“改良三明治”技术在急性A型主动脉夹层中的应用效果  

Application effect of modified sandwich technique in the surgical repair of acute type A aortic dissection

作　　者：蒋捷 顾嘉玺 刘鸿 李明辉 耿乐 倪布清[1] JIANG Jie;GU Jia-xi;LIU Hong;LI Ming-hui;GENG Le;NI Bu-qing(Department of Cardiac Macrovascular Surgery,the First Affiliated Hospital of Nanjing Medical University,Nanjing 213000,Jiangsu,China)

机构地区：[1]南京医科大学附属第一医院心脏大血管外科,南京213000

出　　处：《医学研究生学报》2022年第2期175-179,共5页Journal of Medical Postgraduates

摘　　要：目的 传统三明治技术可能会对夹层累及窦部患者造成假腔封闭不完全,甚至根部扩大,导致可能再次手术的可能。文中总结“改良三明治”技术在急性A型主动脉夹层(ATAAD)手术中的应用效果。方法 回顾性分析2020年1月至12月期间江苏省人民医院收治并采用“改良三明治”技术处理主动脉根部的91例ATAAD患者临床资料。所有患者均在深低温停循环(DHCA)下行急诊手术,术前完成食道超声心动图(TEE)以及CT血管造影(CTA)评估主动脉根部及主动脉瓣情况。结果 本组患者中,45例累及窦部,26例累及冠状动脉(Neri A型18例、Neri B型8例)。18例患者重度主动脉瓣关闭不全(AI),29例中度AI,38例轻度AI,6例无AI。主动脉根部处理采用“改良三明治”技术,依据夹层累及范围,单纯行升主动脉替换4例,半弓或次全弓替换16例,全弓替换+支架象鼻技术71例。全组患者体外循环时间189(170~250)min,主动脉根部处理时间25(22~33)min, DHCA时间14(11~19)min,手术时间306(277~351)min。全组患者围术期死亡7例(7.6%)。术后并发症包括血液透析14例(15.4%),神经系统并发症4例(4.4%),气管切开2例(2.1%);机械通气时间为64(22~98)h,术后住院时间为22(18~25)d。术后6个月复查CTA和二维超声心动图结果显示所有存活患者主动脉根部均无残留夹层,轻度AI 37例,无中度及以上AI病例,主动脉峰值跨瓣压差7.9(4.0~9.5) mmHg。结论 “改良三明治”技术在ATAAD手术中效果满意。其围术期死亡率及并发症发生率均较低。对于夹层累及窦部以及合并重度AI的患者可以有效封闭假腔,保留瓣膜;对于Neri A和Neri B型患者亦可有效保护冠脉。但其远期效果仍需进一步随访。Objective The traditional sandwich technique may cause incomplete closure of the false lumen or even enlargement of the root in patients with dissection involving the sinus, which leads to the possibility of reoperation. This study aims to summarize the efficacy and safety of modified sandwich technique in the surgical repair of acute type A aortic dissection(ATAAD). Methods A retrospective analysis was conducted on the clinical data of 91 ATAAD cases admitted to Jiangsu Provincial People′s Hospital from January to December 2020 and treated with the modified sandwich technique. All patients were performed emergency surgery under deep hypothermic circulatory arrest(DHCA). Transesophageal echocardiography(TEE) and CT angiography(CTA) were conducted before the operation to evaluate the condition of the aortic root and aortic valve. Results Among the patients in this group, 45 cases involved the sinus and 26 cases involved the coronary artery(18 cases of Neri type A and 8 cases of Neri type B). 18 patients were diagnosed with severe aortic insufficiency(AI), 29 moderate AI, 38 mild AI, and 6 with no AI. The aortic root was treated with modified sandwich technique. According to the extent of dissection, isolated ascending aortic replacement was performed in 4 cases, hemiarch replacement in 16 cases, and total arch replacement with frozen elephant trunk technique in 71 cases. The cardiopulmonary bypass(CPB) time, aortic root procedure time, DHCA time, and operation time were 189(170-250), 25(22-33), 14(11-19), and 306(277-351) min respectively. Perioperative mortality was 7.6%(7/91). The main postoperative complications included hemodialysis(15.4%, 14/91), neurological complications(4.4%, 4/91) and tracheotomy(2.1%, 2/91). The mechanical ventilation time was 64(22-98) hours, and the postoperative hospital stay was 22(18-25) day. The results of CTA and two-dimensional echocardiography at 6 months after operation showed that all surviving patients had no residual dissection at the aortic root, 37 cases of mild AI, and

关 键 词：“改良三明治”技术 A型主动脉夹层 主动脉瓣关闭不全 主动脉根部 

分 类 号：R543.1[医药卫生—心血管疾病]