主动脉瓣成形术方法和策略

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:101例主动脉瓣狭窄交界切开:58例结果CPB时间:30-270mins(102.70±39.57)阻断时间:15-175mins(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PDA9MI5VSD15CoA1PAPVC1ASD8Coronaryarterialfistula1PS1主动脉瓣狭窄(2)术前随访无8轻度1635中度2515重度17术前随访Pvalue瓣环直径(mm)14.38±3.3814.77±3.240.406窦径(mm)18.53±5.0317.53±3.870.308LVEDd(mm)34.36±7.7934.79±6.200.775LVEF(%)76.38±6.9172.15±5.870.030室间隔厚度(mm)7.33±2.606.58±0.990.298跨瓣压差(mmHg)77.41±33.6033.80±16.510.001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VSD37Valsavasinusrupture6PDA6ASD2DORV1MI5PS5Subaorticstenosis1主动脉瓣关闭不全:折叠和悬吊(2)术前（例）随访（例）微量15少量2063中量6620大量15主动脉瓣关闭不全:折叠和悬吊(3)术前随访Pvalue瓣环直径(mm)19.78±0.9619.44±0.600.783窦直径(mm)25.42±1.2925.06±0.760.800LVEDd(mm)50.37±1.7640.01±4.910.001LVEF(%)64.88±8.9967.88±9.520.249主动脉瓣关闭不全:瓣叶加高及移植(1)合并其他诊断VSD9CoA1ResidueVSDandAVperforation2PS2Subaorticmembrane1主动脉瓣关闭不全:瓣叶加高(2)术前（例）随访（例）微量12少量15中量224大量9主动脉瓣关闭不全:瓣叶加高及移植(3)•术前随访Pvalue瓣环(mm)20.20±3.1119.60±3.970.553窦径(mm)28.01±5.6625.20±4.490.013LVEDd(mm)47.11±9.3640.80±10.110.004LVEF(%)61.80±7.4364.40±6.800.462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SBE3例其他2例主动脉瓣关闭不全:穿孔闭合(2)术前(例)随访(例)微量4少量313中量113大量6主动脉瓣关闭不全:穿孔闭合(3)•术前随访Pvalue瓣环(mm)22.21±2.7723.60±2.510.423窦径(mm)29.01±3.5429.80±3.110.456LVEDd(mm)56.01±13.3643.83±5.230.043LVEF(%)61.33±6.0363.67±1.150.572主动脉瓣关闭不全:David手术•StanfordA型主动脉夹层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CABG1例腹主动脉替换术1例分组结果:David(2)•手术方法–DavidI手术9例–DavidII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)术前(例)随访(例)微量16少量2324中量142大量72主动脉瓣关闭不全:David手术术前随访瓣环(mm)3024窦径(mm)4834LVEDd(mm)4639主动脉瓣关闭不全:比较传统组延伸组病例数18921年龄（岁）18.60±17.9117.92±16.56体重（Kg）39.01±22.9639.14±23.98CPBtime（min）101.81±40.96110.71±22.76OCLDtime（min）69.81±31.2185.23±24.39主动脉瓣环径21.20±5.4023.52±4.17主动脉窦径27.73±7.4530.18±6.64升主动脉径24.39±6.4423.69±7.63死亡30危险因素分析危险因素Waldx2偏回归系数OR值P值Ao窦径8.0520.21981.2460.0014瓣环径7.9430.39871.3510.0001瓣叶加高4.830－0.98980.3720.028进行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–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。AorticValveRepairPortfolioStrategyWeiWangFuwaiHospitalCAMS&PUMCBackgroundRemainsasurgicalchallengeHighrateofprogressivefailureStrongincentivetodevelopreliabletechniquesandstrategyRetrogradeAnalysis254cases(Oct1996-Dec2007)Male/Female:170/84Age:median18.53±17.74(0.1-73years)Wt:median39.09±23.01(3.4-89kg)Followup:6-121monthsFuWaiExperiencePathologyCusppathologyProlapseofcusptissueCuspperforationorretractionBicuspidanatomyDilatationoftheaorticannular(root)CombinationofbothrootandcusppathologyTheleafletisslightandsoft,withoutcalcificationandContractureSurgicalCategoryAorticinsufficiencyDavid:44casesClosureoftearandperforation:20casesLeafletextensionandcusptransplantation:31casesPlicationandsuspension:101casesAorticstenosisCommissurotomy:58casesResultsCPBperiods:30-270mins(102.70±39.57)Aorticclampingperiods:15-175mins(71.36±30.90)Operativedeath:3casesRe-operation:2casesSubgroupresults:AS(1)ConcomitantdiagnosisPDA9MI5VSD15CoA1PAPVC1ASD8Coronaryarterialfistula1PS1Subgroupresults:AS(2)PreoperationFollow-upTrivial8Mild1635Moderated2515Severe17PreoperationFollowupPvalueDiameterofAnnulus(mm)14.38±3.3814.77±3.240.406DiameterofSinus(mm)18.53±5.0317.53±3.870.308LVEDd(mm)34.36±7.7934.79±6.200.775LVEF(%)76.38±6.9172.15±5.870.030Ventricularseptal(mm)7.33±2.606.58±0.990.298Transvalvulargradient77.41±33.6033.80±16.510.001Subgroupresults:AS(3)AI:Plicateandsuspension(1)ConcomitantdiagnosisVSD37Valsavasinusrupture6PDA6ASD2DORV1MI5PS5Subaorticstenosis1AI:Plicateandsuspension(2)PreoperationFollow-upTrivial15Mild2063Moderated6620Severe15AI:Plicateandsuspension(3)PreoperationFollowupPvalueDiameterofAnnulus(mm)19.78±0.9619.44±0.600.783DiameterofAnnulus(mm)25.42±1.2925.06±0.760.800LVEDd(mm)50.37±1.7640.01±4.910.001LVEF(%)64.88±8.9967.88±9.520.249AI:Leafletextension(1)ConcomitantdiagnosisVSD9CoA1ResidueVSDandAVperforation2PS2Subaorticmembrane1AI:Leafletextension(2)PreoperationFollow-upTrivial12Mild15Moderated224Severe9AI:Leafletextension(3)•PreoperationFollowupPvalueDiameterofAnnulus(mm)20.20±3.