Objective To determine risk factors associated with postoperative hypoxemia after surgery for acute aortic dissection. Methods We retrospectively analyzed clinical data of 116 patients with acute aortic dissection who underwent endovascular stent-graft exclusion or open surgery in Qingdao Municipal Hospital from February 2007 to February 2012. All the 116 patients were diagnosed as acute aortic dissection by CT angiography （CTA），including 60 patients with Stanford type A aortic dissection and 56 patients with Stanford type B aortic dissection. According to whether they had postoperative hypoxemia，all the 116 patients with acute aortic dissection were divided into hypoxemia group［arterial partial pressure of oxygen （PaO2） /fraction of inspired oxygen （FiO2） ＜200 mm Hg］：33 patients including 28 males and 5 females with their age of 52.7±11.4 years； and non-hypoxemia group（PaO2/FiO2≥200 mm Hg）：83 patients including 66 males and 17 females with their age of 55.0±13.8 years. Perioperative clinical data were analyzed and compared between the two groups. Multivariate logistic regression was performed to identify risk factors of postoperative hypoxemia after surgery for acute aortic dissection. Results The incidence of postoperative hypoxemia after surgery for acute aortic dissection was 28.4% （33/116）. Perioperative death occurred in 13 patients（11.2%，including 8 patients in the hypoxemia group and 5 patients in the non-hypoxemia group）. Univariate analysis showed that preoperatively the percentages of patients with body mass index（BMI） ＞ 25 kg/m2，smoking history，duration from onset to operation ＜24 h，preoperative PaO2/FiO2≤300 mm Hg，and patients undergoing open surgery in the hypoxemia group were significantly higher than those in the non-hypoxemia group（P＜0.05）. Deep hypothermic circulatory arrest（DHCA） ratio，blood transfusion in 24 hours postoperatively，mechanical ventilation time，length of ICU stay and hospital stay in the hypoxemia group were significantly higher or longer than those in the non-hypoxemia group（P＜0.05）. Logistic multivariate regression identified BMI＞25 kg/m2（RR=98.861，P=0.006），DHCA（RR=22.487，P=0.007），preoperative PaO2/FiO2≤300 mm Hg（RR=9.080，P=0.037） and blood transfusion＞6 U in 24 hours postoperatively（RR=32.813，P=0.003） as independent predictors of postoperative hypoxemia for open-surgery patients，while BMI＞25 kg/m2 （RR=24.984，P=0.036） and preoperative PaO2/FiO2 ratio≤300 mm Hg （RR=21.145，P=0.042） as independent predictors of hypoxemia for endovascular stent-graft exclusion patients. Conclusion Postoperative hypoxemia is a common complication after surgery for acute aortic dissection. Early interventions for obesity and preoperative hypoxemia，and reducing perioperative blood transfusion may decrease the incidence of postoperative hypoxemia after surgery for acute aortic dissection.
Objective To modify the method for aortic end strengthening in acute type A aortic dissection operation, and investigate its clinical efficacy. Methods We modified the method for aortic end strengthening in acute aortic dissection operation based on ‘Sandwich method’ in the department of thoracic and cardiovascular surgery of West China Hospital. From January 2006 to December 2008, twentyeight patients with acute type A aortic dissection underwent modified aortic end strengthening operation. We made adventitia turn over and enfold to strengthen the aortic end in 10 cases, and placed stripshaped felt or pericardium belts between dissection (between adventitia and intima)and inner intima and strengthened the aortic end by suture in 18 cases. The hemorrhage of anastomotic stoma and the postoperative early prognosis were observed. Results No bleeding complication was found in all the cases. Two cases died, one died of severe low cardiac output syndrome and another died of multiple organ failure. No nervous system complication was found except that 2 cases had delayed revival. No sternum and surgical incision related complication was found. The rest 26 cases were cured and discharged. Conclusion The modified method for aortic end strengthening can not only strengthen the aortic end but also make people be able to find the petechia of anastomotic stoma clearly, then stitch hemostasia could be done effectively. The method is easy to implement and effective, it should be extend in clinic.
【摘要】 目的 研究急性主动脉夹层时间分布规律。 方法 回顾性研究我院2000年1月-2010年12月所有急性主动脉夹层患者的时间资料，分析其月份、季节、周以及时刻分布特点。 结果 急性主动脉夹层月份分布高峰点为1月4日，高峰段为9月21日～次年4月19日（Plt;0.05）；季节分布以冬春季较多（Plt;0.05）；周分布无高峰点及高峰段（Pgt;0.05）；时刻分布高峰点为上午10点及下午4点。 结论 急性主动脉夹层具有明显的时间分布规律，我们应该在该病的高峰时间更加重视其发生的可能，从而减少误诊，改善预后。【Abstract】 Objective To investigate the features of time distribution in the occurrence of acute aortic dissection (AAD). Methods We retrospectively analyzed all the databases of AAD in our hospital between January 1, 2000 and December 31, 2010, and studied the monthly, seasonal, weekly, and circadian distribution of the cases. Results In terms of monthly distribution, the occurrence of AAD peaked at January 4th with the high frequency in the period of September 21st to April 19th of the next year (Plt;0.05). According to the seasonal distribution, the occurrence of AAD peaked in winter and spring (Plt;0.05). There was no peak time in weekly distribution (Pgt;0.05). In accordance with circadian distribution, the occurrence of AAD peaked at 10 and 16 o’clock (Plt;0.05). Conclusion Because of the obvious rhythm of time distribution of AAD, We can pay more attention to the diagnosis of AAD especially in the peak time, thus reducing the mistakes in diagnosis and improving the prognosis.
Objective To identify the predictors of prolonged stay in the intensive care unit (ICU) in patients undergoing surgery for acute aortic dissection type A. Methods We retrospectively analyzed the clinical data of 80 patients who underwent surgery for acute aortic dissection type A in Qingdao Municipal Hospital from December 2009 through December 2013. The mean age of the patients was 48.9±12.5 years, including 54 males (67.5%) and 26 females (32.5%). The patients were divided into two groups based on their stay time in the ICU. Prolonged length of ICU stay was defined as 5 days or longer time in the ICU postoperatively. There were 67 patients with length of ICU stay shorter than 5 days, 13 patients with length of ICU stay 5 days or longer time. Univariate and multivariate analysis (logistic regression) were used to identify the predictive risk factors. Results The length of ICU stay was 63.2±17.4 hours and 206.9±25.4 hours separately. Overall in-hospital mortality was 3.0% and 15.4% respectively in the two groups. In univariate analyses, there were statistically significant differences with respect to the age, the European system for cardiac operative risk evaluation (EuroSCORE), the preoperative D-dimmer level, total cardiopulmonary bypass (CPB) time, deep hypothermic circulatory arrest (DHCA), inotropes and occurrence of postoperative stroke, acute renal failure and acute respiratory failure, ICU stay duration and hospital stay duration between the patients with length of ICU stay shorter than 5 days and longer than 5 days. Multivariate logistic analysis showed that CPB time, occurrence of postoperative stroke, acute renal failure, or acute respiratory failure were independent predictors for prolonged ICU stay. Conclusion The incidence of prolonged ICU stay is high after surgery for acute aortic dissection type A. It can be predicted by CPB time, occurrence of postoperative stroke, acute renal failure, and acute respiratory failure were independent predictors for prolonged ICU stay. For patients with these risk factors, more perioperative care strategies are needed in order to shorten the ICU stay time.
Objective To explore the diagnostic value of a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs (ADAMTS)-9 in acute aortic dissection (AAD). Methods A total of 328 patients with acute onset of chest pain within 24 hours were enrolled in West China Hospital from January 2015 to June 2016 and according to the results of computed tomography angiography they were divided into an AAD group (n=172, 107 males, 65 females, mean age of 50.4±13.1 years) and a control group (n=156, 89 males, 67 females, mean age of 54.9±14.7 years). The enzyme-linked immunosorbent assay (ELISA) test was used to measure the level of ADAMTS-9. Results Patients in two groups had no significant difference in age, gender, smoke history, hypertension history, total cholesterol, triacylglyceride and hemoglobin (P>0.05). But systolic and diastolic blood pressures were significantly higher in the AAD group than those in the control group (P<0.05, respectively). The level of ADAMTS-9 was significantly higher in the AAD group than that in the control group (249.4±186.8 ng/mlvs. 78.2±48.6 ng/ml,t=11.107, P<0.001). Receiver operating characteristic curve analysis showed that ADAMTS-9 (156.7 ng/ml) was predictive in the diagnosis of AAD with sensitivity of 0.942 and specificity of 0.628. Conclusion ADAMTS-9 might be an effective and important biomarker in diagnosis of AAD.
Objective To study the clinical characteristics, therapy strategies and the outcomes of female patients with acute aortic dissection during late pregnancy and puerperal period. Methods We retrospectively analyzed the clinical data of 7 patients with acute aortic dissection during late pregnancy and puerperal period in Shanghai Changhai Hospital between August 2012 and June 2017. Five of the 7 patients were late stage pregnancy, 2 were puerperal period (1 at the postpartum night, 1 in 18 days after delivery). There were 6 patients of Stanford type A aortic dissection (85.7%), and 1 patient of type B aortic dissection (14.3%). The age of the patients ranged from 26 to 34 (30.8±3.1) years. Cardiac ultrasonography of patients with type A showed that the maximum diameter of the ascending aortas was 4.2–5.7 (4.7±0.6) cm, of which 2 patients were aneurysm of aortic sinus, 3 patients were with Marfan syndrome. Bentall procedure was conducted in 1 patient, Bentall+Sun’s surgery in 2 patients, ascending aorta replacement+Sun’s+coronary artery bypass grafting surgery in 1 patient, aortic root remodeling+ascending aorta replacement+Sun’s surgery in 2 patients. One patient with Stanford type B acute aortic dissection was performed with thoracic endovascular aortic repair (TEVAR) after cesarean section. Results Aortic blocking time ranged from 51 to 129 (85.5±22.9) min. Cardiopulmonary bypass time was 75–196 (159.0±44.0) min. Moderate hypothermic circulation arrest with selective cerebral perfusion time was 20–30 (23.8±3.5) min. All maternal and fetuses survived. The infant whose mother received aortic repair in early stage and then received cesarean section was diagnosed with cerebral palsy. Maternal and fetuses were followed up for 9 months to 4 years. During the follow up period, all the fetuses grew well except the cerebral palsy one, and all maternal recovered well. The patient who received aortic repair in the early stage, had a sigmoid rupture during cesarean section and was treated with sigmoid colostomy. Another patient with Stanford type A dissection was diagnosed as left renal vein entrapment syndrome after 2 years. Conclusion Type A aortic dissection is more common in late pregnancy and puerperal patients. And Marfan syndrome is a high-risk factor for acute aortic dissection in pregnancy women. Early and appropriate surgical treatment strategy based on the type of aortic dissection and gestational age are the key points to achieve good outcomes both for maternal and fetus.
ObjectivesTo explore the predictive value of platelet count at admission for long-term prognosis in patients with type B acute aortic dissection (AAD) undergoing endovascular therapy (EVT). MethodsWe investigated 131 consecutive patients with type B AAD after EVT in West China Hospital of Sichuan University from January to December 2012. The patients’ basic clinical data, blood test results, major adverse cardiovascular events, and in-hospital and out-hospital survival status were collected. According to the tri-sectional quantiles of platelet counts, the patients were divided into three groups. Chi-square test was used to analyze the correlation between platelet count and hospital complications. Kaplan-Meier survival analysis and Cox regression analysis were used to analyze the relationship between platelet count and survival in patients with type B AAD. The primary endpoint was all-cause death. ResultsThe overall in-hospital mortality of the 131 patients was 9.9%, and the mortality was 16.0% by the end of the follow-up, the median length of which was 2.1 years. There were 44 cases in T1 group (platelet count >200×10 9/L), 44 cases in T2 group [platelet count (155–200)×109/L], and 43 cases in T3 group [platelet count ≤155×109/L]. The mortality in T3 group (30.2%) was higher than that in T1 group (4.5%) and T2 group (13.6%) (P=0.004). Kaplan-Meier survival analysis showed that the cumulative survival rate of T3 group was significantly lower than that of T1 group and T2 group (69.8% vs. 95.5%, χ2=10.165, P=0.001; 69.8% vs. 86.4%, χ2=5.174, P=0.037). Cox multivariate analysis showed that age [hazard ratio (HR)=1.043, 95% confidence interval (CI) (1.009, 1.079), P=0.013], heart rate [HR=1.030, 95%CI (1.004, 1.058), P=0.024], and platelet count [HR=6.011, 95%CI (1.319, 27.391), P=0.020] were independent risk factors for mortality. Older age, rapid heart rate, and lower platelet count would increase the risk of death. ConclusionPlatelet count may be an independent factor that affects the prognosis of patients with type B AAD after EVT, and a low platelet count at admission increases the risk of death.
Objective To evaluate the significance of lactate dehydrogenase (LDH) as a predictor of in-hospital mortality in patients with acute aortic dissection(AAD). Methods We conducted a retrospective analysis of the clinical data of 445 AAD patients who were admitted to the Second Xiangya Hospital of Central South University and the Changsha Central Hospital from January 2014 to December 2017 within a time interval of ≤14 days from the onset of symptoms to hospital admission, including 353 males and 92 females with the age of 45-61 years. LDH levels were measured on admission and the endpoint was the all-cause mortality during hospitalization. Results During hospitalization, 86 patients died and 359 patients survived. Increased level of LDH was found in non-survivors compared with that in the survived [269.50 (220.57, 362.58) U/L vs. 238.00 (191.25, 289.15) U/L, P<0.001]. A nonlinear relationship between LDH levels and in-hospital mortality was observed. Using multivariable logistic analysis, we found that LDH was an independent predictor of in-hospital mortality in the patients with AAD [OR=1.002, 95% CI (1.001 to 1.014), P=0.006]. Furthermore, using receiver operating characteristic (ROC) analysis, we observed that the best threshold of LDH level was 280.70 U/L, and the area under the curve was 0.624 (95% CI 0.556 to 0.689). Conclusion LDH level on admission is an independent predictor of in-hospital mortality in patients with AAD.