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  • 谈梦伟,徐志云*,韩林,陆方林,唐昊,宋智钢.David手术在马方综合征主动脉根部病变中的应用[J].第二军医大学学报,2019,40(8):873-878    [点击复制]
  • TAN Meng-wei,XU Zhi-yun*,HAN Lin,LU Fang-lin,TANG Hao,SONG Zhi-gang.Application of valve-sparing aortic root reimplantation for aortic root disorders in patients with Marfan syndrome[J].Acad J Sec Mil Med Univ,2019,40(8):873-878   [点击复制]
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David手术在马方综合征主动脉根部病变中的应用
谈梦伟,徐志云*,韩林,陆方林,唐昊,宋智钢
0
(海军军医大学(第二军医大学)长海医院胸心外科, 上海 200433
*通信作者)
摘要:
目的 探讨David手术治疗马方综合征主动脉根部病变的手术指征、技术要点及临床效果。方法 回顾性分析2006年6月至2017年7月在我科行David手术治疗主动脉根部病变的52例马方综合征患者的临床资料。总结患者术前一般资料、手术方法及随访结果。结果 男35例、女17例,平均年龄为(36.6±14.5)岁。术前存在重度主动脉瓣关闭反流37例(71.2%),主动脉瓣环、窦部、窦管交界直径分别为22~30 mm、40~56 mm、34~51 mm。40例主动脉根部真性动脉瘤患者行单纯David手术,主动脉阻断时间为61~108 min,平均为(81.3±11.6)min;体外循环时间为88~129 min,平均为(97.3±10.8)min。12例合并Stanford A型主动脉夹层患者行David手术+全主动脉弓置换+降主动脉象鼻手术,主动脉阻断时间为93~126 min,平均为(107.4±11.2)min;体外循环时间为127~180 min,平均为(143.5±17.1)min。所有患者使用人工血管直径均≤ 30 mm,9例采用右心房分流技术处理主动脉根部渗血。42例患者撤机前行经食道超声心动图检查以评估主动脉瓣功能,结果示无反流16例、微量反流18例、轻度反流8例。全组住院期间死亡1例(1.9%,1/52),所有患者均无二次开胸止血及其他重大并发症。术后平均随访(3.2±2.1)年,完整随访43例,无患者死亡;最近一次随访超声检查示主动脉瓣无反流6例、微量反流24例、轻度反流12例、中度反流1例,无中度及以上反流患者比例达97.7%(42/43);无患者因严重主动脉瓣关闭不全行瓣膜置换手术;美国纽约心脏协会心功能分级Ⅰ级39例(90.7%)、Ⅱ级4例(9.3%)。结论 对马方综合征主动脉根部病变,在基于一定手术指征选择合适患者的基础上,选用口径适宜的人工血管行David手术治疗的安全性高,疗效可靠。
关键词:  保留瓣膜的主动脉根部再植术  马方综合征  主动脉根部瘤  夹层动脉瘤
DOI:10.16781/j.0258-879x.2019.08.0873
投稿时间:2019-02-16修订日期:2019-06-12
基金项目:国家自然科学基金(81770477),上海市科学技术委员会基金(17ZR1438100).
Application of valve-sparing aortic root reimplantation for aortic root disorders in patients with Marfan syndrome
TAN Meng-wei,XU Zhi-yun*,HAN Lin,LU Fang-lin,TANG Hao,SONG Zhi-gang
(Department of Thoracic and Cardiovascular Surgery, Changhai Hospital, Naval Medical University(Second Military Medical University), Shanghai 200433, China
*Corresponding author)
Abstract:
Objective To evaluate the appropriate indications, key points of surgical techniques, and early to mid-term outcomes of valve-sparing aortic root reimplantation in patients with Marfan syndrome. Methods The clinical data of 52 patients with Marfan syndrome who underwent valve-sparing aortic root reimplantation in our department from June 2006 to July 2017 were retrospectively analyzed. Preoperative patient characteristics, surgical techniques, and follow-up outcomes were summarized. Results The patients had a mean age of (36.6±14.5) years, with 35 males and 17 females. Severe aortic valve insufficiency (AI) was found in 37 cases (71.2%) preoperatively. Echocardiography indicated that the average diameter of aortic annulus, aortic sinus, and sinotubular junction of this cohort were 22-30 mm, 40-56 mm, and 34-51 mm, respectively. Pure valve-sparing aortic root reimplantation was performed in 40 patients presenting aortic root aneurysm, with a cross-clamp time of 61-108 min and a mean of (81.3±11.6) min, and with a cardiopulmonary bypass time of 88-129 min and a mean of (97.3±10.8) min. The other 12 patients with Stanford type A aortic dissection underwent concomitant total arch replacement and elephant trunk implantation in the descending aorta, with a cross-clamp time of 93-126 min and a mean of (107.4±11.2) min, and with a cardiopulmonary bypass time of 127-180 min and a mean of (143.5±17.1) min. Vascular prostheses with a diameter of ≤ 30 mm were adopted in all patients. Aortic root bleeding was drained to the right atriums in 9 patients. Transesophageal echocardiography was performed in 42 cases before extracorporeal circulation removal, with 16 cases presenting no AI, 18 presenting trace AI, and 8 presenting mild AI. There was one in-hospital death (1.9%) and no secondary thoracotomy for bleeding or other major complications. The mean follow-up was (3.2±2.1) years, with 43 cases completed the follow-up and no death during follow-up. Echocardiography in the latest follow-up indicated that 6 cases presented no AI, 24 presented trace AI, 12 presented mild AI, and only one case presented moderate AI, with 97.7% (42/43) patients free from moderate AI. No case underwent aortic valve replacement for severe AI. There were 39 (90.7%) patients in New York Heart Association classⅠand 4 (9.3%) patients in classⅡ. Conclusion Application of valve-sparing aortic root reimplantation using vascular prostheses with appropriate diameter is safe and effective for suitable patients with Marfan syndrome, and can obtain satisfactory outcomes.
Key words:  valve-sparing aortic root reimplantation  Marfan syndrome  aortic root aneurysm  dissecting aneurysm