Surgical treatment of aortic dissection. Value of echocardiography and MRI for long-term follow-up

Twenty-five patients aged 31 to 74 years (average 50 years) operated for type A aortic dissection (type I: 19 cases, type II: 6 cases) were included in this study. Surgical repair only concerned lesions of the ascending aorta. The hospital mortality was 20 per cent (5 cases), and usually secondary to extension of the dissection. With the exception of 2 late deaths, all patients were followed up for an average of 3.5 years. A late assessment including nuclear magnetic resonance imaging of the thoracic aorta was obtained in 17 of the 18 survivors. These investigations confirmed the good result of repair of the ascending aorta, the uselessness of systematic aortic valve replacement and the palliative nature of repair of type I dissection as 80 per cent of patients had a persistent patent false lumen in the distal aorta.     

Value of transesophageal echocardiography combined with computed tomography for assessing repaired type A aortic dissection.

Thirty-two patients with repaired type A aortic dissection were examined by transthoracic echocardiography (TTE) (n = 32), transesophageal echocardiography (TEE) (n = 30), computed tomography (CT) (n = 29), or a combination of all 3, to assess course and complications as a function of the surgical procedure. The mean follow-up period was 55.7 months (range 3 to 132). Surgery consisted of a replacement of the ascending aorta in 25 patients (group 1) with extension to the transverse aorta in 7 (group 2). The transverse diameter of the aorta, the persistence of the false lumen, thrombus formation and flow dynamics in the false lumen were evaluated by TEE. Ten patients (31%) had a dilation in the initial ascending aorta (sinus of Valsalva aneurysm in 6 patients, and a false aneurysm in the other 4). Three of 4 patients with a proximal pseudoaneurysm underwent operation after TEE and CT evaluation. In the descending thoracic aorta, there was good agreement between TEE and CT scan determinations of transverse vessel diameter. Persistence of flow within the false lumen was significantly more frequent in patients with a dilated aorta (p < 0.05), whereas thrombosis was seen more often and false lumen less often in patients with nondilated aorta. No significant differences in vessel status or outcome were observed between the 2 groups, although this may have been due to the small size of group 2. TEE is thus a well-tolerated method for postoperative follow-up of type A aortic dissection whatever the type of surgery. For the upper ascending aorta, CT provided sufficient data.     

多平面经食管超声心动图技术对主动脉夹层的诊断价值

目的 探讨多平面经食管超声心动图(TEE)技术对主动脉夹层(AD)的诊断价值。方法 对19例疑诊AD患者进行了多平面TEE检查。结果 19例患者均由多平面TEE明确诊断，其中14例经CT或MRI证实，5例由手术证实，准确性和特异性均为100％。DeBakey分型Ⅰ型夹层患者4例，Ⅱ型3例，破口均位于升主动脉；Ⅲ型12例中，9例破口位于降主动脉近心端，3例未探及内膜破口。结论 多平面TEE技术为AD无创性诊断开辟了新途径。     

Prognosis of surgically corrected chronic aortic insufficiency

It is difficult to determine the surgical indications of asymptomatic chronic aortic regurgitation (AR). This study was undertaken in 205 patients with pure AR, operated between 1970 and 1982: 136 patients were symptomatic (Classes III and IV of the NYHA, +/- cardiac failure +/- angina, mean age: 49.5 years). Sixty nine asymptomatic patients (Classes I and II of the NYHA without cardiac failure or angina, mean age: 42 years). The prognostic value of 58 variables was studied in these two groups. The mortality during the first postoperative month was 14% in the symptomatic patients and the 5 year survival rate was 68.7%; this was significantly lower in patients with ECG changes of systolic left greater than or equal to ventricular overload, with radiological cardiomegaly (cardiotolerance index 0.60) with calcific aortic valve disease, with raised arterio-venous difference and/or low cardiac output, and with a low ejection fraction. In the asymptomatic group, the hospital mortality was zero and the 5 year survival rate 86.8%. This was significantly decreased in patients with an increased PR interval and a low cardiac index. It is possible that the small number of patients did not demonstrate the predictive value of left ventricular function in asymptomatic patients (a hypothesis suggested by the causes of secondary mortality which were the same in both groups of patients).(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnostic goals in aortic dissection. Value of transthoracic and transesophageal echocardiography]

The combination of different ultrasound techniques like transthoracic, suprasternal, subcostal and transesophageal echocardiography have a high sensitivity and specificity in the diagnosis of aortic dissection. The limitation of this combined ultrasound technique is related to the visualization of the ascending part of the aortic arch which, cause of the interposition of the trachea, can not be visualized completely. The beginning or the end of a dissection in this part of the aorta may be misinterpreted. False negative results are rare. False positive results due to artefacts resulting from reverberations in an ectatic ascending aorta have to be taken into account. The most important diagnostic aims in acute or chronic aortic dissection can be described: 1. confirmation of the diagnosis by visualization of the intima membrane, 2. the differentiation of the true and false lumen depending on visualization of spontaneous echocardiographic contrast thrombus formation, slow or reduced reversed flow, systolic diameter reduction and signs of entry jet into the false lumen, 3. detection of intimal tear, demonstrating communication by two-dimensional or color Doppler echocardiography, 4. determination of the extent of the dissection with classification according to DeBakey type I, II and III or Stanford A and B with differentiation to communicating or non-communicating dissection, antegrade or retrograde dissection limited to the descending aorta or expanding to the ascending aorta, 5. detection of wall motion abnormalities as a sign of preexisting coronary artery disease or myocardial ischemia due to ostium occlusion by an intimal flap, coronary artery rupture or collapse of the true lumen during diastole, 6. detection and grading of aortic insufficiency, 7. detection of side branch involvement by suprasternal, subcostal and abdominal sonography, which will gain the information which side can be chosen for cannulation or catheterization at the femoral artery, 8. detection of pericardial pleural effusion and mediastinal hematoma as a sign of emergency as rupture can occur within minutes. Without surgical intervention have be performed. Based on these informations, surgery can be performed in all acute situations in type A dissection without further investigations. This decision is particularly important in patients with signs of emergency like pericardial or pleural effusion or mediastinal hematoma.     

经胸超声心动图对急性Stanford A型主动脉夹层的临床诊断价值

目的探讨经胸超声心动图(TTE)在诊断Stanford A型主动脉夹层中的准确性。方法收集Stanford A型主动脉夹层患者共35例,回顾性分析经胸超声心动图的检查结果;并与增强CT血管造影(CTA)检查结果进行比较。结果 TTE、CTA对Stanford A型主动脉夹层的诊断率分别为91.3%、100%。TTE还能观察主动脉瓣损害、心包积液、心脏功能等情况。结论 TTE是诊断Stanford A型主动脉夹层的可靠方法,为临床急救提供有效依据。     

Transesophageal echocardiography in aortic dissection

Aortic dissection is an emergent and potentially fatal condition requiring prompt and accurate diagnosis. In some patients, aortic dissection is abruptly painful at onset; in others, however, it has a chronic progression-with no apparent symptoms or with symptoms mimicking those of congestive heart failure. Transesophageal echocardiography, a promising new method for diagnosis of aortic dissection, has the advantages of being performed at the patient's bedside and providing results within 15 minutes. This method utilizes endoscopy and traditional noninvasive imaging techniques to provide a definitive picture of most segments of the aorta without the limitations associated with aortography and other invasive procedures. The technique of transesophageal echocardiography and its application in the diagnosis of aortic dissection are described in this report.     

Value of transesophageal echocardiography in the diagnosis of acute aortic dissection]

We describe our experience of six patients with clinical suspicion of acute aortic dissection (AAD) who were studied consecutively by transesophageal echocardiography (TEE) from April to July of 1991. All of them were previously submitted to transthoracic echocardiogram. The diagnosis was correctly established by TEE in five cases, confirmed by aortography and/or surgery (four cases), or by autopsy (one case). In one patient the diagnosis of AAD was excluded by TEE, and posteriorly by nuclear magnetic resonance. Four patients had a Stanford type A, and one patient a type B dissection. The site of entry was identified in three cases; the intimal entry tear of the type B dissection, not observed by TEE, was localized in the aortic arch by aortography. In three of the four type A dissection cases, a thrombus in the false lumen and an aortic regurgitation were found. No other noninvasive methods were used after the diagnosis of AAD by TEE. The surgical repair was successful in three cases, one of which, without previous necessity of aortography. In our experience, TEE increased extraordinarily the diagnosis efficacy of AAD, making possible an earlier therapeutic approach, and probably contributing to the improvement of the prognosis of this pathology.     

Ambulatory follow-up of aortic dissection by transesophageal two-dimensional and color-coded Doppler echocardiography

Follow-up of 18 patients with aortic dissection (five with type I, one with type II, 11 with type III dissection according to DeBakey) by transesophageal, two-dimensional and color-coded Doppler echocardiography showed a persistence of the false lumen in five of seven patients (71%) after surgery and in nine of 11 patients (82%) after medical therapy. In two patients treated with surgery, the dissected part of the aorta had been resected, whereas in two patients treated medically, a progressive and complete obliteration of the false lumen was observed. In the false lumen, thrombus formation was absent in four, localized in four, and progressive in six patients. Flow within the false lumen could be registered in 14 patients, and two distinct flow patterns were differentiated (laminar biphasic flow or slowly circulating flow). Persisting intimal tears were visualized by two-dimensional echocardiography in four patients, whereas color-coded Doppler showed an additional one to three intimal tears in the descending aorta in 10 patients. Flow across these intimal tears was biphasic in 75% of patients; that is, systolic flow was directed from the true to the false lumen with diastolic flow reversal. Unidirectional flow was detected in 25% of the communications, directed in 20% from the true to the false lumen, serving as an entry only and in one (5%) as reentry only. Additional information concerning complications like extension of the dissection (one of 18 patients), localized dilatation of the regurgitation (three of 18 patients) were detected by this method. Concerning the morphologic findings and the detection of flow characteristics, the transesophageal approach was superior to conventional echocardiography especially in the descending thoracic aorta. Thus, transesophageal two-dimensional and color-coded Doppler echocardiography seems to be an ideal method not only for the easy detection of aortic dissection but also for follow-up.     

“一站式”杂交手术在Stanford A型主动脉夹层患者治疗中的应用价值

目的研究"一站式"杂交手术在Stanford A型主动脉夹层患者治疗中的应用价值。方法选取2015年至2018年期间到北京大学深圳医院就诊的200例Stanford A型主动脉夹层患者进行研究,按数字表法随机分为研究组及常规组,每组100例。结果研究组患者addition EuroSCORE>7%以及Logistics EuroSCORE>6%的比例明显高于常规组,差异有统计学意义(66.0%vs. 36.0%,P<0.001;74.0%vs. 39.0%,P<0.001)。研究组患者比常规组患者具有更高的手术风险,差异有统计学意义(P<0.05)。研究组患者体外循环时间以及主动脉阻断时间比常规组均明显缩短,术后重症监护病房初次停留时间比常规组明显长,差异有统计学意义(P<0.001)。两组患者围术期死亡及术后30 d主要复合不良事件、脑卒中、截瘫、肾功能不全需血液透析辅助治疗的发生率比较,差异均无统计学意义(P>0.05)。结论 "一站式"杂交手术在Stanford A型主动脉夹层患者治疗能够缩减体外循环时间及主动脉阻断时间、降低患者手术创伤、提高手术安全。     

急性A型主动脉夹层术前并发严重低氧血症相关因素的回顾性分析

目的:探究急性A型主动脉夹层术前严重低氧血症的相关因素,为该并发症的早期防治提供相关依据。方法:回顾性分析于首都医科大学附属北京安贞医院2015年1月至2018年2月期间,收治的505例急性A型主动脉夹层患者,根据氧合指数是否≤200 mmHg(1 mmHg=0.133 kPa)将其分为低氧血症(+)组和低氧血症(-)组,分析两组患者围术期指标,归纳并总结术前并发低氧血症的相关危险因素。结果:急性A型主动脉夹层术前发生严重低氧血症概率为12%(62/505)。单因素分析中有统计学意义的危险因素包括BMI、手术到发病时间、心包积液、WBC计数、cTnI、活化部分凝血活酶、收缩压、PLT计数、D-Dimer、纤维蛋白原降解产物。Logistic回归分析WBC计数、收缩压为术前并发严重低氧血症的危险因素。结论:12%的患者术前存在严重低氧血症,WBC计数、收缩压为急性A型主动脉夹层术前并发低氧血症的预测因素。     

Detection of aortic dissection by transoesophageal echocardiography.

The diagnostic value of a combination of transoesophageal and transthoracic echocardiography was evaluated in 21 patients with dissection of the aorta. The results were compared with those of computed tomography, aortography, and with findings at operation or necropsy or both. Transthoracic echocardiography identified three of the four patients with type I dissection, two of the five patients with type II dissection, and one of the 12 patients with type III dissection. When transoesophageal echocardiography was used as well the degree of aortic dissection was identified correctly in all 21 patients. In one patient with type I and in eight patients with type III dissection spontaneous echocardiographic contrast with a mural thrombus within the false lumen could be detected. Computed tomography was unable to demonstrate an intimal flap in one of two patients studied with type I dissection, in two of three patients with type II dissection, and in one of nine patients with type III dissection. Aortography was negative in one of two patients studied with type I dissection, two of four patients with type II dissection, and in one of eight patients with type II dissection. The whole thoracic aorta can be imaged by a combination of transthoracic and transoesophageal echocardiography. The addition of transoesophageal echocardiography to transthoracic echocardiography improves the recognition of aortic dissection. Furthermore, this examination can be performed at the bedside and the findings can be used as a basis for treatment.     

Acute type A aortic dissection in a patient with systemic lupus erythematosus

The case of a 27-year-old Japanese woman with type A acute aortic dissection who had been diagnosed with systemic lupus erythematosus (SLE) is presented. The patient also had aortic regurgitation due to non-infective endocarditis and systemic hypertension, and had been maintained on steroid therapy for 15 years. Her twin sister was also diagnosed with SLE. The patient was admitted to emergency due to severe back pain. A chest x-ray showed enlargement of the upper mediastinum. Echocardiography revealed a thickened and deformed aortic valve with aortic regurgitation and dissection of the ascending aorta, but pericardial effusion was not found. Computed tomography demonstrated aortic dissection extending from the ascending aorta to the abdominal aorta. Graft replacement of the ascending aorta and proximal aortic arch was performed under hypothermic circulatory arrest with retrograde cerebral perfusion. The patient recovered uneventfully. Aortic dissection complicated with SLE is extremely rare, and this is only the 15th case reported in the English or Japanese literature.     

Acute type A aortic dissection in a patient with ventricular septal defect

We report the case of a 38-year-old man with a long-standing history of a small ventricular septal defect presented with chest pain. Electrocardiography revealed sinus rhythm, ST-segment elevation in leads V1–6. The chest X-ray showed mild cardiomegaly. He underwent cardiac catheterisation laboratory to primary coronary angioplasty. Coronary angiography showed normal coronary arteries. Aortic root angiography revealed type A aortic dissection. Transthoracic and transesophageal echocardiography showed aortic dissection in ascending aorta and a perimembranous ventricular septal defect. Thoracoabdominal CT angiography confirmed the aortic dissection before the surgery.The patient underwent cardiac surgery immediately. The ventricular septal defect and aortic dissection were repaired successfully. The postoperative recovery was uneventful and he has thus far remained asymptomatic at 6 months' follow-up.     

Aortic dissection type B with aortic arch involvement surgically treated--a case report

A case of a 56-year-old male with acute aortic dissection type B is presented. The patient underwent successful surgery which was very difficult due to the extent of aortic dissection.     

Complication of hybrid treatment in type B aortic dissection diagnosed by echocardiography

This case illustrates an unusual and fatal complication after endovascular treatment of type B aortic dissection and highlights the role of echocardiography in the early diagnosis of complications. In this case, a patient with previous diagnosis of chronic type B aortic dissection and moderate aortic regurgitation underwent endovascular repair of the proximal descending aorta and conservative surgical correction of the aortic valve. On early postoperative, a transesophageal echocardiogram and aortic angiotomography demonstrated proximal endoleak by contrast extravasation around the proximal graft attachment site, causing compression of the stent in its middle portion, resulting in narrowing with reduced cross‐sectional area.     

Risk factors for descending aortic aneurysm formation in medium-term follow-up of patients with type A aortic dissection

BACKGROUND: After surgery to repair a type A aortic dissection, most late complications and mortality result from descending aorta-related problems. This study was performed to determine the risk factors leading to descending aortic aneurysm formation and late mortality in patients undergoing the type A aortic dissection operation. METHODS: The medical records of patients who survived the operation for type A aortic dissection between 1984 and 1998 were reviewed. There were 144 patients (95 men and 49 women), ranging in age from 24 to 78 years (mean age, 52 years). Most patients were acutely ill, 15 patients were in shock, and 54 patients had cardiac tamponade at the time of the surgical procedure. One hundred thirty-seven patients had ascending aortic replacement only, and of the other 6 patients 2 had hemiarch and 4 had total arch replacement using the elephant trunk technique. The aortic valve was replaced in 23 patients, resuspended in 100, and untouched in 21. Twenty-four risk factors were evaluated in statistical analyses for the prediction of descending aortic aneurysm formation and 3-year mortality. Risk factors were investigated using univariate and multiple logistic regression and survival analyses. RESULTS: The 3-year, 5-year, and 8-year cumulative survival rates were 96.2%, 89.1%, and 80.0%, respectively. The 3-year, 5-year, and 8-year cumulative survival rates, free from descending aortic aneurysm formation or descending aorta operation, were 74.7%, 58.6%, and 43.0%, respectively. Multivariate analysis confirmed that patent false lumen and initial descending aortic diameter were statistically significant risk factors for descending aortic aneurysm formation. CONCLUSIONS: The medium-term survival rate of patients who received operations for type A aortic dissection was satisfactory, despite the high incidence of descending aortic aneurysm formation. The intimal entry site over the aortic arch that was resected during the first operation could decrease the patency rate of a false lumen over the descending aorta. In the absence of a patent false lumen over the descending aorta, the chance of descending aortic aneurysm formation or operation is lessened, and the late survival rate is increased.