课件：大血管外科.ppt

* 由于窦管交界处扩张、瓣环扩张，使得瓣叶间彼此分离。 组织学上表现为囊状中层退化，平滑肌细胞减少，胶原纤维退化。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 瓣叶很少受累 * 根据1994年Kunzelman等学者的研究，如果将主动脉瓣窦中部直径定义为100%，窦管交界处的主动脉直径应为81％，瓣环直径应为97％，窦管交界处直径应比瓣环直径小15％-20％。这一结构会使血液在瓣窦与瓣叶之间形成所谓的DaVinci涡流：收缩期时，该涡流能够防止瓣叶与瓣窦的碰撞；在舒张期时，该涡流有助于启动瓣叶的闭合，同时减少瓣叶受损。因此，在某种意义上，窦管交界的形态要比瓣叶本身的结构还要重要。 主动脉瓣叶的高度大于主动脉瓣环半径，这样三个瓣叶可以有效闭合主动脉瓣口。 主动脉瓣叶为半月瓣。瓣叶基底部分长度是游离缘的1.5倍。瓣叶由三部分组成：基底部、瓣体、对合部（游离缘）。基底部可以在压力作用下反复弯曲而不发生疲劳、受损。瓣体由于瓣叶成分中不同层次的侧滑运动导致有限扩张。游离缘可以保证瓣叶在不同的压力负荷下有效对合。组织病理学研究证实组成瓣叶的增厚胶原束可以将压力传输至主动脉壁。 Isolated ascending aortic aneurysms cause aortic insufficiency due to dilation of the STJ which pulls the commissures apart and prevents valve coaptation during diastole (2). If the remainder of the aortic root components are normal, then a reduction of the STJ diameter will restore valve competence. 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. During the operation, the aorta is transected approximately 5mm distal to the STJ and the cusps are inspected. Often the cusps are small, there is minimal annular dilatation and the ridge of the STJ is unrecognizable. If the aortic insufficiency has been chronic, there may be Aortic Valve Sparing Operations 109 pathologic alterations in the cusps. The two most common alterations are elongation of the free margin or stress fenestrations near the commissures. Free margin elongation results in cusp prolapse, which can be corrected with a plication stitch in the center of cusp free margin at the nodule of Arantii. In the case of extensive stress fenestrations, the free margin is reinforced with a double layer 6-0 polytetrafluoroethylene suture. David and colleagues have shown that both of these adjunctive valve repair techniques are durable methods of achieving long-term valve competence with this op