大血管外科讲义教材.pptVIP

主动脉根部扩张病变的外科治疗 Ascending aortic replacement with remodeling of the sinotubular 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 STJ definition, minimal dilation of the sinuses and central aortic insufficiency due to lack of cusp coaptation. 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 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 主动脉瓣关闭不全程度 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 or aortic dissection, concomitant aortic root or ascending replacement is recommended at aortic diameters ≥4.5cm. 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 Bentall 手术 保留瓣膜的主动脉瓣根部置换手术 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，从而形成一个人造的假瓣窦，David V型 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 margin elongation are not contraindications to a valve sparing procedure, and valve repair techniques are often added to an AVS operation. 保留瓣膜的主动脉瓣根部置