Crestanello Juan A, Zehr Kenton J, Daly Richard C, Orszulak Thomas A, Schaff Hartzell V
Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota 55906, USA.
J Heart Valve Dis. 2004 Jan;13(1):57-62; discussion 62-3.
Aortic valve replacement (AVR) in patients with a heavily calcified ascending aorta and aortic root, or with conditions that preclude a median sternotomy, poses a formidable challenge. A left ventricle apical-aortic conduit (AAC) is an alternative in these situations. Herein, the authors' experience with AAC in adult patients with acquired aortic stenosis is reported.
Between 1995 and 2003, 13 patients (mean age 71 years) underwent AAC for severe symptomatic aortic stenosis (mean valve area 0.65 +/- 0.02 cm2). Indications for AAC were heavily calcified ascending aorta and aortic root (n = 5), patent retrosternal mammary grafts (n = 4), calcified ascending aorta and aortic root plus patent retrosternal mammary graft (n = 1), retrosternal colonic interposition (n = 1) and multiple previous sternotomies (n = 2). Seven patients had previous coronary artery bypass grafting (CABG). The mean preoperative left ventricular ejection fraction was 50 +/- 4%.
AAC were performed under cardiopulmonary bypass through a left thoracotomy (n = 10), median sternotomy (n = 2) or bilateral thoracotomy (n = 1). Hearts were kept beating (n = 5) or fibrillated (n = 7). Circulatory arrest was used in one patient. Composite Dacron conduits with biological (n = 6), mechanical (n = 4) or homograft (n = 2) valves were used. Distal anastomoses were performed in the descending thoracic aorta (n = 12) or in the left iliac artery (n = 1). Two patients underwent simultaneous CABG. Three patients died in-hospital from ventricular failure (n = 1), intravascular thrombosis (n = 1) and multi-organ failure (n = 1). The mean hospital stay was 26 days. Complications included respiratory failure requiring tracheostomy (n = 2), stroke (n = 1) and re-exploration for bleeding (n = 2). At a mean follow up of 2.1 years, there have been four late deaths; causes of death were congestive heart failure (n = 2), ischemic cardiomyopathy (n = 1) and cancer (n = 1).
AAC provides an acceptable alternative to AVR in selected patients who are at exceedingly high risk for the standard procedure.
对于升主动脉和主动脉根部严重钙化或存在无法进行正中胸骨切开术情况的患者，主动脉瓣置换术（AVR）是一项艰巨的挑战。左心室心尖 - 主动脉管道（AAC）是这些情况下的一种替代方法。本文报告了作者在成年获得性主动脉瓣狭窄患者中应用AAC的经验。
1995年至2003年间，13例患者（平均年龄71岁）因严重症状性主动脉瓣狭窄（平均瓣口面积0.65±0.02 cm²）接受了AAC手术。AAC的适应证包括升主动脉和主动脉根部严重钙化（n = 5）、胸骨后乳腺移植血管通畅（n = 4）、升主动脉和主动脉根部钙化且胸骨后乳腺移植血管通畅（n = 1）、胸骨后结肠植入（n = 1）以及多次既往胸骨切开术（n = 2）。7例患者既往有冠状动脉旁路移植术（CABG）。术前平均左心室射血分数为50±4%。
AAC手术通过左胸切口（n = 10）、正中胸骨切开术（n = 2）或双侧胸切口（n = 1）在体外循环下进行。心脏保持跳动（n = 5）或颤动（n = 7）。1例患者使用了循环停止技术。使用了带有生物瓣膜（n = 6）、机械瓣膜（n = 4）或同种异体瓣膜（n = 2）的复合涤纶管道。远端吻合在降主动脉（n = 12）或左髂动脉（n = 1）进行。2例患者同时进行了CABG。3例患者在医院内死于心力衰竭（n = 1）、血管内血栓形成（n = 1）和多器官功能衰竭（n = 1）。平均住院时间为26天。并发症包括需要气管切开的呼吸衰竭（n = 2）、中风（n = 1）和因出血再次手术探查（n = 2）。平均随访2.1年，有4例晚期死亡；死亡原因分别为充血性心力衰竭（n = 2）、缺血性心肌病（n = 1）和癌症（n = 1）。
对于标准手术风险极高的特定患者，AAC为AVR提供了一种可接受的替代方法。
