Total aortic arch repair: risk factor analysis and follow-up in 199 patients
Total aortic arch repair: risk factor analysis and follow-up in 199 patients
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DOI：
10.1093/ejcts/ezw158
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发表时间：
2016-11-01
影响因子：
3.4
通讯作者：
Shrestha, Malakh
中科院分区：
文献类型：
--
作者：
Martens, Andreas;Beckmann, Erik;Shrestha, Malakh
目的：主动脉弓手术与显着的围手术期风险相关。新的假体和新的灌注技术已经被开发出来以降低这些手术的风险。这些新技术的常规应用需要重新评估主动脉弓修复的危险因素。方法：2010年4月至2015年12月期间，199名患者[61%为男性，中位年龄63岁（四分位距52-70岁）]在我们机构接受了全主动脉弓修复术。 44% 的患者患有急性主动脉夹层（AD，32% 患有灌注不良），22% 患有慢性主动脉夹层 (CD)，34% 患有退行性动脉瘤，24% 接受了再次手术。我们的手术技术包括心脏手术中的冷血心脏停跳液、主动脉弓修复期间的非心脏停搏持续心肌血液灌注以及远端主动脉弓重建后的早期下半身再灌注。手术结束时进行头部血管吻合术。结果：44% 的患者接受了主动脉根部手术，90% 的患者接受了经典象鼻 (ET) 或冷冻象鼻 (FET)。中位（四分位距）心肺转流时间、心脏缺血时间、低温停循环时间和选择性顺行脑灌注时间分别为248分钟（204-302）、105分钟（51-150）、47分钟（35-61）和93分钟（72-115）。手术死亡率为 16%，中风发生率为 10%，透析发生率为 21%，脊髓损伤发生率为 5%。死亡的独立危险因素是年龄、因出血而开胸手术、术后透析、最大乳酸值和最大肌酐激酶-MB (CK-MB) 值。 “心跳”主动脉弓手术显着降低了死亡风险。灌注不良综合征和冠状动脉旁路移植术是中风的术前预测因素。 CD、术前肾功能不全、手术时间、因出血而开胸手术和低心排血量综合征是术后透析的危险因素。 2 年后主动脉再次手术的几率分别为 91% (AD)、66% (CD) 和 70%（动脉瘤）。 结论：主动脉弓修复仍然是一种高风险手术，尤其是在多节段主动脉疾病中。一些围手术期和术后因素预测了不良结果，表明需要进一步改善围手术期管理（例如器官保护）。必须彻底研究 FET 治疗的适应症（例如 CD 中的 FET）。
OBJECTIVES: Aortic arch surgery is associated with substantial perioperative risks. New prostheses as well as novel perfusion techniques have been developed to reduce the risks of these procedures. The routine application of these new techniques warrants reassessment of risk factors of aortic arch repair.METHODS: Between April 2010 and December 2015, 199 patients [61% male, median age 63 years (interquartile range 52-70 years)] underwent total aortic arch repair in our institution. Forty-four per cent of the patients presented with acute aortic dissections (ADs, 32% with malperfusion), 22% with chronic aortic dissections (CDs), 34% with degenerative aneurysms, 24% underwent reoperations. Our surgical technique involved cold blood cardioplegia for cardiac procedures, non-cardioplegic continuous myocardial blood perfusion during aortic arch repair and early lower body reperfusion after distal aortic arch reconstruction. Anastomosis of head vessels is performed at the end of the procedure.RESULTS: Forty-four per cent of patients underwent aortic root surgery, 90% received a classical elephant trunk (ET) or frozen elephant trunk (FET). Median (interquartile range) cardiopulmonary bypass time, cardiac ischaemia time, hypothermic circulatory arrest time and selective antegrade cerebral perfusion time were 248 min (204-302), 105 min (51-150), 47 min (35-61) and 93 min (72-115), respectively. Operative mortality was 16%, stroke occurred in 10%, dialysis in 21% and spinal cord injury in 5%. Independent risk factors for mortality were age, rethoracotomy for bleeding, postoperative dialysis, maximum lactate value and maximum creatinine kinase-MB (CK-MB) value. 'Beating heart' aortic arch surgery significantly reduced the risk of mortality. Malperfusion syndrome and coronary artery bypass grafting were preoperative predictors of stroke. CD, preoperative renal dysfunction, operation time, rethoracotomy for bleeding and low cardiac output syndrome were risk factors for postoperative dialysis. Freedom from aortic reoperation was 91% (AD), 66% (CD) and 70% (aneurysm) after 2 years.CONCLUSIONS: Aortic arch repair remains a high-risk procedure, especially in multisegment aortic disease. Several peri-and postoperative factors predicted adverse outcome, indicating the need to further improve perioperative management (e. g. organ protection). Indications for FET treatment have to be thoroughly investigated (e.g. FET in CDs).