主動(dòng)脈瓣成形術(shù)方法和策略

1、主動(dòng)脈瓣成形術(shù) 方法和策略,王 巍中國(guó)醫(yī)學(xué)科學(xué)院 阜外心血管病醫(yī)院,背景,仍是心外科難點(diǎn)術(shù)后很大一部分病人病變?nèi)赃M(jìn)行性加重需要可靠的技術(shù)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(dòng)脈瓣環(huán)（根部）擴(kuò)張瓣葉和根部聯(lián)合病變瓣葉菲薄、柔軟、無(wú)鈣化攣縮,外科手術(shù)種類,主動(dòng)脈瓣 關(guān)閉不全David : 44 例瓣葉穿孔和撕脫修補(bǔ): 20 例瓣葉加高和移植: 31 例折疊和懸吊: 101 例主動(dòng)脈瓣狹窄交界切開: 58 例,結(jié)果,CPB 時(shí)間: 30-270 mins (102.70 ±39.57)阻斷時(shí)間:15-175 mins (71.36 ±30.90

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

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

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

8、30例改良David手術(shù)(包裹或三片法） 5例David手術(shù)二次瓣膜替換術(shù)2例分別于術(shù)后10、12月原因分別為無(wú)冠瓣和左冠瓣脫垂,分組結(jié)果: David (3),主動(dòng)脈瓣關(guān)閉不全: David手術(shù),,主動(dòng)脈瓣關(guān)閉不全: 比較,危險(xiǎn)因素分析,進(jìn)行Logistic統(tǒng)計(jì)分析, 發(fā)現(xiàn)術(shù)后主動(dòng)脈瓣反流與主動(dòng)脈瓣環(huán)內(nèi)徑、竇部?jī)?nèi)徑、瓣葉加高手術(shù)方式顯著相關(guān), 前兩者均為危險(xiǎn)因素，而瓣葉加高為保護(hù)性因素,討論,達(dá)到主動(dòng)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(dòng)脈瓣狹窄: 球囊擴(kuò)張還是主動(dòng)脈瓣切開成形 主動(dòng)脈瓣關(guān)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(bǔ)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(xiǎn)因素分析瓣環(huán)和竇管交界大小是獨(dú)立危險(xiǎn)因素在處理瓣葉病變的同時(shí)要注意對(duì)兩個(gè)部分的處理瓣葉加高簡(jiǎn)

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

11、論,改良David手術(shù)有利于主動(dòng)脈瓣和瓣環(huán)處理操作方便 顯露完全 成形充分個(gè)性化重建竇部選擇性重建部分竇部可防止竇管交界擴(kuò)張,結(jié)論,對(duì)于主動(dòng)脈瓣葉菲薄、柔軟、無(wú)鈣化攣縮的患者可以施行主動(dòng)脈成形術(shù)對(duì)于主動(dòng)脈根部擴(kuò)張性疾病所引起的主動(dòng)脈瓣正常的關(guān)閉不全患者，David手術(shù)是一種安全有效的選擇而對(duì)于主動(dòng)脈瓣葉脫垂的患者，應(yīng)該同時(shí)注意瓣葉的修復(fù)與竇管部的處理瓣葉的加高是一種簡(jiǎn)單、安全、更加有效的手術(shù)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