主动脉瓣病变伴根部严重狭小的外科治疗

主动脉瓣置换手术人工瓣膜瓣开面积与患者的体表面积匹配影响手术的远期临床疗效，因此，对于主动脉根部狭小患者，常需行主动脉窦部或瓣环加宽以置换直径较大的人工瓣膜。从1998年1月到2007年12月，我们共实施21例小主动脉根部加宽和主动脉瓣置换手术，取得了满意的临床效果。现报道如下。     

Successful management of dissection of the aortic root during aortic valve replacement

We present a case of intraoperative dissection of the aortic root in a patient with non-calcified aortic valve incompetence. This complication led to life-threatening bleeding from the dissection line into the layers of the left ventricle as well as the aortic wall with formation of an increasing subadventitial hematoma. The only possible management was to remove the valve prosthesis and to close the entry site of the dissection when reinserting the valve implant. The mechanism of this complication is discussed.     

Evaluation and management of tricuspid valve disease

The four groups of pathophysiologic changes of the tricuspid valve are discussed; these include functional insufficiency, organic insufficiency, stenosis, and congenital defects. A thorough understanding of these underlying abnormal changes has led to the ability to correct malfunction of the tricuspid valve in a reliable manner.     

In-vitro comparison of aortic valve hemodynamics between aortic root remodeling and aortic valve reimplantation

BACKGROUND AND AIM OF THE STUDY: Valve-preserving aortic replacement has become an accepted option for patients with aortic valve regurgitation and aortic dilatation. The relative role of root remodeling versus valve reimplantation inside a vascular graft has been discussed, albeit controversially. In the present study, an in-vitro model was used to investigate the aortic valve hemodynamics of root remodeling and valve reimplantation; roots with supracommissural aortic replacement served as controls. METHODS: Aortic roots with aortoventricular diameter 21 mm were obtained from pigs. Root remodeling was performed using a 22-mm graft (group I, n = 6), or valve reimplantation with a 24-mm graft (group II, n = 7). Control roots were treated by supracommissural aortic replacement (22-mm graft; group III, n = 7). Using an electrohydraulic, computer-controlled pulse duplicator, the valves were tested at flows of 2, 4, 5, 7, and 9 I/min at a heart rate of 70 /min and a mean arterial pressure of 100 mmHg. Parameters assessed included: mean pressure gradient, effective orifice area, valve closure and regurgitant volume, and energy loss due to ejection, valve closure and regurgitation. Data were compared using ANOVA. RESULTS: There were no differences between the three groups in terms of regurgitant volume, energy loss due to valve regurgitation, or valve closure. The aortic valve orifice area was largest and systolic gradient lowest in group I at all flow rates (p < 0.001). Ejection energy loss was lowest in group I at all flow rates (9 l/min: group I, 128 +/- 21 mJ; group II, 399 +/- 46 mJ; group III, 312 +/- 27 mJ; p < 0.001). Valve closure volumes were similar in groups I and III, but significantly lower in group II at all flow rates (p = 0.047). CONCLUSION: In this standardized experimental setting, root remodeling--but not valve reimplantation--resulted in physiologic hemodynamic performance of the aortic valve with regard to orifice area, pressure gradient, and systolic energy loss.     

Aortic root size in aortic valve disease Its measurement and significance

In 2 subjects who had a very small aortic root the surgical procedure of aortic valve replacement was greatly complicated, and obstruction of the aortic root and coronary arteries led to early death. All aortic valve replacements at the University of Wisconsin Hospital from 1963 through 1969 were reviewed. With use of the known catheter size as a reference, the size of the aortic root was calculated from preoperative cineangiocardiograms and correlated with the measurements made at operation. A significant correlation was found, especially with small aortic roots. It is stressed that the small aortic root should be recognized preoperatively when aortic valve replacement is contemplated.     

Evaluation of bioprosthetic valve for small aortic root in elderly patients

The hemodynamics of stentless bioprostheses are superior to those of mechanical valves, especially for patients with a small aortic root. Between March 1999 and July 2001, we implanted 18 Freestyle stentless porcine valves using our technique of repeated division of the space by halving the distance. Seven patients received 19-21-mm valves and 11 received 23-25-mm valves. Clinical data and early and midterm outcomes of both groups were compared. The mean preoperative echocardiography gradient of the small valve group was 84.7 mm Hg, and when discharged from hospital, the mean gradient was 14.8 mm Hg. One operative death was encountered due to arrhythmia. This stentless porcine prosthesis has excellent hemodynamics and can be implanted safely and easily, even in elderly patients with a small aortic root, using our suture technique.     

Conservative management of aortic root rupture complicated with cardiac tamponade following transcatheter aortic valve implantation

Aortic root rupture and cardiac tamponade during transcatheter aortic valve implantation is a frightening complication with high mortality rate. A conservative management of this complication could represent an initial strategy,especially in high-risk patients,to avoid emergent cardiac surgery. This conservative management includes:Immediate detection of pericardial effusion by echocardiography,a fast instauration of pericardial drainage,auto-transfusion and anticoagulation reversal. We describe two cases of patients who suffered this complication and were treated successfully with this initial approach.     

A measured approach to managing the aortic root in patients with bicuspid aortic valve disease

Bicuspid (or bicommissural) aortic valve (BAV) is the most common cardiovascular malformation in humans, with a prevalence of 1% to 2% in the general population and a 2:1 male:female ratio. BAV is frequently associated with other cardiovascular malformations, including aortic root dilatation, which affects about 40% of individuals with BAVs and is thought to be associated with increased risk of dissection and/or rupture. Currently, no agreement exists about the optimal management of these patients. We review the pathophysiology and possible determinants of aortic disease associated with BAV, the natural history of aortic wall size progression, and suggest management strategies to prevent acute aortic events.     

Difficulties with horizontal aortic root in transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) emerged to be a viable treatment option for failing bioprosthesis in the aortic position. Transfemoral approach is the most common access route for TAVI and associated with most favorable clinical outcome. However, in the presence of unfavorable aortic root anatomy, TAVI via transfemoral approach provides inadequate support for device manipulation during valve positioning, particularly performed for the indication of severe aortic regurgitation. We report our experience on TAVI utilizing CoreValve for a patient with regurgitant failing bioprosthesis with horizontal aortic root where we encountered difficulties during implantation and retrieval of valve delivery system. © 2012 Wiley Periodicals, Inc.     

Echocardiographic assessment of aortic regurgitation and aortic root dilatation in bicuspid aortic valve]

Aortic regurgitation (AR) and aortic root dilatation in 29 consecutive patients with bicuspid aortic valves but without aortic root disease (20 males, and 9 females: aged 27-85 years) were studied using two-dimensional echocardiography. The normal ranges of aortic root dimensions were calculated from values of 185 normal subjects, as 95% confidence intervals. AR was observed in 17 patients by color flow mapping. In 12 of the 17 AR patients, no significant lesion of the aortic cusp was detected by two-dimensional echocardiography. These 12 AR patients were compared with 12 patients without AR. Increase in dimension of the aortic root was relatively frequent in the 12 AR patients at the aortic annulus (AA) (67 vs 17%, p < 0.05), and at the sinus of Valsalva (A1) (67 vs 17%, p < 0.05). At the ascending aorta 5 mm distal to the sinus of Valsalva (A2), the difference was not significant (58 vs 17%, p < 0.09). The 12 bicuspid AR patients without significant lesions of the aortic cusp were compared with 41 AR patients with normal tricuspid aortic valves. The frequencies of cases with increased aortic root dimension were 67 vs 46% (ns) at the AA, 67 vs 22% (p < 0.05) at A1 and 58 vs 5% at A2 (p < 0.01). Thus, aortic annular dilatation was thought to be the cause of AR in bicuspid and tricuspid aortic valves without significant lesions of the aortic cusps, and generalized dilatation of the aortic root was more frequent in bicuspid AR patients than in tricuspid AR patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Single-stage treatment of aortic coarctation and aortic valve disease

Surgical management of thoracic aortic coarctation associated with severe aortic valve disease is difficult in most cases. As staged procedures are associated with a higher rate of morbidity and mortality, simultaneous operative management of both lesions is desirable. From 1997 to 2001, 9 patients (8 males and 1 female with a mean age of 30.1 +/- 10.4 years) with this condition underwent simultaneous ascending aorta-infrarenal abdominal aorta bypass graft and aortic valve replacement. One patient died from failure of the extracorporeal circulation during the operation. Another patient suffered from partial intestinal obstruction in the early postoperative period but was successfully treated. The underlying pathology was successfully corrected in the 8 surviving patients, whose blood pressure in the upper limbs was reduced while that in the lower limbs rose. Being easier to manage, the single-stage approach with extraanatomic bypass is safe and effective for managing this aortic complication.     

同种异体带瓣主动脉行主动脉根部置换的临床效果

目的 :探讨应用低温保存的同种异体带瓣主动脉行主动脉根部重建手术的临床效果。方法 :85例主动脉瓣膜病变患者行同种主动脉根部置换手术 ,术后随访观察临床结果。结果 :随访 39± 13（1.5～ 91）个月。早期手术死亡率 1% （1/ 85 ） ,远期手术死亡率 6 % （5 / 85 ） ;与术前比较心功能明显改善 （P<0 .0 5 ） ;术后随访心内膜炎发生率占2 % （2 / 85 ） ;生存者中瓣膜无或有轻度返流 84 % （6 6 / 79） ,中度返流 16 % （13/ 79）。结论 :同种异体带瓣主动脉根部重建手术效果可靠 ,且并发症少。     

经心尖主动脉瓣植入术治疗主动脉瓣疾病的手术配合

目的 探讨经心尖主动脉瓣植入术围手术期护理经验,手术配合方法。方法 回顾性总结我院TAVI团队于2018年6月~2018年12月共完成7例经心尖主动脉瓣植入术的围手术期护理及手术配合经验。结果 所有患者均成功完成手术过程,手术时间110-180min。术后24小时内脱离呼吸机,7-10日出院,除1例需要永久起搏器植入外,其余患者均未见明显并发症。结论 针对需要采用经心尖TAVI手术患者,参加手术的器械护士和巡回护士不仅需掌握各种传统开胸手术器械的性能,熟悉介入耗材型号,患者的术前心理护理及病情观察,还需要参加TAVI团队术前病历讨论,全面了解患者的病变特点及具体手术步骤,针对不同患者术中可能发生的突发事情做好应急预案,以保证手术的顺利进行。     

Spontaneous thrombosis of a transcatheter aortic valve replacement-induced aortic root pseudoaneurysm

Aortic annulus rupture or aortic root perforation is a rare complication of transcatheter aortic valve replacement (TAVR), requiring emergent cardiac surgery and carrying a high intraoperative mortality. Few cases can be managed conservatively, provided a strict clinical follow-up. This study describes the case of a 78-year-old patient with a degenerated bicuspid aortic valve stenosis who presented with a late aortic root perforation following TAVR, which was successfully managed applying a “watchful waiting” approach. Cardiac computed tomography imaging played a pivotal role in the diagnosis and subsequent decision on treatment and clinical follow-up.