Lansac Emmanuel, Di Centa Isabelle, Sleilaty Ghassan, Lejeune Stephanie, Khelil Nizar, Berrebi Alain, Diakov Christelle, Mankoubi Leila, Malergue Marie-Christine, Noghin Milena, Zannis Konstantinos, Salvi Suzanna, Dervanian Patrice, Debauchez Mathieu
Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France
Vascular Surgery Unit, Hopital Foch, Suresnes, France.
Eur J Cardiothorac Surg. 2016 Aug;50(2):350-60. doi: 10.1093/ejcts/ezw070.
An untreated dilated aortic annulus is a major risk factor for failure of aortic valve-sparing operations or repair of either bicuspid or tricuspid valve. Aortic annuloplasty efficiently reduces the annulus and increases the coaptation height, thus protecting the repair. This study analyses long-term results of 232 consecutive patients operated on with a standardized and physiological approach to aortic valve repair according to each phenotype of the dystrophic ascending aorta. Subvalvular aortic annuloplasty was systematically added using an external aortic ring to reduce annulus diameter when ≥25 mm.
Data were collected into the multicentric international AVIATOR registry (AorticValve repair InternATiOnal Registry): 149 patients with root aneurysm underwent remodelling with an external ring; 21 patients with tubular aortic aneurysm underwent supracoronary grafts with an external open ring and 62 patients with isolated aortic insufficiency (AI) underwent double sub- and/or supravalvular external open ring annuloplasty. Preoperative AI ≥ Grade III was present in 58.6% (133), and the valve was bicuspid in 37.9% (88).
Cusp repair was performed in 75.4% (175) patients. The 30-day operative mortality rate was 1.4% (3). The mean follow-up was 40.1 ± 37.8 months (0-145.5). The actuarial survival rate at 7 years was 89.9%. The rate of freedom from reoperation at 7 years was similar among each phenotype, being 90.5% for root aneurysms, 100% for tubular aortic aneurysms and 97.5% for isolated AI with no difference between the bicuspid and tricuspid valve. The rates of freedom from AI ≥ Grade 2 and from AI ≥ Grade 3 at 7 years were, respectively, 76.0 and 93.1% for root aneurysms, 92.9 and 100% for tubular aortic aneurysms and 57.3 and 82.2% for isolated AI. Eye balling repair achieved suboptimal valve competency when compared with systematic cusp effective height assessment, which tended to improve the rate freedom from reoperation, respectively, from 85.8 ± 5.5% to 98.9 ± 1.1% and the rate of freedom from AI ≥ Grade 3 from 89.8 ± 4.9% to 100%. For isolated AI, an additional sinotubular junction ring (double sub- and supravalvular annuloplasty) tended to reduce recurrent AI when compared with single subvalvular annuloplasty.
External aortic ring annuloplasty provides a reproducible technique for aortic valve repair with satisfactory long-term results for each ascending aorta phenotype with bicuspid or tricuspid valve. Longer follow-up is ongoing with the AVIATOR registry.
未经治疗的扩张型主动脉瓣环是保留主动脉瓣手术或修复二叶式或三叶式瓣膜失败的主要危险因素。主动脉瓣环成形术可有效缩小瓣环并增加瓣叶对合高度，从而保护修复效果。本研究分析了232例连续接受手术的患者的长期结果，这些患者根据营养不良性升主动脉的每种表型采用标准化和生理性方法进行主动脉瓣修复。当主动脉瓣环直径≥25 mm时，系统地使用外部主动脉环进行瓣下主动脉瓣环成形术以减小瓣环直径。
数据收集于多中心国际AVIATOR注册研究（主动脉瓣修复国际注册研究）：149例根部动脉瘤患者接受了带外部环的重塑手术；21例管状主动脉瘤患者接受了带外部开放环的冠状动脉上移植术，62例单纯主动脉瓣关闭不全（AI）患者接受了双瓣下和/或瓣上外部开放环瓣环成形术。术前AI≥Ⅲ级的患者占58.6%（133例），瓣膜为二叶式的患者占37.9%（88例）。
75.4%（175例）的患者进行了瓣叶修复。30天手术死亡率为1.4%（3例）。平均随访时间为40.1±37.8个月（0 - 145.5个月）。7年时的精算生存率为89.9%。7年时各表型的再次手术率相似，根部动脉瘤为90.5%，管状主动脉瘤为100%，单纯AI为97.5%，二叶式和三叶式瓣膜之间无差异。7年时无≥2级AI和无≥3级AI的发生率，根部动脉瘤分别为76.0%和93.1%，管状主动脉瘤分别为92.9%和100%，单纯AI分别为57.3%和82.2%。与系统的瓣叶有效高度评估相比，眼球修复的瓣膜功能未达最佳，系统的瓣叶有效高度评估倾向于分别将再次手术率从85.8±5.5%提高到98.9±1.1%，将无≥3级AI的发生率从89.8±4.9%提高到100%。对于单纯AI，与单瓣下瓣环成形术相比，额外的窦管交界环（双瓣下和瓣上瓣环成形术）倾向于减少复发性AI。
外部主动脉环瓣环成形术为主动脉瓣修复提供了一种可重复的技术，对于每种伴有二叶式或三叶式瓣膜的升主动脉表型都有令人满意的长期结果。AVIATOR注册研究正在进行更长时间的随访。
