Partial aortic root remodeling for root reconstruction in patients with acute type A dissection

In the present study, we reported our experience with partial aortic root remodeling for root reconstruction in patients with acute type A dissection, which involves in non-coronary sinus and/or the right coronary sinus with just one trimmed Dacron graft. Between February 2001 and May 2010, we performed partial aortic root remodeling in 40 patients, who underwent emergency surgical intervention. The dissected sinuses were excised leaving a 3-5 mm rim of the aortic wall from the attached aortic valve cusps. A short piece （4-5 cm） of collagen coated woven polyester vascular prosthesis was trimmed with one or two ＂tongues＂ to reconstruct the non-coronary sinus and/ or the right coronary sinus, but without using separated patches. Additional procedures were including hemi-arch replacement in 11 patients, and total arch replacement plus stent-elephant trunk in 20 patients. The mean follow-up time was 36.4~3.6 months. In-hospital mortality was only 5.0% （2/40）; furthermore, 3 （8.6%） patients underwent re-operation of the aortic valve and 2 （5.7%） patients died during follow-up. At the end of follow-up, trivial or no aortic regurgitation was found in 33 patients, but mild aortic regurgitation was found in 2 patients. Our data suggest that the early and mid-term results of partial aortic root remodeling were favorable, and it restored valve durability and function. Thus, the use of technique for root reconstruction in patients with acute type A dissection should be vigorously encouraged.

Prenatal Diagnosis of Abnormal Sternum Development and Dilated Aortic Root in a Fetus with a Novel 204 kb Microdeletion of the TGFRB2 Gene

The Loeys-Dietz syndrome (LDS) is a connective tissue disorder that is associated with vascular abnormalities, including aggressive aortic aneurysms, as well as skeletal and craniofacial malformations. The molecular mechanism of this syndrome remains to be fully elucidated. In this case, we describe a 29-year-old woman, gravida 2 para 1, who was referred for consultation after urinary tract malformations were observed during her mid-gestation anatomic survey. Following referral to our unit, ultrasound examination of the 21-week fetus was repeated. The fetus was observed to have a dilated aortic root and a poorly ossified sternum with mild pectus deformity. After elective termination, single nucleotide polymorphism microarray testing identified a novel 204 kb microdeletion involving the short arm of chromosome 3. The deleted genetic material included 4 exons of the TGFBR2 gene. Although the phenotype of LDS may be caused by haploinsufficiency of the TGFBR1 or TGFBR2 gene, our experience suggests a more complex picture of LDS. The study of such cases might further elucidate its pathogenesis.

Aortic Root and Ascending Aortic Aneurysm Related to One Case. Reimplantation of the Right Coronary Artery by 8 mm Dacron Tube (Cabrol Hemi Mustache) and Review of the Literature

The aortic aneurysm is the 13th leading cause of death in Western countries. The incidence of thoracic aortic aneurysms is estimated at 4.5 cases per 100,000. The diagnosis is often made on a chest x-ray or other imaging tests, such as an echocardiogram done for other heart diseases. Echocardiography is the first test to assess the diameter of the ascending aorta and its progression over time. Most patients are first assessed and followed up with spiral thoracic computed tomography with injection of contrast medium, supplemented by 3-dimensional reconstruction of the aneurysm in order to improve the accuracy of measurements, identification of its proximal part and distal. When dilation of the ascending aorta reaches the critical diameter of 50 mm, there is a risk of aortic dissection or rupture. Supravalvular aneurysms are treated by replacing the ectatic portion with a Dacron® tube in the supracoronary position. Aortic root aneurysms, including coronary ostia, require tube replacement, reimplantation of coronary ostia, as well as surgery on the aortic valve. In this article, we report a case of aneurysm of the aortic root and the ascending aorta treated by aortic valve replacement and the ascending aorta associated with the Cabrol hemi-mustache technique and we review the literature.

Konno Procedure for Managing Small Aortic Root during Aortic Valve Replacement Surgery: An Experience of 12 Cases

Background: Small aortic annulus during aortic valve replacement can lead to implanting a smaller sized valve compared to the body surface area thereby causing patient prosthesis mismatch. Various aortic root enlargement techniques have been described depending on anterior or posterior approach. Konno procedure uses anterior approach for aortic root enlargement. In this study, we reviewed results of Konno procedure done from 2011 to 2019 by a single surgeon. Methods: 12 adult patients who underwent aortic valve replacement along with Konno procedure for small aortic root by a single surgeon at a single center between 2011 and 2019 were reviewed. Echocardiographic and demographic data and post-operative data were obtained from medical records. Symptomatic profile was assessed as per New York Heart Association Classification. Intraoperative findings and post-operative period findings were noted. Follow up symptom profile was assessed for these patients. Results: 12 patients underwent Konno procedure between 2011 and 2019 for small aortic root along with valve replacement. The main indication for surgery was aortic stenosis with small aortic annulus, with or without involvement of the mitral valve. Preoperatively, 3 patients had NYHA class II and 9 patients had NYHA class III symptoms. Mean age at operation was 26.42 years, minimum age 10 years, and maximum age 39 years. 3 were females and 9 were males. Mean bypass time was 106.4 minutes and aortic cross clamp time was 80.67 minutes. Mechanical aortic valves were implanted in all patients. Mean post-operative blood loss was 134.2 ml and duration of ventilation before extubation was 14.5 hours. Mean duration of intensive care unit (ICU) stay was 2.83 days and hospital stay was 9.1 days. Mean gradient in the post-operative period was 10.75 mm Hg. There was no mortality in these 12 patients and no reoperation was needed in the follow up period. Follow up in the outpatient department suggested all patients had NYHA class I symptoms and anticoagulation with warfarin adjusted to prothrombin time— International normalised ratio. Conclusion: Konno procedure is effective for managing small aortic root as bigger outflow orifice area through the larger valve prosthesis improves ventricular outflow and hence, improves the outcomes.

Myocardial infarction in non-dissecting aortic root aneurysm

We describe a case of a 49-year-old man who presented with an uncomplicted aortic root aneurysm, aortic insufficiency, and ST-elevation myocardial infarction (STEMI) without obstructive coronary artery disease on angiography. The computed tomo- graphy angiogram (CTA) of the thorax, performed without cardiac gating, was misinterpreted as normal. In retrospect, an overlooked extravasation of contrast material lateral to the aortic root was detected on non-gating magnetic resonance angiography (MRA). Exploration of the aortic root revealed an unsuspected horizontal intimal tear of the left sinus of Valsalva with limited extramural hematoma. The presence of an otherwise silent intimal tear on preoperative imaging studies makes the overall management more problematic. For example, initiating early broad empirical anticoagulants or fibrinolytics therapy to treat the accompanied myocardial infarction may extend the tear into a full life-threatening aortic dissection, tamponade or rupture. We highlight many of the difficulties associated with the diagnosis and treatment of limited sinus tear when aortic root aneurysm is presenting with cryptogenic STEMI. Accurate morphologic characterization of intimal tear would be best defined with either an electrocardiogram-gating CTA or MRA imagings. These non-invasive tests are needed to make appropriate management decisions. Depending on other pathologic components of aortic root, cusps and the commissural geometry, sinus tear is a critical component for the overall treatment plan and it shifts the surgical intervenetion from valve-sparing operation, commissural resuspension and leaflet repair to composite aortic root replacement (modified version of the Bentall procedure).

Late Anatomic Findings after “Rescue CABG” for Peri-Operative Ischemia Following Aortic Root Replacement

Background: Acute myocardial ischemia, seen in about 2% of aortic root replacements (ARR), is acutely life-threatening, manifesting as failure to wean from bypass, ventricular fibrillation, or unstable hemodynamics. The exact precipitating anatomic cause is usually not apparent at the time of surgery. In this report, we take advantage of late computed tomographic (CT) angiograms of long-term survivors of peri-operative ischemia after ARR to determine what abnormalities of the coronary button reattachments produced the peri-operative ischemia. Methods: The database of the Aortic Institute at Yale-New Haven was reviewed to identify all patients undergoing ARR over a 15-year period. Operative records, patient charts, and CT angiograms of patients who had peri-operative ischemia were reviewed in detail, including analysis by an imaging specialist. Results: 271 patients underwent ARR, 220 with mechanical and 51 with biological valved conduits. Hospital mortality was 2.95%. Clinical follow-up ranged from 1 to 182 months. Survival in discharged patients was 97.7% at 5 years and 95.2% at 7 years. Peri-operative ischemia was seen in 4 of 271 patients (1.5%). All four affected patients survived—with interventions including supplemental coronary bypass grafts (4 patients), intra-aortic balloon pump placement (2 patients), and left ventricular assist device insertion (1 patient). Late CT angiograms revealed severe but non-obstructive left main calcification serving as a focal point for coronary angulation in 2 patients, angulation without calcification in 1 patient, and totally normal anatomy in 1 patient. Conclusions: Myo- cardial ischemia after ARR is rare but acutely life-threatening. Prompt recognition and treatment by supplemental coronary artery bypass grafting preserves life and leads to good late survival. Intramural calcification (non-obstructive) of the distal left main coronary artery predisposes to angulation after coronary button creation and should be a “red flag” for this potential problem.

The evolution of surgical and medical treatment of aortic root aneurysm

Since first report of aortic root replacement in 1968, the surgical risk and long term outcome of patients with aortic root aneurysm have been continuously improving. In the last 30 years, the surgical approach is also evolving towards more valve conservation with prophylactical intervention at an earlier clinical stage. Translational research has also led to emerging surgical innovation and new drug therapy. Their efficacies are currently under vigorous clinical trials and evaluations.

Relation of uric acid levels to aortic root dilatation in hypertensive patients with and without metabolic syndrome

Objective:Uric acid(UA) is considered to be a powerful predictor of cardiovascular risk and hyperuricemia might be involved in the metabolic syndrome(MS).This study aims to investigate the relation between UA levels and aortic root dilatation.Methods:A total of 348 hypertensive patients [age(67.5±9.8) years] with or without MS were included in the study.The aortic root diameters at the aortic annulus,the sinuses of Valsalva,the sinotubular junction,and the proximal part of the ascending aorta were measured using a two-dimensional(2D) echocardiography.Serum UA levels were also measured for all patients.Results:A high UA level is independently associated with aortic root diameters at the sinuses of Valsalva(P=0.001) and the proximal ascending aorta(P<0.0001) in the hypertensive patients without MS.In contrast,aortic root diameters were not significantly related to UA levels in the hypertensive patients with MS.Furthermore,increased UA levels were associated with an increased risk for aortic root dilatation in the patients without MS(sex-adjusted hazard ratio 1.75,95% confidence intervals(CI) 1.27-2.41),but not in those with MS.Conclusions:This study demonstrated an independent relationship between the aortic root dimensions and increased levels of serum UA in the hypertensive patients without MS.Further understanding of the mechanisms underlying these associations may allow a clearer interpretation of the potential value of specific urate-lowering treatment on cardiovascular disease.

保留瓣膜两种主动脉根部置换术的生物力学数值模拟

目的阐释运用直筒型人工血管行保留主动脉瓣膜的主动脉根部改良重塑术和佛罗里达袖套术对新生主动脉根部生物力学的影响。方法采用CTA影像重建5例主动脉根部有限元模型,包括2例主动脉根部改良重塑术(A1、A2),2例佛罗里达袖套术(B1、B2)和1例无主动脉根部病变的对照组(C)。通过数值模拟获得血流和压力分布结果,评估主动脉根部的血流动力学差异。结果两种术式的患者和对照组收缩峰值的最大流速之间没有显著差异,但主动脉根部改良重塑术后的流速较为平缓,与对照组模型相近,而其主动脉内平均压力和壁面切应力趋于稳定。佛罗里达袖套术中,存在高速血流冲击血管壁,沿主动脉壁出现不同程度的壁面切应力和压力集中现象。结论保留瓣膜的主动脉根部手术后,新生主动脉根部的血流模式依赖于术后窦部几何形状的变化。观察到两种术式的血流状态均表现良好,但主动脉根部改良重塑术血流模式较佛罗里达袖套术更稳定。

Contained local compression on peri-ascending aortic area for postoperative bleeding control:a case report

After type A acute aortic dissection(AAD)repair or modified Bentall procedure,uncontrollable bleeding from the anastomotic sites of the fragile dissected tissues or aortic root area is a critical situation to a cardiac surgeon.For postoperative care,lots of blood transfusion with strict monitoring on the patient all night and subsequent reoperation for the bleeding control is usually needed.We managed to make contained local compression of upper half of the heart,from upper part of the right ventricle to just above the innominate vein,using bovine pericardium with closing both sides of transverse sinus in two cases of uncontrolled postoperative bleeding(bleeding from distal anastomotic site in type-A AAD and valve sitting site in modified Bentall procedure).Even though reoperations for the removal of packed gauges were done in both cases 2 days later,postoperative courses at intensive care unit were very smooth with little need for transfusion.This kind of contained local compression trial could be a useful strategy for dealing with the malignant uncontrollable bleeding from the fragile aortic tissue or root area after acute dissection or aortic root repair.

以根本原因分析法为导向的针对性护理在主动脉夹层术后低氧血症患者中的应用价值

目的分析以根本原因分析法(RCA)为导向的针对性护理在主动脉夹层术后低氧血症患者干预中应用价值。方法回顾性分析泉州市第一医院心外科于2019年1月至2022年12月收治的89例行主动脉夹层手术患者临床症状,根据其不同护理方案分组,将实施常规护理患者44例纳入对照组,将实施以RCA为导向的针对性护理患者45例纳入研究组。比较两组患者护理前后的血气指标、呼吸频率和呼吸道舒适度评分,统计两组患者拔管后72 h内低氧血症、再次插管率。结果护理后,研究组氧合指数、血氧饱和度、血氧分压均高于对照组(均P<0.05)。护理后,研究组呼吸频率、咽喉疼痛评分和口、鼻腔干燥程度评分、拔管后72 h内低氧血症发生率、再次插管率均低于对照组(均P<0.05)。结论以RCA为导向的针对性护理在主动脉夹层术后低氧血症患者干预中,可减轻呼吸道不适症状,缓解呼吸急促症状,改善其术后氧合状态,降低低氧血症发生率和再次插管发生率。

急性A型主动脉夹层行根部修复手术的早期死亡危险因素分析和护理体会

目的分析急性Stanford A型主动脉夹层患者术后早期死亡危险因素及早期护理需要注意的要点。方法回顾性分析2018年12月至2022年6月期间在空军军医大学第一附属医院行主动脉根部修复手术的281例急性A型主动脉夹层患者。以一般资料、实验室检查指标及影像学指标作为自变量,以患者住院期间/术后30天是否生存作为因变量分为生存组(n=251)和死亡组(n=30),进行单因素分析和多因素logistic回归分析。结果本研究共纳入281例患者,住院期间/术后30天的死亡率为10.7%,通过生存组与死亡组的两组间单因素分析比较发现年龄、既往脑血管意外、既往心源性休克、术前单核细胞数、凝血酶原时间、天冬氨酸转氨酶、丙氨酸转氨酶、D二聚体、脑灌注不良和肾灌注不良的差异具有统计学意义(P<0.05)。多因素logistic回归分析提示,术前脑血管意外、单核细胞数、D-二聚体和脑灌注不良是住院期间/术后30天死亡的独立危险因素。结论关注住院期间/术后30 d死亡的独立危险因素,针对危险因素医护需共同协作积极预防、早期诊疗和护理。

动脉调转术后新主动脉瓣反流及根部扩张成因、转归及预防

动脉调转术(ASO)是治疗完全性大动脉转位(TGA)及Taussig-Bing畸形(TBA)的首选术式。ASO手术发展至今,大量术后患儿已至成年,因此ASO的晚期并发症逐渐引起关注。新主动脉瓣反流(NAVR)和新主动脉根部扩张(NARD)是ASO术后再次手术的第二大原因。本文拟对现有研究进行回顾,总结ASO术后NAVR及NARD的原因和预后,为临床实践提供参考。

A型主动脉夹层术后患者主要照顾者习得性无助感的潜在剖面及影响因素分析

目的探讨A型主动脉夹层术后患者主要照顾者习得性无助感的潜在剖面及影响因素。方法采用便利抽样法于2022年1月—2023年6月选取山西省某三级甲等医院心脏大血管外科A型主动脉夹层术后患者的主要照顾者作为调查对象。采用一般资料调查表、习得性无助量表、照顾者准备度问卷和疾病不确定感家属量表进行问卷调查。使用增长混合模型识别其习得性无助感的潜在剖面,并通过单因素分析和Logistic回归分析识别其潜在剖面的影响因素。结果350名A型主动脉夹层术后患者主要照顾者习得性无助感得分为(50.40±6.28)分,可分为3个潜在剖面,分别是低无助高绝望组(12.57%)、高无助低绝望组(27.43%)、高无助高绝望组(60.00%)。Logistic回归分析显示,患者年龄、术后入住重症监护室时长、照顾者性别、照顾者文化程度、照顾者家庭人均月收入、分担照顾人数、是否为主要决策者、疾病不确定感是A型主动脉夹层术后患者主要照顾者习得性无助感潜在剖面的影响因素(P<0.05)。结论A型主动脉夹层术后患者主要照顾者习得性无助感存在异质性,医护人员可根据不同潜在剖面的影响因素进行个体化干预,以降低照顾者习得性无助感。

急性A型主动脉夹层根部的个体化治疗与精准外科操作策略

目的探讨急性A型主动脉夹层(acute type A aortic dissection,ATAAD)根部的个体化处理策略。方法回顾性分析我院2021年7月~2022年10月77例ATAAD资料,均在急性期(发病时间<14 d)行全主动脉弓替换及降主动脉支架象鼻人工血管置入术(孙氏手术),根部施行个体化治疗与精准外科操作方案,应用“三明治”法31例,改良“三明治”法37例(人工血管片内衬和夹入,外垫毛毡条,其中3例冠脉开口撕裂行“铜钱样”牛心包片修复冠脉开口及窦的根部成形),Bentall术5例,Wheat术1例,改良David术1例,改良Cabrol术2例。其中5例行单支或多支大隐静脉冠状动脉旁路移植术。结果死亡5例,其中2例心肌灌注不良,1例肾灌注不良,1例下肢灌注不良,1例病房猝死。出院72例,其中2例术后直接应用床旁血液滤过,术后出血二次开胸1例,胸骨愈合不良再次胸骨固定1例。出院前全部复查主动脉CTA及心脏超声,无主动脉瓣大量反流,无近端吻合口漏及残余夹层。术后随访3~12个月,平均6个月,均无临床症状,无死亡。术后随访心脏超声及主动脉CTA,无主动脉瓣大量反流。术后3个月随访69例,少量反流2例,中量反流3例;术后6个月随访60例,少量反流4例,中量反流2例;随访1年40例,少量反流5例,中量反流2例。结论应根据ATAAD根部病变的不同程度,应用不同的根部处理方法。

Proximal Aortic Dissection with Rupture into the Main Pulmonary Artery—A Case Report

Aim: To present a rare occurrence of aortopulmonary fistula due to rupture of proximal aortic dissection in a 48-year-old woman. Introduction: Aortic dissection is defined as disruption of the medial layer provoked by intramural bleeding, resulting in separation of aortic wall layers and subsequent formation of a true lumen and a false lumen with or without communication. Case Report: A 48-year-old female presented with vague anterior chest discomfort, high blood pressure, systolic-diastolic murmur in the left sternal border with ECG changes of myocardial ischemia. Echocardiography revealed a dilated aortic root with intimal flaps, a leak into the pulmonary artery and regional hypokinesis with contractile dysfunction suggesting a proximal aortic dissection with rupture into the main pulmonary artery. Discussion: The etiology of aortic dissection was mostly hypertension in 80% of cases and aortopathies such as connective tissue disorders, inflammatory and idiopathic. Aortic wall stress is a major trigger of intimal tear and two-dimensional transthoracic echocardiography is an excellent, initial diagnostic gold standard to detect the dissecting flaps, especially in proximal aortic dissection. Conclusion: Blood pressure control is the mainstay of treatment and urgent surgery is indicated in proximal aortic dissection since there is higher chance of rupture with an increase in mortality.

多普勒超声心动图在先天性心脏病患者封堵术后主动脉根部形态变化中的评价作用分析

目的 探讨先天性心脏病患者封堵术后使用多普勒超声心动图评价其主动脉根部形态变化的作用。方法 筛选出本院先天性心脏病并接受房间隔缺损(ASD)封堵术治疗的患者90例,相关医疗数据来源于2019年3月至2022年3月,对患者进行分组操作,指导依据为主动脉侧边缘长度,主动脉侧边缘<5mm,49例,纳入对照组,主动脉侧边缘≥5mm,41例,纳入研究组。对两组患者手术当天及术后1天的主动脉瓣速度、主动脉窦左右径、前后径以及左室流出道速度进行测量,测量工具:三维超声心动图,同时,评估封堵器与主动脉根部的接触方式。对比两组缺损和封堵器基本情况如缺损最大直径、封堵器直径、封堵器直径/房间隔总长度、以及封堵器置入后主动脉根部的改变情况。结果 研究组缺损最大直径、封堵器直径以及封堵器直径/房间隔总长度均显著小于对照组(P<0.05),研究组封堵器与主动脉根部连续接触患者数量占比少于对照组(P<0.05)。与对照组相比,研究组收缩中期和舒张末期的窦左右径、窦前后径均显著减小(P<0.05),左室流出道流速、主动脉瓣流速较术前无统计学差异(P>0.05)。结论 ASD封堵术后,主动脉边缘缺损的患者更容易出现主动脉根部和封堵器连续接触的现象,且封堵器会对主动脉根部形态产生不同程度的影响。

经导管主动脉瓣置换治疗主动脉瓣狭窄术前超声影像学评估

目的以CT测值为金标准,分析经食道三维超声心动图(3D-TEE)在经导管主动脉瓣置换术(TAVR)术前评估主动脉根部解剖的准确性。方法回顾性研究本院因重度主动脉瓣狭窄(AS)接受TAVR手术患者的资料,其中78例3D-TEE和CT数据符合要求的患者被纳入研究。基于两种不同的影像学资料,利用Mimics软件以及多平面重建的方法,对患者主动脉瓣环直径-面积来源、左室流出道(LVOT)直径、主动脉窦管交界(STJ)直径进行测量和比较。结果对于瓣环和LVOT内径,3D-TEE测值明显小于CT,两组数据的相关系数为0.710~0.928(P<0.01),具有较为明显的相关性。对于STJ,与CT相比,3D-TEE明显低估(P<0.01),两组数据相关系数为0.947~0.970,存在显著的相关性。通过建立直线回归方程,可以计算出两组数据之间的量化关系。结论对于重度AS患者,3D-TEE主动脉根部测值与金标准CT测值具有较好的相关性和一致性。对于CT检查受限的患者,3D-TEE可能成为术前影像评估的另一种选择。

保留主动脉瓣的根部替换术的研究进展

随着外科技术的不断改进、医学工程学与材料学的发展,复合带瓣血管的根部置换术(Bentall手术)成为了主动脉根部病变的标准术式。作为Bentall手术的替代手段,保留主动脉瓣的根部替换术术后避免了终身抗凝和机械瓣膜的相关并发症,降低了血栓栓塞、出血事件的发生率,其有利的血流动力学和潜在更低的心内膜炎风险,保证了术后持久的主动脉瓣功能,患者的生存质量大大提高。本文综述了保留主动脉瓣的根部替换术的适应症、标准化技术要点及其在不同患者中应用的远期结果。

基于根因分析法的针对性干预在复杂胸主动脉夹层腔内隔绝术患者中的应用

目的 探讨基于根因分析法的针对性干预在复杂胸主动脉夹层腔内隔绝术围手术期患者护理中的应用效果。方法选取2020年6月—2022年6月在郑州大学第一附属医院行腔内隔绝术治疗的84例复杂胸主动脉夹层患者,采用随机数字表法分为对照组与观察组,每组42例。对照组患者围手术期采用常规护理干预,观察组患者在对照组基础上采用基于根因分析法的针对性干预。比较2组患者的护理满意度,干预前后的心理状态及术后并发症发生情况。结果 观察组患者干预后健康教育、护理态度、护理环境及工作效率评分均高于对照组,差异均有统计学意义(P<0.05)。2组患者干预前焦虑自评量表(SAS)及抑郁自评量表(SDS)评分比较,差异均无统计学意义(P>0.05);2组患者干预后SAS及SDS评分均低于干预前,且观察组低于对照组,差异均有统计学意义(P<0.05)。观察组患者术后并发症发生率为7.14%,低于对照组的23.81%,差异有统计学意义(χ^(2)=4.459,P=0.035)。结论 对复杂胸主动脉夹层腔内隔绝术围手术期患者进行基于根因分析法的针对性干预效果显著,能有效改善患者心理状态,降低术后并发症发生风险,且患者护理满意度高,值得推广。