心脏术后Stanford A型主动脉夹层的外科治疗

The surgical repair for acute Stanford type A aortic dissection after cardiac surgery

目的 总结心脏手术后StanfordA型主动脉夹层的治疗经验.方法 2006年12月至2019年3月,36例心脏术后A型主动脉夹层的患者接受二次手术治疗,男性30例,女性6例;年龄26~74岁,平均(53.8±11.3)岁.首次心脏手术为非主动脉夹层手术20例,包括主动脉瓣置换9例、二尖瓣置换3例、二尖瓣成形1例、双瓣置换3例、冠状动脉旁路移植2例、主动脉根部置换1例和室间隔缺损修补1例.首次心脏手术为夹层手术的有16例,包括单纯升主动脉置换术后主动脉弓部扩张2例、升主动脉+右半弓置换术后弓部扩张11例、Bentall+孙氏手术后右冠吻合口漏1例、升主动脉+右半弓置换近端吻合漏1例、升主置换+孙氏手术后近端吻合口漏1例.本次手术距首次手术0.3~11年,平均(5.6±3.2)年.结果 所有36例患者均施行了主动脉夹层手术,体外循环90~409 min,平均(224.5±78.7)min;主动脉阻断60~207min,平均(107.2±39.4)min.34例深低温停循环、低流量选择性脑灌注患者低流量时间16~47 min,平均(25.6±8.2)min.死亡2例(5.6%);术后并发症6例(16.7%).生存患者随访1~148个月,平均(40.3±20.3)个月,随访期间无夹层破裂、截瘫和死亡.结论 心脏手术后A型主动脉夹层患者或A型主动脉夹层术后根部残余夹层或远端弓部扩张患者应及时手术治疗,但手术难度及风险均较初次主动脉手术增加,因此进行心脏手术时应特别注意主动脉操作的规范和准确,一旦心脏术后再发A型夹层则应尽量施行全弓支架象鼻手术,可获得较好的近远期临床效果.

Objective To summarize the experience of surgical repair for Stanford type A aortic dissection after cardiac surgery. Methods From December 2006 to March 2019, 36 patients who underwent previous cardiac surgery accepted the aortic surgery for Stanford type A aortic dissection were reviewed. There were 30 males and 6 females. The range o f age was from 26 to 74 years and the mean age was (53.8±11.3) years. The first cardiac surgery of 20 patients are not aortic dissection operation. In these patients, one patient had undergone ventrical septal defect repair, 3 patients had undergone MVR, 1 patient had undergone MVP, 2 patients had undergone CABG , 1 patient had undergone Bentall procedure, 2 patients had undergone DVR replacement and 9 patients had undergone aortic valve replacement. Among the other 16 patients, first time operations were ascending aorta replacement procedure in 2 patients, ascending aorta combined with partial aortic arch replacement in 11 patients, the right coronary ostia anastomosing leaking after aortic root replacement ( Bentall) with Sun's procedure in 1 patient, the proximal anastomosing leaking after aortic valve combined with ascending aorta replacement (Wheat) in 1 patient and ascending aorta combined with Sun's procedure in other patient. The interval between the two operations was 0.3-11 years (5.6±3.2) years. Results All the patients underwent aortic surgery for aortic dissection. The time of cardiopulmonary bypass was 90-409 minutes, the mean value was (224.5±78.7)minutes. Aortic cross clamp time was 60-207 minutes, the mean value w as(107.2±39.4)minutes. 34 patients needed deep hypothermia and selective cerebral perfusion time was 16-47 minutes, the mean value was (25.6±8.2) minutes. 2 patients dead inthe hospital and the mortality was 5.6%.The morbidity was 16.7%.34 patients followed up 1-148 months. No aortic rupture, paraplegia and death were observed in follow-up time. Conclusion The patients with delayed Stanford type A aortic dissection after cardiac surgery or the patients for residual aortic dissection after initial operations on Stanford type A aortic dissection should be attached to great importance and need surgical treatment in time. But the technique is demanding and risk is great for surgeons and patients, which need enough specification and accurate on aortic operation. More importantly, the total arch replacement with the elephant trunk implantation also should be performed on the treatment of residual aortic dissection to obtain the better short and long-term results in the future.