Yankah A C, Weng Y, Hofmeister J, Alexi-Meskhishvili V, Siniawski H, Lange P E, Hetzer R
German Heart Institute, Berlin, Germany.
J Heart Valve Dis. 1996 Sep;5(5):498-504.
The traditional method of aortic valve replacement with a homograft has been free-hand insertion in the subcoronary position. Recently, total root replacement has become increasingly popular. We present our experiences with both methods in this study.
Between January 1, 1987 and March 31, 1996, 208 patients underwent homograft replacement of the aortic valve (free-hand subcoronary technique, n = 147 and root replacement, n = 61). The age of the patients ranged between 1.5 and 78 years with a mean age of 41 years. There were 55 females and 153 males. Ninety-four patients had infected aortic root (with 47 ring abscesses) and 114 patients had sterile aortic roots. In these series, patients with small aortic root, complicated endocarditis, dilated aortic annulus and aneurysm received aortic root replacement.
The hospital mortality of patients with non-infected and infected roots was 2.6% and 8.5% respectively making an overall hospital mortality of 5.2%. In patients with free-hand subcoronary valve implantation (AVR) and root replacement (ARR) techniques the hospital mortality was 3.4% and 9.8% respectively. The major risk factor for death was New York Heart Association functional class IV with sepsis. Eight years patient survival in patients with AVR and ARR was 95% +/- 2% and 86% +/- 4% respectively. Freedom from structural deterioration in patients with AVR and ARR was 96.5% +/- 2% and 98% +/- 3% whereas freedom from reoperation was identical 94% +/- 2% and 93% +/- 4% respectively. However, the incidence of reoperation in patients under 40 years of age, particularly in children (< 16 years of age) during the eight years' follow up was 27%. The rate of recurrent endocarditis was 3.6% in ARR patients and development of postoperative pseudoaneurysm formation occurred in 1.4% of AVR patients with endocarditis.
In conclusion, ARR technique provides low rate of reoperation in the early postoperative period. Cryopreserved homografts in the subcoronary position in adult patients < 40 years of age showed excellent medium term durability and hemodynamic performance providing evidence that long term outcome with a meticulous subcoronary implantation technique is comparable to that with the ARR technique.
同种异体移植物置换主动脉瓣的传统方法是在冠状动脉下位置徒手植入。近年来，全根部置换越来越普遍。我们在本研究中展示了这两种方法的经验。
1987年1月1日至1996年3月31日期间，208例患者接受了同种异体主动脉瓣置换术（徒手冠状动脉下技术，n = 147；根部置换，n = 61）。患者年龄在1.5岁至78岁之间，平均年龄41岁。其中女性55例，男性153例。94例患者有感染性主动脉根部（47例伴有瓣环脓肿），114例患者为无菌性主动脉根部。在这些病例系列中，主动脉根部较小、合并心内膜炎、主动脉瓣环扩张和动脉瘤的患者接受了主动脉根部置换。
非感染性和感染性根部患者的医院死亡率分别为2.6%和8.5%，总体医院死亡率为5.2%。在徒手冠状动脉下瓣膜置换术（AVR）和根部置换术（ARR）患者中，医院死亡率分别为3.4%和9.8%。死亡的主要危险因素是纽约心脏协会功能分级IV级合并败血症。AVR和ARR患者的8年生存率分别为95%±2%和86%±4%。AVR和ARR患者无结构恶化的比例分别为96.5%±2%和98%±3%，而再次手术率分别为94%±2%和93%±4%。然而，在8年随访期间，40岁以下患者，尤其是儿童（<16岁）的再次手术发生率为27%。ARR患者的复发性心内膜炎发生率为3.6%，患有心内膜炎的AVR患者术后假性动脉瘤形成发生率为1.4%。
总之，ARR技术在术后早期提供了较低的再次手术率。40岁以下成年患者冠状动脉下位置的冷冻保存同种异体移植物显示出优异的中期耐久性和血流动力学性能，这表明精心的冠状动脉下植入技术的长期结果与ARR技术相当。
