"视而不见"主动脉根部修复术治疗急性Stanford A型主动脉夹层疗效的前瞻性研究

" Watching without dealing" aortic root repair in the treatment of acute Stanford type A aortic dissection: a prospective observational study

目的介绍"视而不见"主动脉根部修复术并评价其在急性Stanford A型主动脉夹层应用中的临床效果。方法2017年10月至2018年10月,对急性Stanford A型主动脉夹层根部受累的患者行"视而不见"主动脉根部修复术。近端吻合平面均在窦管交界水平,不"追求"彻底切除窦内夹层。通过前瞻性分析患者围手术期临床资料及随访期影像学资料评价该技术的早中期疗效。结果共入选患者20例,男15例,女5例;年龄(48.0±12.1)岁(34~73岁),术前主动脉窦直径(41.3±3.6)mm,主动脉窦管交界直径(43.9±6.6)mm。本组患者均接受升主动脉置换+全弓置换+支架象鼻手术。体外循环(179.5±41.5)min(132~255 min),阻断(120.3±23.7)min(95~180 min)。本组患者围手术期未发生死亡、二次开胸、肾衰、脑梗塞及截瘫等不良事件。患者出院前主动脉CT血管造影(CT angiography,CTA)显示窦内残留假腔均消失,主动脉窦直径(30.8±2.6)mm,主动脉窦管交界直径(27.2±2.5)mm。随访(28.5±7.8)个月(3~35个月),未发生主动脉根部外科再干预。随访期主动脉CTA显示主动脉窦内无残留或新发夹层,主动脉窦直径(30.9±2.4)mm,主动脉窦管交界直径(27.5±2.7)mm;随访期超声心动图显示主动脉瓣结构及功能正常。比较出院时和随访期的主动脉窦部和窦管交界直径,差异无统计学意义。结论"视而不见"主动脉根部修复术相对简单易学,采用该技术对急性Stanford A型主动脉夹层行根部处理,围手术期疗效理想。早中期随访影像学检查显示主动脉窦结构恢复正常。远期临床疗效有待进一步随访观察。

Objective To evaluate the clinical effects of"watching without dealing"aortic root repair technique in acute Stanford type A aortic dissection(ATAAD).Methods From October 2017 to October 2018,"watching without dealing"technique was performed in ATAAD patients with mild aortic root involvement.The proximal aortic anastomosis was at the level of the sinotubular junction,without"pursuing"complete excision of the intra-sinus dissections.The perioperative clinical data and follow-up imaging results of the patients were collected and analyzed to evaluate early and mid-term efficacy of the technique.Results A total of 20 patients received"watching without dealing"technique in our hospital,including 15 males and 5 females with a mean age of(48.0±12.1)years old(34-73 years old).The preoperative aortic sinus diameter was(41.3±3.6)mm and the aortic sinotubular junction diameter was(43.9±6.6)mm.All patients underwent ascending aortic replacement and total arch replacement plus frozen elephant trunk surgery.The cardiopulmonary bypass time was(179.5±41.5)min(132~255 min),the cross-clamp time was(120.3±23.7)min(95~180 min),and the circulatory arrest time was(8.8±7.6)min(2~22 min).During perioperative period,no adverse events such as death,secondary opening,renal failure,cerebral infarction,and paraplegia occurred.The CTA examination of the aorta before the patients were discharged showed that all residual false lumen in the sinus disappeared,the diameter of the aortic sinus was(30.8±2.6)mm,and the diameter of the aortic sinotubular junction was(27.2±2.5)mm.The patients were followed up for mean(28.5±7.8)months(3~35 months).No surgical re-intervention of the aortic root occurred.The aortic CTA during follow-up period showed no residual or new dissection in the aortic sinus,the diameters of the aortic sinus and aortic sinotubular junction were(30.9±2.4)mm and(27.5±2.7)mm respectively;the ultrasonic cardiogram showed normal aortic valve structure and function.No statistically significant differences were found when comparing the aortic sinus diameter and aortic sinotubular junction diameter between two time points of at discharge and follow-up.Conclusion The"watching without dealing"aortic root repair technique for ATAAD is relatively simple to learn and safe in the perioperative period.Early and mid-term follow-up imaging showed normalization of the aortic sinus structure.Further follow-up and observation were necessary to figure out the long-term clinical outcome of this modified aortic root repair.