DavidI手术治疗主动脉根部病变致主动脉瓣关闭不全的效果

Evaluation of valve-sparing aortic root reimplantation procedure in 24 patients with aortic valve insufficiency due toaortic root disease

目的评价DavidI术式治疗主动脉根部病变导致主动脉瓣关闭不全的治疗效果。方法2005年8月至2011年5月，采用David I手术治疗24例主动脉根部病变导致主动脉瓣关闭不全患者。男21例，女3例；年龄24-69岁，平均（47．0±12．3）岁。主动脉夹层13例，主动脉根部瘤7例，马方综合征2例，单纯主动脉瓣环扩张并主动脉瓣关闭不全2例。术前心功能I级20例，Ⅱ级3例，Ⅲ级1例；主动脉瓣反流中度13例，重度11例。David I手术采用直人工血管9例，带Valsalva窦人工血管15例。同期行冠状动脉旁路移植手术6例，主动脉弓置换11例，室间隔缺损修补术1例，房间隔缺损修补术1例，二尖瓣成形＋三尖瓣成形1例。1例术中食管超声提示主动脉瓣大量反流，瓣叶脱垂，即刻决定使用带瓣人工血管行Bentall手术。术后观察患者心功能和主动脉瓣反流情况。结果围术期死亡2例，分别于术后第9天死于感染性休克并多脏器功能衰竭和术后第22天死于肺部感染；近期死亡1例，术后第54天死于肺部感染。本组体外循环（235．9±58．5）min，主动脉阻断（182．7±35．8）min。术后1周超声心动图复查，主动脉瓣无反流11例，轻度反流11例，轻至中度反流1例；所有患者心功能均为I级。术后20例（不包括3例死亡和1例行Bental]术者）随访3-74个月。主动脉瓣无反流3例；轻度反流15例，其中3例半年后再次复查提示主动脉瓣无反流；中度反流2例，其中1例3个月后复查提示反流转为轻度，1例采用直人工血管的马方综合征患者术后55个月复查提示反流转为重度。结论保留主动脉瓣的主动脉根部再植入术（David I术式）是治疗主动脉瓣叶及瓣环结构大致正常的主动脉根部病变引起的主动脉瓣关闭不全的一种理想手术方式，同时应用带Valsalva窦血管能提供更稳定的手术效果。

Objective To observe the clinical results of the valve-sparing root reimplantation procedure（ David 1 proce- dure） in patients with aortic valve insufficiency due to aortic root disease. MethOds Frmn august 2005 to May 2011, aortic valve-sparing root reimplantation was performed in 24 patients with aortic insufficiency due to aortic root disease, 21 males and 3 females; mean age （47.0 ± 12.3 ）years old （from 24years to 69years） ; 20 being of heart functional class [ ,3 of class ]] , and 1 of class Ⅲ; 13 with moderate and 11 with severe aortic insufficiency ; The tubular graft was used in 9 patients and valsal- va conduit was used inl5 patients in David I procedure. Concomitant procedures included 6 CABG operations, 11 aortic arch replacement operations, 1 mitral annuloplasty and tricuspid annuloplasty, l VSD repair and 1 ASD repair operation. Conver- sion to Bentall procedure was necessary in only one patient because transesophageal echoeardiography （TEE） showed moderate aortic insufficiency due to aortic valve prolapse. Post-operative aortic valve regurgitation and heart function were followed up. Results There were two peri-operative deathes（ one died of puhnonary infection in the 22th day postopertatively, another one died of baemategenous septic shock and multiple organ failure in the 9th day postopertatively）, one late death other than opera- tion-related reasons（ died of pulmonary infection in the 54tb day postopertatively ）, The mean extracorporeal circulation time was （235.9 ± 58.5 ） rain, the aortic crossclamp time was （ 182.7 ± 35.8 ） min. 11 patients had no aortic regurgitation, 11 gen-tie and 1 moderate regurgitation postopertativeiy ; The heart functional of all patients changed into class I one week post-opera- tively. 20 patients were followed-up 3 to 74 months, of which 3 with no and 15 with gentle （3 of which showed no aortic regur- gitation in half year later） and 2 with moderate aortic regurgitation （ 1 patient with Marian syndrome used tubular graft showed severe postopertative aortic regurgitation 55 months later）. Conclusion David I procedure is a good option for patients with aortic valve insufficiency due to aortic root disease, and with more or less normal aortic leaflets and valvular ring normal. Fur- thermore using Valsalva conduit in David I procedure could provide a more stable mid and long-term effect.