用无支架生物瓣膜行主动脉瓣置换术的早期临床经验

目的探讨无支架生物瓣的置入技术及其早期临床效果.方法对12例平均年龄65岁的主动脉瓣病变病人,选用St.Jude公司提供的TorontoSPV瓣膜,行主动脉瓣置换术.结果全组手术死亡1例,平均主动脉阻断时间(95.0±12.3)?min,其中单纯主动脉瓣置换者为(74.0±9.2)?min.术后1个月随访超声心动图显示均无主动脉瓣反流,跨瓣压差明显较其他人工瓣膜小,左心室舒张末期内径明显缩小,无栓塞、出血等并发症.结论尽管无支架生物瓣膜置入有一定难度,但其优良的血液动力学性能,提示其能提高病人的远期疗效.     

Early experience of aortic valve replacement with the Freestyle stentless aortic bioprosthesis in elderly patients.

OBJECTIVES: Stentless bioprostheses have been gaining popularity in recent years as hemodynamically superior alternatives to conventional stented bioprostheses. METHODS: Between July 1996 and November 1998, 13 patients with aortic valve disease, 7 males and 6 females with a mean age (+/- SD) of 68 +/- 5 years, underwent an aortic valve replacement using the Medtronic Freestyle aortic bioprosthesis. The predominant lesions were stenosis in 8 patients and regurgitation in 5, while 2 patients had endocarditis. The operation was performed by a subcoronary technique in 9, root-inclusion technique in 3, and full root technique in 1 patient. RESULTS: Throughout the follow-up periods (with average follow-up period of 20.6 months), there was no hospital mortality, though there was one late death of unknown cause. The New York Heart Association class improved in all patients. The peak transvalvular gradient decreased from 18.4 +/- 9.8 to 12.6 +/- 9.6 mmHg, and the effective valve orifice area increased from 2.30 +/- 0.96 to 2.59 +/- 1.05 cm2 between the 1-month and the 6-month follow-up examinations. In patients with aortic regurgitation, the left ventricular end-diastolic/end-systolic volume index significantly decreased from 147 +/- 36/62 +/- 19 to 73 +/- 26/33 +/- 14 ml/m2 at 1 month after the operation. The left ventricular mass index also significantly decreased from 189 +/- 26 to 143 +/- 30 g/m2 in patients with aortic regurgitation and from 171 +/- 28 to 144 +/- 30 g/m2 in those with aortic stenosis. CONCLUSIONS: Although long-term follow-up is required for further evaluation, the early results appeared to indicate that the Freestyle aortic bioprosthesis was suitable for elderly patients requiring aortic valve replacement.     

Early experience with robotic mitral valve repair with intra-aortic occlusion

Objective

To report the learning curve and early results of robotic mitral valve repairs in comparison with propensity score–matched sternotomy controls after the adoption of a robotic mitral valve surgery program in a university teaching hospital.

Clinical experience with stentless pericardial aortic monopatch for aortic valve replacement

A stentless pericardial aortic monopatch was used in 60 consecutive patients undergoing aortic valve replacement. The monopatch is constructed of a sheet of glutaraldehyde-treated bovine pericardium, tailored and shaped to fit the aortic anulus, and is sutured in place without a stent or sewing ring. The valve area is effectively preserved by this method. Results indicate that this technique is simple, inexpensive, and applicable to all cases of aortic valve disease. It does not require anticoagulation and may allow for annular growth when used in children. This technique is particularly suitable for patients with infective endocarditis because the amount of foreign material is minimized.     

Two decades' experience with aortic valve replacement with pulmonary autograft

Aortic valve replacement with a pulmonary autograft was performed on 241 patients between June 1967 and October 1986 at National Heart Hospital, Guy's Hospital, Middlesex Hospital, Harley Street Clinic, and Italian Hospital in London by one of the authors (D.N.R.). The longest follow-up is 18 years 7 months, and the cumulative total follow-up is 1130 patient-years (pt-yr). The overall 30-day mortality rate is 6.6% (16 patients), with no deaths after 1976, and the late mortality rate is 1.7%/pt-yr (19 patients). The actuarial survival rate is 57.3% +/- 9.6% at 19 years. No anticoagulation has been used and there have been no thromboembolic episodes. The incidence of bacterial endocarditis is 1.2%/pt-yr (14 patients), and its actuarial event-free rate is 74.2% +/- 8.1% at 19 years. Reoperation because of failure of the pulmonary autograft was performed on 36 patients, 27 of whom needed valve replacement. The incidence of pulmonary autograft replacement is 2.5%/pt-yr, and its actuarial event-free rate is 48.5% +/- 13.7% at 19 years. For reconstruction of the right ventricular outflow tract, 186 aortic homografts, 26 pulmonary homografts, 16 autologous fascia lata valved conduits, 7 autologous pericardial conduits with or without a valve, and 6 xenograft valved Dacron conduits were used. Thirty-one patients were reoperated on, mostly because of degeneration of this material. Pulmonary rather than aortic homografts are now favored for reconstruction of the right ventricular outflow tract Because of its satisfactory long-term result without the need for anticoagulation, as well as its safety as an established surgical procedure, this operation can be recommended to a wider range of patients.     

Homograft aortic valve replacement: seven years' experience with antibiotic-treated valves.

One hundred and sixty-five patients had their aortic valve replaced with antibiotic-sterilised homograft. In all cases, a two-layered freehand technique of valve implantation was used. Tailoring (narrowing) of the annulus was required in 29 cases, and an aortic root gusset was used to enlarge the non-coronary sinus in 68 cases. There was an early mortality of 1.8% and late mortality of 2.4%. The actuarial survival rate was 95% at a maximum follow-up of seven years. The incidence of valvar regurgitation (early diastolic murmur) was 11.5% up to six months after operation and an additional 7.2% subsequent to this. Overall, it was trivial in 10.3%, mild in 7.8%, and moderate in 0.6%. Most valve regurgitation was non-progressive and actuarial analysis showed 74% regurgitation-free valves at the end of seven years. The age of the donor and the valve storage time showed some relationship to valve deterioration. Special attention has been paid to the control of hypertension to prevent accelerated graft degeneration. The results suggest that this has been successful. Anticoagulant therapy was not used and thromboembolism has not been seen in patients undergoing isolated aortic valve replacement. There was one case of miliary tuberculosis after homograft valve replacement but no pyogenic or fungal endocarditis occurred. No haemolysis, calcification, or valvar stenosis were observed. This series, followed for a maximum of seven years, shows excellent sustained valve performance and a very low incidence of important postoperative regurgitation, with 91.8% of the survivors symptom-free.     

Clinical experience with a porcine aortic valve xenograft for mitral valve replacement

Between March, 1971, and July, 1973, 103 patients underwent mitral valve replacement with a glutaraldehyde-preserved porcine aortic valve mounted on a flexible polypropylene, Dacron-covered stent. Overall operative survival was 95.1%. Actuarial analysis of late postoperative results indicates 92% survival through 2 years, with functional improvement in nearly all patients. The rate of systemic thromboembolism has been approximately 1.7% per patient-year without anticoagulants. No valve failure has occurred. We conclude that this xenograft prosthesis provides a technically and functionally satisfactory valve substitute, the durability of which appears to significantly exceed that of previously available tissue valves for mitral replacement.     

Primary isolated aortic valve replacement. Early and late results

A total of 1689 consecutive patients underwent isolated aortic valve replacement at the Cleveland Clinic Foundation from 1972 through 1986. There were 57 (3.4%) in-hospital deaths. Multivariate analysis identified advanced age (p = 0.0014), preoperative blood urea nitrogen level greater than 25 mg/100 ml (p = 0.008), New York Heart Association function class (p = 0.015), and preoperative atrial fibrillation (p = 0.04) as independent variables associated with increased in-hospital mortality and the use of cardioplegia for myocardial protection (p = 0.006) as a factor decreasing mortality. Follow-up documented survival rates of 85% and 66% and event-free survival rates of 71% and 43% at 5 and 10 postoperative years, respectively. Advanced age, moderate or severe impairment of left ventricular function, coronary artery disease, and preoperative blood urea nitrogen level greater than 25 mg/100 ml were associated with decreased late survival and event-free survival (all p less than 0.05). Patients with bioprostheses had better survival (p = 0.003) and event-free survival (p = 0.0007) rates than patients with mechanical valves. Patients with bioprostheses had superior results only if not receiving warfarin, and they experienced more reoperations and endocarditis; those with mechanical prostheses had more strokes, myocardial infarctions, bleeding complications, and thromboembolic events. Analysis of patients grouped according to age at operation showed that bioprostheses were associated with improved survival and event-free survival for patients 40 years older or older. Younger patients experienced more reoperations and episodes of endocarditis, and older patients more thromboembolic complications. We conclude that 10-year results after isolated aortic valve replacement are influenced by both patient-related and management-related variables, and the impact of these factors is different for patients of different ages.     

Emergency aortic valve replacement.

The aortic valve was replaced as an emergency in twenty-seven patients between July 1970 and December 1974. Twenty-two patients had critical aortic stenosis and five had acute aortic insufficiency. The indications for emergency surgery were cardiac arrest in five patients, low cardiac output in four patients, and medically intractable pulmonary edema in eighteen patients. Cardiac catheterization was not undertaken in ten persons because of their critical condition. The clinical diagnosis in these patients was supported by noninvasive maneuvers. No surgical deaths occurred. Twenty-five patients are well, active and NYHA Class I at five to thirty-three months after surgery. There has been one late death and one patient has some residual exertional dyspnea. One patient required reoperation to relieve a clotted prosthetic valve. These results suggest that the patient with aortic valve disease may be offered a reasonable chance for survival, even when desperately ill.     

Our experience with aortic root replacement using hand-sewn composite valve graft

Background The purpose of this study is to examine our experience with aortic root replacement using composite valve grafts in patients with proximal aortic disease. Methods and Results Since 1986, 16 patients underwent aortic root replacement using composite valve grafts for various indications which were Marfan's syndrome with annuloaortic ectasia (n=2), aortic regurgitation with ascending aortic aneurysm (n=3), aortic stenosis with regurgitation with poststenotic dilatation (n=9) and progressive aortic dilatation following AVR (n=2). There were 12 males and 4 females. The age range varied between 19 years and 52 years. The choice of conduit was a custom made valved graft using a monoleaflet tilting disc valve (Medtronic Hall valve=11, St Vincent's valve=3, TTK Chitra=1 and Bjork Shiley Valve=1) placed in a Dacron graft (Hemashield=13, Verisoft Cooley=3) prepared using a 4-0 polypropylene suture. The average time taken to construct a valved graft was 20 min±8 min. The coronary implantation was by isolated button technique. There was no size mismatch encountered in any patients. Postoperative bleeding necessitated a delayed sternal closure in 3 patients and re-exploration in another 2. The immediate operative mortality was 2, the cause being ventricular arrhythmia in one and cerebrovascular accident in other. Follow-up period ranged from 2 months to 16 years with a median follow-up of 12 months. One patient had an asymptomatic perigraft collection and no intervention was needed. There was no valve related complications in any of these patients. There was one late death of unknown cause. Conclusions Aortic root replacement using a custom made composite graft offers excellent long-term results, with negligible mortality rate and prosthesis related complications. Custom made grafts make this conduit easily affordable in our country and their performance is comparable to other available composite grafts.     

Twelve-year experience with mitral valve replacement.

Between 1962 and 1974, 203 mitral prostheses were implanted in 201 patients. Of the 102 survivors, 29 have Beall, 25 Kay-Shiley, 22 Starr-Edwards (SE) 6000, and 27 SE 6320 valves. Full rehabilitation was achieved in 25 patients with Beall and 23 with SE 6320 valves. Sixteen with SE 6000 valves remain normally active. Only 8 with Kay-Shiley prostheses have resumed normal activities. Systemic embolization occurred with the following frequencies per 1,000 patient-months: 13.7 for those receiving the Kay-Shiley valve; 7.2 in the SE 6000 group; 4.3 after SE 6320 implantations; and 3;1 for the Beall group. Other prosthesis-related complications that were much less frequent included detachment (10), bacterial endocarditis (5), and hemolysis (10). Three Kay-Shiley valves malfunctioned. Life table analyses reveal the following survival rates: 33% after 11 years in the SE 6000 patients, 50% after 7.5 years in the Kay-Shiley group, 69% 2.5 years after SE 6320 implantation, and 65% 3.5 years after replacement with a Beall valve. Evidence is presented to support the extension of operative treatment to patients with less advanced valvular heart disease. Postoperative anticoagulation remains an unresolved issue despite lower rates of thromboembolism. More cumulative analyses of survival and morbidity and follow-up hemodynamic data are needed to assess the Beall and SE 6320 prostheses now employed in our valve replacement program.