Sievers Hans- H, Dahmen Gerlinde, Graf Bernhard, Stierle Ulrich, Ziegler Andreas, Schmidtke Claudia
Clinic of Cardiac Surgery, Institute of Medical Biometrics and Statistics, Department of Cardiology, Klinikum Schwerin, Schwerin, Germany.
Circulation. 2003 Sep 9;108 Suppl 1:II55-60. doi: 10.1161/01.cir.0000087443.84392.32.
Since the early 1990s, the pulmonary autograft is predominantly implanted as a freestanding root for less aortic valve regurgitation is reported. However, there is a certain risk of dilatation of the root over time potentially impairing valve function. We favor since 8 years the original subcoronary or inclusion technique to preserve the root of the patient as a restrain to dilatation.
Between June 1994 and May 2002 the subcoronary (n=228) and inclusion technique (n=17) were performed in 245 patients (191 male, 54 female), mean age 45.7+/-13.4 (15-70) years. The underlying aortic valve disease was an aortic insufficiency in n=83, stenosis in n=48, a combined aortic valve disease in n=111 and an acute endocarditis in n=19 patients. Previous aortic valve surgery was performed in n=23. Last follow-up investigations (within last year) including echocardiography was performed at a mean follow-up of 29.4+/-24.7 months (553.7 patient years). Hospital mortality was n=2, late mortality n=4 (all noncardiac). Two patients were lost to follow-up (99% complete clinical follow-up). Reoperations were necessary in n=7 valves (autograft: endocarditis n=1, malpositioning n=1, leaflet prolapse n=1; homograft: stenosis n=2, insufficiency n=2). Autograft insufficiency (AI) was AI 0 in n=154, AI I n=66, AI II n=8. The maximum/mean pressure gradient across the autograft was 6.6+/-3.4 (2.1 to 25.9)/3.6+/-1.8 (1.2 to 13.2) mm Hg, respectively. Homograft insufficiency was 0 in n=167, I in n=54, II in n=9, and III in n=1. Maximum and mean transhomograft pressure gradients were 11.7+/-6.8 (2.2 to 42.6)/6.2+/-3.8 (1.2 to 24.5) mm Hg. Most patients were NYHA class I (n=214), class II (n=19), class III (n=2). Significant aortic root dilatation was not observed.
Aortic valve replacement with a pulmonary autograft in the subcoronary or inclusion technique provides excellent hemodynamics with no root dilatation at least in a mid term postoperative period. Transhomograft pressure gradients are slightly increased. Longer term results with special emphasis on the pulmonary homograft are necessary.
自20世纪90年代初以来，肺动脉自体移植主要作为独立根部植入，据报道主动脉瓣反流较少。然而，随着时间的推移，根部存在一定的扩张风险，这可能会损害瓣膜功能。自8年前起，我们倾向于采用原始的冠状动脉下或包埋技术来保留患者的根部，以限制扩张。
1994年6月至2002年5月期间，对245例患者（191例男性，54例女性）进行了冠状动脉下（n = 228）和包埋技术（n = 17）手术，平均年龄45.7±13.4（15 - 70）岁。潜在的主动脉瓣疾病包括主动脉瓣关闭不全83例，狭窄48例，主动脉瓣联合疾病111例，急性心内膜炎19例。23例患者曾接受过主动脉瓣手术。最后一次随访调查（在去年内）包括超声心动图检查，平均随访时间为29.4±24.7个月（553.7患者年）。医院死亡率为2例，晚期死亡率为4例（均为非心脏原因）。2例患者失访（临床随访完成率99%）。7个瓣膜需要再次手术（自体移植：心内膜炎1例，位置异常1例，瓣叶脱垂1例；同种异体移植：狭窄2例，关闭不全2例）。自体移植瓣膜关闭不全（AI）为0级的有154例，I级66例，II级8例。自体移植瓣膜的最大/平均压力阶差分别为6.6±3.4（2.1至25.9）/3.6±1.8（1.2至13.2）mmHg。同种异体移植瓣膜关闭不全为0级的有167例，I级54例，II级9例，III级1例。同种异体移植瓣膜的最大和平均跨瓣压力阶差分别为11.7±6.8（2.2至42.6）/6.2±3.8（1.2至24.5）mmHg。大多数患者为纽约心脏协会（NYHA）I级（n = 214），II级（n = 19），III级（n = 2）。未观察到明显的主动脉根部扩张。
采用冠状动脉下或包埋技术进行肺动脉自体移植主动脉瓣置换术至少在术后中期可提供优异的血流动力学，且无根部扩张。同种异体移植瓣膜的压力阶差略有增加。需要更长期的结果，尤其要重点关注肺动脉同种异体移植。
