1、主動脈瓣成形術方法和策略-醫學資料主動脈瓣成形術方法和策略-醫學資料背景仍是心外科難點術后很大一部分病人病變仍進行性加重需要可靠的技術和治療策略背景仍是心外科難點回顧性分析254 例 ( 2019-10 2019-12)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 回顧性分析254 例 ( 2019-10 2019-12)病理改變瓣葉病變瓣葉脫垂瓣葉穿孔和卷曲二瓣化主動脈瓣環（根部）擴張瓣葉和根部聯合病變瓣葉菲薄、柔軟、無鈣化攣縮病理改變瓣葉病變外科手術種類主動脈瓣 關閉不全David :

2、44 例瓣葉穿孔和撕脫修補: 20 例瓣葉加高和移植: 31 例折疊和懸吊: 101 例主動脈瓣狹窄交界切開: 58 例外科手術種類主動脈瓣 關閉不全結果CPB 時間: 30-270 mins (102.70 39.57)阻斷時間:15-175 mins (71.36 30.90) 圍術期死亡: 3 例再次手術: 2 例結果CPB 時間: 30-270 mins (102.70 主動脈瓣狹窄 (1) 合并其他診斷PDA 9MI 5VSD 15CoA 1PAPVC 1ASD8Coronary arterial fistula1PS 1主動脈瓣狹窄 (1) 合并其他診斷主動脈瓣狹窄(2)術前隨訪無

3、8輕度1635中度2515重度17主動脈瓣狹窄(2)術前隨訪無8輕度1635中度2515重度1術前隨訪P value瓣環直徑 (mm)14.38 3.3814.773.240.406竇徑(mm)18.535.0317.533.870.308LVEDd (mm)34.367.7934.796.200.775LVEF(%)76.386.9172.155.870.030室間隔厚度 (mm)7.332.606.580.990.298跨瓣壓差(mmHg)77.4133.6033.8016.510.001主動脈瓣狹窄(3)術前隨訪P value瓣環直徑 (mm)14.38 3.3主動脈瓣關閉不全: 折疊和

4、懸吊(1)合并其他診斷VSD 37Valsava sinus rupture6PDA 6ASD 2DORV 1MI 5PS 5 Subaortic stenosis 1主動脈瓣關閉不全: 折疊和懸吊(1)合并其他診斷主動脈瓣關閉不全: 折疊和懸吊(2)術前（例）隨訪（例）微量15少量2063中量6620大量15主動脈瓣關閉不全: 折疊和懸吊(2)術前（例）隨訪（例）微量主動脈瓣關閉不全: 折疊和懸吊(3)術前隨訪P value瓣環直徑 (mm)19.78 0.9619.44 0.600.783竇直徑(mm)25.42 1.2925.06 0.760.800LVEDd (mm)50.37 1.7

5、640.01 4.910.001LVEF(%)64.88 8.9967.88 9.520.249主動脈瓣關閉不全: 折疊和懸吊(3)術前隨訪P value瓣主動脈瓣關閉不全: 瓣葉加高及移植 (1)合并其他診斷VSD 9CoA 1 Residue VSD and AV perforation 2PS 2Subaortic membrane 1主動脈瓣關閉不全: 瓣葉加高及移植 (1)合并其他診斷主動脈瓣關閉不全: 瓣葉加高(2)術前（例）隨訪（例）微量12少量15中量224大量9主動脈瓣關閉不全: 瓣葉加高(2)術前（例）隨訪（例）微量1主動脈瓣關閉不全: 瓣葉加高及移植(3)術前隨訪P va

6、lue瓣環 (mm)20.20 3.1119.60 3.970.553竇徑(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主動脈瓣關閉不全: 瓣葉加高及移植(3)術前隨訪P val主動脈瓣關閉不全: 穿孔閉合(1)診斷醫源性 AI （ VSD 修補術后） 15例SBE 3例其他2例主動脈瓣關閉不全: 穿孔閉合(1)診斷主動脈瓣關閉不全: 穿孔閉合(2)術前(例)隨訪(例)微量4少量313中量113大量6主動脈瓣關閉不全: 穿孔閉合(2)術前(例)隨訪

7、(例)微量4主動脈瓣關閉不全: 穿孔閉合(3)術前隨訪P value瓣環 (mm)22.21 2.7723.60 2.510.423竇徑(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主動脈瓣關閉不全: 穿孔閉合(3)術前隨訪P value瓣主動脈瓣關閉不全: David手術Stanford A型主動脈夾層15例主動脈根部瘤27例馬凡氏綜合征主動脈根部瘤26例大動脈炎主動脈根部瘤1例主動脈瓣二瓣化畸形合并根部瘤2例主動脈瓣關閉不全: David手術S

8、tanford A型主動主動脈瓣關閉不全: David (1)合并手術全主動脈替換術 1例全主動脈弓部替換術 4例部分主動脈弓部替換術 3例CABG 1例腹主動脈替換術 1例主動脈瓣關閉不全: David (1)合并手術分組結果: David (2)手術方法David I 手術 9例David II手術 30例改良David手術(包裹或三片法） 5例David手術二次瓣膜替換術2例分別于術后10、12月原因分別為無冠瓣和左冠瓣脫垂分組結果: David (2)手術方法分組結果: David (3)術前(例)隨訪(例)微量16少量2324中量142大量72分組結果: David (3)術前(例)

9、隨訪(例)微量16少主動脈瓣關閉不全: David手術 術前隨訪瓣環 (mm)3024竇徑(mm)4834LVEDd (mm)4639主動脈瓣關閉不全: David手術 術前隨訪瓣環 (mm主動脈瓣關閉不全: 比較傳統組 延伸組 病例數 18921年齡（歲） 18.6017.9117.9216.56 體重（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 主動脈瓣環徑 21.205.40 23.524.17 主動脈竇徑 27.737.45 30

10、.186.64 升主動脈徑24.396.44 23.697.63 死亡30主動脈瓣關閉不全: 比較傳統組 延伸組 病例數 18921年危險因素分析危險因素Wald x2偏回歸系數OR值P值Ao竇徑8.0520.21981.2460.0014瓣環徑7.9430.39871.3510.0001瓣葉加高4.8300.98980.3720.028進行Logistic統計分析, 發現術后主動脈瓣反流與主動脈瓣環內徑、竇部內徑、瓣葉加高手術方式顯著相關, 前兩者均為危險因素，而瓣葉加高為保護性因素危險因素分析危險因素Wald x2偏回歸系數OR值P值Ao竇討論 達到主動脈瓣正常功能的理想幾何形態 CLAS

11、S瓣葉交界瓣葉瓣環Valsava 竇竇管交界區討論 達到主動脈瓣正常功能的理想幾何形態 CLASS討論主動脈瓣狹窄: 球囊擴張還是主動脈瓣切開成形 主動脈瓣關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穿孔的瓣葉瓣葉加高討論主動脈瓣狹窄: 球囊擴張還是主動脈瓣切開成形討論瓣葉折疊圓形瓣環成形討論瓣葉折疊圓形瓣環成形討論自體心包加高瓣葉討論自體心包加高瓣葉討論矩形切除討論矩形切除討論危險因素分析瓣環和竇管交界大小是獨立危險因素在處理瓣葉病變的同時要注意對兩個部分的處理瓣葉加高簡單安全有效 增加瓣葉高度增加交界長度產生更多的接觸面積討論危險因素分析瓣環和

12、竇管交界大小是獨立危險因素討論David 手術適應癥：主動脈瓣瓣葉正常的主動脈擴張性疾病升主動脈或主動脈根部瘤結締組織疾病導致的根部擴張（Marfan 綜合征）主動脈夾層累及主動脈根部討論David 手術適應癥：主動脈瓣瓣葉正常的主動脈擴張性疾討論再植 (Reimplantation)防止主動脈瓣瓣環擴張操作復雜主動脈瓣與人工血管“撞擊”成形 (Remodeling)操作簡便主動脈瓣的開閉過程更符合生理竇部和竇管交界有再度擴張可能討論再植 (Reimplantation)討論改良David手術有利于主動脈瓣和瓣環處理操作方便 顯露完全 成形充分個性化重建竇部選擇性重建部分竇部可防止竇管交界擴張

13、討論改良David手術結論對于主動脈瓣葉菲薄、柔軟、無鈣化攣縮的患者可以施行主動脈成形術對于主動脈根部擴張性疾病所引起的主動脈瓣正常的關閉不全患者，David手術是一種安全有效的選擇而對于主動脈瓣葉脫垂的患者，應該同時注意瓣葉的修復與竇管部的處理瓣葉的加高是一種簡單、安全、更加有效的手術方式。結論對于主動脈瓣葉菲薄、柔軟、無鈣化攣縮的患者可以施行主動脈謝謝謝謝Aortic Valve RepairPortfolio StrategyWei WangFuwai Hospital CAMS & PUMCAortic Valve RepairPortfolio BackgroundRemains a

14、 surgical challengeHigh rate of progressive failureStrong incentive to develop reliable techniques and strategyBackgroundRemains a surgical cRetrograde Analysis254 cases (Oct 2019-Dec 2019)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 mont

15、hs Fu Wai ExperienceRetrograde Analysis254 cases (Pathology 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 ContracturePathol

16、ogy Cusp pathologySurgical CategoryAortic insufficiency David : 44 casesClosure of tear and perforation: 20 casesLeaflet extension and cusp transplantation: 31 casesPlication and suspension: 101 casesAortic stenosisCommissurotomy: 58 casesSurgical CategoryAortic insuffResultsCPB periods: 30-270 mins

17、 (102.70 39.57)Aortic clamping periods:15-175 mins (71.36 30.90) Operative death: 3 casesRe-operation: 2 casesResultsCPB periods: 30-270 minSubgroup results:AS (1) Concomitant diagnosisPDA 9MI 5VSD 15CoA 1PAPVC 1ASD8Coronary arterial fistula1PS 1Subgroup results:AS (1) ConcomSubgroup results:AS (2)P

18、reoperationFollow-upTrivial8Mild 1635Moderated2515Severe17Subgroup results:AS (2)PreoperPreoperationFollow upP valueDiameter of Annulus (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.

19、606.580.990.298Transvalvular gradient77.4133.6033.8016.510.001Subgroup results:AS (3)PreoperationFollow upP valueDiAI: Plicate and suspension(1)Concomitant diagnosisVSD 37Valsava sinus rupture6PDA 6ASD 2DORV 1MI 5PS 5 Subaortic stenosis 1AI: Plicate and suspension(1)CAI: Plicate and suspension(2)Pre

20、operationFollow-upTrivial15Mild 2063Moderated6620Severe15AI: Plicate and suspension(2)PAI: 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 8.9967.88 9

21、.520.249AI: Plicate and suspension(3)PAI: Leaflet extension(1)Concomitant diagnosisVSD 9CoA 1 Residue VSD and AV perforation 2PS 2Subaortic membrane 1AI: Leaflet extension(1)ConcomAI: Leaflet extension(2)PreoperationFollow-upTrivial12Mild 15Moderated224Severe9AI: Leaflet extension(2)PreopeAI: Leafle

22、t extension(3)PreoperationFollow 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: Leaflet extension(3)PreopAI: Perforation closure(1)DiagnosisIatrogenic AI 15（ Post VSD re

23、pair ） SBE 3Others2AI: Perforation closure(1)DiagAI: Perforation closure(2)PreoperationFollow-upTrivial4Mild 313Moderated113Severe6AI: Perforation closure(2)PreoAI: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

24、3.110.456LVEDd (mm)56.01 13.3643.83 5.230.043LVEF(%)61.33 6.0363.67 1.150.572AI:Perforation closure(3)PreoAI: DavidStanford type A aortic dissection:15 casesAortic root aneurysm:27 casesMarfan syndrome:26 casesArteritis:1 caseBicuspid with Aortic root aneurysm: 2 casesAI: DavidStanford type A aortiA

25、I: David (1)Concomitant diagnosisTotal aorta replacement: 1 caseTotal arch replacement: 4 casesHemi-arch replacement:3 casesCABG :1 caseAbdominal aorta replacement: 1 caseAI: David (1)Concomitant diagnAI: David (2)Type of operationDavid I :9 casesDavid II: 30 casesModified David : 5 casesReoperation

26、 for valve replacement after David opertation:2 cases10 and 12 months post-operationly Prolapse of non-coronary leaflet and left-coronary leafletAI: David (2)Type of operationAI: David (3)PreoperationFollow-upTrivial16Mild 2324Moderated142Severe72AI: David (3)PreoperationFolloAI: DavidPatient Diagno

27、sis: PreoperationFollow upDiameter of Annulus (mm)3024Diameter of sinus(mm)4834LVEDd (mm)4639AI: DavidPatient Diagnosis: PAI: 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 85.23

28、24.39 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 death30AI: ComparisonPlication ExtensRisk Factors Analysis Risk factorsWald x2Partial regression coefficientORvalueP valueDiameter of Sinus8.0520.21981.2460.0014Diameter of Annulu

29、s7.9430.39871.3510.0001Leaflet 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 leafle

30、t extension is protective factor。Risk Factors Analysis Risk facDiscussion Ideal geometry to achieve aortic valve competence CLASSCommissuresLeafletsAnnulusSinuses of valsavaSinotubular regionDiscussion Ideal geometry toDiscussionAortic stenosis: Balloon or surgical valvotomy Aortic regurgitationLeaf

31、let plication with commissure resuspensionLeaflet thinning, release of thickend leaflets,or partial commissure closureTriangular resection and repair of redundant leafletsRepair of torn or perforated leafletsAortic cusp extensionDiscussionAortic stenosis: BalDiscussionCommissural plicationCircular a

32、nnularplastyDiscussionCommissural plicatioDiscussionLeaflet extension using autologous pericardiumDiscussionLeaflet extension usDiscussionTriangular resectionDiscussionTriangular resectionDiscussionRisk Analysis: Both annulus and ST junction size are independent risk factorsLeaflet extension procedu

33、re is a simple, safe and effective choice increase the height of the leaflets Increase commissurescreating an additional area of coaptation.DiscussionRisk Analysis: BothDiscussionIndication 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 aorti