牛心包单瓣叶置换治疗主动脉瓣返流

147例临床经验

主动脉瓣及主动脉根部

Aortic Valve & Root

A大约55%的主动脉瓣环与纤维组织连接

approximately 55 percent of the circumference of the aortic root is attached to fibrous tissue.

A大约55%的主动脉瓣环与室间隔肌肉组织连接

approximately 45 percent of the circumference is attached to ventricular muscle

瓣叶的解剖
The aortic valve

R瓣叶附着缘的长度是瓣叶游离缘的1.5倍

The length of a normal aortic valve leaflet base is approximately 1.5 times that of the free margin

成人瓣叶的高度大约13到16mm，游离缘28-34mm

the free margin ranges from 28 to 34 mm, average of

32mm,The height ranges from 13 to 16 mm in adults

一般资料
Patients

147 patients

平均年龄

21.3±6.8  years age

(Mean±SD),

（1Y－53Y）

手 术
Operation

Main  procedure主要手术

Aortic valve repair                                      147

CHD_VSD repair   先心修复                            130

Sub-pulmonary     干下 VSD                                     105

Perimembranous  膜周 VSD                                      25

Valve Disease   瓣膜疾病                              17

Concomitants  procedure合并手术

Ruptured sinus Valsalva aneurysm repair               15

Tricuspid valve repair                                  13

Mitral valve repair                                      10

TOF/DORVrepair                                       4

PDA                                                   4

病  理
Etiology

Congenital heart disease 先心          130     88.4%

SBE                                   4       2.7%

Valve Disease          瓣膜病         13      8.8%

病  理
Etiology

右冠瓣叶脱垂Prolapse of right coronary cusp          124        84.3%

无冠瓣叶脱垂Prolapse/rupture of none coronary cusp       15         10.2%

左冠瓣叶脱垂Prolapse of Left coronary cusp        2         1.36%

三个瓣叶脱垂Three cusp lesion             6         4.08%

方  法
METHOD

牛 心 包 瓣 叶 置 换

Bovine pericardial

leaflet replacement

测量瓣叶
Tailored bovine leaflet

切除病变瓣叶
Remove ruptured right leaflet

关闭干下室缺
Close  the SubP VSD

测  量 边 缘
Normal leaflet edge measure

测量高度
The high of normal leaflet measure

裁剪瓣叶
A bovine leaflet

植  入
Prosthetics

检  查
Check it

术前、术后TEE检查
Pre & post operation T E E

AVP录像

TEE

病例二、三

患者、男、31岁，发现心脏杂音5年

超声诊断：

主动脉瓣功能性二瓣化

主动脉瓣脱垂并中度关闭不全

手术方式：

牛心包右冠瓣＋无冠瓣置换成形术（双瓣叶）

患者，男、21岁，发现心脏杂音2年

超声诊断：

  主动脉瓣功能二瓣化

  主动脉瓣脱垂并中度关闭不全

手术方式：

  牛心包单瓣置换成形+自体瓣叶转移修补成形术

患者、女、23岁，发现心脏杂音10年

超声诊断：

  主动脉瓣四瓣化

  主动脉瓣脱垂并重度关闭不全

手术方式：

  自体瓣叶三瓣化成形术

术后随访结果Postoperation remained aortic valve regurgitation & complications during follows up period

无返流 NO-regurgitation                                15           13. 9%

轻度返流Low –grade                                    72          66. 7%

中度返流Moderate                                      20           18.5%

主动脉瓣置换 Aortic valve replacement                     1            0.9%

死亡Death                                              0            0.0%

1例右冠瓣叶置换术后2年因无冠瓣叶继发脱垂加重而行主动脉瓣置换

随访3至49个月Follow-up extended from 3 to 49 momths

讨   论
D I S C U S S

Aortic valve repair

尽管主动脉瓣成形技术复杂、成功率不高，但是其结果是有利于患者的。

In the past few years, aortic valve repair has become an option for patients with many conditions of the aortic valve. Aortic valve repair is performed less often and is more technically difficult than mitral valve repair; however, the leakage  of aortic valves can be repaired with good results.

优  点
Advantages

e主要优点是自然的血流动力学，而且避免了抗凝的困扰

The heart's natural anatomy is preserved and patients do not need to take any blood thinner medications

成形的缺点
Drawbacks

外科技术困难The surgery is technically difficult.

只适用于返流的病例This procedure is not an option for stenotic valves - only leaky aortic valves.

十年随访约20——25%需要瓣膜置换About 20 to 25 percent of patients will require a valve replacement within ten years.

耐久性
Durability after aortic valve repair

不确定Durability after aortic valve repair still remains uncertain.

10年免手术率64%，有7.8%需要再手术治疗The reported 10-year freedom from reoperation rate was 64%, with a reoperation rate of 7.8%.

结   论
Conclusion

TEE

TEE在术前评估和术后检测方面起到只能够要的作用。It helps the surgeon to assess the valve movement preoperation, to assess the need for valve surgery in the operation, to plan the operation

尤其在判断返流的瓣叶和残存的病变确认有利于手术方案的设计。And most important, Can assess the valve function after repair, to identify the valve need to be replaced if there were still have intolerance regurgitation or stenosis

结   论
Conclusion

牛心包瓣叶置换的

不足之处Shortage

• 合并有狭窄的病变，可能涉及多个瓣叶Combined valve stenosis
• 如果其他的正常瓣叶也很薄，耐久性可能受影响Cusp too thin
• 2个或3个瓣叶都有病变More than one cusp diseases 
• 本组有6例约占5.55%术后即刻因仍然存在重度返流而需换瓣手术

本组适用条件

由于一个瓣叶的脱垂导致的瓣膜返流，尤其是右冠瓣

  Lack of coaptation of the leaflets due to   prolapse of one cusp, especially the prolapse of right & none coronary cusp

一个瓣叶的结构毁损

  The damage or destruction of one leaflet

在病变瓣叶无法适用其他成形方法的情况下，我们用裁剪的牛心包制作单瓣叶进行置换。

  The structural modification of the cusps. We  make single valve by bovine pericardial to replace un-repairable leaflet

In this study, aortic regurgitation is produced by

如何提高成功率仍需探索How to reconstruction the aortic valve of aortic regurgitation?

综合多种成形技术甚至包括主动脉根部重建等个体化措施可能是出路之一。Systematically tailored the repair to the individual pathology of cusps and root.

---《Replacement of Right Coronary Leaflet With Bovine Pericardium》

---《ASIAN  CARDIOVASCULAR ＆THORACIC  ANNALS》Number1.Year 2008.

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