| ForewordAcute Type A aortic dissection(AAAD)is the most dangerous emergency in cardiovascular surgery.It is not only the tear of the aortic wall,which can lead to aortic rupture,but also the dysfunction of the important organs supplying blood from the aorta branches.Extensive dissection can also lead to systemic inflammation.The mortality rate of untreated AAAD patients was 33% within 24 hours after onset,and increased by 1% for each additional hour thereafter.More than 70% of AAAD patients died within 1 weeks,mainly due to arterial rupture,cardiac tamponage,malperfusion of vital organs,and heart failure.Malperfusion syndrome is a serious complication of aortic dissection.After aortic dissection,the false lumen compresses the true lumen and the torn diaphragm blocks,leading to aortic branch vascular stenosis,and then leading to peripheral organ ischemia and organ dysfunction.Malperfusion can occur in all aortic branches supplying blood organs,including the brain,coronary arteries,abdominal viscera,kidneys,limbs and even the spinal cord,resulting in liver and kidney function damage,gastrointestinal ischemia necrosis,coma,limb ischemia necrosis,and so on.The more severe the malperfusion syndrome is,the higher the fatality rate is,which is reported to be 10 ? 30 times higher than that of patients without malperfusion syndrome.Surgery is the preferred treatment for aortic dissection,including ascending aorta replacement,Bentall,total arch replacement,interventional stenting,and endocardial fenestration.With the popularization of Sun's surgery,total arch replacement plus stents elephant trunk surgery has become a classic operation for the treatment of acute type A aortic dissection.At present,there are many reports and studies on the operation of acute type A aortic dissection,but less attention is paid to the treatment of acute type A aortic dissection with malperfusion syndrome.There is a certain understanding of the high mortality rate of acute type A aortic dissection with malperfusion syndrome,but there is a lack of in-depth research and treatment progress.How to reduce the mortality rate and improve the prognosis of patients in this patient group is worthy of clinical attention and in-depth study.This study to improve treatment strategies and surgical outcomes of the acute type A aortic dissection with malperfusion syndrome as the breakthrough point.The clinical research was focused on the risk factors of surgical death,surgical methods,surgical techniques and operation time.In this study,a single-center cases of acute type A aortic dissection were selected as the research object,by collecting clinical data and analyzing the risk factors of surgical death.A clinical case-control study was conducted to explore the optimal treatment strategy for acute type A aortic dissection with malperfusion syndrome.Part ? Analysis of risk factors for postoperative death in patients with acute type A aortic dissection Objective:To investigate the risk factors for postoperative death in patients with acute type A aortic dissection.Methods:In August 2006 to 2018 September,299 cases of patients with acute type A aortic dissection in our hospital performed operations according to whether the patients with postoperative death can be divided into death group(61 cases)and survival group(238cases),two groups of patients with perioperative for detailed statistics and comparison,the single factor analysis of meaningful results(P < 0.05)in multiariable Logistic regression independent risk factors,and adopt the receiver-operating characteristic curve(ROC)prediction effectiveness of the obtained risk factors.Results:1.Univariate analysis showed that there were statistically significant differences in preoperative status between the two groups: gender,age,hypoxemia,creatinine level,arterial blood lactate value,malperfusion syndrome,coronary artery malperfusion,and renal malperfusion.2.There were statistically significant differences between the two groups in terms of total arch replacement,Sun's surgery,coronary artery bypass grafting(CABG),extracorporeal circulation time,aortic occlusion time,and circulatory cerebral perfusion time.3.There were statistically significant differences in postoperative complications between the two groups: permanent neurological dysfunction,sepsis,continuous renal replacement therapy(CRRT),and low cardiac output syndrome.4.The classification of the binomial Logistic regression analysis further defined :age ?50years,preoperative malperfusion syndrome,the total arch replacement surgery way(Sun's surgery),low cardiac output syndrome were independent risk factors for postdoperative death of AAAD patients.5.ROC curves,according to a joint prediction probability and the area under the curve is0.949,95% CI: 0.914 ? 0.985,and the independent risk factors of the area under the curve >0.6,the difference was statistically significant(P < 0.01),forecast sensitivity of 98.4%,specificity of 51.5%,showed the study of risk factors to predict mortality postoperatively in patients with acute type A aortic dissection is meaningful,and diagnosis efficiency.Conclusion:1.Age ?50 years,preoperative malperfusion syndrome,total arch replacement(Sun's surgery),and low cardiac output syndrome are independent risk factors for postoperative death in patients with acute type A aortic dissection.2.Acute type A aortic dissection is a fatal emergency with rapid progression and high surgical risk,posing great challenges to cardiac surgeons.Although the postoperative mortality in this study decreased gradually with the improvement of surgical techniques and strategies,it was still more than 10%.3.This study is a single-center retrospective study with certain limitations.However,the multi-factor analysis of death risk factors is helpful to improve clinicians' understanding and judgment of the risk of acute type A aortic dissection,and to provide reference for the development of better surgical treatment strategies.Part ? Comprehensive optimization of treatment strategies in total arch replacement for acute type A aortic dissection with malperfusion syndromeObjective:Optimized arterial perfusion strategy and related comprehensive surgical techniques in total arch replacement for acute type A aortic dissection with malperfusion syndrome.Compared with the traditional Sun's operation of the safety and clinical efficacy.Methods:From January 2017 to December 2019,51 patients with acute type A aortic dissection and malperfusion syndrome who had completed total arch replacement were used comprehensive optimization of treatment strategies in our hospital.51 patients were included in the comprehensive optimization group,including 40 males and 11 females,average age was 47.43±13.39 years.A total of 40 patients with acute type A aortic dissection and malperfusion syndrome who underwent traditional Sun's surgery in the past were taken as the traditional control group,including 31 males and 9 females,average age was50.66±12.05 years old.Perioperative clinical data of two groups of patients were collected.Comprehensive optimal treatment strategies include :(1)Optimize the arterial perfusion method of CPB to achieve selective and uninterrupted bilateral anterograde cerebral perfusion;(2)myocardial protection techniques;(3)Balloon occlusion of descending aorta;(4)Optimal techniques for aortic root reconstruction;(5)blood protection technology.Results:1.There were no statistically significant differences in gender,age and body mass index between the comprehensive optimization group and the traditional control group.There was no significant difference in preoperative symptoms and test indicators,such as hypertension,Marfan syndrome,arterial oxygen partial pressure,and serum creatinine.The preoperative baseline data of the two groups were basically consistent(P >0.05).2.The comparison of operative data between the comprehensive optimization group and the traditional control group showed that: in the optimized perfusion group,the extracorporeal circulation time [(223.64.90±65.13)min vs(266.77±87.04)min,P=0.010],aortic occlusion time [(114.48±27.28)min vs(138.20±39.89)min,P=0.001],and circulation-out cerebral perfusion time [(8.28±3.81)min vs(50.53±23.60)min,P=0.000] were significantly less than those in the traditional control group,the difference was statistically significant(P <0.05).The lowest intraoperative nasopharyngeal temperature in the comprehensive optimization group[(27.10±1.18)? vs(23.6±3.30)?] was significantly higher than that in the traditional control group(P=0.000).3.Postoperative wakefulness time of the comprehensive optimization group [(4.50±1.35)min vs(5.27±1.15)min,P=0.019] was earlier than that of the traditional control group,and the difference was statistically significant.The volume of blood transfusions in the comprehensive optimization group [(13.25±9.06)U vs(16.95±7.53)U,P=0.046] was significantly lower than that in the traditional control group,and the difference was statistically significant.There was no significant difference in ICU time and invasive ventilation time between the two groups(P>0.05).4.Postoperative mortality in the comprehensive optimization group was significantly lower than that in the traditional control group(13.7% vs 27.5%),but the difference was not statistically significant(P=0.102).Postoperative complications of the two groups were statistically analyzed.The incidence of postoperative continuous renal replacement therapy(21.6% vs 42.5%)in the comprehensive optimization group was significantly lower than that in the traditional control group,with a statistically significant difference(P=0.003).The incidence of postoperative delirium,coma,low cardiac row syndrome and limb ischemia in the comprehensive optimization group was lower than that in the traditional control group,but the difference was not statistically significant(P >0.05).The incidence of postoperative hemiplegia,sepsis,and secondary thoracotomy in the comprehensive optimization group was higher than that in the traditional control group,and the difference was not statistically significant(All P >0.05).Conclusion:1.Comprehensive optimal treatment strategies used the arterial perfusion method of "one draw-four" can be used to perform continuous antegrade bilateral cerebral perfusion and upper and lower body perfusion simultaneously,so as to realize continuous intraoperative perfusion of the whole body organs and provide better organ protection..2.Comprehensive optimal treatment strategies can reduce the surgical trauma,shorten the operation time,reduce the perioperative clinical blood consumption,help patients wake up quickly after the operation,and lower the incidence of complications of nervous system,kidney and limb ischemia,thus improving the surgical efficacy and facilitating the patients to recover quickly after the operation.3.Comprehensive optimal treatment strategies and relevant comprehensive surgical techniques have the potential to reduce surgical mortality by inhibiting related risk factors of death,and are suitable for the operation of patients with acute type A aortic dissection with malperfusion syndrome.4.Multi-organs malperfusion,extracorporeal circulation time?240min,aortic occlusion time ?120min,and emergency surgery were independent risk factors for postoperative death in patients with acute type A aortic dissection with malperfusion syndrome.Part ? operation opportunity for acute type A aortic dissection with malperfusion syndrome Objective:Acute type A aortic dissection with malperfusion syndrome has rapid onset,rapid progression and high mortality rate.In this study,clinical data from a single center were used to explore the effect of emergency surgery on the prognosis of acute type A aortic dissection with malperfusion syndrome.Methods:Collected in January 2017 to March 2020,our hospital 60 cases of acute type A aortic dissection with malperfusion syndrome cases of surgical treatment,according to different patients received surgery time(be admitted to hospital to receive surgery within 2 hours,and from the onset of 2 days or less).A total of 36 cases included in the emergency operation group,the rest of the 24 cases included in the non-emergency operation group.After admission,all the patients were immediately moved to the intensive care unit,and treated with routine endotracheal intubation and mechanical ventilation to fully relieve pain and sedation to prevent aortic rupture.Patients in both groups were treated with total arch replacement using our center's comprehensive optimal treatment strategies.3 patients in the non-emergency operation group were first treated with "femoral artery bypass".Results:1.There were no cases of aortic rupture before operation in both groups.In the nonemergency operation group,2 comatose patients and 2 patients with mesenteric malperfusion were discharged automatically,because their families gave up treatment.Three patients with lower limb ischemia were first treated with "femoral artery bypass";one patient was discharged automatically after abandoning treatment due to no improvement in lower limb ischemia and acute renal failure.Finally,a total of 19 patients received total arch replacement surgery,with an average preoperative waiting time of 35.86±33.96 h in the nonemergency group.There was no significant difference in baseline data between the two groups.2.Comparison of surgical data between the two groups showed that the extracorporeal circulation time and aortic occlusion time of the emergency operation group were longer than that of the non-emergency operation group,but the difference was not statistically significant(P>0.05).The time of cerebral perfusion in the two groups was basically the same,and the difference was not statistically significant(P=0.940).Intraoperative blood transfusion volume [(12.28±6.42)U vs(9.02±4.32)U,P=0.024] in the emergency operation group was higher than that in the non-emergency operation group,and the difference was statistically significant.3.The postoperative awake time and ICU time of the emergency operation group were slightly longer than those of the non-emergency operation group,and the invasive ventilation time was slightly shorter,and the differences were not statistically significant(P>0.05).In terms of postoperative complications,the incidence of coma,hemiplegia,sepsis,low cardiac discharge syndrome,continuous renal replacement therapy,limb ischemia,and secondary thoracotomy in the emergency operation group was higher than that in the non-emergency operation group,but the difference was not statistically significant(P>0.05).Postoperative mortality in the emergency operation groupwas higher than that in the non-emergency operation group(13.9% vs 10.5%),the difference was not statistically significant(P=1.000).However,there were 5 cases of preoperative death(automatic discharge)in the non-emergency operation group.According to mortality rate statistics,the non-emergency operation group was significantly higher than the emergency operation group(29.2% vs13.9%,P=0.193).4.The recovery of organ function after postoperative perfusion in the two groups was observed,and the end point was postoperative death or discharge.The results showed that the total organ perfusion recovery rate was 72.2% in the emergency operation group and58.3% in the non-emergency operation group.In the emergency operation group,the recovery rate of cerebral malperfusion was the lowest(25.0%),followed by mesenteric malperfusion(66.7%),while the recovery rate of coronary artery malperfusion and renal malperfusion were the highest(higher than 80%).The recovery rate of all organs in the nonemergency operation group was almost lower than that of the emergency operation group.There was no statistically significant difference between the two groups.5.Follow-up results: 41 cases were followed up through outpatient department and network platform,7 cases were lost to follow-up,the follow-up time was 3?72 months,with an average of 31.3±11.5 months.There were no death cases during follow-up,and no cases of reoperation in both groups,and the organ functions of the patients with malperfusion were basically recovered.Follow-up patients were reexamined with cardiac ultrasound and aortic CTA every six months to one year.CTA showed that there were residual dissections in the distal end of descending aortic stents in all patients,but there was no need for intervention.In 23 patients,the false lumen of thoracic and abdominal aortic dissections were smaller than before.Conclusion:1.Emergency total arch replacement surgery for acute type A aortic dissection with malperfusion syndrome has a good early effect,does not significantly increase the surgical mortality,and can reduce the fatality rate of patients.Emergency surgery is the preferred treatment option for patients with acute type A aortic dissection with malperfusion syndrome in heart centers without a compound operating room.2.In patients with acute type A aortic dissection accompanied by malperfusion syndrome,endotracheal intubation should be performed immediately upon admission.Sufficient analgesia and sedation can effectively reduce the occurrence of preoperative aortic rupture.3.Emergency total arch replacement for acute type A aortic dissection with malperfusion syndrome has a high recovery rate of perfusion in coronary arteries,kidneys and limbs,but poor perfusion in brain and mesentery. |
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