晚期妊娠合并急性Stanford A型主动脉夹层的诊疗分析  

Surgical management of acute Stanford type A aortic dissection associated with late pregnancy

作　　者：陆利冲[1] 程永庆[1] 葛敏[1] 陈成[1] 王志刚[1] 王东进[1] 王哲芸[1] 叶家欣[1] Lu Lichong;Cheng Yongqing;Ge Min;Chen Cheng;Wang Zhigang;Wang Dongjin;Wang Zheyun;Ye Jiaxin(Department of Cardiovascular and Thoracic Surgery,the Affiliated Drum Tower Hospital of Nanjing University Medical School,Nanjing 210008,China)

机构地区：[1]南京大学医学院附属鼓楼医院心胸外科,南京210008

出　　处：《中华解剖与临床杂志》2022年第9期640-645,共6页Chinese Journal of Anatomy and Clinics

基　　金：江苏十三五科教强卫工程医学重点学科(ZDXKA2016019)。

摘　　要：目的探讨妊娠晚期合并急性Stanford A型主动脉夹层的诊疗方法及治疗效果。方法回顾性研究。纳入2016年5月—2021年11月南京大学医学院附属鼓楼医院6例晚期妊娠合并急性Stanford A型主动脉夹层孕妇的临床资料。患者年龄25~37岁(平均31.7岁),孕周31~37周(平均35.3周)。其中初产妇1例,经产妇5例;术前心脏彩色多普勒超声检查主动脉瓣反流程度,轻度1例、中度2例、重度3例;主动脉根部直径40~60 mm(平均47.7 mm);合并马凡综合征1例,脑梗1例,妊娠期高血压3例。根据孕周及夹层病变程度制定手术方案。观察指标:围术期指标包括术中体外循环时间、主动脉阻断时间、停循环时间,术后拔除气管插管时间、监护病房停留时间、并发症及新生儿体质量、新生儿Apgar评分(1 min、5 min)等。术后定期随访再次手术及生存情况。结果6例患者先行剖宫产后再行主动脉修复手术,两次手术间隔时间为0~12 h(平均5.7 h)。Bentall+Sun’s手术2例(其中1例同期行右冠搭桥术),升主动脉置换+Sun’s手术2例(其中1例行头臂干支架置入术),Bentall+次全弓置换+近端头臂干置换术1例,升主动脉置换+全弓及降主动脉支架植入术1例。6例患者体外循环167~350 min(平均275 min),主动脉阻断139~264 min(平均212 min),停循环15~40 min(平均31.7 min),术后拔除气管插管时间23~106 h(平均45.5 h),监护病房停留时间4~8 d(平均5.7 d);术后产妇与胎儿均存活,产妇无二次开胸、气管切开、心跳骤停、脏器灌注不良等并发症。6例新生儿中足月产2例,早产4例;出生体质量2250~3355 g(平均2697 g);出生后1 min Apgar评分为4~9分、平均6分,出生后5 min Apgar评分为8~10分、平均9分,其中轻度窒息4例。6例患者术后均获随访1~66个月,复查CT人工血管血流通畅,支架远端自体血管无扩张,无二次手术;1例患者术后8个月因抑郁症死亡;6例婴幼儿均生长发育良好。结论晚期妊娠Objective This study explores the diagnosis and treatment of late pregnancy-associated acute Stanford type A aortic dissection to improve the maternal and fetal outcomes.Methods A retrospective search of the cardiothoracic surgical database was conducted at the Affiliated Drum Tower Hospital of Nanjing University Medical School from May 2016 to November 2021 identified five pregnant women with type A dissection.The age of the patients ranged from 25 years old to 37 years old(median 31.7 years old)with gestational weeks of 31 to 37 weeks(median 35.3 weeks)upon diagnosis.One primipara and five multiparas were recorded.Transthoracic echocardiography showed that the degree of aortic regurgitation was mild in one case,moderate in two cases,and severe in three cases.The diameter of the aortic root was 40 mm to 60 mm,with an average of 47.7 mm.One case showed combined Marfon syndrome,one case showed preoperative combined cerebral infarction,and three cases showed gestational hypertension.The surgical plan was developed by considering the gestational week and the degree of entrapment.The observation indexes were cardiopulmonary bypass time,aortic blocking time,circulatory arrest time,time of postoperative tracheal extubation,ICU stay time,complications,neonatal weight,Apgar score at 1 min and 5 min,and others.Regular postoperative follow-ups for reoperation and survival were performed.Results All patients underwent Cesarean section first,and then,surgical aortic repair was performed.The interval was 0 h to 12 h(mean 5.7 h)between the two operations.Bentall+Sun's surgery was performed in two cases(one case with coronary artery bypass grafting).Ascending aorta replacement+Sun's surgery was performed in two cases(one case with brachiocephalic trunk stent placement).Bentall+partial arch replacement+proximal brachiocephalic trunk replacement surgery was performed in one case.Ascending aorta replacement+arch fenestrated stent surgery was performed in one case.Cardiopulmonary bypass time was 167 min to 350 min(mean,275 min).Aor

关 键 词：动脉病 夹层 主动脉夹层 妊娠末期 手术治疗 妊娠结局 

分 类 号：R714.252[医药卫生—妇产科学]