Prager R L, Fischer C R, Kong B, Byrne J P, Jones D J, Hance M L, Gago O
Section of Cardiac and Thoracic Surgery, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA.
Ann Thorac Surg. 1997 Sep;64(3):659-63; discussion 663-4. doi: 10.1016/s0003-4975(97)00623-1.
Homograft aortic valve replacement has been performed in 107 patients during the past 7 years. Two primary methods of implantation were used (intraaortic and root replacement). Results of both methods are presented.
Intraaortic implantation (subcoronary or cylinder technique) was performed in 36 patients (mean age, 54 years) for aortic stenosis or regurgitation (31 patients) and endocarditis (5 patients). Aortic root replacement was performed in 71 patients (mean age, 62 years). The majority (58 patients) had complex root pathologies such as ascending aneurysm, dissection, or prosthetic endocarditis with annular destruction. Early results were assessed with intraoperative or predischarge echocardiography; annual echocardiograms provided long-term follow-up. Left ventricular mass was calculated in patients with long-standing pathology for whom preoperative and postoperative data were available.
Early valvular insufficiency was documented in 16 of the 36 intraaortic implants (44%); 9 of these have had progression of the insufficiency. Of the 20 patients who had trivial or no early insufficiency, significant insufficiency has developed in 7 and mild insufficiency has developed in 5. Calculation of left ventricular mass revealed a mean reduction of 11% at 1 year. There has been no mortality, endocarditis, or homograft-related reoperation in the intraaortic group with a mean follow-up of 50 months. The root replacement group had a hospital mortality of 17%. The cardiac pathology was limited to the aortic valve in 12 patients; mortality in this subset was zero. There has been no significant early or late postoperative valvular insufficiency in the 59 surviving patients. More rapid left ventricular mass reduction was seen in this group with a 26% mean reduction within 1 year. A mean follow-up of 32 months in the root replacement group has seen no homograft-related reoperations.
Although the lack of early mortality in the intraaortic group makes this technique appealing, the high incidence of early insufficiency with the realistic expectation of progression has led to our abandonment of the intraaortic technique. Homograft aortic root replacement confers a higher mortality based on the severity of aortic pathology, but offers excellent long-term hemodynamics in any patient. We have expanded our indication for homograft root replacement to include patients with isolated valvular disease rather than reserving it for those patients with extensive root pathology.
在过去7年中，对107例患者实施了同种异体主动脉瓣置换术。采用了两种主要植入方法（主动脉内植入和根部置换）。本文展示了两种方法的结果。
对36例患者（平均年龄54岁）采用主动脉内植入（冠状动脉下或柱状技术）治疗主动脉狭窄或反流（31例患者）以及心内膜炎（5例患者）。对71例患者（平均年龄62岁）实施了主动脉根部置换。大多数患者（58例）患有复杂的根部病变，如升主动脉瘤、夹层或人工瓣膜心内膜炎伴瓣环破坏。通过术中或出院前超声心动图评估早期结果；每年的超声心动图检查提供长期随访。对有长期病变且具备术前和术后数据的患者计算左心室质量。
36例主动脉内植入患者中有16例（44%）记录到早期瓣膜关闭不全；其中9例关闭不全有进展。在20例早期无或仅有轻微关闭不全的患者中，7例出现了明显关闭不全，5例出现了轻度关闭不全。左心室质量计算显示，1年后平均降低11%。主动脉内植入组平均随访50个月，无死亡、心内膜炎或与同种异体移植相关的再次手术。根部置换组的医院死亡率为17%。12例患者的心脏病变仅限于主动脉瓣；该亚组死亡率为零。59例存活患者术后早期或晚期均未出现明显的瓣膜关闭不全。该组左心室质量下降更快，1年内平均下降26%。根部置换组平均随访32个月，未出现与同种异体移植相关的再次手术。
尽管主动脉内植入组早期无死亡率这一特点使其具有吸引力，但早期关闭不全发生率高且预期会进展，导致我们放弃了主动脉内植入技术。基于主动脉病变的严重程度，同种异体主动脉根部置换的死亡率较高，但对任何患者都能提供出色的长期血流动力学效果。我们已扩大同种异体根部置换的适应证，将孤立性瓣膜疾病患者纳入其中，而不是仅将其用于根部病变广泛的患者。
