Bilateral subdural hematoma following aortic root and subtotal aortic arch replacement

We report herein a case of subdural hematoma following aortic root and subtotal aortic arch replacement with selective cerebral perfusion in a 78-year-old woman. Her level of consciousness gradually deteriorated on postoperative day (POD) 2. Subdural hematoma, including fresh bleeding in bilateral frontal and parietal regions, was detected on brain computed tomography (CT) on POD 3. No head injury had been sustained previously. As the brain was not under pressure and disturbance of consciousness improved the next day, she was observed conservatively with follow-up brain CT. The subdural hematoma disappeared within about 2 months. The patient recovered completely and was discharged without sequelae.     

保留瓣叶的主动脉根部置换术近期疗效

目的 评价使用保留瓣叶的主动脉根部置换术(David手术)治疗主动脉根部瘤、升主动脉瘤和急性夹层分离的近期疗效.方法 2005年5月至2007年1月10例主动脉瘤病人行保留瓣叶的主动脉根部置换术,其中男9例,女1例.年龄24～64 岁,平均(42.9±12.7)岁.比较其术前、术后心功能、左心室直径和主动脉瓣反流程度的变化.结果 无手术死亡和严重并发症发生.体外循环(174.0±41.2)min,主动脉阻断(132.8±35.7)min,深低温停循环3例.术后随访9～17 个月,平均(12.6±2.8)个月,术后心功能较术前明显改善,NYHA心功能分级从术前2.7±0.48到术后1.80±0.63(P＜0.05).左心室射血分数(LVEF)从术前0.62±0.10增加到术后0.64±0.14(P＞0.05).左心室腔明显缩小,左心室舒张末直径(LVEDD)从术前(62.00±13.58)mm缩小到术后(49.9±13.59)mm(P＜0.05),左心室收缩末直径(LVESD)从术前(41.8±10.97)mm缩小到术后(32.8±12.41)mm(P＜0.05).术后主动脉瓣反流程度明显减轻,从术前3.00±0.82下降到术后1.40±0.84(P＜0.05).结论 保留瓣叶的主动脉根部置换术治疗主动脉根部瘤、升主动脉瘤和急性夹层分离的近期疗效满意.     

主动脉机械瓣膜置换术后低强度抗凝研究

目的探讨人工机械主动脉瓣膜置换术后行低强度抗凝的可行性及安全强度。方法85例主动脉机械瓣膜置换的患者，按国际标准化比值（INR）分为A、B两组，定时分别检测其INR、D-二聚体浓度与抗凝血酶Ⅲ活性（AT—Ⅲ：C），并定时监测术后出血及血栓形成的发生率。结果两组术后AT-Ⅲ：C分别与对照组差异均无统计学意义（P〉0．05）。D-二聚体与对照组比较B组增高，A组无明显变化，A、B两组间差异有统计学意义（P〈0．05）。两组均出现临床轻微出血现象（牙龈出血、眼睑或皮下紫瘢），其中A组4人次（4／50），B组3人次（3／35）。A组无一例出现栓塞，B组中3例患者出现单侧肢体轻微栓塞现象。结论我国南方地区主动脉瓣人工机械瓣膜置换术后行较低强度抗凝治疗是可行的，INR值控制在1．5—1．8范围较安全。     

Comparison of aortic root replacement in patients with Marfan syndrome

Objectives: Although the aortic-valve-sparing (AVS) reimplantation technique according to David has shown favorable durability results in mid-term and long-term studies, composite valve grafting (CVG) according to Bentall is still considered the standard procedure. Methods: Retrospectively, we evaluated the results of aortic root replacement of patients with Marfan syndrome (MFS) who underwent surgery between January 1995 and January 2010. MFS was diagnosed using the Ghent criteria. AVS was used in 58 patients and CVG in 30 patients with MFS. AVS was done for aortic-root aneurysm (n = 48) or aortic dissection type A (n = 10). CVG was used for aortic-root aneurysm in 14 patients or aortic dissection type A in 16 patients. The mean follow-up was 3.2 (95% CI: 2.4–4.2) years. Results: In both groups, 30-day mortality was 0%. Three patients (10.0%) in the CVG group required resternotomy for postoperative bleeding versus two patients (3.4%) in the AVS group (p = 0.3). At follow-up, mortality was 10% in the CVG group versus 3.4% in the AVS group (p = 0.3). Re-operation was required in two patients (3.4%) after AVS and in three patients after CVG (10%) (p = 0.3). Three patients (10.0%) who underwent CVG had endocarditis and two patients (6.7%) had a stroke during follow-up, whereas no endocarditis and stroke occurred after AVS. After 14 years, stratified event-free survival was better in the AVS group (event-free survival was 82.3% vs 58.6%, log-rank test p = 0.086), especially after aneurysm (p = 0.057). After 10 years, freedom from aortic regurgitation ≥II° in the AVS group was 80% for aneurysm and 50% after dissection (p = 0.524). Conclusion: The reimplantation technique according to David was associated with excellent survival, good valve function and a low rate of re-operation, endocarditis, and stroke. There was a trend to better event-free survival for AVS patients making it the procedure of choice in MFS patients.     

心脏术后再次行主动脉根部置换的临床分析

目的 探讨心脏术后再次行主动脉根部置换手术的病因、手术操作及临床疗效.方法 回顾性分析2013年12月至2019年12月30例心脏手术后于我院行再次主动脉根部置换手术患者的临床资料,其中男20例、女10例,年龄(50.4±12.7)岁.再次手术时间间隔(8.0±8.5)年,再次手术原因包括:主动脉窦部扩张及升主动脉瘤1...     

Long-term outcomes after ascending aortic replacement and aortic root replacement for type A aortic dissection

 Open in a separate windowOBJECTIVESWe investigated whether the selective use of supracoronary ascending aorta replacement achieves late outcomes comparable to those of aortic root replacement for acute Stanford type A aortic dissection (TAAD).METHODSPatients who underwent surgery for acute type A aortic dissection from 2005 to 2018 at the Helsinki University Hospital, Finland, were included in this analysis. Late mortality was evaluated with the Kaplan–Meier method and proximal aortic reoperation, i.e. operation on the aortic root or aortic valve, with the competing risk method.RESULTSOut of 309 patients, 216 underwent supracoronary ascending aortic replacement and 93 had aortic root replacement. At 10 years, mortality was 33.8% after aortic root replacement and 35.2% after ascending aortic replacement (P = 0.806, adjusted hazard ratio 1.25, 95% confidence interval, 0.77–2.02), and the cumulative incidence of proximal aortic reoperation was 6.0% in the aortic root replacement group and 6.2% in the ascending aortic replacement group (P = 0.65; adjusted subdistributional hazard ratio 0.53, 95% confidence interval 0.15–1.89). Among 71 propensity score matched pairs, 10-year survival was 34.4% after aortic root replacement and 36.2% after ascending aortic replacement surgery (P = 0.70). Cumulative incidence of proximal aortic reoperation was 7.0% after aortic root replacement and 13.0% after ascending aortic replacement surgery (P = 0.22). Among 102 patients with complete imaging data [mean follow-up, 4.7 (3.2) years], the estimated growth rate of the aortic root diameter was 0.22 mm/year, that of its area 7.19 mm²/year and that of its perimeter 0.43 mm/year.CONCLUSIONSWhen stringent selection criteria were used to determine the extent of proximal aortic reconstruction, aortic root replacement and ascending aortic replacement for type A aortic dissection achieved comparable clinical outcomes.     

升主动脉置换术或成形术治疗主动脉瓣病变合并的升主动脉瘤样扩张

目的 对比分析主动脉瓣病变合并升主动脉瘤扩张在行主动脉瓣置换术(AVR)的同时施行升主动脉置换术(A组)或成形术(B组)的结果,探讨两种方法的临床效果及适应证.方法 A、B两组术前年龄、性别、心功能分级、主动脉瓣病变、左室射血分数等差异均无统计学意义.A组主动脉直径(49.45±3.96)mm,B组(49.31±3.68)mm,差异亦无统计学意义.行AVR后A组常规置换升主动脉,B组纵行切除部分升主动脉壁,缝合后包裹28～30 mm人工血管.结果 A、B两组术后均无死亡.A组主动脉阻断(71.70±17.13)min、体外循环(110.52±27.51)min,均明显大于B组的(57.13±16.32)min(P=0.025)和(97.31±19.46)min(P=0.004).两组术中及术后输血量、并发症发生率差异无统计学意义.结论 主动脉瓣病变合并升主动脉瘤样扩张,年轻病人主动脉直径≥40 mm时应积极手术处理扩张的升主动脉.升主动脉成形术,同时外包裹人工血管的方法较升主动脉置换术更为简单、安全,但升主动脉壁必须无粥样硬化或溃疡.     

Stanford A 型主动脉夹层手术中的主动脉根部处理

目的 总结Stanford A型主动脉夹层手术中主动脉根部处理的临床经验.方法 根据主动脉夹层累及主动脉根部的程度及主动脉根部基础病变,对59例Stanford A型主动脉夹层病人进行主动脉根部处理.Bentall手术31例,Wheat手术15例,David手术13例.结果 手术死亡1例(1.72%).术后一过性精神状态异常17例;术后感染2例,1例死亡;胸骨哆开1例;单侧下肢血供障碍1例,二期行股股分流术后恢复正常.出院前复查心脏彩超、主动脉CT血管成像及心电图,均正常.随访2～54个月,4例死于非心源性疾病,余者正常.结论 根据主动脉夹层累及主动脉根部的程度及主动脉根部基础病变,制定相应处理方案,可显著提高手安全性并改善预后.

Abstract：

Objective To summarize the experience of aortic root surgery in Stanford A aortic dissection operations.Methods From January 2005 to September 2010, the clinical data of 59 patients with Stanford A aortic dissection was analyzed. There were 43 men and 16 women , ranging in age from 21 to 74 years old, duration of disease varied from 16 hours to 27 days. Among the group, 31 complicated by aortic valve incompetence, 12 Marfan syndrome, 9 single lower limb blood supply dysfunction, 6 right coronary artery involvement. All cases received aortic root surgery under deep hypothermic circulatory arrest. Bentall procedure was performed in 31 patients, Wheat procedure in 15 patients and David procedure in 13 patients.Results The time of cardiopulmonary bypass in the group was 149 to 204 min with an average of ( 171 ± 19) min,and the cross clamp time was 81 to 122 min with an average of (104 ±13) min, and the arrest time was 30 to 47 min with an average of (39 ±7) min. There was 1 case of operative death, which was treated on an emergency basis. Postoperative complications occurred in 20 cases. 17 cases experienced temporary mental dysfunction, 2 cases were infected with MRS A, 1 of which died from MODS, 1 case of single lower limb blood supply dysfunction remained after the first operation and recovered by reoperation (bilateral femoral bypass operation) . All cases were reexamined before discharge, postoperative mean LVEF was (56. 3 ±3.4)% (ranged 51% -62%), aortic annular diameter varied from 22 mm to 27 mm, aortic sinus diameter range from 23 mm to 31mm. 51 patients were followed up, with a mean follow-up time of (24.9 ± 17.2) months (ranged 2-54 months). 54 patients of Stanford A aortic dissection survived well with normal lives and activities. Four non cardiac deaths, one was chronic renal failure, the others were brain hemorrhage. Conclusion Prognosis and operative security of Stanford A aortic dissection patients can be significantly improved by individualized aortic root surgery.     

经胸骨小切口主动脉根部置换术

目的比较经胸骨小切口主动脉根部置换术与经传统切口手术的临床结果。方法1999年7月至2001年10月行。Bentall手术60例。采用胸骨小切口15例，传统胸骨正中切口45例。结果两组病例均无围手术期死亡。术后早期并发症发生率两组间差异无显著性(P=0．661)。小切口组的手术时间及体外循环时间长于传统切口组(P=0．027，P=0．015)。小切口组的机械通气时间、输血量、未输库存血率、胸腔引流量及总住院时间均优于传统切口组，但差异无显著性。结论经小切口的Bentall手术，不增加手术风险。胸骨上段小切口适用于Bentall手术及部分弓置换术，胸骨下段小切口适用于心脏巨大或同期行心内畸形的矫治者。     

Results of prosthetic valve replacement for aortic stenosis

Background: Aortic valve replacement with mechanical valves is associated with a small but constant risk of valve thrombosis and thromboembolic and hemorrhagic complications. The surgical outcome of patients with Aortic Stenosis who had aortic valve replacement with mechanical valves is reported here. Methods: Between January 1990 and October 1999, 275 patients underwent prosthetic valve replacement for isolated aortic stenosis. The age ranged between 13 years and 75 years and 230 were males. The cause of aortic stenosis was rheumatic in 185 patients (67.3%), followed by bicuspid aortic valve in 75 patients (27.3%) and degenerative in 15 patients (5.4%). Results: The early mortality was 1.5%. The follow up was 96% complete and ranged from 1 to 104 months (mean 54±24.5months). Six patients (2.2%) developed prosthetic valve endocarditis. Paravalvular leak occurred in 3 (0.9%) patients. Valve thrombosis occurred in 10 patients (1.0% per patient year). The actuarial survival was 81±7% at 5 years and 64±13% at 8 years. Event free survival was 40±14% at 8 years. Conclusion: With current operative techniques and myocardial preservation aortic stenosis patients are at low risk for surgery. However, long term survival is limited due to prosthesis related complications.     

Minimally-invasive versus conventional aortic valve replacement – perioperative course and mid-term results

Objective: We performed a case-control-study to compare perioperative and mid-term results of minimally invasive with conventional aortic valve replacement. Methods: Between 8/96 and 7/97, 113 patients underwent isolated aortic valve replacement (minimally invasive: 29, conventional: 84) in our Department. Diagnosis, ejection fraction, pressure gradient/regurgitation fraction, age, gender and body-mass-index were used as matching criteria for the case-control-study. For qualitative data correspondence was requested, for quantitative data deviations up to 10% were accepted. With these criteria 25 patients of the minimally invasive group were matched to 25 patients of conventional group. All patients were reexplored 1 year after aortic valve replacement. Statistical analysis was done by the Fisher's exact test for qualitative data and the Mann–Whitney test for quantitative data. Results: We implanted 15 (20) bioprosthesis’ and 10 (five) mechanical prosthesis’ in the minimally invasive, respectively, conventional group. There were no statistically significant differences between both groups with respect to the perioperative course, only duration of surgery (mean 201.6 vs. 143.9 min, P<0.01) and extracorporeal circulation (mean 116.1 vs. 71.3 min, P<0.01) as well as aortic-cross-clamp-time (mean 77.9 vs. 46.9 min, P<0.01) were significantly longer in the minimally invasive group. Postoperative complications occurred in one patient of the minimally invasive group (dissection of the right coronary artery) and four patients of the conventional group (third degree AV block, pneumothorax, grand mal convulsion, cardiopulmonary resuscitation). Two patients, one of each group, died during follow-up for unknown reasons. Follow-up revealed no significant differences with respect to clinical and echocardiographic data, but the shorter skin incision was cosmetically more accepted by patients of the minimally invasive group. Minor paravalvular leaks occurred in four patients of the minimally invasive and three patients of the conventional group as diagnosed by transthoracic echocardiography. Conclusions: Both surgical techniques may be performed with comparable perioperative and mid-term results, but the better cosmetic result in the minimally invasive group is paid by a longer duration of surgery.     

Aortic valve leaflet sparing and salvage surgery: evolution of techniques for aortic root reconstruction

Over the past 20 years, a series of procedures have been designed to reconstruct the aortic root of patients with aortic insufficiency, in whom the pathology and hence the surgery spares the valve leaflets. Such techniques have various names. Usually ‘valve sparing’ is used in context with chronic aortic dissection or aortic root aneurysm as in patients with Marfan's syndrome. ‘Aortic valve salvage’ tends to be the term of choice for similar surgical reconstruction in the setting of aortic dissection. ‘Aortic valve repair’ is often chosen when direct surgical procedures are performed on the leaflets themselves. All of the techniques have evolved based upon an increased understanding of the functional anatomy of the aortic root complex. The different technical approaches, their applications and results need to be understood by the cardiology community. The failure modes for such techniques are specific and different from prosthetic valve failure modes, but are adequately followed with echocardiography. Over two-thirds of patients remain free of re-development of significant aortic insufficiency at 8–10 years following surgery. The overall patient survival is more dependent upon the underlying cardiovascular status of the patient than the surgical technique itself. Perioperative mortalities vary between 0 and 6% and are comparable to composite valve+graft techniques and isolated aortic valve replacement, in which the operative mortality approximates 3.3–4%. Long-term results are good to excellent and spare the patient anticoagulation and prosthetic valve disease.     

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.     

Twenty-four year experience with reoperations after ascending aortic or aortic root replacement

Objective: A retrospective analysis of early and late outcome for late (>4 weeks) reoperations on the ascending aorta or aortic root. Materials and methods: During a 24-year interval, starting in 1974, 834 patients underwent replacement of the ascending aorta (39.2%) or aortic root (60.8%). During the same period, 56 patients with a mean age of 51.1±14.4 years underwent reoperation after ascending aortic or aortic root replacement. Predominant indications for reoperation were false aneurysm in 25 (44.6%) patients and true aneurysm in 18 (32.1%) patients. Most frequent surgical procedures were redo aortic root replacement in 30 (53.6%) patients and closure of a false aneurysm in 14 (25.0%) patients. Median interval between the operations was 51 months. Eighteen (32.2%) patients underwent concomitant partial or total aortic arch replacement. Results: Hospital mortality was 5.4% (n=3; 70% CL: 2.4–8.4%). Cause of death was low cardiac output in two patients and rupture of the aorta at the distal suture line in one patient. Univariate analysis identified two or more previous operations (P=0.038) and the interval between initial operation and reoperation for complication of less than 8 months (P=0.005) as risk factors for hospital death. Multivariate analysis indicated operation for active endocarditis or vascular graft infection as an independent risk factor for hospital death (P=0.038, odds 14.6). Follow-up was complete, median 3.1 years. Nine (16.9%; 70% CL: 11.7–22.1%) patients died during that period. Estimated survival at 1, 5 and 10 years was 91.2, 84.0 and 76.4%. One patient underwent another reoperation. Estimated event-free survival at 1, 5 and 10 year is 84.3, 72.2 and 65.6%. Conclusion: False aneurysm formation and progression of aneurysmatic disease are the predominant causes for late reoperations after aortic root or ascending aortic replacement. Reoperations can be performed with low hospital mortality and good late results.     

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,...     

单纯无名动脉灌注的主动脉弓置换术21例

目的 探讨主动脉弓置换术中使用单纯无名动脉灌注进行脑保护的安全性和有效性.方法 2004年1月至2007年7月,2l例主动脉弓置换者使用单纯无名动脉灌注技术进行脑保护,男19例,女2例;年龄29-72岁,平均(46.5±11.4)岁.A型(Stanford分型)主动脉夹层19例,其中7例合并主动脉瓣关闭不全;升主动脉及主动脉弓真性动脉瘤伴降主动脉受累2例.所有病例均在深低温、使用单纯无名动脉选择性脑灌注下进行升主动脉、主动脉弓置换+降主动脉覆膜支架置入术.同时行Benlall手术6例,David手术1例.结果 升主动脉阻断(109.6.4-29.6)min;体外循环(186.7±56.2)min;最低鼻咽温(19.O±3.3)℃;选择性脑灌注时间(38.3.4-11.5)Ⅲ.m,流量每分钟(6.8±2.6)ml,l‘g.术后无中枢神经系统并发症.呼吸机辅助(38.6±29.O)h.1例因低心排输出量综合征于术后第5 d死亡.术后随访2-45个月,平均(24.0±12.5)个月,无死亡及心脑血管意外发生.结论 深低温、单纯无名动脉选择性脑灌注下行主动脉弓置换是安全、有效的.     

Chronic kidney disease stage stratifies short- and long-term outcomes after aortic root replacement

OBJECTIVESChronic kidney disease (CKD) is prevalent in patients undergoing cardiovascular surgery, and it negatively impacts procedural outcomes; however, its influence on the outcomes of aortic surgery has not been well studied. This study aims to elucidate the importance of CKD on the outcomes of aortic root replacement (ARR).Open in a separate windowMETHODSPatients who underwent ARR between 2005 and 2019 were retrospectively reviewed (n = 882). Patients were divided into 3 groups based on the Kidney Disease: Improving Global Outcomes criteria: Group 1 [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m², n = 421); Group 2 (eGFR = 30–59 ml/min/1.73 m², n = 424); and Group 3 (eGFR < 30 ml/min/1.73 m², n = 37). To reduce potential confounding, a propensity score matching was also performed between Group 1 and the combined group of Group 2 and Group 3. The primary end point was 10-year survival. Secondary end points were in-hospital mortality and perioperative morbidity.RESULTSSevere CKD patients presented with more advanced overall chronic and acute illnesses. Kaplan–Meier analysis showed a significant correlation between CKD stage and 10-year survival (log-rank P < 0.001). The number of events for Group 1 was 15, Group 2 was 49 and Group 3 was 11 in 10 years. Group 3 had significantly higher in-hospital mortality (13.5% vs 3.5% in Group 2 vs 0.7% in Group 1, P < 0.001) and stroke (8.1% vs 7.1% vs 1.2%, P < 0.001) as well as introduction to new dialysis (27.0% vs 5.4% vs 1.7%, P < 0.001). eGFR was shown to be an independent predictor of mortality (hazard ratio, 0.98; 95% confidence interval, 0.96–0.99). Comparison between propensity matched groups showed similar postoperative outcomes, and eGFR was still identified as a predictor of mortality (hazard ratio, 0.97; 95% confidence interval, 0.95–0.99).CONCLUSIONSHigher stage in CKD negatively impacts the long-term survival in patients who are undergoing ARR.     

一期全主动脉置换术治疗广泛主动脉瘤样病变早中期结果

目的 总结一期全主动脉置换术治疗广泛主动脉瘤样病变的早、中期结果和单中心临床经验.方法 2004年2月至2011年2月,21例广泛主动脉瘤样病变的患者进行了一期全主动脉或次全主动脉置换术.男16例,女5例;年龄(34±9)岁.病因为高血压10例,马方综合征9例,其他1例;其中20例为主动脉夹层.手术采用深低温停循环顺行脑灌注技术,分段阻断病变主动脉,通过胸部正中切口,应用四分支人工血管依次置换升主动脉、主动脉弓及三支头臂血管.通过胸腹联合切口经腹膜后入路,应用另一四分支人工血管置换全胸腹主动脉至髂动脉分支处.术中对胸(T)6-12肋间动脉和腰(L)1、2动脉行动脉管法原位重建,分别将腹腔干、肠系膜上动脉、左右肾动脉和双侧髂动脉与人工血管主干和分支吻合.结果 无术中死亡.术后早期1例死于肾功能衰竭,2例发生脑梗塞但无脊髓损伤所致截瘫和下肢轻瘫.随访18 -84个月,出院20例患者均生存.3例重建肋间动脉的动脉管发生闭塞,但无截瘫症状.结论 一期全主动脉置换术是治疗广泛主动脉病变安全而有效的方法,患者早、中期生存情况良好.     

Patient-specific computational fluid dynamics analysis of transcatheter aortic root replacement with chimney coronary grafts

OBJECTIVESTranscatheter aortic root repair (TARR) consists of the simultaneous endovascular replacement of the aortic valve, the root and the proximal ascending aorta. The aim of the study is to set-up a computational model of TARR to explore the impact of the endovascular procedure on the coronary circulation supported by chimney grafts.Open in a separate windowMETHODSComputed tomography of a patient with dilated ascending aorta was segmented to obtain a 3-dimensional representation of the proximal thoracic aorta, including aortic root and supra-aortic branches. Computed assisted design tools were used to modify the geometry to create the post-procedural TARR configuration featuring the main aortic endograft integrated with 2 chimney grafts for coronary circulation. Computational Fluid Dynamics simulations were run in both pre- and post-procedural configurations using a pulsatile inflow and lumped parameter models at the outflows to simulate peripheral aortic and coronary circulation. Differences in coronary flow and pressure along the cardiac cycle were evaluated.RESULTSAfter the virtual implant of the TARR device with coronary grafts, the flow became more organized and less recirculation was seen in the ascending aorta. Coronary perfusion was guaranteed with negligible flow differences between pre- and post-procedural configurations. However, despite being well perfused by chimney grafts, the procedure induces an increase of the pressure drop between the coronary ostia and the ascending aorta of 8 mmHg.CONCLUSIONSThe proposed numerical simulations, in the specific case under investigation, suggest that the TARR technique maintains coronary perfusion through the chimney grafts. This study calls for experimental validation and further analyses of the impact of TARR on cardiac afterload, decrease of aortic compliance and local pressure drop induced by the coronary chimney grafts.