Knott-Craig C J, Elkins R C, Stelzer P L, Randolph J D, McCue C, Wright P A, Lane M M
Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190.
Ann Thorac Surg. 1994 Jun;57(6):1501-5; discussion 1505-6. doi: 10.1016/0003-4975(94)90109-0.
Homograft replacement of the aortic valve has inherent advantages for the patient in terms of decreased incidence of thromboembolism, endocarditis, and anticoagulation-related complications. Limitations in its use stem from a significant incidence of postoperative aortic regurgitation, related to difficulty with consistent commissural and sinotubular geometry when inserted in the subcoronary position. To minimize this complication, we used a homograft as a functional unit in 71 patients between 1986 and May 1993, either as a root replacement (n = 58) or as an intraaortic inclusion cylinder (n = 13). There were 4 pulmonary and 67 aortic homografts. Mean age of the 16 female and 55 male patients was 42 +/- 19 years (range, 0.6 to 84 years). Thirty patients had predominantly aortic regurgitation, 19 aortic stenosis, 18 mixed aortic valve disease, and 4 primary aneurysmal disease. Eighteen (25.4%) had infective endocarditis. Thirty-five patients (49%) had a previous operation on the aortic valve. Hospital mortality was 14.1% (10/71), 0% for inclusion cylinders and 17.2% (10/58) for root replacements (p = not significant). Recent follow-up was obtained in all hospital survivors. Mean follow-up period was 35 months (range, 1 to 81 months). There were six late deaths, 1/13 for inclusion cylinders and 5/48 for root replacements. Actuarial survival at 5 years was 74.9% +/- 5.6%. Reoperation was required in 3 patients (all with root replacements), 1 for postoperative endocarditis, 1 for left coronary ostial obstruction, and 1 for late onset of aortic dilatation and regurgitation (pulmonary homograft used as a root replacement). Two patients currently have asymptomatic greater than 2/4 aortic regurgitation. Freedom from significant aortic regurgitation was 88% +/- 7% at 6-year follow-up. More consistent maintenance of the sinotubular and commissural geometry of the aortic homograft may be achieved with the root replacement or the inclusion cylinder techniques. This may reduce the incidence of postoperative aortic regurgitation and further benefit the patient by reducing the need for reoperation in the future.
就降低血栓栓塞、心内膜炎及抗凝相关并发症的发生率而言，主动脉瓣同种异体移植对患者具有内在优势。其应用的局限性源于术后主动脉瓣反流的发生率较高，这与在冠状动脉下位置植入时难以保持一致的瓣叶交界和窦管交界几何形态有关。为尽量减少这一并发症，我们在1986年至1993年5月期间，将同种异体移植物作为一个功能单元应用于71例患者，其中58例进行根部置换，13例进行主动脉内植入柱置换。使用了4个肺动脉和67个主动脉同种异体移植物。16例女性和55例男性患者的平均年龄为42±19岁（范围0.6至84岁）。30例主要为主动脉瓣反流，19例为主动脉瓣狭窄，18例为混合性主动脉瓣疾病，4例为原发性动脉瘤疾病。18例（25.4%）有感染性心内膜炎。35例患者（49%）曾接受过主动脉瓣手术。医院死亡率为14.1%（10/71），植入柱置换患者死亡率为0%，根部置换患者死亡率为17.2%（10/58）（p值无显著性差异）。所有住院幸存者均获得了近期随访。平均随访期为35个月（范围1至81个月）。有6例晚期死亡，植入柱置换患者1/13，根部置换患者5/48。5年精算生存率为74.9%±5.6%。3例患者（均为根部置换）需要再次手术，1例因术后心内膜炎，1例因左冠状动脉开口梗阻，1例因晚期主动脉扩张和反流（肺动脉同种异体移植物用于根部置换）。2例患者目前有大于2/4级的无症状主动脉瓣反流。6年随访时无明显主动脉瓣反流的患者比例为88%±7%。采用根部置换或植入柱置换技术，可能更一致地维持主动脉同种异体移植物的窦管交界和瓣叶交界几何形态。这可能会降低术后主动脉瓣反流的发生率，并通过减少未来再次手术的需求进一步使患者受益。
