急性主动脉夹层累及根部的外科治疗

Surgical Treatment for Acute Aortic Dissection with Involvement of Aortic Root

目的探讨Stanford A型急性主动脉夹层累及根部的手术治疗策略。方法上海交通大学医学院附属仁济医院自2005年1月至2010年12月,共62例Stanford A型急性主动脉夹层累及根部的患者接受手术治疗。根据对夹层近心端采用的不同手术处理方法分为3组,A组:28例,男20例、女8例,年龄(45.2±15.6)岁;行主动脉瓣交界悬吊+升主动脉置换术;B组:10例,男7例、女3例,年龄(44.6±14.9)岁;行部分窦部成形+升主动脉置换术;C组:24例,男17例、女7例,年龄(46.2±15.6)岁;行Bentall手术。比较分析3组患者的临床效果。结果围术期死亡6例,病死率为9.67%(6/62)。共随访54例,随访(27.3±15.7)个月。随访期间死亡2例,1例死亡原因不明,1例死于肺癌。A组1例患者术后6个月复查CT显示主动脉窦部假性动脉瘤。C组体外循环时间、主动脉阻断时间明显较A组和B组长[(274±97)min vs.(194±65)min、(210±77)min,t=22.482,30.419,P=0.002,0.122;(150±56)min vs.(97±33)min、(105±46)min,t=12.630,17.089,P=0.000,0.034]。3组患者的住院死亡率(t=1.352,P=0.516)及围术期二次开胸、急性肾损伤、神经系统并发症发生情况差异无统计学意义(t=0.855,0.342,2.281;P=0.652,0.863,0.320)。结论针对急性主动脉夹层病变累及根部的手术治疗可以采用主动脉瓣交界悬吊+升主动脉置换术、部分窦部成形+升主动脉置换术和Bentall手术等方法,并各有其优缺点。掌握每种方法的手术指征,灵活运用,可以获得满意的临床效果。

Objective To evaluate surgical strategies for the treatment of acute Stanford type A aortic dissection with involvement of the aortic root. Methods From January 2005 to December 2010, 62 consecutive patients underwent emergency surgical intervention for acute Stanford type A aortic dissection with involvement of the aortic root in Renji Hospital Affiliated to Medical School of Shanghai Jiaotong University. According to different methods for the management of proximal aortic dissection, these patients were divided into 3 groups： group A, aortic valve commissural suspension ＋ supracommissural replacement of the ascending aorta （SCR） ,including 28 patients （20 males and 8 females, mean age 45.2 ± 15.6 years） ; group B, partial sinus remodeling＋ascending aortic replacement, including 10 patients （7 males and 3 females, mean age 44. 6 ± 14. 9 years） ; group C, Bentall procedure,including 24 patients （ 17 males and 7 females, mean age 46.2± 15.6 years）. Clinical outcomes were compared among the three groups. Results Six patients died peri-operatively and in-hospital mortality was 9.67% （6/62）. Fifty-four patients were followed up, and the mean followup time was 27.3 ± 15.7 months. During follow up, 2 patients died, one for lung cancer and the other for unknown reason. One patient in group A underwent CT scan 6 months after surgery which showed aortic root pseudo-aneurysm. Cardiopulmonary bypass time and aortic cross-clamping time of group C were significantly longer than those of group A and group B （274±97 min vs. 194±65 min, 210±77 min, t=22. 482, 30. 419, P=0. 002, 0. 122; 150±56 min vs. 97±33 min, 105 ± 46 min, t= 12. 630, 17. 089, P=-0. 000, 0.034）. There was no statistical difference in mortality （t= 1.352, P=-0.516）, incidence of postoperative reexploration for bleeding, acute renal failure and neurological complication （t=-0. 855, 0. 342, 2. 281; P=-0. 652, 0. 863, 0. 320）among the three groups. Conclusion For patients with acute aortic dissection involving the aortic root, aortic valve commissural suspension＋SCR, partial sinus remodeling ＋ ascending aortic replacement and Bentall procedure may be considered the surgical treatment of choice with respective advantages and disadvantages. Satisfactory clinical outcomes can be achieveed if surgical indications and procedures are properly employed.