Lund Jens T, Jensen Maiken B, Arendrup Henrik, Ihlemann Nikolaj
Department of Cardiothoracic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.
Interact Cardiovasc Thorac Surg. 2013 Jul;17(1):79-83. doi: 10.1093/icvts/ivt087. Epub 2013 Mar 25.
In aortic valve bypass (AVB) a valve-containing conduit is connecting the apex of the left ventricle to the descending aorta. Candidates are patients with symptomatic aortic valve stenosis rejected for conventional aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI). During the last one and a half year, 10 patients otherwise left for medical therapy have been offered this procedure. We present the Danish experiences with the AVB procedure with a focus on patient selection, operative procedure and short-term results.
AVB is performed through a left thoracotomy. A 19-mm Freestyle(®) valve (Medtronic) is anastomosed to a vascular graft and an apex conduit. The anastomosis to the descending aorta is made prior to connecting the conduit to the apex. In 1 patient, we used an automated coring and apical connector insertion device (Correx(®)). The device results in a simultaneous coring and insertion of an 18-mm left ventricle connector in the apical myocardium. AVB is routinely performed without circulatory assistance.
Ten patients have been operated on since April 2011: eight females and 2 males with a median age of 76 (65-91) years. Seven patients had a severely calcified ascending aorta. Three of these had previously had a sternotomy, but did not have an AVR because of porcelain aorta. Six patients had a very small left ventricle outflow tract (<18 mm). The median additive EuroSCORE was 12 (10-15). Seven patients were operated on without circulatory assistance. Two patients had a re-exploration for bleeding and 1 developed a ventricle septum defect 1 month postoperatively and was treated with surgical closure. The median follow-up was 7 (2-15) months and was without mortality. New York Heart Association class was reduced from 2.5 to 2 at the follow-up, but some patients were still in the recovery period. The total valve area (native plus conduit) was 2.2 (1.9-2.5) cm(2) and 1.34 (1.03-1.46) cm(2)/m(2), indexed to the body surface area. There was no AV block or stroke.
AVB can be performed with low mortality and acceptable results in selected patients. The procedure can be offered to patients rejected for conventional aortic valve replacement and TAVI and results in a larger total valve area than by insertion of standard bioprosthesis.
在主动脉瓣旁路术（AVB）中，一个包含瓣膜的管道将左心室心尖与降主动脉相连。适用对象为因传统主动脉瓣置换术（AVR）或经导管主动脉瓣植入术（TAVI）被拒的有症状主动脉瓣狭窄患者。在过去一年半时间里，我们为10名原本准备接受药物治疗的患者实施了该手术。我们介绍丹麦在AVB手术方面的经验，重点关注患者选择、手术操作和短期结果。
AVB通过左胸切口进行。将一个19毫米的Freestyle（®）瓣膜（美敦力公司）与一个血管移植物和一个心尖管道进行吻合。在将管道连接到心尖之前，先与降主动脉进行吻合。在1例患者中，我们使用了一种自动取芯和心尖连接器插入装置（Correx（®））。该装置可在心肌心尖部同时进行取芯并插入一个18毫米的左心室连接器。AVB常规在无循环辅助的情况下进行。
自2011年4月以来，已有10例患者接受了手术：8名女性和2名男性，中位年龄为76（65 - 91）岁。7例患者升主动脉严重钙化。其中3例此前曾行胸骨切开术，但因主动脉瓷化未进行AVR。6例患者左心室流出道非常小（<18毫米）。EuroSCORE评分中位数为12（10 - 15）。7例患者在无循环辅助的情况下接受了手术。2例患者因出血进行了再次手术探查，1例患者术后1个月出现室间隔缺损并接受了手术修补。中位随访时间为7（2 - 15）个月，无死亡病例。随访时纽约心脏协会心功能分级从2.5降至2级，但部分患者仍处于恢复期。总瓣膜面积（自身瓣膜加管道瓣膜）为2.2（1.9 - 2.5）平方厘米，体表面积校正后为1.34（1.03 - 1.46）平方厘米/平方米。未发生房室传导阻滞或中风。
在选定患者中，AVB手术死亡率低，结果可接受。该手术可提供给因传统主动脉瓣置换术和TAVI被拒的患者，与植入标准生物假体相比，可获得更大的总瓣膜面积。
