主动脉瓣成形术方法和策略课件

主动脉瓣成形术方法和策略1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234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5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6主动脉瓣狭窄(1)合并其他诊断PDAMIVSDCoAPAPVCASDCoronary

arterial

fistulaPS9515118117主动脉瓣狭窄(2)术前随访无8轻度1635中度2515重度178术前随访P

value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±16.51<0.001主动脉瓣狭窄(3)9主动脉瓣关闭不全:折叠和悬吊(1)合并其他诊断VSDValsava

sinus

rupturePDAASDDORVMIPSSubaortic

stenosis37662155110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1511主动脉瓣关闭不全:折叠和悬吊(3)12术前随访P

value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

±4.91<0.001LVEF(%)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

1Residue

VSD

and

AV

perforation

2PS2Subaortic

membrane113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914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)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

±6.800.46215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16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617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

±3.110.456LVEDd

(mm)56.01

±13.3643.83

±5.230.043LVEF(%)61.33

±6.0363.67

±1.150.57218主动脉瓣关闭不全:David手术15例27例Stanford A型主动脉夹层主动脉根部瘤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19主动脉瓣关闭不全:David

(1)合并手术全主动脉替换术全主动脉弓部替换术1例4例部分主动脉弓部替换术3例CABG腹主动脉替换术1例1例20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21分组结果:David

(3)术前(例)随访(例)微量16少量2324中量142大量7222主动脉瓣关闭不全:

David手术术前随访瓣环(mm)3024窦径(mm)4834LVEDd

(mm)463923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±23.98CPB

time（min）101.81±40.96110.71±22.76OCLD

time（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

24危险因素分析25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7.9430.39871.351<0.0001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26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27讨论28瓣叶折叠圆形瓣环成形讨论29自体心包加高瓣叶讨论矩形切除30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31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32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33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34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。3536Aortic

Valve

RepairPortfolio

StrategyWei

WangFuwai

HospitalCAMS

&

PUMC37BackgroundRemains

a

surgical

challengeHigh

rate

of

progressive

failureStrong

incentive

to

develop

reliabletechniques

and

strategy38Retrograde

Analysis254

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

monthsFu

WaiExperience39PathologyCusp

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

andContracture40Surgical

CategoryAortic

insufficiencyDavid

: 44

casesClosure

of

tear

and

perforation:

20

casesLeaflet

extension

and

cusp

transplantation:

31

casesPlication

and

suspension:

101

casesAortic

stenosisCommissurotomy:

58

cases41ResultsCPB

periods:30-270

mins

(102.70

±39.57)Aortic

clamping

periods:15-175

mins

(71.36±30.90)Operative

death:

3

casesRe-operation:

2cases42Subgroup

results:AS

(1)Concomitant

diagnosisPDAMIVSDCoAPAPVCASDCoronary

arterial

fistulaPS95151181143Subgroup

results:AS

(2)PreoperationFollow-upTrivial8Mild1635Moderated2515Severe1744PreoperationFollow

upP

valueDiameter

ofAnnulus

(mm)14.38

±3.3814.77±3.240.406Diameter

ofSinus(mm)18.53±5.0317.53±3.870.308LVEDd

(mm)34.36±7.7934.79±6.200.775LVEF(%)76.38±6.9172.15±5.870.030Ventricular

septal(mm)7.33±2.606.58±0.990.298Transvalvulargradient77.41±33.6033.80±16.51<0.00145Subgroup

results:AS

(3)AI:

Plicate

and

suspension(1)Concomitant

diagnosisVSDValsava

sinus

rupturePDAASDDORVMIPSSubaortic

stenosis37662155146AI:

Plicate

and

suspension(2)PreoperationFollow-upTrivial15Mild2063Moderated6620Severe1547AI:

Plicate

and

suspension(3)PreoperationFollow

upP

valueDiameter

ofAnnulus

(mm)19.78

±0.9619.44

±0.600.783Diameter

ofAnnulus(mm)25.42

±1.2925.06

±0.760.800LVEDd

(mm)50.37

±1.7640.01

±4.91<0.001LVEF(%)64.88

±8.9967.88

±9.520.24948AI:

Leaflet

extension(1)Concomitant

diagnosisVSD

9CoA

1Residue

VSD

and

AV

perforation

2PS2Subaortic

membrane149AI:

Leaflet

extension(2)PreoperationFollow-upTrivial12Mild15Moderated224Severe950AI:

Leaflet

extension(3)

PreoperationFollow

upP

valueDiameter

ofAnnulus

(mm)20.20

±3.1119.60

±3.970.553Diameter

ofAnnulus(mm)28.01

±5.6625.20

±4.490.013LVEDd

(mm)47.11

±9.3640.80

±10.110.004LVEF(%)61.80

±7.4364.40

±6.800.46251AI:

Perforation

closure(1)DiagnosisIatrogenic

AI15（

Post

VSD

repair

）SBE3Others252AI:

Perforation

closure(2)PreoperationFollow-upTrivial4Mild313Moderated113Severe653AI:Perforation

closure(3)

PreoperationFollow

upP

valueDiameter

ofAnnulus

(mm)22.21

±2.7723.60

±2.510.423Diameter

ofsinus(mm)29.01

±3.5429.80

±3.110.456LVEDd

(mm)56.01

±13.3643.83

±5.230.043LVEF(%)61.33

±6.0363.67

±1.150.57254AI:

DavidStanford

type

A

aortic

dissection:15

casesAortic

root

aneurysm:Marfan

syndrome:Arteritis:27cases26cases1

caseBicuspid

with

Aortic

root

aneurysm:

2

cases55AI:

David

(1)Concomitant

diagnosisTotal

aorta

replacement:Total

archreplacement:Hemi-arch

replacement:CABG

:Abdominal

aorta

replacement:1case4cases3cases1case1case56AI:

David

(2)Type

ofoperationDavid

I

:David

II:Modified

David

:9cases30cases5casesReoperation

for

valve

replacement

after

David

opertation:2cases10

and

12

months

post-operationlyProlapse

of

non-coronary

leaflet

and

left-coronaryleaflet57AI:

David

(3)PreoperationFollow-upTrivial16Mild2324Moderated142Severe7258AI:

DavidPatient

Diagnosis:PreoperationFollow

upDiameter

ofAnnulus

(mm)3024Diameter

ofsinus(mm)4834LVEDd

(mm)463959AI:

ComparisonPlicationExtensioncases18921Age

(years)18.60±17.9117.92±16.56weight（Kg）39.01±22.9639.14±23.98CPB

time（min）101.81±40.96110.71±22.76OCLD

time（min）69.81±31.2185.23±24.39Diameter

of

Annulus21.20±5.4023.52±4.17Diameter

of

Sinus27.73±7.4530.18±6.64Diameter

of

Ao(mm)24.39±6.4423.69±7.63death30

60Risk

FactorsAnalysis61Risk

factorsWald

x2Partial

regressioncoefficientORvalueP

valueDiameter

ofSinus8.0520.21981.2460.0014Diameterof

Annulus7.9430.39871.351<0.0001Leafletextension4.830－0.98980.3720.028By

logistic

statistical

analysis,it

is

found

that

aortic

regurgitationpostoperationly

is

correlative

evidently

with

diameter

of

annulus

anddiameter

of

sinus

and

leaflet

extension

procedure.The

former

twoarerisk

factors

,as

the

leaflet

extension

is

protective

factor。DiscussionIdeal

geometry

to

achieve

aortic

valvecompetence

CLASSCommissuresLeafletsAnnulusSinuses

of

valsavaSinotubular

region62DiscussionAortic

stenosis:

Balloon

or

surgical

valvotomyAortic

regurgitationLeaflet

plication

with

commissure

resuspensionLeaflet

thinning,

release

of

thickend

leaflets,orpartial

commissure

closureTriangular

resection

and

repair

ofredundantleafletsRepair

of

torn

or

perforated

leafletsAortic

cusp

extension63Discussion64Commissural

plicationCircular

annularplastyDiscussion65Leaflet

extension

using

autologous

pericardiumDiscussionTriangularresection66DiscussionRisk Analysis:

Both

annulus

and

ST

junctionsize

are

independent

risk

factorsLeaflet

extension

procedure

is

a

simple,safeand

effective

choiceincrease

the

height

of

the

leafletsIncrease

commissurescreating

an

additional

area

of

coaptation.67DiscussionIndication

of

David

procedure

：aortic

rootdilation

with

normal

leafletAscending

Aortic

aneurysm

or

aorticrootaneurysmaortic

root

dilation

arise from

connectivetissue

disease

（Marfan）Aortic

dissection

involving

aortic

root68Discussion69

Reimplantation

Prevent

dilationof aortic

annulus

Complex