A型主动脉夹层患者术后呼吸功能不全死亡的相关危险因素分析

目的：分析Stanford A型主动脉夹层患者在主动脉瓣替换术后呼吸功能不全死亡的相关危险因素。
　　方法：2010-01至2012-12在开胸手术下行主动脉瓣替换术的A型主动脉夹层患者223例,术后出现呼吸功能不全80例,男61例,女19例;年龄（49.2±11.6）岁。根据术后是否出现死亡分为死亡组（n=18）和非死亡组（n=62）。记录人口学特征,性别、年龄、吸烟史、糖尿病史、高血压史、马凡综合征;术前急性或慢性夹层、二次手术、术前低氧、器官灌注不良、左心室舒张末径及射血分数;术中心肺转流时间、主动脉阻断时间、深低温停循环时间、右半弓或全弓替换、同期冠状动脉旁路移植手术、主动脉瓣替换或成形术出血（术中及术后24 h内输浓缩红细胞或二次开胸止血）;术后重症监护室(ICU)停留时间、呼吸机使用时间、气管切开、永久性脑部并发症（昏迷或一侧偏瘫）、截瘫、肺部感染、心脏不良事件（停跳或重度低心排）、肾功能衰竭、肝功能不全、败血症、伤口愈合不良,进行术后呼吸功能不全死亡的相关危险因素分析。
　　结果：术后早期（<3天）呼吸功能不全发生率为35.8%,其中18例死亡,占22.5%。呼吸功能不全死亡的相关危险因素包括：女性（P=0.019）;出血（P<0.01）;呼吸机使用时间（P=0.011）;永久性脑部并发症（P=0.013）;肺部感染（P=0.001）;心脏不良事件（P=0.022）;肾功能衰竭（P<0.01）;肝功能不全（P<0.01）;败血症（P=0.001）;其中女性（P=0.019）和肾功能衰竭（P=0.001）是术后呼吸功能不全死亡的独立危险因素。
　　结论：A型主动脉夹层术后呼吸功能不全的发生率及病死率较高,其中女性患者及合并肾功能衰竭患者术后死亡风险显著增加。     

急性A型主动脉夹层术后急性呼吸功能不全的治疗

目的:探讨急性A型主动脉夹层患者在深低温停循环(DHCA)下行主动脉替换手术后,急性呼吸功能不全(ARD)发生的临床特点及治疗策略。方法:2009年2月至2011年1月,急性A型主动脉夹层患者202例,在DHCA(鼻温降至22℃)下行主动脉弓替换。ARD定义为术后72 h内发生的低氧血症(PaO2/FiO2<150),除外术后心源性肺水肿、肺部感染、血/气胸等因素引起的低氧血症。27例患者术后发生ARD,发生率13.4%(27/202)。所有患者分为两组:ARD组和非ARD组,比较两组的临床特点。ARD诊断后立即采取①肺保护性通气;②膨肺;③提高心排量等综合治疗。结果:ARD组体质量指数和DHCA时间明显高于非ARD组(P<0.05)。27例ARD患者经治疗后,26例成功拔除气管插管,仅1例因机械通气时间>7 d行气管切开,术后20 d拔除气切套管出院。ARD平均持续时间3.2 d,住ICU时间(4.5±2.1)d,ARD组无医院死亡。结论:急性主动脉夹层术后早期ARD发生率为13.4%,肺保护性通气结合综合治疗策略对于急性A型主动脉夹层术后ARD有很好的疗效。     

主动脉夹层院内死亡相关危险因素分析

目的分析主动脉夹层(AD)患者院内死亡的相关危险因素。方法回顾性分析厦门市心脏中心2002年1月至2011年10月确诊急性AD患者175例的临床资料,其中男性129例,女性46例,平均年龄(56.8±12.1)岁。按住院期间是否死亡进行分组,分为存活组(n=141)及死亡组(n=34),分析年龄、性别、既往病史、血压水平、症状、并发症及实验室指标与死亡的相关性,并用Logistic回归分析危险因素与病死率的关系。结果与存活组比较,死亡组D-二聚体水平升高,意识障碍和心包填塞比例增加,手术或支架治疗比例减少,差异有统计学意义(P均0.05)。Logistic回归分析结果表明,D-二聚体水平升高(OR=1.325,95%CI:1.436~1.973,P=0.004)、伴意识障碍(OR=2.481,95%CI:1.302~3.203,P=0.003)、心包填塞(OR=7.726,95%CI:1.762~34.003,P=0.008)为AD患者住院死亡的独立危险因素,手术或介入治疗(OR=0.101,95%CI:1.762~34.003,P=0.044)为保护因素。结论 AD患者中D-二聚体明显升高,并发意识障碍、心包填塞者病死率高,临床上应予高度重视,依据病情采取手术或介入治疗有利于降低AD患者的病死率。     

急性Stanford A型主动脉夹层患者术后肝功能不全的危险因素及预后分析

目的 探讨急性Stanford A型主动脉夹层患者术后发生肝功能不全(HD)的危险因素和预后.方法 回顾性分析青岛市市立医院2014年5月至2018年5月156例接受外科手术的急性Stanford A型主动脉夹层患者围术期资料.采用终末期肝病模型(MELD)评分评估患者术后肝功能,并分为HD组35例(MELD评分≥15...     

主动脉夹层患者住院死亡危险因素分析

目的:探讨主动脉夹层(AD)患者住院期间死亡相关危险因素。方法:回顾性分析徐州医学院附属淮安医院及东南大学附属医院2004年1月至2009年1月确诊AD120病例临床资料,按住院期间是否发生死亡进行分组,分析患者性别、体质量指数、临床症状、体征和生化指标与死亡的相关性,并用Logistic回归分析其与病死率的关系。结果:1.120例AD患者中男女性别之比为2.0:1。平均年龄(54.7±10.3)岁,急性期院内病死率17.5%;2.死亡组与存活组中:女性、舒张压、超敏C反应蛋白水平、并发意识障碍及心包填塞差异有统计学意义(P0.05);3.女性多元回归分析(OR=2.052;95%CI=1.084～4.470;P=0.010)、超敏C反应蛋白水平(OR=1.436;95%CI=1.325～1.862;P=0.008)及合并意识障碍(OR=2.370;95%CI=1.290～3.192;P=0.04)是AD死亡的独立危险因素(P0.05),舒张压水平(OR=0.532;95%CI=0.262～0.843;P=0.030)为预后保护因素。结论:AD患者中超敏C反应蛋白水平、女性、合并意识障碍,是导致急性期院内死亡的独立危险因素,舒张压水平为保护性因素。     

急性StanfordA型主动脉夹层患者体外循环术后急性肾损伤的危险因素分析

目的 分析急性StanfordA型主动脉夹层患者体外循环术后发生急性肾损伤的相关危险因素。方法 回顾性分析2016年7月至2018年12月哈尔滨医科大学附属第一医院心脏大血管外科收治的急性StanfordA型主动脉夹层手术患者的临床资料。根据KDIGO标准分为AKI组及非AKI组,将两组资料进行对比分析,探讨TA-AAD患者术后发生AKI的危险因素。结果 共入选患者134例,未发生AKI患者68例;发生AKI患者66例（49.3%）,其中24例患者需要肾脏替代治疗（CRRT）。AKI组死亡率明显高于非AKI组。单因素分析显示患者性别、术前血红蛋白以及高血压疾病史、体外循环时间、主动脉阻断时间、术后ICU停留时间、术后气管插管时间及术后死亡率差异有统计学意义。Logistic回归分析显示女性患者、高血压疾病史、术后气管插管时间为TA-AAD患者体外循环术后发生AKI的独立危险因素。 结论 女性患者、高血压疾病史、术后气管插管时间为TA-AAD患者体外循环术后发生AKI的独立危险因素。     

急性主动脉夹层死亡的危险因素分析

目的:探讨急性主动脉夹层的预测死亡的危险因素。方法:采用回顾性分析方法分析1995~2006年资料完整的67例主动脉夹层病例,使用Logistic回归分析年龄、性别、病因、临床症状及体征、治疗方法的选择与急性主动脉夹层的临床病死率的线性关系。结果:①总体临床病死率为14.90%。其中按Stanford分型,Stan-fordA型患者临床病死率为18.75%,StanfordB型患者临床病死率为11.40%。②Logistic回归分析示神经系统症状(P=0.0166)、心包积液(P=0.0183)、局部肢体缺血(任一肢体)(P=0.0407)为急性主动脉夹层预测死亡的危险因素。结论:神经系统症状、心包积液、局部肢体缺血为急性主动脉夹层的独立死亡危险因素。     

急性Stanford A型主动脉夹层患者术后感染的危险因素分析

目的 分析急性Stanford A型主动脉夹层患者术后感染的危险因素。 方法 分析2017年6月～2019年12月本院收治的急性Stanford A型主动脉夹层接受外科手术治疗的患者（n = 104）,根据术后是否发生感染,将患者分为非感染组(n = 35)和感染组(n = 69)。 结果 与非感染组相比,感染组术前体温明显升高（P<0.05）;术中心肺转流（cardiopulmonary bypass,CPB）时间和主动脉阻断（aortic cross clamp,ACC）时间明显延长（P<0.01）,深低温停循环（deep hypothermic circulatory arrest,DHCA）时间明显延长（P<0.05）;术后机械通气时间、重症监护室（intensive care unit,ICU）住院时间和总住院时间明显延长（P<0.01）;术后急性肺损伤、急性肾损伤和全身炎症反应综合征（systemic inflammatory response syndrome,SIRS）发生率明显增高（P<0.01）。多因素Logistic回归分析发现:ICU住院时间（OR = 1.503,95%CI:1.013～2.230,P<0.05）和SIRS（OR = 11.635,95%CI:1.515～89.336,P<0.05）是急性Stanford A型主动脉夹层患者术后感染的独立危险因素。分析受试者工作特征曲线发现ICU住院时间的临界值为7.5 d,曲线下面积为0.865（P<0.01）。 结论 术后感染将明显不利于急性Stanford A型主动脉夹层患者的临床预后。ICU住院时间>7.5 d及术后出现SIRS是术后感染发生的独立危险因素。     

Severe aortic regurgitation with intimal intussusception secondary to Debakey type I aortic dissection

Aortic regurgitation (AR) with intimal intussusception, secondary to aortic dissection, is relatively rare and the images are interesting findings. We report a typical case of severe AR with intimal intussusception, secondary to DeBakey type I aortic dissection, detected by contrast-enhanced computed tomography (CECT) and transesophageal echocardiography (TEE). Since there are three types of aortic regurgitation with aortic dissection, it is imperative to consider the most appropriate intervention for AR. The combination of CECT, TEE, and surgical findings may play an important role in determining the optimum surgical procedure for AR with aortic dissection.     

Risk factors analysis for in-hospital death of acute Stanford type B aortic dissection

Background Data is limited regarding the correlation between related factors and in-hospital death of Stanford type B acute aortic dissection (AAD). Methods We registered consecutive Stanford type B AAD patients, who were in the Guangdong Cardiovascular Institute of Guangdong General Hospital from October 2010 to August 2011, and the onset day to admission day were less than or equal to 2 weeks. We collected in-hospital mortality, history of disease, laboratory parameters, some biochemical markers tests, treatment and so on, analyzed the relationship between risk factors and mortality. Results One hundred and five Stanford B AAD patients were enrolled, 9 patients died, accounting for 8.6%. There are 24 patients treated with medicine, and 4 cases finally died. Endovascular aortic repair (EVAR) 62 cases, 2 cases died. EVAR combined carotid artery bypass (CAB) 19 cases, and 3 cases died. Among the three treatments, there was no significant difference in statistics (P = 0.063). Compared with the survivors, the death group had higher D-dimer (P = 0.016) and NT-proBNP (P = 0.014) level, and more patients with myocardial infarction (P = 0.007), hypotension or shock (P = 0.019), a- cute renal failure (P = 0.005), nervous system related events (P 0.001). After adjusting for other predictors of in-hospital death, logistic regression analysis shows that the nervous system related events (odds ratio: 21.648; 95% CI: 1.228-381.704, P = 0.036 is the independent risk factor for death. Conclusions D-dimer, hypotension or shock, acute renal failure, nervous system related events are associated with hospitalization death of Stanford type B AAD patients, while nervous system related events is an independent risk factor for in-hospital death.     

Risk factors for diagnostic delay in acute aortic dissection

In acute aortic dissection (AAD), timely diagnosis is challenging. However, dedicated studies of the entity and determinants of delay are currently lacking. We surveyed pre-/in-hospital time to diagnosis and explored risk factors for diagnostic delay. We analyzed the dedicated database of a metropolitan AAD network (161 patients diagnosed since 1996; 115 Stanford type A) in terms of hospital arrival times (from pain to presentation at any hospital) and in-hospital diagnostic times (presentation to final diagnosis). Median (interquartile range) in-hospital diagnostic times were approximately twofold greater than hospital arrival times (177 minutes, 644, vs 75 minutes, 124, p = 0.0001, Wilcoxon test). Median annual in-hospital diagnostic times were most often approximately 3 hours (spread was wide, but decreased after 2001; rho = -0.94, p = 0.005). Risk factors (univariate analysis) for in-hospital diagnostic time >75th percentile (12 hours) included pleural effusion (odds ratio 3.96, 95% confidence interval 1.80 to 8.69), dyspneic presentation (odds ratio 3.33, 95% confidence interval 1.93 to 8.59), and age <70 years (odds ratio 2.34, 95% confidence interval 1.03 to 5.36). Systolic arterial pressure < or =105 mm Hg decreased the likelihood of lengthy diagnosis (odds ratio 0.08, 95% confidence interval 0.01 to 0.59). In patients (n = 82) with routine values (since 2000), troponin positivity (odds ratio 3.63, 95% confidence interval 1.12 to 11.84) and an acute coronary syndrome-like electrocardiogram (odds ratio 2.88, 95% confidence interval 1.01 to 8.17) were also risk factors. In conclusion, in a metropolitan setting, most of the diagnostic delay may occur in hospital. At presentation, pleural effusion, troponin positivity, acute coronary syndrome-like electrocardiogram, and dyspnea are possible "clinical confounders" associated with particularly long in-hospital diagnostic times.     

Risk factors for prolonged mechanical ventilation following surgery for acute type a aortic dissection

BACKGROUND: The aim of this study was to identify predictors of prolonged mechanical ventilation (PMV) following surgery for acute type A aortic dissection (AAAD) and to assess the influence of this complication on clinical outcomes. METHODS AND RESULTS: A total of 243 patients underwent emergency surgery for AAAD in the period of 1997-2006. Ten patients died within 48 h after surgery. The remaining 233 patients were divided into 2 groups according to the duration of mechanical ventilation; less than 48 h (group A: n=149) or 48 h or longer (group B; n=84). Multivariate analysis was used to identify predictors of PMV. Short and late outcomes were compared between groups. Multivariate analysis showed that shock (systolic BP <90 mmHg; p=0.007), postoperative renal dysfunction (creatinine >2.0 mg/dl; p=0.016), coronary artery bypass grafting (CABG) (p=0.017), and limb ischemia (p=0.044) were independent predictors of PMV. There was no significant difference in in-hospital mortality (group A, 2.7% vs group B, 3.6%) or 5-year survival (group A, 85.9% vs group B, 76.8%). CONCLUSIONS: Shock, limb ischemia, CABG, and postoperative renal dysfunction increase the risk for PMV. Knowing the predictors of PMV should help optimize postoperative management of these patients.     

妊娠期合并Ⅰ型主动脉夹层伴主动脉瓣关闭不全一例

患者，女性，35岁，因“反复胸背痛半年，加重伴呼吸困难3d”入院。患者半年前（怀孕25周）出现背痛，呈撕裂样疼痛，伴呕吐、大汗淋漓，持续约36h后缓解。当地医院诊断为前置胎盘。16d前（怀孕40周）患者又出现剧烈胸背部疼痛，左肩背更为显著，以前置胎盘急症行剖宫产术，患者术后自觉症状缓解。3d前患者因情绪激动再次出现背痛伴呼吸困难收入当地医院。病情逐渐加重，肢端发凉、发绀，少尿和低血压，静脉滴注多巴胺转入我院。