急性 A 型主动脉夹层 (AAAD) 患者的术前心包血肿：我们需要调整治疗吗？,Journal of Cardiothoracic Surgery

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急性 A 型主动脉夹层 (AAAD) 患者的术前心包血肿：我们需要调整治疗吗？
Journal of Cardiothoracic Surgery ( IF 1.6 ) Pub Date : 2023-02-09 , DOI: 10.1186/s13019-023-02152-1
Tim Kaufeld ₁ , Erik Beckmann _{1,

2} , Linda Rudolph ₁ , Heike Krüger ₁ , Ruslan Natanov ₁ , Morsi Arar ₁ , Wilhelm Korte ₁ , Tobias Schilling ₁ , Axel Haverich ₁ , Andreas Martens ₁ , Malakh Shrestha _{1,

3}

Affiliation

急性 A 型主动脉夹层 (AAAD) 是一种危重的急症，并且仍然是心胸外科中最具挑战性的疾病之一。主动脉破裂引起的心包血肿可显着降低生存机会（Jerzewski 和 Kulik，J Card Surg 29(4):529–530, 2014；Mehta 等人，Circulation 105(2):200– 206, 2002；Gilon 等人在 Am J Cardiol 103(7):1029–1031, 2009；Isselbacher 等人在 Circulation 90(5):2375–2378, 1994）。我们评估了 AAAD 和心包血肿高危患者的手术结果。在这项研究中，我们纳入了 430 名患者（67% 为男性；中位年龄：64 岁），他们于 2000 年 1 月至 2018 年 1 月期间在我们的设施接受 DeBakey I 型急性主动脉夹层手术治疗。我们将队列分为两组：A 组由有心包血肿的高危患者 (n = 162) 和 B 组无心包血肿的患者 (n = 268) 组成。术前心包血肿患者对术前机械复苏的要求明显更高（A：21%；B：1.5%；P：<0.001），并且在插管状态下更频繁地进入手术室（A：19.8%）；B：8.6%；P：< 0.001）。两组的内脏灌注不良发生率差异显着（A. 11.7%，B. 6:0%；P: 0.034）。高危组首选有限主动脉弓修复术（近端主动脉弓置换）（A：51.9%；B：40.3%；P：0.020）。然而，这些患者的生存时间普遍缩短（A：7.5 年；B：9.9 年）。术前心包血肿的 AAAD 患者存在潜在的致命情况，内脏灌注不良的发生率明显更高。尽管存在这种风险因素，但有限的足弓修复仍受到青睐。我们已经证明，心脏压迫与术前插管和机械复苏有关。心包血肿患者必须进一步评估术前心包引流。如果转移到主动脉中心的时间较长，则应讨论缓慢引流以防止早期死亡。心包血肿患者必须进一步评估术前心包引流。如果转移到主动脉中心的时间较长，则应讨论缓慢引流以防止早期死亡。心包血肿患者必须进一步评估术前心包引流。如果转移到主动脉中心的时间较长，则应讨论缓慢引流以防止早期死亡。

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Preoperative pericardial hematoma in patients with acute type A aortic dissection (AAAD): Do we need an adjusted treatment?

An acute type A aortic dissection (AAAD) is a critical emergency and remains one of the most challenging diseases in cardiothoracic surgery. The existence of a pericardial hematoma caused by an aortic rupture can dramatically reduce the chances of survival (Jerzewski and Kulik in J Card Surg 29(4):529–530, 2014; Mehta et al. in Circulation 105(2):200–206, 2002; Gilon et al. in Am J Cardiol 103(7):1029–1031, 2009; Isselbacher et al. in Circulation 90(5):2375–2378, 1994). We assessed the surgical outcome of a high-risk group of patients with AAAD and a pericardial hematoma. In this study we included 430 Patients (67% male; median age: 64 years) who received surgical treatment between January 2000 and January 2018 at our facility for acute aortic dissection DeBakey type I. We divided the cohort in two groups: Group A consisted of high-risk patients with a pericardial hematoma (n = 162) and Group B of patients without pericardial hematoma (n = 268). Patients with a preoperative pericardial hematoma had a significantly higher requirement for preoperative mechanical resuscitation (A: 21%; B: 1.5%; P: < 0.001) and were relevantly more frequently admitted to the operation theater with an intubated status (A: 19.8%; B: 8.6%; P: < 0.001). The incidence of visceral malperfusion differed significantly between both groups (A. 11.7%, B. 6:0%; P: 0.034). Limited aortic arch repair (proximal aortic arch replacement) was preferred in the high-risk group (A: 51.9%; B: 40.3%; P: 0.020). However, survival time was generally reduced in these patients (A: 7.5 y; B: 9.9 y). AAAD patients with preoperative pericardial hematoma present themselves in potentially lethal conditions, with a significantly higher rate of visceral malperfusion. Despite the existence of this risk factor, a limited arch repair was favored. We have proven that cardiac compression is associated with preoperative intubation and mechanical resuscitation. Patients with pericardial hematoma must be further evaluated for preoperative pericardial drainage. In the event of long transfer times to an aortic center a slow drainage should be discussed to prevent early mortality.

更新日期：2023-02-09

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