妊娠合并Stanford A型主动脉夹层的外科治疗

Surgical outcomes of type A aortic dissection in pregnancy

目的:回顾性分析妊娠合并Stanford A型主动脉夹层(TAAD)的治疗结果及策略。方法:回顾性分析2009年1月至2021年1月间,北京安贞医院大血管中心收治35例妊娠合并TAAD患者的临床资料。年龄(30.7±4.4)岁,马凡综合征15例(42.9%)。早期妊娠2例(5.7%),中期妊娠11例(31.4%),晚期妊娠15例(42.9%),产褥期7例(20.0%)。根据孕周(GWs)制定管理策略:分娩优先9例(25.7%),同期处理18例(51.4%),手术优先7例(20%),保守治疗1例(2.9%)。结果:手术优先、同期处理和分娩优先组的患者及胎儿死亡率分别为14.3%(1/7)、57.1%(4/7);5.6%(1/18)、15.8%(3/19)和11.1%(1/9)、22.2%(2/9);1例行保守治疗,患者及胎儿5 d后死于主动脉破裂。中位随访时间16.7(2.5,56.2)个月,2例(6.7%)患者及3例(12.0%)胎儿/新生儿死亡,6年总生存率分别为81.7%、63.5%。结论:结合GWs制定的TAAD诊疗策略切实可行。TAAD发生在28 GWs后,同期处理可以挽救母婴生命;但28 GWs前胎儿的死亡风险高,应优先挽救孕产妇的生命。

Objective To conduct retrospective analysis of outcomes and strategies of the treatment of Stanford type A aortic dissection(TAAD)in pregnancy.Methods A retrospective study was performed on the clinical data of 35 patients with TAAD in pregnancy admitted to Aortic Disease Center of Beijing Anzhen Hospital,Capital Medical University from January 2009 to January 2021.The mean age of the patients was(30.7±4.4)years and 15 cases(42.9%)were with Marfan syndrome.Among all the cases,2 were in the first trimester(5.7%),11 in the second trimester(31.4%),15 in the third trimester(42.9%)and 7 in the postpartum period(20.0%).Management strategies were designed based on gestational week(GW):delivery first for 9 cases(25.7%),single-stage delivery and aortic repair for 18 cases(51.4%),aortic repair first for 7 cases(20%),and conservative treatment for 1 case(2.9%).Results The maternal and fetal mortality rates were respectively 14.3%(1/7)and 57.1%(4/7)in the"aortic repair first"group;5.6%(1/18)and 15.8%(3/19)in the"single-stage delivery and aortic repair"group;11.1%(1/9)and 22.2%(2/9)in the"delivery first"group while for the 1 case of the"conservative treatment"group,the patient and the fetus died 5 days later of aortic dissection.The median follow-up time was 16.7(2.5,56.2)months.Two(6.7%)maternal deaths and 3 fetal/neonatal deaths occurred.The 6-year overall survival rates of patients and fetuses/newborns were 81.7%and 63.5%respectively.Conclusion The management strategy of TAAD based on the GWs is feasible.After 28 GWs,delivery followed by surgical repair can achieve maternal and fetal survival adequately while before 28 GWs,maternal survival should be prioritized given the high risk of fetal death.