主動脈瓣成形術方法和策略

1、主動脈瓣成形術 方法和策略,王 巍中國醫(yī)學科學院 阜外心血管病醫(yī)院,背景,仍是心外科難點術后很大一部分病人病變仍進行性加重需要可靠的技術和治療策略,回顧性分析,254 例 ( 1996-10– 2007-12)男/女: 170/84年齡: 18.53 ±17.74 (0.1-73歲) 體重: 39.09 ±23.01 (3.4-89kg)隨訪: 6-121 月,病理改變,瓣葉病變瓣葉脫垂

2、瓣葉穿孔和卷曲二瓣化主動脈瓣環(huán)（根部）擴張瓣葉和根部聯(lián)合病變瓣葉菲薄、柔軟、無鈣化攣縮,外科手術種類,主動脈瓣 關閉不全David : 44 例瓣葉穿孔和撕脫修補: 20 例瓣葉加高和移植: 31 例折疊和懸吊: 101 例主動脈瓣狹窄交界切開: 58 例,結果,CPB 時間: 30-270 mins (102.70 ±39.57)阻斷時間:15-175 mins (71.36 ±30.90

3、) 圍術期死亡: 3 例再次手術: 2 例,主動脈瓣狹窄 (1),合并其他診斷PDA 9MI 5VSD 15CoA 1PAPVC 1ASD8Coronary arterial fistula1PS 1,主動脈瓣狹窄(2),主動脈瓣狹窄(3),主動脈瓣關閉不全: 折疊和懸吊(1),合并其他診斷VSD 37Valsava

4、 sinus rupture6PDA 6ASD 2DORV 1MI 5PS 5 Subaortic stenosis 1,主動脈瓣關閉不全: 折疊和懸吊(2),主動脈瓣關閉不全: 折疊和懸吊(3),主動脈瓣關閉不全: 瓣葉加高及移植 (1),合并其他診斷VSD

5、 9CoA 1 Residue VSD and AV perforation 2PS 2Subaortic membrane 1,主動脈瓣關閉不全:

6、 瓣葉加高(2),主動脈瓣關閉不全: 瓣葉加高及移植(3),,主動脈瓣關閉不全: 穿孔閉合(1),診斷醫(yī)源性 AI （ VSD 修補術后） 15例SBE 3例其他2例,主動脈瓣關閉不全: 穿孔閉合(2),主動脈瓣關閉不全: 穿孔閉合(3),,主動脈瓣關閉不全: David手術,Stanford A型主動脈夾層15例主動脈根部瘤27例馬凡氏綜合征主動脈根部瘤26例大動脈炎主動脈根部

7、瘤1例主動脈瓣二瓣化畸形合并根部瘤2例,主動脈瓣關閉不全: David (1),合并手術全主動脈替換術 1例全主動脈弓部替換術 4例部分主動脈弓部替換術 3例CABG 1例腹主動脈替換術 1例,分組結果: David (2),手術方法David I 手術 9例David II手術

8、30例改良David手術(包裹或三片法） 5例David手術二次瓣膜替換術2例分別于術后10、12月原因分別為無冠瓣和左冠瓣脫垂,分組結果: David (3),主動脈瓣關閉不全: David手術,,主動脈瓣關閉不全: 比較,危險因素分析,進行Logistic統(tǒng)計分析, 發(fā)現(xiàn)術后主動脈瓣反流與主動脈瓣環(huán)內徑、竇部內徑、瓣葉加高手術方式顯著相關, 前兩者均為危險因素，而瓣葉加高為保護性因素,討論,達到主動脈瓣正常功能的理想幾何形

9、態(tài) CLASS瓣葉交界瓣葉瓣環(huán)Valsava 竇竇管交界區(qū),討論,主動脈瓣狹窄: 球囊擴張還是主動脈瓣切開成形 主動脈瓣關閉不全交界懸吊使瓣葉折疊瓣葉切薄或切除增厚瓣葉或部分交界縫合矩形切除后將剩余瓣葉成形修補穿孔的瓣葉瓣葉加高,討論,瓣葉折疊,圓形瓣環(huán)成形,討論,自體心包加高瓣葉,討論,矩形切除,討論,危險因素分析瓣環(huán)和竇管交界大小是獨立危險因素在處理瓣葉病變的同時要注意對兩個部分的處理瓣葉加高簡

10、單安全有效 增加瓣葉高度增加交界長度產生更多的接觸面積,討論,David 手術適應癥：主動脈瓣瓣葉正常的主動脈擴張性疾病升主動脈或主動脈根部瘤結締組織疾病導致的根部擴張（Marfan 綜合征）主動脈夾層累及主動脈根部,討論,再植 (Reimplantation)防止主動脈瓣瓣環(huán)擴張操作復雜主動脈瓣與人工血管“撞擊”成形 (Remodeling)操作簡便主動脈瓣的開閉過程更符合生理竇部和竇管交界有再度擴張可能,討

11、論,改良David手術有利于主動脈瓣和瓣環(huán)處理操作方便 顯露完全 成形充分個性化重建竇部選擇性重建部分竇部可防止竇管交界擴張,結論,對于主動脈瓣葉菲薄、柔軟、無鈣化攣縮的患者可以施行主動脈成形術對于主動脈根部擴張性疾病所引起的主動脈瓣正常的關閉不全患者，David手術是一種安全有效的選擇而對于主動脈瓣葉脫垂的患者，應該同時注意瓣葉的修復與竇管部的處理瓣葉的加高是一種簡單、安全、更加有效的手術方式。,謝謝,Aortic V

12、alve RepairPortfolio Strategy,Wei WangFuwai Hospital CAMS & PUMC,Background,Remains a surgical challengeHigh rate of progressive failureStrong incentive to develop reliable techniques and strategy,Retrogra

13、de 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 pathologyProlap

14、se of cusp tissueCusp perforation or retractionBicuspid anatomyDilatation of the aortic annular (root)Combination of both root and cusp pathologyThe leaflet is slight and soft ,without calcification and Contracture,

15、Surgical Category,Aortic insufficiency David : 44 casesClosure of tear and perforation: 20 casesLeaflet extension and cusp transplantation: 31 casesPlication and suspension: 101 casesAortic stenosisCommissurotomy:

16、 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

17、9MI 5VSD 15CoA 1PAPVC 1ASD8Coronary arterial fistula1PS 1,Subgroup results:AS (2),Subgroup results:AS (3),AI: Plicate and suspension(1),Concomitant diagnosisVSD 37V

18、alsava 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

19、 9CoA 1 Residue VSD and AV perforation 2PS 2Subaortic

20、 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),A

21、I:Perforation closure(3),,AI: David,Stanford type A aortic dissection:15 casesAortic root aneurysm:27 casesMarfan syndrome:26 casesArteritis:1 caseBicuspid with Aortic root aneurysm: 2 cases,AI: David (1),Co

22、ncomitant diagnosisTotal aorta replacement: 1 caseTotal arch replacement: 4 casesHemi-arch replacement:3 casesCABG :1 caseAbdominal aorta replacement: 1 case,AI: David (2),Type of operationDavid I :9

23、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: Davi

24、d (3),AI: David,Patient Diagnosis:,AI: Comparison,Risk Factors Analysis,By logistic statistical analysis, it is found that aortic regurgitation postoperationly is correlative evidently with diameter of annulus and diamet

25、er of sinus and leaflet extension procedure. The former two are risk factors ,as the leaflet extension is protective factor。,Discussion,Ideal geometry to achieve aortic valve competence CLASSCommissuresLeafletsAnn

26、ulusSinuses of valsavaSinotubular region,Discussion,Aortic stenosis: Balloon or surgical valvotomy Aortic regurgitationLeaflet plication with commissure resuspensionLeaflet thinning, release of thickend leaflets,or

27、partial commissure closureTriangular resection and repair of redundant leafletsRepair of torn or perforated leafletsAortic cusp extension,Discussion,Commissural plication,Circular annularplasty,Discussion,Leaflet exte

28、nsion using autologous pericardium,Discussion,Triangular resection,Discussion,Risk Analysis: Both annulus and ST junction size are independent risk factorsLeaflet extension procedure is a simple, safe and effective ch

29、oice increase the height of the leaflets Increase commissurescreating an additional area of coaptation.,Discussion,Indication of David procedure ：aortic root dilation with normal leafletAscending Aortic aneurysm or a

30、ortic root aneurysmaortic root dilation arise from connective tissue disease （Marfan）Aortic dissection involving aortic root,Discussion,ReimplantationPrevent dilation of aortic annulusComplex operationImpact betwe

31、en aortic valve and prosthetic graftRemodelingSimple performanceOpening and closing of valve accord more With the physiologicalPossibility of re-dilation of sinus or Sinotubular junction region,Discussion,Modified Da

32、vid procedureEasy to deal with aortic valve and annulusConvenient to operate and exposure Reconstruction of sinus individually Selective reconstruction of partial sinusPrevent dilation of Sinotubular junction region

33、,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

34、 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 ef