Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Eur J Cardiothorac Surg. 2020 Jun 1;57(6):1137-1144. doi: 10.1093/ejcts/ezaa009.
Aortic insufficiency (AI) is common in patients with proximal aortic disease, but limited options exist to facilitate aortic valve repair (AVr) in this population. This study reports 'real-world' early results of AVr using newly FDA-approved trileaflet and bicuspid geometric annuloplasty rings for patients with AI undergoing proximal aortic repair (PAR) in a single referral centre.
All patients undergoing AVr with a rigid internal geometric annuloplasty ring (n = 47) in conjunction with PAR (ascending +/- root +/- arch) were included. Thirty-six patients underwent AVr with a trileaflet ring, and 11 patients underwent AVr with a bicuspid ring. The rings were implanted in the subannular position, and concomitant leaflet repair was performed if required for cusp prolapse identified after ring placement.
The median age was 58 years [interquartile range (IQR) 46-70]. PAR included supracoronary ascending replacement in 26 (55%) patients and remodelling valve-sparing root replacement with selective sinus replacement in 20 (42%) patients. Arch replacement was performed in 38 (81%) patients, including hemi-arch in 34 patients and total arch in 4 patients. There was no 30-day/in-hospital mortality. Preoperative AI was 3-4+ in 37 (79%) patients. Forty-one (87%) patients had zero-trace AI on post-repair transoesophageal echocardiography, and 6 patients had 1+ AI. The median early post-repair mean gradient was 13 mmHg (IQR 5-20). Follow-up imaging was available in 32 (68%) patients at a median of 11 months (IQR 10-13) postsurgery. AI was ≤1+ in 97% of patients with 2+ AI in 1 patient. All patients were alive and free from aortic valve reintervention at last follow-up.
Early results with geometric rigid internal ring annuloplasty for AVr in patients undergoing PAR appear promising and allow a standardized approach to repair with annular diameter reduction and cusp plication when needed. Longer-term follow-up will be required to ensure the durability of the procedure.
主动脉瓣关闭不全（AI）在近端主动脉疾病患者中较为常见，但该人群中进行主动脉瓣修复（AVr）的选择有限。本研究报告了在单一转诊中心中，使用新获得 FDA 批准的三叶和双叶几何瓣环对接受近端主动脉修复（PAR）的 AI 患者进行 AVr 的“真实世界”早期结果。
所有接受带刚性内部几何瓣环（n=47）的 AVr 联合 PAR（升主动脉 +/- 根部 +/- 弓部）的患者均纳入研究。36 例患者接受三叶瓣环 AVr，11 例患者接受双叶瓣环 AVr。这些瓣环被植入瓣环下位置，如果在瓣环放置后发现瓣叶脱垂，需要进行瓣叶修复。
中位年龄为 58 岁[四分位距（IQR）46-70]。PAR 包括 26 例（55%）患者的冠状动脉以上升主动脉置换和 20 例（42%）患者的改良保留瓣膜根部置换伴选择性窦部置换。38 例（81%）患者进行了弓部置换，其中 34 例为半弓置换，4 例为全弓置换。无 30 天/住院期间死亡。术前 AI 为 3-4+的患者有 37 例（79%）。41 例（87%）患者术后经食管超声心动图检查显示 AI 为零迹，6 例患者 AI 为 1+。中位术后早期平均跨瓣压差为 13mmHg（IQR 5-20）。32 例（68%）患者在术后中位 11 个月（IQR 10-13）时获得随访影像学资料。97%的患者 AI 为≤1+，1 例患者 AI 为 2+。所有患者在末次随访时均存活，且无主动脉瓣再介入。
在接受 PAR 的患者中，使用几何刚性内部瓣环行 AVr 的早期结果令人鼓舞，可通过瓣环直径缩小和瓣叶折叠来标准化修复，必要时可进行修复。需要进行更长时间的随访以确保手术的耐久性。
