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1、大血管外科,1,主动脉根部扩张病变的外科治疗,大血管外科,2,主动脉根部病变的病因,继发于升主动脉瘤的主动脉根部扩张 结缔组织病如Marfan综合征和Ehlers-Danlos综合征：病变可累及主动脉窦、主动脉瓣环以及窦管交界，但瓣叶较少累及。受累部位可导致主动脉根部扩张 主动脉根部、升主动脉夹层 合并有退行性变的老年患者，尤其是合并动脉粥样硬化者 先天性疾病如主动脉瓣二叶化畸形、主动脉瓣上狭窄 其他：如大动脉炎、外伤、感染等,大血管外科,3,主动脉根部解剖结构,大血管外科,4,Ascending aortic replacement with remodeling of the sinotu
2、bular junction Aortic insufficiency can occur in the setting of either isolated ascending aortic aneurysms or due to aortic root aneurysms. Typically these patients are older and have a large ascending aortic aneurysm and aortic insufficiency. The preoperative echocardiogram will demonstrate loss of
3、 STJ definition, minimal dilation of the sinuses and central aortic insufficiency due to lack of cusp coaptation.,大血管外科,5,大血管外科,6,常见的主动脉根部外科治疗方法,Wheat手术 Carbrol手术 Bentall手术 David手术 Ross手术,大血管外科,7,适 应 症,症状 主动脉直径 三叶瓣患者：直径5.5cm 二叶瓣、 Marfan 综合征、Ehlers-Danlos、Turner 综合征或动脉瘤家族史 ：直径5cm 生长速度：0.5cm/年 主动脉瓣关闭不
4、全程度,大血管外科,8,适 应 症,symptoms of congestive heart failure left ventricular dysfunction with an ejection fraction 50% at rest concomitant cardiac or aortic surgery LV end-diastolic dimension of 75mm LV end-systolic dimension of 55mm declining exercise tolerance When operating for a valvular indication o
5、r aortic dissection, concomitant aortic root or ascending replacement is recommended at aortic diameters 4.5cm.,大血管外科,9,Bentall 手术,1969年经典手术：可重复、安全、效果持久 手术的指征：瓣叶形态不对称或瓣叶穿孔造成的严重主动脉瓣反流；主动脉瓣二瓣化畸形，合并有明显狭窄、瓣叶增厚、脱垂或穿孔的升主动脉瘤 需终生抗凝治疗。与抗凝治疗相关的血栓或出血并发症的年发生率在2-4左右 生活质量 妊娠风险,大血管外科,10,Bentall 手术,大血管外科,11,保留瓣膜的主动
6、脉瓣根部置换手术,大血管外科,12,保留瓣膜的主动脉瓣根部置换手术,1992年，David及Feindel发表文章，David I型 1993年，Sarsam与Yacoub提出 “主动脉瓣环成形术” 1995年，David提出了适用于无主动脉瓣环扩张患者的“成形法”，David II型 1996年，David在David II的基础上，利用特氟龙毡条对主动脉瓣环进行了加固，David III型 将原David I术式中所用涤纶管道的直径增加4mm，并增加了对新窦管交界的皱缩操作，David IV型术式 将原David I术式中所用涤纶管道的直径增加8mm，并增加了对新窦管交界和根部的皱缩操作，
7、从而形成一个人造的假瓣窦，David V型,大血管外科,13,适 应 症,Significant calcification of the annulus and cusps are generally considered prohibitive of an AVS operation. Severe free margin thickening has also been demonstrated to limit long term valve durability following AVS operations. Stress fenestrations and free margi
8、n elongation are not contraindications to a valve sparing procedure, and valve repair techniques are often added to an AVS operation.,大血管外科,14,保留瓣膜的主动脉瓣根部置换手术,大血管外科,15,保留瓣膜的主动脉瓣根部置换手术,大血管外科,16,保留瓣膜的主动脉瓣根部置换手术,大血管外科,17,保留瓣膜的主动脉瓣根部置换手术,大血管外科,18,保留瓣膜的主动脉瓣根部置换手术,大血管外科,19,保留瓣膜的主动脉瓣根部置换手术,大血管外科,20,保留瓣膜的主动
9、脉瓣根部置换手术,大血管外科,21,保留瓣膜的主动脉瓣根部置换手术,大血管外科,22,Remodeling or reimplantation,remodeling procedure maintains the independent mobility of the individual sinus segments. Sinus segment mobility is crucial to facilitating changes in aortic root distensibility throughout the cardiac cycle. Root expansion and c
10、ontraction is thought to maximize blood flow through the valve apparatus while minimizing stress and strain on the leaflets. The remodeling procedure fails to stabilize the annulus, which is important in preventing future annular dilatation,大血管外科,23,Remodeling or reimplantation,Remodeling of the aor
11、tic root is ideal for patients with primarily ascending aortic aneurysm and AI with or without aortic sinuses aneurysm, or aortic root aneurysms with normal aortic annulus. Reimplantation of the aortic valve is ideal for patients with primarily aortic root aneurysm because of inherited connective ti
12、ssue disorders such as Marfan syndrome, and familial aneurysms in whom dilation of the aortic annulus is common. A recent collective review of 14 published series totaling 1338 patients concluded that current evidence is in favor of reimplantation rather than remodeling “in pathologies such as Marfa
13、n syndrome, acute type A aortic dissection, and excessive annular dilatation that may impair aortic root integrity.”,大血管外科,24,Remodeling or reimplantation,Most surgeons recommend that patients with annuloaortic ectasia, Marfan syndrome and other connective tissue disorders are best served by a reimp
14、lantation procedure. The remodeling procedure should be reserved for older patients with a normal aortic annulus (25mm woman, 27mm man),大血管外科,25,Bentall or AVS operation,二者的手术指征并不相同：主动脉瓣是否可以保留是选择两类术式的关键之一 两类术式病情严重程度不同：前者的患者常有较为严重的主动脉瓣关闭不全（3+/4+），更容易出现主动脉夹层，更容易以急诊手术的形式出现 由于使用了机械瓣膜，Bentall术后发生血栓事件或出血事件的可能性也会更大，而行保留瓣膜的主动脉根部置换手术的患者如果要再次手术，其原因无一例外的都是因为主动脉瓣关闭不全 由于术者常常倾向于为年轻的患者保留自身瓣膜，因此Bentall手术人群的年龄相比较而言，都会更大一些,