本文選題：主動(dòng)脈夾層 + 三明治�。� 參考：《浙江大學(xué)》2017年博士論文

【摘要】：研究背景及目的:主動(dòng)脈夾層(aortic dissection,AD)屬于心血管系統(tǒng)的急重癥。近年來(lái)主動(dòng)脈夾層的診斷水平提高,手術(shù)量呈井噴式增多。急性DeBakeyⅠ型主動(dòng)脈夾層是累及升主動(dòng)脈、主動(dòng)脈弓及降主動(dòng)脈的一種病變類型。其治療目標(biāo)是預(yù)防夾層進(jìn)展和致死性并發(fā)癥發(fā)生。開(kāi)放手術(shù)仍然是治療急性Ⅰ型主動(dòng)脈夾層的金標(biāo)準(zhǔn)。非馬凡式綜合征(Manfan'ssyndrome,MFS)的Ⅰ型主動(dòng)脈夾層患者,常不伴主動(dòng)脈竇部擴(kuò)大及主動(dòng)脈瓣關(guān)閉不全,因此可以保留主動(dòng)脈竇部及主動(dòng)脈瓣。對(duì)于近端主動(dòng)脈的處理常采取"三明治"技術(shù),即使用兩條毛氈片、人工血管條、牛心包或其他材料加固血管。"三明治"技術(shù)一方面加固近端血管與人工血管的吻合,另一方面減少血管和人工血管直接吻合的出血,同時(shí)夾閉近端的假腔防止夾層的繼續(xù)發(fā)展。然而"三明治"技術(shù)在近端血管的處理存在一定的隱患。即使"三明治"封閉近端主動(dòng)脈的假腔,但由于近端主動(dòng)脈血壓高,仍然可能從吻合口的針眼進(jìn)入假腔,從而使近端的夾層繼續(xù)向根部撕脫,最終導(dǎo)致竇部增大及主動(dòng)脈瓣環(huán)增大或結(jié)構(gòu)發(fā)生變化,形成主動(dòng)脈瓣關(guān)閉不全。本課題基于近年來(lái)我院采取"三明治"技術(shù)處理近端主動(dòng)脈的非MFS急性Ⅰ型主動(dòng)脈夾層患者,分析該群體患者術(shù)后隨訪出現(xiàn)主動(dòng)脈關(guān)閉不全的比例,從而評(píng)價(jià)"三明治"技術(shù)在急性Ⅰ型主動(dòng)脈夾層手術(shù)中的效果。臨床資料與方法:本研究采用回顧性研究方法,納入2007年至2016年于浙江大學(xué)附屬第一醫(yī)院心胸外科住院行主動(dòng)脈夾層手術(shù)治療患者177例,排除DeBakeyⅡ型、DeBakeyⅢ型及MFS患者52例,共計(jì)125例非MFS急性Ⅰ型主動(dòng)脈夾層患者,其中93例采取"三明治"技術(shù)處理近端主動(dòng)脈。13例發(fā)生住院死亡,7例失隨訪。隨訪超聲心動(dòng)圖及胸主動(dòng)脈CTA,觀察主動(dòng)脈瓣關(guān)閉不全程度,統(tǒng)計(jì)發(fā)生中度及以上的主動(dòng)脈瓣關(guān)閉不全的例數(shù),從而評(píng)價(jià)"三明治"技術(shù)加固主動(dòng)脈近端的可行性。結(jié)果:共納入73例采取"三明治"技術(shù)加固主動(dòng)脈近端的非MFS急性Ⅰ型主動(dòng)脈夾層患者。該人群平均年齡51.5±10.9歲,男女比例3:1,67.1%有既往高血壓病史。平均隨訪時(shí)間為14.8±16.6月,8例在之后的隨訪中死亡。3例竇部直徑較術(shù)前增加5mm以上,但這3例并未發(fā)生中度及以上的主動(dòng)脈瓣關(guān)閉不全。另外有3例在隨后的隨訪中出現(xiàn)中度主動(dòng)脈瓣關(guān)閉不全,但這3例均未出現(xiàn)明顯的氣急、胸痛等癥狀,竇部直徑也并未增大,胸主動(dòng)脈CTA未提示夾層繼續(xù)向竇部發(fā)展。結(jié)論:近端主動(dòng)脈"三明治"技術(shù)廣泛應(yīng)用于主動(dòng)脈夾層手術(shù),雖然在本研究中采用該技術(shù)有3例術(shù)后隨訪中出現(xiàn)了中度及以上的主動(dòng)脈瓣關(guān)閉不全,但發(fā)生率低(4.1%),且并沒(méi)有嚴(yán)重影響其日常生活質(zhì)量。因此本研究未發(fā)現(xiàn)近端"三明治"技術(shù)對(duì)急性Ⅰ型主動(dòng)脈夾層術(shù)后主動(dòng)脈瓣產(chǎn)生不良影響,其遠(yuǎn)期效果尚可,從而證明"三明治"技術(shù)的安全性及可行性
[Abstract]:Background and objective: aortic dissection (ADA) is an acute disease of the cardiovascular system.In recent years, the diagnostic level of aortic dissection has been improved, and the volume of operation has increased.Acute DeBakey type I aortic dissection is a type of disease involving ascending aorta, aortic arch and descending aorta.The goal of treatment is to prevent the progression of dissection and the occurrence of fatal complications.Open surgery remains the gold standard for the treatment of acute type I aortic dissection.Patients with type I aortic dissection with non-Marfan syndrome (Manfanssyndromeg MFS) are often not accompanied by dilation of the aortic sinus and insufficiency of the aortic valve, so the aortic sinus and aortic valve can be preserved."for proximal aorta, the" sandwich "technique is often used to reinforce blood vessels with two blankets, artificial vascular strips, bovine pericardium, or other materials."Sandwich "technique not only strengthens the anastomosis of proximal and artificial blood vessels, but also reduces the bleeding caused by direct anastomosis of blood vessels and artificial vessels, while clamping the false cavity of proximal end to prevent the development of dissection.However, sandwich technique has some hidden dangers in the treatment of proximal vessels.Even if the "sandwich" closes the false lumen of the proximal aorta, because of the high blood pressure of the proximal aorta, it is still possible to enter the false cavity from the needle eye of the anastomotic stoma, so that the proximal dissection continues to tear off toward the root.Finally, the enlargement of the sinus and the enlargement or structural change of the aortic annulus result in aortic valve insufficiency.Based on the "sandwich" technique adopted by our hospital in recent years to treat non-acute MFS type I aortic dissection patients with proximal aorta, we analyzed the incidence of aortic insufficiency after follow-up in this group of patients.The effect of sandwich technique on acute type I aortic dissection was evaluated.Clinical data and methods: a retrospective study was conducted in 177 patients with aortic dissection in cardiothoracic surgery department of the first affiliated Hospital of Zhejiang University from 2007 to 2016, and 52 patients with DeBakey 鈪，

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