David Ⅰ与David Ⅱ手术治疗急性Stanford A型主动脉夹层的中期疗效对比

Mid-term result of valve-sparing root replacement in acute type A aortic dissection: comparison of reimplantation versus remodeling

目的:比较再植技术(reimplantation;David Ⅰ)与重塑技术(remodeling;David Ⅱ)两种不同的保留主动脉瓣的主动脉根部置换技术在急性Stanford A型主动脉夹层中的中期疗效。方法:回顾性分析2009年3月至2019年12月,41例接受保留主动脉瓣的主动脉根部置换术的急性Stanford A型主动脉夹层患者,平均年龄(44.63±11.34)岁,男36例,女5例。5例采用David Ⅱ技术,36例采用David Ⅰ技术。比较两组患者围术期相关指标、术后的主动脉瓣反流情况以及术后生存情况。结果:住院死亡占4.9%,两组各死亡1例,差异无统计学意义。David Ⅱ组在血液制品(红细胞、血浆及血小板)应用量、术后机械通气时间、二次开胸止血、急性肾功能衰竭需要床旁血液滤过等方面明显劣于David Ⅰ组,差异有统计学差异。39例出院生存患者中位随访时间为34.56(3~121)个月,随访率100%。两组均无随访死亡患者,无出血及血栓事件发生,无心血管再干预手术。术后出现主动脉瓣2级或以上反流方面,David Ⅱ组明显高于David Ⅰ组( P=0.02)。应用 Cox回归分析术后主动脉瓣反流的危险因素发现David Ⅱ手术是术后出现主动脉瓣反流的独立危险因素。 结论:在急性A型主动脉夹层患者中,与David Ⅱ手术相比,David Ⅰ手术具有更好的围术期及中期结果,二次开胸止血及血制品应用率、术后发生主动脉瓣反流概率明显降低,远期结果尚待进一步随访。

Objective To compare the mid-term result of two different valve-sparing root replacement techniques in acute type A aortic dissection:including reimplantation and remodeling.Methods From March 2009 to December 2019,41 patients with acute type A dissection and root involvement,who underwent a valve-sparing root replacement using reimplantation(36 cases)or remodeling(5 cases)were retrospectively analyzed in current study.The average age was(44.63±11.34)years old,36 males.The differences of perioperative variables,postoperative aortic insufficiency and postoperative survival were compared between the two groups.Results Thirty-day mortality for two groups was 2.8% and 20%(P=0.23).Remodeling group was significantly inferior to reimplantation group in terms of blood consumption(red blood cells,plasma and platelets),postoperative mechanical ventilation time,reoperation for bleeding and hemofiltration for acute renal failure.The median follow-up time of 39 discharged survivors was 34.56(3-121)months,and the follow-up rate was 100%.There was no follow-up death,no bleeding or embolism events,and no cardiovascular reoperation.Grade 2 or sever aortic regurgitation in remodeling group was significantly higher than that in reimplantation group(P=0.02).A Cox regression analysis identified that the remodeling technique was the independent risk factors of postoperative aortic regurgitation.Conclusion Compared with remodeling technique,reimplantation technique has better perioperative and mid-term results in patients with acute type A aortic dissection.The rate of reoperation for bleeding,the blood consumption and the postoperative aortic regurgitation are significantly reduced.The long-term results need further follow-up.