主动脉瓣重置术治疗瓣膜备用主动脉根置换的规范化技术
1Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Assistance Publique,Hopitaux de Paris (APHP), Institut de Cardiologie, 2Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology,University of Zurich, 3Herzzentrum Hirslanden,Klinik St Anna
Summary
瓣膜备用主动脉根置换具有保留患者自身主动脉瓣的优点。迄今为止, 报告的技术的复杂性限制了它们对数量有限的心脏外科医生的使用。该协议描述了由更多的心脏外科医生可重现的标准化技术的循序渐进。
Abstract
尽管在主动脉根部置换术中保留正常主动脉瓣具有明显的优越性, 但瓣膜备用程序的复杂性使许多心脏外科医生无法将其纳入其实践中。本协议的目的是描述一个简化和用户友好的技术, 主动脉瓣备用根置换 (VSRR) 程序的重新植入主动脉瓣。对患者的正确选择和技术的局限性进行了探讨。
在连续54例患者中, 正常出现的主动脉瓣在商用聚酯假体中重新植入, 并采用一种简化和标准化的方法。放置第一行的近缝合线, 选择的假肢大小, 和调整的高度 commissures 的病人到固定高度的假体的窦部分, 从参考技术略有修改, 与目的提高其他心脏外科医生使用的可行性。所有患者都收集了早期死亡率和发病率以及5年生存期、主动脉瓣再手术的自由以及从复发性中返流中解脱出来的自由。
三十天的死亡率, 胸骨出血, 重新胸骨纵隔, 中风的发病率非常低, 每 1.8% (1 54)。没有病人需要永久性的速度制造者植入。5年来, 存活, 从主动脉瓣膜再手术的自由, 以及从复发性中返流的自由分别为97.5%、95.2% 和91.6%。
我们对主动脉瓣瓣膜置换术的规范化技术的中期结果是非常好的, 与经验丰富的外科医生报告的复杂技术比较。按照现行的标准化再植入技术的协议, 更多的心脏外科医生可以执行这一程序, 效果可比较好。
Introduction
在过去的二十年中, 由于一系列旨在保存本机主动脉瓣的外科手术, 在正常或接近正常的主动脉尖头手术治疗主动脉根动脉瘤的过程已经演变为:1,2, 3,4,5。瓣膜备用主动脉根置换主要是通过在合成接枝内的主动脉瓣重新植入1,3,4,6或通过重塑技术完成的。恢复主动脉根的生理解剖2。尽管在主动脉根部置换术中保留正常主动脉瓣的明显优点, 许多心脏外科医生还是用机械或生物瓣膜替代物代替主动脉瓣。根据胸外科医生数据库的数据, 在美国2004和2010间接受主动脉根置换术的患者中, 只有14% 的人收到了一个瓣膜备用程序7。
在原有的再植入技术中, 主动脉瓣在管状水平卷曲的合成接枝中缝合8。虽然这种技术稳定的主动脉环, 它消除了鼻窦的佛氏。为了重新创建佛氏的鼻窦, 这项技术已经经历了一些修改由它的发明者以及其他作者9。这种技术的变化已经提出了拉玛et 等人, 其中的主动脉壁残余的支持 commissures 被缝合成纵向开口, 在管状聚乙烯对苯二甲酸乙二醇酯接枝4。
重构技术实现了对主动脉根的更多解剖重建, 但使主动脉环不受支持, 暴露于未来的扩张。各种外科技术的设计, 以适应主动脉环形基地的主动脉根部重塑, 包括亚连合主动脉三尖瓣 10, 周向缝合三尖瓣 11, 以及内部或外部三尖瓣通过合成部分或完整环12。
尽管有经验的作者报告了优秀的结果, 这些程序的复杂性和周期性的修改, 阻碍了其他心脏外科医生的重现性, 从而防止一些合适的患者受益于保留其自己的主动脉瓣。为了提高再植入技术的重现性, 我们使用了一种具有 uncrimped、预成形窦部分的商用合成嫁接, 并简化了植入技术。本议定书的目的是详细描述这一标准化和可重复的技术, 特别强调对近端缝合线第一行的管理和在移植内的 commissures 位置和移植的选择大小.提出了早期结果和中期结果。对患者的正确选择和本程序的局限性进行了讨论。
Protocol
该议定书遵循人类研究伦理学委员会的机构准则。 1. 病人的预先选择 使用手术前计算机断层扫描 (CT) 检查佛氏的鼻窦扩张不超过60毫米的患者。 接下来, 在这些患者中选择一个正常或接近正常出现的主动脉瓣尖头的亚群在其术前超声心动图。 通知工作人员有无瓣膜备用主动脉根置换术的可能性。 在主动脉瓣检查后, 进行手术后的最终决定。验证…
Representative Results
统计分析: 连续变量被表示为平均的标准偏差和分类变量作为百分比。卡普兰-梅尔曲线是为生存, 从主动脉瓣再手术的自由, 并从复发性中返流的自由使用一个商业上可用的软件包计算。 患者人数: VSRR 根据本协议在连续54例患者中进行了主?…
Discussion
在主动脉根部动脉瘤与正常或接近正常主动脉尖头的患者中, 保留瓣膜的主动脉根置换术是一种更具生理性, 因此更有吸引力的替代主动脉和主动脉瓣复合移植替换机械或组织瓣膜。在本协议中, 我们描述了一个简单的技术, 备用瓣膜置换术的主动脉瓣重新植入。与以前报告的大多数技术3、8不同, 在本协议中, 第一行的床垫缝合不对称地分布, 以避免对膜?…
Divulgazioni
The authors have nothing to disclose.
Acknowledgements
这项工作得到了瑞士心血管基金会的赠款 (N° 32117) 的支持。
Materials
| Heart surgery infrastructure: | |||
| Heart Lung Machine | Stockert | SIII | |
| EOPA 24Fr. arterial cannula | Medtronic | 77624 | |
| Atrial caval venous cannula 34/48Fr. | Medtronic | 93448 | |
| LV vent catheter 17Fr. | Edwards | E061 | |
| Antegrade 9Fr. cardioplegia cannula | Edwards | AR012V | |
| Retrograde 14Fr. cardioplegia cannula | Edwards | NPC014 | |
| Coronary artery ostial cannula 90° | Medtronic | 30155 | |
| Coronary artery ostial cannula 45° | Medtronic | 30255 | |
| Name | Company | Catalog Number | Comments |
| Pre-shaped sinus graft | |||
| Cardioroot 28 mm | Maquet | HEWROOT0028 | |
| Cardioroot 30 mm | Maquet | HEWROOT0030 | |
| Cardioroot 32 mm | Maquet | HEWROOT0032 | |
| Name | Company | Catalog Number | Comments |
| Electrocautery | Covidien | Force FX | |
| Name | Company | Catalog Number | Comments |
| Sutures: | |||
| Polypropylene 4/0 | Ethicon | 8871H | |
| Polypropylene 5/0 | Ethicon | 8870H | |
| Polypropylene 6/0 | Ethicon | EH7400H | |
| Braided polyesther 2/0 ligature with polybutylate coating | Ethicon | X305H | |
| Name | Company | Catalog Number | Comments |
| Micro knife Sharpoint | TYCO Healthcare PTY | 78-6900 | |
| Name | Company | Catalog Number | Comments |
| Drugs: | |||
| Midazolam | Roche Pharma | N05CD08 | |
| Rocuronium | MSD Merck Sharp & Dohme | M03AC09 | |
| Propofol | Fresenius Kabi | N01AX10 | |
| Fentanil | Actavis | N01AH01 | |
| Heparin | Braun | B01AB01 | |
| Protamin | MEDA Pharmaceutical | V03AB14 | |
| Name | Company | Catalog Number | Comments |
| Instruments: | |||
| Cooley vascular aortic clamp | Delacroix-Chevalier | DC40810-16 | |
| Dissection forceps Carpentier | Delacroix-Chevalier | DC13110-28 | |
| Scissors Metzenbaum | Delacroix-Chevalier | B351751 | |
| Needle holder Ryder | Delacroix-Chevalier | DC51130-20 | |
| Dissection forceps DeBakey | Delacroix-Chevalier | DC12000-21 | |
| Micro needle holder Jacobson | Delacroix-Chevalier | DC50002-21 | |
| Micro scisors Jacobson | Delacroix-Chevalier | DC20057-21 | |
| Lung retractor | Delacroix-Chevalier | B803990 | |
| Allis clamp | Delacroix-Chevalier | DC45907-25 | |
| O’Shaugnessy Dissector | Delacroix-Chevalier | B60650 | |
| 18 blade knife | Delacroix-Chevalier | B130180 | |
| Leriche haemostatic clamp | Delacroix-Chevalier | B86555 | |
| Name | Company | Catalog Number | Comments |
| Data analysis | |||
| Kaplan Meier curves | GraphPad | Prism 7 |
Riferimenti
- David, T. E., Feindel, C. M., Bos, J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg. 109 (2), 345-352 (1995).
- Yacoub, M. H., Gehle, P., Chandrasekaran, V., Birks, E. J., Child, A., Radley-Smith, R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg. 115 (5), 1080-1090 (1998).
- De Paulis, R., et al. One-year appraisal of a new aortic root conduit with sinuses of Valsalva. J Thorac Cardiovasc Surg. 123 (1), 33-39 (2002).
- Rama, A., Rubin, S., Bonnet, N., Gandjbakhch, I. New technique of aortic root reconstruction with aortic valve annuloplasty in ascending aortic aneurysm. Ann Thorac Surg. 83 (5), 1908-1910 (2007).
- Richardt, D., Karluss, A., Schmidtke, C., Sievers, H. H., Scharfschwerdt, M. A new sinus prosthesis for aortic valve-sparing maintaining the shape of the root at systemic pressure. Ann Thorac Surg. 89 (3), 943-946 (2010).
- Schmidtke, C., et al. First clinical results with the new sinus prosthesis used for valve-sparing aortic root replacement. Eur J Cardiothorac Surg. 43 (3), 585-590 (2013).
- Stamou, S. C., Williams, M. L., Gunn, T. M., Hagberg, R. C., Lobdell, K. W., Kouchoukos, N. T. Aortic root surgery in the United States: a report from the Society of Thoracic Surgeons database. J Thorac Cardiovasc Surg. 149 (1), 116-122 (2015).
- David, T. E., Feindel, C. M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 103 (4), 617-621 (1992).
- Hopkins, R. A. Aortic valve leaflet sparing and salvage surgery: evolution of techniques for aortic root reconstruction. Eur J Cardiothorac Surg. 24 (6), 886-897 (2003).
- Mve Mvondo, C., et al. Surgical treatment of aortic valve regurgitation secondary to ascending aorta aneurysm: is adjunctive subcommissural annuloplasty necessary?. Ann Thorac Surg. 95 (2), 586-592 (2013).
- Aicher, D., Schneider, U., Schmied, W., Kunihara, T., Tochii, M., Schäfers, H. J. Early results with annular support in reconstruction of the bicuspid aortic valve. J Thorac Cardiovasc Surg. 145 (3 Suppl), S30-S34 (2013).
- Lansac, E., et al. Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure?. Eur J Cardiothorac Surg. 29 (4), 537-544 (2006).
- Tavakoli, R., Jamshidi, P., Gassmann, M. Full-root aortic valve replacement by stentless aortic xenografts in patients with small aortic root. J Vis Exp. (123), e55632 (2017).
- Zoghbi, W. A., et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 16 (7), 777-802 (2003).
- Cohle, S. D., Delavan, J. W. Coronary artery compression by teflon pledget granuloma following aortic valve replacement. J Forensic Sci. 42 (5), 945-946 (1997).
- Vallabhajosyula, P., et al. Geometric orientation of the aortic neoroot in patients with raphed bicuspid aortic valve disease undergoing primary cusp repair and a root reimplantation procedure. Eur J Cardiothorac Surg. 45 (1), 174-180 (2014).
- David, T. E., David, C. M., Feindel, C. M., Manlhiot, C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg. 153 (2), 232-238 (2017).
- Zehr, K. J. Form ever follows function. J Thorac Cardiovasc Surg. 151 (1), 120-121 (2016).
- De Paulis, R., et al. Long-term results of the valve reimplantation technique using a graft with sinuses. J Thorac Cardiovasc Surg. 151 (1), 112-119 (2016).
- Gleason, T. G. New graft formulation and modification of the David reimplantation technique. J Thorac Cardiovasc Surg. 130 (2), 601-603 (2005).
- Demers, P., Miller, D. C. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses. Ann Thorac Surg. 78 (4), 1479-1481 (2004).
- David, T. E., Maganti, M., Armstrog, S. Aortic root aneurysm: principles of repair and long-term follow-up. J Thorac Cardiovasc Surg. 140 (6S), S14-S19 (2010).
- Shrestha, M., et al. Long-term results after aortic valve-sparing operation (David I). Eur J Cardiothorac Surg. 41 (1), 56-61 (2012).
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Citazione di questo articolo
Tavakoli, R., Lebreton, G., Gassmann, M., Jamshidi, P., Leprince, P. Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement. J. Vis. Exp. (130), e56790, doi:10.3791/56790 (2017).