Mazzitelli Domenico, Stamm Christof, Rankin J Scott, Pfeiffer Steffen, Fischlein Theodor, Pirk Jan, Choi Yeong-Hoon, Detter Christian, Kroll Johannes, Beyersdorf Friedhelm, Shrestha Malakh, Schreiber Christian, Lange Rüdiger
German Heart Center Munich, Munich, Germany.
German Heart Center Berlin, Berlin, Germany.
Ann Thorac Surg. 2014 Dec;98(6):2053-60. doi: 10.1016/j.athoracsur.2014.06.052. Epub 2014 Dec 1.
Refining leaflet reconstruction has become a primary issue in aortic valve repair. This descriptive analysis reviews leaflet pathology, repair techniques, and early results in a prospective regulatory trial of aortic valve repair.
Sixty-five patients underwent valve repair for predominant moderate to severe aortic insufficiency (AI). The mean age was 63 ± 13 years, and 69% of the patients were male. Ascending aortic/root replacement was required in 62%. As a first step, ring annuloplasty was performed, and then leaflet repair included leaflet plication for prolapse, nodular unfolding, double pericardial patching of commissural defects or holes, complete pericardial leaflet replacement, leaflet extension, and Gore-Tex reinforcement. Leaflet techniques and causes of adverse outcomes were evaluated.
The follow-up time was 2-years maximal and 0.9 years mean, with a survival of 97%. Eighty percent of patients required repair of leaflet defects: leaflet prolapse (52/65-80%), ruptured commissures (6/65-9%), leaflet holes (4/65-6%), and nodular retraction (6/65-9%). The average preoperative AI grade of 2.9 ± 0.8 fell to 0.7 ± 0.7 (p < 0.0001). Three patients (4.6%) required interval valve replacement because of (1) suture untying, (2) iatrogenic leaflet tear, or (3) diphtheroid endocarditis. Five other patients experienced grade 2 or grade 3 AI: probable suture untying in 1 patient, ineffective leaflet extensions in 2 patients, and unsuccessful Gore-Tex reinforcements in 2 patients. Two patients with single pericardial leaflet replacements and all those with double pericardial reconstructions did well.
Leaflet defects are common in patients with moderate to severe AI. Leaflet plication, nodular unfolding, and double pericardial patching performed well. Gore-Tex and leaflet extension seemed less satisfactory. Standardization and experience with leaflet reconstruction will be important for optimizing the outcomes of aortic valve repair.
优化瓣叶重建已成为主动脉瓣修复的首要问题。本描述性分析回顾了在一项主动脉瓣修复的前瞻性监管试验中瓣叶病理、修复技术及早期结果。
65例患者因主要为中重度主动脉瓣关闭不全（AI）接受瓣膜修复。平均年龄为63±13岁，69%的患者为男性。62%的患者需要进行升主动脉/根部置换。第一步进行环缩成形术，然后瓣叶修复包括针对脱垂的瓣叶折叠、结节展开、对合处缺损或孔洞的双层心包修补、完整的心包瓣叶置换、瓣叶延长以及戈尔特斯（Gore-Tex）加固。评估了瓣叶技术及不良后果的原因。
随访时间最长为2年，平均为0.9年，生存率为97%。80%的患者需要修复瓣叶缺损：瓣叶脱垂（52/65 - 80%）、对合处破裂（6/65 - 9%）、瓣叶孔洞（4/65 - 6%）以及结节回缩（6/65 - 9%）。术前平均AI分级为2.9±0.8降至0.7±0.7（p < 0.0001）。3例患者（4.6%）因（1）缝线松解、（2）医源性瓣叶撕裂或（3）双态杆菌性心内膜炎需要进行间隔期瓣膜置换。另外5例患者出现2级或3级AI：1例患者可能是缝线松解，2例患者瓣叶延长无效，2例患者戈尔特斯加固失败。2例单心包瓣叶置换患者及所有双心包重建患者情况良好。
中重度AI患者中瓣叶缺损常见。瓣叶折叠、结节展开及双层心包修补效果良好。戈尔特斯和瓣叶延长似乎不太令人满意。瓣叶重建的标准化及经验对于优化主动脉瓣修复结果很重要。
