Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany.
Eur J Cardiothorac Surg. 2012 Aug;42(2):261-6; discussion 266-7. doi: 10.1093/ejcts/ezs011. Epub 2012 Feb 9.
The David aortic valve-sparing reimplantation (AVr-D) operation is increasingly being used in patients with aortic root aneurysmal disease and pliable aortic cusps. The objective of this study was to assess our early and medium-term outcomes with the AVr-D operation.
Between 2003 and 2011, a total of 179 patients underwent AVr-D procedures. The mean patient age was 49.7 ± 15.1 years, and 23.5% (n = 42) were females. Marfan syndrome was present in 17.3% of patients (n = 31), and acute Type A aortic dissection in 15.6% (n = 28). Clinical follow-up was 100% complete and was 1.8 ± 1.6 years (0 days to 7.5 years) long. Echocardiographic follow-up was performed 2.2 ± 1.5 years (0 days to 7.5 years) postoperatively and was 77% complete.
Early mortality was 1.1% (n = 2), with both deaths occurring in patients with Type A dissection. Pre-discharge echocardiography revealed no patients with >2+ aortic insufficiency (AI), 19.6% of patients (n = 34) with 1+ or 2+ AI and 80.4% of patients (n = 145) with trace or no AI. Left ventricular end-diastolic diameters decreased significantly from 5.6 ± 0.9 to 5.1 ± 0.8 cm early postoperatively (P < 0.01). Transvalvular maximum gradients were similar before discharge and at last follow-up (10.6 ± 5.4 vs. 10.0 ± 8.2 mmHg, P = 0.4). AI grade increased significantly over time (0.3 ± 0.4 before discharge vs. 0.5 ± 0.6 at follow-up, P = 0.01), but remained less than moderate in 93.6% of patients. Four patients required aortic valve re-replacement during follow-up, two due to early endocarditis and two due to non-coronary leaflet prolapse in Marfan patients. Five-year freedom from aortic valve reoperation was 95.9 ± 2.0%.
AVr-D is associated with a low mortality and morbidity rate, even in patients with Type A aortic dissection. Although a slightly higher rate of recurrent AI may be present in patients with Marfan syndrome, freedom from recurrent AI and reoperation remains excellent during medium-term follow-up. The David operation should be considered the gold standard for patients with proximal aortic root pathology (aneurysm or dissection) and pliable aortic cusps.
越来越多的患者因主动脉根部瘤样病变和柔软主动脉瓣而接受 David 主动脉瓣保留再植入术（AVr-D）。本研究旨在评估我们的 AVr-D 手术的早期和中期结果。
2003 年至 2011 年间，共 179 例患者接受 AVr-D 手术。患者平均年龄为 49.7 ± 15.1 岁，23.5%（n=42）为女性。17.3%的患者（n=31）患有马凡综合征，15.6%（n=28）患有急性 A 型主动脉夹层。临床随访完成率为 100%，随访时间为 1.8 ± 1.6 年（0 天至 7.5 年）。术后 2.2 ± 1.5 年（0 天至 7.5 年）进行超声心动图随访，随访完成率为 77%。
早期死亡率为 1.1%（n=2），均发生在 A 型夹层患者中。出院前超声心动图检查未见>2+主动脉瓣关闭不全（AI），19.6%（n=34）患者为 1+或 2+AI，80.4%（n=145）患者为微量或无 AI。左心室舒张末期直径在术后早期显著减小，从 5.6±0.9cm 降至 5.1±0.8cm（P<0.01）。出院时和最后一次随访时跨瓣最大梯度相似（10.6±5.4 vs. 10.0±8.2mmHg，P=0.4）。AI 分级随时间显著增加（出院前为 0.3±0.4，随访时为 0.5±0.6，P=0.01），但在 93.6%的患者中仍小于中度。4 例患者在随访期间需要再次主动脉瓣置换，2 例因早期心内膜炎，2 例因马凡综合征患者非冠状动脉瓣叶脱垂。5 年无主动脉瓣再手术率为 95.9±2.0%。
即使在 A 型主动脉夹层患者中，AVr-D 手术也与较低的死亡率和发病率相关。尽管马凡综合征患者中可能存在更高的复发性 AI 发生率，但在中期随访中，无复发性 AI 和再次手术的成功率仍然很高。David 手术应被视为近端主动脉根部病变（动脉瘤或夹层）和柔软主动脉瓣患者的金标准。
