Trends and Outcomes of Elective Thoracic Aortic Repair and Acute Thoracic Aortic Syndromes in the United States

BackgroundThere is a paucity of data on the contemporary outcomes and trends of elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome.MethodsWe queried the National Inpatient Sample (NIS) database years 2012-2016 to identify hospitalizations for elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. The main study outcome was in-hospital mortality.ResultsThe analysis yielded 24,295 hospitalizations for elective thoracic aortic aneurysm repair and 8875 hospitalizations for aneurysm-associated acute aortic syndrome. The number of hospitalizations for elective aortic repair significantly increased from 4375 in 2012 to 5450 in 2016 (P_trend = .01). The number of hospitalizations for acute aortic syndrome numerically increased from 1545 in 2012 to 2340 in 2016 (P_trend = .10). Overall in-hospital mortality for elective aortic repair was 2.4% with no change over time. In-hospital mortality for acute aortic rupture was 39.4% and for acute aortic dissection was 6.2% with no change over time. Hospitalizations for elective aortic repair had lower incidence of complications compared with those for aneurysm-associated acute aortic syndrome, including cardiogenic shock, cardiac arrest, acute stroke, and shorter length of stay. Factors associated with higher mortality among admissions undergoing elective aortic repair included older age, heart failure, valvular disease, and chronic kidney disease. Older age, coagulopathy, and fluid/ electrolytes disorders were associated with increased mortality among those with acute aortic syndrome.ConclusionContemporary elective thoracic aortic aneurysm repair is associated with lower in-hospital mortality and morbidity when compared with a clinical presentation for an aneurysm-associated acute aortic syndrome. This should be taken into account when deciding the timing of elective aortic aneurysm repair and balancing the risks and benefits.     

升主动脉瘤合并主动脉瓣关闭不全的外科治疗

目的：回顾性总结自１９９１年１２月至１９９９年５月期间,３３例升主动脉瘤伴主动脉瓣关闭不全外科治疗的经验。方法：３３例升主动脉瘤中,１例为真性动脉瘤。３２例为夹层动脉瘤。夹层动脉瘤按ＤｅＢａｋｅｙ分型法,Ｉ型８例,ＩＩ型２４例,均伴主动脉关闭不全,均行Ｂｅｎｔａｌｌ手术,１０例合并二、三尖瓣关闭不全,做二、三尖瓣整形手术。１例合并冠心病,做内乳动脉与前降支搭桥术,结果：手术死亡率为６．０％（２／３３）,２例分别死于感染性心内膜为和吻合不可控制性渗血,２例有严重脑部并发症,随访时间１～５５个月,远期死亡２例,均系错迷窒息死亡,其余２９例心功能明显改善,眩动脉瘤无复发。结论：（１）升主动脉瘤合并主动脉瓣关闭不全行Ｂｅｎｔａｌｌ手术,采用良好的心肌保护方法,注意吻合技术防止出血,可以取得良好的手术效果。（２）对Ｄ     

Short term outcome of thoracic endovascular aortic repair in patients with thoracic aortic diseases

Aim and background

Open surgical repair for thoracic aortic diseases is associated with a high perioperative mortality and morbidity. Most of type B aortic dissections are uncomplicated and are medically treated which carries a high mortality rate. Thoracic endovascular aortic repair is the first-line therapy for isolated aneurysms of the descending aorta and complicated type B aortic dissection. The aim of this study is to test the safety of early thoracic endovascular aortic repair in patients with uncomplicated type B aortic dissection and patients with thoracic aortic aneurysms.

主动脉根部瘤的外科治疗

1978年1月至1992年11月期间,阜外医院外科手术治疗主动脉根部瘤105例,手术方法分为四种:Bentall手术50例;Wheat手术21例;同种主动脉根部移植7例;非典型主动脉根部替换术27例。总手术死亡率12.4%,近四年来降至4.0%。手术存活的92例心功能明显改善;七年生存率75.4±12.3%。作者对影响主动脉根部瘤外科治疗效果的因素进行了分析,对手术方法和外科技术进行了探讨。     

Giant Proximal Aorta Aneurysm: A Successfully Managed Time Bomb

Management of aortic aneurismatic disease is often care of specialists, from vascular to cardiac surgeons. However, initial diagnosis and management are not unfrequently responsibility of an emergency staff as the disease presentation may be dramatically acute. Thoracic aortic aneurysms (TAA) in particular have a silent clinical history until they become evident with dissection or rupture with a high global mortality rate. The importance of a rapid diagnosis and of correct management in such a subsetting is clear, but recent guidelines where published with the declared rationale of emphasizing the importance of an early detection of the disease. The goal is to reduce morbidity and mortality and improvement of quality of life of such patients. We present a case of successfully managed asymptomatic giant proximal aortic aneurysm in a healthy young man. On a routine transthoracic echocardiogram, severe dilatation of the proximal aorta was detected, with severe aortic regurgitation in a normal tricuspid valve determining left ventricle (LV) dilatation and impaired contractility. Computed tomography scan was scheduled, confirming the findings and open heart surgery performed within 1 week. Clinical and echocardiographical follow-up was started; after 2 months imaging studies showed good surgical results with well-functioning, non-regurgitant prosthetic aortic valve and initial recovery of left ventricular dilatation; at the last control, 14 months later, LV mass and dimensions where markedly improved, with no more signs of hypertrophy nor dilatation. TAA needs a rapid diagnosis and appropriate management. Clinicians should be aware of proper diagnostic tools and of applicable therapeutic strategies in order to grant the better assistance to the patient. In this setting, the role of echocardiography remains pivotal.     

Screening, Evaluation, and Early Management of Acute Aortic Dissection in the ED

Acute aortic dissection (AAD) is a rare and lethal disease with presenting signs and symptoms that can often be seen with other high risk conditions; diagnosis is therefore often delayed or missed. Pain is present in up to 90% of cases and is typically severe at onset. Many patients present with acute on chronic hypertension, but hypotension is an ominous sign, often reflecting hemorrhage or cardiac tamponade. The chest x-ray can be normal in 10-20% of patients with AAD, and though transthoracic echocardiography is useful if suggestive findings are seen, and should be used to identify pericardial effusion, TTE cannot be used to exclude AAD. Transesophageal echocardiography, however, reliably confirms or excludes the diagnosis, where such equipment and expertise is available. CT scan with IV contrast is the most common imaging modality used to diagnose and classify AAD, and MRI can be used in patients in whom the use of CT or IV contrast is undesirable. Recent specialty guidelines have helped define high-risk features and a diagnostic pathway that can be used the emergency department setting. Initial management of diagnosed or highly suspected acute aortic dissection focuses on pain control, heart rate and then blood pressure management, and immediate surgical consultation.     

升主动脉瘤的外科治疗

目的总结升主动脉瘤的临床诊断和外科治疗经验。方法自2003年3月至2008年11月,20例升主动脉瘤患者中马凡综合征11例、升主动脉瘤伴主动脉瓣关闭不全3例、单纯升主动脉瘤3例、急性夹层动脉瘤伴主动脉瓣关闭不全2例、升主动脉瘤伴主动脉瓣关闭不全并感染性心内膜炎1例。行单纯Bentall手术10例、Bentall手术加右半弓人工血管置换2例、Wheat手术4例、Cabrol手术1例、David手术1例、主动脉瓣置换加主动脉弓置换加象鼻手术1例、主动脉瓣置换术加升主动脉成形术1例。结果全组无手术死亡和术后严重并发症发生。结论早期诊断、精细的手术操作技巧、据病情选择合适的手术方式,是改善升主动脉根部瘤患者预后的关键。     

Infectious aneurysm of the ascending aorta – Successful conservative treatment in a high-risk patient

Infectious aortic aneurysm is a rare disease requiring early and comprehensive management to prevent the development of serious complications. While surgical repair is still the gold standard, an endovascular approach is an alternative for some patients. Conservative management is traditionally associated with the worst prognosis. We report a case of an infectious aneurysm of the ascending aorta with an atypical clinical manifestation and a complicated diagnostic process, which resulted in successful comprehensive conservative management of a high-risk patient who rejected radical surgical treatment.     

Delayed enhancement on computed tomography in abdominal aortic aneurysm wall

The purpose of this study was to evaluate delayed enhancement (DE) of the aortic wall of atherosclerotic aneurysms using computed tomography and to evaluate the relationships between DE and wall thickness of abdominal aortic aneurysm (AAA), diameter of AAA, serum levels of C-reactive protein (CRP) which indicate inflammation status, and pathological findings. Computed tomographic images of atherosclerotic AAA in 110 patients were studied between July 2001 and March 2003. Computed tomography (CT) scanning included unenhanced, enhanced early, and enhanced delayed phases. Pathological findings were obtained from 19 of the 110 patients. We determined DE of the AAA wall and assessed the association between DE and AAA wall thickness, AAA diameter, serum levels of CRP, and pathological findings. Delayed enhancement on CT was demonstrated in 66 of 110 patients with atherosclerotic AAA (60.0%). Patients with DE demonstrated significantly larger AAA diameter (4.8 ± 0.9 versus 3.9 ± 0.6 cm, P < 0.0001) and significantly higher levels of CRP (5.0 ± 6.0 versus 2.3 ± 2.9 mg/l, P = 0.033) than those patients without DE. Patients with DE also had significantly thicker and more severe atheroma and a tendency toward more prominent inflammation and vascularity in pathologic findings. There was no significant difference in wall thickness between AAA with and without DE (1.44 ± 0.7 versus 1.24 ± 0.22 mm, P = 0.352). Delayed enhancement on CT demonstrated in over half of atherosclerotic AAA may be associated with chronic inflammation by atherosclerosis.     

白塞氏病合并升主动脉瘤和主动脉瓣关闭不全的外科治疗——个案报告与文献复习

目的 :报告 1例Beh et’s病合并升主动脉瘤、主动脉瓣关闭不全的外科治疗 ,结合文献 ,探讨其相关问题和解决方法。方法 :1例Beh et’s患者经激素加免疫抑制剂治疗后进行升主动脉与主动脉瓣替换手术 ,术后给予激素、抗凝、抗炎治疗 ,并随访 ;阅读分析相关文献 ,探讨解决方案。结果 :本例患者术后早期恢复良好 ,彩色多普勒超声心动图示人工瓣情况无异常 ,随访 6个月情况良好 ,后因主动脉人工瓣脱落导致急性心衰而死亡。结论 :Beh et’s合并升主动脉瘤及主动脉瓣关闭不全手术后容易并发瓣周漏或人工瓣脱落 ,尽管已提出了一些预防方法 ,但从根本上尚无有效的防治办法。     

硫化氢减缓主动脉夹层发生发展中的机制探讨

主动脉夹层（Aortic dissection, AD）是一种以多种炎性细胞和炎症因子参与的，以细胞外基质降解及血管重构为主要特征的、威胁生命的心血管疾病。硫化氢（Hydrogen sulfide, H2S）是继一氧化氮（Nitric oxide, NO）、一氧化碳（Carbon monoxide, CO）后发现的另一重要内源性气体递质。H2S的抗炎、抗氧化、抗细胞凋亡、抗高血压等效应在动脉粥样硬化、缺血/再灌注损伤、心肌梗死、高血压等心血管疾病中发挥重要作用。但在主动脉夹层形成中的作用鲜有报道，本文将从血管重构、高血压、炎症、microRNAs (miRNAs)等方面探讨H2S在AD发生发展中的作用及相关机制。     

Aortic root complications of infective endocarditis--influence on surgical outcome

Fifty cases of aortic valve endocarditis during a 6-year period between 1982 and 1988 were reviewed. Twenty-three (46%) had aortic root complications by way of aortic root abscess or mycotic aneurysm in the perivalvular area. Patients with root complications were grouped into the aortic root abscess (ARA) group and those without into a non root abscess (NARA) group. Prosthetic valve endocarditis dominated in the ARA group (12 and four cases of prosthetic valve infection in the ARA and NARA groups, respectively; P less than 0.01). Surgical mortality was significantly higher at 13.6% in the ARA group as opposed to 2.2% in the NARA group (P less than 0.05). Post-operative aortic regurgitation was present in 8 (57%) of 14 patients in the ARA group surviving surgery but in only two (8.7%) of 23 patients in the NARA group (P less than 0.03). We conclude that aortic root complications are a frequent occurrence in aortic valve endocarditis, lead to an increased operative mortality and is associated with a high incidence of post-operative aortic regurgitation.     

老年人腹主动脉瘤的临床观察

目的 观察老年腹主动脉瘤患者的临床特征.方法 对60岁以上老年腹主动脉瘤患者进行回顾性分析,根据超声随访结果,了解腹主动脉瘤的自然发展情况,分析患者年龄和瘤体大小对动脉瘤增长的影响.结果 78例患者多存在吸烟、高血压、高胆固醇血症、动脉粥样硬化等危险因素,20例并存其他部位动脉瘤(占25.6%);瘤体破裂发生在动脉瘤较大、生长速度较快的患者.64例患者接受每年1次的超声随访,动脉瘤瘤体平均年增长0.14 cm;在60～69岁、70～79岁、80～89岁、90～100岁4个年龄阶段,瘤体平均年增长0.14～0.18 cm,各年龄间差异无统计学意义(P>0.05);当动脉瘤体直径<3.0 cm、3.0～4.9 cm、≥5.0 cm时,瘤体平均年增长分别为0.13 cm、0.09cm、0.46 cm,后者较前两者明显增加,差异有统计学意义(P<0.01).结论 年龄不是老年人腹主动脉瘤增长快慢的影响因素;当瘤体直径小于5.0 cm时,腹主动脉瘤随增龄增长缓慢,≥5.0 cm时,随增龄增长快,破裂发生率增加,应行积极干预治疗.