Milano A, Pratali S, De Carlo M, Borzoni G, Tartarini G, Bortolotti U
Department of Cardiac Surgery, University of Pisa Medical School, Italy.
J Heart Valve Dis. 1998 Jan;7(1):75-80.
The surgical management of patients with aortic valve disease associated with ascending aortic dilatation is a controversial issue. Structural abnormalities of the aortic wall predispose to further aortic enlargement and possibly to ascending aortic dissection (AAD). Indications to concomitant replacement of aortic valve and ascending aorta have not yet been clearly defined.
We reviewed eight consecutive patients (seven males and one female) among 2202 patients who underwent aortic valve replacement (AVR) between 1982 and 1996. These eight were subsequently reoperated on because of AAD, between November 1987 and November 1996. Indications for initial AVR were aortic regurgitation due to annular ectasia in five patients, combined aortic stenosis and regurgitation in two, and isolated aortic stenosis in one patient.
The interval between AVR and AAD ranged from four months to 10.5 years. Five patients presented with acute AAD, and three with chronic AAD. Retrospectively, four patients showed progressive increase in ascending aortic diameter after AVR, with a mean diameter of 72+/-9 mm at reoperation. Histological examination showed cystic medial necrosis in three patients, atherosclerotic degeneration in one patient, and normal aortic wall structure in one. There was one operative death due to low cardiac output; the hospital mortality rate was 13%. There were no late deaths and no major adverse events during a mean follow up of 5+/-3 years (range: 8 months to 10 years).
In patients with ascending aortic dilatation (> or = 55 mm diameter), AVR alone may not prevent progression of aortic root enlargement. In these patients, the ascending aorta should be concomitantly replaced. Following AVR, all patients with mildly or moderately dilated aortic root should be periodically controlled to detect signs of progression of aortic dilatation.
主动脉瓣疾病合并升主动脉扩张患者的外科治疗是一个存在争议的问题。主动脉壁的结构异常易导致主动脉进一步扩张，并可能引发升主动脉夹层（AAD）。主动脉瓣和升主动脉同期置换的指征尚未明确界定。
我们回顾了1982年至1996年间接受主动脉瓣置换术（AVR）的2202例患者中的连续8例患者（7例男性和1例女性）。这8例患者在1987年11月至1996年11月期间因AAD而再次接受手术。初次AVR的指征为：5例患者因瓣环扩张导致主动脉反流，2例患者合并主动脉瓣狭窄和反流，1例患者为单纯主动脉瓣狭窄。
AVR与AAD之间的间隔时间为4个月至10.5年。5例患者表现为急性AAD，3例患者表现为慢性AAD。回顾性分析显示，4例患者在AVR后升主动脉直径逐渐增加，再次手术时平均直径为72±9mm。组织学检查显示，3例患者为囊性中层坏死，1例患者为动脉粥样硬化退变，1例患者主动脉壁结构正常。1例患者因低心排血量死亡；医院死亡率为13%。在平均5±3年（范围：8个月至10年）的随访期间，无晚期死亡病例，也无重大不良事件发生。
对于升主动脉扩张（直径≥55mm）的患者，单纯AVR可能无法预防主动脉根部扩张的进展。对于这些患者，应同期置换升主动脉。AVR后，所有主动脉根部轻度或中度扩张的患者均应定期进行检查，以发现主动脉扩张进展的迹象。
