介入封堵与外科手术治疗主动脉窦瘤破裂的疗效及安全性

目的比较介入封堵与外科手术治疗主动脉窦瘤破裂(RSVA)的疗效及安全性。方法选取RSVA患者22例,介入封堵治疗10例(介入组),外科手术治疗12例(手术组)。术后随访6—24个月,比较两组临床症状、是否存在残余分流、有无瓣膜反流、封堵器有无移位、肺动脉压变化及心功能状态。结果介入组均完全封堵;与术中比较,术后肺动脉收缩压、肺动脉平均压均降低,差异均有统计学意义(P均0.05);术后即刻造影示少量残余分流1例。手术组完全封堵率为91.67%(11/12);术后出现较大的残余分流和严重低心排量综合征各1例。两组随访期内均未发生右心衰竭、栓塞、感染性心内膜炎、主动脉瓣反流、溶血和死亡等。结论介入封堵治疗主动脉窦瘤破裂与外科修补疗效相当,且具有较好的安全性。     

Austrian triad with sinus of Valsalva aneurysm and rupture

An interesting case of a young patient presenting with Austrian's Triad: pneumococcal pneumonia, pneumococcal meningitis, and pneumococcal endocarditis. On echocardiogram the patient was noted to have a noncoronary sinus of Valsalva aneurysm and vegetations on the aortic cusps resulting in disruption of valvular integrity and severe aortic insufficiency. Color Doppler also revealed rupture of the aneurysm into the right atrium. The patient was taken to surgery where the noncoronary cusp was noted to be completely replaced with vegetative lesions. The aortic valve was replaced with a No. 21 Carpentier-Edwards bioprosthetic valve (Edwards Lifesciences, Irvine, CA), and the noncoronary sinus of Valsalva was repaired with concomitant closure of the fistula using glutaraldehyde autologous pericardium.     

Surgical repair of ruptured aortic sinus of Valsalva aneurysm

Surgical repair of ruptured aortic sinus of Valsalva aneurysm was performed on six patients. The NYHA functional class was I in one case, II in three and III in two cases. All aneurysms had ruptured into the right atrium. Three originated from the right, and three from the non-coronary aortic sinus of Valsalva. The preoperative shunt was 55-200% (mean 118%) of the peripheral cardiac output. At aneurysmal repair, closure of secundum-type atrial septal defect was performed in one case and insertion of a St Jude Medical aortic valve in another. There were no perioperative deaths. Five patients were asymptomatic in the follow-up period (5 months-17 years). One patient died of cardiomyopathy 11 years postoperatively. The long-term results after surgical repair of ruptured aortic sinus of Valsalva aneurysm thus were good, and early operation is recommended in order to avoid congestive heart failure.     

Surgical correction of rupture of aneurysm of the sinus of Valsalva

Operations were performed on 48 patients with aneurysms of the thoracic aorta, one of them had a rupture of aneurysm of the noncoronary sinus followed by the formation of a fistula between the aorta and the right atrium. The fistula was ligated by an access through the right atrium with good nearest and long-term results.     

Repair of intrapericardial rupture of left sinus of Valsalva aneurysm

A 62-year-old man with no history of preexisting heart disease was seen in cardiogenic shock. Prompt cardiac catheterization and aortography revealed pericardial tamponade and aneurysms of the right and left sinuses of Valsalva. Immediate sternotomy relieved the tamponade, which was secondary to an aneurysm of the left sinus of Valsalva rupturing into the transverse pericardial sinus. Endoaneurysmorrhaphy was performed successfully.     

Fatal rupture after successful surgical thrombosis of an abdominal aortic aneurysm

Fatal aortic rupture in a patient 2 weeks after successful thrombosis of an abdominal aneurysm by bilateral iliac artery ligation is reported. The procedure apparently failed to protect the proximal aortoaneurysmal junction, which led to rupture and exsanguination. In view of our present experience, reevaluation of these aneurysm-thrombosing procedures, particularly pertaining to the protection of the proximal aortoaneurysmal junction, is suggested.     

Ruptured congenital aneurysm of the sinus of Valsalva: surgical technique and long-term follow-up.

Congenital ruptured aneurysm of the sinus of Valsalva is a rare anomaly usually causing decrease of cardiac performance. Eight patients with a ruptured congenital aneurysm of the sinus of Valsalva were operated upon at the University Hospital Zurich between 1970 and 1991. There were four female and four male patients aged from 15 to 48 years (mean, 36 years). Three patients were asymptomatic and five symptomatic. Associated congenital cardiac defects were found in six patients. Surgical techniques consisted of direct suture in seven patients and closure with a Dacron patch in one. A secondary Dacron patch closure was performed on the second postoperative day in a patient with suture insufficiency after direct closure. Associated operations were closure of ventricular septal defect in two patients, aortic valve replacement in two, aortic valve reconstruction in one and aortic valve commissurotomy in one patient. There were no operative deaths. The mean follow-up was 9 years, range 7 months to 17 years. There were two late deaths due to endocarditis and recurrent cerebral embolisation. An operation for a ruptured aneurysm of the sinus of Valsalva has a low operative risk, but patients remain prone to development of late valvular complications.     

Ruptured aneurysm of sinus of Valsalva into the right atrium with aortic valve perforation

A 58-year-old female was admitted to our hospital because of sudden dyspnea and general malaise. A continuous murmur was heard along the left sternal border. A chest X-ray showed cardiomegaly and pulmonary vascular marking. Doppler echocardiography confirmed the presence of an aneurysmatic mass, originating from the non-coronary sinus of Valsalva and extending to the right atrium, with a turbulent flow into the right atrium, aortic regurgitation (II/IV) and tricuspid regurgitation (III/IV). Ascending aortography demonstrated a communication between the aortic sinus and the right atrium. The pulmonary-to-systemic flow ratio was calculated to be 2.04. Oblique aortotomy and right atriotomy were performed. The aneurysm was resected and its origin was directly closed with horizontal mattress sutures through the aortic side and right atrial side. Perforation of a non-coronary cusp that caused aortic regurgitation was found following aortotomy and it was closed with an autologous pericardial patch. Tricuspid annuloplasty was performed using DeVega's technique. The postoperative course was uneventful, and she was discharged on the 10th postoperative day.     

Unruptured aneurysm of the right coronary sinus of Valsalva with type B aortic dissection

A seventy-two year-old man, who complained of severe back pain, was referred to our hospital. Digital subtraction angiogram (DSA) delineated an extracardiac unruptured aneurysm of the right coronary sinus of Valsalva and acute type B aortic dissection. Patch plasty of the right coronary sinus with reimplantation of the right coronary artery using a Dacron graft was performed. Postoperative DSA confirmed successful reconstruction of the aortic root and the patent right coronary artery.     

主动脉窦瘤破裂的外科治疗及远期疗效

目的 总结主动脉窦瘤破裂的临床特点及外科疗效,讨论对合并感染性心内膜炎及主动脉瓣关闭不全患者的处理.方法 回顾性分析1997年9月至2007年9月43例主动脉窦瘤破裂患者的临床资料.其中男性32例,女性11例;年龄11～50岁,平均年龄(29.0±11.5)岁.破口源于右冠状动脉窦34例,无冠状动脉窦9例.破入有心室30例,右心房8例,右心室及右心房3例,破人室间隔2例.合并室间隔缺损26例,主动脉瓣关闭不全15例,感染性心内膜炎8例,三尖瓣反流6例,房间隔缺损4例,二尖瓣反流2例,动脉导管未闭2例,肺动脉赘牛物1例.全部患者于心肺转流下行窦瘤修补及合并畸形矫治术.结果 无围手术期死亡.并发症5例,包括急性左心功能衰竭3例,Ⅲ度房室传导阻滞2例.随访6～120个月,平均(68.0±17.7)个月;2例分别于术后第6、8年行主动脉瓣置换术,2例进展为Ⅱ级主动脉瓣父闭小全.结论 主动脉窦瘤破裂外科治疗可获得满意效果.对合并主动脉瓣关闭小全及感染性心内膜炎的患者应早期手术,积极防治术后并发症并长期随访.     

Prediction of outcome after abdominal aortic aneurysm rupture

BACKGROUND: Most vascular surgeons practice a selective policy of operative intervention for patients with ruptured abdominal aortic aneurysm (AAA). The evidence on which to justify operative selection remains uncertain. This review examines the prediction of outcome after attempted open repair of ruptured AAA. METHODS: The Medline and EMBASE databases and Cochrane Database of Systematic Reviews were searched for clinical studies relating to the prediction of outcome after ruptured AAA. Reference lists of relevant articles were also reviewed. RESULTS: The last 20 years has seen >60 publications considering variables predictive of outcome after AAA rupture. Four predictive scoring systems are reported: Hardman Index, Glasgow Aneurysm Score, Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM), and the Vancouver Scoring System. No scoring system has been shown to have consistent or absolute validity. Of the remaining data, there are no individual or combination of variables that can accurately and consistently predict outcome. CONCLUSIONS: Little robust evidence is available on which to base preoperative outcome prediction in patients with ruptured AAA. Experienced clinical judgement will remain of foremost importance in the selection of patients for ruptured AAA repair.     

Severe jaundice after rupture of abdominal aortic aneurysm

Eight patients after operation for ruptured abdominal aortic aneurysm developed severe jaundice. The jaundice became clinically apparent by the sixth postoperative day, and the average peak total bilirubin level reached 28.4 mg/100 ml, alkaline phosphatase level 8.6 BL units/l, and SGOT 95 Karmen units/ml. In addition to the hepatic dysfunction, all patients developed acute renal failure, seven of eight patients experienced hypovolemic shock, and six of eight patients had respiratory insufficiency requiring ventilatory support. The overall mortality was 83 per cent. The most probable causes for the severe jaundice were increased bile pigment load and hepatocellular dysfunction due to ischemic hypoxic injury of hepatocytes secondary to shock. Morphologically, a picture of cholestasis existed with severe bile-staining of hepatocytes and intracanalicular and intraductal bile thrombi. No evidence of recent or resolving hepatic necrosis was observed.