风湿性主动脉瓣疾病术后再发主动脉病变的外科治疗

Reoperation for Secondary Aortic Diseases of Patients with Previous History of Aortic Valve Surgery for Rheumatic Aortic Valve Disease

目的探讨风湿性主动脉瓣疾病术后再发主动脉疾病的外科治疗,提高对主动脉瓣术后继发主动脉病变防治的认识。方法回顾性分析2003年8月至2012年5月阜外心血管病医院收治的风湿性主动脉瓣疾病术后再发主动脉病变患者27例的临床资料,男20例、女7例,年龄28~69（50±10）岁。继发主动脉病变包括Standford A型主动脉夹层13例（急性夹层4例,慢性夹层9例）,升主动脉瘤6例,主动脉根部瘤8例。所有患者均行手术治疗,主动脉根部置换7例,升主动脉＋全主动脉弓置换＋象鼻支架植入术6例,主动脉根部置换＋全主动脉弓置换＋支架象鼻手术6例,升主动脉置换8例。对所有出院患者进行门诊复查和电话随访。结果再次手术间隔时间6~110（57±32）个月,术后早期无死亡,再次手术体外循环时间50~274（143±65）min,住院时间13~27（19±11）d。术后早期并发症包括肾功能不全4例,神经功能障碍3例（无轻瘫或截瘫发生）,肺部并发症4例,肠道并发症2例。术后随访率81.5%,随访时间4~118（43.5±32.2）个月,随访期间4例死亡,3年生存率为85.1%。结论对因风湿性主动脉瓣疾病行主动脉瓣手术的患者,若同期合并主动脉病变,需积极处理;即使未合并主动脉病变,也应严格随访,定期复查,减少术后主动脉不良事件的发生。

Objective To explore the reoperation on aortic diseases in patients with previous aortic valve surgery due to rheumatic aortic valve disease,improve the understanding of aortic valve disease secondary to surgery of aortic valve. Methods We retrospectively analyzed the data of twenty-seven patients with previous aortic valve replacement due to rheumatic aortic valve disease underwent aortic root or other aortic operation in Fu Wai Cardiovascular Hospital because of new aortic root or aortic diseases between August 2003 and May 2012. All the patients with new aortic diseases were diagnosed by cardiac ultrasound and aortic computed tomography. The new diseases included type A aortic dissection in 13 patients,ascending aortic aneurysm in 6 patients,and aortic root aneurysm in 8 patients. There were 20 males and 7 females with mean age of 50±10 years（ranged 28-69 years）. Seven patients underwent aortic root replacement,6 patients received ascending aorta and total aortic arch replacement combined with stented graft implantation into the descending aorta,6 patients received aortic root and total aortic arch replacement combined with stented graft,and 8 patients received the ascending aorta replacement. All patients were followed by clinic interview or telephone. Results The interval time for reoperation was 6-110（57±32） months. No patient died within 30 days after operation. Cardiopulmonary bypass time was 50-274（143±65） minutes;hospital stay was 13-27（19±11） days. Four patients had renal insufficiency after operation and all were cured by hemofiltration before departure. Three patients had neurological complications of transient brain dysfunction,and there was no postoperative spinal cord deficits occurred. Four patients had pulmonary complication. The mean follow up time were 4-118（43.5±32.2） months. Five patients were missed and 4 cases died during the follow-up. The follow-up rate was 81.5%. Three-year survival rate was 85.1%. There was no case received third operation due to aortic disease during the follow-up. Conclusion We should pay more attention to patients with previous surgery due to rheumatic aortic valve disease,especially to patients combined with enlarged ascending aorta,so that aortic adverse events following to aortic valve operation can be reduced or be avoided in long term.