Stanford A型主动脉夹层患者术后血流感染病原菌分布及其影响因素的Logistic回归分析

摘要 目的：分析Stanford A型主动脉夹层患者术后血流感染病原菌分布及其影响因素。方法：选取2020年6月-2023年1月新疆医科大学第一附属医院收治的102例Stanford A型主动脉夹层患者为研究对象。患者均接受手术治疗,统计术后血流感染的发生率、病原菌分布情况。根据患者术后血流感染的发生情况将患者分为感染组（n=17）和未感染组（n=85）。收集患者的临床资料,以单因素和多因素Logistic回归分析Stanford A型主动脉夹层患者术后血流感染的危险因素。结果：102例Stanford A型主动脉夹层患者术后出现血流感染17例,感染发生率为16.67%。17例血流感染患者分离病原菌45株,其中革兰氏阴性菌29株（64.44%）、革兰氏阳性菌13株（28.89%）、真菌3株（6.67%）。感染组患者的年龄、糖尿病史、抗生素疗程、手术时长、植入人工瓣膜比例、二次气管插管比例、机械通气比例、深静脉置管时长均高于未感染组（P<0.05）。多因素Logistic回归分析发现,高龄、二次气管插管、机械通气、深静脉置管时间长、手术时长、植入人工瓣膜比例高是患者术后血流感染的独立危险因素（P<0.05）。结论：Stanford A型主动脉夹层患者术后有较高的血流感染发生率,且主要感染致病菌以革兰氏阴性菌为主,其中高龄、二次气管插管、机械通气、深静脉置管时间长、手术时长、植入人工瓣膜比例高是患者术后血流感染的危险因素。     

Aortic dissection presenting as acute myocardial infarction: potential harm of antithrombin and antiplatelet therapy

In the treatment of acute myocardial infarction, antithrombin and antiplatelet therapy are indicated according to the current guidelines. When a patient presents with symptoms and signs of acute myocardial infarction, an extensive list of diagnoses should be considered. Because of the nonspecific symptoms of aortic dissection, the disease may be easily misdiagnosed. A high clinical suspicion of aortic dissection is therefore required. Once aortic dissection has been diagnosed, surgical intervention provides the only definitive treatment for these patients, regardless of antithrombin and antiplatelet therapy.     

Uncommon acquired Gerbode defect following extensive bicuspid aortic valve endocarditis

Gerbode defect is a rare type of left ventricle to right atrium shunt. It is usually congenital in origin, but acquired cases are also described, mainly following infective endocarditis, valve replacement, trauma or acute myocardial infarction. We report a case of a 50-year-old man who suffered an extensive and complex infective endocarditis involving a bicuspid aortic valve, the mitral-aortic intervalvular fibrosa and the anterior leaflet of the mitral valve. After dual valve replacement and annular reconstruction, a shunt between the left ventricle and the right atrium - Gerbode defect, and a severe leak of the mitral prosthesis were detected. Reintervention was performed with successful shunt closure with an autologous pericardial patch and paravalvular leak correction. No major complications occurred denying the immediate post-surgery period and the follow-up at the first year was uneventful.     

老年Stanford A 型主动脉夹层外科治疗*

目的:总结老年Stanford A型主动脉夹层外科治疗经验,探讨手术方式的选择,以提高手术疗效。方法:2008年9月至2011年5月对31例老年Stanford A型主动脉夹层行手术治疗,根据夹层破口位置、累及范围、主动脉根部病变情况采取相应术式,W-heat手术2例,David+全弓置换+支架象鼻术3例,Bentall+全弓置换+支架象鼻术9例,改良Wheat+全弓置换+支架象鼻术1例,升主动脉+全弓置换+支架象鼻术16例。同时行冠状动脉旁路移植术4例,心包剥脱术1例。结果:全组体外循环(221±43)min,平均心肌阻断(132±41)min,深低温停循环(47±12)min。术后并发症12例(38.7%),其中2例死亡,8例治愈(66.7%),2例术后出现肾功能衰竭家属放弃治疗。全组病人出院前复查主动脉CTA,见升主动脉、弓部人工血管血流通畅,支架位置正常,无明显移位。支架远端降主动脉假腔闭合率87.1%。随访2~35个月,术后近期死亡1例(3.2%),无再次手术者。结论:对老年StanfordA型主动脉夹层这一高危人群,术中根据其病变部位施行最佳的外科手术方式,可明显降低死亡率,改善患者预后。     

影响复杂性Stanford B型主动脉夹层院内死亡的危险因素分析

目的:探讨复杂性Stanford B型主动脉夹层患者院内死亡的危险因素。方法:回顾性分析2010年1月至2015年6月急诊收治入院的98例复杂性Stanford B型主动脉夹层患者的住院病例资料,对可能影响复杂Stanford B型主动脉夹层院内死亡的15项临床病理因素:患者年龄、性别、治疗方式、发病至就诊时间、既往是否有高血压病史、就诊时收缩压、入院时是否合并肺部感染、慢性肾功能不全、既往结缔组织病、主动脉扩张、急性肾损伤、心包积液、胸腔积液、腹腔积液、心肌灌注、肠系膜动脉灌注、下肢灌注,进行单因素和多因素回归分析。结果:单因素分析结果显示:患者年龄、就诊时收缩压、治疗方式、急性肾损伤、心肌灌注不良、心包积液、主动脉扩张、下肢灌注不良与院内死亡有关(P0.1)。经COX多因素回归分析结果显示:TEVAR治疗(HR=8.437CI 1.048-67.925 P=0.045),心包积液(HR=4.010 CI 1.675-9.598 P=0.002),下肢灌注不良(HR=3.133 CI 1.083-9.064 P=0.035)与院内死亡有关(P0.05)。结论:心包积液及下肢灌注不良可使复杂性Stanford B型主动脉夹层患者院内死亡率增加,而TEVAR可有效改善患者早期预后。     

Conditions mimicking acute ST-segment elevation myocardial infarction in patients referred for primary percutaneous coronary intervention

Background/Objectives. A rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is mandatory for optimal treatment. However, a small proportion of patients with suspected STEMI suffer from other conditions. Although case reports have described these conditions, a contemporary systematic analysis is lacking. We report the incidence, clinical characteristics and outcome of patients with suspected STEMI referred for primary percutaneous coronary intervention (PCI) with a final diagnosis other than STEMI. Methods. From January 2004 to July 2005, 820 consecutive patients were included with suspected STEMI who were referred for primary PCI to a university medical centre, based on a predefined protocol. Clinical characteristics, final diagnosis and outcome were obtained from patient charts and databases. Results. In 19 patients (2.3%), a final diagnosis other than myocardial infarction was established: coronary aneurysm (n=1), (myo)pericarditis (n=5), cardiomyopathy (n=2), Brugada syndrome (n=1), aortic stenosis (n=1), aortic dissection (n=3), subarachnoidal haemorrhage (n=2), pneumonia (n=1), chronic obstructive pulmonary disease (n=1), mediastinal tumour (n=1), and peritonitis after recent abdominal surgery (n=1). These patients less often reported previous symptoms of angina (p<0.001), smoking (p<0.05) and a positive family history of cardiovascular diseases (p<0.05) than STEMI patients. Mortality at 30 days was 16%. Conclusion. A 2.3% incidence of conditions mimicking STEMI was found in patients referred for primary PCI. A high clinical suspicion of conditions mimicking STEMI remains necessary. (Neth Heart J 2008;16:325-31.)     

经胸超声胸骨右缘切面对Stanford A型主动脉夹层诊断价值的研究

目的:通过经胸超声心动图获取胸骨右缘升主动脉长短轴切面观察Stanford A型主动脉夹层患者的升主动脉结构,探讨对该类患者进行检查时该切面的应用价值。方法:31例经CTA或手术证实为A型主动脉夹层的连续性患者,超声心动图检查除常规通过胸骨左缘切面观察升主动脉结构外,均做胸骨右缘切面以进一步观察升主动脉结构,包括最大内径,有无撕脱内膜及内膜活动情况,同时应用常规胸骨左缘切面和胸骨右缘切面对A型主动脉夹层能够清晰显示出的病例比例加以比较。结果:胸骨左缘切面能够清晰显示升主动脉结构9例,占比例29%。胸骨右缘切面能够清晰显示升主动脉结构20例,比例65%。将两种切面结合能够清晰显示升主动脉结构的比例升高到74%。胸骨右缘肋间切面测得的升主动脉最大径线数值与CTA结果的一致性更好。结论:胸骨右缘肋间切面对A型主动脉夹层显示的清晰度更好,有助于临床诊断,具有重要的参考价值,值得临床广泛推广。     

Histopathological studies of aortic dissection in streptozotocin-induced diabetic APA hamsters.

Syrian hamsters of the APA strain (APA hamsters) are known to show continuous diabetes accompanied by its complications, such as glomerulosclerosis and atherosclerosis, following a single injection of streptozotocin (SZ). Recently, we observed Stanford type B aortic dissection in three diabetic APA hamsters and histopathological analysis was performed. The histopathologic observations in the false lumen, such as proliferation of granulation tissues, neointima and pseudoneointima, corresponded to the non-thrombosed type of human aortic dissection, and blood clots of the thrombosed type were similar to the remodeling structures of aortic dissection found in human cases. Thus, this model may be useful for investigating the etiology and pathogenesis of aortic dissection accompanying diabetes mellitus in humans.     

Seasonal incidence of hospital admissions for Stanford type A aortic dissection

The objective of this study was to test the hypothesis that there is seasonal variation in the incidence of Stanford type A aortic dissection (SA-AoD) among patients admitted to our cardiovascular surgical service. A sinusoidal logistic regression model was used to analyze event data for 6081 calendar days. A cyclic peak risk for SA-AoD was observed for calendar day 304 (p?=?0.019). The odds ratios for the 3- and 6-month window surrounding this peak were 1.6 (p?=?0.054) and 1.7 (p?=?0.0040), respectively. Our results suggest than a seasonal variation exists in the incidence of SA-AoD.     

Coronary artery dissection following blunt chest trauma: a case report

Coronary artery dissection following blunt chest trauma is rare. We report the case of a 43-year-old woman who was admitted with a subacute inferior myocardial infarction due to dissection of the right coronary artery. Ten days earlier, she had sustained a minimal chest trauma. The literature is reviewed and management is discussed.     

36 例急性Stanford A 型主动脉夹层动脉瘤的外科治疗体会

目的:总结急性Stanford A型主动脉夹层动脉瘤的外科治疗体会。方法:选择36例急性Stanford A型主动脉夹层动脉瘤患者,根据病变夹层破口的位置、累及范围、有无合并主动瓣关闭不全选择相应的手术方式,观察患者治疗后的临床疗效并随访治疗6个月后的临床预后。结果:3例患者术中死亡,术中死亡率为8.3%,平均手术时间156.7±56.7min,平均阻断时间98.5±32.7min,平均选择性脑灌注时间56.1±20.7min,术后平均ICU住院时间6.2±3.8d,术后平均总计住院时间25.4±7.3d;术后6个月后随访,3例患者死亡,其余30例患者恢复满意,生活质量与治疗前相比,均得到显著提高。结论:急性Stanford A型主动脉夹层动脉瘤患者应积极施行早期外科治疗,术前快速准确诊断,根据患者病情制定相应的手术方案,术后采取措施避免术后并发症。     

36例急性StanfordA型主动脉夹层动脉瘤的外科治疗体会

目的：总结急性StanfordA型主动脉夹层动脉瘤的外科治疗体会。方法：选择36例急性StanfordA型主动脉夹层动脉瘤患者,根据病变夹层破口的位置、累及范围、有无合并主动瓣关闭不全选择相应的手术方式,观察患者治疗后的临床疗效并随访治疗6个月后的临床预后。结果：3例患者术中死亡,术中死亡率为8．3％,平均手术时间156．7±56．7min,平均阻断时间98．5±32．7min,平均选择性脑灌注时1．756．1±20．7min,术后平均ICU住院时间6．2±3．8d,术后平均总计住院时间25．4±7．3d;术后6个月后随访．3例患者死亡,其余30例患者恢复满意,生活质量与治疗前相比,均得到显著提高。结论：急性Stanford A型主动脉夹层动脉瘤患者应积极施行早期外科治疗,术前快速准确诊断,根据患者病情制定相应的手术方案,术后采取措施避免术后并发症。     

Surgical treatment of aortic dissection in a patient with metastatic prostate cancer

Acute aortic dissection bears all the stigmata of a true clinical emergency. The natural history of this acute aortic syndrome warrants prompt surgical intervention, with only a few absolute contraindications to this line of treatment. We present a 74-year-old man with documented metastatic prostate cancer who underwent emergent surgery for acute Stanford A aortic dissection. Having acknowledged the relatively favorable evolution of our patient's malignant disease, we were not deterred by its presence from pursuing surgical treatment of his aortic dissection.     

Pregnancy-related myocardial infarction

Introduction

The risk of acute myocardial infarction in young women is low, but increases during pregnancy due to the physiological changes in pregnancy, including hypercoagulability. Ischaemic heart disease during pregnancy is not only associated with increased maternal morbidity and mortality, but also with high neonatal complications. Advancing maternal age and other risk factors for cardiovascular diseases may further increase the risk of ischaemic heart disease in young women.

Methods

We searched the coronary angiography database of a Dutch teaching hospital to identify women with acute myocardial infarction who presented during pregnancy or postpartum between 2011 and 2013.

Results

We found two cases. Both women were in their early thirties and both suffered from myocardial infarction in the postpartum period. Acute myocardial infarction was due to coronary stenotic occlusion in one patient and due to coronary artery dissection in the other patient. Coronary artery dissection is a relatively frequent cause of myocardial infarction during pregnancy. Both women were treated by percutaneous coronary intervention and survived.

Conclusion

Physicians should be aware of the increased risk of myocardial infarction when encountering pregnant or postpartum women presenting with chest pain.

     

Trichinosis presenting as acute myocardial infarction

A 20-year-old male patient is presented as a case of trichinous myocarditis with clinical symptoms and electrocardiographic evidence of an acute inferior myocardial infarction. He recovered rapidly and completely without any specific therapy. This seems to be a distinct rarity, having never been previously reported, but is of importance because of the almost uniformly excellent prognosis in this condition in contradistinction to that of a bona fide myocardial infarction occurring at this age.     

A mechanical device for aortic compliance modulation: in vitro simulation of aortic dissection treatment

Stanford type A aortic dissection often rapidly leads to death from aortic rupture. We considered the possibility of introducing a passive counterpulsating damper into the dissected aorta in order to limit the physical stress associated with ventricular ejection and increase the diastolic aorto-ventricular pressure gradient. We conceived a damping device comprising an intravascular balloon connected to an adjustable external reservoir to regulate the air pressure inside the balloon, and performed a simulation study using a mechanical model of the cardiovascular system, mimicking aortic dissection. When the balloon was completely deflated, the behavior of the aortic pressure signal was typical of low-compliance aortic dissection, as characterized by an augmented maximum systolic value, accentuated diastolic decay, and a very low end-diastolic value. Balloon inflation (at incremental steps to 90 mmHg) progressively restored the aorto-ventricular pressure gradient and reduced peak systolic pressure values, leading to progressive improvements in the characteristics of the aortic pressure curve in terms of reduction in the maximum systolic value and slower diastolic decay. The proposed mechanism might exert beneficial effects at two levels: (1) directly, by reducing mechanical stress on the arterial wall; (2) indirectly, by allowing safer use of pharmaceutical agents (beta-blockers etc.). In vivo animal simulation studies are warranted to verify the effects of the device and optimize balloon shape and volume in a realistic pathophysiological setting.     

Acute phase of aortic dissection: a pilot study on CD40L,MPO, and MMP-1, -2, 9 and TIMP-1 circulating levels in elderly patients

Background

Acute aortic dissection (AAD) is an event which may be rapidly fatal without early diagnosis and treatment. Aging is one of the main risk factors that could leading to AAD. To date, no specific biomarkers are available to increase the speed of diagnosis. CD40 ligand (CD40L), myeloperoxidase (MPO), matrix metalloproteinase (MMP)-1, -2, -9 and metallopeptidase tissue inhibitor 1 (TIMP-1) are biologically related molecules which integrate inflammation, tissue injury and remodeling, all events associated to AAD.Our is a pilot study to evaluate whether circulating levels of these molecules may be used as potential biomarkers in timely diagnosis of AAD.

Results

Within 24 h of symptom onset, circulating CD40L, MPO, MMP-1,-2,-9 and TIMP-1 were quantified by enzyme-linked immunosorbent assays in 22 patients (40–86 years of age) with AAD of ascending aorta (type A according to Stanford classification) and 11 patients with AAD of descending aorta (type B). 30 healthy individuals age matched were used as control group compared to controls, both type A and B AAD patients had higher CD40L (p?<?0.001) and MPO (p?<?0.01) levels. MMP-1 was higher in the overall AAD group (p?<?0.01). After Stanford classification, type A group had increased level compared to both control and type B (p?<?0.01 and p?<?0.05, respectively). TIMP-1 was higher in both A and B groups compared to controls (p?<?0.001). No differences were observed in MMP-2 and MMP-9 levels.

Conclusions

The simultaneous evaluation of CD40L, MPO and MMP-1 and TIMP-1, which may contribute to structural changes in aortic tissue in AAD patients, seems to be a novel promising diagnostic panel.

     

Impact of temperature and atmospheric pressure on the incidence of major acute cardiovascular events

Background

The impact of meteorological conditions on the occurrence of various cardiovascular events has been reported internationally. Data about the Dutch situation are limited.

Objectives

We sought to find out a correlation between weather conditions and the incidence of major acute cardiovascular events such as type A acute aortic dissection (AAD), acute myocardial infarction (AMI) and acutely presented abdominal aortic aneurysms (AAAA).

Methods

Between January 1998 and February 2010, patients who were admitted to our hospital (Catharina Hospital, Eindhoven, the Netherlands) because of AAD (n = 212), AMI (n = 11389) or AAAA (n = 1594) were registered. These data were correlated with the meteorological data provided by the Royal Dutch Meteorological Institute (KNMI) over the same period.

Results

During the study period, a total number of 11,412 patients were admitted with AMI, 212 patients with AAD and 1593 patients with AAAA. A significant correlation was found between the daily temperature and the number of hospital admissions for AAD. The lower the daily temperature, the higher the incidence of AAD (p = 0.002). Lower temperature was also a predictor of a higher incidence of AMI (p = 0.02). No significant correlation was found between daily temperature and onset of AAAA.

Conclusions

Cold weather is correlated with a higher incidence of AAD and AMI.     

Stanford A型主动脉夹层血管壁及外周血中热休克蛋白90的表达及意义

目的:探索热休克蛋白90(Heat shock protein 90, HSP90)在Stanford A型主动脉夹层(Aortic dissection, AD)血管壁组织中的表达及其与平滑肌细胞(Smooth muscle cells, SMCs)表型标志物的相关性。方法:收集本院急性Stanford A型主动脉夹层患者病变主动脉壁组织和外周血标本(AD组,20例),心脏移植供体等来源的正常主动脉壁组织和外周血标本(正常组,10例);ELISA法检测血浆HSP90含量;免疫组化染色检测HSP90的表达差异及定位;Western blot检测组织标本中蛋白的表达差异;应用Spearman分析HSP90和SMCs表型标志物表达的相关性。结果:AD患者血浆中HSP90的含量显著高于正常组(142.38±40.16ng/mL vs. 54.99±24.46 ng/mL,P<0.01)。相对于正常主动脉壁组织,主动脉夹层血管壁组织中HSP90表达明显升高,且主要分布在血管壁中层细胞的胞浆中,分泌型SMCs标志物OPN的表达明显增多,而收缩型标志物α-SMA表达则显著减少。HSP90和α-SMA的蛋白表达呈负相关(R2=0.677,P<0.01),和OPN呈正相关(R²=0.572,P<0.01)。结论:主动脉夹层患者的血管壁组织及外周血中的HSP90含量明显升高,参与了主动脉夹层的发生发展。