主动脉瓣环扩大联合环上瓣置换术治疗成人小瓣环主动脉瓣狭窄近中期疗效分析

目的评价主动脉瓣环扩大联合环上瓣置换术治疗成人小瓣环主动脉瓣狭窄的近中期结果。方法对2007年1月至2011年7月北京安贞医院心外科38例成人小瓣环主动脉瓣狭窄患者行主动脉瓣环扩大后植入环上型人工瓣膜,男12例、女26例,年龄16~58（38.6±21.0）岁,体重48~78（58.5±12.0）kg,身高153~176（162.8±12.0）cm,体表面积（1.67±0.32）m2。风湿性主动脉瓣狭窄19例,先天性主动脉瓣二叶瓣畸形合并狭窄11例,主动脉瓣退行性钙化伴狭窄5例,主动脉瓣狭窄合并感染性心内膜炎3例。入院时心功能分级（NYHA）Ⅱ级8例,Ⅲ级29例,Ⅳ级1例。主动脉瓣环内径15~20（17.6±2.8）mm,平均跨瓣压差53~75（62.8±10.5）mm Hg。结果体外循环时间83~145（112±29）min,升主动脉阻断时间58~116（87±28）min,手术中测瓣器测得主动脉瓣环径15~20（17.3±2.6）mm,扩大瓣环后测瓣器测得瓣环径20~25（22.6±2.3）mm,主动脉瓣环周径增加12~17（14.0±2.6）mm,植入瓣膜增加2~3个标号。无围手术期死亡,无出血等严重并发症。住ICU时间12~41（26±14）h,总住院时间9~15（12.5±3.2）d。37例（97.4%）门诊随访2年以上,所有患者心功能分级（NYHA）Ⅰ级,3例主动脉瓣听诊区存在2/6级收缩期杂音。35例心电图显示左心室肥厚心电图表现显著改善或消失,2例表现为左心室轻度肥厚劳损,无明显心肌缺血表现,无室性心律失常及严重房室传导阻滞。结论主动脉瓣环扩大联合环上瓣置换术治疗成人小瓣环主动脉瓣狭窄近中期效果满意,远期结果有待进一步随访。

Early and Midterm Results of Aortic Root Enlargement Combined with Supra-annular Valve Implantation for Adult Patients with Aortic Stenosis and Small Aortic Root

Objective To evaluate early and midterm outcomes of aortic root enlargement （ARE） combined with supra-annular valve implantation for adult patients with aortic stenosis （AS） and small aortic roots （SARs）. Methods From January 2007 to July 2011, ARE combined with supra-annular valve implantation was performed for 38 adult patients with AS and SARs in Department of Cardiac Surgery of Beijing Anzhen Hospital There were 12 males and 26 females with their age of 16-58 （ 38.6 ± 21.0） years, body weight of 48-78 （ 58.5 ±12.0） kg, body height of 153-176 （ 162.8 ±12.0 ） cm and a mean body surface area （BSA） of 1.67±0.32 m2. There were 19 patients with rheumatic AS, 11 patients with congenital bicuspid aortic valve and AS, 5 patients with degenerative AS and 3 patients with AS and infective endocarditis. Preopera- tively, 8 patients were in NYHA class 11,29 patients were in NYHA class HI, and 1 patient was in NYHA class 1V. Aortic annular diameter （AAD） was 15-20 （ 17.6± 2.8 ） mm and trans-aortic pressure gradient was 53-75 （62.8 ±10.5 ） mm Hg. Results Cardiopulmonary bypass time was 83-145 （ 112 ± 29） minutes, and aortic cross-clamping time was 58-116 （ 87± 28 ） minutes. Intraoperative measurement of AAD was 15-20 （ 17.3 ±2.6 ） mm, AAD after ARE was 20-25 （22.6 ± 2.3 ） mm. AAD after ARE was 12-17 （ 14.0 ± 2.6） mm larger than AAD before ARE. Actual size of prosthetic valves was 2-3 sizes larger than predicted size without ARE in all the patients. There was no perioperative death or severe complication including bleeding. Length of ICU stay was 12-41 （26± 14） hours, and length of hospital stay was 9-15 （ 12.5±3.2） days. A total of 37 patients （97.4%） were followed up for over 2 years after discharge. All the patients were in NYHA class I . Grade 2/6 systolic murmur was heard in 3 patients. Electrocardiogram （ECG） showed significant improvement or complete disappearance of left ventricular hypertrophy in 35 patients, and mild left ventri