3例主动脉瘤及主动脉夹层合并主动脉良性肿瘤及瘤样病变的临床病理学分析

目的:发生在主动脉的良性肿瘤并伴有主动脉疾病(主动脉瘤、主动脉夹层及马方综合征)是少见病例。本文总结分析伴有主动脉疾病的主动脉良性肿瘤及瘤样病变的临床病理特点,复习发生于主动脉良性肿瘤的文献,探讨其发生与主动脉疾病之间的关系。方法:回顾性分析我院病理科2006年至2012年,手术切除的胸主动脉瘤及胸主动脉夹层的标本129例,通过复习临床病历,观察HE染色切片,辅以弹力/VG及Masson等组织化学染色及SMA、CD31及CD34等免疫组织化学染色,对主动脉壁结构的改变进行分析。结果:所有病例主动脉壁均发生了结构的改变,主要是中膜弹力纤维、平滑肌及基质的变化,但有3例标本内膜增生明显,1例形成了平滑肌瘤,另2例发生了内膜下弹力纤维瘤样增生及平滑肌瘤样增生。结论:主动脉壁内不同组成成分的改变,使得主动脉壁重构,导致主动脉瘤及主动脉夹层的形成,而某一单一成分过度增生可形成主动脉腔内的肿瘤。     

3D-echo in preoperative assessment of aortic cusps effective height

Effective height,which represents the height difference between the central free margins and the aortic insertion lines can be easily determined by 2-D echocardiography and allows for identification of prolapse in the native cusps and assessment of prolapse correction after valve repair.Nonetheless,it allows to see only two of three aortic valve(AV)coaptation planes and this may lead to misunderstanding of the underlying pathophysiological mechanism for aortic regurgitation and hence in unsuccessful repair.In contrast,3D transoesophageal echocardiography and multiple plane reconstruction lets visualize all the three coaptation planes between the AV cusps and it represents an invaluable tool in the assessment of aortic valve geometry.It is highly recommendable before AV repair to accurately study the complex three dimensional cusps anatomy and their geometric interrelation with aortic root.     

Aortic valve repair in patients with aortic regurgitation: Experience with the first 100 cases

IntroductionThe aim of this study was to analyze short- and mid-term results of aortic valve repair.Material and methodsOne hundred consecutive patients (24 females; mean age 50.3 years, range 23–77 years) with aortic regurgitation underwent aortic valve repair between November 2007 and October 2012. Sixty patients had bicuspid aortic valve, and 82 patients demonstrated aortic regurgitation greater than mild (> grade 2). The ascending aorta/aortic root was replaced in 67 patients. Aortic cusp repair was necessary in 74 patients and additional aortic annulus stabilization was required in 48 cases. Follow-up ranged from 1 to 59 months (cumulative of 220 patient-years, median 25 months) and was complete in 100%.ResultsThere was no 30-day mortality and two patients died in the follow-up. The overall 4-year survival was 98% and freedom from cardiac death was 99% at 4 years. During the follow-up eight patients underwent aortic valve-related reoperation due to progression of aortic regurgitation and another six patients showed aortic regurgitation more than mild (> grade 2). In both aspects there was no statistically significant difference between patients without and with aortic root replacement (p=0.402 and p=0.650). There were no significant bleeding or thromboembolic events during the follow-up.ConclusionsShort- and mid-term data analysis revealed an excellent survival and acceptable results of aortic repair, comparable with other larger published studies. We think, therefore, aortic valve repair should be a part of contemporary cardio-surgical armamentarium, especially in younger patients with an appropriate indication.     

Aortic valve repair and valve sparing procedures

Aortic valve repair and valve sparing procedures enable restoration of competence in regurgitant aortic valve, and thus to avoid the risks related to valve replacement. Successful aortic valve repair requires deep understanding of the static and dynamic geometry of the aortic valve and aortic root. Aortic regurgitation originates from malapposition of the aortic leaflets and it is also frequently connected to dilation of the aortic root and ascending aorta. Techniques of surgical procedures for aortic regurgitation have been subject of historical development and currently tend to simplification and standardisation. Basic principles stand upon morphological normalisation at the level of the basal ring, sinotubular junction and valve leaflets. Remodelation of the aortic root and reimplantation of the aortic valve keep to be standard procedures in case of a dystrophic dilation of the aortic root.     

Current knowledge and contemporary management of non-A non-B aortic dissections

Non-A non-B aortic dissection (AAD) is an infrequently documented condition, comprising of only a small proportion of all AADs. The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD, have led to an ongoing controversy around the topic. It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections, frequently leading to serious complications and thus mandating early intervention. Currently, the available treatment methods in the surgical armamentarium are conventional open, endovascular techniques and combined hybrid methods. The optimum approach is tailored in every individual case and may be determined by the dissection’s location, extent, the aortic diameter, the associated complications and the patient’s status. The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached. In an attempt to provide further insight into this perplexing entity, we performed a minireview of the literature, aiming to elucidate the epidemiology, clinical course and the optimal treatment modality.     

Successful endovascular management of an aortic rupture following stent placement for severe atherosclerotic stenosis: A case report

Aortic rupture during endovascular procedures is a devastating complication that mandates expedient intervention. The present report describes a case in which endovascular treatment was used to successfully manage an aortic rupture following placement of a covered stent graft for severe infrarenal aortic stenosis. Successful management of this case was the result of the procedure being performed in an operating room under appropriate anesthesia and close hemodynamic monitoring. Bilateral common femoral arterial access and use of covered aortic stent grafts also contributed to a favourable outcome.     

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.     

Ventricular energetics in aortic root replacement for annuloaortic ectasia with aortic regurgitation

Aortic root replacement (Bentall operation) is the standard operation for patients who have lesions of the ascending aorta associated with aortic valve disease. We analyzed the mid-term results for left ventricular energetics after the Bentall operation for annuloaortic ectasia with aortic regurgitation. We measured left ventricular contractility (end-systolic elastance; Ees), afterload (effective arterial elastance; Ea), and efficiency (ventriculoarterial coupling; Ea/Ees, and the ratio of stroke work and pressure-volume area; SW/PVA) based on transthoracic echocardiography data before, after, and approximately 1 year after the Bentall operation in 15 patients with annuloaortic ectasia with aortic regurgitation. Left ventricular volume was calculated by the Teichholz M-mode method. Ees and Ea were approximated as follows: Ees = mean blood pressure/minimal left ventricular volume, and Ea = systolic blood pressure/(maximal left ventricular volume — minimal left ventricular volume). Ea/Ees and SW/PVA were then calculated. Left ventricular volume was normalized with body surface area. Ees increased after the Bentall operation and around 1 year later (from 2.17 ± 1.09 to 3.92 ± 2.26 and 5.33 ± 1.90 mmHg·m²/ml, P < 0.001), thus resulting in an improvement in SW/PVA (from 68.8 ± 8.2 to 70.9 ± 9.5 and 74.7 ± 5.2%, P = 0.045). Ea also increased after the Bentall operation and 1 year later (from 1.77 ± 0.61 to 2.88 ± 1.28 and 3.54 ± 1.43 mmHg·m²/ml, P < 0.001). The mid-term results for ventricular contractility and efficiency after the Bentall operation for annuloaortic ectasia with aortic regurgitation are excellent and satisfactory.     

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...     

主动脉夹层和主动脉瘤与高血浆同型半胱氨酸

目的观察主动脉夹层及主动脉瘤患者血浆同型半胱氨酸(Hcy)的水平。方法病例组为确诊的106例主动脉夹层患者及38例主动脉瘤患者,对照组为199例在性别、高血压病史、饮酒史等与病例组相匹配的门诊查体者。常规检测血生化指标,高效液相方法测定血浆同型半胱氨酸。结果主动脉夹层合并主动脉瘤组血浆Hcy水平较对照组增高,分别为(19.75±12.77)μmol/L和(13.43±5.15)μmol/L,(P<0.001),病例组高血浆同型半胱氨酸患者的比率高于对照组,分别为67.4%和38.5%(P<0.01)。主动脉夹层组血浆Hcy水平较主动脉瘤组稍高,分别为(20.25±13.96)μmol/L和(18.76±8.55)μmol/L,但差异不显著。主动脉夹层急性期与慢性期组的血浆Hcy水平无差别。将病例组按性别分层后,血浆Hcy水平与对照组相比,仅女性主动脉瘤组无差异,其余各组均显著增高(P<0.01或P<0.05)。结论主动脉夹层合并主动脉瘤组血浆Hcy水平较对照组增高,高血浆Hcy与主动脉夹层合并主动脉瘤的发生、发展密切相关。     

主动脉瓣脱垂与关闭不全的外科治疗（附56例报告）

用主动脉成形术治疗主动脉瓣脱垂与关闭不全患者５６例，无手术死亡者。术后平均随访２５．６个月，心功能Ｉ级５０例，Ⅱ级６例；７例仍有舒张期杂音者术后３年无变化。认为其手术的关键是主动脉瓣成形效果，并主张积极处理轻度主动脉瓣脱垂与关闭不全。     

MiRNA与获得性主动脉疾病的研究进展

获得性主动脉疾病包括主动脉夹层（aortic dissection,AD）、主动脉瘤（aortic aneurysm,AA）、多发性大动脉炎等,其中AD与AA的发病率最高,为3～4人·10万人-1·年-1[1],其总体病死率和手术相关死亡率都很高.年龄、吸烟、男性、高血压、动脉粥样硬化是导致AA与AD形成的危险因素,主动脉中层的退化、变性、坏死是AD与AA的致病基础.目前已有很多研究致力于阐释获得性主动脉疾病的发病机制,大部分研究着重于基因起源异常、临床病理不同及主动脉的血流动力学作用[2-4].     

Comparing outcomes after transcatheter aortic valve replacement in patients with stenotic bicuspid and tricuspid aortic valve: A systematic review and meta‐analysis

Background

Transcatheter aortic valve replacement (TAVR) has become an alternative treatment to surgery in patients with severe aortic stenosis. However, patients with bicuspid aortic stenosis (BAV) are usually excluded from major TAVR studies. The aim of this study is to reexamine current evidence of TAVR in patients with severe aortic stenosis and BAV compared with tricuspid aortic valve (TAV).

Hypothesis

There might be differences in outcomes post TAVR between patients with BAV comparing to TAV.

Method

Databases were systematically searched for relevant articles featuring cohort studies that included patients with BAV and TAV who underwent TAVR studies, of which reported outcomes of interest included mortality and complications in both groups. Pooled effect size was calculated with a random‐effect model and weighted for the inverse of variance, to compare outcomes post‐TAVR between BAV and TAV.

Results

Nine studies were included in the meta‐analysis. There was no difference in 30‐day mortality rate in patients with BAV compared with TAV (OR: 1.27, 95% CI: 0.84–1.93, I² = 0). Patients with BAV were more likely to have a moderate to severe paravalvular leak (9 studies; OR: 1.42, 95% CI: 1.08–1.87, I² = 0) and conversion to surgery (5 studies; OR: 5.48, 95% CI: 1.74–17.27, I² = 0), and less likely to have device success compared with patients with TAV (5 studies; OR: 0.57, 95% CI: 0.40–0.81, I² = 0%).

Conclusions

There was no difference in mortality post‐TAVR in patients with BAV compared with TAV. Further randomized studies should be done in newer‐generation prostheses to assess this association.     

孤立性升主动脉炎的外科病理学观察

目的 拟对比累及升主动脉的大动脉炎,分析孤立性升主动脉炎外科病理学特点.方法 从阜外医院近20年共965例升主动脉病理资料中筛选出主动脉炎40例.收集临床资料如病史、实验室检查及影像学数据、手术所见、激素治疗与否及随访情况.病理测量主动脉壁及各层的厚度,判断炎症的活动性,观察有无多核巨细胞、炎性坏死、层状坏死和粥样硬化.2组均值比较采用t检验,而率比较采用Fisher精确概率法.结果 40例升主动脉炎中检出25例孤立性升主动脉炎(占升主动脉疾病的2.6%),8例大动脉炎,其他7例.孤立性升主动脉炎的发病年龄略高于大动脉炎[(46±12)岁与(34±14)岁,t=2.30,P>0.05],而男女之比接近(1.1与1.0,t=0.01,P>0.05).临床表现主要为动脉瘤,但孤立性主动脉炎的主动脉外径高于大动脉炎[(59±18)与(46±12)mm,P>0.05],并有较多的无症状病例(28%与0,x2=2.98,P>0.05).红细胞沉降率(ESR)多不升高[(15±17)与(27±25)mm/1 h,U=48.50,P<0.05].2组均有过半的病例术中可见主动脉壁水肿、增厚或钙化.孤立性升主动脉炎不及大动脉炎动脉壁增厚明显[(2506±493)与(3300±430)μm,t=-3.00,P<0.01],但前者的多核巨细胞、炎性坏死、层状坏死和伴发粥样硬化多见.2组分别有80.0%和87.5%的病例出现主动脉瓣反流,但是瓣叶炎症均少见.使用激素的5例孤立性升主动脉炎随访期内无并发症发生,20例未用激素的患者中3例出现瓣周漏.而3例激素治疗的大动脉炎中1例术后新发腹主动脉瘤,5例未用激素患者2例术后分别出现瓣周漏和锁骨下动脉闭塞.结论 孤立性升主动脉炎较大动脉炎累及升主动脉常见,但两者的临床与病理表现有一定差别.由于孤立性升主动脉炎激素疗效的不确定性,为避免过度治疗,建议术后暂不启动激素治疗,而应加强随访.

Abstract：

Objective To analyze the surgical and pathologic features of isolated ascending aortitis without evidence of rheumatologic or autoimmune diseases by comparing that of Takayasu's arteritis.Methods Consecutive 965 excised ascending aortas were reviewed and 40 cases with aortitis were selected from the pathological archives of past 20 years in Fuwai Hospital.The clinical history,laboratory and angiographic data,surgical findings,steroid therapy and followup results of these 40 cases were reviewed.Pathological parameters included the thickness of aortic wall and its various layers,inflammation activity,multinuclear giant cells,inflammatory necrosis,laminar necrosis and atheroselerosis.The t test and Chi square analysis were used to compare the means and the rates between the two groups.Results Twenty-five of 40 cases were diagnosed with isolated aortitis and its prevalencei was 2.6%(25/965),while 8 cases with Takayasu's arteritis and 7 cases with other vasculitis were confirmed.The age of isolated ascending aortitis was older than that of Takayasu's arteritis[(46±12)y vs(34±14)y,t=2.30,P>0.05] while the male/female ratio was similar in both groups(1.1 vs 1.0,t=0.01,P>0.05).Their main clinical manifestation was aortic aneurysm with a bigger aortic diameter in isolated aortitis than that in Takayasu's arteritis [(59±18)vs(46±12)mm,P>0.05].The asymptomatic cages mostly were found in isolated ascending aortitis (28%vs 0,x2=2.98,P>0.05).The erythrocyte sedimentary rate was normal in isolated aortitis but increased in Takayasu's arteritis[(15±17)mm/1 hvs[27±25)mm/1 h,U=48.50,P<0.05 ].Inflammatory edema,thickening and calcification were noted in more than half cases of both groups.but slighter thickening of aortic wall was foand in isolated ascending aortitis in contrast to the remarkable thickening in Takayasu artefifis[(2506±493)vs (3300±430)μm,t=-3.00,P<0.01].Giant cells,inflammatory necrosis,laminar necrosis and accompanied atherosclerosis were more common in isolated ascending aortitis.Aortic regurgitation was common but inflammatory invasion wege found in few aortic valves. Steroid was prescribed in 5 cases with isolated ascending aortitis and none of them was reported with complications while aortic perivalvular leakage occurred in 3 of 20 cases without steroids therapy. In the Takayasu's arteritis cases, new aneurysm of abdominal aorta was found in 1 of 3 cases with steroid therapy. Meanwhile, perivalvular leakage and subclavian artery stenosis occurred in 2 of 5 cases without steroid. Conclusion Isolated aortitis is more common than Takayasu's arteritis in ascending aortic diseases and there is some definite difference in clinical and pathological aspects between these two diseases. Since the effect of steroid therapy is uncertain and in order to avoid overtreatment, we suggest that steroid should not be given to cases with isolated ascending aortitis after surgery and clinical and angiographic follow-up should be emphasized.