迈向可预测的主动脉瓣反流修复：一种针对双瓣叶修复的系统形态学导向方法。

Toward predictable repair of regurgitant aortic valves: a systematic morphology-directed approach to bicommissural repair.

作者信息

Pettersson Gösta B, Crucean Adrian C, Savage Robert, Halley Carmel M, Grimm Richard A, Svensson Lars G, Naficy Sepehre, Gillinov A Marc, Feng Jingyuan, Blackstone Eugene H

机构信息

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.

出版信息

J Am Coll Cardiol. 2008 Jul 1;52(1):40-9. doi: 10.1016/j.jacc.2008.01.073.

DOI:10.1016/j.jacc.2008.01.073

PMID:18582633

Abstract

OBJECTIVES

Our purpose was to investigate a new approach to bicommissural repair of regurgitant aortic valves.

BACKGROUND

Repair of regurgitant aortic valves is not widely accepted, but interest is increasing, particularly for bicuspid valves. We hypothesize that a systematic, segmental approach to morphology and corresponding morphology-directed repair will improve decision making and success.

METHODS

From December 2001 to July 2007, a systematic surgical approach to valve analysis and bicommissural repair was applied prospectively to 63 consecutive patients with pure aortic valve regurgitation, mean age 40 +/- 12 years. Cusp, commissure, and root morphologies were analyzed sequentially by direct inspection. Each abnormality was corrected by corresponding morphology-directed repair procedures. Retrospectively, 2 echocardiographic indexes--of tissue pliability (change in systolic to diastolic area) and coaptation deficiency (conjoint and reference cusp heights vs. "annulus" diameter)--were developed to evaluate repairability.

RESULTS

Forty-two (67%) valves were repaired and 21 (33%) replaced. Regurgitation was related primarily to cusp (prolapse, restriction) and commissure (splaying) morphology; root pathology was less important. Morphology-directed repair included cusp maneuvers in all, commissural maneuvers in 71%, and root procedures in 33%. Restriction and cusp tissue deficiency limited repairability. Echocardiography reflected this in greater tissue pliability of successfully repaired valves compared with replaced ones (conjoint cusp 61 +/- 16% vs. 34 +/- 17%; reference cusp 65 +/- 16% vs. 42 +/- 16%; p = 0.0001) and less coaptation deficiency (1.06 +/- 0.24 for repaired and 1.27 +/- 0.19 for replaced valves; p = 0.002).

CONCLUSIONS

Systematic segmental analysis of morphology and a logical morphology-directed surgical approach facilitate aortic valve repair. Initial application of this paradigm suggests sufficient mobile cusp tissue is a key determinant of repairability.

摘要

目的

我们的目的是研究一种反流性主动脉瓣双联合修复的新方法。

背景

反流性主动脉瓣修复术尚未被广泛接受，但人们的兴趣正在增加，尤其是对于二叶式瓣膜。我们假设，一种针对形态学的系统性、分段方法以及相应的形态学导向修复将改善决策制定并提高成功率。

方法

从2001年12月至2007年7月，一种针对瓣膜分析和双联合修复的系统性手术方法被前瞻性地应用于63例连续的单纯主动脉瓣反流患者，平均年龄40±12岁。通过直接检查依次分析瓣叶、联合部和根部形态。每种异常情况均通过相应的形态学导向修复程序进行纠正。回顾性地，开发了2种超声心动图指标——组织柔韧性（收缩期至舒张期面积变化）和对合不全（联合瓣叶和参照瓣叶高度与“瓣环”直径之比）——以评估可修复性。

结果

42个（67%）瓣膜得以修复，21个（33%）被置换。反流主要与瓣叶（脱垂、受限）和联合部（分离）形态有关；根部病变的重要性较低。形态学导向修复包括所有病例均进行的瓣叶操作、71%病例进行的联合部操作以及33%病例进行的根部手术。受限和瓣叶组织不足限制了可修复性。超声心动图显示，与置换的瓣膜相比，成功修复的瓣膜组织柔韧性更高（联合瓣叶61±16%对34±17%；参照瓣叶65±16%对42±16%；p = 0.0001），对合不全更少（修复的瓣膜为1.06±0.24，置换的瓣膜为1.27±0.19；p = 0.002）。