Giambuzzi M, Spagnolo S, Dottori V, Parodi E, De Gaetano G
Cardiac Surgery Division, San Martino Hospital, Genoa, Italy.
Eur J Cardiothorac Surg. 1998 Aug;14(2):148-51. doi: 10.1016/s1010-7940(98)00161-4.
Aortic valve incompetence associated with severe aortic ectasia is usually treated by aortic valve and ascending aorta replacement. In cases of isolated aortic ectasia or in Type A aortic dissection the valve is often normal and the incompetence is just due to annular dilatation. Such conditions lead to the application of various valve-sparing surgical techniques, as described by Senning et al., showing the advantages of preservation of the native valve, but the disadvantage of a high technical complexity and a high incidence of recidivation.
We describe a valve-sparing surgical procedure, which has the advantage of a direct and simple approach together with satisfying mid-term results. After the aortic bulb has been fully transected, the excessive wall tissue is resected by two or three triangular excisions just above the valve commissures. Wall excision was indicated in those patients with an aortic diameter exceeding 65 mm at the sino-tubular junction. Tissue excision should not exert tension on to the coronary ostia or excessively reduce aortic diameter. Three external Teflon strips, overriding each other, are placed around the aortic bulb and are included in the direct suture of the edges of the triangular excisions. They are fixed by a running suture over the free border of the bulb. Aortic valve commissures are resuspended when needed. In this way, the aortic bulb, with a competent valve, is wrapped in a prosthetic and inextensible graft. The aortic continuity is then re-established with the interposition of a tubular dacron graft.
From April 1990 to December 1995, 21 patients (mean age 48 years, range 32-70) scheduled for surgery for aortic valve incompetence associated with annuloaortic ectasia were treated with this technique. In one patient the procedure failed to achieve a satisfying valve competence and the valve was replaced. In another case a prolapse of the non-coronary cusp required reoperation with aortic valve replacement, without further complications. At follow-up time (mean 42 months, range 18-78), all patients were well and healthy, with control echoes showing no residual valve incompetence and with invariate bulb diameters at every successive examination.
Our experience shows that this new valve-sparing approach allows safe and persistent correction of aortic valve incompetence and annuloaortic ectasia although longer term follow up is needed.
与严重主动脉扩张相关的主动脉瓣关闭不全通常通过主动脉瓣和升主动脉置换术进行治疗。在孤立性主动脉扩张或A型主动脉夹层的病例中，瓣膜通常正常，关闭不全仅由于瓣环扩张所致。这些情况导致了各种保留瓣膜手术技术的应用，如森宁等人所述，显示了保留天然瓣膜的优点，但存在技术复杂性高和复发率高的缺点。
我们描述了一种保留瓣膜的手术方法，其优点是手术方法直接简单，中期结果令人满意。在主动脉球完全横断后，在瓣膜交界上方通过两到三个三角形切除切除多余的壁组织。对于在窦管交界处主动脉直径超过65mm的患者，应进行壁切除。组织切除不应给冠状动脉口施加张力或过度减小主动脉直径。将三条相互重叠的外部特氟龙条带放置在主动脉球周围，并包含在三角形切除边缘的直接缝合中。它们通过连续缝合固定在球的自由边缘上。必要时重新悬吊主动脉瓣交界。通过这种方式，具有功能正常瓣膜的主动脉球被包裹在假体且不可伸展的移植物中。然后通过插入管状涤纶移植物重建主动脉连续性。
1990年4月至1995年12月，21例（平均年龄48岁，范围32 - 70岁）计划因与瓣周主动脉扩张相关的主动脉瓣关闭不全接受手术的患者采用了该技术治疗。1例患者手术未能实现令人满意的瓣膜功能，进行了瓣膜置换。在另1例病例中，无冠瓣脱垂需要再次手术置换主动脉瓣，无进一步并发症。在随访时（平均42个月，范围18 - 78个月），所有患者情况良好且健康，对照超声心动图显示无残余瓣膜关闭不全，每次连续检查时球直径不变。
我们的经验表明，这种新的保留瓣膜方法能够安全且持久地纠正主动脉瓣关闭不全和瓣周主动脉扩张，尽管需要更长时间的随访。
