主动脉瓣病变合并升主动脉扩张的“背心式”人工血管包裹术及其应用效果

Application and results of Robicsek procedure for dilated ascending aorta associated with aortic valve disease

目的:总结一种“背心式”升主动脉和根部成形术对于防止主动脉瓣病变同时合并轻、中度升主动脉扩张的患者术后中、远期发生旷置的升主动脉进行性扩张或急性主动脉夹层的效果及应用该术式的体会。方法:对2002年10月至2006年6月间采用主动脉置换或成形、升主动脉缩小成形、升主和根部背心式人工血管包裹术(“背心式”手术)治疗的30例主动脉瓣病变和升主动脉扩张的临床病例进行回顾性分析和随访,平均随访时间(18±10.5)个月。结果:30例“背心式”手术并同期其他部位手术病例的总体外循环平均时间(103.4±21.7)min(80～151min),主动脉阻断平均时间(73.0±21.6)min(48～120min),其中19例单纯行“背心式”手术的患者体外循环平均时间仅为(91.3±8.9)min(80～118min),主动脉阻断平均时间(61.6±11.3)min(48～82min),无住院死亡。平均随访18个月,无复发性主动脉扩张和夹层形成,升主动脉平均直径由术前的(46.7±3.1)mm(40～53mm)降为(33.7±2.5)mm(30～43mm)。在本组30例患者中16例为先天性主动脉二瓣化畸形,23例主动脉瘤壁病理结果显示主动脉壁弹力纤维断裂(6例)、稀少(1例)和中、重度黏液性变(16例)。结论:由于主动脉壁本身存在病理改变和血液动力学冲击,为防止远期升主动脉进一步瘤变或夹层形成,对以主动脉瓣病变为主的轻、中度主动脉根部扩张采用Robicsek术更为合理。相比Bentall和David术,此术式不仅可以缩短手术时间和减小手术风险,而且能够达到同样甚至更好的手术效果。

Objective： To introduce the Robicsek procedure and summarize its short to mid-term results for patients with dilatation of the ascending aorta associated with aortic valve disease. Methods： From December 2002 to June 2006, 30 patients with a moderately dilated ascending aorta [ mean diameter, （46.7 ±3.1 ） mm] underwent concomitant aortic valve replacement （AVR） or repairing and reinforced aortoplasty with a well-tailored Dacron vascular graft. Follow-up was obtained on all patients with ultrasonic cardiography （UCG） or computed tomography （CT） scan and was （18.0 ± 10.5） months. Restilts： The total average cardio-pulmonary bypass （CPB） time was （103.4 ± 21.7） min （80 -151 min）, and aortic arrest time was （73.0 ±21.6） min （48 - 120 min）, whereas the average CPB time and aortic arrest time of 19 patients who underwent the isolated Robicsek procedure were only （91.3 ± 8.9） min （80- 118 min） and （61.6 ±11.3） min（48 -82 min）. No mortality occurred in the hospital. During follow-up of 18 months, no recurrent ascending aortic dilatation and dissection were observed, and the average aortic diameter was reduced to （33.7 ±2.5 ） mm. Sixteen of the 30 patients were diagnosed as bicuspid aortic valve （BAV）. The ascending aortic media were histologically abnormal in 23 patients. Conclusion： Considering the underlying wall deficiency and the homodynamic stress, the Robicsek operation should be an optimal choice to those patients with a mild to moderate dilated ascending aorta caused by aortic valve lesion. Compared with the Bentall and David procedures, the Robicsek procedure could achieve the same or even better clinical results with less operative time and risks.