張大發(fā)++++++陳亦江++++++邵永豐++++++張石江++++++韋俊
[摘要] 目的 探討保留瓣膜的改良主動(dòng)脈根部成形術(shù)治療急性Stanford A型夾層的近中期效果。 方法 選取2012年1月~2016年12月南京醫(yī)科大學(xué)第一附屬醫(yī)院胸心外科診斷Stanford A1及A2型急性主動(dòng)脈夾層的患者32例作為研究對(duì)象,均施行標(biāo)準(zhǔn)孫氏手術(shù),根部處理均采用保留瓣膜的改良根部成形技術(shù),將保留的全部血管外膜包繞人工血管近遠(yuǎn)端吻合口,并吻合至右心耳。通過(guò)圍術(shù)期觀察及術(shù)后隨訪,了解竇部病變進(jìn)展、假腔及內(nèi)引流隧道血栓化情況,比較術(shù)前及術(shù)后左室射血分?jǐn)?shù)(EF)、左室舒張末內(nèi)徑、主動(dòng)脈竇部直徑等,評(píng)估該術(shù)式的近中期療效。 結(jié)果 無(wú)手術(shù)室死亡發(fā)生,4例患者在院死亡,無(wú)截癱等嚴(yán)重并發(fā)癥。出院患者無(wú)失訪,隨訪時(shí)間為19~60個(gè)月,隨訪期間死亡2例,22例患者夾層假腔完全血栓化,2例出現(xiàn)胸降主動(dòng)脈擴(kuò)張。至最后一次隨訪時(shí),左室EF[(56.4±6.7)%比(59.1±8.2)%,P=0.700]、左室舒張末內(nèi)徑[(46.5±4.2)比(46.9±5.7)mm,P=0.532]、主動(dòng)脈竇部直徑[(34.2±5.3)比(35.5±6.1)mm,P=0.564)]均較術(shù)前無(wú)顯著改變。 結(jié)論 急性主動(dòng)脈夾層累及主動(dòng)脈根部病變復(fù)雜,對(duì)于竇部累及不嚴(yán)重且竇部無(wú)明顯擴(kuò)張的患者施行改良的根部成形技術(shù)、精確的外科縫合及根部包裹引流技術(shù),可以有效提高手術(shù)成功率,且近中期臨床療效較滿意。
[關(guān)鍵詞] 急性主動(dòng)脈夾層;Stanford A;根部成形;近中期療效
[中圖分類號(hào)] R654.2 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1673-7210(2017)11(b)-0055-04
[Abstract] Objective To investigate the early to middle term efficacy of modified aortic root plasty with valve sparing in the treatment of acute Stanford A dissection. Methods From January 2012 to December 2016, 32 patients were diagnosed for acute aortic dissection with Stanford A1 and A2 types in Department of Cardiothoracic Surgery, the First Affiliated Hospital of Nanjing Medical University. All patients were underwent the standard Sun's procedure. Modified aortic root plasty with valve sparing was applied in the root treatment. A fistulization was made with the adventitia wrapped around the artificial vessel and shunted to the right atrial appendage. Through the perioperative observation and postoperative follow up, disease progress, false lumen and thrombosis were all recorded. And the early-to-middle term results of the operation were assessed by comparing of preoperative and postoperative left ventricular ejection fraction (EF), left ventricular end diastolic diameter and aortic sinus diameter. Results There was no operation room death, but 4 deaths in the hospital. No serious complications such as paraplegia occurred. The discharged patients were followed up for 19-60 months. During the follow-up period, 2 patients died, 22 patients had complete thrombosis of the false lumen and 2 dilatations were observed in the descending thoracic aorta. There were no significant differences in the left ventricular EF [(56.4±6.7)% vs (59.1±8.2)%, P=0.700], left ventricular end diastolic dimension [(46.5±4.2) vs (46.9±5.7) mm, P=0.532] and aortic sinus diameter [(34.2±5.3) vs (35.5±6.1) mm, P=0.564] between the pre-operation and the last follow-up. Conclusion The pathological changes of acute aortic dissection involving the aortic root are complex. It is feasible to perform modified aortic root plasty with valve sparing in those without significant sinus extension and valve insufficiency. Improved success rate of operation and early to middle term clinical efficacy can both be achieved by the combination of accurate surgical suture and right-to-left shunt techniques.endprint
[Key words] Acute aortic dissection; Stanford A; Root plasty; Early to middle term efficacy
近年來(lái),隨著影像學(xué)診斷方法的進(jìn)步,急性主動(dòng)脈夾層的診斷率逐漸提高。其中,Stanford A型夾層的病情較為兇險(xiǎn),如得不到有效治療,患者多數(shù)在數(shù)小時(shí)至數(shù)天內(nèi)死亡。手術(shù)是Stanford A型夾層最有效的治療手段[1]。隨著手術(shù)經(jīng)驗(yàn)的不斷積累,以孫氏手術(shù)為代表的全動(dòng)脈弓置換及遠(yuǎn)端象鼻支架植入技術(shù),因適應(yīng)證廣泛、手術(shù)死亡率低、遠(yuǎn)期療效確切,已成為處理動(dòng)脈弓部及降主動(dòng)脈病變的標(biāo)準(zhǔn)術(shù)式[2]。然而,對(duì)于夾層累及主動(dòng)脈根部的外科處理技術(shù),意見(jiàn)并不一致,手術(shù)方式包括主動(dòng)脈瓣交界懸吊、Wheat術(shù)、Bentall或David術(shù)等,但均存在操作復(fù)雜、出血風(fēng)險(xiǎn)較高或術(shù)后藥物依賴等問(wèn)題,影響臨床應(yīng)用。本研究根據(jù)孫氏主動(dòng)脈夾層改良細(xì)化分型,對(duì)于Stanford A1及A2型患者,即夾層累及主動(dòng)脈竇部、1~2個(gè)瓣交界撕脫、伴輕中度主動(dòng)脈瓣關(guān)閉不全、竇部直徑<4 cm者,施行保留瓣的改良根部成形技術(shù),近中期臨床療效滿意,報(bào)道如下:
1 資料與方法
1.1 一般資料
選取2012年1月~2016年12月因Stanford A(Stanford A1及A2)型急性主動(dòng)脈夾層在南京醫(yī)科大學(xué)第一附屬醫(yī)院胸心外科住院治療的患者32例,術(shù)前均經(jīng)心臟彩超及CTA檢查確診,除外馬方綜合征或其余疑似結(jié)締組織病、竇部顯著擴(kuò)張、竇部嚴(yán)重累及合并重度主動(dòng)脈瓣關(guān)閉不全者。其中,男23例(72%),女9例(28%);年齡36~74歲,平均(55.2±8.9)歲;體重指數(shù)(BMI)>30 kg/m2者2例;合并高血壓病28例,2型糖尿病5例,慢性腎功能不全2例,腦血管意外病史2例,伴血性心包積液24例,胸腔積液18例,低氧血癥(血氧飽和度< 95%)12例;術(shù)中發(fā)現(xiàn)破口位于升主動(dòng)脈17例,破口位于主動(dòng)脈弓者13例;9例患者伴輕中度主動(dòng)脈瓣關(guān)閉不全,其余23例主動(dòng)脈瓣關(guān)閉良好。術(shù)中根部處理技術(shù)均采取保留主動(dòng)脈瓣的改良根部成形術(shù)。
1.2 方法
取胸骨正中切口,常規(guī)右腋動(dòng)脈及右心房插管開(kāi)始體外循環(huán),部分患者同時(shí)行股動(dòng)脈插管,升主動(dòng)脈遠(yuǎn)端阻斷后,順行灌停心臟后持續(xù)逆行灌注,心包腔內(nèi)置冰水降溫。在降至深低溫過(guò)程中先處理主動(dòng)脈根部,清除假腔血栓,竇管交界上方切除升主動(dòng)脈內(nèi)膜,保留全部外膜。探查瓣竇,裁剪鴨舌形滌綸補(bǔ)片,襯入主動(dòng)脈無(wú)冠竇內(nèi),如有右冠竇撕脫,裁剪U型補(bǔ)片,環(huán)繞冠脈開(kāi)口襯入。另裁剪一條5~7 mm寬的長(zhǎng)條形滌綸補(bǔ)片,環(huán)形襯入動(dòng)脈腔內(nèi)。5-0 prolene線間斷褥式縫合數(shù)針,將滌綸補(bǔ)片、動(dòng)脈內(nèi)膜、滌綸補(bǔ)片及外膜固定,重建根部解剖。主動(dòng)脈瓣試水,如合并輕中度關(guān)閉不全,則5-0 prolene行瓣膜交界懸吊。選取合適管徑的人工血管,4-0 peolene線與加固的竇管交界全層縫合。經(jīng)人工血管順行灌注,檢查瓣膜關(guān)閉及吻合口出血情況,如有血液漏出,再次間斷縫合修正。降至深低溫后,完成降主動(dòng)脈象鼻支架植入以及弓部四分支血管置換。復(fù)溫過(guò)程完成升主動(dòng)脈人工血管與四分支血管的吻合,排氣后開(kāi)放升主動(dòng)脈。心臟復(fù)搏后,將保留的全部血管外膜包繞主動(dòng)脈近遠(yuǎn)端吻合口,并開(kāi)口吻合至右心耳,形成內(nèi)引流。
1.3 臨床隨訪
所有患者出院前復(fù)查動(dòng)脈造影,了解竇部病變進(jìn)展、假腔及內(nèi)引流隧道血栓化情況。出院后隨訪控制血壓、心率,血壓盡量控制在120/80 mmHg(1 mmHg=0.133 kPa)以下,心率低于80次/min。每半年門(mén)診隨訪心臟彩超及動(dòng)脈造影,記錄最后一次左室射血分?jǐn)?shù)、左室舒張末內(nèi)徑、主動(dòng)脈竇直徑、主動(dòng)脈瓣瓣環(huán)及胸降主動(dòng)脈直徑,并與術(shù)前比較。
1.4 統(tǒng)計(jì)學(xué)方法
采用SPSS 19.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析,計(jì)量資料數(shù)據(jù)用均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,兩組間比較采用t檢驗(yàn),以P < 0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 術(shù)后早期資料
全組患者無(wú)手術(shù)室死亡發(fā)生,在院死亡4例,1例死于腎功能衰竭后繼發(fā)感染,1例死于腹腔動(dòng)脈缺血后頑固性代謝性酸中毒,1例死于腦梗死后肺部感染,1例患者術(shù)后9 d突發(fā)胸痛及低血壓,心臟超聲提示左側(cè)大量胸腔積液,考慮降主動(dòng)脈破裂,送數(shù)字減影血管造影手術(shù)途中死亡。全組無(wú)截癱等嚴(yán)重并發(fā)癥,二次開(kāi)胸止血1例,術(shù)后第1天引流量>800 mL者7例,ICU停留>5 d者17例,主要為術(shù)后肺部氧合障礙及肺部感染,術(shù)后腦血管意外2例,切口并發(fā)癥1例,換藥后好轉(zhuǎn)。術(shù)中行瓣膜交界懸吊者14例,全組體外循環(huán)時(shí)間為(225.6±39.5)min,主動(dòng)脈阻斷時(shí)間為(82.1±27.6)min,深低溫停循環(huán)時(shí)間為(26.7±3.6)min。
2.2術(shù)后隨訪資料
出院患者無(wú)失訪,隨訪時(shí)間為9~60個(gè)月,平均37個(gè)月。隨訪期間死亡2例,1例術(shù)后3年死于車禍外傷,1例術(shù)后7個(gè)月夜間猝死,具體原因不明。2例患者在隨訪期間出現(xiàn)新主動(dòng)脈瓣輕中度關(guān)閉不全,主動(dòng)脈竇及左心室無(wú)明顯擴(kuò)張,無(wú)臨床癥狀。至最后一次隨訪時(shí),22例(64.6%,22/26)患者夾層假腔完全血栓化,2例患者出現(xiàn)胸降主動(dòng)脈擴(kuò)張,無(wú)臨床癥狀,仍在隨訪中,其余患者隨訪期間無(wú)異常狀況發(fā)生。與術(shù)前比較,患者末次隨訪左室射血分?jǐn)?shù)、左室舒張末內(nèi)徑、主動(dòng)脈竇直徑、主動(dòng)脈瓣瓣環(huán)及胸降主動(dòng)脈直徑均無(wú)顯著改變(P > 0.05)。見(jiàn)表1。
3 討論
急性Stanford A型主動(dòng)脈夾層病情兇險(xiǎn),發(fā)病后死亡率隨時(shí)間遞增,半數(shù)患者在2 d內(nèi)死亡,死因主要有動(dòng)脈壁破裂出血引起的心包壓塞、失血性休克、冠狀動(dòng)脈缺血或急性主動(dòng)脈瓣關(guān)閉不全、充血性心力衰竭等,是心胸外科最危險(xiǎn)的急癥之一,外科手術(shù)目前仍是急性主動(dòng)脈夾層最有效的治療手段[1]。然而,由于主動(dòng)脈根部解剖復(fù)雜,夾層對(duì)于主動(dòng)脈根部的累及程度個(gè)體差異較大,良好的協(xié)作及合適的手術(shù)方式,對(duì)于保障患者的近遠(yuǎn)期療效尤為重要[3]。endprint
早期的手術(shù)經(jīng)驗(yàn)要求完全切除病變的血管內(nèi)膜,加強(qiáng)縫合主動(dòng)脈緣,消除假腔,目前臨床仍應(yīng)用廣泛,即主動(dòng)脈瓣交界懸吊及升主動(dòng)脈置換術(shù)[4],其操作簡(jiǎn)便,手術(shù)時(shí)間短,短期效果好,遠(yuǎn)期則避免了瓣膜抗凝相關(guān)風(fēng)險(xiǎn)。但由于病變的竇部被保留,術(shù)后易再次出現(xiàn)夾層或根部假性動(dòng)脈瘤,或繼發(fā)的主動(dòng)脈瓣功能障礙[5]。國(guó)外報(bào)道中,有應(yīng)用生物蛋白膠黏合假腔,降低操作難度,并降低再手術(shù)風(fēng)險(xiǎn),但膠水的生物安全性及遠(yuǎn)期效果仍需檢驗(yàn)[6-7]。國(guó)內(nèi)有報(bào)道行滌綸補(bǔ)片加固成形主動(dòng)脈根部,近中期療效顯著[8-9]。筆者在上述基礎(chǔ)上,嚴(yán)格把握手術(shù)指征,對(duì)于無(wú)明顯冠脈受累、竇部直徑<3.5 cm、主動(dòng)脈瓣結(jié)構(gòu)完整無(wú)脫垂者,除外馬方綜合征、白塞病等結(jié)締組織病后,施行改良的根部成形術(shù),臨床效果滿意,在院及隨訪過(guò)程中,均未觀察到與竇部病變相關(guān)事件發(fā)生。認(rèn)為在血管內(nèi)膜的內(nèi)外面襯以滌綸補(bǔ)片,縫線穿行過(guò)程中降低了組織張力,有效避免了對(duì)病變內(nèi)膜血管的切割,加強(qiáng)了吻合口并防止其口出血。
對(duì)于根部病變嚴(yán)重的患者,術(shù)式選擇主要有帶瓣人工管道行主動(dòng)脈根部替換術(shù)[10](Bentall術(shù))及保留主動(dòng)脈瓣的根部替換術(shù)[11](David術(shù))。Bentall手術(shù)完全切除病變的主動(dòng)脈根部,操作簡(jiǎn)單,手術(shù)成功率高,術(shù)后根部再次出現(xiàn)病變的概率較小,最早于1968年被報(bào)道,其后手術(shù)細(xì)節(jié)不斷改進(jìn),現(xiàn)已成為Stanford A型夾層合并主動(dòng)脈瓣關(guān)閉不全的標(biāo)準(zhǔn)術(shù)式[12]。該術(shù)式缺點(diǎn)亦較明顯,術(shù)后需終身抗凝,竇部較小且冠脈開(kāi)口低的患者術(shù)中操作困難,隨訪過(guò)程中冠脈開(kāi)口常易出現(xiàn)真假性動(dòng)脈瘤,改進(jìn)為“紐扣法”吻合冠脈后雖可降低上述風(fēng)險(xiǎn),但不利于術(shù)中止血及分流,手術(shù)并發(fā)癥風(fēng)險(xiǎn)顯著增高[13]。David術(shù)對(duì)上述手術(shù)方式再做改進(jìn),保留了主動(dòng)脈瓣及避免長(zhǎng)期抗凝,近年來(lái)越來(lái)越多應(yīng)用于Stanford A型夾層的手術(shù)治療[14]。手術(shù)方式包括成形法及再植法,以后細(xì)節(jié)上以不斷改進(jìn),臨床報(bào)道中遠(yuǎn)期療效滿意,有效降低了再手術(shù)概率及腦卒中風(fēng)險(xiǎn),但近期手術(shù)時(shí)間、體外循環(huán)時(shí)間及手術(shù)死亡率等較高,對(duì)于急診手術(shù)中是否應(yīng)用仍有爭(zhēng)議[15-16]。
無(wú)論采取以上何種術(shù)式,夾層術(shù)后出血仍是困擾臨床的一項(xiàng)難題,其原因有凝血功能障礙、人工血管滲血及吻合口出血等[17]。將殘余瘤壁包裹人工血管及吻合口并與右心房分流的手術(shù)方法[18],目前仍有爭(zhēng)議,有研究者認(rèn)為精細(xì)的外科操作可減少出血,并可能壓迫冠狀動(dòng)脈引起嚴(yán)重的并發(fā)癥[19-22]。本研究常規(guī)在主要吻合口完成后,等待體外循環(huán)復(fù)溫過(guò)程中,將殘余瘤壁包繞近遠(yuǎn)端吻合口及人工血管主干,并向右心耳做“V”字分流,少量滲血不予特殊處理,拔除右心插管的過(guò)程中,擴(kuò)大吻合口。術(shù)后患者引流明顯減少,血制品需求及相關(guān)的并發(fā)癥亦明顯減少,有效縮短了手術(shù)時(shí)間并提高了手術(shù)成功率,全組患者無(wú)手術(shù)室內(nèi)死亡。在隨訪過(guò)程中,術(shù)后1個(gè)月后分流腔內(nèi)基本血栓化,其后的隨訪中無(wú)冠狀動(dòng)脈壓迫或血栓脫落等發(fā)生,臨床效果滿意。
本組患者為選擇的病例,根部病變較輕,發(fā)病前均無(wú)明顯的主動(dòng)脈根部病變,且排除了馬方綜合征等結(jié)締組織病,近中期手術(shù)效果較好,但仍需長(zhǎng)期隨訪驗(yàn)證。此外,對(duì)于夾層累及冠脈或竇部已有擴(kuò)大的患者,能否應(yīng)用上述簡(jiǎn)化手術(shù)方式,或與既往手術(shù)方式療效對(duì)照,仍需進(jìn)一步的臨床研究。
綜上所述,急性主動(dòng)脈夾層累及主動(dòng)脈根部病變復(fù)雜,對(duì)于竇部累及不嚴(yán)重且竇部無(wú)明顯擴(kuò)張的患者,血管內(nèi)膜內(nèi)外面滌綸補(bǔ)片加強(qiáng)、精確的外科縫合及根部包裹引流技術(shù)可以有效提高手術(shù)成功率,且近中期臨床療效較滿意。
[參考文獻(xiàn)]
[1] Elsayed RS,Cohen RG,F(xiàn)leischman F,et al. Acute Type A Aortic Dissection [J]. Cardiol Clin,2017,35(3):331-345.
[2] Sun LZ,Ma WG,Zhu JM,et al. Sun's procedure for chronic type A aortic dissection:total arch replacement using a tetrafurcate graft with stented elephant trunk implantation [J]. Ann Cardiothorac Surg,2013,2(5):665-666.
[3] Preventza O. In type A aortic dissection repair,an effective team approach and relational coordination are more important for patients' outcomes than surgeon volume [J]. J Thorac Cardiovasc Surg,2017,154(2):407-408.
[4] Olsson C,Eriksson N,Stahle E,et al. Surgical and long-term mortality in 2634 consecutive patients operated on the proximal thoracic aorta [J].Eur J Cardiothorac Surg,2007, 31(6):963-969.
[5] Hata H,Takano H,Matsumiya G,et al. Late complications of gelatin resorcin formalin glue in the repair of acute type A aortic dissection [J]. Ann Thorac Surg,2007,83(5):1621-1626.
[6] Ohira S,F(xiàn)ukumoto A,Matsushiro T,et al. Novel technique using polyester fabric and fibrin sealant patch for acute aortic dissection [J]. Heart Lung Circ,2016,25(8):885-887.endprint
[7] Kimura C,Takihara H,Okada S. Coronary embolism probably caused by surgical glue after operation for acute aortic dissection. report of a case [J]. Kyobu Geka,2016,69(7):548-551.
[8] 宣煜龍,潘俊,周慶,等.滌綸片加固成形根部重建在急性A型主動(dòng)脈夾層中的應(yīng)用[J].中華胸心血管外科雜志,2015,31(12):725-728.
[9] 師恩祎 谷天祥 于洋,等.不同手術(shù)方式治療急性Stanford A型主動(dòng)脈夾層——單中心5年臨床經(jīng)驗(yàn)[J].中國(guó)胸心血管外科臨床雜志,2014,21(2):198-202.
[10] Mookhoek A,Korteland NM,Arabkhani B,et al. Bentall Procedure.A Systematic Review and Meta-Analysis [J]. Ann Thorac Surg,2016,101(5):1684-1689.
[11] Leshnower BG,Myung RJ,McPherson L,et al. Midterm results of David V valve-sparing aortic root replacement in acute type A aortic dissection [J]. Ann Thorac Surg,2015, 99(3):795-800.
[12] Wang CS,Li J,Lai H. Clinical practice and thoughts on the strategy of root reconstruction for Stanford type A aortic dissection [J]. Zhonghua Wai Ke Za Zhi,2017,55(4):245-250.
[13] Varrica A,Satriano A,De Vincentiis C,et al. Bentall operation in 375 patients: long-term results and predictors of death [J]. J Heart Valve Dis,2014,23(1):127-134.
[14] Ouzounian M,Rao V,Manlhiot C,et al. Valve-Sparing Root Replacement Compared With Composite Valve Graft Procedures in Patients With Aortic Root Dilation [J]. J Am Coll Cardiol,2016,68(17):1838-1847.
[15] Dhurandhar V,Parikh R,Saxena A,et al. Early and late outcomes following valve sparing aortic root reconstruction:The ANZSCTS database [J]. Heart Lung Circ,2016, 25(5):505-511.
[16] Esaki J,Leshnower BG,Binongo JN,et al. The David V valve-sparing root replacement provides improved survival compared with mechanical valve-conduits in the treatment of young patients with aortic root pathology [J]. Ann Thorac Surg,2016,102(5):1522-1530.
[17] Guan XL,Wang XL,Liu YY,et al. Changes in the Hemostatic System of Patients With Acute Aortic Dissection Undergoing AorticArch Surgery [J]. Ann Thorac Surg,2016,101(2):945-951.
[18] 周子凡,師啟眾,劉現(xiàn)民,等.主動(dòng)脈根包裹手術(shù)治療主動(dòng)脈根部動(dòng)脈瘤[J].心肺血管病雜志,2016,35(3):196-199.
[19] 孫明,張榮林.急診搶救室血D-二聚體濃度對(duì)急性主動(dòng)脈夾層的診斷價(jià)值[J].中國(guó)醫(yī)藥科學(xué),2015,5(24):16-19,38.
[20] Pagni S,Mascio C,Trivedi,et al. Type A aortic dissection complicated with fistulization into the right atrium and right-to-left shunt [J]. Interact Cardiovasc Thorac Surg,2013,16(6):909-911.
[21] 葉華安,封加濤,彭峰,等.急性Stanford A型主動(dòng)脈夾層的外科治療體會(huì)[J].疑難病雜志,2016,15(11):1101-1103,1107.DOI:10.3969/j.issn.1671-6450.2016.11.001.
[22] Yang WJ,Duan QJ,Cheng HF,et al. A case study of pulmonary embolism from the right atrial shunt after acute type a aortic dissection surgery [J]. J Cardiothorac Surg,2014,9(1):1-3.endprint