David Ⅰ手术治疗主动脉根部病变致主动脉瓣关闭不全的效果

目的 评价David Ⅰ术式治疗主动脉根部病变导致主动脉瓣关闭不全的治疗效果.方法 2005年8月至2011年5月,采用David Ⅰ手术治疗24例主动脉根部病变导致主动脉瓣关闭不全患者.男21例,女3例;年龄24 ～ 69岁,平均(47.0±12.3)岁.主动脉夹层13例,主动脉根部瘤7例,马方综合征2例,单纯主动脉瓣环扩张并主动脉瓣关闭不全2例.术前心功能Ⅰ级20例,Ⅱ级3例,Ⅲ级1例;主动脉瓣反流中度13例,重度11例.David Ⅰ手术采用直人工血管9例,带Valsalva窦人工血管15例.同期行冠状动脉旁路移植手术6例,主动脉弓置换11例,室间隔缺损修补术1例,房间隔缺损修补术1例,二尖瓣成形+三尖瓣成形1例.1例术中食管超声提示主动脉瓣大量反流,瓣叶脱垂,即刻决定使用带瓣人工血管行Bentall手术.术后观察患者心功能和主动脉瓣反流情况.结果 围术期死亡2例,分别于术后第9天死于感染性休克并多脏器功能衰竭和术后第22天死于肺部感染;近期死亡1例,术后第54天死于肺部感染.本组体外循环(235.9±58.5) min,主动脉阻断(182.7±35.8) min.术后1周超声心动图复查,主动脉瓣无反流11例,轻度反流11例,轻至中度反流1例;所有患者心功能均为Ⅰ级.术后20例(不包括3例死亡和1例行Bentall术者)随访3～74个月.主动脉瓣无反流3例;轻度反流15例,其中3例半年后再次复查提示主动脉瓣无反流;中度反流2例,其中1例3个月后复查提示反流转为轻度,1例采用直人工血管的马方综合征患者术后55个月复查提示反流转为重度.结论 保留主动脉瓣的主动脉根部再植入术(David Ⅰ术式)是治疗主动脉瓣叶及瓣环结构大致正常的主动脉根部病变引起的主动脉瓣关闭不全的一种理想手术方式,同时应用带Valsalva窦血管能提供更稳定的手术效果.     

Ken-Valve经心尖途径导管主动脉瓣置换术治疗主动脉瓣重度狭窄合并重度反流一例

经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）在治疗重度主动脉瓣狭窄中的应用不断增加。新一代介入瓣膜器械的应用,增强了手术的安全性和有效性。本文报道了1例72岁主动脉重度反流合并中度狭窄的男性患者,经评估为外科中高风险,应用Ken-Valve瓣膜经心尖途径TAVR。手术导管操作时间8 min,术中失血量50 mL,术后手术室即刻拔除气管插管,术后第4 d复查超声心动图,主动脉瓣叶活动良好,无瓣口及瓣周漏,术后第5 d出院。经心尖入路Ken-Valve瓣膜治疗主动脉瓣疾病,操作简单,手术时间短。     

单个主动脉瓣叶牛心包置换术治疗儿童室间隔缺损合并主动脉瓣反流

目的 探讨儿童单个主动脉瓣叶牛心包置换在室间隔缺损合并严重主动脉瓣反流患儿中的疗效。 方法回顾性分析2006年3月至2009年9月武汉亚洲心脏病医院室间隔缺损合并严重主动脉瓣关闭不全42例患儿行单个主动脉瓣叶牛心包置换术的临床资料。其中男28例、女14例,平均年龄2～14 （9.0±3.6） 岁。所有心功能分级（NYHA）均为Ⅱ级。 结果 手术没有死亡以及并发症的发生。术后即刻经食管超声心动图提示手术成功修复主动脉瓣,瓣叶均对合正常。所有患者主动脉瓣反流均在轻度以内,跨主动脉瓣峰压差为（14.2±2.8） mm Hg。住院时间11 d,没有任何不良症状。全组患者随访32～72 （50±16） 个月。术后心功能均为Ⅰ级,无反流17例,轻度反流21例,中度反流4例。跨主动脉瓣峰压差为（12.4±3.2） mm Hg。随访中无死亡和需要二次手术患者。随访观察中未见牛心包瓣叶结构性衰败。 结论 对于室间隔缺损合并重度主动脉瓣关闭不全的患者,单个主动脉瓣叶牛心包置换术具有良好的血流动力学和中期效果。     

保留主动脉瓣主动脉根部置换术治疗主动脉根部瘤的疗效分析

目的评价使用保留主动脉瓣主动脉根部置换术治疗主动脉根部瘤的临床应用疗效。方法 2001年2月至2010年9月阜外心血管病医院对60例主动脉根部瘤患者行保留主动脉瓣主动脉根部置换术,其中男44例,女16例;年龄9～64(37.2±13.0)岁。主动脉夹层15例,升主动脉瘤10例,马方综合征25例,主动脉瓣二瓣化畸形2例。行主动脉根部重建术53例,主动脉瓣瓣叶再植术7例。比较术前、术后心功能及主动脉瓣反流程度等指标。结果全组中无手术死亡和严重并发症发生,呼吸机使用时间中位数为13(2～1 110)h,住ICU时间1～18(2.7±2.5)d。术后复查超声心动图提示:主动脉瓣反流程度均明显减轻,仅3例为中大量反流,其余无反流或微少量反流。术后随访2～122(61.5±35.9)个月,随访56例,失访4例,随访期间死亡9例,生存率83.9%(47/56)。2例因主动脉瓣反流分别于术后13个月和14个月再次入院行主动脉瓣置换术。47例患者心功能较术前明显改善,心功能Ⅰ级35例(74.4%),Ⅱ级8例(17.0%)。免于主动脉瓣中重度反流40例(85.1%)。结论保留瓣叶的主动脉根部置换术治疗主动脉根部瘤的远期疗效满意,瓣膜相关并发症发生率低。     

Ross术后中远期主动脉瓣反流的危险因素分析

目的 分析影响Ross手术后中、远期主动脉瓣反流的危险因素.方法 自1998年3月至2007年7月,47例主动脉瓣瓣膜疾病病人接受Ross手术,其中男25例,女22例;平均年龄(13.31±5.79)岁.术前诊断风湿性心脏病6例,先天性心脏病41例.病人均采用经胸超声评价主动脉瓣反流情况,采用Logistic:回归分析主动脉瓣反流危险因素.结果 全部病例随访(36.15±22.1)个月,均生存.主动脉窦径及主动脉瓣环直径均较术前明显增加,新主动脉瓣免于轻度以上反流率为82.9%.Logistic回归分析发现,术前主动脉瓣二瓣化畸形、术前主动脉瓣环扩大及病人年龄大于14岁为术后主动脉瓣反流的危险因素.结论 Ross手术治疗主动脉瓣膜疾病安全、有效,主动脉瓣可随机体发育而生长,其中、远期效果满意.年龄大于14岁、术前主动脉瓣环扩大及术前主动脉瓣二瓣化畸形是增加Ross手术后主动脉瓣反流的危险因素.     

保留主动脉瓣的根部重建术治疗马方综合征主动脉根部瘤

目的 总结保留主动脉瓣的根部重建术治疗马方综合征主动脉根部瘤的经验.方法 2003年7月至2007年12月22例马方综合征患者接受保留主动脉瓣的根部重建术.其中男性12例,女性10例;年龄10～57岁;平均(28±10)岁.手术方法包括再植技术9例、成形技术8例、单片法2例,再植手术+全主动脉置换1例,成形手术+全弓置换+支架象鼻手术1例,单片法+全弓置换+支架象鼻手术1例.术后随访17～64个月,平均随访(46±16)个月.结果 无住院及随访期死亡,1例患者再次开胸止血,随访期无瓣膜相关并发症发生.截至最后一次随访,16例无主动脉瓣反流,4例少量反流,中度及重度反流各1例.中度及重度反流的患者于术后1年进行了再次瓣膜置换手术.结论 保留主动脉瓣的根部重建术早、中期效果满意,可用于治疗马方综合征患者的主动脉根部瘤.     

牛心包主动脉瓣叶置换术在主动脉瓣二瓣化畸形合并主动脉瓣反流中的应用

目的探讨主动脉瓣叶牛心包置换术在主动脉瓣二瓣化畸形合并主动脉瓣反流患者中的疗效。方法回顾性分析2008年6月至2013年12月武汉亚洲心脏病医院主动脉瓣二瓣化畸形合并主动脉瓣重度反流的79例患者行主动脉瓣叶牛心包置换术的临床资料。其中男60例、女19例,平均年龄12~78(38±14)岁。全组心功能分级(NYHA)均为Ⅱ级。主动脉窦管交界及升主动脉扩张患者26例。结果全组无死亡及并发症发生。术后即刻经食管超声心动图提示手术成功重建主动脉瓣,瓣叶均有正常对合,所有患者主动脉瓣反流均在1级以内,跨主动脉瓣峰压差(14.2±2.8)mm Hg。住院时间15 d,没有任何不良症状。全组患者随访9~64(50±16)个月。术后心功能均为Ⅰ级。末次随访显示:主动脉瓣反流0级57例,1级16例,2级5例,3级1例;跨主动脉瓣峰压差(12.4±3.2)mm Hg;主动脉窦管交界及升主动脉扩张患者窦管交界平均直径为2.7 cm,窦管交界形态正常;超声测量主动脉瓣对合缘高度为0.58 cm。随访中无死亡和需要二次手术患者。随访中未见牛心包瓣叶结构性衰败。结论对于主动脉瓣二瓣化畸形合并严重主动脉瓣反流的患者,主动脉瓣三叶牛心包置换术具有良好的血流动力学和中期效果。对于主动脉窦管交界及升主动脉扩张的患者,需要同期行主动脉窦管交界及升主动脉成形术。     

四叶式主动脉瓣畸形的诊断及外科治疗

目的 总结四叶式主动脉瓣畸形的超声心动图诊断并探讨外科治疗.方法 回顾分析上海市心血管病研究所2004年1月至2007年5月超声心动图资料,总结四叶式主动脉瓣膜病例的超声诊断特点.观察23例四叶式主动脉瓣四叶分布形态、回声、启闭及血流动力学情况.并总结分析手术治疗的9例病人的资料.结果 在92656例心脏超声检查中,共检出四叶式主动脉瓣膜畸形23例,检出率为0.248‰.年龄19～83岁,平均(50.3±18.8)岁;男11例,女12例.23例中22例合并不同程度主动脉瓣膜反流,仅1例主动脉瓣膜功能正常.其中9例行主动脉瓣膜置换手术,术中发现A型8例,F型1例.结论 四叶式主动脉瓣膜畸形是非常少见的先天性心脏畸形,多数由超声心动图检查发现,实时三维超声心动图对可疑病例可明确诊断.四叶式主动脉瓣膜畸形主要并发主动脉瓣膜反流,严重者应手术治疗.     

小主动脉瓣环患者主动脉瓣置换术41例

目的总结主动脉瓣环加宽后的主动脉瓣置换术治疗小主动脉瓣环合并主动脉瓣病变患者的临床经验。方法对41例小主动脉瓣环合并主动脉瓣病变患者(瓣环直径为15~21 mm)行主动脉瓣环加宽后的主动脉瓣置换术,主动脉瓣环加宽采用改良N icks法11例,改良M anougn ian法29例,K onno法1例。结果41例患者主动脉瓣环加宽后都可以植入比测量的主动脉瓣环直径大1#或2#的主动脉瓣,无手术死亡。术后所有患者随访4~36个月(13±2个月),无死亡、瓣周漏、二尖瓣反流和主动脉扩张;超声心动图检查示:人工瓣跨瓣峰值压差为9~25mmHg(17±6mmHg),与术前的70~105mmHg(80±15mmHg)比较差别有统计学意义(P<0.01)。结论小主动脉瓣环合并主动脉瓣病变患者,在置换主动脉瓣时先行主动脉瓣环加宽,能使患者在术后获得良好的血流动力学效果,是一种安全、有效的手术术式。     

自体心包片加高法治疗主动脉瓣脱垂

目的总结用自体心包加高方法矫正主动脉瓣脱垂的临床经验。方法2000年5月至2007年7月,阜外心血管病医院共对17例主动脉瓣脱垂患者施行自体心包片加高手术,其中主动脉右冠瓣脱垂15例,左冠瓣脱垂1例,无冠瓣脱垂1例;主动脉瓣中度反流10例,重度反流7例。取自体心包,用5-0或6-0 Prolene线连续缝合加高脱垂的主动脉瓣。术中经食管超声心动图（TEE）检查提示：主动脉瓣微量至少量反流;对术前、术后超声心动图检查结果进行比较。结果术前、术后超声心动图检查结果比较：术后左心室舒张期末内径较术前明显缩小（38．3±9．6mm vs．47．2±10．3mm,P=0．013）;主动脉瓣收缩期压差（9．8±5．6mmHg vs．10．3±5．3mmHg,P=0．792）,主动脉瓣舒张期压差均较术前有明显缩小（45．7±13．6mmHg vs．78．4±19．9mmHg,P=0．000）。出院前超声心动图检查提示：无明显主动脉瓣反流4例,轻度反流9例,轻至中度反流4例。平均随访32个月（4～74个月）,1例术后4个月因主动脉瓣大量反流行主动脉瓣置换术,其余患者均不需要进行二次手术。结论主动脉瓣瓣叶自体心包加高成形其手术方法简便,对儿童或小主动脉瓣患者是一种良好的手术方式。     

Successful valve repair for congenital bicuspid aortic valve and degenerated prolapsed mitral valve

A 54-year-old man with congenital bicuspid aortic valve underwent simultaneous valve repair for aortic and mitral regurgitation. Surgical technique consisted of plication of redundant aortic valve repair and mitral annuloplasty with chordal replacement. One-year follow-up transthoracic echocardiography showed no valve regurgitation. Valve repair for both bicuspid aortic valve and mitral valve regurgitation should be the first option in this subset of patients.     

Aortic Dissecting Aneurysm with a Bicuspid Aortic Valve in Turner's Syndrome: Report of a Case

We herein report the performance of a successful, modified Bentall procedure and a total arch replacement for a Stanford type A chronic aortic dissection and a bicuspid aortic valve in Turner's syndrome (TS). The patient was a 45-year-old woman with 45, XO karyotype TS, who had had a history of hypertension since the age of 20. She had also been diagnosed as having a dilatation of the ascending aorta and a bicuspid aortic valve 3 years earlier. The patient became aware of back pain 6 months prior to the current admission, and was diagnosed as having a Stanford type A chronic aortic dissection and a bicuspid aortic valve with mild aortic regurgitation. One of the greatest concerns in TS is the risk of aortic dissection. Regarding the operation, aortic root replacement is one of the options for a bicuspid aortic valve so as to avoid high-risk surgical procedures in TS.     

Valvuloplasty for aortic valve regurgitation resulting from cusp prolapse

Three adults, 2 with tricuspid aortic valve and 1 with bicuspid valve, underwent valvuloplasty for aortic valve regurgitation resulting from cusp prolapse. Surgical procedures consisted of combined cusp plication by triangular cusp resection and subcommissural annuloplasty. Doppler echocardiography revealed trivial aortic valve regurgitation intraoperatively and less than I/IV at discharge in all cases. After mean follow-up of 15 months, 2 tricuspid aortic valve patients remain I/IV regurgitation and II/IV in the bicuspid patient. Although long-term results remain unclear, our results show that this procedure is feasible and beneficial in patients with aortic valve regurgitation due to cusp prolapse.     

Ascending aorta dissection associated with bicuspid aortic valve

Aortic dissection etiology involve many factors that are difficult to identify clearly. We report a 47-year-old man who underwent a Bentall operation with reattachment of bypass grafts for a dissecting aneurysm (DeBakey type II) 4 years after combined triple coronary artery bypass grafting and mitral valve replacement. This case appeared to be associated with factors leading to dissecting aneurysm although it remains unclear which was more influential congenital bicuspid aortic valve or proximal anastomosis of venous grafts or both. This case suggests the need to consider appropriate timing in surgical intervention for cases of congenital bicuspid aortic valves and the selection of additional aortic valve replacement in initial surgery.     

Balloon aortic valvuloplasty: Treatment of rapid deployment aortic valve replacement complicated by a paravalvular leak

The Edwards Intuity Elite valve system was designed to facilitate minimally invasive surgery and streamline complex aortic valve replacements and has since gained more popularity. Despite the superior results shown with rapid deployment aortic valve replacement (RDAVR) utilizing this valve system, paravalvular leaks (PVL), as a complication, remains a concern. Currently, there is no universally agreed single treatment option. A 53‐year‐old male with a history of well‐controlled diabetes mellitus and hypertension presented to the emergency room with a 1‐month history of angina, syncope on exertion and dyspnea. On further workup, he was found to have severe aortic stenosis in the setting of a bicuspid aortic valve, with non‐obstructive coronary artery disease. He proceeded to urgent RDAVR with a 23 mm Edwards Intuity Valve. Six months post‐RDAVR he re‐presented with dyspnea on exertion and near syncopal episodes. Postoperative transthoracic and transesophageal echocardiography revealed moderate to severe PVL posterior to the prosthetic aortic valve. Balloon valvuloplasty with a 25 mm True Balloon was performed. Resolution of the PVL was confirmed postprocedure both by angiography and echocardiography. The patient was followed for 1 year and remained symptom‐free with evidence of mild PVL on surveillance echocardiography. In conclusion, multiple treatment options for RDAVR complicated by PVL exist; however mid to long‐term outcome data are lacking. We presented one such case successfully treated with balloon aortic valvuloplasty.     

经主动脉切口治疗主动脉根部瘤合并二尖瓣病变

目的 总结经主动脉切口治疗主动脉根部瘤合并二尖瓣病变的初步经验。方法 2009年3月至2010年12月,经主动脉瓣口行二尖瓣手术16例中男13例,女3例;年龄18～ 75岁,平均(40±10)岁。16例中Bentall+ MVR术12例,Bentall+ MVP术1例,Bentall+全弓置换+支架象鼻+MVP术1例,...     

Surgically treated aortic root aneurysm following aortic valve replacement

A 65-year-old man with aortic regurgitation underwent aortic valve replacement with a St. Jude Medical prosthetic valve about 6 years ago. At that time, the aortic root was slightly dilated at about 40 mm in diameter and the ascending aorta was within the normal range. This year, the man was diagnosed with an aortic root aneurysm in regular follow-up echocardiography. Chest-enhanced computed tomography and chest aortography at our hospital demonstrated a pear-like aortic root aneurysm about 60 mm in diameter. Elective operation for the aortic root aneurysm was conducted September 29, 1999, based on the Bentall procedure. Composite graft replacement with coronary reconstruction was conducted using a 28-mm Hemashield prosthetic graft and a 23-mm St. Jude Medical prosthetic valve under cardiopulmonary bypass. An 8-mm Hemashield graft was interposed on the left main coronary artery and the right coronary artery was directly anastomosed using a Carrel patch method. The postoperative course was uneventful and post-operative examination demonstrated good surgical results. Histological findings of the aortic aneurysm wall showed cystic medial necrosis. Surgical cases of aortic root aneurysm after aortic valve replacement are rare, but serious complications with the possibility of rupture or dissection warrant surgical intervention.     

Transapical combined transcatheter aortic valve-in-valve implant and ascending aorta endovascular repair

We report the case of a 64-year-old patient who previously had an aortic valve replacement with a stentless aortic valve and an ascending aorta replacement for a DeBakey type II aortic dissection. The patient was referred to us for symptomatic aortic regurgitation related to bioprosthesis degeneration and a pseudoaneurysm at the distal anastomotic site of the vascular graft. Due to the presence of several comorbidities, the patient had a combined transapical transcatheter aortic valve-in-valve implant and an ascending aorta endovascular repair.     

Two decades of experience with root remodeling and valve repair for bicuspid aortic valves

Objective

Bicuspid aortic valve anatomy is associated with ascending aortic aneurysm in approximately 50% of individuals and may lead to severe aortic regurgitation with aortic dilatation. Both entities may be treated by valve repair and root remodeling. The objective was to review the cumulative experience of 20 years.

Stenosis of the bicuspid aortic valve with systemic lupus erythematosus

We herein present a rare case of severe aortic valve stenosis with a bicuspid valve in a patient with systemic lupus erythematosus. The symptoms resulted from aortic valve stenosis, such as chest pain, dyspnea and syncope, which subsided after the insertion of an intra-aortic balloon pump. Thereafter, a calcified bicuspid aortic valve was successfully replaced with a mechanical valve. The pathological findings of the resected valve included irregular fibrotic thickening and marked calcification without any vegetation or thrombus formation. The efficacy of an intra-aortic balloon pump for the relief of symptoms associated with severe aortic valve stenosis indicates its usefulness for such critically ill patients prior to undergoing valvular surgery.