主动脉瓣下狭窄的外科治疗

目的：总结42例主动脉瓣下狭窄的手术治疗体会,探讨各种不同病变分型的较好手术方式。方法：本组42例中男27例,女15例;年龄2～38岁,平均13．6岁。均经超声心动图及术中证实为主动脉瓣下狭窄,其中纤维隔膜型28例,纤维肌隔型11例,管状型3例。分别行狭窄隔膜切除、纤维肌隔及部分左室肌肉切除和左室流出道跨瓣扩大成形 主动脉瓣置换治疗。合并畸形29例,同期行矫治手术。结果：本组无手术死亡,经观察疗效满意。结论：主动脉瓣下狭窄临床诊断一旦确立,应尽早手术;术前超声心动图检查及术中常规主动脉根部探查,对防止有合并畸形时本病的漏诊尤为重要;经室间隔缺损手术径路具有操作简便、避免损伤冠状动脉及主动脉瓣的优点;手术要求彻底疏通左室流出道;术中应尽量避免对二尖瓣、主动脉瓣及传导束的损伤。     

主动脉瓣下狭窄的外科治疗

先天性主动脉瓣下狭窄是少见的先天性心脏畸形。１９８６年－１９９４年收治了６例该病患才，其中５例隔膜型狭窄、１例最性心肌病狭窄，均进行了手术治疗，无手术死亡；除１例术后并发室上性心动迂速外，无其他并发症。术后患得恢复良好，平均随诊４９个月，效果优良。认为只要对该病病理解剖了解清楚，手术时操作仔细，手术治疗是安全可行的方法。     

外科治疗主动脉瓣下狭窄的疗效分析

目的 探讨手术治疗主动脉瓣下狭窄的临床疗效.方法 1996年12月至2009年10月在我中心接受手术治疗的58例主动脉瓣下狭窄的患者,其中男性35 例,女性23 例;年龄1～49 (15.9±5.7)岁.局限型主动脉瓣下狭窄56 例(纤维隔膜型33 例、纤维肌隔型21 例),隧道型主动脉瓣下狭窄2 例.局限型行狭窄隔...     

手术治疗主动脉瓣下狭窄11例

目的总结主动脉瓣下狭窄的外科治疗经验。方法回顾性分析11例2006年4月至2012年11月在河南省人民医院心血管外科行主动脉瓣下狭窄疏通术患者的临床资料,并对患者治疗情况随访10～78个月,观察患者的治疗效果及并发症发生情况。结果11例患者中围术期死亡1例,死于术后低心排血量综合征,余患者均恢复良好。所有患者无房室传导阻滞、瓣周漏、残余漏等严重术后并发症。2例患者术后残余轻微主动脉瓣听诊区收缩期I一Ⅱ／6级杂音,但无需再次手术治疗。随访10～78个月,除失访1例外其余患者心功能均达到美国纽约心脏病学会心功能分级I一Ⅱ级,工作生活均未受明显影响。结论主动脉瓣下狭窄一旦确诊,应尽快手术;手术效果的关键是术中彻底疏通左心室流出道,同时应避免损伤传导束和切穿室间隔。     

局限型主动脉瓣下狭窄的外科治疗

目的总结局限型主动脉瓣下狭窄外科手术治疗的临床经验。方法1999年7月～2002年12月我院共手术治疗14例局限型主动脉瓣下狭窄,患儿平均年龄为(5.14±3.92)岁。所有患儿均合并其他心脏畸形,并同期纠治合并畸形;均在体外循环下行瓣下纤维狭窄切除术,其中2例分别加行左室流出道部分肌肉切开术和肌肉切除术。结果本组无一例发生手术并发症和死亡,术后左室流出道残余压差较术前明显下降(P<0.001),手术前、后主动脉瓣返流程度的差异无显著性。平均随访17.8个月,无一例狭窄复发。结论局限型主动脉瓣下狭窄不是一种简单的良性病变;纤维嵴切除加部分肌肉切开和(或)切除术可有效治疗主动脉瓣下狭窄;术中彻底解除狭窄可预防狭窄复发。     

儿童主动脉瓣上狭窄的外科治疗

目的总结先天性主动脉瓣上狭窄(SVAS)外科治疗体会。方法选择2003年3月至2010年5月收治的7例SVAS患儿,均在体外循环下以自体心包片用单片法加宽主动脉。结果 7例患儿体外循环时间61～98min,平均(75.9±12.2)min;主动脉阻断时间35～63min,平均(46.2±9.7)min。本组手术无严重并发症及死亡,术后超声心动图检查左室——主动脉压差10～21mmHg,平均(13.3±3.8)mmHg,无主动脉瓣关闭不全。结论主动脉单片法加宽治疗局限性SVAS可以获得理想的治疗效果。对William综合征患儿术前应进行更为详细的检查,了解是否合并其他心血管畸形。     

主动脉瓣上狭窄13例的外科治疗

目的 总结先天性主动脉瓣上狭窄(SVAS)术前诊断和外科治疗中的经验.方法 2005年1月-2011年6月收治SVAS患者13例,男8例,女5例,年龄1.9～19.0岁,平均(5.73±6.36)岁,局限性狭窄11例(84.6％),弥漫性狭窄2例(15.4％).Williams综合征4例(30.7％),9例合并其他心脏畸形,包括主动脉瓣狭窄3例,主动脉瓣关闭不全2例,冠状动脉畸形1例,合并动脉导管未闭1例,2例合并肺动脉狭窄,术前超声心动图检查漏诊1例,并发主动脉瓣狭窄.单片法加宽9例,倒“Y”法2例,三片法2例.结果 本组手术早期死亡2例,其余患者痊愈出院.局限型SVAS狭窄解除满意,压差降至0～20mmHg;弥漫型效果不佳,1例术后随访3年仍有轻到中度狭窄,目前仍在随访中.11例术后随访1个月～5年平均随访3.5年,心功能Ⅰ级10例,1Ⅱ级1例;随访无假性动脉瘤形成.结论 局限性主动脉瓣上狭窄的手术治疗效果良好,弥漫型手术治疗效果不佳,应谨慎选择手术治疗.     

主动脉瓣上狭窄的外科治疗(附一例报告)

主动脉瓣上狭窄是一种较为少见的先天性心血管畸形。我院于１９９７年成功地收治１例主动脉瓣上狭窄患者,对其诊治进行探讨。临床资料一、病例介绍患者男,１１岁。出生后１个月体检时发现心脏杂音,平时活动后心慌,气急。无紫钳和蹲踞史。活动耐力较同龄儿童差。体检：...     

主动脉瓣上隔膜型狭窄1例

1 病例介绍 患者,男,72岁.主诉:胸闷、气促5月,加重2天.查体:血压130/60mmHg,双肺呼吸音清晰,未闻及干湿啰音,心界向左增大,心率75次/分,律齐,主动脉瓣第一、第二听诊区闻及收缩期喷射性杂音及舒张期叹气样杂音.     

主动脉瓣狭窄治疗

正常主动脉瓣口面积为2.6～3.5c m2.轻度主动脉瓣狭窄对血流动力学影响不大,当瓣口面积减少到＜1 c m2时左心室排血明显受阻,为重度狭窄.在我国,风湿性心瓣膜病仍然是主动脉瓣狭窄的最主要原因之一,老年人退行性钙化病变和先天性二叶瓣畸形等所导致的主动脉瓣狭窄也逐渐增多.     

Transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis: a meta analysis

Background Transcatheter aortic valve implantation (TAVI) has emerged as the treatment choice for non-operable patients with severe symptomatic aortic stenosis (AS) and may be a good alternative to sur...     

国人主动脉瓣狭窄主动脉根部解剖的研究

目的:随着经导管主动脉瓣置换术的发展,了解主动脉根部的解剖对于主动脉瓣瓣膜支架的选择和减少并发症是非常必要的?方法:34例主动脉瓣狭窄患者及39例正常对照行双源CT(Dual Source CT,DSCT)及经胸心脏超声(transthoracic echocardiography,TTE)检查,DSCT在斜冠状面及矢状面分别测量收缩末期及舒张末期主动脉根部各径线,瓣环直径和左室流出道直径?超声测量主动脉根部及左室流出道直径,并且和DSCT测量值对比?结果:主动脉瓣狭窄组左冠状动脉(left coronary ostia,LCO)高度?右冠状动脉(right coronary ostia,RCO)高度?冠状窦(sinus of Valsalva,SV)直径?左右冠状窦高度与对照组相比,差异无统计学意义;主动脉瓣狭窄组瓣环(aortic annulus,AA)直径?主动脉窦和升主动脉连接处(Sino-Tubular Junction,STJ)直径?升主动脉 (ascending aorta,AO) 直径?左室流出道 (left ventricular outer tract,LVOT) 直径?主动脉瓣和二尖瓣之间纤维结构(continuity fibrous,CF)距离,室间隔 (interventricular septum,IVS) 厚度明显比对照组大(P < 0.05)?主动脉瓣狭窄组及对照组收缩末期AA?SV?STJ?AO直径?IVS厚度明显比舒张末期大(P < 0.05),收缩末期LVOT直径明显比舒张末期小(P < 0.05)?主动脉瓣狭窄组及对照组AA及LVOT直径冠状面测量值均大于矢状面测量值?主动脉根部直径(AA?SV?STJ?AO)TTE测量值与DSCT测量值相比,相关性好(相关系数分别为r = 0.84,r = 0.87,r = 0.82,r = 0.82),差异均有统计学意义(P < O.05)?结论:主动脉瓣狭窄患者主动脉根部扩张?左室流出道变长扩张?室间隔变厚及冠状动脉变异较大,由于TTE的诊断作用有限,因此经导管主动脉瓣置换患者术前进行DSCT检查对于瓣膜支架的选择及减少并发症有重要意义?     

非人工通气兔主动脉瓣上狭窄模型的建立及评价

目的探讨在非人工通气的条件下通过升主动脉缩窄的方法建立主动脉瓣上狭窄模型的可行性并进行评价。方法将20只新西兰大白兔完全随机分为升主动脉缩窄组(n=12)和假手术组(n=8)。在非人工通气的条件下,在主动脉近端根部结扎升主动脉,使其缩窄。假手术组只行开胸手术,不行升主动脉结扎。术后2、4、8、12、16、20、24周行超声心动图检查,测量心室内径及心功能。术后8、24周行光学显微镜及透射电子显微镜检查,观察心肌组织形态学改变。结果超声心动图检查示:升主动脉缩窄组术后8周时左室质量指数(left ventricular mass index,LVMI)明显增大[(2.30±0.11)mg/g],较术前[(1.02±0.05)mg/g]及假手术组[(0.98±0.01)mg/g]均有显著差异(P<0.01),左室短轴缩短率(fractional shortening,FS%)自术后4周始逐渐下降,术后24周时较术前降低了9.3%,有显著差异(P<0.01)。组织学检查示:心肌纤维排列紊乱,心肌细胞肥大,间质胶原纤维显著增生。结论通过非人工通气升主动脉缩窄的方法成功建立了兔主动脉瓣上狭窄的模型,该方法简单、有效、重...     

先天性主动脉瓣下狭窄的外科治疗

目的探讨先天性主动脉瓣下狭窄（congenital subvalvular aortic stenosis，CSAS）的临床特点及手术疗效。方法全组32例，男16例，女16例。年龄4～57岁，平均年龄31岁；纤维隔膜型24例，纤维肌束型6例，弥漫型2例；手术在体外循环下进行，单纯纤维隔膜切除24例，纤维隔膜切除并室间隔肌肉切除术7例，Kono术1例。主动脉瓣机械瓣置换术6例，主动脉瓣成形3例，主动脉瓣二尖瓣机械瓣替换1例，同期矫治其它合并畸形。结果术后无早期死亡。全部患者术后瓣下压差较术前显著下降，术前、后LVEDD，EF差异无显著性。全部病例随访，随访时间1～60个月。长期生存者，心功能恢复至Ⅰ级31例，Ⅱ级1例。结论CSAS一旦确诊，应尽早手术。手术关键要根据病理解剖特点彻底疏通左室流出道。     

Percutaneous balloon aortic valvuloplasty in the treatment of congenital valvu lar aortic stenosis in children

Objective To assess the effect of the balloon valvuloplasty for congenital valvular aortic stenosis (AS) in children.Methods A total of 27 (mean age 6.09 years) children with AS accepted the treatment of percutaneous balloon aortic valvuloplasty (PBAV).The ratios of balloon/valve were 0.95±0.08 for 19 cases of typical AS and 1.00±0.11 for 8 cases of hyp oplastic AS.The patients were evaluated by the gradients across aotic valves i n pre- and post-PBAV and by echocardiogram during the follow-up period.Results Fifteen of 19 （78.9%）cases of typical AS had a better outcome and the gradien t of the remaining 4 cases (26.7%) had increased after follow-up (ΔP&gt;50 mm Hg).Four of 8 (50.0%) cases of hypoplastic AS had satisfactory responses and the gradient of the remaining 3 cases (75.0%) rose.There was no moderate to s evere aortic insufficiency (AI). Conclusion The balloon aortic valvuloplasty provides safe and significant hemodynamic and c linical improvement in pediatric patients.The outcome of PBAV for typical AS is better than for hypoplastic AS.     

经导管主动脉瓣膜植入与常规主动脉瓣膜置换手术在多风险因素主动脉瓣狭窄患者中的应用

［摘要］ 目的评价经导管主动脉瓣膜植入（transcatheter aortic valve implantation,TAVI）与常规主动脉瓣膜置换在高风险因素患者中应用的安全性及效果。 方法选择主动脉瓣狭窄患者80例,按手术方式分为常规组47例、小切口组18例和TAVI组15例。常规组采用常规开胸主动脉瓣膜置换手术,小切口组采用胸骨上段小切口主动脉瓣膜置换手术,TAVI组采用全身麻醉非体外循环下TAVI。比较3组患者手术效果及并发症发生情况。 结果小切口组24 h引流量明显少于常规组（P＜0.01）。常规组和小切口组阻断时间差异无统计学意义（P＞0.05）。小切口组手术时间、呼吸机辅助通气时间、重症监护室（intensive care unit,ICU）停留时间短于常规组,术中出血量少于常规组（P＜0.01）;TAVI组手术时间、呼吸机辅助通气时间、ICU停留时间短于常规组和小切口组,术中出血量少于常规组和小切口组,平均动脉压（mean artery pressure,MAP)变化值大于常规组和小切口组,住院费用多于常规组和小切口组（P＜0.05或P＜0.01）。3组并发症发生率差异无统计学意义（P＞0.05）。 结论TAVI手术在治疗高风险因素的患者中较常规主动脉瓣膜置换手术安全性高,创伤小,并发症少,恢复快,值得临床推广应用。     

One-year results of transcatheter aortic valve implantation as an alternative treatment for severe aortic stenosis in high-risk patients

BackgroundAortic valve replacement (AVR) remains the gold standard treatment for symptomatic severe aortic stenosis (AS). For the past 10 years, transcatheter aortic valve implantation (TAVI) has been applied in patients with high surgical mortality and morbidity risks. The preliminary results of our TAVI patients are presented in this study.MethodsTen high-risk patients with severe AS, for AVR, were referred and accepted for TAVI in the 6 month period from May 2010 to October 2010. The patient age, logistic EuroSCORE, femoral arterial diameter, aorta annulus size, aorta valve area (AVA), mean aortic pressure gradient (MPG), as well as coronary angiography results were all collected. Six patients were treated via the transapical approach in March 2010, whereas the other four were treated with the transfemoral approach, according to their femoral artery diameter and arterial quality. This study focuses on the immediate, 1 month, 3 month, and 1 year results of TAVI.ResultsThe average age of the 10 patients receiving TAVI was 81.5 years. The mean calculated EuroSCORE was 28.3 ± 7.9%. The mean AVA was 0.61 ± 0.19 cm². The MPG was 48 ± 16 mmHg. The surgical technical success achieved 100%. There was no reported moderate to severe postoperative paravalvular aortic regurgitation, permanent complete atrioventricular block, major access site complication, or embolic stroke. Chronic renal failure, which necessitated permanent hemodialysis, developed in 10% of the patients. One acute myocardial infarction and one case of pneumonia developed postoperatively. The AVA was increased by 251%, whereas the MPG was decreased by 80% at the 3 month follow-up. The 30-day mortality rate was 10%. The all-cause 1-year mortality rate was 20%.ConclusionThis new technique and device requires greater caution and needs more practice to accumulate sufficient experience. The studied patients were very fragile, due to old age and multiple comorbidities. Our results are similar to findings of multicenter trials. With careful patient screening and selection, TAVI can be a promising treatment for high-risk severe AS patients.     

Incidence of coronary artery disease before valvular surgery in isolated severe aortic stenosis

Background Angina pectoris has been recognized as one of the principal symptoms of aortic valve stenosis （AS）,even in patients without significant coronary artery disease （CAD）.However,the incidence of angina pectoris and related CAD in such patients is controversial.There is continuing debate as to whether coronary angiography is necessary before aortic valve replacement （AVR） in patients with severe AS.The purpose of this study was to evaluate the incidence and predictors of CAD in patients with severe AS in a Korean population.Methods Data from all consecutive patients with severe AS undergoing AVR at a major tertiary cardiac and vascular center in Korea were entered in a prospective registry beginning in 1995.Clinical and echocardiographic follow-up data were recorded into the database annually.Significant CAD was defined as one or more major coronary arteries having an estimated narrowing of ≥70％ and left main coronary arteries having an estimated narrowing of ≥50％ on coronary angiography.We excluded patients with multiple valve disease,significant aortic regurgitation,or prior CAD or valve surgery.Results Totally 574 patients with severe AS （mean age,（65.9±9.6） years） were enrolled in this study.Significant CAD was found in 61 patients （10.6％）.Factors associated with increased likelihood of CAD were age,hypertension,diabetes mellitus,chronic renal failure,carotid disease,and aorta calcification.In Logistic regression analysis,the independent predictor of the presence of CAD was age （P=0.011）.The incidence of CAD increased significantly at 69.2 years of age.Having two risk factors for cardiovascular disease was the most useful cutoff to predict whether a patient was going to have significant CAD.Conclusions There was a low incidence of significant CAD in a population of Korean patients with severe AS.Therefore,coronary angiography before AVR will be considered in patients with multiple risk factors for cardiovascular disease or in patients more than 69 years of age with