非原位主动脉瓣置换术治疗主动脉瓣环严重毁损性病变的方法与疗效

Methods and Results of Supra-annular Aortic Valve Replacement for Patients with Severely Damaged Aortic Annulus

目的总结非原位主动脉瓣置换术(AVR)的方法和疗效。方法 2008年3月至2010年12月第二军医大学长海医院收治5例主动脉瓣环严重毁损患者,男4例,女1例;平均年龄46.3(38～53)岁。AVR术后并发严重瓣周漏再次手术4例(白塞氏病2例、大动脉炎2例),严重主动脉瓣感染性心内膜炎1例。术中发现主动脉瓣环严重毁损,无法施行常规AVR,改行非原位AVR,即将人工主动脉瓣环固定的位置提高到毁损的主动脉瓣环以上,固定人工瓣环的缝线从主动脉腔外进针、腔内出针。必要时行冠状动脉旁路移植术(CABG)。结果 5例手术患者均顺利康复出院,无出血再次手术或其它并发症。术后5例患者均获得随访,生存良好,心功能分级(NYHA)Ⅰ～Ⅱ级;分别于术后6个月(4例)、1年(2例)和3年(1例)行主动脉心脏三维CT成像(CTA)检查,均未见有主动脉根部瘤或假性动脉瘤形成,显示左心室流出道延长,左、右冠状动脉形态良好。心脏超声心动图检查均未发现有瓣周漏。结论对主动脉瓣环毁损严重的患者采用非原位AVR,人工瓣膜固定可靠,可以防止术后并发瓣周漏或根部假性动脉瘤。

Objective To summarize the methods and results of supra-annular aortic valve replacement（AVR） in patients with severely damaged aortic annulus.Methods Supra-annular AVR was performed in 5 patients between March 2008 and Dec.2010 in Changhai Hospital,Second Military Medical University.There were 4 males and 1 female with their mean age of 46.3 years（ranging from 38 to 53 years）.Non-specific infectious diseases were diagnosed in 4 patients who had severe paravalvular leakage after their first AVR operations（2 patients with Behcet’s disease and 2 patients with arteritis）,and one patient had severe infectious endocarditis.All the patients had severely destroyed aortic annulus and could not undergo routine AVR.The prosthetic valves were fixed to the aortic sinus wall between the annulus and coronary arterial ostia,and the sutures passed through from the outside of aortic wall into the inside and prosthetic valve ring.Coronary artery bypass grafting was performed if the coronary ostium was involved.Results All patients recovered from the operations uneventfully,and were followed up from 6 months to 3 years.All patients were in New York Heart Association（NYHA）functional class Ⅰ or Ⅱ during the follow-up period,and paravalvalar leakage,pseudoaneurysm and aortic root aneurysm were not found by the examination of 3D computed tomographic angiography and echocardiography at 6 months（4 cases）,1 year（2 cases）,and 3 years（1 case）,respectively.Conclusions Supra-annular AVR is an alternative surgical method for patients with severely damaged aortic annulus.The procedure is simple and effective to prevent paravalvular leakage and pseudoaneurysm formation.