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著者: Marco Di Eusanio, Himanshu J Patel, Christoph A Nienaber, Daniel M Montgomery, Amit Korach, Thoralf M Sundt, Carlo Devincentiis, Matthias Voehringer, Mark D Peterson, Truls Myrmel, Gianluca Folesani, Magnus Larsen, Nimesh D Desai, Joseph E Bavaria, Jehangir J Appoo, Teresa M Kieser, Rossella Fattori, Kim Eagle, Roberto Di Bartolomeo, Santi Trimarchi
雑誌名: J Thorac Cardiovasc Surg. 2013 Mar;145(3 Suppl):S213-21.e1. doi: 10.1016/j.jtcvs.2012.11.054.
Abstract/Text
OBJECTIVES: The management strategy remains controversial for patients presenting with type A acute aortic dissection with cerebrovascular accident or coma. The present study aimed to help guide surgeons treating these high-risk patients.
METHODS: Of 1873 patients with type A acute aortic dissection enrolled in the International Registry for Acute Dissection, 87 (4.7%) presented with cerebrovascular accident and 54 (2.9%) with coma. The hospital and 5-year results were stratified by the presence and type of brain injury (no injury vs stroke vs coma) and management type (medical vs surgical). Independent predictors of short- and mid-term survival were identified.
RESULTS: Presentation with shock, hypotension, or tamponade (46.8% vs 25.2%; P < .001) and arch vessel involvement (55.0% vs 36.1%; P < .001) was more likely in patients with brain injury. Surgical management was avoided more often in patients with coma (33.3%) or cerebrovascular accident (24.1%) than in those without brain injury (11.1%; P < .001). The overall hospital mortality was 22.7% without brain injury, 40.2% with cerebrovascular accident, and 63.0% with coma (P < .001). Mortality varied among the management types for both cerebrovascular accident (76.2% medical vs 27.0% surgical; P < .001) and coma (100% medical vs 44.4% surgical; P < .001). Postoperatively, cerebrovascular accident and coma resolved in 84.3% and 78.8% of cases, respectively. On logistic regression analysis, surgery was protective against mortality in patients presenting with brain injury (odds ratio 0.058; P < .001). The 5-year survival of patients presenting with cerebrovascular accident and coma was 23.8% and 0% after medical management versus 67.1% and 57.1% after surgery (log rank, P < .001), respectively.
CONCLUSIONS: Brain injury at presentation adversely affects hospital survival of patients with type A acute aortic dissection. In the present observational study, the patients selected to undergo surgery demonstrated improved late survival and frequent reversal of neurologic deficits.
Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
PMID 23410778 J Thorac Cardiovasc Surg. 2013 Mar;145(3 Suppl):S213-21.e1. doi: 10.1016/j.jtcvs.2012.11.054.
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