主动脉瓣置换术后发生A型主动脉夹层的危险因素

The risk factors study of type A aortic dissection and aneurysm after aortic valve replacement

目的探讨主动脉瓣置换术后A型主动脉夹层发病的危险因素，以期确定有效的防治方法。方法回顾首都医科大学附属北京安贞医院2009年至2012年收治的主动脉瓣置换术后主动脉病变患者，A型主动脉夹层23例，升主动脉瘤20例，总结该类患者的临床特点、病理表现及手术经过，探讨主动脉瓣置换术后发生A型主动脉夹层危险因素及预防方法。结果主动脉瓣置换术后A型主动脉夹层组和升主动脉瘤组患者的年龄（P=0．012）、主动脉瓣二瓣化畸形（P=0．014）、主动脉瓣置换病因（P=0．009）和术后病理结果（P=0．001）差异有统计学意义，其中年龄、主动脉瓣关闭不全和病理是主动脉瓣置换术后发生主动脉夹层的重要危险因素（P=0．032、0．046和0．002）。结论主动脉瓣置换术患者，如主动脉直径大于45mm或伴有主动脉瓣关闭不全，既往高血压病史，术中见动脉壁纤薄或动脉壁弹性明显下降，除非患者有明显手术禁忌，均应积极行升主动脉置换或包裹成形以预防主动脉瓣置换术后A型主动脉夹层。如果术中未进行处理，应严密随访，观察主动脉扩张进展，如主动脉扩张大于5mm／年或主动脉直径大于50mm，则应积极再次手术。

Objective This retrospective study was perform to assess risk factors of the type A aortic dissection after aortic valve replacement, in order to provide a basis for devising a strategy for future treatment. Methods From 2009 to 2012, 23 patients were found type A aortic dissection and 20 patients were found aortic aneurysm after aortic valve replacement in Beijing Anzhen hospital. Analysis the clinical, pathology and surgery procedure characteristics of these patients, and assess the risk factors for type A aortic dissection after aortic valve replacement. Results After aortic valve replacement, There were signifi- cant different in age（ P = 0. 012 ） , bicuspid aortic valves（ P = 0. 014 ） , aortic valve regurgitation（ P = 0. 009 ） and postopera- tive pathoanatomical characteristics（P =0. 001 ） between type A aortic dissection group and ascending aortic aneurysm group. Multivariate logistic regression analysis indicated that age（ P = 0. 032 ）, aortic valve regurgitation （P = 0. 046 ） and pathoana- tomical characteristics （P = 0. 002） were important risk factor for type A aortic dissection after aortic valve replacement , re- spectively. Conclusion Older age, aortic regurgitation combined and thinned or fragile aortic walls with systemic hypertension in patients with ascending aortic dilatation （/〉45 mm diameter） at the time of AVR might be predisposing factors for postsurgi- cal type A aortic dissection. These patients should be considered for concomitant replacement or repair of the ascending aorta unless the patient has a high operative risk.