急性主动脉夹层分离合并术前中度以上低氧血症患者手术策略的选择-to wait or not to wait

Management strategy in acute type A aortic dissection patients with moderate to severe hypoxemia-to wait or not to wait

目的:分析合并中度以上低氧血症(HO)的急性A型主动脉夹层分离(TAAAD)患者两种不同手术策略的临床资料,即优先处理HO,待患者HO改善后再手术,或不处理HO而急诊手术,比较两种治疗方式在此类患者中的优劣。方法:筛选出152例TAAAD患者术前合并中度以上HO,即氧合指数(PaO2/FiO2)≤150,且不合并夹层累及重要脏器血管造成急性缺血、主动脉瓣大量反流而致急性心力衰竭等应尽早手术的并发症,或疼痛剧烈,CT显示有夹层破裂征象者。其中62例患者急诊手术(NW组),另90例患者先保守治疗,待HO改善后,再行手术(W组)。收集整理所有入选患者详细术前、术中及围手术期临床资料。结果:两组术前临床资料无统计学差异,P>0.05。但W组在优先治疗HO中,全部需要机械通气治疗,其中3例需要床旁股静脉-股动脉体外膜肺氧合(ECMO);有10例出现肾功能不全表现,其中4例需床旁血液透析治疗;有8例死亡。两组在术中情况,包括主动脉根部及弓部的术式、主动脉阻断时间、深低温停循环时间、手术时间等方面未见明显差别,P>0.05。W组在围手术期病死率和术后肾、呼吸功能衰竭、感染等并发症方面和HO程度、机械通气时间、ECMO辅助循环、床旁血液透析、ICU时间和术后住院天数上,优于NW组,P<0.05。和W组相比,NW组在术后胸腔引流量及输血量上,有明显增多的情况,P<0.05。但W组如果附加上术前治疗HO时的临床数据,两组在总体肾功能衰竭发生率、床旁血液透析方面两组未见明显差别,P>0.05。而总体病死率、ECMO辅助循环、机械通气时间和ICU时间上,W组优于NW组,P<0.05。结论:对于合并中度以上HO的部分AAD患者,在合理的医疗决策下,优先保守处理HO,待患者HO改善后再手术,可以获得较好的临床疗效。

Objective：To compare the clinical outcomes of two kinds of operative strategy,i.e,emergency operation priority or treatment of hypoxemia（HO）first,in acute type A aortic dissection（TAAAD）patients with moderate to severe HO.Method：One hundred and fifty-two AAD patients in Stanford A type with moderate to severe HO,namely the oxygenation index（PaO2/FiO2）≤ 150,had not the complications which need emergency operation,such as acute ischemia in important organs caused by vascular dissection,severe aortic valve regurgitation and acute heart failure,or signs of aortic dissection rupture by CT scan.Among those patients,62 patients received emergency operation（group NW）,the other 90 cases were conservatively treated for HO first（group W）.Preoperative,intra-operative and peri-operative clinical data of all the patients were collected.Result：The preoperative clinical data of the two groups had no significant difference,P〉0.05.But in the W group,during the conservative treatment of HO,82 patients required mechanical ventilation therapy;3 cases need to extracorporeal membrane oxygenation（ECMO）;10 patients had renal insufficiency,4 patients needed bedside hemodialysis therapy;8 cases died.The intro-operative data,including surgical procedure,time of cardiopulmonary bypass,aorta cross-clamping,deep hypothermic circulatory arrest,operation time,had no significant difference between the two groups,P〉0.05.W group had lower rate of peri-operative mortality or morbidity,such as renal,respiratory failure,infection and the degree of HO,duration of mechanical ventilation,ECMO,bedside hemodialysis,ICU time and postoperative hospital stay,compared with NW group,P〈0.05.And postoperative chest drainage and blood transfusion in NW group were significantly increased,P〈0.05.But when overall consideration,the overall incidence of renal failure,bedside hemodialysis between the two groups had no obvious difference,P〉0.05.The overall mortality,ECMO assisted circulation,mechanical ventilation time and ICU time of W group were betterthan those in NW group,P〈0.05.Conclusion：For some AAD patients with moderate to severe HO,priority treatment of HO could reduce peri-operative mortality or morbidity and obtain better clinical outcomes.