Surgical risk of preoperative malperfusion in acute type A aortic dissection
Surgical risk of preoperative malperfusion in acute type A aortic dissection
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DOI：
10.1016/j.jtcvs.2009.04.059
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发表时间：
2009-12-01
影响因子：
6
通讯作者：
Mohr, Friedrich-Wilhelm
中科院分区：
文献类型：
--
作者：
Girdauskas, Evaldas;Kuntze, Thomas;Mohr, Friedrich-Wilhelm
目的：A型夹层合并术前血流灌注不良综合征的患者被认为具有极高的手术风险。方法：从1994年10月至2008年1月，共有276名患者(174名男性，平均年龄59.5±13.4岁)接受了急性A型夹层的手术治疗。术前诊断灌注不良综合征93例(33.7%)，冠脉循环41例(15%)，中枢神经系统39例(14%)，肢体缺血32例(11.6%)，肠系膜循环8例(3%)。结果：I组住院病死率为29.0%，II组为13.6%(P<0.002)。术后重症监护病房住院时间，灌注不良组较长(11.4±9.7天vs7.7±6.9天；P=0.04)。共有6例(75%)肠系膜灌注不良患者死亡。术后1-122个月的长期随访率为100%。I组1年和5年总生存率分别为49.8%+/-11.8%和41.8%+/-12.6%，而II组分别为70.4%+/-7.6%和56%+/-10.4%(P=0.005)。Cox回归分析显示，术前血流灌注不良是A型夹层手术后长期死亡率的重要危险因素(风险比为1.7；95%可信区间为1.2-3.1)。结论：术前血流灌注不良是影响急性A型夹层手术围手术期和术后长期生存的重要危险因素。对于临床表现明显的肠系膜灌注不良患者，应考虑经皮介入治疗和延迟手术，因为立即手术治疗的预后很差。(胸心外科杂志2009；138：1363-9)
Objective: Patients who have type A dissection with preoperative malperfusion syndromes are believed to be at extremely high surgical risk. Our aim was to evaluate perioperative and long-term results of patients with preoperative malperfusion.Methods: A total of 276 patients (174 men; mean age 59.5 +/- 13.4 years) underwent surgery for acute type A dissection between October 1994 and January 2008. Preoperative malperfusion syndromes were diagnosed in 93 (33.7%) patients (group I) and involved coronary circulation in 41 (15%) patients, central nervous system in 39 (14%) patients, limb ischemia in 32 (11.6%) patients, and mesenteric circulation in 8 (3%) patients. Postoperative results were compared between patients with preoperative malperfusion and those without this complication (group II, n = 183).Results: In-hospital mortality was 29.0% in group I versus 13.6% in group II (P - .002). The postoperative intensive care unit stay was longer (11.4 +/- 9.7 vs 7.7 +/- 6.9 days; P = .04) in the malperfusion group. A total of 6 (75%) patients with mesenteric malperfusion died. Long-term follow-up (range, 1-122 months postoperatively) was available in 100% of survivors. One-year and 5-year overall survivals were 49.8% +/- 11.8% and 41.8% +/- 12.6% in group I versus 70.4% +/- 7.6% and 56% +/- 10.4% in group II (P = .005). Cox regression analysis identified preoperative malperfusion as a significant risk factor for long-term mortality after surgery for type A dissection (hazard ratio, 1.7; 95% confidence intervals, 1.2-3.1).Conclusions: Preoperative malperfusion is a significant risk factor influencing perioperative and long-term survival after surgery for acute type A dissection. Percutaneous interventional procedures and delayed surgery should be considered in patients with clinically apparent mesenteric malperfusion because of the dismal prognosis of immediate surgical therapy. (J Thorac Cardiovasc Surg 2009;138:1363-9)