Ferrari Enrico, Franciosi Giorgio, Clivio Sara, Faletra Francesco, Moccetti Marco, Moccetti Tiziano, Pedrazzini Giovanni, Demertzis Stefanos
Cardiac Surgery Unit, Cardiocentro Ticino Foundation, Lugano, Switzerland.
Cardiac Anaesthesia Unit, Cardiocentro Ticino Foundation, Lugano, Switzerland.
Interact Cardiovasc Thorac Surg. 2017 Mar 1;24(3):319-323. doi: 10.1093/icvts/ivw397.
The goal was to show the technical details, feasibility and clinical results of balloon-expandable stent valve implantation in the aortic position during conventional redo open-heart surgery in selected obese patients with a small aortic prosthesis and severe patient-prosthesis mismatch.
Two symptomatic overweight patients (body mass index of 31 and 38), each with a small aortic prosthesis (a 4-year-old, 21-mm Hancock II biological valve and a 29-year-old, 23-mm Duromedic mechanical valve), increased transvalvular gradients (59/31 and 74/44 mmHg) and a reduced indexed effective orifice area (0.50 and 0.43 cm 2 /m 2 ) underwent implantation of two 26-mm balloon-expandable Sapien 3 valves during standard on-pump redo valve surgery.
Using full re-sternotomy, cardiopulmonary bypass and cardioplegic arrest, the two balloon-expandable stent valves were implanted under direct view using a standard aortotomy, after prosthesis removal and without annulus enlargement. Aortic cross-clamp times were 162 and 126 min; cardiopulmonary bypass times were 178 and 180 min; total surgical times were 360 and 318 min. At discharge, echocardiograms showed transvalvular peak and mean gradients of 13/9 and 23/13 mmHg and indexed effective orifice areas of 0.64 and 1.08 cm 2 /m 2 . The 3-month echocardiographic follow-up showed transvalvular peak and mean gradients of 18/9 and 19/11 mmHg and indexed effective orifice areas of 0.78 cm 2 /m 2 and 0.84 cm 2 /m 2 , with improved symptoms (New York Heart Association class 1).
Implantation of a balloon-expandable stent valve during redo aortic valve surgery is feasible in selected cases and prevents patient-prosthesis mismatch in obese patients without need for aortic annulus enlargement. Moreover, in the case of stent valve degeneration, this approach permits additional valve-in-valve procedures with large stent valves and prevents re-redo surgery.
本研究旨在展示在选定的肥胖患者中，于传统再次开胸心脏手术期间，在主动脉位置植入球囊扩张式支架瓣膜的技术细节、可行性及临床结果，这些患者使用的主动脉假体较小且存在严重的患者 - 假体不匹配情况。
两名有症状的超重患者（体重指数分别为31和38），每人都有一个较小的主动脉假体（一个使用4年的21毫米汉考克II生物瓣膜和一个使用29年的23毫米杜罗梅迪克机械瓣膜），跨瓣压差增加（分别为59/31和74/44 mmHg）且有效瓣口面积指数降低（分别为0.50和0.43 cm²/m²），在标准体外循环再次瓣膜手术期间植入了两个26毫米的球囊扩张式Sapien 3瓣膜。
通过完全再次胸骨切开术、体外循环和心脏停搏，在移除假体且未扩大瓣环的情况下，经标准主动脉切开术在直视下植入了两个球囊扩张式支架瓣膜。主动脉阻断时间分别为162分钟和126分钟；体外循环时间分别为178分钟和180分钟；总手术时间分别为360分钟和318分钟。出院时，超声心动图显示跨瓣峰值压差和平均压差分别为13/9和23/13 mmHg，有效瓣口面积指数分别为0.64和1.08 cm²/m²。3个月的超声心动图随访显示跨瓣峰值压差和平均压差分别为18/9和19/11 mmHg，有效瓣口面积指数分别为0.78 cm²/m²和0.84 cm²/m²，症状有所改善（纽约心脏协会心功能分级为1级）。
在选定病例中，再次主动脉瓣膜手术期间植入球囊扩张式支架瓣膜是可行的，可防止肥胖患者出现患者 - 假体不匹配，且无需扩大主动脉瓣环。此外，在支架瓣膜退变的情况下，这种方法允许使用大型支架瓣膜进行额外的瓣中瓣手术，并避免再次进行再次手术。
