Goebel Nora, Nagib Ragi, Salehi-Gilani Schahriar, Ahad Samir, Albert Marc, Ursulescu Adrian, Franke Ulrich F W
Department of Cardiac and Vascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany.
Thorac Cardiovasc Surg. 2019 Aug;67(5):372-378. doi: 10.1055/s-0038-1667179. Epub 2018 Jul 30.
Valve sparing aortic root repair by reimplantation (David procedure) is an established technique in acute aortic dissection Stanford type A involving the aortic root. In DeBakey type I dissection, aortic arch replacement using the frozen elephant trunk (FET) was introduced to promote aortic remodeling of the downstream aorta. The combination of these two complex procedures represents a challenging surgical strategy and was considered too risky so far.
All patients with acute aortic dissection DeBakey type I undergoing valve sparing aortic root repair by reimplantation technique of David combined with extended aortic repair using the FET at our center between October 2009 and December 2016 were evaluated. Outcomes are compared with patients who underwent prosthetic aortic root replacement and FET for aortic dissection in the same timeframe.
A total of 28 patients received combined David and FET procedure, while 20 patients received prosthetic aortic root replacement and FET procedure. Thirty-day mortality was 10.7% ( = 3) for the David group and 20% ( = 4) for the root replacement group ( = 0.43). Postoperative echocardiographic control revealed an excellent aortic valve function with regurgitation grade 0° or maximum grade I° and a mean gradient of 4.3 ± 2.1 mm Hg in all patients in the David group versus 7.2 ± 2.4 mm Hg in the aortic root replacement group, = 0.003. Computed tomography angiography scan showed positive aortic remodeling in all but three patients (91.9%). Mid-term follow-up survival was 82.1% in the David group and 68.4% in the root replacement group, = 0.28. There was no need for reintervention at the root or descending aorta.
Simultaneous application of the David and FET procedure in patients with acute aortic dissection is safe and feasible in experienced hands as compared with standard aortic root replacement plus FET. The mid-term outcomes are encouraging and noninferior to conventional surgery results.
通过再植入进行保留瓣膜的主动脉根部修复术（David手术）是治疗累及主动脉根部的急性Stanford A型主动脉夹层的成熟技术。在DeBakey I型夹层中，引入了使用冰冻象鼻技术（FET）进行主动脉弓置换，以促进下游主动脉的重塑。这两种复杂手术的联合是一种具有挑战性的手术策略，迄今为止被认为风险过高。
对2009年10月至2016年12月期间在本中心接受David再植入技术保留瓣膜的主动脉根部修复术并联合使用FET进行主动脉广泛修复的所有急性DeBakey I型主动脉夹层患者进行评估。将结果与同期接受人工主动脉根部置换和FET治疗主动脉夹层的患者进行比较。
共有28例患者接受了David手术和FET联合治疗，而20例患者接受了人工主动脉根部置换和FET手术。David组30天死亡率为1〇.7%（n = 3），根部置换组为20%（n = 4）（P = 0.43）。术后超声心动图检查显示，David组所有患者的主动脉瓣功能良好，反流程度为0级或最大I级，平均压差为4.3±2.1 mmHg，而主动脉根部置换组为7.2±2.4 mmHg，P = 0.003。计算机断层扫描血管造影显示，除3例患者（91.9%）外，所有患者的主动脉均有积极重塑。David组中期随访生存率为82.1%，根部置换组为68.4%，P = 0.28。无需对根部或降主动脉进行再次干预。
与标准主动脉根部置换加FET相比，在有经验的医生手中，对急性主动脉夹层患者同时应用David手术和FET是安全可行的。中期结果令人鼓舞，且不劣于传统手术结果。
