Sugimura S, Watanabe K, Iriyama T, Hattori Y, Negi K, Yamashita M
Department of Thoracic Surgery, Fujita Health University, Aichi, Japan.
Nihon Kyobu Geka Gakkai Zasshi. 1997 Aug;45(8):1147-51.
A 55-year-old man was operated on urgently for aortic valve endocarditis complicated by an annular abscess at the base of the non-coronary leaflet extending down to the left ventricle. Rapidly progressive heart failure and presence of a friable-appearing vegetation on echocardiography were the indications for urgent operation. Preoperative electrocardiogram showed first degree A-V block. At operation the aortic valve was generally thickened with mild calcification about the commissures. Non-coronary cusp was severely deformed and was nearly detached at its base due to annular abscess formation. Native valve was completely excised and the abscess was debrided. A club or a tongue-shaped pedicled aortic wall flap was prepared to the left of the oblique aortotomy incision with its free end to the distal side of the aorta. The flap was folded inward at its pedicle about 1 cm above the non-coronary annulus and was used to patch the abscess cavity. The aortic valve was replaced with a SJM 23 mm aortic valve prosthesis. The remaining defect of the aortic wall was repaired with a patch of woven-dacron vascular prosthesis. Post-operative hemodynamics of the patient was uneventful and he was given a 6-week course of parenteral antibiotics. He developed complete A-V block during the operation, and a permanent pacemaker was implanted on the 6th postoperative day. One year after operation he has not had recurrent infection and is leading a normal life. When used in the repair of ventriculo-aortic discontinuity created by infective endocarditis, the pedicled aortic wall flap has several advantages. It is easily obtainable and can cover abscesses of almost any shape and size. Unlike aortic root homograft, there is no problem of availability. Technically it is relatively simple to prepare a flap, bring it down through the non-coronary sinus and suture over the abscess. Aortic wall has just appropriate thickness and strength to reinforce the weakened periannular area, and if the debrided cavity is deep, the flap can be folded to obtain double thickness. By using this flap, potentially infected cavity is covered and packed by autologous tissue alone, and the synthetic patch to repair the aortic wall defect is placed well away from the site of possible contamination. In addition to the use in infective endocarditis, the aortic wall flap can predictably be used in the repair of aortic annular defect created by over-zealous removal of calcium in the surgery of calcific aortic stenosis, and in intracardiac patching in aortic annular enlargement operation such as Manouguian operation. To our knowledge, the use of pedicled aortic wall flap for aortic annular reconstruction has not been reported in the literature.
一名55岁男性因主动脉瓣心内膜炎合并非冠状动脉瓣叶基部向下延伸至左心室的环形脓肿而紧急接受手术。快速进展的心力衰竭以及超声心动图显示出现易碎的赘生物是紧急手术的指征。术前心电图显示一度房室传导阻滞。手术中，主动脉瓣普遍增厚，瓣叶交界处有轻度钙化。非冠状动脉瓣叶严重变形，由于环形脓肿形成，其基部几乎分离。切除了自体瓣膜并清除了脓肿。在斜行主动脉切口左侧制备了一个棒状或舌状带蒂主动脉壁瓣，其游离端位于主动脉远端。瓣叶在其蒂部于非冠状动脉瓣环上方约1cm处向内折叠，用于修补脓肿腔。用一个23mm的圣犹达主动脉瓣假体替换主动脉瓣。用一块编织涤纶血管假体修补主动脉壁的剩余缺损。患者术后血流动力学平稳，并接受了为期6周的静脉抗生素治疗。他在手术过程中出现了完全性房室传导阻滞，并在术后第6天植入了永久性起搏器。术后一年，他没有发生反复感染，过着正常生活。当用于修复感染性心内膜炎造成的心室-主动脉连续性中断时，带蒂主动脉壁瓣有几个优点。它很容易获得，能覆盖几乎任何形状和大小的脓肿。与主动脉根部同种异体移植不同，不存在可用性问题。从技术上讲，制备一个瓣叶、将其经非冠状动脉窦向下牵拉并缝合在脓肿上方相对简单。主动脉壁具有合适的厚度和强度来加强瓣环周围薄弱区域，如果清创后的腔隙较深，瓣叶可以折叠以获得双层厚度。通过使用这个瓣叶，潜在的感染腔仅由自体组织覆盖和填充，而用于修补主动脉壁缺损的合成补片放置在远离可能污染部位的地方。除了用于感染性心内膜炎外，主动脉壁瓣可预期用于修复钙化性主动脉瓣狭窄手术中因过度清除钙而造成的主动脉瓣环缺损，以及用于主动脉瓣环扩大手术（如马诺吉安手术）中的心脏内修补。据我们所知，文献中尚未报道使用带蒂主动脉壁瓣进行主动脉瓣环重建。
