主动脉根部疾病治疗的新理念课件

主动脉根部疾病治疗的新理念主动脉根部重建主动脉瓣狭窄主动脉瓣关闭不全二瓣化畸形四瓣化畸形主动脉壁病变先天性主动脉瓣病变主动脉瓣的功能正常主动脉瓣主动脉瓣狭窄主动脉瓣关闭不全主动脉根部重建的理念主动脉根部的概念及其功能主动脉瓣的功能由五个部分组成，主动脉窦虽不参与主动脉瓣功能，但可能影响主动脉瓣的修复及远期效果主动脉瓣置换:放弃了上述五个部分的功能主动脉瓣成形:至少保留上述功能的1/5则可以视为成形手术主动脉根部病变的分型正常的主动脉根部有三个主动脉窦及三个正常的瓣叶I型：瓣叶有病变但能正常运动；大多数修复技术适用于此种类型。II型：主动脉根部病变而瓣叶正常；主动脉根部的结构变形导致主动脉瓣的功能障碍。III型：瓣叶和主动脉根部结构的复合病变针对III型：重点在此种类型瓣环能重建瓣叶不可修复瓣环不能重建部分瓣环和瓣叶可以利用用牛心包替换三个瓣叶升主动脉成形必要时行“morrow术”III型:对瓣叶不能修复，但瓣环可以重建的病人牛心包片植入后可能会发生收缩Three

cusps

lesion

–

three

cusps

replacement用牛心包替换三个瓣叶三瓣叶替换三瓣叶替换（九点定位）三瓣叶替换手术视频（先固定六个点）升主动脉成形如果无冠窦明显扩张，采用V形、楔形切除，以缩小窦管交界必要时“morrow”：狭窄的病人室间隔切开牛心包片三个瓣叶替换（二瓣化畸形）三瓣叶替换（四瓣化畸形）三瓣叶替换III型:瓣叶不能修复+瓣环不可以重建：冠脉起源异常“鼎” 状成形难以行瓣叶成形或重建(难以分辨主动脉窦或者伴有冠状动脉开口异常）当主动脉瓣环完整时不建议采用此项技术，因其血流动力学效果不及三个瓣叶替换。此项技术最常适用于儿童，修复材料采用自体心包片。心包片的尺寸设计如果以窦管交界为标准，则不必参考瓣环径。瓣叶和瓣环重建的困难病例采用肺动脉瓣单叶--儿童

或采用牛心包做成瓣叶--成人或采用牛颈静脉的一个瓣叶--婴儿二叶瓣+ 小主动脉根部III型:部分瓣叶和瓣环可以利用二叶主动脉瓣+小主动脉根部切取一叶肺动脉瓣后用带单瓣叶的牛静脉片修补缺失的肺动脉瓣二叶主动脉瓣+小主动脉根部二叶主动脉瓣病变(BAV) 约占1.36%最常见的合并畸形是升主动脉扩张通常成年后才出现症状临床表现与主动脉瓣的功能有关(狭窄或关闭不全)二叶主动脉瓣二叶主动脉瓣病变(合并小主动脉根部)--增加一个窦+单瓣叶替换牛心包替换三个主动脉瓣叶（小主动脉根部）三瓣叶重建的原则尽可能多地保留自体瓣叶组织尽可能的重建三个瓣叶（及主动脉窦）重建后的瓣叶大小足够-- 三个瓣叶游离缘的总长度= 窦管交界直径--

具有足够的对合缘<20%窦管交界和根部直径的差距coaptationKaplan-Meier

analysis

curve

showing

cumulative

survivalof

patients

undergoing

aortic

cusp

replacement.Follow-upReconstruction--

Three

leaflets

by

Bovine

pericardiumReplacement

(Bioprothetic

Valve)Fig

4.

Patient

survival

by

age

groupsPatients

younger

than

60

years

of

age

at

implantation

had

a

15-year

survivalaveraging

54%±5%

compared

with

patients

between

60

and

70

years

of

ageaveraging

46%

±3%

and

with

patients

older

than

70

years

of

age

averaging28%±3%Jessica

Forcillo,

Michel

Pellerin,

Louis

P.

et

al.

PerraultCarpentier-Edwards

Pericardial

Valve

in

the

Aortic

Position:

25-Years

Experience.Ann

Thorac

Surg

2013;96:486–93.97.2

±1%Estimated

freedom

from

redo

aortic

valve

surgery

of

patients

undergoingaortic

cusps

replacement.Fig

5.

Freedom

rate

from

reexploration

for

prosthesis

valve

dysfunction

by

agegroups

(excluding

endocarditis)The

freedom

rate

from

reoperation

for

prosthesis

valve

dysfunction

averaged98%

±

1%,

90%

±

3%,

60%

±6%,

and

30%±8%

at

5,

10,

15,

and

20

yearsaftersurgery

in

patients

younger

than

60

years

of

age

compared

with

99%

±0.3%,95%

±

1%,

90%

±

3%

at

5,

10,

and

15

years

after

surgery

in

patients

agedbetween

60

and

70

years

old,

and

100%,

99%±

0.5%

at

5

and

10

yearsaftersurgery

in

patients

older

than

70

years

of

age.Jessica

Forcillo,

Michel

Pellerin,

Louis

P.

et

al.

PerraultCarpentier-Edwards

Pericardial

Valve

in

the

Aortic

Position:

25-Years

Experience.Ann

Thorac

Surg

2013;96:486–93.ReconstructionReplacement

(Bioprothetic

Valve)93.8±3%91.3±3.8%Aortic

Regurgitation:

moderate

and

severeAortic

stenosis:mean

gradient

or

peak

gradient

＞36mmHgFollow-up--

Three

leaflets

by

Bovine

pericardium针对II型:主动脉根部重建David

procedure主动脉根部重建David手术针对II型:主动脉根部重建Davidprocedure

主动脉根部重建David手术针对II型:主动脉根部重建Remodeling

of

aortic

root主动脉根部重建Remodeling手术针对II型:主动脉根部重建减小左室—主动脉连接直径瓣叶置换通过缝合缩小左室—主动脉连接缩小瓣环缩小左室—主动脉连接针对II型:主动脉根部重建Ascending

aorta

reduction

orreplacement升主动脉的成形或置换针对II型:主动脉根部重建Williams

Syndrome威廉姆斯综合征手术方法主动脉“一窦”扩大成形术（McGoon法）主动脉“二窦”扩大成形术（Doty法）主动脉“三窦”扩大成形术（Brom法）改良主动脉“四窦”扩大成形术（Myers法）升主动脉端端吻合术单瓣叶成形Single

leaflet

repair：瓣叶修复瓣叶的解剖瓣叶附着缘的长度是瓣叶游离缘的1.5倍The

length

of

a

normal

aortic

valve

leaflet

base

is

approximately

1.5

times

that

of

the

free

margin.成人瓣叶的高度大约13到16mm，游离缘28-34mmThe

free

margin

ranges

from

28

to

34

mm,

average

of

32mm,The

height

ranges

from

13

to

16

mm

inadults.瓣叶与窦部相匹配(瓣缘与STJ、高度与窦部）瓣叶成形术Leaflet

angioplasty交界悬吊Suspension

of

commissure延长的瓣膜游离缘缩短术Shortening

free

edge

of

redundantcusps瓣膜边缘折叠术Plication

of

valvular

edge瓣膜中部楔形切除术Wedge

resection

of

central

part

ofleaflets瓣膜破损修补术Repairing

the

damaged

valve瓣膜面积扩大术Valve

area

augmentation增厚瓣膜削切术Thinning

the

thickened

cuspsAVP主要方法病变瓣叶与其他正常瓣叶不能对和，病变瓣叶延长，由于瓣膜脱垂的部位不定，主要是对其进行处理。Extended

valve

leaflet

cannot

anneal

with

other

normal

leaflets.

We

should

repair

the

prolapsed

cusp.处理策略Surgical

technique瓣膜游离缘缩短术是最常用的，包括瓣膜折叠悬吊术和瓣膜楔形切除术

Shortening

the

valvular

free

edge

is

the

most

commonly

used

technique,

involvingplication

and

suspension

of

cusps

and

wedge

resection

of

partial

leaflets.单瓣叶病变—病变瓣叶高度正常一侧边缘延长折叠悬吊Plication

and

suspension单瓣叶病变—病变瓣叶高度正常一侧边缘延长Single

cusp

lesion

–

Height

of

leaflet

normal,

one

valve

edge

extended瓣缘中部折叠缝合Plication

and

suture单瓣叶病变—病变瓣叶高度正常一侧边缘延长Single

cusp

lesion

–

Height

of

leaflet

normal,

one

valve

edge

extended瓣叶中部延长，结节多消失，失去主动脉小结的瓣膜

不但低于其他两个正常瓣膜，而且中央部分失去小结，因此可以切除。单瓣叶病变—瓣叶中部延长切除缝合Resection

and

suture细菌性心内膜炎主动脉瓣穿孔Aortic

valvular

perforation

due

to

bacterial

endocarditis单瓣叶病变—穿孔修补单瓣叶病变—瓣叶高度降低瓣叶扩大Expending

valve

leaflet缩短并加高瓣叶单瓣叶病变—合并窦瘤形成、穿孔主动脉瓣窦的先天性缺陷，主动脉根部的扩大等可造成窦瘤形成甚至穿孔，这种最容易发生在右冠窦，窦瘤的扩张和穿孔还可以使右冠瓣低于其他连个瓣膜，可于主动脉瓣环与窦瘤颈部间补以心包补片，处理窦瘤穿孔。Formation

and

rupture

of

sinus

of

Valsalva

aneurysm

may

due

to

congenital

abnormality

or

extended

aortic

root.They

are

most

likely

located

in

the

right

sinus.

The

right

coronary

valve

may

be

lower

than

the

other

cusps

due

toexpansion

and

rupture

of

the

Valsalva

aneurysm.

We

can

repair

the

sinus

of

Valsalva

aneurysm

with

suturing

apericardial

patch

among

aortic

annulus

and

the

neck

of

sinus

aneurysm.单瓣叶病变—合并窦瘤形成(穿孔)、室间隔缺损单瓣叶毁坏的主要原因是紧邻主动脉瓣下的先天性室间隔缺损常见的有Single

cusp

abnormality

mainly

due

tojuxta-aortic

VSD单瓣叶置换Single

cusp

replacement干下室缺、右冠窦瘤、右冠瓣脱垂（约占75%）Doubly

committed

subarterial

VSD,

right

sinus

of

Valsalva

aneurysm,prolapsed

right

aortic

cusp

(about

75%)膜周室缺、无冠窦瘤、无冠瓣脱垂（约占25%）Perimembranous

VSD,noncoronary

sinus

of

Valsalva

aneurysm,prolapsednoncoronary

aortic

cusp

(about25%)测量瓣叶Measure

aortic

valveleaflets单瓣叶病变—单瓣叶置换术裁剪瓣叶Tailor

bovinepericardium单瓣叶病变—单瓣叶置换术检查Inspect单瓣叶病变—单瓣叶置换术单瓣叶置换替代本瓣叶的功能增加与另外两个瓣叶的对合缘弥补另外两瓣叶轻度的功能不全单瓣叶置换术单瓣叶置换术单瓣叶置换术中TEEPrePost瓣叶组合成形co-leaflet

repairA

200

Normal

Hearts

Study

(Vollebergh

Femg,1977)RCC(25.9*14.1)>NCC(25.5*14.1)>LCC(25.0*14.2)The

total

length

of

free

margin

of

the

aortic

valve

leaflets

is

equal

to

aortic

perimeter=

2πR≈2R+2R+2RR主动脉瓣边缘长度总和与主动脉内径相同二瓣化畸形的分型尽管type

2只占5%,但却占据60%的主动脉瘤的病例，提示发现此型多为不良表现型，手术应该积极Though

only

5%

patients

are

diagnosed

with

type

2,

of

those

patients

about

60%

paientscomplaicated

with

aortic

aneurysm.

The

procedure

should

be

performed

as

soon

aspossible.按窦分型更易做成形手术AVP

is

easy

to

perform

just

as

the

sinus

classification单、双、三、四瓣叶是逐渐过渡型病理改变，术中需仔细观察Single,

bicuspid,

tricuspid

and

quadricuspid

aoritic

leaflets

are

the

transitionalpathologic

lesion,

which

should

be

inspected

during

the

procedure二瓣化畸形双瓣叶病变—功能二瓣化双瓣叶病变—功能二瓣化(改良加高）沿瓣根部部分切开向上反折利用自体瓣重建一个瓣叶ReconstructavalveleafletwithautologousaorticvalveIncisepartofvalveleafletalongthevalvularrootandfoldupward牛心包单叶瓣重建另一瓣叶Reconstructanothercuspwithbovinepericardium双瓣叶病变—功能二瓣化双瓣叶病变（根部较大的）—真二瓣化设计并加高三交界仅限于成人大小的主动脉Only

suitable

for

adult-size

aortic

rootDesign

and

heighten

the

three

commissures双瓣叶病变—功能二瓣化以心包置换共瓣的两个瓣叶当瓣叶无法完美分割，其中有一个瓣叶变形严重，可以只保留一个功能正常的自体瓣叶，适用于主动脉直径接近成人的患者（Reoplace

tw

cusps

with

bovine

pericardium.

When

the

two

cusps

cannot

bedivided

in

the

commissures,we

can

resect

the

severely

diseased

cusp

and

retain

the

other

functionally

normal

autologouscusp.This

technique

is

suitable

for

adult-size

aortic

root.

）三瓣叶中二瓣叶病变，患者为正常的三窦三瓣叶，有两个瓣叶病变,分别按单瓣叶修复（If

two

cusps

o