Ruchat P, Hurni M, Stumpe F, Fischer A P, von Segesser L K
Department of Cardiovascular Surgery, University Hospital Center, Lausanne, Switzerland.
Eur J Cardiothorac Surg. 1998 Nov;14(5):449-52. doi: 10.1016/s1010-7940(98)00224-3.
This retrospective study was designed to assess the risks of acute ascending aorta dissection (AAD) as a rare but potentially fatal complication of open heart surgery.
Among 8624 cardiac surgical procedures under cardiopulmonary bypass (CPB) and cardioplegic myocardial protection from 1978 to 1997, 10 patients (0.12%) presented with a secondary or so called 'iatrogenic' AAD. There were seven men and three women, mean age 64 +/- 9 years, ranging from 47 to 79. The original procedures involved five coronary artery bypass grafts (CABG), one repeat CABG, one aortic valve replacement (AVR), one AVR and CABG, one mitral valvuloplasty (MVP) and CABG and one ascending aorta replacement. We retrospectively analyzed their hospital records.
Group I consisted of seven patients with AAD intraoperatively and group II consisted of three patients who developed acute AAD 8-32 days after cardiac surgery. In group I, treatment consisted of the original procedure, plus grafting of the ascending aorta in six patients and closed plication and aortic wrapping in one. In group II, two patients received a dacron graft and one patient developed lethal tamponnade due to aortic rupture before surgery. Postoperatively, six patients responded well and three died (33%), two patients from group I on the 2nd postoperative day with severe post-anoxic encephalopathy, and one from group II with severe peroperative cardiogenic shock.
Preventing AAD with the appropriate means remains standard practice in cardiac surgery. If AAD occurs, it requires prompt diagnosis and interposition graft to allow a better prognosis. Intraoperative AAD happens at the beginning of CPB jeopardizing perfusion of the supra-aortic arteries.
本回顾性研究旨在评估急性升主动脉夹层（AAD）作为心脏直视手术一种罕见但可能致命的并发症的风险。
在1978年至1997年期间接受体外循环（CPB）和心脏停搏液心肌保护的8624例心脏手术中，10例患者（0.12%）出现继发性或所谓“医源性”AAD。其中男性7例，女性3例，平均年龄64±9岁，范围为47至79岁。最初的手术包括5例冠状动脉旁路移植术（CABG）、1例再次CABG、1例主动脉瓣置换术（AVR）、1例AVR和CABG、1例二尖瓣成形术（MVP）和CABG以及1例升主动脉置换术。我们回顾性分析了他们的住院记录。
第一组包括7例术中发生AAD的患者，第二组包括3例心脏手术后8 - 32天发生急性AAD的患者。在第一组中，治疗包括原手术，另外6例患者进行升主动脉移植，1例进行闭合折叠和主动脉包裹。在第二组中，2例患者接受了涤纶补片移植，1例患者在手术前因主动脉破裂发生致命性心包填塞。术后，6例患者恢复良好，3例死亡（33%），第一组2例患者在术后第2天因严重缺氧性脑病死亡，第二组1例患者因严重围手术期心源性休克死亡。
采用适当方法预防AAD仍是心脏手术的标准做法。如果发生AAD，需要及时诊断并进行介入性移植以获得更好的预后。术中AAD发生在CPB开始时，会危及主动脉上动脉的灌注。
