主动脉瓣成形术方法和策略医学课件

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 ( 2019-10 2019-12)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

2、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)术前随访无8轻度1635中度2515重度17术前随访P value瓣环直径 (mm)14.38 3.3814.773.240.406窦径(mm)18.535.0317.533.870.308LVEDd (mm)34.367.793

3、4.796.200.775LVEF(%)76.386.9172.155.870.030室间隔厚度 (mm)7.332.606.580.990.298跨瓣压差(mmHg)77.4133.6033.8016.510.001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VSD 37Valsava sinus rupture6PDA 6ASD 2DORV 1MI 5PS 5 Subaortic stenosis 1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P value瓣环直径 (mm

4、)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)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P value瓣环 (mm)

5、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SBE 3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P value瓣环 (mm)22.21 2.7723.60 2.510.423窦径(mm)29.01 3.5429.80

6、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Stanford A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

7、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） 18.6017.9117.9216.56 体重（Kg） 39.0122.96 39.1423.98 CPB time（min） 101.8140.96 110.7122.76 OCLD time（min） 69.8131.21 85.

8、2324.39 主动脉瓣环径 21.205.40 23.524.17 主动脉窦径 27.737.45 30.186.64 升主动脉径24.396.44 23.697.63 死亡30危险因素分析危险因素Wald x2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4.8300.98980.3720.028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

9、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 (Reimplantat

10、ion)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。谢谢Aortic Valve RepairPor

11、tfolio StrategyWei WangFuwai Hospital CAMS & PUMCBackgroundRemains a surgical challengeHigh rate of progressive failureStrong incentive to develop reliable techniques and strategyRetrograde Analysis254 cases (Oct 2019-Dec 2019)Male/Female: 170/84Age: median 18.53 17.74 (0.1-73years) Wt: median 39.09

12、 23.01 (3.4-89kg)Follow up: 6-121 months Fu Wai ExperiencePathology Cusp pathologyProlapse 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 Contractu

13、reSurgical CategoryAortic insufficiency David : 44 casesClosure of tear and perforation: 20 casesLeaflet extension and cusp transplantation: 31 casesPlication and suspension: 101 casesAortic stenosisCommissurotomy: 58 casesResultsCPB periods: 30-270 mins (102.70 39.57)Aortic clamping periods:15-175

14、mins (71.36 30.90) Operative death: 3 casesRe-operation: 2 casesSubgroup results:AS (1) Concomitant diagnosisPDA 9MI 5VSD 15CoA 1PAPVC 1ASD8Coronary arterial fistula1PS 1Subgroup results:AS (2)PreoperationFollow-upTrivial8Mild 1635Moderated2515Severe17PreoperationFollow upP valueDiameter of Annulus

15、(mm)14.38 3.3814.773.240.406Diameter of Sinus(mm)18.535.0317.533.870.308LVEDd (mm)34.367.7934.796.200.775LVEF(%)76.386.9172.155.870.030Ventricular septal (mm)7.332.606.580.990.298Transvalvular gradient77.4133.6033.8016.510.001Subgroup results:AS (3)AI: Plicate and suspension(1)Concomitant diagnosisV

16、SD 37Valsava sinus rupture6PDA 6ASD 2DORV 1MI 5PS 5 Subaortic stenosis 1AI: Plicate and suspension(2)PreoperationFollow-upTrivial15Mild 2063Moderated6620Severe15AI: Plicate and suspension(3)PreoperationFollow upP valueDiameter of Annulus (mm)19.78 0.9619.44 0.600.783Diameter of Annulus(mm)25.42 1.29

17、25.06 0.760.800LVEDd (mm)50.37 1.7640.01 4.910.001LVEF(%)64.88 8.9967.88 9.520.249AI: Leaflet extension(1)Concomitant diagnosisVSD 9CoA 1 Residue VSD and AV perforation 2PS 2Subaortic membrane 1AI: Leaflet extension(2)PreoperationFollow-upTrivial12Mild 15Moderated224Severe9AI: Leaflet extension(3)Pr

18、eoperationFollow upP valueDiameter of Annulus (mm)20.20 3.1119.60 3.970.553Diameter of Annulus(mm)28.01 5.6625.20 4.490.013LVEDd (mm)47.11 9.3640.80 10.110.004LVEF(%)61.80 7.4364.40 6.800.462AI: Perforation closure(1)DiagnosisIatrogenic AI 15（ Post VSD repair ） SBE 3Others2AI: Perforation closure(2)

19、PreoperationFollow-upTrivial4Mild 313Moderated113Severe6AI:Perforation closure(3)PreoperationFollow upP valueDiameter of Annulus (mm)22.21 2.7723.60 2.510.423Diameter of sinus(mm)29.01 3.5429.80 3.110.456LVEDd (mm)56.01 13.3643.83 5.230.043LVEF(%)61.33 6.0363.67 1.150.572AI: DavidStanford type A aor

20、tic dissection:15 casesAortic root aneurysm:27 casesMarfan syndrome:26 casesArteritis:1 caseBicuspid with Aortic root aneurysm: 2 casesAI: David (1)Concomitant diagnosisTotal aorta replacement: 1 caseTotal arch replacement: 4 casesHemi-arch replacement:3 casesCABG :1 caseAbdominal aorta replacement:

21、 1 caseAI: David (2)Type 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 leafletAI: David (3)PreoperationFollow-upTrivial16Mild 2

22、324Moderated142Severe72AI: DavidPatient Diagnosis: PreoperationFollow upDiameter of Annulus (mm)3024Diameter of sinus(mm)4834LVEDd (mm)4639AI: ComparisonPlication Extensioncases18921Age (years) 18.6017.9117.9216.56 weight（Kg） 39.0122.96 39.1423.98 CPB time（min） 101.8140.96 110.7122.76 OCLD time（min）

23、 69.8131.21 85.2324.39 Diameter of Annulus 21.205.40 23.524.17 Diameter of Sinus27.737.45 30.186.64 Diameter of Ao(mm)24.396.44 23.697.63 death30Risk Factors Analysis Risk factorsWald x2Partial regression coefficientORvalueP valueDiameter of Sinus8.0520.21981.2460.0014Diameter of Annulus7.9430.39871

24、.3510.0001Leaflet extension4.8300.98980.3720.028By 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 i

25、s protective factor。Discussion Ideal geometry to achieve aortic valve competence CLASSCommissuresLeafletsAnnulusSinuses of valsavaSinotubular regionDiscussionAortic stenosis: Balloon or surgical valvotomy Aortic regurgitationLeaflet plication with commissure resuspensionLeaflet thinning, release of

26、thickend leaflets,or partial commissure closureTriangular resection and repair of redundant leafletsRepair of torn or perforated leafletsAortic cusp extensionDiscussionCommissural plicationCircular annularplastyDiscussionLeaflet extension using autologous pericardiumDiscussionTriangular resectionDis

27、cussionRisk Analysis: Both 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.DiscussionIndication of David procedure ：aortic root dilation with normal leafletAscending Aortic aneurysm or aortic root aneurysmaortic root dilation arise from connective tissue disease （Marfan）Aortic dissection involving aortic rootDiscussionReimplantationPrevent dilation of aort