近端“三明治”技术对急性Ⅰ型主动脉夹层术后主动脉瓣预后影响的研究

发布时间：2018-04-10 12:18

  本文选题：主动脉夹层 + 三明治　； 参考：《浙江大学》2017年博士论文

【摘要】：研究背景及目的:主动脉夹层(aortic dissection,AD)属于心血管系统的急重症。近年来主动脉夹层的诊断水平提高,手术量呈井喷式增多。急性DeBakeyⅠ型主动脉夹层是累及升主动脉、主动脉弓及降主动脉的一种病变类型。其治疗目标是预防夹层进展和致死性并发症发生。开放手术仍然是治疗急性Ⅰ型主动脉夹层的金标准。非马凡式综合征(Manfan'ssyndrome,MFS)的Ⅰ型主动脉夹层患者,常不伴主动脉窦部扩大及主动脉瓣关闭不全,因此可以保留主动脉窦部及主动脉瓣。对于近端主动脉的处理常采取"三明治"技术,即使用两条毛毡片、人工血管条、牛心包或其他材料加固血管。"三明治"技术一方面加固近端血管与人工血管的吻合,另一方面减少血管和人工血管直接吻合的出血,同时夹闭近端的假腔防止夹层的继续发展。然而"三明治"技术在近端血管的处理存在一定的隐患。即使"三明治"封闭近端主动脉的假腔,但由于近端主动脉血压高,仍然可能从吻合口的针眼进入假腔,从而使近端的夹层继续向根部撕脱,最终导致窦部增大及主动脉瓣环增大或结构发生变化,形成主动脉瓣关闭不全。本课题基于近年来我院采取"三明治"技术处理近端主动脉的非MFS急性Ⅰ型主动脉夹层患者,分析该群体患者术后随访出现主动脉关闭不全的比例,从而评价"三明治"技术在急性Ⅰ型主动脉夹层手术中的效果。临床资料与方法:本研究采用回顾性研究方法,纳入2007年至2016年于浙江大学附属第一医院心胸外科住院行主动脉夹层手术治疗患者177例,排除DeBakeyⅡ型、DeBakeyⅢ型及MFS患者52例,共计125例非MFS急性Ⅰ型主动脉夹层患者,其中93例采取"三明治"技术处理近端主动脉。13例发生住院死亡,7例失随访。随访超声心动图及胸主动脉CTA,观察主动脉瓣关闭不全程度,统计发生中度及以上的主动脉瓣关闭不全的例数,从而评价"三明治"技术加固主动脉近端的可行性。结果:共纳入73例采取"三明治"技术加固主动脉近端的非MFS急性Ⅰ型主动脉夹层患者。该人群平均年龄51.5±10.9岁,男女比例3:1,67.1%有既往高血压病史。平均随访时间为14.8±16.6月,8例在之后的随访中死亡。3例窦部直径较术前增加5mm以上,但这3例并未发生中度及以上的主动脉瓣关闭不全。另外有3例在随后的随访中出现中度主动脉瓣关闭不全,但这3例均未出现明显的气急、胸痛等症状,窦部直径也并未增大,胸主动脉CTA未提示夹层继续向窦部发展。结论:近端主动脉"三明治"技术广泛应用于主动脉夹层手术,虽然在本研究中采用该技术有3例术后随访中出现了中度及以上的主动脉瓣关闭不全,但发生率低(4.1%),且并没有严重影响其日常生活质量。因此本研究未发现近端"三明治"技术对急性Ⅰ型主动脉夹层术后主动脉瓣产生不良影响,其远期效果尚可,从而证明"三明治"技术的安全性及可行性
[Abstract]:Background and objective: aortic dissection (ADA) is an acute disease of the cardiovascular system.In recent years, the diagnostic level of aortic dissection has been improved, and the volume of operation has increased.Acute DeBakey type I aortic dissection is a type of disease involving ascending aorta, aortic arch and descending aorta.The goal of treatment is to prevent the progression of dissection and the occurrence of fatal complications.Open surgery remains the gold standard for the treatment of acute type I aortic dissection.Patients with type I aortic dissection with non-Marfan syndrome (Manfanssyndromeg MFS) are often not accompanied by dilation of the aortic sinus and insufficiency of the aortic valve, so the aortic sinus and aortic valve can be preserved."for proximal aorta, the" sandwich "technique is often used to reinforce blood vessels with two blankets, artificial vascular strips, bovine pericardium, or other materials."Sandwich "technique not only strengthens the anastomosis of proximal and artificial blood vessels, but also reduces the bleeding caused by direct anastomosis of blood vessels and artificial vessels, while clamping the false cavity of proximal end to prevent the development of dissection.However, sandwich technique has some hidden dangers in the treatment of proximal vessels.Even if the "sandwich" closes the false lumen of the proximal aorta, because of the high blood pressure of the proximal aorta, it is still possible to enter the false cavity from the needle eye of the anastomotic stoma, so that the proximal dissection continues to tear off toward the root.Finally, the enlargement of the sinus and the enlargement or structural change of the aortic annulus result in aortic valve insufficiency.Based on the "sandwich" technique adopted by our hospital in recent years to treat non-acute MFS type I aortic dissection patients with proximal aorta, we analyzed the incidence of aortic insufficiency after follow-up in this group of patients.The effect of sandwich technique on acute type I aortic dissection was evaluated.Clinical data and methods: a retrospective study was conducted in 177 patients with aortic dissection in cardiothoracic surgery department of the first affiliated Hospital of Zhejiang University from 2007 to 2016, and 52 patients with DeBakey 鈪，

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