心脏手术史不是A型主动脉夹层孙氏手术院内死亡的独立危险因素

摘要

目的 探讨心脏手术史是否是A型主动脉夹层患者全主动脉弓替换加支架象鼻手术(孙氏手术)后院内死亡的独立危险因素.方法 2009年2月至2012年2月,共384例A型主动脉夹层患者纳入研究.其中36例术前有心脏手术史:Bentall手术16例,升主动脉替换术7例,Wheat手术4例,主动脉瓣置换术4例,Bentall加二尖瓣手术2例,二尖瓣及主动脉瓣双瓣置换术1例,房间隔缺损修补术1例,冠状动脉旁路移植术1例.将可能与术后死亡相关的因素先行单因素分析,单因素分析有意义的变量纳入多因素logistic回归分析.结果 孙氏术后院内死亡共31例,占8.07％.有心脏手术史患者36例中共死亡3例,占8.33％.单因素分析结果显示年龄和发病至手术时间小于1周为术前危险因素;体外循环时间超过300 min,主动脉夹层累及冠状动脉需要行冠状动脉旁路移植术为术中危险因素.将此4种危险因素纳入多因素logistic回归,结果显示,发病至手术时间小于1周(P=0.038,OR=2.43)、体外循环超过300 min(P＜0.001,OR=12.05)为孙氏术后患者院内死亡的独立危险因素.心脏手术史不是A型主动脉夹层行孙氏手术后院内死亡的危险因素.有心脏手术史患者术后住ICU时间(2.09±1.89)天,首次手术患者(2.71±3.01)天,组间差异无统计学意义(P=0.25).有心脏手术史患者术后机械通气(30.09 ±33.42)h,首次手术(33.86±40.98)h,组间差异亦无统计学意义(P=0.61).有心脏手术史患者术后因出血导致二次开胸率3.03％,首次手术1.88％,组间差异无统计学意义(P=0.50).结论 心脏手术史不是A型主动脉夹层孙氏手术后院内死亡的独立危险因素,术后并发症发生率未显著增加.对于有心脏手术史的A型主动脉夹层患者,应该积极外科手术治疗.%Objective The aim of this study was to evaluate whether the reoperation is the risk factor for mortality after Sun's procedure(Total aortic arch replacement + frozen elephant trunk) for Stanford type A aortic dissection involving aortic arch.Methods Between February 2009 to February 2012,data from 383 patients who underwent Sun's procedure for Stanford type A aortic dissection involving aortic arch were collected retrospectively.35 patients had history of cardiac surgery.Of these patients,16 patients had underwent Bentall procedure,7 patients ascending aortic replacement,4 patients Wheat surgery,4 patients aortic valve replacement,2 patents Bentall combined with mitral valve replacement or plasty,1 patient bivalve replacement,1 patient atrial septal defect repair,1 patient coronary artery surgery.All the risk factors related to mortality were analyzed by univariate statistical analysis.Significant univariate variables were entered into multiple logistic analysis.Results Total 31 patients died in the hospital and the mortality was 8.07％.Of the 35 patients with history of cardiac surgery,3 patients died and the mortality was 8.33％.Univariate analysis showed that symptom onset before surgery less than 1 week,preoperative limb ischemia,combining with coronary artery surgery and cardiopulmonary bypass time longer than 300 minutes in the operative were risk factors for mortality.After these factors were entered into multiple logistic regression analysis,the result showed that symptom onset before surgery less than 1 week (P =0.038,OR =2.43),cardiopulmonary bypass time longer than 300 minutes(PP ＜0.001,OR =12.05) were final independent risk factors for mortality.Reoperation was not the independent risk factor for mortality.The intensive care unit and mechanical ventilation length of reoperation group was (2.09 ± 1.89) days and(30.09 ±33.42) hours respectively,while that of primary group was(2.71 ±3.01) days (P =0.25) and(33.86 ±40.98) hours(P =0.61) respectively.The incidence of postoperative bleeding of reoperation group was 3.03％,while that of primary group was 1.88％ (P =0.50).Conclusion Reoperation was not the independent risk factor for mortality after Sun's procedure for Stanford type A aortic dissection involving aortic arch and the morbidity was also not higher than primary surgery.For these patients,sun' s procedure should be advocated.