复合带瓣人工血管替换升主动脉和主动脉瓣

报告２４例或主动脉瘤伴主动脉瓣关闭不全行升主动脉和主动脉瓣替换及冠状动脉开口移植术。１３例伴有升主动脉夹层分离，对其中９例ＤｅＢａｋｅｙＩ型者，以Ｔｅｆｌｏｎ毡条内外加固主动脉切端后吻合。１３例用人工血管周围间隙与右心耳吻合以控制升主动脉吻合以控制升主动脉吻合上的出血。３例以人工血管片环包主动脉吻合口控制局部广泛渗血及出血。２例术毕不能脱离体外循环死亡。手术死亡率８．３％。随访平均２１．８个月，２     

应用同种动脉治疗主动脉根部病变

报告５例采用同种动脉（ＨＡＶ）治疗５例主动脉根部病变（主动脉瓣狭窄１例，关闭不全４例）。男３例，女２例；年龄１３～４７岁。病因为细菌性心内膜炎２例（包括先天主动脉瓣二瓣化畸型１例），Ｍａｒｆａｎ综合征２例，风湿性主动脉瓣关闭不全１例。术中采用同种主动脉全根置换３例（Ｂｅｎｔａｌｌ手术），其中１例用ＨＡＶ上的二尖瓣前叶加宽主动脉瓣环（Ｍａｎｏｕｇｕｉａｎ手术），余２例用自体肺动脉移置主动脉根部，另取同种肺动脉做原位移置（Ｒｏｓｓ手术）。结果死亡１冽，４例存活，且无并发症发生。术后超声心动图提示主动脉根部良好，无主动脉瓣反流。随访２．５～３．５年疗效满意。     

连续5例Cabrol手术治疗马凡综合征主动脉根部病变

自１９９３年９月至１９９５年６月，连续治疗５例马凡综合征病人。其中１例在住院期间瘤体破裂，严重心包填塞、休克，急诊行Ｃａｂｒｏｌ手术获得成功。采用带瓣人工血管作升主动脉及主动脉瓣替换（经典Ｂｅｎｔａｌ手术），冠脉移植采用一根中介人工血管，两端分别与左右冠状动脉开口作端—端吻合，中介人工血管再与置换的升主动脉人工血管作侧—侧吻合（Ｃａｂｒｏｌ手术）。５例病人均手术成功，心包纵隔引流总量７１０～１４７０ｍｌ，平均９４８ｍｌ。无二次开胸止血者。术后早期无死亡，随访３～２２个月，平均１０个月，心功能均为ＩＩ级，心电图与术前比较无显著变化，但心胸比率明显下降，超声心动图示左室较术前明显缩小。病理结果均为中层弹力纤维严重断裂，重度粘液变性。结论：Ｃａｂｒｏｌ手术是治疗马凡综合征主动脉根部病变的有效手术方法之一，特别适于冠状动脉开口移位较小的病人。     

升主动脉瘤伴主动脉瓣关闭不全外科治疗25例

报告２５例升主动脉瘤伴主动脉瓣关闭不全的手术经验。方法１１例伴有主动脉夹层分离，其中ＤｅＢａｋｅｙⅠ型６例、Ⅱ型５例。施行Ｂｅｎｔａｌ手术１９例，分别置换主动脉瓣及升主动脉１例，升主动脉置换加主动脉瓣悬吊５例。结果因止血困难采用Ｃａｂｒｏｌ分流止血２例；术后１６小时延迟大出血１例；无早期死亡病例。远期因心内膜炎死亡２例；术后３０月发生胸降主动脉瘤１例；无假性动脉瘤发生。结论应根据升主动脉瘤的病变类型及范围采用不同的手术方式。准确的吻合技术、保留瘤壁的完整性，使升主动脉瘤的手术治疗更为安全。心内膜炎是Ｂｅｎｔａｌ手术后最主要的远期并发症，须引起高度重视     

主动脉瓣上狭窄的外科治疗

１９８８年６月至１９９６年１２月我们治疗３例局限型主动脉瓣上狭窄（ＳＶＡＳ）病人,现报告如下。临床资料　３例病儿均为男性,年龄分别为２、５、６岁。主动脉瓣区均有响亮收缩期喷射性杂音伴震颤。超声检查均见主动脉瓣上有狭窄区。心导管检查左室主动脉压差（ＳＰ）分别为１２９．８ｍｍＨｇ（１ｍｍＨｇ＝０．１３３ｋＰａ）、８４．８ｍｍＨｇ和７２．８ｍｍＨｇ。造影见主动脉瓣上狭窄处及主动脉瓣环直径分别为８ｍｍ／１３ｍｍ、９ｍｍ／１４ｍｍ、８ｍｍ／１４ｍｍ,其中１例升主动脉亦显示有轻度狭窄。手术采用正中切口,中…     

DAVID-Ⅰ式手术治疗主动脉根部动脉瘤12例

长期以来应用带主动脉瓣（机械瓣或生物瓣）的人工血管替换病变主动脉及主动脉瓣并重新移植冠状动脉开口（BENTAL手术）是治疗升主动脉及主动脉根部动脉瘤的标准术式，但其存在与人工瓣相关的问题。1992年David和Feindel提出了保留主动脉瓣的主动脉根部修复术（DAVID手术）治疗升主动脉瘤和主动脉根部扩张。我们于2002年10月至2003年10月在法国冈城大学医疗中心研修期间参加了12例DAVID-Ⅰ式手术，现报告如下。     

瘤袋与右房搭桥吻合治疗升主动脉夹层动脉瘤术后出血

瘤袋与右房搭桥吻合治疗升主动脉夹层动脉瘤术后出血杨辰垣，蓝鸿钧，孙宗全，张凯伦，刘成硅升主动脉夹层动脉瘤切除手术后出血，用常规方法往往难以控制。１９９３年３月～１９９４年１２月我们采用Ｃａｂｒｏｌ手术方案连续为３例升主动脉夹层动脉瘤病人作了手术。其中...     

主动脉瓣上狭窄的外科治疗

报告１３例主动脉瓣上狭窄（ｓｕｐｒａｖａｌｖｕｌａｒａｏｒｔｉｃｓｔｅｎｏｓｉｓ，ＳＶＡＳ）病例的治疗。其中局限型１１例，弥漫型２例。合并的心血管畸形包括：主动脉瓣狭窄５例，主动脉瓣反流２例，主动脉瓣环发育不全２例，冠状动脉畸形６例，动脉导管未闭１例，多发肺动脉狭窄１例，肺动脉瓣上隔膜１例，头臂动脉畸形５例。１３例病人中，９例行狭窄解除术，１例用同种升主动脉行心尖至胸主动脉架桥术，１例单纯动脉导管结扎术，２例未手术。结果手术早期死亡２例，晚期死亡１例。作者认为ＳＶＡＳ手术治疗的要点为：（１）充分解除主动脉瓣上狭窄；（２）避免一切影响冠状动脉灌注的因素；（２）妥善处理并存的主动脉瓣病变。     

A型主动脉夹层动脉瘤的外科治疗

目的　总结 1996年 1月至 2 0 0 2年 8月收治的 34例 A型主动脉夹层动脉瘤的外科治疗经验。　方法　应用 Bentall手术 19例 ,升主动脉人工血管置换术 7例 ,升主动脉人工血管置换加主动脉瓣成形术 (Trusler's法 )5例 ,分别行升主动脉人工血管置换及主动脉瓣置换术 (Wheat术 ) 2例 ,升主动脉、主动脉弓人工血管置换术 1例。结果　手术死亡 6例 ,死亡率 17.6 %。其中慢性主动脉夹层动脉瘤死亡 3例 ,急性夹层动脉瘤死亡 3例。随访 2 0例 ,随访率 71.4 %。随访时间 2～ 4 6个月 ,平均 2 4 .7个月 ,1例术后 3个月猝死 (原因不明 ) ,1例术后 6个月死于心内膜炎。18例存活患者情况良好。　结论　应根据夹层动脉瘤的部位及范围采用不同的手术方式 ,保留主动脉瓣的升主动脉人工血管置换术治疗该病效果较好 ,准确可靠的吻合技术、保留瘤壁的完整性 ,将使手术更为安全。     

双吻合器吻合法在直肠癌保肛手术中的应用

目的评估双吻合器吻合法在直肠癌保肛手术应用中的安全性和实用性。方法回顾总结４年中采用该技术行直肠癌手术９７例。癌灶下缘距肛缘平均距离８２ｃｍ，其中３～７ｃｍ４２例（４３３％，４２／９７），大于８ｃｍ５５例（５６７％，５５／９７）。结果所有患者吻合器切除圈完整。术后吻合口漏９例（９３％，９／９７），肿瘤距肛缘小于７ｃｍ患者的吻合口漏发生率显著高于距离大于７ｃｍ的患者（Ｐ＜０．０５），神经性膀胱排空障碍５例（５２％，５／９７），切口感染７例（７２％，７／９７），吻合口出血４例（４１％，４／９７），术后肛门部疼痛１例（１０％，１／９７）。结论双吻合器吻合法可作为低位直肠癌保肛手术的一种安全可靠的术式选择。     

Aortic root remodeling in atheromatous aneurysms: the role of selected sinus repair.

OBJECTIVE: Atheromatous ascending aortic aneurysms (AAA) frequently present with aortic regurgitation (AR) from dilatation of the sino-tubular junction (STJ) and extension of the pathological process into the root. Experience suggests that root dilatation begins in the non-coronary, then right coronary sinus. Rather than employ aortic root replacement or the David procedure, we have elected to replace the ascending aorta and remodel the STJ and involved sinuses. We studied the outcome after selective sinus replacement in 29 consecutive AAA patients between 1995 and 2001. METHODS: There were nine male and 20 females. Age ranged from 47 to 79 years (mean 67.5). Seven had arch aneurysms and four coronary artery disease. Nineteen were NYHA III or IV. Grade of AR was IV in 20, III in five and II in four. The STJ was dilated >50% of annulus diameter in each case (5.3-10.0 cm, mean 6.4 cm). All valves had three cusps. All patients underwent ascending aortic replacement. Seven had arch replacement and four coronary artery bypass. Seven had replacement of both right and non-coronary sinuses with re-implantation of the right coronary ostium. Twelve had replacement of the non-coronary sinus alone whilst nine had right coronary sinus replacement. One with dextrocardia had left coronary sinus replacement with ostial re-implantation. The graft size was within 2 mm of annulus size except for two patients (24 mm 12, 26 mm 11, and 28 mm six). Post operative echocardiographic studies were performed. None of the patients received anticoagulation. RESULTS: There were no hospital or late deaths and no thromboembolic or infective complications. Two patients had mild to moderate aortic regurgitation. These had a size 28 graft, which in retrospect was too large. Others had no significant regurgitation. CONCLUSIONS: The native aortic valve can be preserved in the majority of patients with AAA. Remodelling of the STJ and selective sinus replacement restores valve competence. Anticoagulation and prosthesis related complications are thereby avoided.     

升主动脉瘤的外科治疗

目的探讨升主动脉瘤治疗经验。方法Marfan’s综合征12例，其中6例合并二尖瓣关闭不全。升主动脉夹层动脉瘤伴主动脉瓣关闭不全6例，升主动脉瘤合并主动脉瓣、二尖瓣关闭不全2例，单纯升主动脉瘤5例，行Bentall手术12例，Cabrol手术3例，Wheat手术5例；单纯升主动脉替换术5例。结果全组无手术死亡。结论Bentall手术是外科治疗升主动脉瘤的主要术式。早期诊断、早期手术是改善升主动脉瘤患者疗效的关键。     

腹主动脉瘤手术并发结肠缺血的临床分析

目的：探讨腹主动脉瘤（abdominal aortic aneurysm,AAA)手术并发结肠缺血的病因和防治措施。方法：对140例AAA手术并发经肠缺血的7例患者进行回顾性分析。结果：3例患者为AAA破裂急诊手术,7例患者均行AAA切除,人工血管置换术及肠系膜下动脉（inferior mesenteric artery,IMA)结扎术,有2例患者同时结扎双侧髂内动脉（internal iliac artery,IIA),2例患者同时结扎一侧IIA,3例患者行肠切除术,1例患者行IMA重,3例患者行保守疗法,术后3例患者因多器官功能衰竭死亡。结论：正确防治结肠缺血和坏死可有效降低AAA 手术病死率,有利于术后的康复。     

Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta

BACKGROUND: Aortic valve-sparing operations are an alternative to aortic root replacement in patients with aortic root aneurysms, or aortic valve replacement and supracoronary replacement of the ascending aorta in patients with ascending aorta aneurysms and dilated sinotubular junctions with consequent aortic insufficiency. METHODS: From 1988 to 2001, 230 patients underwent aortic valve-sparing operations for aortic root aneurysms (151 patients) or ascending aortic aneurysms with aortic insufficiency (79 patients). Two types of aortic valve-sparing operations were performed in patients with aortic root aneurysms: reimplantation of the aortic valve and remodeling of the aortic root. Mean follow-up was 3.8 +/- 2.8 years. RESULTS: Patients with aortic root aneurysms were younger, had less severe aortic insufficiency, less extensive vascular disease, and better left ventricular function than patients with ascending aorta aneurysms. The 8-year survival was 83% +/- 5% for the first group and 36% +/- 14% for the second. The freedom from aortic valve reoperation at 8 years was 99% +/- 1% for the first group and 97% +/- 2% for the second. In patients who had aortic root aneurysms, 3 developed severe aortic insufficiency (AI), and 15 developed moderate AI, for an 8-year freedom from significant AI of 67% +/- 7%. But freedom from AI was 90% +/- 3% after the technique of reimplantation, and 55% +/- 6% after the technique of remodeling (p = 0.02). In patients with ascending aortic aneurysms, the freedom from AI greater than 2+ at 8 years was 67% +/- 11%. CONCLUSIONS: The long-term results of aortic valve sparing for aortic root aneurysms are excellent, and reimplantation of the aortic valve may provide a more stable repair of the aortic valve than remodeling of the aortic root.     

A New Operation for Far-Advanced Cystic Medial Necrosis of the Aortic Root

Three patients with far-advanced cystic medial necrosis of the aorta, which had produced giant bulbous enlargement of the aortic root and severe aortic regurgitation, were operated on using a procedure not previously described. Measurements of the aortic valve annulus and ascending aorta were made from aortograms. A knitted polyester arterial prosthesis was sewn together to form a circle. This circular prosthesis was sewn to a 31 mm Björk-Shiley aortic valve prosthesis in the way that a tire is fitted onto a wheel. The resulting composite prosthesis, which had the same diameter as the aortic root, was used to replace the excised valve. In all cases a composite prosthesis measuring greater than 50 mm in diameter was used. In 2 of the 3 patients the ascending aorta was replaced with a tubular graft reshaped as a truncated cone. This reshaping was done by inserting multiple gussets into one end of the aortic prosthesis so that the flanged end fit precisely to the enlarged valve prosthesis and the other end fit precisely to the transverse aortic arch. Two patients are asymptomatic more than two years following operation. The third patient died suddenly of a ventricular arrhythmia on the twenty-third postoperative day.     

Results of aortic valve-sparing operations.

OBJECTIVE: To review the late results of valve-sparing operations in patients with aortic root aneurysm and in those with ascending aortic aneurysm and aortic insufficiency. METHODS: From May 1988 to June 2000, 120 patients with aortic root aneurysm and 68 with ascending aortic aneurysm and aortic insufficiency underwent aortic valve-sparing operations. Patients with aortic root aneurysm were younger, were predominantly male, and had less severe aortic insufficiency than patients with ascending aortic aneurysm, who were older and often had aneurysm of the transverse arch. Forty-eight patients with aortic root aneurysm had the Marfan syndrome. The prevalence of aortic dissection was similar in both groups. Reconstruction of the aortic root was performed by reimplanation of the aortic valve in 64 patients and by remodeling of the aortic root in 56. Patients with ascending aortic aneurysm and aortic insufficiency were treated by replacement of the ascending aorta with reduction in the diameter of the sinotubular junction. Approximately two thirds of the latter patients also required replacement of the transverse aortic arch. The mean follow-up was 35 +/- 31 months for patients with aortic root aneurysm and 26 +/- 23 months for those with ascending aortic aneurysm. RESULTS: There were 2 operative and 5 late deaths in patients with aortic root aneurysm and 1 operative and 9 late deaths in patients with ascending aortic aneurysm. The 5-year survival for patients with aortic root aneurysm was 88% +/- 4% and for patients with ascending aortic aneurysm, 68% +/- 12% (P =.01). Severe aortic insufficiency developed in 2 patients, and they required aortic valve reoperation. The 5-year freedom from aortic valve reoperation was 99% +/- 1% for patients with aortic root aneurysm and 97% +/- 4% for those with ascending aortic aneurysm. Seven patients had moderate aortic insufficiency at the latest echocardiographic study. The 5-year freedom from severe or moderate aortic insufficiency was 90% +/- 4% in patients who had aortic root aneurysm and 98% +/- 2% in those who had ascending aortic aneurysm. CONCLUSIONS: Aortic valve-sparing operations have provided excellent clinical outcomes and few valve-related complications. The function of the reconstructed aortic root remains unchanged in most patients during the first 5 years of follow-up.     

Repair in traumatic ascending aortic rupture and valve insufficiency

An 18-year-old patient who had chronic traumatic ascending aortic lesion and valve insufficiency, with severe LV dysfunction, was treated by repair of the aortic wall without prosthesis and of the aortic valve by a gluteraldehyde-treated autologous pericardial patch. The patient had an uneventful recovery and minimal residual aortic regurgitation at one-month echocardiographic follow-up. Conservative surgery of these lesions is feasible, with good results, in some cases.     

人工四分支血管在主动脉外科的应用

目的总结应用人工四分支血管行不同部位主动脉替换术的经验。方法自2003年8月至2005年5月,我中心采用人工四分支血管行不同部位的主动脉替换术142例。男118例、女24例,年龄(44±12)岁(22~78岁),体重(72±20)kg(49~130kg)。其中:StanfordA型主动脉夹层94例(18例为马凡综合征);StanfordB型主动脉夹层34例(6例为马凡综合征),真性动脉瘤11例,假性动脉瘤3例。在深低温停循环选择性脑灌注下,行升主动脉及全弓替换85例(83例远端加带膜支架);分段停循环下,行全胸腹主动脉替换术38例;深低温选择性脑灌注分段停循环下,行全或次全主动脉替换8例;常温非体外循环下,行全主动脉弓替换11例(3例远端加带膜支架)。结果术后早期死亡6例,病死率4·2%。术后神经并发症,较严重,严重脑功能障碍(昏迷超过3d)16例(11·3%);永久性脊髓损伤2例(1·4%);一过性脊髓损伤4例(2·8%)。结论人工四分支血管可应用于主动脉外科,能达到尽可能的缩短主动脉阻断时间和快速重建血管的目的。     

Aortic valve sparing operations: an update

Background. Aortic valve sparing operations in patients with ascending aorta and/or aortic root aneurysms have been performed for a decade in our institution. Initially only patients with normal aortic valve leaflets had these operations, but more recently we utilized them in patients with prolapse of a single leaflet and in those with a bicuspid aortic valve. This article is an update on the clinical results of these operations.

Methods. From May 1988 to December 1997, 126 patients with ascending aorta and/or aortic root aneurysms and aortic insufficiency underwent replacement of the ascending aorta with reconstruction of the aortic root and preservation of the native aortic valve. There were 85 men and 41 women, with a mean age of 54 years (range, 14 to 84). Thirty-two patients had the Marfan syndrome; 17 patients had acute and 10 had chronic type A aortic dissection; 23 had a transverse arch aneurysm; 26 had coronary artery disease, and 8 had mitral regurgitation. The aortic valve sparing operation consisted of simple adjustment of the sinotubular junction in 33 patients, adjustment of the sinotubular junction and replacement of one or more aortic sinuses in 60, and reimplantation of the aortic valve in a tubular Dacron (C.R. Bard, Haverhill, PA) graft in 33. Fifteen patients also had repair of aortic leaflet prolapse. Only 4 patients had a bicuspid aortic valve.

Results. There were 3 operative deaths due to cardiac failure. Patients were followed from 2 to 117 months, with a mean of 31. There were 11 late deaths: 7 cardiovascular and 4 from unrelated causes. The actuarial survival was 72 ± 8% at 7 years. Two patients required aortic valve replacement; the freedom from aortic valve replacement was 97 ± 2% at 7 years. Doppler echocardiography revealed absent, trivial or mild aortic insufficiency in most patients; only 9 patients had moderate aortic insufficiency.

Conclusions. Aortic valve sparing operations are feasible in most patients with ascending aorta and/or aortic root aneurysms who have normal or near normal aortic leaflets. The functional results of the repaired aortic valve are excellent, and the repair appears to be durable.     

The Damus-Stansel-Kaye procedure: anatomical determinants and modifications

Seven of 119 patients undergoing anatomical correction for transposition of the great arteries and Taussig-Bing anomalies without pulmonary stenosis had the Damus-Stansel-Kaye procedure and the rest, the arterial switch. The age of the patients having the Damus-Stansel-Kaye procedure ranged from 0.5 year to 5 years (mean age, 2.2 +/- 1 years). Four patients had transposition, 2 had Taussig-Bing anomaly, and 1 had corrected transposition. Indications for the Damus-Stansel-Kaye procedure were side-by-side great arteries associated with difficult coronary anatomy (5 patients), single coronary system (1 patient), and subaortic stenosis (1). A graft between the ascending and descending aorta for interrupted aortic arch made mobilization and posterior displacement of the ascending aorta for the arterial switch difficult. Subaortic stenosis (1 patient), subpulmonary ventricular septal defect (2 patients), and restrictive ventricular septal defect (4) precluded the Rastelli procedure. In 6 patients, the main pulmonary artery was transected at the band, a proximal main pulmonary artery to aorta anastomosis was complemented with a synthetic patch, and a right ventricle to distal main pulmonary artery valved conduit was inserted. Four patients had closure of the aortic outflow. Two patients had postoperative bleeding and 2, heart block. The only patient who did not have transection of the main pulmonary artery, an omission that led to an obstructed conduit at the distal anastomosis, died late. Two patients subsequently needed aortic outflow closure for critical aortic insufficiency. The Damus-Stansel-Kaye procedure has a definite role and can be safely performed in patients with transposition of the great arteries and Taussig-Bing anomalies.(ABSTRACT TRUNCATED AT 250 WORDS)