Abstract：
OBJECTIVE: The mortality of acute type A aortic dissection (ATAAD) with malperfusion syndrome (MPS) is high. However, the management strategy remains controversial. We aimed to evaluate the strategy for MPS at our institution.
METHODS: Among 724 patients with ATAAD, 167 patients with MPS were treated with immediate central repair (1st stage) or an optimized strategy (2nd stage). In 2nd stage, the optimized strategy used was based on 6-hour threshold from symptom onset. For MPS with symptom onset within 6 hours, immediate central repair was performed followed by endovascular reperfusion if malperfusion persisted. With symptom onset beyond 6 hours, individualized delayed central repair was performed. We compared outcomes between the 1st and 2nd stage.
RESULTS: The in-hospital mortality of ATAAD was significantly decreased when the optimized strategy was used (4.3% in 2nd stage vs. 12.5% in 1st stage, P<0.01). In 2nd stage, the in-hospital mortality for MPS was decreased (10.2% vs. 33.9%, P<0.01). Moreover, the in-hospital mortality for MPS with symptom onset within or beyond 6 hours decreased from 24% to 7.5% and from 41.2% to 11.8%, respectively. The operative mortality of MPS in 2nd stage was comparable with patients without MPS (4.0% vs. 2.4%, P>0.05).
CONCLUSIONS: The optimized strategy significantly improved the outcomes of MPS. The 6-hour threshold from symptom onset could be very useful in determining the timing of central repair. For MPS with symptom onset within 6 hours, immediate central repair is reasonable. For those with symptom onset beyond 6 hours, individualized delayed central repair should be considered.
METHODS: Among 724 patients with ATAAD, 167 patients with MPS were treated with immediate central repair (1st stage) or an optimized strategy (2nd stage). In 2nd stage, the optimized strategy used was based on 6-hour threshold from symptom onset. For MPS with symptom onset within 6 hours, immediate central repair was performed followed by endovascular reperfusion if malperfusion persisted. With symptom onset beyond 6 hours, individualized delayed central repair was performed. We compared outcomes between the 1st and 2nd stage.
RESULTS: The in-hospital mortality of ATAAD was significantly decreased when the optimized strategy was used (4.3% in 2nd stage vs. 12.5% in 1st stage, P<0.01). In 2nd stage, the in-hospital mortality for MPS was decreased (10.2% vs. 33.9%, P<0.01). Moreover, the in-hospital mortality for MPS with symptom onset within or beyond 6 hours decreased from 24% to 7.5% and from 41.2% to 11.8%, respectively. The operative mortality of MPS in 2nd stage was comparable with patients without MPS (4.0% vs. 2.4%, P>0.05).
CONCLUSIONS: The optimized strategy significantly improved the outcomes of MPS. The 6-hour threshold from symptom onset could be very useful in determining the timing of central repair. For MPS with symptom onset within 6 hours, immediate central repair is reasonable. For those with symptom onset beyond 6 hours, individualized delayed central repair should be considered.
摘要：
目的：急性A型主动脉夹层（ATAAD）伴灌注不良综合征（MPS）的死亡率较高。然而,管理策略仍然存在争议。我们的目标是评估我们机构的MPS策略。
方法：在724例ATAAD患者中，167例MPS患者接受了立即中央修复（第一阶段）或优化策略（第二阶段）的治疗。在第二阶段,所使用的优化策略基于从症状发作开始的6小时阈值.对于症状在6小时内出现的MPS，如果灌注不良持续,则立即进行中心修复,然后进行血管内再灌注.症状超过6小时，进行个体化延迟中央修复.我们比较了第一阶段和第二阶段的结果。
结果：使用优化策略后，ATAAD的住院死亡率显着降低（第二阶段为4.3％vs.第一阶段为12.5%，P<0.01)。在第二阶段,MPS的住院死亡率降低(10.2%vs.33.9%,P<0.01)。此外，在6小时内或超过6小时内出现症状的MPS的住院死亡率从24％下降到7.5％，从41.2％下降到11.8％，分别。第二阶段MPS的手术死亡率与无MPS的患者相当(4.0%vs.2.4%,P>0.05)。
结论：优化策略可显著改善MPS的预后。从症状发作开始的6小时阈值对于确定中央修复的时机非常有用。对于症状在6小时内出现的MPS，立即中央维修是合理的。对于那些症状发作超过6小时的人，应考虑个性化延迟中央修复。
方法：在724例ATAAD患者中，167例MPS患者接受了立即中央修复（第一阶段）或优化策略（第二阶段）的治疗。在第二阶段,所使用的优化策略基于从症状发作开始的6小时阈值.对于症状在6小时内出现的MPS，如果灌注不良持续,则立即进行中心修复,然后进行血管内再灌注.症状超过6小时，进行个体化延迟中央修复.我们比较了第一阶段和第二阶段的结果。
结果：使用优化策略后，ATAAD的住院死亡率显着降低（第二阶段为4.3％vs.第一阶段为12.5%，P<0.01)。在第二阶段,MPS的住院死亡率降低(10.2%vs.33.9%,P<0.01)。此外，在6小时内或超过6小时内出现症状的MPS的住院死亡率从24％下降到7.5％，从41.2％下降到11.8％，分别。第二阶段MPS的手术死亡率与无MPS的患者相当(4.0%vs.2.4%,P>0.05)。
结论：优化策略可显著改善MPS的预后。从症状发作开始的6小时阈值对于确定中央修复的时机非常有用。对于症状在6小时内出现的MPS，立即中央维修是合理的。对于那些症状发作超过6小时的人，应考虑个性化延迟中央修复。
