改良Bentall手术在StanfordA3型主动脉夹层治疗中的应用

目的总结改良主动脉根部置换手术（改良Bentall手术）j在Stanford A3型主动脉夹层（aortic dissection，AD）手术中的应用经验及其效果。方法2004年1月至2013年6月南京医科大学附属南京医院共对54例Stan-fbrd A3型主动脉夹层（根据孙立忠的主动脉夹层细化分型原则）患者施行了主动脉根部置换手术，其中男41例、女13例，年龄21～73岁；Bentall手术12例，Bentall＋右半弓置换手术14例，Bentall＋全弓置换＋支架象鼻手术28例。根据手术方式不同，将54例患者分为两组，A组：36例，主动脉根部置换施行传统Bentall手术；B组：18例，主动脉根部置换施行改良Bentall手术，即在传统Bentall手术的基础上，对窦部直径小于45mm、冠状动脉开口移位不明显的患者采用“城门洞”法冠状动脉开口吻合技术。比较两组患者的术后转归和并发症发生情况。结果两组患者的年龄、性别比率差异无统计学意义。A组窦部直径明显大于B组（52．11±3．62）mm vs．（40．72±2．67）mm，P=0.000]，差异有统计学意义；两组患者的手术时间、体外循环时间、术中深低温停循环时间、术后胸腔引流量和住ICU时间差异均无统计学意义（P〉0．05）。术后死亡4例，其中A组2例，B组2例，两组住院死亡率差异无统计学意义5．56％（2／36）VS．11．11％（2／18），P=0．462]；2例因无法控制的渗血、1例因腹主动脉夹层动脉瘤破裂、1例因急性肺梗塞死亡。随访48例，随访时间3个月，失访2例。随访期间有48例患者复查CTA（computed tomography angiography），主动脉根部未见假性动脉瘤形成，冠状动脉开口未见动脉瘤或狭窄。结论主动脉夹层累及主动脉根部时需要行主动脉根部置换手术，对于窦部直径小于45mm、冠状动脉开口移位不明显的患者，可以施行改良Bentall手术，即“城门洞”法冠状动脉开口吻合技术，其技术简?

Modified Bentall Procedure for the Treatment of Stanford Type A3 Aortic Dissection

Objective To summarize clinical experience and outcomes of modified Bentall procedure for the treatment of Stanford type A3 aortic dissection （AD）. Methods Fifty-four patients with Stanford type A3 AD underwent aortic root replacement in Nanjing Hospital Affiliated to Nanjing Medical University from January 2004 to June 2013. There were 41 male and 13 female patients with their age of 21-73 years. According to different surgical methods, all the 54 patients were divided into 2 groups. In group A, there were 36 patients who received conventional Bentall procedure. In group B, there were 18 patients who received modified Bentall procedure （ ＇gate＇ anastomosis of the coronary ostia for patients with aortic root less than 45 mm and nonsignificant displacement of the coronary ostia）. Postoperative outcomes were compared between the 2 groups. Results There was no statistical difference in age or gender between the 2 groups. Mean diameter of the aortic root of group A was significantly larger than that of group B （ 52.11±3.62 mm vs. 40.72 ±2.67 mm, P=0.000）. There was no statistical difference in operation time, cardiopulmonary bypass time, intraoperative circulation arrest time, postoperative thoracic drainage or length of ICU stay between the 2 groups （P 〉 0.05 ）. Four patients died postoperativel） including 2 patients with uncontrollable bleeding, 1 patient with abdominal AD rupture and 1 patient with acute pulmonar） embolism. There was no statistical difference in in-hospital mortality between group A and group B E 5.56% （2/36） vs 11.11% （2/18）, P=0.4623. Forty-eight patients were followed up for 3 months, and 2 patients were lost during follow-up Forty-eight patients received computed tomography angiography without false aneurysm formation in the aortic root, coronat3 ostial aneurysm or stenosis. Conclusion Modified Bentall procedure （ ＇gate＇ anastomosis of the coronary ostia） is simpl~ and effective for patients with aortic root less than 45 mm and nonsignificant displac