Hôpital Foch, Suresnes, France.
Eur J Cardiothorac Surg. 2010 Aug;38(2):147-54. doi: 10.1016/j.ejcts.2010.01.041. Epub 2010 Mar 7.
Multiplicity of aortic valve repair or sparing techniques results in a lack of standardisation, limiting widespread adoption of such procedures. To treat dilated diameters at the aortic annular base and sinotubular junction while maintaining root dynamics, we propose a standardised and physiological repair approach to the surgical management of aortic root aneurysms, consisting of root remodelling, cusp re-suspension and subvalvular aortic ring annuloplasty.
From May 2003 to September 2009, 144 unselected patients with aortic root aneurysms underwent remodelling with external subvalvular ring annuloplasty in 13 centres (21 surgeons). Preoperative aortic insufficiency (AI) > or =grade 2 was present in 63.9% (92), Marfan syndrome in 12.5% (18) and bicuspid valve in 22.9% (33). Cusp repair was performed in 40.3% (58) patients.
Valve repair was successful in all but two cases. Repair of cusp prolapse was necessary in 58 patients, significantly more frequent in bicuspid (24/33, 72.7%) than in tricuspid (34/111, 30.6%) valves (p<0.05). Operative mortality was 2.8% (four). Subvalvular ring implantation produced a significant annular base reduction from 27.6+/-2.5 mm to 20.5+/-2.6 mm (p<0.01) without significant mean trans-valvular gradient (7.2+/-1.7 mmHg). During follow-up (median 2.2 years (0.75-4.4, maximum 6.25 years)), five patients died while eight required a re-operation. Six were operated on during our early experience. Strategy for cusp re-suspension evolved over three operative periods, with a significant increase in the rate of cusp repair. From May 2003 to December 2006: eye balling evaluation (15/67 (22.4%)); from January 2007 to August 2008: alignment of cusp free edges (17/38 (44.7%)); and from September 2008 to September 2009: a two-step standardised repair consisting of alignment of cusp free edges and effective height re-suspension (26/39 (66.7%) p<0.05). Freedom from AI> or =grade 2 was 91.3% (115) at the end of follow-up.
Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with satisfactory preliminary results. The ongoing CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root) will compare this standardised repair technique using an expansible aortic ring to mechanical valve replacement.
主动脉瓣修复或保留技术的多样性导致缺乏标准化，限制了此类手术的广泛采用。为了在保持根部动力学的同时治疗主动脉瓣环基底和窦管交界处的扩张直径，我们提出了一种标准化和生理性的主动脉根部瘤手术处理方法，包括根部重塑、瓣叶再悬吊和瓣下主动脉环瓣环成形术。
2003 年 5 月至 2009 年 9 月，13 个中心（21 名外科医生）对 144 例未经选择的主动脉根部瘤患者进行了外部瓣下环瓣环成形术的重塑。术前主动脉瓣关闭不全（AI）≥2 级的有 63.9%（92 例），马凡综合征 12.5%（18 例），二叶瓣 22.9%（33 例）。40.3%（58 例）患者行瓣叶修复。
除 2 例外，其余患者的瓣膜修复均成功。在二叶瓣（24/33，72.7%）中，瓣叶脱垂的修复比三叶瓣（34/111，30.6%）更常见（p<0.05）。手术死亡率为 2.8%（4 例）。瓣下环植入后，瓣环基底直径从 27.6+/-2.5 毫米显著减少到 20.5+/-2.6 毫米（p<0.01），而平均跨瓣梯度无显著变化（7.2+/-1.7mmHg）。在随访期间（中位数 2.2 年（0.75-4.4，最长 6.25 年）），5 例患者死亡，8 例患者需要再次手术。其中 6 例在我们的早期经验中进行了手术。瓣叶再悬吊的策略经历了三个手术阶段，瓣叶修复的比例显著增加。从 2003 年 5 月到 2006 年 12 月：眼球评价（15/67（22.4%））；从 2007 年 1 月到 2008 年 8 月：瓣叶游离缘对齐（17/38（44.7%））；从 2008 年 9 月到 2009 年 9 月：采用两步标准化修复，包括瓣叶游离缘对齐和有效高度再悬吊（26/39（66.7%），p<0.05）。随访结束时，无 AI>或=2 级的患者为 91.3%（115 例）。
主动脉环的植入提供了一种可重复的主动脉瓣修复技术，具有满意的初步结果。正在进行的 CAVIAAR 试验（保守性主动脉瓣手术治疗主动脉瓣关闭不全和主动脉根部瘤）将比较使用可扩张主动脉环的这种标准化修复技术与机械瓣膜置换术。
