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。     

同种异体带瓣主动脉移植治疗累及主动脉瓣的感染性心内膜炎临床分析

目的:回顾分析30例应用低温保存的同种异体带瓣主动脉对累及主动脉瓣的感染性心内膜炎的治疗结果。 方法:30例主动脉瓣炎或脓肿患者采用低温保存的同种异体带瓣主动脉行主动脉根部置换手术,术后随访5-86个月观察临床结果。 结果:随访5-86(40.8±15.3)个月。术后早期死亡率3.3％(1/30),远期死亡率6.7％(2/30);与术前比较心功能明显改善(P<0.01);术后随访心内膜炎的发生率占6.7％(2/30);生存者中瓣膜无或有轻度反流81.5％(22/27),中度反流18.5％(5/27)。 结论:同种异体带瓣主动脉移植治疗感染性主动脉瓣炎或脓肿具有较好的疗效。     

保留主动脉瓣主动脉根部替换术的临床应用评价

目的评价保留自身主动脉瓣的主动脉根部替换的可行性和疗效。方法自1998年1月至2004年9月,对我院24例主动脉病变导致主动脉瓣关闭不全但瓣膜本身无明显异常的患者,实施了保留主动脉瓣的主动脉根部替换术,并术后随访观察主动脉瓣反流和心功能改善情况。结果全组无住院死亡。除1例仍为中度反流外,术后主动脉瓣反流均明显改善。随访中有2例非手术相关死亡,无主动脉瓣反流需再次手术者。全组心功能恢复满意。结论主动脉根部替换手术时,对由于主动脉根部瘤或升主动脉瘤导致的主动脉瓣反流者,可优选采用保留主动脉瓣的主动脉根部替换术。     

David-Ⅰ手术治疗主动脉夹层合并主动脉瓣反流

目的:总结David-Ⅰ手术治疗主动脉夹层合并主动脉瓣反流的临床经验。方法:回顾性分析2005-2010年我科收治的9例主动脉夹层合并主动脉瓣反流患者行David-Ⅰ手术的临床资料。其中急诊手术2例,余7例为常规择期手术;术前心功能Ⅰ级7例,Ⅲ级2例;术前心脏超声测定主动脉瓣轻度反流6例,中度2例,重度1例;术前心脏超声、16排螺旋CT测定主动脉瓣瓣环7例轻度扩张,2例无扩张;9例全部行David-Ⅰ手术。结果:术后患者死亡1例,其余8例康复出院。手术体外循环时间(206.3±11.1)min,阻断时间(141.3±11.2)min。术后随访(12.8±1.0)个月,8例康复出院患者心功能均为Ⅰ级;术后主动脉瓣无反流5例,轻度反流3例。随访心脏超声发现8例患者均无瓣环扩张,无患者需二次换瓣治疗。结论:对主动脉夹层合并主动脉瓣反流者,可优先采用保留主动脉瓣的主动脉根部替换术。     

Ross手术治疗主动脉瓣膜病变中期随访结果

目的:观察Ross手术治疗主动脉瓣膜病变的中期临床结果。方法:1998年3月至2003年11月我院完成的24例Ross手术病例,其中男性13例,女性11例,年龄3～34岁,平均(13.96±5.76)岁,所有患者均以主动脉病变为主,其中主动脉瓣二叶化畸形12例,手术在体外循环下进行,取自体肺动脉移植于主动脉瓣位,并行冠状动脉原位移植,同种肺动脉瓣移植于肺动脉瓣位。所有患者均用多普勒彩色超声心动图进行评估。结果:随访所有患者,随访时间4～78个月,平均(34.2±20.1)个月,均存活,没有感染、栓塞和再次手术。自体肺动脉瓣(新主动脉瓣)平均流速为(1.46±0.49)m/s,中度反流2例,重度反流1例。同种肺动脉瓣(新肺动脉瓣)平均流速为(1.73±0.99)m/s,1例跨瓣压差超过80mmHg(1mmHg=0.133kPa),2例中度反流。结论:Ross手术治疗主动脉瓣膜病变获得较好的中期疗效,尤其对不适合瓣膜成形和瓣膜置换术的儿童型主动脉瓣膜病变是一个很好的选择。     

升主动脉根部和主动脉弓替换的外科治疗

目的总结并讨论我科15例升主动脉和主动脉弓替换手术的临床体会。方法在中低温体外循环下,应用带瓣人工管道行升主动脉根部替换手术10例。用人工血管和人工瓣自行缝制带瓣管道3例,预制带瓣人工管道6例。1例行主动脉瓣替换加升主动脉补片术,1例行腔内人工血管移植术。冠状动脉移植应用纽扣法6例,直接移植3例,Cabrol法1例。在深低温停循环脑顺行灌注下行人造主动脉弓(用Medox24mm和8mm人工血管自行缝制)替换3例。其中1例DeBakeyⅢ型术后6年的患者复发,DeBakeyI同时行升主动脉根部替换。结果行主动脉根部替换平均主动脉阻断时间130min。行主动脉弓替换主动脉阻断时间为112～240min(平均170min),停循环30～65min(平均46min),脑选择顺行灌注63～92min(平均80min)。无脑及脊髓并发症。声音嘶哑1例。术后早期死亡1例。随访2～8年,病情稳定,术后心脏功能NYHAⅠ级11例,Ⅱ级3例。结论升主动脉根部手术,特别是联合主动脉弓替换,手术复杂,风险大。为确保手术成功,各吻合口要精确吻合,无张力,无扭转,对头臂干的吻合宜采取分支吻合的方法。应用深低温停循环联合选择性脑顺行灌注进行脑保护。     

主动脉根部替换手术93例

目的 :探讨主动脉根部替换手术的手术适应证、基本方法和手术技术。　　方法 :主动脉根部替换手术 93例 ,平均年龄 41.2岁 (2 3～ 6 9岁 )。对于主动脉夹层或累及主动脉弓的动脉瘤 ,选择右锁骨下动脉插管 ,行象鼻手术时加用股动脉插管。以复合带瓣人工血管行根部替换。 2例合并象鼻手术。　　结果 :93例主动脉根部替换手术平均心肌阻断时间 72 .5± 17.9分钟 (42～ 133分钟 ) ,平均体外循环时间 113.6±32 .7分钟 (6 0～ 2 32分钟 )。住院死亡 1例 (1.0 8% )。 8例手术未输血。　　结论 :精湛的手术技术和麻醉、体外循环等整体水平的提高是主动脉根部替换手术取得良好效果的关键。     

83例主动脉根部疾病经典和非经典新术式外科治疗的临床经验和体会

目的:探讨主动脉根部病变外科治疗的经典和非经典术式的适应证和前景,总结经验教训。方法:2003年至2006年在8例新术式的基础上,我们对2000年至2004年北京安贞医院75例连续经典Bentall手术临床资料进行回顾性分析,根据保留瓣膜的主动脉根部成形术或重建术的适应证原则,即瓣环直径<28mm且瓣叶无明显病变,计算其潜在的应用百分率。结果:75例Bentall术死亡3例,死亡率为4.0%。4例改良Bentall术和4例保留瓣膜的主动脉根部成形术无手术和住院死亡,1例Yacoub术后第8个月因继发主动脉瓣返流而行2次瓣膜置换术。75例Bentall术中理论上适合进行瓣膜保留的主动脉根部成形术者有18例(24.0%)。结论:经典Bentall术依然是治疗主动脉根部病变和升主动脉扩张的标准术式,改良Bentall术理论上可能延长机械或生物瓣膜的使用寿命,更适合儿童马方综合征患者;尽管Yacoub术和David术存在主动脉瓣关闭不全(AI)复发的缺点,但是对主动脉瓣正常的根部病变是一种理想术式,并具有良好的应用前景。     

应用同种主动脉置换主动脉根部治疗人造瓣膜心内膜炎

应用同种主动脉置换主动脉根部及冠状动脉再植治疗活动性人造瓣膜感染性心内膜炎以往尚未见报道。本文报道6例手术治疗成功。置换前这些病人曾接受原发孔型房间隔缺损修补,室间隔缺损修补,Morrow氏手术或主动脉成形术,以及Starr-Edwards,Carpentier-Edwards或阔筋膜加同种主动脉瓣主动脉瓣置换木。6例均有人造瓣膜旁渗漏。有的人造瓣膜缝环脱开达1/3瓣环周径。术中见赘生物2例;左冠状窦和无冠状窦均各有脓肿2例;无冠状窦和前窦感染者见溃疡下延至二尖瓣叶与室     

主动脉根部瘤的外科治疗

1978年1月至1992年11月期间,阜外医院外科手术治疗主动脉根部瘤105例,手术方法分为四种:Bentall手术50例;Wheat手术21例;同种主动脉根部移植7例;非典型主动脉根部替换术27例。总手术死亡率12.4%,近四年来降至4.0%。手术存活的92例心功能明显改善;七年生存率75.4±12.3%。作者对影响主动脉根部瘤外科治疗效果的因素进行了分析,对手术方法和外科技术进行了探讨。     

3例主动脉瘤及主动脉夹层合并主动脉良性肿瘤及瘤样病变的临床病理学分析

目的:发生在主动脉的良性肿瘤并伴有主动脉疾病(主动脉瘤、主动脉夹层及马方综合征)是少见病例。本文总结分析伴有主动脉疾病的主动脉良性肿瘤及瘤样病变的临床病理特点,复习发生于主动脉良性肿瘤的文献,探讨其发生与主动脉疾病之间的关系。方法:回顾性分析我院病理科2006年至2012年,手术切除的胸主动脉瘤及胸主动脉夹层的标本129例,通过复习临床病历,观察HE染色切片,辅以弹力/VG及Masson等组织化学染色及SMA、CD31及CD34等免疫组织化学染色,对主动脉壁结构的改变进行分析。结果:所有病例主动脉壁均发生了结构的改变,主要是中膜弹力纤维、平滑肌及基质的变化,但有3例标本内膜增生明显,1例形成了平滑肌瘤,另2例发生了内膜下弹力纤维瘤样增生及平滑肌瘤样增生。结论:主动脉壁内不同组成成分的改变,使得主动脉壁重构,导致主动脉瘤及主动脉夹层的形成,而某一单一成分过度增生可形成主动脉腔内的肿瘤。     

3D-echo in preoperative assessment of aortic cusps effective height

Effective height,which represents the height difference between the central free margins and the aortic insertion lines can be easily determined by 2-D echocardiography and allows for identification of prolapse in the native cusps and assessment of prolapse correction after valve repair.Nonetheless,it allows to see only two of three aortic valve(AV)coaptation planes and this may lead to misunderstanding of the underlying pathophysiological mechanism for aortic regurgitation and hence in unsuccessful repair.In contrast,3D transoesophageal echocardiography and multiple plane reconstruction lets visualize all the three coaptation planes between the AV cusps and it represents an invaluable tool in the assessment of aortic valve geometry.It is highly recommendable before AV repair to accurately study the complex three dimensional cusps anatomy and their geometric interrelation with aortic root.     

Aortic valve repair and valve sparing procedures

Aortic valve repair and valve sparing procedures enable restoration of competence in regurgitant aortic valve, and thus to avoid the risks related to valve replacement. Successful aortic valve repair requires deep understanding of the static and dynamic geometry of the aortic valve and aortic root. Aortic regurgitation originates from malapposition of the aortic leaflets and it is also frequently connected to dilation of the aortic root and ascending aorta. Techniques of surgical procedures for aortic regurgitation have been subject of historical development and currently tend to simplification and standardisation. Basic principles stand upon morphological normalisation at the level of the basal ring, sinotubular junction and valve leaflets. Remodelation of the aortic root and reimplantation of the aortic valve keep to be standard procedures in case of a dystrophic dilation of the aortic root.     

Aortic valve repair in patients with aortic regurgitation: Experience with the first 100 cases

IntroductionThe aim of this study was to analyze short- and mid-term results of aortic valve repair.Material and methodsOne hundred consecutive patients (24 females; mean age 50.3 years, range 23–77 years) with aortic regurgitation underwent aortic valve repair between November 2007 and October 2012. Sixty patients had bicuspid aortic valve, and 82 patients demonstrated aortic regurgitation greater than mild (> grade 2). The ascending aorta/aortic root was replaced in 67 patients. Aortic cusp repair was necessary in 74 patients and additional aortic annulus stabilization was required in 48 cases. Follow-up ranged from 1 to 59 months (cumulative of 220 patient-years, median 25 months) and was complete in 100%.ResultsThere was no 30-day mortality and two patients died in the follow-up. The overall 4-year survival was 98% and freedom from cardiac death was 99% at 4 years. During the follow-up eight patients underwent aortic valve-related reoperation due to progression of aortic regurgitation and another six patients showed aortic regurgitation more than mild (> grade 2). In both aspects there was no statistically significant difference between patients without and with aortic root replacement (p=0.402 and p=0.650). There were no significant bleeding or thromboembolic events during the follow-up.ConclusionsShort- and mid-term data analysis revealed an excellent survival and acceptable results of aortic repair, comparable with other larger published studies. We think, therefore, aortic valve repair should be a part of contemporary cardio-surgical armamentarium, especially in younger patients with an appropriate indication.     

Current knowledge and contemporary management of non-A non-B aortic dissections

Non-A non-B aortic dissection (AAD) is an infrequently documented condition, comprising of only a small proportion of all AADs. The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD, have led to an ongoing controversy around the topic. It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections, frequently leading to serious complications and thus mandating early intervention. Currently, the available treatment methods in the surgical armamentarium are conventional open, endovascular techniques and combined hybrid methods. The optimum approach is tailored in every individual case and may be determined by the dissection’s location, extent, the aortic diameter, the associated complications and the patient’s status. The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached. In an attempt to provide further insight into this perplexing entity, we performed a minireview of the literature, aiming to elucidate the epidemiology, clinical course and the optimal treatment modality.     

Successful endovascular management of an aortic rupture following stent placement for severe atherosclerotic stenosis: A case report

Aortic rupture during endovascular procedures is a devastating complication that mandates expedient intervention. The present report describes a case in which endovascular treatment was used to successfully manage an aortic rupture following placement of a covered stent graft for severe infrarenal aortic stenosis. Successful management of this case was the result of the procedure being performed in an operating room under appropriate anesthesia and close hemodynamic monitoring. Bilateral common femoral arterial access and use of covered aortic stent grafts also contributed to a favourable outcome.     

Rates and determinants of progressive aortic valve dysfunction in aortic coarctation

Purpose

Aortic valve dysfunction is common in coarctation patients(CoA). Bicuspid aortic valve (BAV) in CoA is associated with aortic valve stenosis (AS), aortic valve regurgitation (AR), and ascending aortic dilatation. The aim of this study was to evaluate the progression of and predictors for aortic valve dysfunction in CoA.

Methods

96 CoA patients prospectively underwent echocardiography twice between 2001 and 2010. AS was defined as an aortic valve gradient ≥ 20 mm Hg, AR as none/minor, or moderate/severe. Aortic dilatation as an ascending aortic diameter ≥ 37 mm.

Results

All patients (median age 28.0 years, range 17–61 years; male 57%) were followed with a median follow-up of 7.0 years. Sixty patients (63%) had BAV. At baseline 10 patients had AS (10%, 9 BAV), 6 patients AR (6%, 3 BAV) and 11 patients aortic dilatation (11%, 11 BAV). At follow-up 15 patients had AS (15%, 13 BAV) and 12 patients AR. (13%, 8 BAV).Median AS progression was 1.1 mm Hg/5 years (range — 13–28). Determinants for AS at follow-up were age (ß = 0.20, P = 0.01), aortic dilatation (ß = 4.6, P = 0.03), and baseline aortic valve gradient (ß = 0.93, P < 0.001). BAV was predictive for AR. (ß = 0.91, P = 0.049).

Conclusion

Progression of AS in adult CoA patients is mild in this young population. Older age, aortic dilatation and the baseline aortic valve gradient are determinants for AS at follow-up. BAV is predictive for AR. These findings point towards a common embryological pathway of both valvular and aortic disease in CoA.     

Ventricular energetics in aortic root replacement for annuloaortic ectasia with aortic regurgitation

Aortic root replacement (Bentall operation) is the standard operation for patients who have lesions of the ascending aorta associated with aortic valve disease. We analyzed the mid-term results for left ventricular energetics after the Bentall operation for annuloaortic ectasia with aortic regurgitation. We measured left ventricular contractility (end-systolic elastance; Ees), afterload (effective arterial elastance; Ea), and efficiency (ventriculoarterial coupling; Ea/Ees, and the ratio of stroke work and pressure-volume area; SW/PVA) based on transthoracic echocardiography data before, after, and approximately 1 year after the Bentall operation in 15 patients with annuloaortic ectasia with aortic regurgitation. Left ventricular volume was calculated by the Teichholz M-mode method. Ees and Ea were approximated as follows: Ees = mean blood pressure/minimal left ventricular volume, and Ea = systolic blood pressure/(maximal left ventricular volume — minimal left ventricular volume). Ea/Ees and SW/PVA were then calculated. Left ventricular volume was normalized with body surface area. Ees increased after the Bentall operation and around 1 year later (from 2.17 ± 1.09 to 3.92 ± 2.26 and 5.33 ± 1.90 mmHg·m²/ml, P < 0.001), thus resulting in an improvement in SW/PVA (from 68.8 ± 8.2 to 70.9 ± 9.5 and 74.7 ± 5.2%, P = 0.045). Ea also increased after the Bentall operation and 1 year later (from 1.77 ± 0.61 to 2.88 ± 1.28 and 3.54 ± 1.43 mmHg·m²/ml, P < 0.001). The mid-term results for ventricular contractility and efficiency after the Bentall operation for annuloaortic ectasia with aortic regurgitation are excellent and satisfactory.