Acute Ascending Aortic Dissection

Thirty of 33 patients (ages 18-67) with acute dissection of the ascending aorta underwent surgical intervention. There were four deaths. There were eight male and five female patients and 15 patients were known to be hypertensive. Severe chest pain, widened mediastinum (demonstrated radiographically), and varying degrees of aortic insufficiency were present in each patient. Heart failure was present in 13 patients, numbness and coolness of an extremity in seven patients, and central nervous system changes were present in three patients. The diagnosis in each instance was confirmed by aortography. Three patients treated nonoperatively died during hospitalization following aortic rupture into the mediastinum and pericardium. The remaining 30 patients were managed by insertion of a woven Dacron^® graft sutured distal to the coronary arteries and proximal to the origin of the great vessels. This was accompanied with resuspension of the aortic valve in 24 patients and valve replacement in six patients. Each of the latter six patients had a history of aortic valve disease. The goals of the operation were: 1) correction of the accompanying aortic insufficiency, either by valve replacement or resuspension of the valve and 2) placement of a prosthetic graft into the ascending aorta, thereby obliterating the false lumen and preventing involvement of the coronary arteries or rupture into the mediastinum or the pericardium. Hypertensive patients were managed pre- and postoperatively with nitroprusside and then with propranolol HCI, methyldopa, or hydralazine HCI and hydrochlorothiazide. One late death occurred six months after myocardial infarction and a second late death occurred from a presumed cardiac arrhythmia. One patient had a femorofemoral graft two months after the initial operation and another patient has mild aortic insufficiency. It is concluded that prompt surgical management is mandatory in acute ascending aortic dissection, and in most patients aortic valve competency can be re-established with resuspension of the valve preventing the added morbidity associated with a prosthetic valve. Four patients have been followed for five years and additional follow-up data will better define long-term survival.     

Missed Acute Ascending Aortic Dissection

We describe a patient who presented with classic symptoms and signs of acute aortic dissection that escaped detection despite state-of-the-art imaging techniques. We review the pertinent literature concerning the diagnosis of acute dissection of the ascending aorta and describe the types of dissection that might be missed with conventional diagnostic techniques. Repeated efforts should be made to diagnose aortic dissection even though initial studies may be negative in patients with clinical evidence of dissection.     

马方综合征并发A型主动脉夹层的手术疗效

目的观察并评价马方综合征(Marfan syndrome,MFS)并发A型主动脉夹层(type A aortic dissection,AAD)的手术疗效。方法回顾性分析2006年1月至2012年1月武汉亚洲心脏病医院收治44例MFS并发AAD患者的临床资料,其中男31例,女13例;年龄12～54(33.0±9.8)岁。23例在AAD发病后不同疾病阶段施行外科手术治疗,均行Bentall手术;21例因经济或其它原因未采取手术治疗。采用含时变协变量的COX回归分析,分别以主要终点事件、主要+次要终点事件作为结局变量对相关因素进行分析,观察手术患者术后手术疗效和生活质量,并与未手术患者的随访资料进行对比。结果术后有1例手术患者死于多器官功能衰竭,其余22例手术均成功。随访43例,随访时间1～75个月。22例手术患者术后3年生存率为95.7%,随访期间生活质量良好。未行手术治疗的21例患者生存状况及生活质量较差,13例(61.9%)死亡,主要死亡原因:急性心脏压塞、主动脉夹层破裂、急性心肌梗死并发心源性休克等;发病后3年生存率仅为31.7%。采用含时变协变量COX回归模型分析校正手术时间不一产生影响后的结果显示,手术治疗患者与未手术治疗患者相比较,其临床疗效的差异有统计学意义(T_COV_的OR值=0.088,P=0.028),手术治疗死亡风险仅为非手术治疗的8.8%(P<0.05)。结论 MFS并发AAD预后凶险,应尽早外科手术,不论是急性期还是慢性期均可获益,疗效可靠,随访结果令人满意。     

Primary Anastomosis for Acute Ascending Aortic Dissection

Intimal tear resection and primary anastomosis of the aorta were used for the treatment of eight patients with DeBakey I and II type acute aortic dissection. Five patients were of DeBakey I type, and three patients were of the II type. Moderate or severe aortic regurgitation (AR) was observed in six of eight patients. The site of the intimal tear was diagnosed by intraoperative echocardiography, and the adventitia corresponding to the intimal tear was transversely opened under total cardiopulmonary bypass. While resuspension of the aortic valve was performed on only one of six patients, AR disappeared in four, postoperatively. Two of eight patients died early postoperatively. The cause of death was postoperative cardiac tamponade in one patient and cerebral herniation in the remaining one. The other six patients have been observed for a mean period of 27 months. There is no late death, and they show no dilatation of the aortic root and deterioration of AR. We believe that this operative method is a simple and safe emergency procedure for DeBakey I and II type acute aortic dissection.     

A Novel Approach to the Treatment of Distal Malperfusion Secondary to Ascending Aortic Dissection

Abstract Acute Type A dissection is a surgical emergency. The presence of visceral and extremity malperfusion syndromes increases perioperative mortality twofold. On occasion, significant malperfusion may best be addressed in a staged fashion with preliminary attention to specific vascular beds with delayed repair of the dissection itself. We present a subacute Type A dissection associated with malperfusion of multiple vascular beds (mesenteric, renal, and iliofemoral) managed with a complication‐specific approach utilizing endovascular thoracoabdominal aortic repair prior to ascending repair. (J Card Surg 2010;25:220‐222)     

2例升主动脉合并降主动脉夹层杂交手术的配合

介绍2例采用腔内隔绝术和体外循环下升主动脉人工血管置换术相结合的杂交手术方法治疗升主动脉合并降主动脉夹层的术中护理要点.提出手术室护士熟悉手术过程,术前充分准备,术中默契配合是手术成功的重要因素.     

Reversal of Paraplegia Following Repair of an Ascending Aortic Dissection

Abstract   We report the case of a patient who presented with sudden onset of paraplegia following an acute ascending aortic dissection extending to the arch, descending, and abdominal aorta. The paraplegia was fully reversed following an emergent replacement of the ascending aorta and hemi-arch repair. (J Card Surg 2010;25:65-66)     

Results of Aortic Surgery in Patients with Marfan Syndrome

Purpose We reviewed the outcome of aortic operations in patients with Marfan syndrome to evaluate the immediate and long-term results of surgical treatment.Methods Between January 1985 and June 2002, 22 patients with Marfan syndrome underwent surgical treatment for aortic diseases at our hospital. Eight patients had Stanford type A aortic dissection and ten patients had aortic root aneurysm with aortic regurgitation. We performed aortic root replacement in 21 patients. Subsequent aortic operations were done in 11 patients, 6 of whom required a third operation. Five patients underwent repeat surgery of the previously operated aortic segment. A collective a total of 42 aortic operations were performed in the 22 patients. Seven patients underwent total aortic replacement.Results The in-hospital mortality rate was 4.5%, and there were three late deaths: two caused by rupture of the dissected aorta, 17 months and 24 months after the last surgical intervention, respectively, and one caused by heart failure 27 months after a total aortic replacement. The overall actuarial survival was 90.2% at 5 years and 74.4% at 10 years.Conclusions Surgical treatment of patients with Marfan syndrome can be accomplished with low mortality; however, new aortic lesions should be promptly explored, and appropriately timed surgical treatment can substantially improve the prognosis of patients with Marfan syndrome.