Surgery for acute type A aortic dissection: The Hopital Foch experience (1977-1998)
Surgery for acute type A aortic dissection: The Hopital Foch experience (1977-1998)
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DOI：
10.1016/s0003-4975(99)00433-6
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发表时间：
1999-06-01
影响因子：
4.6
通讯作者：
Guilmet, D
中科院分区：
文献类型：
--
作者：
Bachet, J;Goudot, B;Guilmet, D
1977年1月至1998年3月，我院急诊手术治疗A型主动脉夹层204例，男146例，女58例，年龄15~79岁，平均54 ± 11岁。165例患者（84%）在症状发作后48小时内进行了手术。28例（13.7%）有马凡氏综合征。在43例患者（23%）中，主动脉瓣被单独置换（6，3%）或通过复合移植物置换（37，18.1%）。由于内膜撕裂的位置，主动脉置换术包括横弓60例（29.4%）。结果医院死亡率为21%（39例）：25%的患者与弓置换术和19.4%的患者没有弓置换术（NS）。161例患者出院并随访2个月至21年（平均85 ± 66个月）。在此期间，25例患者（15.5%）需要再次手术，共计33例再次手术。7例患者（28%）在再次手术时死亡。单因素分析显示，马凡氏综合征（p <0.05）和未行牙弓置换（p <0.02）是再次手术的危险因素。急诊手术（P <0.01）和胸腹联合置换（P <0.04）是再次手术死亡的危险因素。1年、5年、10年和15年时的精算无再次手术率（Kaplan-Meier，置信区间95%）分别为96.1%（90.9%-98.2%）、87.6%（79.8%-92.7%）、80.9%（70.8%-88.1%）和66.4%（51.1%-78.9%）。随访期间共有39例患者（24.3%）死亡。马凡氏综合征（p <0.01）、再次手术（p <0.02）、卒中（p <0.05）和心力衰竭（p <0.05）是晚期死亡率的危险因素。包括住院死亡率在内的晚期生存率为71.5%（64.3%-77.8%）1年时，66%（58.3%-73%）5年时，56.4%（47.7%-64.7%），46.3%结论GRF胶在急性A型夹层的急诊初次手术中被证明是非常有用的，使得手术更加容易和安全。由于这种手术改进，GRF胶的使用似乎对后期结果产生了有益的影响，但这些也取决于患者的基本状况。
BackgroundIn 1977, we proposed the use of gelatin-resorcinol-formol (GRF) biological glue during surgery for acute type A aortic dissection.MethodsFrom January 1977 to March 1998, 204 patients (146 men and 58 women) aged from 15 to 79 years (mean 54 ± 11) underwent emergency operation for type A aortic dissection in our institution. One hundred sixty-five patients (84%) were operated on within 48 h after the onset of symptoms. Twenty-eight patients (13.7%) had Marfan’s syndrome. In 43 patients (23%), the aortic valve was replaced either independently (6, 3%) or by means of a composite graft (37, 18.1%). Because of the location of the intimal tear, aortic replacement included the transverse arch in 60 patients (29.4%).ResultsHospital mortality was 21% (39 patients): 25% in patients with arch replacement and 19.4% in patients without arch replacement (ns). One hundred sixty-one patients were discharged and followed from 2 months to 21 years postoperatively (mean 85 ± 66 months). During this interval, 25 patients (15.5%) required reoperation for a total of 33 reoperations. Seven patients (28%) died at reoperation. Upon univariate analysis, presence of Marfan’s syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were risk factors for reoperation. Emergency operation (p < 0.01) and thoracoabdominal replacement (p < 0.04) were risk factors for death at reoperation. The actuarial freedom from reoperation (Kaplan-Meier, confidence interval 95%) is 96.1% (90.9%–98.2%) at 1 year, 87.6% (79.8%–92.7%) at 5 years, 80.9% (70.8%–88.1%) at 10 years, and 66.4% (51.1%–78.9%) at 15 years. A total of 39 patients (24.3%) died during follow-up. The presence of Marfan’s syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were risk factors for late mortality. The actuarial late survival including hospital mortality is 71.5% (64.3%–77.8%) at 1 year, 66% (58.3%–73%) at 5 years, 56.4% (47.7%–64.7%) at 10 years, and 46.3% (36.4%–56.5%) at 15 years.ConclusionsThe GRF glue has proven extremely useful during emergency initial surgery for acute type A dissection, making the procedure much easier and safer. As a result of this operative improvement, the use of the GRF glue seems to have had a beneficial influence on late results, but these also depend upon the patient’s basic condition.