部分主动脉根部重建术在急性Stanford A型主动脉夹层的应用

目的分析部分主动脉根部重建术在急性Stanford A型主动脉夹层的临床效果。方法 2010年1月至2015年12月,南京医科大学附属南京医院共30例急性A型主动脉夹层累及根部患者行手术治疗,其中男25例、女5例,年龄27~72(51.2±8.0)岁。夹层近心端施行了部分主动脉根部重建术:部分根部成形+升主动脉置换术9例,部分根部成形+升主动脉置换+半弓置换术6例,部分根部成形+升主动脉置换+孙氏手术15例。术后随访10~60(37.9±3.2)个月。比较术前、术后主动脉瓣反流程度等指标。结果全组中无手术死亡发生,1例患者术后15 d死于肺炎,生存率96.7%(29/30)。1例患者随访期间死亡,2例患者因主动脉瓣严重反流分别于术后1年和15个月再次入院行主动脉瓣置换术。截至最后一次随访,24例无主动脉瓣膜反流,2例少量反流。结论 Stanford A型主动脉夹层导致主动脉根部病变,部分主动脉根部重建术能够保留主动脉瓣瓣膜的持久性和功能性,可获得较满意的早、中期疗效。     

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。     

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.     

保留主动脉瓣的主动脉根部重建手术

对于累及主动脉根部的病变如A型主动脉夹层、主动脉根部瘤和马方综合征等,比较传统的手术方式是Bentall手术.尽管Bentall手术的近远期效果尚好,但仍有与人工瓣膜相关的并发症发生[1].部分主动脉根部病变的患者,其主动脉瓣是正常或基本正常的,对于这类患者保存其自身主动脉瓣可提高术后远期疗效.现将保留主动脉瓣的主动脉根部重建术的手术方式及其演变、手术指征、术后疗效比较和评价等综述如下.     

马方综合征主动脉根部手术后远端主动脉病变再次外科治疗

目的 总结马方综合征主动脉根部手术后远端主动脉病变的再次外科治疗结果,探讨相关治疗策略。方法 2000年1月至2010年1月,28例马方综合征主动脉根部手术后远端主动脉病变患者进行再次手术治疗。其中男20例,女8例;年龄23～52岁,平均(38.5±8.7)岁。首次手术包括Bentall手术24例,David手术4例。Stanford A型夹层8例,主动脉根部瘤20例。再次手术包括：胸腹主动脉置换术10例,全主动脉弓置换及支架象鼻术7例,胸降主动脉置换术6例,全主动脉置换术2例,全主动脉弓置换术2例,部分主动脉弓置换术1例。两次手术间隔1 ～12年,平均(6.43 ±3.07)年。结果 术后发生神经系统并发症4例(17％),包括脑卒中1例,截瘫1例,单侧下肢一过性运动障碍2例。二次开胸止血3例,急性肾功能衰竭接受血滤治疗1例。3例因术后呼吸机辅助时间延迟接受气管切开术。术后全部随访,随访时间10～ 118个月,平均(40.8±29.5)个月。住院死亡2例(7.1％),术后1年、5年实际生存率分别为(94.5±1.3)％、(90.6±1.4)％。结论 马方综合征行主动脉根部手术后因远端主动脉病变再次外科治疗临床结果满意。对于患主动脉A型夹层的马方综合征,首次手术即采用积极的主动脉全弓置换及象鼻手术更好。     

主动脉瓣置换术后患者再次主动脉外科干预47例

目的 回顾性分析47例主动脉瓣术后再次主动脉外科治疗病例,提高对主动脉瓣术后主动脉疾病再治疗的认识.方法 2003年1月至2012年6月,47例患者因主动脉瓣术后接受再次主动脉手术治疗.男38例,女9例,再次手术间隔时间(6.0±3.8)年.行主动脉根部替换14例,升主动脉替换10例,主动脉根部/升主动脉+全弓替换+象鼻支架置入术21例,全胸腹主动脉替换2例.所有出院患者均行门诊复查和电话随访.结果 47例患者中主动脉夹层25例(53％),升主动脉瘤12例(26％),主动脉根部瘤10例(21％).风湿性心脏病患者升主动脉直径年增长值高于马方综合征患者(P＜0.05).47例均接受外科手术治疗,术中死亡1例;余患者均出院并随访,随访时间(53.49±33.79)个月,3年生存率83％.结论 对马方综合征、风湿性心脏病等主动脉瓣疾病合并主动脉病变要积极干预、严格随访,减少术后主动脉不良事件.     

保留主动脉瓣根部手术治疗马方综合征的近期疗效CSCD

目的 评价保留主动脉瓣根部手术治疗马方综合征的近期疗效.方法 54例患者,男38例,女16例;年龄20～50岁,平均（31.26±7.80）岁.术前均根据1996年制定的Ghent标准确诊为马方综合征.术前超声心动图示主动脉瓣反流微量5例,少量12例,中量22例,大量15例.根据影像学资料及术中探查,决定是否保留主动脉瓣,其中行Bentall＋二尖瓣成形（MVP）手术2例,Bentall＋二尖瓣置换（MVR）手术4例,Bentall＋全弓＋象鼻手术2例,Bentall手术27例,David＋MVP手术6例,David手术13例.根据术式分为Bentall手术组35例和David手术组19例.随访12～48个月,比较两组手术前、后和不同方案的疗效差异.结果 手术死亡2例,Bentall手术组1例死于术后无法控制的大出血,,David手术组1例死于术后肺部感染、多脏器功能衰竭.52例恢复良好,术后心包及纵隔引流310～820 ml;住院11～29天,平均（16.43±4.38）天.Bentall手术组体外循环（141.09±15.48）min,主动脉阻断（93.82±15.06）min.David手术组体外循环（186.32±23.96）min,主动脉阻断（140.21±22.13）min.术后两种术式的射血分数、左心室径、左心室收缩期末容量、左心室舒张末期容量、短轴缩短率改善与术前相比差异有统计学意义（P〈0.05）,但组间差异无统计学意义（P〉0.05）,术后早期并发症发生比例组间差异无统计学意义,晚期并发症Bentall手术组明显高于David手术组.术后David手术组主动脉瓣反流程度较术前明显减轻（1.37±0.95对2.53±0.84,P〈0.05）.随访期间David手术组1例主动脉瓣重度关闭不全行主动脉瓣置换术;Bentall手术组1例再发腹主动脉夹层手术治疗,6例因华法林抗凝出现出血、栓塞并发症.结论 保留主动脉瓣的根部处理治疗马方综合征的近期疗效满意.     

Bentall术联合全弓置换及支架象鼻手术治疗危重Debakey Ⅰ型主动脉夹层动脉瘤

目的 总结Bentall术同期全弓置换加支架象鼻手术治疗危重Debakey I型主动脉夹层动脉瘤的经验.方法 2005年1月至2007年12月共12例危重Debakey I型主动脉夹层动脉瘤患者接受手术治疗.男性10例,女性2例,平均年龄(40.1±9.5)岁.急性夹层10例,慢性2例.主动脉根部内径平均(5.3±1.8)cm.包括马方综合征4例,主动脉瓣关闭不全12例,持续剧烈胸痛9例,急性左心功能不全8例,心包填塞4例.患者在深低温停循环、低流量选择性脑灌注下行Bentall术+全弓替换+支架象鼻手术.结果 急诊手术9例,从发病到手术完成的时间(41.0±15.9)h.全组心肺转流时间(191±26)min,主动脉阻断时间(134±31)min,深低温停循环时间(50.0±14.5)min.术后死亡1例;出现神志异常6例,偏瘫、偏盲1例,截肢1例,出血二次开胸止血1例,消化道出血1例,胸腔积液2例.11例随访8周～36个月,人工血管通畅无扭曲,支架位置及形态正常,无二次手术病例,1例患者于术后6个月死亡.结论 在充分的器官保护和完善的心肺转流下,Bentall术+全弓置换+支架象鼻手术治疗危重Debakey I型主动脉夹层动脉瘤安全有效.     

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,...     

保留瓣膜的主动脉根部置换术治疗法洛四联症术后主动脉根部扩张的临床疗效

目的 评价保留瓣膜的主动脉根部置换术（valve-sparing aortic root replacement,VSARR）治疗法洛四联症术后主动脉根部扩张的临床效果。方法 回顾性分析2016—2022年四川省人民医院采用VSARR治疗法洛四联症术后合并主动脉根部扩张患者的临床资料。结果 共纳入14例患者,其中男8例、女6例,中位年龄22(12～48)岁。主动脉瓣重度反流5例、中度反流4例、轻度及以下反流5例。主动脉窦部扩张6例,升主动脉明显扩张8例,同期合并室间隔缺损残余分流1例,合并重度肺动脉瓣反流9例。VSARR方式为David手术10例,Yacoub手术2例,Florida sleeve 2例。全组无手术死亡。术后患者中位随访时间2.9(0.4～6.0)年,1例患者出现轻度主动脉瓣反流,其余患者均为微量或无主动脉瓣反流,1例患者出现左室流出道轻度狭窄,余所有患者左室流出道未见明显狭窄。结论 VSARR在法洛四联症术后主动脉根部扩张患者中治疗结果满意,中期随访未见明显左室流出道狭窄,主动脉瓣反流发生率无明显上升。     

Surgery of the aortic root: should we go for the valve-sparing root reconstruction or the composite graft-valve replacement is still the first choice of treatment for these patients?

Objective

To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graftvalve replacement.

Methods

From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation.

Results

In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation.

Conclusion

The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.     

Valve-sparing aortic root replacement in children: intermediate-term results

Valve-sparing root replacement (VSRR) is an attractive option for aortic aneurysm in children with low-operative risk, but mid- and late-term results are not yet known. Between 1997 and 2009, 56 children (mean age 11.5 years) underwent VSRR at our institution. Twenty-six (46.4%) had Marfan syndrome and 24 (42.8%) had Loeys-Dietz syndrome. Mean preoperative max sinus diameter was 4.2±0.8 cm (Z-score 7.7±2.9). Five (8.9%) had >2+ aortic insufficiency (AI). Two (3.6%) underwent David I reimplantation with a straight-tube, 12 (21.4%) had a Yacoub remodeling procedure, and 42 (75.0%) had reimplantation using a Valsalva-graft. There were one (1.8%) operative and three (5.4%) late deaths. One patient required reoperation for bleeding and one required late repair of a distal pseudoaneurysm. Mean follow-up was 5.2 years (range 0-12 years). No patients suffered thromboembolic events or had endocarditis. Of the 12 remodeling patients, four (33.3%) developed >2+ AI and required aortic valve repair or replacement. No patient developed >2+ AI after reimplantation. VSRR in children is a safe alternative to aortic root replacement with mechanical or biological prostheses. In this particular group of patients with connective tissue disorders and proclivity toward annular dilation and late AI, reimplantation is superior to remodeling.     

Acute type A dissection: conservative methods provide consistently low mortality

BACKGROUND: A wide spectrum of operative techniques are applied in acute type A dissection. Most convey hospital mortality between 10% and 20%. In this high-risk setting, we believe that a conservative approach to the aortic root and the complete resection of the primary tear are important. We reviewed the results of this policy from our aortic surgery database. METHODS: Between 1988 and December 2000, 95 acute type A dissection patients were operated on by one surgeon. They included 70 men and 25 women aged 37 to 81 years (mean 65 years). Six had Marfan syndrome. Aortic root restoration or replacement was performed during cooling, open arch repair during circulatory arrest, and hemostasis while rewarming. Eighty-seven patients had ascending aortic replacement with glue resuspension of the valve. Two others had had aortic valve replacement previously. Aortic root and partial arch replacement was performed in 6 Marfan patients. Eighteen patients had hemiarch replacement, and 6 had total arch replacement to excise the tear. RESULTS: Five patients died in hospital (5.3% 30-day mortality) and another after early readmission for mediastinal infection (6.3% total mortality). There were no deaths from bleeding. Two patients required aortic valve replacement for aortic regurgitation 2.5 and 3.0 years postoperatively. Two others required total arch replacement and thromboexclusion procedures, respectively. CONCLUSIONS: Our policy of primary tear excision and preservation of the native aortic valve has resulted in low overall mortality. We still prefer to replace the aortic root in dissected Marfan patients. In this high-risk condition, hospital survival is of paramount importance. A conservative "pathology-oriented" approach helps to achieve this aim.     

Novel technique of valve-sparing aortic root replacement in two children younger than 3 years of age

A novel technique of valve-sparing aortic root replacement was applied to 2 children younger than 3 years of age with Marfan syndrome and large aortic root aneurysms. Using elements of both the remodeling and reimplantation techniques, circumferential rings from a 20-mm to 22-mm polyester graft provide stabilization at the subannular and sinotubular levels, and bovine pericardial patches create pseudosinuses. Follow-up at 2 years in 1 patient and 7 months in a second patient revealed satisfactory valve function with stable aortic root size.     

Results of surgery for aortic root aneurysm in patients with Marfan syndrome

OBJECTIVES: This study was undertaken to examine the long-term results of surgery for aortic root aneurysm in patients with Marfan syndrome. METHODS: Forty-four patients underwent aortic root replacement and 61 underwent aortic valve-sparing operations for aortic root aneurysm. Patients who underwent aortic root replacement had more severe symptoms, worse left ventricular function, more severe aortic insufficiency, and larger aortic root aneurysms than did patients who had aortic valve-sparing operations. Two types of valve-sparing operations were performed: reimplantation of the aortic valve in 39 patients and remodeling of the aortic root in 22 patients. Echocardiography was performed annually during follow-up. The mean follow-ups were 75 +/- 54 months for the aortic root replacement group and 49 +/- 38 months for the aortic valve-sparing group. RESULTS: There were 1 early death and 7 late deaths; 6 deaths were in the aortic root replacement group and 2 were in the aortic valve-sparing group. Survivals at 10 years were 87% in the aortic root replacement group and 96% in the aortic valve-sparing group (P =.3). Freedoms from reoperation at 10 years were 75% in the root replacement group and 100% in the valve-sparing group (P =.1). Freedoms from valve-related mortality and morbidity were 65% after root replacement and 100% after valve-sparing operation (P =.02). Freedom from aortic insufficiency greater than 2+ after aortic valve-sparing operations was 75% at 10 years and was similar for both types of valve-sparing operations; however, the diameters of the aortic annulus and neoaortic sinuses increased only after the remodeling procedure. CONCLUSIONS: This study suggests that aortic valve-sparing operations provide similar survival but lower rates of valve-related complications than aortic root replacement for patients with Marfan syndrome. Reimplantation of the aortic valve may be more appropriate than remodeling of the aortic root to prevent dilation of the aortic annulus, and for this reason we now use only this technique to treat patients with Marfan syndrome.     

Aortic valve repair and root preservation by remodeling, reimplantation, and tailoring: technical aspects and early outcome

OBJECTIVES: Evaluate aortic root preserving/sparing procedures for various pathologies associated with ascending aortic aneurysms, including aortic valve regurgitation. METHODS: From the end of 1990 through end of 2004, 388 patients had aortic root preserving procedures (reimplantation 72, remodeling 77, tailoring 239) +/- leaflet repair. Preoperatively, in-house grade aortic regurgitation was 1(+) in 58, 2(+) in 110, 3(+) in 101, and 4(+) in 66. Concurrent leaflet repairs were done in 197 (50.8%, Cabrol/Trusler commissure stitch 158, leaflet plication 36, supracommissure stitch 42, leaflet resection and repair 16, perforation repair 18, and debridement 11). Additional procedures included arch repair in 227 (58%), coronary bypass in 83 (21.4%), elephant trunk in 33 (8.5%), and minimally invasive approach in 30 (7.7%). Pathologies included dissection in 140 (36%; 86 acute), Marfan syndrome in 39 (10%), bicuspid valve in 78 (20%), and degenerative aneurysm in 142 (36.6%). The CLASS (Commissure, Leaflet, Annulus, Sinuses, Sinotubular) evaluation schema is described that is used for selecting either reimplantation, remodeling, or tailoring of the aortic root according to underlying pathology. RESULTS: Hospital survival was 97.4% (378/388) and stroke occurred in 4.6% (18/388, four permanent, [1%]). On postoperative echocardiography, patients had either no (0) or 1(+) regurgitation (1(+)= 98);13 (3.4%) had 2(+). Three patients (1%) required reoperation for aortic valve failure before discharge (two tailoring, one remodeling). CONCLUSIONS: Excellent early results can be achieved by aortic root preserving procedures and concurrent aortic valve leaflet repairs when appropriately selected for a diverse class of pathologies.     

True Aneurysm of the Left Main Trunk in a Marfan Syndrome Patient at Remote Period after Bentall Operation and Total Arch Replacement: A Case Report

In 2002, a 37-year-old male with Marfan syndrome underwent the Bentall operation, total arch replacement, and aortobifemoral bypass for DeBakey type IIIb chronic aortic dissection, annuloaortic ectasia, and aortic regurgitation. In 2007, mild mitral regurgitation (MR) caused by mitral valve prolapse was identified. In April 2017, echocardiography revealed the worsening of MR and moderate tricuspid regurgitation (TR). Moreover, coronary angiography (CAG) revealed a coronary artery aneurysm in the left main trunk (LMT). In August 2017, the patient underwent mitral valve replacement (MVR), tricuspid annuloplasty (TAP), and coronary artery reconstruction. We reconstructed the LMT aneurysm using an artificial graft. True aneurysm of the coronary artery complicated with Marfan syndrome is a rare complication that has seldom been reported. This case highlights that it is essential to carefully follow-up patients with Marfan syndrome after the Bentall operation.     

主动脉根部瘤外科治疗危险因素和疗效评估

目的 评估主动脉根部瘤外科治疗危险因素和疗效.方法 1996年8月至2009年11月,连续92例主动脉根部瘤手术中男56例,女36例;年龄14～77岁,平均(44.8±1.4)岁.合并主动脉夹层动脉瘤45例,中度以上主动脉瓣关闭不全72例,马方综合征47例.行经典Bentall术59例,纽扣法Bentall术13例,主动脉瓣悬吊术14例,用带主动脉窦人工血管作David Ⅰ术6例.结果 住院死亡8.7%,并发症率31.7%.随访期死亡18例,远期并发症12例.单变量分析术后并发症危险因素为男性、非马方综合征、同期手术、深低温停循环、主动脉阻断≥120 min和术后第1天输血＞1500 ml;住院死亡危险因素为紧急手术、同期手术、主动脉阻断≥120 min、主动脉夹层和术后第1天输血＞1500 ml.Logistic多因素回归分析认为同期手术和术后第1天输血＞1500 ml是并发症和住院死亡危险因素.所有病人1年、5年和10年生存率分别为(97.1±2.0)%、(88.1±4.7)%和(54.0±9.2)%,平均生存(9.9±0.6)年,95%可信区间8.7～11.0.结论 各种主动脉根部瘤手术安全、有效,早、中、长期结果较满意,提倡用纽扣法Bentall术,谨慎选择合适病人作主动脉根部重建术.

Abstract：

Objective Evaluate the outcome of aortic root reconstruction on the analysis of the risk factors influencing surgical results. Methods Between August 1996 and November 2009, 92 patients(56 men, 36 women) aged from 14 to 77years [mean (44.8 ±1.4) years] with aortic root aneurysm underwent aortic root reconstruction. 72 patients had over moderate aortic valve insufficiency. 47 patients suffered from Marfan syndrome. The aortic pathology was aortic dissection in 45. Bentall technique was used in 59 patients, the button technique in 13, the David I with the Valsalva graft in 6 patients and the aortic valve resuspension in 14 patients. Results The hospital mortality rate was 8.7%. The major complications 31. 7%. 18patients died during the period of follow-up. Late complications among 55 survivors were 12. Univariate predictors of the morbidity were the presence of male, non-Marfan, concomitant procedure, deep hypothermia cardiac arrest, aortic cross clamp time and blood infusion. Risk facts for mortality were emergent or urgent operation, aortic dissection, concomitant procedure, aortic cross clamp time and blood infusion. Multivariate analysis revealed risk factors of concomitant procedure and blood infusion were responsible for both morbidity and mortality. The overall long-term survival rate is (97.1 ±2.0)% at 1-year, (88.1 ±4.7)% at 5-year, (54.0 ±9.2)% at 10-year. The mean for survival time is (9.9 ±0.59) years, 95% confidence interval 8.70 -11.01. Conclusion The aortic root restitution procedures are safe and effective in general. The short and long-term outcome is satisfactory. The button technique is the first choice for reimplantation coronary patch. Valve-sparring aortic root reconstructions show promise in safety and applicability.     

Aortic root surgery in Marfan syndrome: Comparison of aortic valve-sparing reimplantation versus composite grafting

OBJECTIVE: The objective of this study was to compare the results of aortic valve-sparing reimplantation and aortic root replacement with mechanical valve conduits in patients with Marfan syndrome undergoing operation for aortic root aneurysms.Patients and methods Between March 1979 and April 2002, 119 patients with clinical evidence of Marfan syndrome underwent composite graft replacement with mechanical valve conduits (n = 74) or aortic valve-sparing reimplantation according to David (n = 45). The underlying causes were aortic dissection type A (43 patients) and aneurysms (76 patients). RESULTS: Patients undergoing aortic valve reimplantation were younger compared with patients undergoing composite grafting (28 vs 35 years, P =.002) and had longer intraoperative aortic crossclamp times (125 vs 78 minutes, P <.0001) and extracorporeal circulation times (162 vs 124 minutes, P <.0001). Early postoperative mortality was 6.8% (n = 5) in patients undergoing composite grafting and 0% in patients undergoing aortic valve reimplantation (P =.15). Mean follow-up was 30 months for patients undergoing aortic valve reimplantation and 114 months for patients undergoing composite grafting. Freedom from reoperation and death after 5 years postoperatively was 92% and 89% in patients undergoing composite grafting and 84% and 96% in patients undergoing aortic valve reimplantation (P =.31; P =.54), respectively. Thromboembolic complications or late postoperative bleeding occurred in 17 patients undergoing composite grafting, and an early postoperative event occurred in 1 patient undergoing aortic valve reimplantation. CONCLUSIONS: The results of aortic valve reimplantation and composite grafting of the aortic valve and ascending aorta with mechanical valve conduits are similar with regard to early and mid-term postoperative mortality and to the incidence of late reoperations in patients with Marfan syndrome. The low risk of thromboembolic or bleeding complications favors aortic valve reimplantation in these patients.