手术治疗老年Stanford A型急性主动脉夹层的近期和远期疗效分析

目的:探讨外科手术治疗老年Stanford A型急性主动脉夹层(AAD)的近远期疗效。方法:回顾性分析2008年6月—2017年3月郑州大学第二附属医院心血管外科应用手术治疗的196例Stanford A型AAD患者资料,患者均采用全麻、深低温停循环加单侧选择性脑灌注技术进行外科手术治疗,其中33例患者年龄≥60岁(老年组),163例患者年龄60岁(年轻组),比较两组患者的临床资料和预后情况。结果:与年轻组比较,老年组男性患者比例低(45.5%vs.73.0%,P=0.000),De Bakey II型主动脉夹层发病率高(21.2%vs.6.7%,P=0.009);升主动脉置换+全弓置换+象鼻支架术应用比例低于年轻组(9.1%vs.28.2%,P=0.021)升主动脉置换+全弓置换+象鼻支架术应用比例减少(9.1%vs.28.2%,P=0.021),但单纯升主动脉置换比例增加(21.2%vs.2.5%,P=0.000),平均体外循环时间、主动脉阻断时间、手术时间均缩短(215.70 min vs.252.98 min,P=0.000;121.12 min vs.134.00 min,P=0.008;489.15 min vs.533.52 min,P=0.004);术后ICU停留时间延长(235.27 h vs.163.55 h,P=0.011),术后肾功能不全(21.2%vs.6.7%,P=0.009)、感染发生率(30.3%vs.9.8%,P=0.002)升高;术后生存率差异无统计学意义(P=0.1466)。全组病例分析显示,体外循环时间是AAD患者手术后院内死亡的危险因素(OR=0.987,95%CI=0.977~0.997,P=0.011),而年龄(OR=1.790,95%CI=0.651~4.921,P=0.259)与其他因素并非手术后院内死亡的危险因素。结论:对于老年AAD患者,根据夹层累及范围选择恰当的手术方式可以取得较满意的预后,术中尽可能缩短体外循环时间有助于提高手术疗效。

Analysis of short- and long-term efficacy of surgical treatment for Stanford type A acute aortic dissection in elderly patients

Objective: To investigate short- and long-term efficacy of surgical treatment for Stanford type A acute aortic dissection (AAD) in elderly patients. Methods: The clinical data of 196 patients with Stanford type A AAD undergoing surgical treatment in the Department of Cardiovascular Surgery of the Second Affiliated Hospital of Zhengzhou University from June 2013 to September 2016 were retrospectively analyzed. All patients underwent surgical repair under general anesthesia with deep hypothermic circulatory arrest and unilateral selective cerebral perfusion. The patients consisted of 33 cases with age equal to or over 60 years (elderly group) and 163 cases with age below 60 years (nonelderly group). The clinical variable and outcomes of the two groups of patients were compared. Results: In elderly group compared with nonelderly group, the proportion of male cases was lower (45.5% vs. 73.0%, P=0.000), the proportion of DeBakey type II dissection was increased (21.2% vs. 6.7%, P=0.009); the proportion of cases undergoing ascending aortic replacement plus total aortic arch replacement with stent elephant trunk implantation was decreased (9.1% vs. 28.2%, P=0.021), but the proportion of cases undergoing a simple ascending aortic replacement was increased (21.2% vs. 2.5%, P=0.000); the average extracorporeal circulation time, aorta occlusion time and operative time were all shortened (215.70 min vs. 252.98 min, P=0.000; 121.12 min vs. 134.00 min, P=0.008; 489.15 min vs. 533.52 min, P=0.004); the length of the postoperative ICU stay was prolonged (235.27 h vs. 163.55 h, P=0.011), and the incidence of postoperative renal dysfunction (21.2% vs. 6.7%, P=0.009) and infections (30.3% vs. 9.8%, P=0.002) were increased; the postoperative survival showed no significant difference (P=0.1466). Statistical analysis of the entire group of patients showed that extracorporeal circulation time was an independent risk factor for postoperative in-hospital death (OR=0.987, 95% CI=0.977 0.997, P=0.011), while the age (OR=1.790, 95% CI=0.651 4.921, P=0.259) and other factors were not significantly associated with the risk of postoperative in-hospital death. Conclusion: For elderly AAD patients, surgical procedure selected according to the extent of the dissection involvement may offer a satisfactory result. Surgical efficacy can be improved by keeping the extracorporeal circulation time as short as possible.