1、主动脉瓣成形术 方法和策略,王 巍中国医学科学院 阜外心血管病医院,背景,仍是心外科难点术后很大一部分病人病变仍进行性加重需要可靠的技术和治疗策略,回顾性分析,254 例 ( 1996-10 2007-12)男/女: 170/84年龄: 18.53 17.74 (0.1-73岁) 体重: 39.09 23.01 (3.4-89kg)随访: 6-121 月,病理改变,瓣叶病变瓣叶脱垂瓣叶穿孔和卷曲二瓣化主动脉瓣环（根部）扩张瓣叶和根部联合病变瓣叶菲薄、柔软、无钙化挛缩,外科手术种类,主动脉瓣 关闭不全David : 44 例瓣叶穿孔和撕脱修补: 20 例瓣叶加高和移植: 31 例折叠和悬吊: 1
2、01 例主动脉瓣狭窄交界切开: 58 例,结果,CPB 时间: 30-270 mins (102.70 39.57)阻断时间:15-175 mins (71.36 30.90) 围术期死亡: 3 例再次手术: 2 例,主动脉瓣狭窄 (1),合并其他诊断PDA 9MI 5VSD 15CoA 1PAPVC 1ASD8Coronary arterial fistula1PS 1,主动脉瓣狭窄(2),主动脉瓣狭窄(3),主动脉瓣关闭不全: 折叠和悬吊(1),合并其他诊断VSD 37Valsava sinus rupture6PDA 6ASD 2DORV 1MI 5PS 5 Subaortic sten
3、osis 1,主动脉瓣关闭不全: 折叠和悬吊(2),主动脉瓣关闭不全: 折叠和悬吊(3),主动脉瓣关闭不全: 瓣叶加高及移植 (1),合并其他诊断VSD 9CoA 1 Residue VSD and AV perforation 2PS 2Subaortic membrane 1,主动脉瓣关闭不全: 瓣叶加高(2),主动脉瓣关闭不全: 瓣叶加高及移植(3),主动脉瓣关闭不全: 穿孔闭合(1),诊断医源性 AI （ VSD 修补术后） 15例SBE 3例其他2例,主动脉瓣关闭不全: 穿孔闭合(2),主动脉瓣关闭不全: 穿孔闭合(3),主动脉瓣关闭不全: David手术,Stanford A型主动
4、脉夹层15例主动脉根部瘤27例马凡氏综合征主动脉根部瘤26例大动脉炎主动脉根部瘤1例主动脉瓣二瓣化畸形合并根部瘤2例,主动脉瓣关闭不全: David (1),合并手术全主动脉替换术 1例全主动脉弓部替换术 4例部分主动脉弓部替换术 3例CABG 1例腹主动脉替换术 1例,分组结果: David (2),手术方法David I 手术 9例David II手术 30例改良David手术(包裹或三片法） 5例David手术二次瓣膜替换术2例分别于术后10、12月原因分别为无冠瓣和左冠瓣脱垂,分组结果: David (3),主动脉瓣关闭不全: David手术,主动脉瓣关闭不全: 比较,危险因素分析,进
5、行Logistic统计分析, 发现术后主动脉瓣反流与主动脉瓣环内径、窦部内径、瓣叶加高手术方式显著相关, 前两者均为危险因素，而瓣叶加高为保护性因素,讨论,达到主动脉瓣正常功能的理想几何形态 CLASS瓣叶交界瓣叶瓣环Valsava 窦窦管交界区,讨论,主动脉瓣狭窄: 球囊扩张还是主动脉瓣切开成形 主动脉瓣关闭不全交界悬吊使瓣叶折叠瓣叶切薄或切除增厚瓣叶或部分交界缝合矩形切除后将剩余瓣叶成形修补穿孔的瓣叶瓣叶加高,讨论,瓣叶折叠,圆形瓣环成形,讨论,自体心包加高瓣叶,讨论,矩形切除,讨论,危险因素分析瓣环和窦管交界大小是独立危险因素在处理瓣叶病变的同时要注意对两个部分的处理瓣叶加高简单安全有效
6、 增加瓣叶高度增加交界长度产生更多的接触面积,讨论,David 手术适应症：主动脉瓣瓣叶正常的主动脉扩张性疾病升主动脉或主动脉根部瘤结缔组织疾病导致的根部扩张（Marfan 综合征）主动脉夹层累及主动脉根部,讨论,再植 (Reimplantation)防止主动脉瓣瓣环扩张操作复杂主动脉瓣与人工血管“撞击”成形 (Remodeling)操作简便主动脉瓣的开闭过程更符合生理窦部和窦管交界有再度扩张可能,讨论,改良David手术有利于主动脉瓣和瓣环处理操作方便 显露完全 成形充分个性化重建窦部选择性重建部分窦部可防止窦管交界扩张,结论,对于主动脉瓣叶菲薄、柔软、无钙化挛缩的患者可以施行主动脉成形术对
7、于主动脉根部扩张性疾病所引起的主动脉瓣正常的关闭不全患者，David手术是一种安全有效的选择而对于主动脉瓣叶脱垂的患者，应该同时注意瓣叶的修复与窦管部的处理瓣叶的加高是一种简单、安全、更加有效的手术方式。,谢谢,Aortic Valve RepairPortfolio Strategy,Wei WangFuwai Hospital CAMS & PUMC,Background,Remains a surgical challengeHigh rate of progressive failureStrong incentive to develop reliable techniques an
8、d strategy,Retrograde Analysis,254 cases (Oct 1996-Dec 2007)Male/Female: 170/84Age: median 18.53 17.74 (0.1-73years) Wt: median 39.09 23.01 (3.4-89kg)Follow up: 6-121 months,Fu Wai Experience,Pathology,Cusp pathologyProlapse of cusp tissueCusp perforation or retractionBicuspid anatomyDilatation of t
9、he aortic annular (root)Combination of both root and cusp pathologyThe leaflet is slight and soft ,without calcification and Contracture,Surgical Category,Aortic insufficiency David : 44 casesClosure of tear and perforation: 20 casesLeaflet extension and cusp transplantation: 31 casesPlication and s
10、uspension: 101 casesAortic stenosisCommissurotomy: 58 cases,Results,CPB periods: 30-270 mins (102.70 39.57)Aortic clamping periods:15-175 mins (71.36 30.90) Operative death: 3 casesRe-operation: 2 cases,Subgroup results:AS (1),Concomitant diagnosisPDA 9MI 5VSD 15CoA 1PAPVC 1ASD8Coronary arterial fis
11、tula1PS 1,Subgroup results:AS (2),Subgroup results:AS (3),AI: Plicate and suspension(1),Concomitant diagnosisVSD 37Valsava sinus rupture6PDA 6ASD 2DORV 1MI 5PS 5 Subaortic stenosis 1,AI: Plicate and suspension(2),AI: Plicate and suspension(3),AI: Leaflet extension(1),Concomitant diagnosisVSD 9CoA 1
12、Residue VSD and AV perforation 2PS 2Subaortic membrane 1,AI: Leaflet extension(2),AI: Leaflet extension(3),AI: Perforation closure(1),DiagnosisIatrogenic AI 15（ Post VSD repair ） SBE 3Others2,AI: Perforation closure(2),AI:Perforation closure(3),AI: David,Stanford type A aortic dissection:15 casesAor
13、tic root aneurysm:27 casesMarfan syndrome:26 casesArteritis:1 caseBicuspid with Aortic root aneurysm: 2 cases,AI: David (1),Concomitant diagnosisTotal aorta replacement: 1 caseTotal arch replacement: 4 casesHemi-arch replacement:3 casesCABG :1 caseAbdominal aorta replacement: 1 case,AI: David (2),Ty
14、pe of operationDavid I :9 casesDavid II: 30 casesModified David : 5 casesReoperation for valve replacement after David opertation:2 cases10 and 12 months post-operationly Prolapse of non-coronary leaflet and left-coronary leaflet,AI: David (3),AI: David,Patient Diagnosis:,AI: Comparison,Risk Factors
15、 Analysis,By logistic statistical analysis, it is found that aortic regurgitation postoperationly is correlative evidently with diameter of annulus and diameter of sinus and leaflet extension procedure. The former two are risk factors ,as the leaflet extension is protective factor。,Discussion,Ideal
16、geometry to achieve aortic valve competence CLASSCommissuresLeafletsAnnulusSinuses of valsavaSinotubular region,Discussion,Aortic stenosis: Balloon or surgical valvotomy Aortic regurgitationLeaflet plication with commissure resuspensionLeaflet thinning, release of thickend leaflets,or partial commis
17、sure closureTriangular resection and repair of redundant leafletsRepair of torn or perforated leafletsAortic cusp extension,Discussion,Commissural plication,Circular annularplasty,Discussion,Leaflet extension using autologous pericardium,Discussion,Triangular resection,Discussion,Risk Analysis: Both
18、 annulus and ST junction size are independent risk factorsLeaflet extension procedure is a simple, safe and effective choice increase the height of the leaflets Increase commissurescreating an additional area of coaptation.,Discussion,Indication of David procedure ：aortic root dilation with normal l
19、eafletAscending Aortic aneurysm or aortic root aneurysmaortic root dilation arise from connective tissue disease （Marfan）Aortic dissection involving aortic root,Discussion,ReimplantationPrevent dilation of aortic annulusComplex operationImpact between aortic valve and prosthetic graftRemodelingSimpl
20、e performanceOpening and closing of valve accord more With the physiologicalPossibility of re-dilation of sinus or Sinotubular junction region,Discussion,Modified David procedureEasy to deal with aortic valve and annulusConvenient to operate and exposure Reconstruction of sinus individually Selectiv
21、e reconstruction of partial sinusPrevent dilation of Sinotubular junction region,Conclusion,Rrecommended when the leaflet is slight and soft , without calcification and contractureDavid procedure is safe and effective to the patients that aortic valve is insufficient caused by aortic root dilation and leaflet is normal It should be noticed to repaire leaflet and deal with sinotubular junction region for the patients with Prolapse of cusp tissue of aortic valveLeaflet extension procedure is a simple, safe and effective choice,Thanks,
