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1、主动脉瓣成形术主动脉瓣成形术 方法和策略方法和策略王王 巍巍中国医学科学院中国医学科学院 阜外心血管病医院阜外心血管病医院背景仍是心外科难点仍是心外科难点术后很大一部分病人病变仍进行性加重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q瓣叶病变瓣叶病变瓣叶脱垂瓣叶脱垂瓣叶穿孔和卷曲瓣叶穿孔和卷曲二瓣化二瓣化q主动脉瓣环（根部）扩张主动脉瓣环（根部
2、）扩张q瓣叶和根部联合病变瓣叶和根部联合病变q瓣叶菲薄、柔软、无钙化挛缩瓣叶菲薄、柔软、无钙化挛缩外科手术种类q主动脉瓣主动脉瓣 关闭不全关闭不全David : 44 David : 44 例例瓣叶穿孔和撕脱修补瓣叶穿孔和撕脱修补: 20 : 20 例例瓣叶加高和移植瓣叶加高和移植: 31 : 31 例例折叠和悬吊折叠和悬吊: 101 : 101 例例q主动脉瓣狭窄主动脉瓣狭窄交界切开交界切开: 58 : 58 例例结果qCPB CPB 时间时间: 30-270 : 30-270 minsmins (102.70 (102.70 39.5739.57) )q阻断时间阻断时间:15-175 :1
3、5-175 minsmins (71.36 (71.36 30.90) 30.90) q围术期死亡围术期死亡: 3 : 3 例例q再次手术再次手术: 2 : 2 例例主动脉瓣狭窄 (1)q 合并其他诊断合并其他诊断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瓣环直径瓣环直径 (mm)14.38 3.3814.773.240.406窦径(mm)18.535.0317.533.870.308LVEDd (mm)34.367.7934.79
4、6.200.775LVEF(%)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瓣环直径瓣环
5、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)n 术前随访
6、P value瓣环瓣环 (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)诊断诊断医源性医源性 AI （ VSD 修补术后）修补术后） 15例例SBE 3例例其他其他2例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)n 术前随访P value瓣环瓣环 (mm)22.21 2.7723
7、.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nStanford A型主动脉夹层15例n主动脉根部瘤27例n马凡氏综合征主动脉根部瘤26例n大动脉炎主动脉根部瘤1例n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)n合并手术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)
8、n手术方法nDavid I 手术 9例nDavid II手术 30例n改良David手术(包裹或三片法） 5例nDavid手术二次瓣膜替换术2例n分别于术后10、12月n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）
9、 101.8140.96 110.7122.76 OCLD time（min） 69.8131.21 85.2324.39 主动脉瓣环径主动脉瓣环径 21.205.40 23.524.17 主动脉窦径主动脉窦径 27.737.45 30.186.64 升主动脉径升主动脉径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进行进行Logistic统计分析统计分析, 发现术后主动脉瓣反流与主动发现
10、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前两者均为危险因素，而瓣叶加高为保护性因素讨论讨论 达到主动脉瓣正常功能的理想几何形态达到主动脉瓣正常功能的理想几何形态 CLASS瓣叶交界瓣叶交界瓣叶瓣叶瓣环瓣环Valsava 窦窦窦管交界区窦管交界区讨论讨论主动脉瓣狭窄主动脉瓣狭窄: 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讨论瓣叶折叠圆形瓣环成形讨论讨论自
11、体心包加高瓣叶讨论讨论矩形切除讨论讨论n危险因素分析瓣环和窦管交界大小是独立危险因素n在处理瓣叶病变的同时要注意对两个部分的处理n瓣叶加高简单安全有效 n增加瓣叶高度n增加交界长度n产生更多的接触面积讨论讨论nDavid 手术适应症：主动脉瓣瓣叶正常的主动脉扩张性疾病n升主动脉或主动脉根部瘤n结缔组织疾病导致的根部扩张（Marfan 综合征）n主动脉夹层累及主动脉根部讨论讨论再植 (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讨论n改良改良DavidDavi
12、d手术手术n有利于主动脉瓣和瓣环处理n操作方便 显露完全 成形充分n个性化重建窦部n选择性重建部分窦部n可防止窦管交界扩张结论n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n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n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n瓣叶的加高是一种简单、安全、更加有效的手术方式。Aortic Valve RepairPortfolio StrategyWei WangFuwai Hospital CAMS & PUMCBackgroundRemains a surgical
13、 challengeHigh rate of progressive failureStrong incentive to develop reliable techniques and strategyRetrograde 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 months Fu Wai ExperiencePathology qCusp pat
14、hologyProlapse of cusp tissueCusp perforation or retractionBicuspid anatomyqDilatation of the aortic annular (root)qCombination of both root and cusp pathologyqThe leaflet is slight and soft ,without calcification and ContractureSurgical CategoryqAortic insufficiency David : 44 casesClosure of tear
15、and perforation: 20 casesLeaflet extension and cusp transplantation: 31 casesPlication and suspension: 101 casesqAortic stenosisCommissurotomy: 58 casesResultsqCPB periods: 30-270 mins (102.70 39.57)qAortic clamping periods:15-175 mins (71.36 30.90) qOperative death: 3 casesqRe-operation: 2 casesSub
16、group results:AS (1)q Concomitant diagnosisPDA 9MI 5VSD 15CoA 1PAPVC 1ASD8Coronary arterial fistula1PS 1Subgroup results:AS (2)PreoperationFollow-upTrivial8Mild 1635Moderated2515Severe17PreoperationFollow upP valueDiameter of Annulus (mm)14.38 3.3814.773.240.406Diameter of Sinus(mm)18.535.0317.533.8
17、70.308LVEDd (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 diagnosisVSD 37Valsava sinus rupture6PDA 6ASD 2DORV 1MI 5PS 5 Subaortic sten
18、osis 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 1.2925.06 0.760.800LVEDd (mm)50.37 1.7640.01 4.910.001LVEF(%)64.88 8.9
19、967.88 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)n PreoperationFollow upP valueDiameter of Annulus (mm)20.20 3.1119.6
20、0 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)PreoperationFollow-upTrivial4Mild 313Moderated113Severe6AI:Perfo
21、ration closure(3)n 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: DavidnStanford type A aortic dissection:15 casesnAortic root aneurysm:27 casesnMarfan
22、syndrome:26 casesnArteritis:1 casenBicuspid with Aortic root aneurysm: 2 casesAI: David (1)nConcomitant diagnosisTotal aorta replacement: 1 caseTotal arch replacement: 4 casesHemi-arch replacement:3 casesCABG :1 caseAbdominal aorta replacement: 1 caseAI: David (2)nType of operationnDavid I :9 casesn
23、David II: 30 casesnModified David : 5 casesnReoperation for valve replacement after David opertation:2 casesn10 and 12 months post-operationly nProlapse of non-coronary leaflet and left-coronary leafletAI: David (3)PreoperationFollow-upTrivial16Mild 2324Moderated142Severe72AI: DavidqPatient Diagnosi
24、s: 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） 69.8131.21 85.2324.39 Diameter of Annulus 21.20
25、5.40 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 Annulus7.9430.39871.3510.0001Leaflet extension4.8300.98980.3720.028
26、By 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 is protective factor。Discussion Ideal geometry to
27、 achieve aortic valve competence CLASSCommissuresLeafletsAnnulusSinuses of valsavaSinotubular regionDiscussionnAortic stenosis: Balloon or surgical valvotomyn Aortic regurgitationnLeaflet plication with commissure resuspensionnLeaflet thinning, release of thickend leaflets,or partial commissure clos
28、urenTriangular resection and repair of redundant leafletsnRepair of torn or perforated leafletsnAortic cusp extensionDiscussionCommissural plicationCircular annularplastyDiscussionLeaflet extension using autologous pericardiumDiscussionTriangular resectionDiscussionnRisk Analysis: Both annulus and S
29、T junction size are independent risk factorsnLeaflet extension procedure is a simple, safe and effective choice nincrease the height of the leaflets nIncrease commissuresncreating an additional area of coaptation.DiscussionnIndication of David procedure ：aortic root dilation with normal leafletnAsce
30、nding Aortic aneurysm or aortic root aneurysmnaortic root dilation arise from connective tissue disease （Marfan）nAortic dissection involving aortic rootDiscussionReimplantationPrevent dilation of aortic annulusComplex operationImpact between aortic valve and prosthetic graftRemodelingSimple performa
31、nceOpening and closing of valve accord more With the physiologicalPossibility of re-dilation of sinus or Sinotubular junction regionDiscussionnModified David procedureModified David procedurenEasy to deal with aortic valve and annulusnConvenient to operate and exposure nReconstruction of sinus indiv
32、idually nSelective reconstruction of partial sinusnPrevent dilation of Sinotubular junction regionConclusionnRrecommended when the leaflet is slight and soft , without calcification and contracturenDavid procedure is safe and effective to the patients that aortic valve is insufficient caused by aortic root dilation and leaflet is normal nIt should be noticed to repaire leaflet and deal with sinotubular junction region for the patients with Prolapse of cusp tissue of aortic valvenLeaflet extension procedure is a simple, safe and effective choice
