活性带瓣主动脉补片重建成人重症法乐氏四联症右室流出道临床研究

重症法乐氏四联症(TOF)根治手术的关键是流出道的疏通、重建。目前，右室流出道(RVOT)重建多采用自体心包片跨肺动脉瓣环补片扩大右室流出道，因为肺动脉瓣环剪开及加宽后破坏了肺动脉瓣关闭的严密性，造成其关闭不全，致肺动脉瓣返流，加重了右室负荷，所以术后易发生心功能不全，难管理，病死率高。我们选择2000年1月至2003年6月收治的20例成人重症TOF患者应用活性同种带瓣主动脉片重建右室流出道，并与常规方法的20例进行对比研究，显示了满意效果。现报道如下。     

人体同种主动脉瓣临床应用一附7例报告

本文报告７例液氮（－１９６°Ｃ）保存的人体主动脉瓣分别应用于主动脉瓣替换５例（其中１例合并瓣环扩大）、肺动脉瓣替换及法乐四联症右室流出道成形各１例．术后随访５月～６年，临床效果满意．对同种瓣的特点、同种瓣替换的手术适应证及术后遗留杂音和返流进行了讨论．     

人造单瓣补片扩大右室流出道根治法洛氏四联症的近期疗效

本对重症法洛氏四联症采用人造单瓣补片扩大右室流出道进行根治术。病例共４０例,随机分为Ａ、Ｂ两组。Ａ组为带瓣组,采用带自体心包单瓣进行跨肺动脉瓣扩大右室流出道。Ｂ组为对照组,用相应大小自体心包进行跨肺动脉瓣扩大右室流出道。观察两组病例在术前、术后一周、术后３个月及６个月的心电图、Ｘ线胸片及心脏超声检查指标,比较两组病例肺动脉瓣返流面积和心功能变化。结果显示带瓣组肺动脉瓣返流面积术后一周、３个月及６     

儿童同种主动脉和自体肺动脉移植物作主动脉瓣或主动脉根部替换的比较

为了评价同种主动脉和自体肺动脉移植物植入儿童左室流出道的晚期结果,作者回顾了自1964年11月至1990年4月间146例年龄18岁或不足18岁的患儿作主动脉瓣或主动脉根部替换的病史资料。103例(12±3.9岁)用同种主动脉移植,43例(14±4.1岁)用自体肺动脉移植。用同种主动脉瓣行主动脉瓣替换54例,用同种主动脉根部行主动脉根部替换49例;用自体肺动脉瓣行主动脉瓣替换36例,用自体肺动脉行主动脉根部替换7例。当肺动脉取下后,右室流出道用同种主动脉瓣重建25例,用同种肺动脉瓣重建     

同种主动脉瓣在心脏外科的应用

目的总结同种主动脉瓣在心脏外科的应用,探讨其优越性。方法1995年1月至2000年12月,应用同种带瓣主动脉手术治疗先天性及后天性瓣膜疾病18例。其中完全性大动脉转位并右室双出口1例,行Rastelli手术;主动脉瓣狭窄及（或）关闭不全17例,先天性8例,风湿性9例,1例行Ross手术,余皆行主动脉瓣置换手术。结果早期死亡1例：Rastelli手术患者术后因严重低心排死亡;其余均顺利康复。随诊2～10年,1例主动脉瓣置换术后1年因同种瓣严重瓣损毁行二次手术置换机械瓣,术后18d死于多器官系统功能衰竭;其余患者术后生存状态均良好。结论同种主动脉瓣用于心脏瓣膜的置换及心室流出道的重建,可获得很好的临床效果。     

带瓣牛颈静脉补片在右室流出道重建中的临床应用

目的 总结带瓣牛颈静脉补片在右室流出道重建中的临床经验和术后早期效果.方法 2006年6月至2008年12月,16例患者应用带瓣牛颈静脉补片进行右室流出道重建.与同期手术行右室流出道重建使用自体心包组术后早期进行对比.结果 全组无死亡,术后3个月超声检查右室流出道通畅,4例有轻度反流.结论 带瓣牛颈静脉作为右室流出道重建的替代材料,具有易于获取、型号齐全、早期临床效果好的特点,但中远期效果仍待随访观察.     

自体肺动脉瓣移植作主动脉瓣换置的长期结果

作者等从1967年7月到1972年7月在英国国家心脏病医院作此手术85例,其中77例右室流出道重建应用同种异体移植物,8例应用自体阔筋膜。患者年龄12岁～55岁,平均33岁。85例中26例系重度主动脉瓣关闭不全或混合性主动脉瓣病变伴有主动脉根部扩大。出院后1个月起每6个月随访一次,包括体检、心电图、胸片、心音图,54例作了心导管检查,测量右室流出道压力阶差,部分作主动脉与肺动脉造影术。     

同种主动脉跨环补片用于法鲁四联症根治术

本文报告６例法鲁四联症（ＴＯＦ）采用同种主动脉瓣（ＨＡＶ）保留二尖瓣前叶法行根治术，ＨＡＶ采用液氮保存，全组均为男性，年龄２．５－８岁，均有肺动脉发育不全。跨环补片采用ＨＡＶ主动脉壁加宽肺动脉，二尖瓣前叶加宽右室流出道；６例全部存活，无并发症；术后超声心动图（ＵＣＧ）示右室流出道疏通满意，无肺动脉瓣返流。     

同种主动脉瓣行右室流出道跨环补片

在4例法乐氏四联症的根治木中,用同种异休主动脉瓣完成右室流出道至主肺动脉的跨环补片。术后病人紫绀和心脏杂音消失。有2例手术后复查超声心动图,表明同种主动脉瓣近期活动良好,无返流。文章还对新鲜同种主动脉瓣的制备和保存技术作了介绍。     

新型无支架生物瓣带瓣管道用于右室流出道重建

目的:验证新型无支架生物瓣带瓣管道应用于右室流出道重建术中的有效性和安全性。方法:2007年11月～2008年5月,全组7例复杂先天性心脏病患者使用了新型无支架牛心包带瓣管道重建右室流出道,其中Rastelli手术6例、Nikaidoh手术1例。通过术后不同时期超声检查结果,记录肺动脉压、血流速度、新建肺动脉瓣跨瓣压差及开口面积和返流情况,了解肺动脉管道直径、有无瘤样扩张以及远端吻合口压差等,对移植的无支架生物瓣带瓣管道的临床性能进行评价。结果:所有患者住院期间均无吻合口渗血、心内膜炎、血栓栓塞等带瓣管道相关并发症发生,恢复顺利,均治愈出院。术后1～4月和6月以上超声检查均提示移植的管道通畅,管壁无变薄、钙化,无瘤样扩张,无明显肺动脉瓣返流等。结论:新型无支架生物瓣带瓣管道具有管壁弹性好、易于缝合、术后排斥反应少等优点,且有良好抗返流作用,早期疗效满意。     

The Ross procedure as the surgical treatment of active aortic valve endocarditis

BACKGROUND AND AIM OF THE STUDY: The authors' experience is reported of aortic valve replacement (AVR) using the pulmonary autograft in patients with active aortic valve endocarditis, including an urgent Ross procedure in infants with the acute condition. METHODS: Nine patients aged between 8 months and 38 years, with a diagnosis of aortic valve endocarditis, have undergone AVR using the Ross procedure at the authors' institution since October 1997. The diagnosis was established by clinical and echocardiographic findings. Indications for surgery were severe aortic insufficiency and congestive heart failure in all patients, with the addition of thromboembolic events (n = 3), persistent hyperpyrexia (n = 3) and vegetations (n = 5). Four infants with no history of congenital cardiac malformation underwent urgent surgery because of acute bacterial endocarditis and rapid hemodynamic deterioration. Blood cultures were positive for Streptococcus pneumoniae in three patients, and Kingella kingi and Staphylococcus aureus in one patient each. Four patients were culture-negative. All patients were treated with intravenous antibiotics for four to six weeks postoperatively. RESULTS: There were no perioperative or late deaths, and no recurrent endocarditis at the implanted valves. Echocardiographic evaluation at discharge showed trivial to mild aortic insufficiency, with no stenosis at the left ventricular outflow tract. Similar findings were found across the right ventricular outflow tract. At follow up (range: 4 months to 5.5 years), none of the patients showed progression of aortic valve insufficiency or developed stenosis; three had mild and moderate homograft stenosis (Doppler gradient 20-40 mmHg), and all children had moderate homograft insufficiency. CONCLUSION: The Ross procedure is an excellent therapeutic option for active aortic valve endocarditis in young patients, and demonstrates low morbidity and mortality. Early surgery may be indicated in patients with acute aortic valve endocarditis because of the rapidly progressive nature of this disease.     

Fate of the autograft and homograft following Ross aortic valve replacement: reoperative frequency, outcome, and management

BACKGROUND AND AIM OF THE STUDY: The optimal hemodynamic performance and potential for growth of the pulmonary autograft has led to expanded indications for the Ross aortic valve replacement (AVR) procedure in some centers. The authors' institutional mid-term experience was reviewed to assess autograft and homograft hemodynamics, growth profile of the autograft, and reoperative frequency following Ross AVR. METHODS: Between June 1993 and June 2005, 167 consecutive patients (mean age 24.9 +/- 15.5 years; range: 1 month to 61 years) underwent Ross AVR: 48% of patients were aged < 19 years. Additional procedures (n = 78) were performed in 55 patients (33%) at the time of the Ross procedure. In total, 151 patients had isolated aortic valve disease and 16 pediatric patients had more complex, multi-level left ventricular outflow tract obstruction. RESULTS: There were two early deaths (1.2%) and one late death (0.6%) over a mean follow up of 5.1 +/- 3.0 years (range: 1 month to 11 years). Actuarial survival at 10 years was 98%. In pediatric patients with Konno procedure (n = 16), the pulmonary autograft mean annulus diameter increased from 10.2 to 19.9 mm. Twelve patients underwent 12 reoperations without mortality for autograft insufficiency or an ascending aortic aneurysm at a median interval of 5 years (range: 2 to 8 years): aortic annuloplasty and ascending aorta replacement (n = 4), composite aortic root replacement (n = 7), and repair of left ventricular pseudoaneurysm (n = 1). Freedom from replacement of the pulmonary autograft was 96% at 10 years. Five of the 164 surviving patients (3%) developed significant obstruction of the pulmonary homograft and required conduit replacement at a median of four years. CONCLUSION: The Ross AVR can be performed with good mid-term results, including the pediatric age group. The potential for development of significant autograft insufficiency and homograft stenosis warrants annual follow up through the intermediate and late terms.     

Aortic valve replacement with a pulmonary autograft (the Ross operation) in adult and pediatric patients. A preliminary study

INTRODUCTION AND OBJECTIVES: Aortic valve replacement with the patients own pulmonary autograft (the Ross procedure) is by now, the best surgical method for the replacement of the diseased aortic valve in certain groups of patients, this is particularly true for young adults and children or neonates with complex left ventricular outflow tract obstructions. The procedure was described by Donald Ross in 1967, and many years have passed. So in view of the accumulated experience the indications have extended to a wide group of patients which include children, neonates and young adults with formal contraindications for anticoagulation. In this publication we present our experience and our preliminary results in a group of fifteen patients which include adult and pediatric. MATERIAL AND METHODS: In six patients the etiology of lesion was congenital and in the remainder nine the valve had an acquired lesion. Two patients had an open heart procedure before this operation both of them to relieve an obstruction to the left ventricular outflow tract. In this group of patients the Ross procedure was carried out inserting the pulmonary autograft in the aortic position as a total root which was always reconstructed with cryopreserved pulmonary homograft, the mean homograft diameter was 26.1 +/- 4 mm (19-35). RESULTS: In all patients a transesophageal echocardiogram was performed in the operating room and postoperative, 1 or 2 months later. Only in one patient a mild aortic regurgitation was detected, no significant transaortic or transpulmonary gradients were detected postoperative. One patient was reoperated for bleeding in the postoperative course, there was no hospital mortality in our group and all the patients had an uneventful postoperative period. In the short term follow-up (41-155 days). All the patients are free of anticoagulant therapy, all them are in New York Heart Association Functional Class I. CONCLUSIONS: The patients presented in this publication which include adult and pediatric, are the first group of patients operated in our country with some excellent preliminary results. We hope that this procedure will become popular and that other surgical groups will adopt it as another surgical tool to replace a diseased aortic valve.     

Ross operation in children: late results.

BACKGROUND AND AIM OF THE STUDY: Although the Ross operation has become the accepted aortic valve replacement in children, the long-term fate of the pulmonary autograft valve remains unknown. To assess mid-term and late results of autograft valve durability, patient survival and valve-related morbidity, a retrospective review of patients (age range: 3 days to 17 years) having a Ross operation between November 1986 and May 2001 were reviewed. METHODS: Medical records and patient contacts with all but two of 167 current survivors of 178 consecutive patients having an aortic valve replacement as a Ross operation have been completed during the past two years. The most recent echocardiographic evaluation was reviewed for autograft valve and homograft valve function. RESULTS: Operative mortality was 4.5% (8/178), with three late deaths (two were non-valve-related) for an actuarial survival of 92+/-3% at 12 years. Actuarial freedom from autograft valve degeneration (reoperation or severe insufficiency of autograft valve or valve-related death) was 90+/-4% at 12 years. Autograft valve degeneration was not affected by technique of insertion (141 root replacement, 37 intra-aortic), aortic valve morphology (157 bicuspid or unicuspid, 26 tricuspid), or age at operation. Autograft valve degeneration was worse in patients with a primary lesion of aortic insufficiency than in those with aortic stenosis (p = 0.03). Autograft valve reoperation was required in 12 patients, with autograft valve replacement in seven. Actuarial freedom from autograft replacement was 93+/-3% at 12 years. Homograft valve replacement was required in seven patients, with actuarial freedom from replacement of 90+/-4% at 12 years. Eight additional patients have homograft valve obstruction (gradient > or =50 mmHg), and seven have severe pulmonary insufficiency. CONCLUSION: Survival and freedom from aortic valve replacement are excellent in children. Homograft valve late function remains a concern, and efforts to improve homograft durability should be encouraged.     

Exercise echocardiographic comparison of pulmonary autograft and aortic homograft replacements for aortic valve disease in adults

BACKGROUND AND AIM OF THE STUDY: The pulmonary autograft, or Ross procedure, has theoretical hemodynamic benefits over other aortic valve replacements. The hemodynamic performance of the pulmonary autograft and pulmonary homograft components of this procedure have not been well defined. METHODS: Twenty patients with pulmonary autograft replacement of the aortic valve and six with aortic homografts underwent exercise echocardiography with assessment of exercise duration, left ventricular dimensions, mass, and function. Hemodynamics at rest and maximal exercise, including Doppler gradients and effective orifice area (EOA), were measured across the pulmonary autograft and aortic homograft valves. Doppler gradients across the pulmonary homograft valves were compared to native pulmonary valve gradients at rest and maximal exercise. RESULTS: Both groups of patients had excellent self-reported and measured exercise capacity. In comparison to the aortic homograft, the pulmonary autograft had lower peak Doppler gradients across the neoaortic valve at rest (5 +/- 2 versus 11 +/- 4 mmHg; p = 0.027) and maximal exercise (10 +/- 5 versus 15 +/- 5 mmHg; p = 0.003) and larger indexed EOA. However, the Ross procedure patients had higher gradients across the pulmonary homograft both at rest (14 +/- 10 versus 3 +/- 1 mmHg; p < 0.001) and maximal exercise (25 +/- 22 versus 5 +/- 4 mmHg; p = 0.004). Two patients in the Ross procedure group had significant pulmonary homograft stenosis in short- or mid-term follow up. CONCLUSION: In comparison to aortic homograft replacement of the aortic valve, pulmonary autograft replacement has superior hemodynamics at rest and during exercise. However, the pulmonary homograft replacement may develop hemodynamically significant stenosis after the Ross procedure.     

The use of cryopreserved homografts in reconstructing the right ventricular outflow tract in congenital cardiopathies]

In recent years the use of cryopreserved allograft valves has become very popular. Homograft valves have been used for aortic valve replacement and for reconstruction of the outflow tract of the right ventricle for more than 30 years with very good results. Recently the method of cryopreservation has made possible the creation of valve banks. The use of this cryopreserved valves has obtained very good short and medium term results. We present our experience with the use of cryopreserved allograft valves in the reconstruction of the right ventricular outflow tract in the treatment of complex cardiac malformations. We have operated 15 children. Six were diagnosed of different types of transpositions of the great arteries with ventricular septal defect and pulmonary atresia or stenosis. There were 2 deaths not related to the use of the allograft valves. Nine other patients were diagnosed of different types of complex cardiac malformations. One patient with a univentricular heart and pulmonary stenosis and a neonate presenting with a truncus arteriosus communis died after the operation; again the deaths were not related to the use of the homograft conduits. Our technique of cryopreservation consists in the procurement of aortic and pulmonary valves from multiorgan donor patients. The valves are sterilized in antibiotics for 48 hours. Then the process of freezing is began with a period of progressive cooling down to -40 degrees C and second phase of storage in liquid nitrogen to a temperature of -178 degrees C. The short and medium term results are very satisfactory. We have not seen late important complications.     

Hemodynamic performance during maximum exercise in adult patients with the ross operation and comparison with normal controls and patients with aortic bioprostheses

This study examines the resting and exercise hemodynamic performance of the pulmonary autografts in the aortic position as well as of the homografts used for right ventricular outflow reconstruction in patients undergoing the Ross operation. Previous studies have reported excellent resting hemodynamics in patients who underwent aortic valve replacement with a pulmonary autograft. However, there are very few studies of their hemodynamic performance during exercise. Twenty adult subjects who underwent the Ross operation and 12 normal control subjects were submitted to maximum romp bicycle exercise. The valve effective orifice areas and transvalvular gradients of both aortic (autograft) and pulmonary (homograft) valves were measured at rest and at peak of maximum exercise using Doppler echocardiography. Valve areas were indexed for body surface area. The hemodynamics of the aortic valve were very similar in Ross subjects and in control subjects at rest and during exercise. However, the indexed valve area of the pulmonary valve at rest was significantly (p < 0.001) lower in the Ross subjects (1.10 +/- 0.46 cm2/ m2) than in the control subjects (1.95 +/- 0.41 cm2/m2), resulting in higher (p = 0.004) mean gradients at rest (Ross: 9 +/- 7 mm Hg vs control: 2 +/- 1 mm Hg) and at peak exercise (Ross: 21 +/- 14 mm Hg vs control: 7 +/- 2 mm Hg). The pulmonary autograft provided excellent hemodynamics in the aortic position either at rest or during maximum exercise, whereas moderately high gradients were found during exercise across the homograft implanted in the pulmonary valve position. Future improvement of the Ross procedure should be oriented toward the search of new methods to prevent the deterioration of the homografts.     

Partial and transient relief of conduit obstruction by low-pressure balloon dilation in patients with congenital heart disease

Seven patients underwent attempted low pressure balloon dilation of stenotic conduits or homografts from right ventricle to pulmonary artery (n=5), in the aortic valve position (n=1), or from right atrium to left pulmonary artery (n=1). In the right ventricle to pulmonary artery group, mean gradient reduction was only 17%. At follow-up, two patients underwent surgical conduit replacement, one had a stent implanted at cardiac catheterization, the other two are awaiting surgical intervention. The patient with a homograft in the aortic valve position had a good initial result but restenosed within 1 year and underwent a pulmonary autograft operation. The patient with the Fontan homograft stenosis had transient obstruction relief but subsequently required stent implantation. Low-pressure balloon dilation of conduits or homografts is only partially and transiently successful. Whether stent implantation will offer better long-term results remains to be determined.     

Aortic valve replacement by a pulmonary homograft

Minor experience still exists in our country with regard to the use of valve homografts in cardiac surgery. Only a few implantations have been performed in cases of right ventricular outflow tract reconstruction in addition to our own experience in cases of infective endocarditis of the aortic valve. We present a case of aortic valve replacement by using an antibiotic-sterilized fresh pulmonary valve autograft. The case is described and the possible advantages of the use of pulmonary allografts in the aortic position are discussed.     

Long-term results of pulmonary autograft for aortic valve replacement.

Eighty-five survivors who left hospital after pulmonary autograft replacement for severe aortic regurgitation have been followed critically. Five patients died in the first five years and 80 were followed for six to 11 years. Important aortic regurgitation occurred only early and was always related to technical malpositioning of one autograft cusp. Seven patients with fascial pulmonary valves had problems, requiring removal in four. There was a small (2%) morbidity from the right sided homograft and six were removed five to seven years later for progressive calcification; three of these had been irradiated. Despite a high incidence of trivial diastolic murmurs this valve replacement is still preferred for young patients without dilated aortic roots since the survivors remain well, with excellent, maintained relief of outflow obstruction, without problems from haemolysis and thromboembolism, and without deteriorating autograft function or need for anticoagulants. Histology of five autografts examined up to seven years after operation has shown normal living architecture.