改良Bentall单补片Konno扩大技术治疗主动脉瓣狭窄及人工瓣膜-患者不匹配
Modified-Bentall Single-Patch Konno Enlargement Technique for Aortic Stenosis and Prosthesis-Patient Mismatch.
作者信息
Roselli Eric E, Kramer Benjamin P, Thompson Matthew A, Ngauv Julie, Snyder Abigail M, Hargrave Jennifer, Rodriguez Leonardo, Elgharably Haytham, McCurry Kenneth, Tong Michael Z, Vargo Patrick R, Blackstone Eugene H
机构信息
Aortic Center and Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
出版信息
Ann Thorac Surg. 2025 Jul;120(1):51-59. doi: 10.1016/j.athoracsur.2024.10.033. Epub 2024 Dec 7.
BACKGROUND
Aortic stenosis and prosthesis-patient mismatch complicate surgery for patients with small left ventricular outflow tracts. We present outcomes of a modified-Bentall single-patch Konno enlargement (BeSPoKE) technique for complex left ventricular outflow tract obstruction in adults.
METHODS
The BeSPoKE technique facilitates a true outflow tract enlargement through an anterior septoventriculoplasty, using a single pericardial patch, followed by composite aortic valve-graft root replacement. Postoperative outflow tract geometry and valvular physiology were compared against preoperative measurements using echocardiography and computed tomographic angiography. Clinical outcomes at 2 years were assessed.
RESULTS
From October 2017 to March 2022, 25 adults (median age, 60 years; 84% women) underwent a BeSPoKE repair. Mean preoperative aortic valve gradient was 44 ± 19 mm Hg. Twenty-one patients (84%) had previous aortic valve replacements with prosthesis-patient mismatch; median implant size preoperatively was 19 mm. Postoperatively, all patients received a prosthesis of at least 21 mm, with a median upsizing of 2 (15th-85th percentile, 2-3 sizes). Mean postoperative aortic valve gradient was 8.5 ± 4.1 mm Hg (P < .001). The mean 2-year gradient was 8.3 ± 1.3 mm Hg. All patients with bioprosthetic replacements qualified for future transcatheter valve replacements. Postoperative complications included atrial fibrillation in 9 (36%) and complete heart block requiring pacemaker placement in 8 (32%). There were no operative deaths, and no reoperations were reported. There were 2 late noncardiac-related deaths; 2-year survival was 92%.
CONCLUSIONS
The BeSPoKE technique facilitates larger prosthesis placement, improves hemodynamics, and enables future transcatheter reinterventions. This approach is a safe treatment for complex left ventricular outflow tract obstruction and prosthesis-patient mismatch in adults.
背景
主动脉瓣狭窄和人工瓣膜-患者不匹配使左心室流出道狭小的患者手术复杂化。我们展示了一种改良的Bentall单补片Konno扩大术（BeSPoKE）治疗成人复杂左心室流出道梗阻的效果。
方法
BeSPoKE技术通过前间隔心室成形术，使用单个心包补片，实现真正的流出道扩大，随后进行复合主动脉瓣-移植物根部置换。使用超声心动图和计算机断层血管造影将术后流出道几何形状和瓣膜生理学与术前测量值进行比较。评估2年时的临床结果。
结果
2017年10月至2022年3月，25名成人（中位年龄60岁；84%为女性）接受了BeSPoKE修复术。术前平均主动脉瓣压差为44±19mmHg。21名患者（84%）曾因人工瓣膜-患者不匹配接受过主动脉瓣置换术；术前植入的人工瓣膜中位尺寸为19mm。术后，所有患者均接受了至少21mm的人工瓣膜，中位尺寸增大了2个（第15至85百分位数，2至3个尺寸）。术后平均主动脉瓣压差为8.5±4.1mmHg（P<.001）。平均2年压差为8.3±1.3mmHg。所有接受生物瓣膜置换的患者均符合未来经导管瓣膜置换术的条件。术后并发症包括9例（36%）房颤和8例（32%）需要植入起搏器的完全性心脏传导阻滞。无手术死亡病例，未报告再次手术情况。有2例晚期非心脏相关死亡；2年生存率为92%。
结论
BeSPoKE技术有助于植入更大尺寸的人工瓣膜，改善血流动力学，并为未来的经导管再次干预创造条件。这种方法是治疗成人复杂左心室流出道梗阻和人工瓣膜-患者不匹配的安全治疗方法。
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