保留瓣膜的改良主动脉根部成形术治疗急性StanfordA型夹层的近中期效果观察

Early to middle term efficacy of modified aortic root plasty with valve sparing in the treatment of acute Stanford A dissection

目的探讨保留瓣膜的改良主动脉根部成形术治疗急性Stanford A型夹层的近中期效果。方法选取2012年1月~2016年12月南京医科大学第一附属医院胸心外科诊断Stanford A1及A2型急性主动脉夹层的患者32例作为研究对象,均施行标准孙氏手术,根部处理均采用保留瓣膜的改良根部成形技术,将保留的全部血管外膜包绕人工血管近远端吻合口,并吻合至右心耳。通过围术期观察及术后随访,了解窦部病变进展、假腔及内引流隧道血栓化情况,比较术前及术后左室射血分数(EF)、左室舒张末内径、主动脉窦部直径等,评估该术式的近中期疗效。结果无手术室死亡发生,4例患者在院死亡,无截瘫等严重并发症。出院患者无失访,随访时间为19~60个月,随访期间死亡2例,22例患者夹层假腔完全血栓化,2例出现胸降主动脉扩张。至最后一次随访时,左室EF[(56.4±6.7)%比(59.1±8.2)%,P=0.700]、左室舒张末内径[(46.5±4.2)比(46.9±5.7)mm,P=0.532]、主动脉窦部直径[(34.2±5.3)比(35.5±6.1)mm,P=0.564)]均较术前无显著改变。结论急性主动脉夹层累及主动脉根部病变复杂,对于窦部累及不严重且窦部无明显扩张的患者施行改良的根部成形技术、精确的外科缝合及根部包裹引流技术,可以有效提高手术成功率,且近中期临床疗效较满意。

Objective To investigate the early to middle term efficacy of modified aortic root plasty with valve sparing in the treatment of acute Stanford A dissection. Methods From January 2012 to December 2016, 32 patients were diagnosed for acute aortic dissection with Stanford A1 and A2 types in Department of Cardiothoracic Surgery, the First M- filiated Hospital of Nanjing Medical University. All patients were underwent the standard Sun＇s procedure. Modified aortic root plasty with valve sparing was applied in the root treatment. A fistulization was made with the adventitia wrapped around the artificial vessel and shunted to the right atrial appendage. Through the perioperative observation and postoperative follow up, disease progress, false lumen and thrombosis were all recorded. And the early-to-middle term results of the operation were assessed by comparing of preoperative and postoperative left ventricular ejection fraction （EF）, left ventricular end diastolic diameter and aortic sinus diameter. Results There was no operation room death, but 4 deaths in the hospital. No serious complications such as paraplegia occurred. The discharged patients were fol- lowed up for 19-60 months. During the follow-up period, 2 patients died, 22 patients had complete thrombosis of the false lumen and 2 dilatations were observed in the descending thoracic aorta. There were no significant differences in the left ventricular EF [（56.4±6.7）% vs （59.1±8.2）%, P=0.700], left ventricular end diastolic dimension [（46.5±4.2） vs （46.9±5.7） mm, P=0.532] and aortic sinus diameter [（34.2±5.3） vs （35.5±6.1） mm, P=0.564] between the pre-operation and the last follow-up. Conclusion The pathological changes of acute aortic dissection involving the aortic root are complex. It is feasible to perform modified aortic root plasty with valve sparing in those without significant sinus exten-sion and valve insufficiency. Improved success rate of operation and early to middle term clinical efficacy can both be achieved by the Combination of accurate surgical suture and right-to-left shunt techniques.