升主动脉成形术中期效果分析

目的 分析升主动脉成形术治疗主动脉瓣病变伴升主动脉扩张病人的中期随访结果并总结其临床经验.方法 1996年10月至2007年4月对54例主动脉瓣病变伴升主动脉扩张的病人行主动脉瓣膜置换和升主动脉成形术,术后随访13～96个月,平均(23±16)个月.分别于术前、出院前及术后随访中,通过心脏超声检查测量升主动脉直径.结果 围术期死亡2例.术前升主动脉直径(45.77±6.02)mm与出院前升主动脉直径(34.67±4.81)mm二者比较差异有统计学意义(P<0.01).术后随访升主动脉直径(37.65±6.35)砌与术前及术后出院前比较差异亦均有统计学意义(P<0.01).单纯主动脉瓣狭窄的基础病变和术后出院前升主动脉直径大于40mm是升主动脉再扩张的独立风险因素.结论 升主动脉成形术中未用人工血管包裹治疗主动脉瓣病变伴升主动脉扩张或者升主动脉瘤的中期疗效欠佳.单纯主动脉瓣狭窄是这种术式的适应证,成形术必须将主动脉直径减至40mm以下,以减少远期再扩张.     

无包裹-纵切口升主动脉成形术治疗升主动脉扩张的疗效分析

目的探讨无包裹-纵切口升主动脉成形术治疗升主动脉扩张的临床疗效。方法 2005年9月-2011年5月,对53例主动脉瓣病变伴升主动脉扩张患者行主动脉瓣置换加无包裹-纵切口升主动脉成形术治疗。男41例,女12例;年龄22～75岁,平均52岁。病程1个月～14年。心脏彩色超声多普勒检查示术前升主动脉直径为(45.9±3.3)mm;主动脉瓣三叶瓣40例,主动脉瓣二叶畸形13例。心功能根据纽约心脏病协会(NYHA)分级标准:Ⅱ级19例,Ⅲ级33例,Ⅳ级1例。结果术后发生1例纵隔广泛渗血、3例肺部感染、1例Ⅲ度房室传导阻滞。患者均无升主动脉成形术相关并发症。53例均获随访,随访时间3～68个月,平均15个月。患者均无明显胸闷、心累。末次随访时心功能NYHA分级Ⅰ级22例,Ⅱ级31例。升主动脉直径为(35.2±4.0)mm,与术前比较差异有统计学意义(P=0.000);与术后出院时(34.0±2.5)mm比较差异无统计学意义(P=0.245)。其中,随访时间≥60个月者末次随访时升主动脉直径与术前、术后出院时比较,差异均有统计学意义(P<0.05);主动脉瓣二叶畸形患者末次随访时升主动脉直径与术前比较差异有统计学意义(P<0.05);术前升主动脉直径>50 mm患者末次随访时升主动脉直径与术前比较,差异无统计学意义(P>0.05)。结论无包裹-纵切口升主动脉成形术治疗主动脉瓣病变伴升主动脉轻-中度(直径范围40～50 mm)扩张患者可获得较好早中期疗效,但应严格选择患者,远期效果需进一步随访观察。     

升主动脉成形术的早中期临床结果分析

目的分析升主动脉成形术治疗主动脉瓣病变伴升主动脉扩张患者的临床随访结果,总结其临床经验,以提高治疗效果。方法回顾性分析2002年1月至2010年8月北京阜外心血管病医院36例主动脉瓣病变伴升主动脉扩张患者行主动脉瓣置换和升主动脉成形术的临床资料,其中男26例、女10例,年龄7~72（51±16）岁。分别于术前、术后出院前及随访中通过心脏超声心动图检查测量升主动脉直径,并进行比较。结果无围术期死亡。体外循环时间（96.2±28.3）min,主动脉阻断时间（69.2±22.1）min,术后住院时间（11.0±7.8）d。36例患者全部进行随访,术后随访1.1~9.0（4.0±2.3）年,随访期间死亡1例,无二次手术患者。心脏超声心动图提示：主动脉瓣功能正常,术后升主动脉直径较术前减小[（36.4±6.1）mm vs.（46.8±4.6）mm,t=13.12,P=0.00];随访期间升主动脉直径与术后相比有所增加[（40.8±6.8）mm vs.（36.4±6.1）mm,t=-2.64,P=0.01],与术前相比减小[（40.8±6.8）mm vs.（46.8±4.6）mm,t=3.48,P=0.00]。结论升主动脉成形术治疗主动脉瓣病变伴升主动脉扩张患者可获得较好的早中期疗效,但远期效果需进一步随访观察。     

主动脉成形术治疗主动脉瓣病变伴升主动脉扩张的疗效分析

目的总结主动脉成形术治疗主动脉瓣病变伴升主动脉扩张患者的临床经验及疗效。方法1998年2月至2004年5月共对23例主动脉瓣病变伴升主动脉扩张的患者行主动脉瓣膜置换和纵行切除部分升主动脉壁的主动脉成形术,术后随访4～78个月,平均(36±25)个月,分别于术前、术后出院前及术后随访中,通过心脏超声检查测量主动脉直径。结果主动脉直径术前为(4.8±0.5)cm,术后出院前为(3.6±0.4)cm,两者比较差异有统计学意义(P<0.01)。术后随访中,主动脉直径为(3.7±0.4)cm,与术前比较差异有统计学意义(P<0.01),与术后出院前比较差异无统计学意义(P>0.05)。结论应用切除部分升主动脉壁的主动脉成形术治疗主动脉瓣病变伴升主动脉扩张或升主动脉瘤,中期疗效良好。     

二叶式主动脉瓣合并升主动脉扩张的外科治疗:升主动脉置换还是成形?

目的比较升主动脉置换和成形对二叶式主动脉瓣合并升主动脉扩张患者的近中期疗效。方法从2007年3月至2014年4月,南京市心血管病医院共对70例二叶式主动脉瓣(bicuspid aortic valve,BAV)合并升主动脉扩张的患者进行了手术治疗。回顾性分析这一临床资料根据升主动脉的处理方式,将他们分为两组:升主动脉成形组(A组),共37例,其中男28例、女9例,年龄(58.68±8.01)岁;主动脉置换组(B组),共33例,其中男25例、女8例,年龄(54.18±11.97)岁,出院后进行随访。比较A、B两组的围术期临床资料以及近中期的随访结果。结果A组患者的体外循环时间、主动脉阻断时间、住ICU时间均比B组短,其差异有统计学意义[(105.19±11.17)min vs.(180.94±32.10)min,P=0.000;(78.65±13.18)min vs.(110.24±29.64)min,P=0.000;(1.62±1.09)d vs,(3.58±2.89)d,P=0.001]。术后死亡2例,其余68例患者顺利出院。两组患者的总存活率差异无统计学意义(P=0.582)。术后随访结果显示:A、B两组患者的升主动脉直径均比他们各自术前的升主动脉直径明显缩小;A组患者的最后随访升主动脉直径较出院前有所增加,差异有统计学意义[(38.50±1.77)mm vs。(34.85±1.53)mm,P=0.0071;而B组患者则无变化。结论对于BAV合并升主动脉扩张的患者,需要同时对升主动脉进行处理;血管成形和置换均可以达到满意的近中期效果。     

主动脉瓣置换术后升主动脉瘤形成的外科治疗

目的 总结主动脉瓣置换术后升主动脉瘤形成的外科治疗经验。 方法 2008年10月至2013年4月郑州大学第一附属医院收治6例主动脉瓣置换术后升主动脉瘤形成患者,其中男2例,女4例;年龄45～63（56.5±3.2） 岁。主动脉瓣置换术后44～82 （59.5±24.3） 个月,均为单纯人工机械主动脉瓣置换术后。5例行单纯升主动脉置换术,1例行David手术。 结果 体外循环时间140～270 （185.2±90.1） min,升主动脉阻断时间60～220 （121.9±78.6） min。6例患者均康复出院。术后将血压控制于120/90 mm Hg以下,应用华法林,维持国际标准化比值（INR） 1.5～2.5。术后均给予琥珀酸美托洛尔25 mg ,每天2次。出院前复查彩色超声心动图（UCG）示：升主动脉内经28～30 mm。术后对6例患者随访3～12个月,门诊复查UCG示：人工血管内径较出院时无明显改变。 结论 主动脉瓣置换术后患者应定期复查UCG,对主动脉内经呈进行性增宽或主动脉瘤形成患者应及早行外科手术治疗。     

急性主动脉夹层累及根部的外科治疗

目的探讨Stanford A型急性主动脉夹层累及根部的手术治疗策略。方法上海交通大学医学院附属仁济医院自2005年1月至2010年12月,共62例Stanford A型急性主动脉夹层累及根部的患者接受手术治疗。根据对夹层近心端采用的不同手术处理方法分为3组,A组:28例,男20例、女8例,年龄(45.2±15.6)岁;行主动脉瓣交界悬吊+升主动脉置换术;B组:10例,男7例、女3例,年龄(44.6±14.9)岁;行部分窦部成形+升主动脉置换术;C组:24例,男17例、女7例,年龄(46.2±15.6)岁;行Bentall手术。比较分析3组患者的临床效果。结果围术期死亡6例,病死率为9.67%(6/62)。共随访54例,随访(27.3±15.7)个月。随访期间死亡2例,1例死亡原因不明,1例死于肺癌。A组1例患者术后6个月复查CT显示主动脉窦部假性动脉瘤。C组体外循环时间、主动脉阻断时间明显较A组和B组长[(274±97)min vs.(194±65)min、(210±77)min,t=22.482,30.419,P=0.002,0.122;(150±56)min vs.(97±33)min、(105±46)min,t=12.630,17.089,P=0.000,0.034]。3组患者的住院死亡率(t=1.352,P=0.516)及围术期二次开胸、急性肾损伤、神经系统并发症发生情况差异无统计学意义(t=0.855,0.342,2.281;P=0.652,0.863,0.320)。结论针对急性主动脉夹层病变累及根部的手术治疗可以采用主动脉瓣交界悬吊+升主动脉置换术、部分窦部成形+升主动脉置换术和Bentall手术等方法,并各有其优缺点。掌握每种方法的手术指征,灵活运用,可以获得满意的临床效果。     

114例升主动脉瘤的外科治疗

目的　总结升主动脉瘤手术治疗的经验 ,并分析探讨其相关的问题。　方法　对 114例升主动脉瘤患者(其中 6 2例伴升主动脉夹层分离 )施行了手术治疗。 10 5例升主动脉瘤伴主动脉瓣关闭不全患者行 Bentall手术 (升主动脉和主动脉瓣置换术以及冠状动脉开口移植术 ) ,其余 9例患者仅行升主动脉置换术。　结果　手术死亡 7例(6 .14 % ) ,其中 6例为术前心功能 (NYHA) 级患者。随访 10 7例 ,随访时间 7天～ 12 .4年 (40± 30月 ) ,死亡 8例 ,死于颅内出血 3例 ,腹内动脉瘤破裂出血 3例 ,急症冠状动脉旁路移植术 1例 ,原因不明猝死 1例。存活的 99例(86 .8% )情况良好 ,心功能为 、 级。　结论　主动脉置换术治疗升主动脉瘤、Bentall手术治疗升主动脉瘤合并主动脉瓣关闭不全 ,术后可使大多数存活患者获得良好的功能恢复和生活质量 ,手术效果满意。     

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。     

alpha-1抗胰蛋白酶在升主动脉夹层及瘤样扩张血管组织中的表达

目的 观察正常升主动脉、升主动脉瘤样扩张及Stanford A型夹层动脉瘤(TAAD)患者升主动脉血管组织中alpha-1抗胰蛋白酶表达的差异,探讨alpha-1抗胰蛋白酶对于维持升主动脉血管结构完整性中的作用.方法 收集28例升主动脉血管组织标本,TAAD 14例,升主动脉瘤样扩张7例,心脏移植供体心脏升主动脉7例.采用组织学、逆转录-聚合酶链反应(RT-PCR)法及Western blot 法对标本组织中的alpha-1抗胰蛋白酶进行检测分析.结果 在基因水平上,alpha-1抗胰蛋白酶在升主动脉瘤样扩张中表达最高,正常血管组织中表达次之,TAAD患者升主动脉中表达最低(2.192±0.133、1.213±0.156、0.672±0.101,P<0.05).在蛋白水平上,alpha-1抗胰蛋白酶在升主动脉瘤样扩张中表达明显升高,TAAD患者升主动脉中表达次之,正常血管组织中最低(0.285±0.010、0.153±0.011、0.102±0.010,P<0.05).结论 alpha-1抗胰蛋白酶在正常人、升主动脉瘤样扩张及TAAD患者升主动脉血管组织均有表达,表达差异有统计学意义.alpha-1抗胰蛋白酶对于维持升主动脉血管结构的完整性具有潜在的保护作用.     

Surgical approach to ascending aorta in bicuspid aortic valve

OBJECTIVE: Former studies have pointed out that hemodynamic stress imposed by associated valvular disease is the primary factor in the development of ascending aorta dilatation. At present, intrinsic wall pathology is blamed for dilatation and aneurysm formation in bicuspid aortic valve (BAV). MATERIALS AND METHODS: Aortic valve replacement (AVR) was performed on 78 adult patients with BAV. Patients were divided into two groups. Group I (n = 27) underwent only AVR. Group II (n = 51) underwent AVR and additional ascending aorta procedures such as Shawl-Lapel aortoplasty (n = 12) and tailoring aortoplasty (n = 9). Dacron wrapping was performed after both techniques were done. Ascending aorta replacement was done on 11 patients by using composite graft. Supracoronary graft replacement was performed in 3 patients after AVR. RESULTS: Ascending aorta diameter increment was 1.25 mm/year in normotensive and 2.80 mm/ year in hypertensive patients. Ascending aorta aneurysm (diameter > 55 mm) developed in eight patients in the postoperative period in group I. Ascending aorta dilatation did not develop in group II patients. Mean survival time +/- standard error (SE) was 128 +/- 11 and 99 +/- 4 months and survival possibility was 77.78% and 92.16%. Freedom from reoperation was 65.4% and 95.9% in 8 years in group I and group II, respectively. CONCLUSION: Aortic wrapping with or without aortoplasty has a beneficial effect not only in dilated ascending aorta but also in all nondilated BAV patients with normal-sized aortic diameter. Ascending aorta wrapping in BAV patients preserves the endothelial lining and prevents further dilatation, aneurysm formation, and dissection.     

Repair of an ascending aortic aneurysm using reduction aortoplasty in a Jehovah's Witness

Reduction ascending aortoplasty has been advocated as a possible alternative to traditional graft replacement for treatment of aneurysms of the ascending aorta and root. We report a case of a 58-year-old Jehovah's Witness female, with a 5.5-cm ascending aortic aneurysm and critical aortic stenosis. She underwent aortic valve replacement and reduction aortoplasty buttressed with a Dacron graft. We reviewed the history and contemporary applications of this technique and concluded that aortic reduction with externally supported aortoplasty may represent a viable option to treat Jehovah's Witness patients with ascending aorta and root aneurysm.     

Effects of ascending aorta replacement on aortic root dilatation.

OBJECTIVE: Because of an increase of aortic root wall stress, prosthetic replacement of the ascending aorta might be a risk factor for the progressive increase of the aortic root dimension. Aim of the present study was to evaluate the aortic root diameter change and the progression of aortic valve regurgitation late after ascending aorta replacement for different ethiology. METHODS: Sixty-three late survivors after supracoronary ascending aortic replacement were evaluated. Forty-one patients were operated on for acute aortic dissecting aneurysm (group I) and 22 for chronic atherosclerotic non-dissecting aneurysm (group II). Aortic root diameter and aortic valve regurgitation were assessed echocardiografically after a mean follow-up of 63+/-31 months and were compared with those early after surgery. RESULTS: Seven patients of group I (17%) needed reoperation for aortic root dilatation or dissection. Twenty-five percent of the patients (15 of group I and 1 of group II) showed at least a 10% increase in aortic root diameter at follow-up (46.8+/-6.1 vs. 38.1+/-6.1mm, P<0.0001). Aortic root diameter increased almost exclusively in patients operated on for acute dissecting aneurysm. A significant worsening of aortic valve insufficiency with time was evident only in patients operated on for acute dissecting aneurysm with an higher incidence in those with progressive root dilatation. CONCLUSIONS: Both the increase of aortic root diameter and the progressive worsening of aortic valve insufficiency seem to justify a more aggressive treatment of the aortic root at the time of surgery for acute aortic dissecting aneurysm but not for chronic atherosclerotic non-dissecting aneurysms.     

A case of combined operation of aortic valve slicing and root remodeling for ascending aortic aneurysm with aortic regurgitation]

A 56-year-old female admitted with severe back pain, and her chest computed tomography demonstrated non-dissecting sclerotic aneurysm of the ascending aorta. Aortography and echocardiography showed marked dilatation of the ascending aorta and the Valsalva sinuses resulting in disappearance of the sinotubular junction. Aortic regurgitation of grade three was, also, recognized. A combined operation of aortic valve slicing of the right and the left coronary cusps and aortic root remodeling (Yacoub's method) was successfully performed. A woven Dacron double-veloured graft (Hemashield) of 22 mm in diameter was used for reconstruction of the ascending aorta and its root. Postoperative aortography figured the new sinotubular junction and the new Valsalva-like sinus composed by the graft, and aortic regurgitation was controlled to grade one.     

升主动脉瘤合并主动脉瓣关闭不全的外科治疗

目的总结21例升主动脉瘤合并主动脉瓣关闭不全的外科治疗经验。方法19例行Bentall手术,2例行Cabrol手术;5例同时置换二尖瓣。术前心功能IV级15例,III级6例。动脉瘤直径6～11 cm,平均(8.5±2.6) cm;17例主动脉内膜有撕裂,其中5例升主动脉远端仍有夹层。主动脉瓣环直径2.7～5.4 cm,平均(3.2±1.8）cm。超声心动图检查均示主动脉瓣严重关闭不全。结果手术后无早、晚期死亡,术后超声心动图和造影检查示主动脉瓣关闭良好,移植的冠状动脉通畅、无扭曲,效果满意。结论动脉瘤直径大于6 cm时应及时随访和做预防性手术,一旦发现夹层动脉瘤应立即手术,Bentall手术治疗升主动脉瘤效果良好。     

Ross procedure for ascending aortic replacement

Background. Patients with aortic valve disease and aneurysm or dilatation of the ascending aorta require both aortic valve replacement and treatment of their ascending aortic disease. In children and young adults, the Ross operation is preferred when the aortic valve requires replacement, but the efficacy of extending this operation to include replacement of the ascending aorta or reduction of the dilated aorta has not been tested.

Methods. We reviewed the medical records of 18 (5.9%) patients with aortic valve disease and an ascending aortic aneurysm and 26 (8.5%) patients with dilation of the ascending aorta, subgroups of 307 patients who had a Ross operation between August 1986 and February 1998. We examined operative and midterm results, including recent echocardiographic assessment of autograft valve function and ability of the autograft root and ascending aortic repair or replacement to maintain normal structural integrity.

Results. There was one operative death (2%) related to a perioperative stroke. Forty-two of 43 survivors have normal autograft valve function, with trace to mild autograft valve insufficiency, and one patient has moderate insufficiency at the most recent echocardiographic evaluation. None of the patients has dilatation of the autograft root or of the replaced or reduced ascending aorta.

Conclusions. Early results with extension of the Ross operation to include replacement of an ascending aortic aneurysm or vertical aortoplasty for reduction of a dilated ascending aorta are excellent, with autograft valve function equal to that seen in similar patients without ascending aortic disease.     

Is size-reducing ascending aortoplasty with external reinforcement an option in modern aortic surgery?

OBJECTIVE: Enlargement of the ascending aorta is often combined with valvular, coronary, or other cardiac diseases. Reduction aortoplasty can be an optional therapy; however, indications regarding the diameter of aorta, the history of dilatation (poststenosis, bicuspid aortic valve), or the intraoperative management (wall excision, reduction suture, external reinforcement) are not established. METHODS: In a retrospective study between 1997 and 2005, we investigated 531 patients operated for aneurysm or ectasia of the ascending aorta (diameter: 45-76mm). Of these, in 50 patients, size-reducing ascending aortoplasty was performed. External reinforcement with a non-coated dacron prosthesis was added in order to stabilize the aortic wall. RESULTS: Aortoplasty was associated with aortic valve replacement in 47 cases (35 mechanical vs 12 biological), subvalvular myectomy in 29 cases, and CABG in 13 cases. The procedure was performed with low hospital mortality (2%) and a low postoperative morbidity. Computertomographic and echocardiographic diameters were significantly smaller after reduction (55.8+/-9mm down to 40.51+/-6.2mm (CT), p<0.002; 54.1+/-6.7mm preoperatively down to 38.7+/-7.1mm (echocardiography), p<0.002), with stable performance in long-term follow-up (mean follow-up time: 70 months). CONCLUSIONS: As demonstrated in this study, size reduction of the ascending aorta using aortoplasty with external reinforcement is a safe procedure with excellent long-term results. It is a therapeutic option in modern aortic surgery in patients with poststenotic dilatation of the aorta without impairment of the sinotubular junction of the aortic valve and root.