de Kerchove Laurent, Glineur David, Poncelet Alain, Boodhwani Munir, Rubay Jean, Dhoore William, Noirhomme Philippe, El Khoury Gébrine
Division of Cardiovascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
Eur J Cardiothorac Surg. 2008 Oct;34(4):785-91. doi: 10.1016/j.ejcts.2008.06.030. Epub 2008 Jul 26.
Leaflet plication (PL), triangular resection (TR), resuspension with running suture of Gore-Tex (GTx) and extension with autologous pericardial patch (PP) are different techniques to repair aortic leaflet prolapse (LP) for aortic insufficiency (AI). In this study, we report and compare the early and mid-term results of these techniques for aortic valve repair.
From 1996 to 2006, 298 patients underwent elective aortic valve (AV) repair. In 146 of them, prolapse of one (n=72) or more than one leaflet (n=74) was found. LP was defined either as a longer or lower leaflet free margin compared to the other leaflet(s) or a relatively low coaptation level of all leaflets. When leaflet tissues were of good quality (thin and pliable), prolapse was treated by GTx (n=39), PL (n=25) or GTx+PL (n=23). When leaflet tissues were of poor quality (thickened, calcified), prolapse was treated by TR or PP (n=13) or TR or PP+GTx (n=47).
There was no hospital mortality. During the initial hospitalization two patients required reoperation for recurrent AI and one for aorto-right ventricular fistula; of them, two were re-repaired. Median follow-up was 35 months (range 9-136). Three patients needed late reoperation for recurrent AI. At 4 years, overall survival was 99+/-1% and freedom from reoperation and from recurrent AI (grade >2) was 94+/-5% and 91+/-7% respectively. Freedom from recurrent AI was similar in patients having one versus more than one LP repair (88+/-11% vs 92+/-8%, p=0.2) and among the different techniques used to repair leaflet of good quality (PL: 95+/-8% vs GTx: 83+/-18% vs PL+GTx: 100%; p=0.37). When leaflet resection was needed, the addition of GTx significantly reduced the recurrence of AI (TR or PP: 82+/-18% vs TR or PP+GTx: 97+/-4%; p=0.026).
Leaflet plication and Gore-Tex resuspension are both effective and durable techniques for aortic leaflet prolapse repair. The addition of Gore-Tex to triangular resection and pericardial patch repair techniques is efficient to reinforce the suture line and to improve the outcome of the repair. Multiple leaflet prolapse is not a prohibitive factor for successful repair even in the absence of a clear reference level such as a normal leaflet, as long as normal anatomical coaptation is achieved.
瓣叶折叠术（PL）、三角形切除术（TR）、用 Gore-Tex 连续缝合进行悬吊术以及用自体心包补片（PP）进行扩大术是修复主动脉瓣脱垂（LP）所致主动脉瓣关闭不全（AI）的不同技术。在本研究中，我们报告并比较了这些主动脉瓣修复技术的早期和中期结果。
1996 年至 2006 年，298 例患者接受了择期主动脉瓣（AV）修复术。其中 146 例发现一个瓣叶（n = 72）或多个瓣叶（n = 74）脱垂。LP 的定义为与其他瓣叶相比瓣叶游离缘更长或更低，或者所有瓣叶的对合水平相对较低。当瓣叶组织质量良好（薄且柔韧）时，脱垂采用 Gore-Tex 治疗（n = 39）、PL 治疗（n = 25）或 Gore-Tex + PL 治疗（n = 23）。当瓣叶组织质量差（增厚、钙化）时，脱垂采用 TR 或 PP 治疗（n = 13）或 TR 或 PP + Gore-Tex 治疗（n = 47）。
无院内死亡。在初次住院期间，2 例患者因复发性 AI 需要再次手术，1 例因主动脉 - 右心室瘘需要再次手术；其中 2 例进行了再次修复。中位随访时间为 35 个月（范围 9 - 136 个月）。3 例患者因复发性 AI 需要晚期再次手术。4 年时，总体生存率为 99±1%，免于再次手术和复发性 AI（>2 级）的比例分别为 94±5%和 91±7%。单个 LP 修复与多个 LP 修复患者的复发性 AI 免于率相似（88±11%对 92±8%，p = 0.2），并且在用于修复质量良好瓣叶的不同技术中也是如此（PL：95±8%对 Gore-Tex：83±18%对 PL + Gore-Tex：100%；p = 0.37）。当需要瓣叶切除时，添加 Gore-Tex 显著降低了 AI 的复发率（TR 或 PP：82±18%对 TR 或 PP + Gore-Tex：97±4%；p = 0.026）。
瓣叶折叠术和 Gore-Tex 悬吊术都是修复主动脉瓣脱垂的有效且持久的技术。在三角形切除术和心包补片修复技术中添加 Gore-Tex 可有效加强缝合线并改善修复效果。即使在没有如正常瓣叶这样明确参考水平的情况下，只要实现正常的解剖对合，多个瓣叶脱垂也不是成功修复的阻碍因素。
