De Bakey I、II型主动脉夹层手术、术后康复及中期随访

Operation and postoperative rehabilitation and mid-term follow-up of De Bakey type I or II aortic dissection

目的总结主动脉夹层病人的外科治疗、术后康复经验及中期随访结果。方法2001年3月～2004年5月对36例DeBakeyI、II型主动脉夹层患者进行手术治疗,其中11例行Bentall手术;11例行Bentall手术+二尖瓣置换+三尖瓣成形术;5例行升主动脉置换术+主动脉瓣成形手术+全弓置换术+象鼻手术或降主动脉支架术(腔内隔绝术);3例行升主动脉置换术;2例行Bentall手术+次全弓置换术;2例行升主动脉置换术+主瓣动瓣置换术;2例行升主动脉置换术+主动脉瓣成形术。出院病人由专人负责术后康复治疗和定期随访。术后早期使用血管紧张素转换酶抑制、β受体阻滞剂和醛固酮拮抗剂,心功能恢复后使用β受体阻滞剂和长效钙拮抗剂严格控制血压和心率,并正确抗凝治疗。结果本组总死亡率为2.78%,其中急诊手术为12例,死亡1例,急诊手术死亡率为8..3%;择期手术24例,无死亡。主动脉阻断时间和体外循环时间与气管拔管时间呈正相关,相关系数分别为r=0.510,P=0.029和r=0.624,P=0.004,有显著相关性。主动脉阻断时间>100分钟和体外循环时间>200分钟与分别≤100分钟和≤200分钟的病人住院死亡和并发症的发生率的差异有统计学意义(P=0.003)。出院35例患者全部接受术后康复治疗及中期随访。术后康复治疗3个月至36个月后(平均治疗9个月)。

Objective To review the operative treatment and postoperative rehabilitation of De Bakey type I or II aortic dissection. Method From Mar 2001 to May 2004 ,36 patients with De Bakey type I or II aortic dissection underwent operative treatment .There were 11 cases of Bentall operation . The Bentall procedure and the mitral valve replacement with tricuspid valvoplasty were perfomed in 11 patients . The graft replacement of ascending aorta and aortic valve plastic surgery and aortic arch replacement with Elephant Trunk or endovascular graft exclusion were performed in 5 patient . There were 3 cases of graft replacement of ascending aorta .The Bentall procedure and partial aortic arch replacement were performed in 2 patient . A graft replacement of ascending aorta and aortic valve replacement were performed in 2 patients . There were two case s of graft replacement of ascending aorta and aortic valve plastic surgery . The all discharge patients were follow up and treated by the specialist . During postoperative early , the patients were treated with ACE inhibitors and beta- blockers and aldosterone antagonists . After heart function restored normal, blood pressures and heart rates were controled strictly with beta- blockers and long-acting calcium channel blockers . The anticoagulative therapies of individual must be right . Results There was 1 death within 15 days after surgery . The overall operative mortality rate was 2. 78% . The emergent operative mortality rate was 8.3 %(1 of 12 patients ) . There were significant correlation between endotracheal intubation time and duration of aortic cross-clamp time or cardiopulmonary bypass time (r= 0.510 , P= 0.029 and r= 0.624 , P= 0.004) . The aortic cross-clamp time (>100 minutes) or cardiopulmonary bypass time (>200 minutes) were statistically significant predictors of hospital death and complications (P=0.003) . NYHA heart functions were class I ～2 and the size of left ventricle (LV), left ventricular ejection fraction (LVEF) were normal in thirty of 31 patients with abnormal heart function . when average time (from 3 months to 36 momths ) was 9 months by postoperative rehabilitative treating strictly. The preoperative left ventricular end-diastolic diameter and left ventricular ejection fraction. as factors associated to postoperative rehabilitative treating time( r=0.724 , P=0.0016 , r=- 0.83 , P=0.002 ). Postoperative mid-term follow-up from 3 months to 40 months with mean period of 25.7 months .There was no late death during the follow-up period .The patients returned to their daily life and are working well after the rehabilitation . Conclusion The results of surgical treatment of De Bakey type I or II aortic dissection are excellent by selecting proper surgical procedures. The long aortic cross-clamp time (>100 minutes) and cardiopulmonary bypass time (>200 minutes ) during operation were identified as significant independent risk factors for hospital mortality and complications morbidity. earlier prompt referral before development of preoperative complications and to shorten duration of aortic cross-clamp time or cardiopulmonary bypass time appear essential to improve surgical results. The patients suffered from larger left ventricular end-diastolic diameter and lower left ventricular ejection fraction that postoperative rehabilitative treating time wanted to be enough long .Careful follow-up, adequate selection of medical are important in the postoperative patients . By paying attention to patient education and periodic late the using of drug therapy , it is anticipated that further improvement will be observed in late results.