孙氏A2型主动脉夹层的细化分型及其应用

目的: 探讨孙氏 A2型主动脉夹层的细化分型及其应用,观察并分析疗效。方法: 选择2013年1月至2018年9月, 我院经外科治疗的孙氏A2型主动脉夹层患者408例,根据主动脉窦、冠状动脉开口受累程度及主动脉瓣膜交界剥离程度再细化分为三种类型,其中轻型180例,中型188例,重型40例。主动脉根部手术方式根据窦部受累情况选择以保留主动脉瓣的根部重建术为主的手术方式。主动脉弓部根据病情采用半弓置换、全弓置换及支架象鼻术。观察死亡率、严重并发症发生率、保留自体主动脉瓣膜比例及随访期间主动脉根部再次干预情况。结果:住院病死率5.4%,并发症发生率21.3%。三组保留自体主动脉瓣膜比例分别为100.0%、88.3%、62.5%,差异有统计学意义（P＜0.05）。随访6个月~6年,重型组有2例于术后6个月及2年出现重度主动脉瓣关闭不全,再次行主动脉瓣置换治愈;有12例（3.3%）出现中度主动脉瓣关闭不全,无临床症状,随访中;余患者无中量及以上主动脉瓣关闭不全及再次主动脉根部干预。结论: 对孙氏A2型主动脉夹层进一步细化分型更有助于临床医师制定手术策略,个体化采用以保留主动脉瓣的根部重建术为主的手术方式是可行的。     

仿“Z”字主动脉窦部成形技术在急性Stanford A型主动脉夹层中的应用

目的：评估仿“Z”字主动脉窦部成形技术在急性Stanford A型主动脉夹层中的临床疗效;方法：回顾性分析自2014年9月至2018年12月在武汉亚洲心脏病医院大血管中心共收治急性Stanford A型主动脉夹层412例,其中入组125例,包含主动脉瓣重度关闭不全患者60例。男性80例,女性45例;年龄 30-77岁,平均年龄（51.9±9.37）岁。该组患者根部处理均应用仿“Z”字主动脉窦部成形技术,远端半主动脉弓置换15例,全主动脉弓置换110例。全主动脉弓置换患者均置入“象鼻”支架。结果：全组体外循环时间（170±41.2）min;主动脉阻断时间（130.1±30.6）min;深低温停循环时间（25.1±5.9）min。术后随访1.5月—4.3年,术后所有患者主动脉瓣返流程度均为0-1级。 术后经食道超声检查即刻主动窦部残余夹层3例,分别随访1.5年、2.5年和3.0年,未形成动脉瘤,主动脉窦部直径分别为4.3cm、4.2cm和4.5cm。余患者随访期间未发现因主动脉瓣返流及窦部情况再次手术。结论;仿“Z”字主动脉窦部成形技术在急性Stanford A型主动脉夹层中的临床疗效较好,手术操作简单、易掌握、安全有效、易开展。尤其在合并主动脉瓣反流的患者中,避免了换瓣手术,缩短了手术时间,提高了患者的生活质量。     

心脏术后Stanford A型主动脉夹层的外科治疗

目的 总结心脏手术后A型主动脉夹层的治疗经验。方法 2006年12月至2019年03月,36例心脏术后A型主动脉夹层的患者接受二次手术治疗,男30例,女6例;年龄26-74岁,平均(53.8+11.3)岁。首次心脏手术为非主动脉夹层手术20例,包括主动脉瓣置换9例,二尖瓣置换3例,二尖瓣成形1例,双瓣置换3例,冠脉搭桥2例,主动脉根部替换1例和室间隔缺损修补1例。首次心脏手术为夹层手术的有16例,包括单纯升主动脉替换术后主动脉弓部扩张2例,升主动脉+右半弓替换术后弓部扩张11例,Bentall+孙氏手术后右冠吻合口漏1例,升主动脉+右半弓替换近端吻合漏1例,升主替换+孙氏手术后近端吻合口漏1例。本次手术距首次手术0.3-11年（5.6±3.2y）。结果 所有36例患者均施行了主动脉夹层手术,体外循环90-409min(平均224．5±78.7)min;主动脉阻断60-207min,(平均107．2+39．4)min。34例深低温停循环、低流量选择性脑灌注患者低流量时间16～47min,(平均25.6±8.2)min。死亡2例(5.6％);术后并发症6例(16.7％)。生存患者随访1～148个月（平均40.3+20.3m）,随访期间无夹层破裂、截瘫和死亡。结论 心脏手术后A型主动脉夹层患者或A 型主动脉夹层术后根部残余夹层或远端弓部扩张患者应及时手术治疗,但手术难度及风险均较初次主动脉手术增加,因此进行心脏手术时应特别注意主动脉操作的规范和准确,一旦心脏术后再发A型夹层则应尽量施行全弓支架象鼻手术,可获得较好的近远期临床效果。     

改良吻合技术在Bentall手术中的应用

目的 采用改良的人工血管吻合技术在Bentall手术中的应用,分析并总结其临床经验。方法 回顾性分析自2018年1月至2019年6月在武汉亚洲心脏病医院心脏大血管中心连续收治的48例主动脉根部病变（包括马凡氏综合征、急性主动脉夹层）单纯行改良Bentall手术治疗患者的临床资料。其中男39例,女9例;年龄（51.23±13.83）岁,其中34例单纯行Bentall手术,4例行生物瓣Bentall手术,6例同期行半弓置换术,4例行同期行二尖瓣置换,深低温停循环5例。结果 进行改良Bentall手术患者的体外循环时间为（166.31±44.99）min;主动脉阻断时间为（114.38±34.43）min;机械通气时间为16.33±7.69h;术后重症监护病房治疗时间为3.2±1.47d;术后住院时间为13.25±6.3d。二次开胸止血1例,无围术期死亡。随访48例,随访时间1-19个月,随访结果满意。结论 改良人工血管吻合技术在Bentall手术中的应用效果满意,可有效降低术中及术后出血风险,早期预后良好。     

保留主动脉瓣的根部修复技术在Stanford A型主动脉夹层的应用

目的评价保留主动脉瓣的主动脉瓣根部修复技术在StanfordA型主动脉夹层中的应用效果。方法回顾性分析本中心2001年1月至2011年6月间采取保留主动脉瓣的主动脉瓣根部修复技术治疗83例StanfordA型主动脉夹层患者的临床资料,男性63例,女性20例,年龄22-71（47．4±10．9）岁。采取封闭主动脉根部夹层、主动脉瓣交界悬吊加固并于窦管交界上方置换升主动脉的主动脉根部重建术74例,David手术9例。结果全组住院期间死亡7例（8．4％）。随访71例,平均随访（3．4±1．5）年,心功能恢复良好,NYHA分级I级66例、Ⅱ级5例;主动脉瓣轻度反流6例,中度反流2例;无因主动脉根部病变而需再次手术治疗者。结论结合StanfordA型主动脉夹层根部病变的特点,采取保留主动脉瓣的主动脉根部修复技术可取得良好的手术效果。     

传统及改良孙氏手术在急性Stanford A型主动脉夹层的应用

目的 探讨急性Stanford A型主动脉夹层外科治疗应用孙氏手术（主动脉全弓置换+象鼻支架手术）的效果,总结手术经验。方法 回顾性分析2017年09月至2018年06月间收治的急性Stanford A型主动脉夹层17例行孙氏手术治疗的临床资料（均为男性; 年龄为54.5±8.8岁）,统计分析患者手术、术后及随访资料。结果 患者行传统孙氏手术13例,改良孙氏手术（保留头臂动脉的孙氏手术）4例。全组体外循环时间(176.7±25.6)min,主动脉阻断时间(96.6±30.1)min,停循环时间(19.4±3.9)min, 辅助时间(74.2±20.7)min。治愈患者12例,术后30天内患者死亡5例,治愈患者随访2-10个月,均无再次手术,心功能Ⅰ级11例,1例为心功能Ⅱ级。结论 传统以及改良的孙氏手术治疗急性Stanford A型主动脉夹层近中期效果确切,远期疗效有待于进一步监测与随访。     

右胸前外侧小切口微创主动脉瓣置换的倾向评分匹配研究

目的：总结右胸前外侧小切口微创主动脉瓣置换的技术和结果。 方法：回顾性研究我院2010年1月至2017年6月单纯主动脉瓣置换患者资料,分为微创组（N=65）和常规组（正中开胸,N=182）,胸骨上段小切口患者予以排除。微创组采用股动静脉插管建立体外循环,右侧第三肋间胸骨旁小切口,直视下置换主动脉瓣。采用Logistic模型对患者的性别、年龄、体重指数、主动脉瓣病变类别、心脏射血分数、心功能等级进行倾向评分匹配 （Propensity score matching）,匹配比例1:1,研究微创主动脉瓣置换技术的对临床结局的影响。 结果：全组患者3例死亡,均为常规组病人（3/182,1.6%）,微创组无中转开胸、无二次手术。进行倾向评分匹配后得出新的常规对照组（N=65）,术前资料与微创组无差异;与该组相比,微创组体外循环时间和主动脉阻断时间显著延长（103.6±37.2 vs 88.3±27.2 min, P=0.01; 68.3±18.6 vs 48.8±18.9 min, P<0.01）;微创组术后ICU停留1.9±0.4天,住院8.4±1.8天,均显著低于常规组（2.4±0.9天,10.6±3.2天,P<0.01）;微创组术后第一天引流量较少（281±53 vs 432±88ml,P<0.01）。两组间死亡率、深部切口感染率及输血率无显著差异（0 vs 1.5%, P=0.32; 0 vs 3.1%, P=0.15; 23.1% vs 35.4%, P=0.13）。 结论：经右胸前外侧小切口微创主动脉瓣置换技术安全可行。该技术尽管增加体外循环时间和主动脉阻断时间,但可减少引流,加速术后康复。     

David-Ⅰ手术治疗主动脉夹层合并主动脉瓣反流

目的:总结David-Ⅰ手术治疗主动脉夹层合并主动脉瓣反流的临床经验。方法:回顾性分析2005-2010年我科收治的9例主动脉夹层合并主动脉瓣反流患者行David-Ⅰ手术的临床资料。其中急诊手术2例,余7例为常规择期手术;术前心功能Ⅰ级7例,Ⅲ级2例;术前心脏超声测定主动脉瓣轻度反流6例,中度2例,重度1例;术前心脏超声、16排螺旋CT测定主动脉瓣瓣环7例轻度扩张,2例无扩张;9例全部行David-Ⅰ手术。结果:术后患者死亡1例,其余8例康复出院。手术体外循环时间(206.3±11.1)min,阻断时间(141.3±11.2)min。术后随访(12.8±1.0)个月,8例康复出院患者心功能均为Ⅰ级;术后主动脉瓣无反流5例,轻度反流3例。随访心脏超声发现8例患者均无瓣环扩张,无患者需二次换瓣治疗。结论:对主动脉夹层合并主动脉瓣反流者,可优先采用保留主动脉瓣的主动脉根部替换术。     

胸主动脉夹层动脉瘤的外科治疗——手术适应证手术方法的选择及疗效

目的 :探讨胸主动脉夹层动脉瘤外科治疗的手术适应证及手术方法的选择和疗效。方法 :1982年 5月至 2 0 0 2年 6月 ,治疗各类胸主动脉夹层动脉瘤 4 2 7例 ,其中DeBakeyⅠ型 116例 ,Ⅱ型 133例 ,Ⅲ型 178例 ,平均年龄 2 7 5± 10 7(2 3～ 74 )岁 ,体重 72 5± 13 2 (5 2～ 12 0 )kg。手术方法包括 :改良Bentall手术 176例 ,Bentall及右半弓人工血管置换 1例 ;Wheat手术 2 0例 ,Wheat及右半弓人工血管置换 4例 ;升主动脉人工血管置换 2 1例 ,升主动脉及全弓人工血管置换 10例 ,升主动脉及右半弓人工血管置换 4例 ,升主动脉置换及弓部破口修补 3例 ,升主动脉置换及主动脉瓣成型 3例 ;全弓部人工血管置换 7例 ;降主动脉置换 4 1例 ,降主动脉及左半弓人工血管置换 2例 ,降主动脉补片成型 12 9例 ;腔内覆膜支架介入治疗降主动脉夹层动脉瘤 6例。其中急诊手术 5 4例。全组病人升主动脉手术采用股动脉及右房插管全心转流 ,弓部手术采用深低温停循环加上腔静脉脑逆灌 ,降主动脉采用左上肺静脉及股动脉插管左心转流的方法。结果 :手术死亡 4 3例 ,死亡率 10 1% ;与手术相关的并发症包括 :术后心律失常 7例 ,脑功能障碍 5例 ,脊髓损伤影响下肢活动 5例 ,感染引起胸骨裂开 4例 ,术后出血而 2次开胸 8例 ,肾功能衰?     

孙氏手术与联合三分支支架血管术中置入治疗急性Stanford A型主动脉夹层对比

目的 探讨孙氏手术、联合三分支支架血管术中置入两手术方式治疗急性Stanford A型主动脉夹层的疗效.方法 2011年1月至2013年1月我院收治的急性Stanford A型主动脉夹层患者,以孙立忠教授主动脉细化分型中AC型为入选标准,选取患者24例.孙氏手术组患者12例,单纯行升主动脉及全弓替换加支架“象鼻”手术9例,同期主动脉根部替换手术（Bentall术）2例,主动脉瓣成形1例.联合三分支支架血管术中置入组患者12例,单纯三分支支架术中置入3例,同期升主动脉替换8例,主动脉根部替换手术（Bentall术）1例.出院前、术后3个月、术后每年复查主动脉全程重建CT.结果 孙氏手术组：平均手术时间（10.00±1.60）h,平均体外循环时间（253.33±49.33）min,平均心肌阻断时间（141.41±27.58）min,选择性脑灌注时间（39.67±10.28）min.住院死亡4例,死亡原因：多脏器衰竭2例,术后肾功能衰竭1例,术后呼吸功能衰竭1例.联合三分支支架血管术中置入组：平均手术时间（7.77±2.06）h,平均体外循环时间（168.25±32.05）min,平均心肌阻断时间（79.75±29.54）min,选择性脑灌注时间（24.33±6.53）min.住院死亡2例,死亡原因：术后呼吸功能衰竭死亡1例,1例术后一直未醒,术后第5天少尿,家属放弃治疗.孙氏手术组随访（11.09±6.87）个月,无死亡及需再次手术者.联合三分支支架术中置入组随访（18.40±8.03）个月,术后死亡2例,1例术后1年胸痛发作,心脏彩超提示升主动脉明显增宽,主动脉后壁分离为两层,当即死亡;1例术后2年随访主动脉全程重建CT提示无名动脉近端内漏.结论 孙氏手术和联合三分支支架血管术中置入术是治疗大多数急性Stanford A型主动脉夹层安全有效的方法.作为一种崭新的技术手段,联合三分支支架血管术中置入简化了手术步骤,术后内漏是高危因素,对该种手术方式患者选取应有一定针对性,根据患者信息订制更加个体化支架,并且需要长期随访.     

Valve preserving surgery in patients with bicuspid aortic valve

Bicuspid aortic valve can be associated with clinically important aortic regurgitation and dilatation of ascending aorta. Aortic valve repair seems to be optimal therapeutic option how to avoid valve-related and anticoagulation-related complications. We have analyzed midterm outcomes of patients after bicuspid aortic valve repair.MethodsBetween January 2008 and December 2015, 91 patients (mean age 40.9 ± 12.2) with bicuspid aortic valve (type 0 or 1) underwent valve-sparing surgery for aortic valve insufficiency or aortic aneurysm. Urgent procedures and patients of age more than 65 were not included. The cohort of patients was retrospectively divided into two groups. Forty-nine patients underwent aortic valve-sparing procedure with root replacement (group 1). Forty-two patients underwent aortic valve repair without root replacement (group 2). The mean length of follow-up was 57.5 months.ResultsThere was no death in connection with aortic valve repair during follow up. Three patients from group 2 required in-hospital reoperation for early repair failure. Another seven patients (4 from group 1 and 3 from group 2) were reoperated for recurrent aortic insufficiency during follow-up period. Freedom from aortic valve reoperation at 5 years was 90% in group 1 and 87% in group 2. Freedom from recurrent aortic insufficiency (>2°) at 5 years was 85% in group 1 and 78% in group 2.ConclusionBicuspid aortic valve repair is a safe procedure, which can be performed with acceptable midterm results. Risk of repair failure depends on preoperative valve morphology and choice of repair technique. Repair technique needs to be tailored to the specific anatomy of the valve.     

Effects of Gender on Outcomes and Survival Following Repair of Acute Type A Aortic Dissection

Previous studies have demonstrated gender-related differences in early and late outcomes following type A dissection diagnosis. However, it is widely unknown whether gender affects early clinical outcomes and survival after repair of type A aortic dissection. The goal of this study was to compare the early and late clinical outcomes in women versus men after repair of acute type A aortic dissections.Between January 2000 and October 2010 a total of 251 patients from four academic medical centers underwent repair of acute type A aortic dissection. Of those, 79 were women and 172 were men with median ages of 67 (range, 20–87 years) and 58 years (range, 19–83 years), respectively (p < 0.001). Major morbidity, operative mortality, and 10-year actuarial survival were compared between the groups.Operative mortality was not significantly influenced by gender (19% for women vs. 17% for men, p = 0.695). There were similar rates of hemodynamic instability (12% for women vs. 13% men, p = 0.783) between the two groups. Actuarial 10-year survival rates were 58% for women versus 73% for men (p = 0.284).Gender does not significantly impact early clinical outcomes and actuarial survival following repair of acute type A aortic dissection.     

Anuloaortic ectasia: A clinical and echocardiographic study

Twenty-six patients with an aortic root diameter ≥ 3.7 cm by 2-dimensional echocardiography (2-D echo) were studied. Group I consisted of 14 patients (mean age 50 ± 14 years) with idiopathic anuloaortic ectasia and group II consisted of 12 patients (mean age 60 ± 12 years) with secondary causes of aortic root dilatation. Patients in group I had a significantly larger aortic root diameter at the level of the aortic valve (5.0 ± 0.7 cm) and 2 cm above the aortic valve (5.3 ± 1.2 cm) as assessed by echo than did patients in group II (4.1 ± 0.3 and 4.4 ± 0.4 cm, respectively, p < 0.025). The diameter of descending thoracic aorta was slightly larger in patients in group II (3.1 ± 0.8 vs 2.7 ± 0.5 cm, difference not significant). Over a mean follow-up period of 18 months, in group I, aortic dissection developed in 3 patients and severe aortic regurgitation and congestive heart failure in 2; 7 patients had aortic root grafting, aortic valve replacement or both. The 3 patients in group I with aortic dissection had an aortic root diameter ≥ 5.3 cm, but 4 asymptomatic patients also had a diameter > 5 cm. Only 1 patient in group II required surgery for aortic dissection. Thus, 2-D echo is useful in identifying and following high-risk patients with anuloaortic ectasia.     

Endovascular stent-grafts for acute and chronic type B aortic dissection: comparison of clinical outcomes

Within the recent months, endovascular repair of aor- tic aneurysms has become a rather interesting alternative to patients considering open surgery. In the past, the proce- dure was typically and more solely reserved to a selected group of elderly patients with several co-morbidities. Currently, there are a number of ongoing trials that are com-     

TAVR for Failed Surgical Aortic Bioprostheses Using a Self-Expanding Device: 1-Year Results From the Prospective VIVA Postmarket Study

ObjectivesThe VIVA (Valve in Valve) trial was designed to systematically and prospectively collect data regarding the use of transcatheter aortic valve replacement in patients with failing surgical aortic bioprostheses at high-risk for reoperation.BackgroundSurgical aortic valve replacement has been the standard of care in symptomatic patients with aortic valve disease. However, bioprosthetic valves degenerate over time, requiring redo surgery.MethodsVIVA is an international, observational, single-arm, postmarket study conducted at 23 sites that enrolled 202 patients with symptomatic degeneration of an aortic bioprosthesis eligible for elective treatment with a CoreValve or Evolut R self-expanding transcatheter aortic valve.ResultsPatients were elderly (mean age 79.9 years), 47.5% were men, and they had a mean Society of Thoracic Surgeons score of 6.6%. Although 41.8% of patients had surgical bioprostheses with labeled size ≤21 mm, valve hemodynamic parameters were markedly improved from baseline (mean aortic valve gradient 35.0 ± 16.3 mm Hg) to discharge (17.5 ± 8.6 mm Hg) and were sustained at 1 year (15.5 ± 7.5 mm Hg). At 1 year, total aortic regurgitation greater than mild was measured in 1.1% of patients. Clinical outcomes at 30 days demonstrated low mortality (2.5%), no disabling strokes, a 0.5% rate of acute kidney injury, and an 8.0% rate of new pacemaker implantation. At 1 year, the mortality rate remained low (8.8%), with 1 disabling stroke (0.6%). Five patients (2.5%) experienced coronary artery obstructions, 3 during and 1 immediately after the procedure and 1 several months later.ConclusionsDegenerated surgical bioprostheses can be safely treated with the CoreValve or Evolut R platform using the catheter-based valve-in-valve procedure. Excellent 1-year clinical and hemodynamic outcomes were achieved in this real-world patient population. (CoreValve VIVA Study Evaluation of the Clinical Outcomes of CoreValve in Degenerative Surgical Aortic Bioprosthesis; NCT02209298)     

Transapical Transcatheter Aortic Valve for Severe Aortic Regurgitation: Expanding the Limits

ObjectivesThis study sought to evaluate the self-expandable ACURATE TA device (Symetis SA, Ecublens, Switzerland) in a cohort of patients with pure aortic regurgitation (AR).BackgroundTranscatheter aortic valve replacement (TAVR) has been initially considered as an alternative for high-risk patients with aortic stenosis. Although the current experience is limited, TAVR might be also an alternative to treat patients with pure, severe AR.MethodsBetween April 2012 and December 2013, a total of 8 high-risk patients with pure, severe AR were enrolled (grade III+). Clinical and hemodynamic data as well as data on device and procedure parameters and outcomes were collected.ResultsPatient mean was 72.5 ± 8.4 years, and 37.5% of patients were female. Logistic EuroSCORE was 34.0 ± 7.9% and the Society of Thoracic Surgeons score was 7.3 ± 3.3% on average. Two patients had undergone emergency aortic operation before due to acute type A aortic dissection, and both were treated by replacement of the ascending aorta (including root reconstruction) and the aortic arch combined with or without E-vita Open stent graft (Jotec GmbH, Hechingen, Germany) (January 2011 and March 2012), whereas the other patients experienced primary AR. All patients underwent successful transapical TAVR with the transapical ACURATE TA device (size small, n = 1, size medium, n = 3, size large, n = 4) without any intraprocedural complications according to the Valve Academic Research Consortium 2 criteria. Post-procedure AR grade I+ or lower, as revealed by transoesophageal echocardiography and angiography, was present in all 8 patients. At 30 days, the stroke incidence and all-cause mortality rate were 0%.ConclusionsThis small single-center series demonstrates the feasibility of transapical TAVR with the self-expandable ACURATE TA device in high-risk patients with severe AR.     

Prolapse of the "floppy" aortic valve as a cause of aortic regurgitation. A clinico-morphologic study

A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.     

联合检测血浆D-二聚体、基质金属蛋白酶-9对急性主动脉夹层的诊断及预后判断价值

目的 研究联合检测血浆D-二聚体（plasma d-dimer,D-D）、基质金属蛋白酶-9（matrix metalloproteinase-9,MMP-9）对急性主动脉夹层的诊断及预后判断价值。方法 以2012年1月至2016年12月期间沧州市中心医院急诊科收治的急性主动脉夹层患者200例为研究对象,记为主动脉夹层组。另取同时期沧州市中心医院急诊科就诊的胸痛患者200例记为对照组。比较两组患者病历资料、病史、血压、血浆D-D、MMP-9水平。采用受试者工作特征曲线（receiver operating characteristic curve,ROC）判断血浆D-D、MMP-9单独检测以及联合检测诊断急性主动脉夹层的效能。对急性主动脉夹层组患者随访12个月,其中死亡组31例、生存组169例。结果急性主动脉夹层组收缩压[(165.32±14.83)mm Hg比(112.57±11.76)mm Hg,t=39.415]与舒张压[(97.82±9.74)mm Hg比(86.39±8.25)mm Hg,t=16.342]分别高于对照组,差异均有统计学意义（P均<0.05）。急性主动脉夹层组患者血浆D-D[(1.62±0.84)mg/L比(0.37±0.19)mg/L,t=20.526]与MMP-9[(1327.32±398.57)ug/L比(256.38±89.74)ug/L,t=37.071]水平分别高于对照组,差异有统计学意义（P均<0.05）。D-D联合MMP-9诊断急性主动脉夹层的敏感度为0.807、特异度为0.815。急性主动脉夹层死亡组患者血浆D-D[(2.43±1.02)mg/L比(1.41±0.77)mg/L,t=6.423]与MMP-9[(1745.73±414.92)ug/L比(1105.67±346.17)ug/L,t=9.165]水平分别高于生存组,差异有统计学意义（P均<0.05）。结论 联合检测血浆D-D、MMP-9应用于急性主动脉夹层中的诊断效能较高,可能成为患者预后评估的有效指标。     

Aortic valve sparing operations versus composite graft implantation in acute aortic dissections

ObjectivesType A acute aortic dissection is life threatening disease requiring urgent operation. This type of the operation is often a subject of discussion. In our study we present our first experience with two different types of operations with and without preservation of the aortic valve.Patients and methodsFrom January 2009 to December 2011 fifty six patients underwent the operation due to the acute aortic dissection type A. Ascending aorta was replaced in 32 cases and more complex operation was performed in 24 patients due to the simultaneous severe aortic root damage by dissection (study group). In eleven patients (group A) replacement of aortic valve, aortic root and ascending aorta by composite graft (modified Bentall procedure) was performed and in 13 patients (group B) valve sparing operation (reimplantation according to David) was carried out.ResultsThere were no significant differences between the groups in preoperative variables. The only significant difference was mean duration of hospitalisation; 26.7±13.7 days in group A and 16.4±7.7 days in group B. Hospital mortality was 18.2% (n=2) after Bentall procedure, no patient died in group B. There were no or minimal aortic regurgitation in all patients of group B on echocardiography before discharge. The mean follow-up was 17.6 months (3.6–35.8) in group A, and 23.5 months (7.9–38.9) in group B. During this period of time three patients in group A and one patient in group B died; two of cardiac and two of noncardiac reasons. In group B no patient had aortic regurgitation higher than grade I and all patients were in New York Heart Association functional class I or II.ConclusionAortic valve reimplantation in patients with type A dissection can be performed with excellent early and mid-term results. In the hands of an experienced surgeon it represents a good alternative to the Bentall operation. Its main advantage is the preservation of the native valve without the necessity of anticoagulation therapy.     

左颈总动脉至左锁骨下动脉转流加支架象鼻术治疗复杂Stanford B型主动脉夹层

目的:总结左颈总动脉至左锁骨下动脉转流,加支架象鼻术治疗复杂Stanford B型主动脉夹层的临床经验及效果。方法:回顾性分析2009年1月至2011年12月,北京安贞医院5例男性复杂型Stanford B型主动脉夹层患者,行左颈总动脉至左锁骨下动脉转流加直视下支架象鼻手术。平均年龄(48.4±10.5)岁,合并高血压5例,急性夹层2例,慢性夹层3例,胸降主动脉覆膜支架置入术后Ⅰ型内漏2例。合并风湿性心脏病1例,合并糖尿病1例。结果:5例Stanford B型主动脉夹层患者均于全麻下行左颈总动脉至左锁骨下动脉转流加直视下支架象鼻术。同期手术包括1例主动脉瓣及二尖瓣机械瓣置换术。平均体外循环时间(151.8±29.2)min,心肌阻断时间平均(76.0±34.39)min,选择性脑灌注时间平均(21.2±8.0)min。住院时间平均(19.8±6.2)d,术后住院时间平均(9.0±2.7)d,ICU时间平均(1.4±0.5)d。5例患者均无截瘫、脑梗死,无围手术期死亡。术后复查夹层破口均封闭良好,未见残余漏。结论:左颈总动脉至左锁骨下动脉转流加直视下支架象鼻手术对复杂型Stanford B型夹层,是有效的外科治疗手段。近期效果满意,远期效果有待进一步观察。