ann Thorac Surg. 1998 Aug;66(2):388-95. doi: 10.1016/s0003-4975(98)00535-9.

DOI:10.1016/s0003-4975(98)00535-9

PMID:9725374

Abstract

BACKGROUND

Treatment of aneurysms of the ascending aorta, arch aorta, or both is surgically challenging and has traditionally carried a high hospital mortality rate. The use of refined operative techniques, including improved grafts, enhanced myocardial protection, retrograde cerebral perfusion with circulatory arrest, transesophageal echocardiography, and control of hematologic factors, has resulted in reduced hospital mortality rates.

METHODS

We conducted a retrospective analysis of records of 117 consecutive patients who underwent 118 procedures between March 1987 and September 1997, for graft replacement of the ascending or transverse aortic arch with or without aortic valve reconstruction or replacement. There were 67 men (57.3%) and 50 women (42.7%). The mean age was 61.4 years (range, 16 to 81 years). Aortic abnormalities were medial degeneration in 59 patients (50.0%), dissection in 28 patients (23.7%), atherosclerosis in 16 patients (13.6%), Marfan's syndrome in 8 patients (6.8%), and other in 7 patients (5.9%).

RESULTS

The ascending aorta alone was replaced in 58 patients (49.2%), ascending and arch aorta in 56 patients (47.5%), and isolated arch aorta in 4 patients (3.4%). Twenty-six patients (22.0%) required aortic valve reconstruction, 17 patients (14.4%) had separate aortic valve replacement, and 37 patients (31.4%) received a valve conduit. Overall hospital mortality rate was 3.4% (4 of 117 patients). Postoperative complications included myocardial infarction in 3 patients (2.5%), stroke in 7 patients (5.9%), pulmonary insufficiency in 22 patients (18.6%), renal insufficiency in 4 patients (3.4%), and reoperation for bleeding in 8 patients (6.8%). There were no deep sternal wound infections. Follow-up was completed for 112 (99.1%) of 113 survivors and ranged from 1 month to 10.6 years (mean, 39.5 months). Actuarial survival for patients discharged from the hospital was 87.9%+/-3.7% (standard error of the mean) at 3 years and 79.7%+/-5.8% at 6 years.

CONCLUSIONS

Graft replacement of the ascending and transverse aortic arch, although technically demanding, can be performed with low hospital mortality and morbidity rates.

摘要

背景

升主动脉、主动脉弓或二者的动脉瘤治疗在外科手术上具有挑战性，传统上医院死亡率较高。采用精细的手术技术，包括改进的移植物、增强的心肌保护、循环阻断下的逆行脑灌注、经食管超声心动图以及血液学因素的控制，已使医院死亡率降低。

方法

我们对1987年3月至1997年9月间连续117例患者的记录进行了回顾性分析，这些患者接受了118次手术，用于升主动脉或横主动脉弓的移植物置换，伴或不伴有主动脉瓣重建或置换。其中男性67例（57.3%），女性50例（42.7%）。平均年龄为61.4岁（范围16至81岁）。主动脉异常情况为：中层退变59例（50.0%），夹层28例（23.7%），动脉粥样硬化16例（13.6%），马方综合征8例（6.8%），其他7例（5.9%）。

结果

仅置换升主动脉58例（49.2%），置换升主动脉和主动脉弓56例（47.5%），单纯置换主动脉弓4例（3.4%）。26例（22.0%）患者需要进行主动脉瓣重建，17例（14.4%）患者单独进行主动脉瓣置换，37例（31.4%）患者接受带瓣管道。医院总体死亡率为3.4%（117例患者中有4例）。术后并发症包括心肌梗死3例（2.5%），中风7例（5.9%），肺功能不全22例（18.6%），肾功能不全4例（3.4%），因出血再次手术8例（6.8%）。无深部胸骨伤口感染。113例幸存者中有112例（99.1%）完成随访，随访时间从1个月至10.6年（平均39.5个月）。出院患者的3年精算生存率为87.9%±3.7%（均值标准误），6年为79.7%±5.8%。