主动脉瓣病变合并升主动脉扩张的外科治疗疗效观察

Efficacy of the surgical management in patients with aortic valve diseases complicating ascending aortic dilatation

目的比较主动脉瓣病变合并升主动脉扩张（40～55mm）外科处理的3种不同术式（单纯主动脉瓣置换（AVR）、同期行主动脉成形术、和同期行主动脉置换术）的近、中期结果。方法对112例排除了马凡综合征（Marfan’s syndrome）、主动脉夹层（aortic dissection）、严重主动脉粥样硬化（atheroselerosis of aorta）等病变的主动脉瓣病变合并升主动脉扩张的患者临床资料进行回顾性分析。随访统计分析其心功能（NYHA分级）、左室射血分数（LVEF）、主动脉直径、计算其扩张速率及主动脉不良事件。结果失访及数据不完整的共有8例，数据较完整104例，随访2～54个月。平均（28．0±16．9）月。其中，男74例，女30例，平均年龄（54．9±9．8）岁。单纯行AVR组56例、AVR同期行升主动脉成形组17例（使用人工血管外包裹主动脉成形法4例）和AVR同期行升主动脉置换组31例。随访期间未发现主动脉并发症，未见有夹层形成，主动脉瓣狭窄、关闭不全、狭窄伴关闭不全的主动脉扩张速率差异无统计学意义（P=0．18）；同时，最初主动脉直径和主动脉扩张速率差异无统计学意义（γ=0．16，P〉0．05）。结论对于主动脉瓣病变合并升主动脉扩张（40～55mm）的患者，单纯行AVR可取得良好效果，其升主动脉直径总体上出现缩小的趋势；主动脉瓣形态及最初主动脉直径不影响主动脉扩张速率。

Objective The optimal surgical management of dilated ascending aorta( 40 ~ 55 mm) in patients with aortic valve diseases remains controversial. This study compared the recent and future therapeutic effect outcomes among 3 different managements( AVR alone,simultaneous aorta plasty,and simultaneous aorta replacement) for the dilated ascending aorta and studied the surgical indications and the surgical methods. Methods We studied 112 patients with aortic valve diseases concomitant with ascending aorta dilatation( diameter range from 40 mm to 55 mm) and excluded patients with Marfan's syndrome,aortic dissection,atherosclerosis of aorta at the First Affiliated Hospital of Anhui Medical University from January 2009 to June 2015. The clinical materials were retrospectively analyzed. During the follow-up,we evaluated the cardiac function( NYHA),left ventricular ejection fractions( LVEF),the aortic diameter,the aortic expansion rate by echocardiography and recorded adverse aortic events. Results Complete data were obtained of 104 patients which were followed up for an average of( 28. 0 ± 16. 9) months( range 2 ~ 54 months). Seventy-four were males and thirty were females with a mean age of( 54. 9 ± 9. 8) years. A total of 56 patients had AVR,17 patients ascending aortoplasty( 13 patients reduction angioplasty and 4 patients aorta wrapping),and 31 patients aorta replacement. There were no aortic complication and aortic dissection occurrence during the follow-up interval of 2 to 54 months. There was no significant difference between the three groups( aortic valve stenosis vs aortic insufficiency vs aortic valve stenosis combining insufficiency),moreover,there was no significant difference between the aortic expansion rates and the initial aorta diameter( γ = 0. 16,P > 0. 05). Conclusions Aortic valve replacement alone may be reasonable in patients with aortic valve diseases concomitant with ascending aorta dilatation( diameter range from 40 mm to 55mm); the aortic expansion rates were affected neither by the morphology of aortic valves nor by the initial aorta diameter.