Shrestha Malakh, Boethig Dietmar, Krüger Heike, Kaufeld Tim, Martens Andreas, Haverich Axel, Beckmann Erik
Department of Cardio-thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Department of Cardio-thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
J Thorac Cardiovasc Surg. 2023 Nov;166(5):1387-1397.e10. doi: 10.1016/j.jtcvs.2022.01.061. Epub 2022 Apr 15.
We present our 25-year experience with valve-sparing aortic root replacement using a straight tube graft (David-I).
From 1993 to 2019, 677 patients (median age, 56.0 years; range, 42-65) underwent the David-I procedure with a straight tube graft. A total of 24 different surgeons performed these operations. Marfan syndrome was present in 111 patients (16.4%), and bicuspid aortic valve was present in 71 patients (10.5%). Aortic root aneurysm was present in 544 patients (80.4%), and acute dissection was present in 133 patients (19.6%).
Ministernotomy was used in 57 patients (8.4%). Additional cusp plasty was performed in 84 patients (12.4%). Concomitant procedures were coronary artery bypass grafting (n = 122, 18.0%), mitral valve surgery (n = 34, 5%), proximal arch replacement (n = 125, 18.4%), subtotal arch replacement (n = 43, 6.4%), and total arch replacement (n = 102, 15.1%). Overall in-hospital mortality was 4.0% (n = 27), and perioperative stroke occurred in 26 patients (3.8%). Postoperative echocardiography showed aortic insufficiency less than I° in 600 of 623 (96.3%). The 1-, 5-, 10-, 15-, and 20-year survivals were 97%, 92%, 79%, 68%, and 50%, respectively. The rates for freedom from aortic valve-related reoperation at 1, 5, 10, 15, and 20 years were 97%, 92%, 87%, 84%, and 80%, respectively. Multivariate Cox regression analysis identified age (odds ratio, 0.974; 95% confidence interval, 0.957-0.992; P = .004), senior surgeon (odds ratio, 0.546; 95% confidence interval, 0.305-0.979; P = .042), and residual postoperative aortic insufficiency (odds ratio, 4.864; 95% confidence interval, 1.124-21.052; P = .034) as independent risk factors for aortic valve-related reoperation.
The aortic valve-sparing David-I procedure can be performed with very low perioperative morbidity and mortality. The short- and long-term results are excellent. The straight tube graft does not lead to increased leaflet erosion. This procedure is reproducible by multiple surgeons.
我们展示了使用直管型移植物（David - I术式）进行保留瓣膜主动脉根部置换术25年的经验。
1993年至2019年，677例患者（中位年龄56.0岁；范围42 - 65岁）接受了使用直管型移植物的David - I手术。共有24位不同的外科医生进行了这些手术。111例患者（16.4%）患有马凡综合征，71例患者（10.5%）患有二叶式主动脉瓣。544例患者（80.4%）存在主动脉根部瘤，133例患者（19.6%）存在急性主动脉夹层。
57例患者（8.4%）采用了胸骨上段小切口。84例患者（12.4%）进行了额外的瓣叶成形术。同期手术包括冠状动脉旁路移植术（n = 122，18.0%）、二尖瓣手术（n = 34，5%）、近端主动脉弓置换术（n = 125，18.4%）、次全主动脉弓置换术（n = 43，6.4%）和全主动脉弓置换术（n = 102，15.1%）。总体住院死亡率为4.0%（n = 27），围手术期卒中发生在26例患者（3.8%）。术后超声心动图显示，623例患者中有600例（96.3%）主动脉瓣反流小于I°。1年、5年、10年、15年和20年生存率分别为97%、92%、79%、68%和50%。1年、5年、10年、15年和20年免于主动脉瓣相关再次手术的发生率分别为97%、92%、87%、84%和80%。多因素Cox回归分析确定年龄（比值比，0.974；95%置信区间，0.957 - 0.992；P = 0.004）、资深外科医生（比值比，0.546；95%置信区间，0.305 - 0.979；P = 0.042）以及术后残余主动脉瓣反流（比值比，4.864；95%置信区间，1.124 - 21.052；P = 0.034）为主动脉瓣相关再次手术的独立危险因素。
保留主动脉瓣的David - I手术可在非常低的围手术期发病率和死亡率下进行。短期和长期结果都很出色。直管型移植物不会导致瓣叶侵蚀增加。该手术可由多位外科医生重复进行。
