Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, Calif 94305-5247, USA.
J Thorac Cardiovasc Surg. 2013 Mar;145(3 Suppl):S35-40.e1-2. doi: 10.1016/j.jtcvs.2012.11.043. Epub 2012 Dec 20.
The durability of valve-sparing aortic root replacement with or without cusp repair in patients with bicuspid aortic valve (BAV) disease is questioned. We analyzed the results of 75 patients with a BAV undergoing Tirone David reimplantation valve-sparing aortic root replacement.
Average age was 45 ± 10 years; 80% were male; 31% had 2+ or greater aortic regurgitation (AR); annular diameter averaged 28 ± 3 mm; 32% had a Sievers' type 0 BAV, and 66% underwent concomitant cusp repair (usually cusp free margin shortening) to correct prolapse. Early (6 ± 3 days) and late (2.9 ± 1.7, 1-10 years) postoperative echocardiographic results were compared (cumulative echocardiographic follow-up, 190 patient-years; median late interval, 2 years [interquartile range, 0.68, 4.2]). Seven patients remained at risk beyond 6 years. Clinical outcome and valve function were analyzed using log-rank calculations.
Actuarial survival was 99% ± 2%; freedom from reoperation was 90% ± 5%, infection 98% ± 2%, and stroke 100% at 6 years. After initial improvement in degree of AR (P < .001), minor subclinical progression of AR was observed (P > .5); however, freedom from AR of more than 2+ was 100%. Cusp free margin shortening was not associated with valve deterioration, but commissural suspensory polytetrafluoroethylene neochord creation (n = 4) portended a higher probability of recurrent AR (P = .025).
After David procedure and cusp repair in patients with a BAV, midterm clinical and valve function outcomes were favorable out to 6 years. More follow-up is required to determine long-term valve durability and the hazard of other clinically important late adverse events, including eventual reoperation, to beyond 10 years.
对于二叶式主动脉瓣（BAV）疾病患者，行保留瓣膜的主动脉根部替换术（David 手术）加或不加瓣叶修复的耐久性存在争议。我们分析了 75 例行保留瓣膜的 David 手术的 BAV 患者的结果。
平均年龄为 45 ± 10 岁；80%为男性；31%存在 2+或更严重的主动脉瓣反流（AR）；瓣环直径平均为 28 ± 3mm；32%为 Sievers 0 型 BAV，66%行瓣叶修复（通常为瓣叶游离缘缩短）以纠正脱垂。比较了早期（术后 6 ± 3 天）和晚期（术后 2.9 ± 1.7 年，1-10 年）的超声心动图结果（累计超声心动图随访 190 患者-年；中位晚期随访时间为 2 年[四分位距，0.68，4.2]）。7 例患者在 6 年后仍处于风险中。使用对数秩检验分析临床结局和瓣膜功能。
actuarial 生存率为 99% ± 2%；无再次手术率为 90% ± 5%，感染率为 98% ± 2%，卒中性为 100%，在 6 年时。在 AR 严重程度最初改善后（P＜.001），观察到轻微的亚临床 AR 进展（P＞.5）；然而，AR 程度超过 2+的无 AR 率为 100%。瓣叶游离缘缩短与瓣膜恶化无关，但行交界区悬吊聚四氟乙烯人工腱索（n = 4）与更高的复发性 AR 风险相关（P =.025）。
在 BAV 患者中行 David 手术和瓣叶修复后，至 6 年时中期临床和瓣膜功能结局良好。需要更多的随访来确定长期瓣膜耐久性和其他重要的晚期不良临床事件的风险，包括 10 年后的再次手术。
