Cardiothoracic Surgery, University Hospital, Coimbra, Portugal.
Eur J Cardiothorac Surg. 2011 Aug;40(2):441-7. doi: 10.1016/j.ejcts.2010.11.064. Epub 2011 Jan 13.
To analyze the short-term outcome of aortic root enlargement (ARE) using death and adverse events as end points.
From January 1999 through December 2009, 3339 patients were subjected to aortic valve replacement (AVR). A total of 678 were considered to have small aortic roots (SARs) in which an aortic prosthesis size 21 mm or smaller was implanted. ARE using a bovine pericardial patch was performed in another 218 patients, who constitute the study population. This comprised 174 females (79.8%); the mean age was 69.4 ± 13.4 years (8-87, median 74 years), the body surface area (BSA) was 1.59 ± 0.15m² and the body mass index (BMI) 25.77 ± 3.16 k gm⁻², and 192 (88.5%) were in New York Heart Association (NYHA) II-III. Preoperative echocardiography revealed significant left ventricular (LV) dysfunction in 17 patients (8%), a mean aortic valve area of 0.57 ± 0.27 cm², and a mean gradient of 62.51 ± 21.25 mm Hg. A septal myectomy was performed in 129 subjects (59.2%), and other associated procedures, mostly coronary artery bypass grafting (CABG), in 60 (27.5%). Bioprostheses were implanted in 161 patients (73.9%). The mean valve size was 21.9 ± 1.0 (21-25). The mean extracorporeal circulation (ECC) and aortic clamping times were 82.8 ± 19.8 min and 56.8 ± 12.5 min, respectively.
Hospital mortality was 0.9% (n=2) for ARE as compared with 0.6% (n=4) for the SAR group (p=0.8). Inotropic support was required in only 13 (5.9%) patients and the first 24-h chest drainage was 336.2 ± 202 ml. Other complications included pacemaker implantation (7.8%), acute renal failure (10.6%), respiratory (4.1%), and CVA/transient ischemic attack (CVA/TIA) (3.2%). Postoperative echocardiographic evaluation showed a significant decrease in peak and mean aortic gradients (23.7 ± 9.5 and 14 ± 6.2 mm Hg, respectively, p<0.0001). The mean indexed effective orifice area (iEOA) was 0.92 ± 0.01 cm² m⁻² (vs 0.84±0.07 cm² m⁻², in SAR, p<0.0001). Only 11% of patients (n=24) with ARE exhibited moderate patient-prosthesis mismatch (PPM) and none had severe PPM. Mean hospital stay was 9.7 ± 9.29 days (median 7 days).
With the growing number of patients with degenerative aortic valve pathology, mainly an older population, sometimes with calcified and fragile aortic wall, the issue of dealing with an SAR poses the dilemma of whether to implant a smaller prosthesis and admit some degree of PPM, or to enlarge the aortic root. This study demonstrates that the latter can be done in a safe and reproducible manner.
以死亡和不良事件为终点，分析主动脉根部扩大（ARE）的短期结果。
1999 年 1 月至 2009 年 12 月，共有 3339 例患者接受主动脉瓣置换术（AVR）。其中 678 例被认为存在小主动脉瓣环（SARs），即植入 21 毫米或更小的主动脉假体。另外 218 例患者采用牛心包补片进行 ARE，构成了研究人群。其中包括 174 名女性（79.8%）；平均年龄为 69.4±13.4 岁（8-87 岁，中位数 74 岁），体表面积（BSA）为 1.59±0.15m²，体重指数（BMI）为 25.77±3.16kgm⁻²，纽约心脏协会（NYHA）心功能分级 II-III 级 192 例（88.5%）。术前超声心动图显示 17 例（8%）患者存在明显左心室（LV）功能障碍，主动脉瓣有效面积为 0.57±0.27cm²，平均梯度为 62.51±21.25mmHg。129 例患者（59.2%）接受了间隔心肌切除术，60 例（27.5%）患者接受了其他相关手术，主要是冠状动脉旁路移植术（CABG）。161 例患者（73.9%）植入了生物假体。平均瓣膜尺寸为 21.9±1.0（21-25）。体外循环（ECC）和主动脉阻断时间的平均值分别为 82.8±19.8min 和 56.8±12.5min。
ARE 组的院内死亡率为 0.9%（n=2），SAR 组为 0.6%（n=4）（p=0.8）。仅 13 例（5.9%）患者需要使用正性肌力药物支持，24 小时内的首引流量为 336.2±202ml。其他并发症包括起搏器植入（7.8%）、急性肾功能衰竭（10.6%）、呼吸（4.1%）和 CVA/短暂性脑缺血发作（CVA/TIA）（3.2%）。术后超声心动图评估显示，峰值和平均主动脉瓣跨瓣梯度均显著降低（分别为 23.7±9.5mmHg 和 14±6.2mmHg，p<0.0001）。平均有效指数瓣口面积（iEOA）为 0.92±0.01cm²m⁻²（与 SAR 组的 0.84±0.07cm²m⁻²相比，p<0.0001）。仅 11%（n=24）的 ARE 患者出现中度患者-假体不匹配（PPM），无一例出现严重 PPM。平均住院时间为 9.7±9.29 天（中位数 7 天）。
随着退行性主动脉瓣病变患者数量的增加，特别是老年患者，有时伴有钙化和脆弱的主动脉壁，处理 SAR 带来了是否植入较小假体并承认一定程度的 PPM，或扩大主动脉根部的难题。本研究表明，后一种方法可以安全且可重复地进行。
