開心手術併發主動脈剝離之病例報告

Intraoperative Aortic Dissection-- A Case Report

心臟手術中發生主動脈剝離是一個罕見但卻可致命的併發症。迅速診斷並同時進行外科手術修補，可減少剝離的範圍和病人合併症及死亡率。在此我們提出一位開第二次心臟手術病人在體外循環結束時拔除動脈管，產生急性type A升主動脈剝離。外科醫師立即在股動脈進行再次動脈插管，並降溫進行修補。不幸，病人仍於第二天因大量失血造成心包膜填塞而死亡。文獻中報導長期患有嚴重高血壓，或主動脈壁有粥狀動脈硬化、變薄或擴張者較易發生此併發症。在手術過程中，使用各種外科器械時盡量避免傷害到主動脈壁，減少主動脈剝離的發生優於任何治療方式。但若不幸發生此併發症時，可使用食道超音波確定診斷並立即進行外科手術。

Intraoperative aortic dissection is a rare but potentially fatal complication of cardiac surgery. Prompt recognition and repair are necessary to limit the extent of dissection to minimize morbidity and mortality. Here, we present a case of acute type A dissection of ascending aortic artery occurring after removal of aortic cannula at the end of cardiopulmonary bypass. The surgeon immediately recannulated him at the femoral artery and repaired the dissection under deep hypothermia. Ascending aorta was replaced with Hemashield graft and venous graft was reimplanted. Unfortunately, the patient expired the following day due to cardiac tamponade resulting from uncontrolled bleeding. Long-standing severe hypertension, severe atherosclerotic change of the aortic wall, thin and dilating ascending aorta and cystic medial necrosis or collagen vascular disease were thought to predispose him to this complication. Gentle manipulation and surgical discreetness to forestall aoratic injury could minimize the risk of intraoperative aortic dissection. Once aortic dissection has been suspected, prompt application of transesophageal echocardiography to confirm the diagnosis, and rapid as well as appropriate surgical management are necessary to grasp a better outcome.