Ross手术的临床应用

目的 :总结我院心外科Ross手术临床应用情况。方法 :8例患者均在全麻体外循环中度低温下进行 ,采用Ross手术方法治疗主动脉瓣病变 ,根据超声心动图检查结果分析手术前后患者的心内结构变化 ,血液动力学变化以及患者的心功能。结果 :全组患者无手术死亡率及并发症 ,术后主动脉瓣跨瓣压差在正常范围 ,为 6 6 5± 1 4 1mmHg,心功能 (NYHA)Ⅱ级 ;3例远期随访中有 1例术后 1年发生同种瓣霉菌性心内膜炎再次手术治疗 ,术后因低心排死亡 ;另 2例随访 8年 ,均存活良好 ,心功能均Ⅰ级 ,主动脉瓣轻度返流 ,左室内径正常、肺动脉瓣均功能良好。 5例近期患者随访 1～ 6个月 ,心功能Ⅰ～Ⅱ级 ,主动脉瓣、肺动脉瓣均功能良好。结论 :Ross手术是一种临床疗效好的矫治主动脉瓣病变的手术方法     

Clinical outcome and quality of life in octogenarians following transcatheter aortic valve implantation (TAVI) for symptomatic aortic stenosis

Objective

TAVI is the alternative option in pts with AS deemed ineligible for surgery. Although mortality and morbidity are measures to assess the effectiveness of treatments, quality of life (QOL) should be an additional target. We assessed clinical outcome and QOL in octogenarians following TAVI.

Design

All octogenarians with a risk profile considered by the Heart Team to be unacceptable for surgery entered in this registry. QOL was assessed by questionnaires concerning physical and psychic performance.

Patients

A hundred forty-five octogenarians (age: 84.7 ± 3.4 years; male: 48.3%) underwent TAVI for AS (97.2%) or isolated AR (2.8%). NYHA class: 2.8 ± 0.6; Logistic EuroScore: 26.1 ± 16.7; STS score: 9.2 ± 7.7.Echocardiographic assessments included AVA (0.77 ± 0.21 cm2), mean/peak gradients (54.5 ± 12.2/88 ± 19.5 mmHg), LVEF (21% = EF ≤ 40%), sPAP (43.1 ± 11.6 mmHg).

Interventions

All pts underwent successful TAVI using Edward-SAPIEN valve (71.2%) or Medtronic CoreValve (28.8%).

Main outcome measures

Rates of mortality at 30 days, 6 months and 1 year were 2.8%, 11.2% and 17.5%.

Results

At 16-month follow up, 85.5% survived showing improved NYHA class (2.8 ± 0.6 vs 1.5 ± 0.7; p < 0.001), decreased sPAP (43.1 ± 11.6 mmHg vs 37.1 ± 7.7 mmHg; p < 0.001) and increased LVEF in those with EF ≤ 40% (34.9 ± 6% vs 43.5 ± 14.4%; p = 0.006). Concerning QOL, 49% walked unassisted, 79% (39.5% among pts ≥ 85 years) reported self-awareness improvement; QOL was reported as “good” in 58% (31.4% among pts ≥ 85 years), “acceptable according to age” in 34% (16% among pts ≥ 85 years) and “bad” in 8%.

Conclusion

TAVI procedures improve clinical outcome and subjective health-related QOL in very elderly patients with symptomatic AS.     

应用自体肺动脉瓣置换病变主动脉瓣（附4例报告）

应用自体肺动脉瓣置换病变主动脉瓣、同种肺动脉瓣原拉重建右室流出道（Ross手术）治疗4例主动脉瓣病变患者,成功3例。1例主动脉瓣二瓣化畸形术后存在轻度主动脉瓣返流。超声心动图均提示主动脉根部及同种瓣良好。1例术中误伤自体肺动脉瓣,改机械瓣置换。认为用自体肺动脉瓣置换病变主动脉瓣效果满意,术中预防自体肺动脉瓣损伤和主动脉瓣返流是手术成功的关键,同种肺动脉瓣原位重建右室流出道可为常规选择的管道。     

Minimally invasive aortic valve surgery

Aortic valve disease is a prevalent disorder that affects approximately 2% of the general adult population. Surgical aortic valve replacement is the gold standard treatment for symptomatic patients. This treatment has demonstrably proven to be both safe and effective. Over the last few decades, in an attempt to reduce surgical trauma, different minimally invasive approaches for aortic valve replacement have been developed and are now being increasingly utilized. A narrative review of the literature was carried out to describe the surgical techniques for minimally invasive aortic valve surgery and report the results from different experienced centers. Minimally invasive aortic valve replacement is associated with low perioperative morbidity, mortality and a low conversion rate to full sternotomy. Long-term survival appears to be at least comparable to that reported for conventional full sternotomy. Minimally invasive aortic valve surgery, either with a partial upper sternotomy or a right anterior minithoracotomy provides early- and long-term benefits. Given these benefits, it may be considered the standard of care for isolated aortic valve disease.     

Percutaneous valved stent repair of a failed homograft: implications for the Ross procedure

A case of percutaneous pulmonary valve implantation following a failed homograft in the pulmonary position is reported. A 16-year-old boy developed infective endocarditis of his pulmonary homograft, which was implanted four years earlier during a Ross procedure for congenital aortic stenosis. Following successful medical therapy, the boy was symptomatic due to pulmonary stenosis and regurgitation. A 22 mm Melody valve (Medtronic, USA) was successfully implanted percutaneously. His symptoms resolved and he was discharged home one day after the procedure. Echocardiography at the six-month follow-up demonstrated a normally functioning pulmonary valve. Percutaneous pulmonary valve replacement may make the Ross procedure a more attractive option for patients with aortic stenosis, particularly in the pediatric population.     

Transcatheter aortic valve implantation: Current status and future perspectives

Although surgical aortic valve replacement is the standard therapy for severe aortic stenosis(AS),about one third of patients are considered inoperable due to unacceptable surgical risk.Under medical treatment alone these patients have a very poor prognosis with a mortality rate of 50%at 2 years.Transcatheter aortic valve implantation(TAVI)has been used in these patients,and has shown robust results in the only randomized clinical trial of severe AS treatment performed so far.In this review,we will focus on the two commercially available systems:Edwards SAPIEN valve and CoreValve Revalving system.Both systems have demonstrated success rates of over 90%with 30-d mortality rates below 10%in the most recent transfemoral TAVI studies.Moreover,long-term studies have shown that the valves have good haemodynamic performance.Some studies are currently exploring the non-inferiority of TAVI procedures vs conventional surgery in high-risk patients,and long-term clinical results of the percutaneous valves.In this article we review the current status of TAVI including selection of patients,a comparison of available prostheses,results and complications of the procedure,clinical outcomes,and future perspectives.     

Effect of transcatheter aortic valve implantation on health-related quality of life in older adults with multimorbidity

PurposeThe purpose of this study was to determine the effect of transcatheter aortic valve implantation on health-related quality of life in older adults with multimorbidity and to evaluate the predictive factors for postoperative quality of life impairment in such patients.Material and methodThis study included 141 older adults with severe aortic stenosis scheduled for elective transcatheter aortic valve implantation. Quality of life was examined in all patients using the Short-Form 36 Health Survey Questionnaire, before and 2 years after surgery. Comorbidity was assessed using the Charlson Comorbidity Index.ResultsIn older adult patients with aortic stenosis and multimorbidity, transcatheter aortic valve implantation significantly improved both physical and mental components of quality of life 2 years after surgery. A Charlson Comorbidity Index ≥5 points was independently associated with the absence of positive dynamics in Physical Health score [odds ratio (OR) 0.38 (0.20–0.75), p = 0.007]. Charlson Comorbidity Index ≥5 points [OR 0.31 (0.19–0.58), p = 0.026] and new-onset arrhythmia [OR 0.54 (0.38–0.78), p = 0.017] were independent predictors of the absence of positive dynamics in Mental Health score after transcatheter aortic valve implantation.ConclusionsHigh-level comorbidity (Charlson Comorbidity Index ≥5 points) predicts both Physical and Mental Health scores for quality of life impairment following transcatheter aortic valve implantation in older adults, and new-onset arrhythmia predicts the Mental Health score for quality of life impairment following transcatheter aortic valve implantation in these patients.     

Impact of pulmonary hypertension on mortality after operation for isolated aortic valve stenosis

Background

Pulmonary hypertension (PH) is a well-known independent risk factor for mortality and morbidity after cardiac surgery. However, no weight is given to PH in the current guidelines for the management of patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of our study was to evaluate the impact of preoperative PH on early and five-year survival in patients with severe AS undergoing isolated AVR.

Methods

From January 2005 to July 2010, 422 consecutive patients with severe AS underwent isolated AVR. According to systolic pulmonary artery pressure (sPAP), PH was classified as none (sPAPS < 35 mmHg, N = 224), mild–moderate (35 ≤ sPAP < 50 mmHg, N = 159) and severe (sPAP ≥ 50 mmHg, N = 39).

Results

Overall in-hospital mortality was 2.8%. Unadjusted mortality was 0.9%, 3.8% and 10.2% for patients with normal, mild–moderate and severe PH (p = 0.003). In multivariable analysis, severe PH (OR 4.1, 95 CI 1.1–15.3, p = 0.04) and New York Heart Association class III–IV (OR 14.9, 95% CI 1.8–117.8, p = 0.01) were independent risk factors of in-hospital mortality. Multivariable predictors of five-year survival were extracardiac arteriopathy (HR 2.8, 95%CI 1.6–4.9, p < 0.0001), severe PH (HR 2.4, 95%CI 1.2–4.6 p = 0.01), NHYA III–IV class (HR 2.3, 95% CI 1.3–4, p = 0.003), preoperative serum creatinine (HR 2.2, 95%CI, 1.6–3.1,p < 0.0001) and age (HR 1.08, 95%CI 1.03 - 1.13, p = 0.01). Five-year survival was 86% ± 3% with normal sPAP, 81% ± 4% with mild–moderate PH and 63 ± 10% with severe PH (p < 0.001).

Conclusions

In patients undergoing isolated AVR with severe AS, severe PH is an independent predictor of in-hospital mortality and five-year survival     

老年人主动脉瓣置换术后病死率分析

目的 对年龄≥70岁的主动脉瓣狭窄患者主动脉瓣置换术后的病死率进行分析.方法 回顾性分析246例年龄≥70岁、并接受主动脉瓣置换的主动脉瓣狭窄患者的临床资料.其中高血压144例(58.5%),心房颤动42例(17.1%),肥胖27例(11.0%),有心脏手术史18例(7.3%).结果 手术30 d内死亡29例,病死率为...     

Ross procedure after prosthetic valve thrombosis in a patient with antiphospholipid syndrome and recurrent bleeding

The Ross procedure allows replacement of a diseased aortic valve with pulmonary root autograft, possibly avoiding the highly thrombotic mechanical valves and immunologic deterioration of tissue valves in antiphospholipid syndrome (APS). Here, we present the use of the Ross procedure in a 42-year-old woman with mild intellectual disability, APS, and a complex anticoagulation history after she presented with thrombosis of her mechanical On-X aortic valve previously implanted for non-bacterial thrombotic endocarditis.     

Rates and determinants of progressive aortic valve dysfunction in aortic coarctation

Purpose

Aortic valve dysfunction is common in coarctation patients(CoA). Bicuspid aortic valve (BAV) in CoA is associated with aortic valve stenosis (AS), aortic valve regurgitation (AR), and ascending aortic dilatation. The aim of this study was to evaluate the progression of and predictors for aortic valve dysfunction in CoA.

Methods

96 CoA patients prospectively underwent echocardiography twice between 2001 and 2010. AS was defined as an aortic valve gradient ≥ 20 mm Hg, AR as none/minor, or moderate/severe. Aortic dilatation as an ascending aortic diameter ≥ 37 mm.

Results

All patients (median age 28.0 years, range 17–61 years; male 57%) were followed with a median follow-up of 7.0 years. Sixty patients (63%) had BAV. At baseline 10 patients had AS (10%, 9 BAV), 6 patients AR (6%, 3 BAV) and 11 patients aortic dilatation (11%, 11 BAV). At follow-up 15 patients had AS (15%, 13 BAV) and 12 patients AR. (13%, 8 BAV).Median AS progression was 1.1 mm Hg/5 years (range — 13–28). Determinants for AS at follow-up were age (ß = 0.20, P = 0.01), aortic dilatation (ß = 4.6, P = 0.03), and baseline aortic valve gradient (ß = 0.93, P < 0.001). BAV was predictive for AR. (ß = 0.91, P = 0.049).

Conclusion

Progression of AS in adult CoA patients is mild in this young population. Older age, aortic dilatation and the baseline aortic valve gradient are determinants for AS at follow-up. BAV is predictive for AR. These findings point towards a common embryological pathway of both valvular and aortic disease in CoA.     

Noninvasive quantification of the aortic valve area in aortic stenosis by Doppler echocardiography

To develop a noninvasive approach to the quantification of thestenotic aortic valve area, Doppler echocardiography and cardiaccatheterisation were performed in 24 patients with pure aorticstenosis. The transmitral volumetric flow was measured by Dopplerechocardiography and calculated as the product of the correctedmitral orifice area (CM A) and the diastolic velocity integral(DVI). The maximal aortic jet velocities were recorded by Dopplertechnique and integrated to obtain the systolic velocity integral(SVl). Assuming that the aortic and mitral volumetric flowsare equal, the aortic valve area (A VA) was calculated as: AVA= CM A x DVI/SVI. Mean pressure gradient and cardiac outputwere measured during catheterisation and the aortic valve areawas calculated by the Gorlin formula. Comparison between theaortic valve area determined by Doppler technique and catheterisationyielded a close correlation (r = 0.92, P<0.001), and therewas no significant difference between the two measurements.Good correlations of the instantaneous pressure gradient andthe stroke volume were also obtained between the two techniques(r = 0.91 and r = 0.90, respectively, P<0.001). These resultsdemonstrate that our Doppler echocardiographic method providesa promising approach to the noninvasive quantification of theaortic valve area in aortic stenosis     

钙化性主动脉瓣狭窄的外科治疗

目的评价钙化性主动脉瓣狭窄外科治疗效果及成功因素。方法对26例钙化性主动脉瓣狭窄患者随访分析,年龄55～70岁,平均62岁。主动脉跨瓣压差52～191mmHg,平均97mmHg,室间隔、左室后壁厚度14～19mm,合并关闭不全7例。手术均在全麻、低温和体外循环下行机械瓣置换,同期行Manouguian法扩大主动脉瓣环9例、CABG3例、Wheat术1例。结果术后早期和晚期各死亡1例。随访心脏超声LVEF为51%～72%,室间隔及左室后壁厚度8～12mm,人工瓣跨瓣压差8～26mmHg。心功能为Ⅰ～Ⅱ级。结论瓣膜置换是治疗钙化性主动脉瓣狭窄唯一安全有效的方法,恰当的手术时机、合适的瓣膜型号是提高手术远期疗效的重要保证。     

Recent developments and controversies in transcatheter aortic valve implantation

Interventional cardiology has been revolutionised by transcatheter aortic valve implantation (TAVI), which has become established as the benchmark treatment for severe aortic stenosis in patients at high risk for surgical aortic valve replacement (AVR). Increased procedural familiarity and progression in device technology has enabled improvements to be made in complication rates, which have led to a commensurate expansion in the use of TAVI; it is now a viable alternative to AVR in patients at intermediate surgical risk, and has been used in cohorts such as those with bicuspid aortic valves or pure, severe aortic regurgitation. Given the rapid expansion in the use of TAVI, including cohorts of younger patients with fewer co‐morbidities, attention must be paid to further reducing remaining complications, such as cardiac tamponade or stroke. To this end, novel techniques and devices have been devised and trialled, with varying levels of success. Furthermore, significant work has gone into refining the technique with exploration of alternative imaging modalities, as well as alternative access routes to provide greater options for patients with challenging vascular anatomy. Whilst significant progress has been made with TAVI, areas of uncertainty remain such as the management of concomitant coronary artery disease and the optimum post‐procedure antiplatelet regimen. As such, research in this field continues apace, and is likely to continue as use of TAVI becomes more widespread. This review provides a summary of the existing evidence, as well as an overview of recent developments and contentious issues in the field of TAVI.     

Selective Application of the Pediatric Ross Procedure Minimizes Autograft Failure

Objective. Pulmonary autograft aortic root replacement (Ross' operation) is now associated with low operative risk. Recent series suggest that patients with primary aortic insufficiency have diminished autograft durability and that patients with large discrepancies between pulmonary and aortic valve sizes have a low but consistent rate of mortality. Therefore, Ross' operation in these patients has been avoided when possible at Texas Children's Hospital. Our objective was to report outcomes of Ross' operation when selectively employed in pediatric patients with aortic valve disease. Methods. Between July 1996 and February 2006, 55 patients (mean age 6.8 ± 5.5 years) underwent Ross' procedure. Forty‐seven patients (85%) had a primary diagnosis of aortic stenosis, three (5%) patients had congenital aortic insufficiency, and five (9%) patients had endocarditis. Forty‐two (76%) patients had undergone prior aortic valve intervention (23 [55%] percutaneous balloon aortic valvotomies, 12 [29%] surgical aortic valvotomies, 12 [29%] aortic valve replacements, 2 [5%] aortic valve repairs). Fourteen (25%) patients had ≥2 prior aortic valve interventions. Thirty‐two patients (58%) had bicuspid aortic valves. Follow‐up was 100% at a mean of 3 ± 2.5 years. Results. Hospital and 5‐year survival were 100% and 98%, respectively. Morbidity included one reoperation (2%) for bleeding. Median length of hospital stay was 6 days (3 days–3 months). Six (11%) patients needed a right ventricular to pulmonary artery conduit exchange at a median time of 2.3 years. Freedom from moderate or severe neoaortic insufficiency at 6 years is 97%. Autograft reoperation rate secondary to aortic insufficiency or root dilation was 0%. Conclusions. By selectively employing Ross' procedure, outcomes of the Ross procedure in the pediatric population are associated with minimal autograft failure and mortality at mid‐term follow‐up.