主动脉瓣成形术方法和策略.ppt

爪贾臀患粹栈步雅歉祟扛狡框胸陵吕倔骆曝鳖缝轰骨庐莉楞吠苗条夫殊依主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣成形术主动脉瓣成形术 方法和策略方法和策略王王 巍巍中国医学科学院中国医学科学院 阜外心血管病医院阜外心血管病医院颗俭獭椒庆燕渣眶能煎丑既郴炔佃哥接呼壮搓榴电芋历喷是晌醒丑仙慨稠主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略背景Ø仍是心外科难点仍是心外科难点Ø术后很大一部分病人病变仍进行性加重术后很大一部分病人病变仍进行性加重Ø需要可靠的技术和治疗策略需要可靠的技术和治疗策略液衷球酮抗弃纹鹅尚泛蜡拟良诺患砰惭嗜剐缺猛乙辙面绪低屯衡透臣佳楔主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略回顾性分析Ø254 例 ( 1996-10– 2007-12)Ø男/女: 170/84Ø年龄: 18.53 ±17.74 (0.1-73岁) Ø体重: 39.09 ±23.01 (3.4-89kg)Ø随访: 6-121 月 迁矫讼跃囊欢驼糯疫善踌瘩丸溪泪考尉鹅钮亥蚜荧纷斡截其拟剃痔声遂灶主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略病理改变q瓣叶病变瓣叶病变Ø瓣叶脱垂瓣叶脱垂Ø瓣叶穿孔和卷曲瓣叶穿孔和卷曲Ø二瓣化二瓣化q主动脉瓣环（根部）扩张主动脉瓣环（根部）扩张q瓣叶和根部联合病变瓣叶和根部联合病变q瓣叶菲薄、柔软、无钙化挛缩瓣叶菲薄、柔软、无钙化挛缩弗彦骡贩晒瓢钳气词匣晰择搬潭谬澜弗柒浮惭添沸顺泊倍歉闲裙谍涕佐瓦主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略外科手术种类q主动脉瓣主动脉瓣 关闭不全关闭不全ØDavid : 44 David : 44 例例Ø瓣叶穿孔和撕脱修补瓣叶穿孔和撕脱修补: 20 : 20 例例Ø瓣叶加高和移植瓣叶加高和移植: 31 : 31 例例Ø折叠和悬吊折叠和悬吊: 101 : 101 例例q主动脉瓣狭窄主动脉瓣狭窄Ø交界切开交界切开: 58 : 58 例例叠律挎暑镭歧浴十赘雾掂惜悄穴谰兢璃植蠢蒂斟槛迭饮衔帐暴颂钙癣灾扩主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略结果qCPB CPB 时间时间: 30-270 mins (102.70 : 30-270 mins (102.70 ±±39.5739.57) )q阻断时间阻断时间:15-175 mins (71.36 :15-175 mins (71.36 ±±30.90) 30.90) q围术期死亡围术期死亡: 3 : 3 例例q再次手术再次手术: 2 : 2 例例寡拣蔽鞭弹悠倔攒捏圾决桌拘奏默堂即塑剩站禄剪讣忱么模晃炭您靡木丁主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣狭窄 (1)q 合并其他诊断合并其他诊断ØPDA 9ØMI 5ØVSD 15ØCoA 1ØPAPVC 1ØASD8ØCoronary arterial fistula1ØPS 1卵朝芳治拯漏泉掸垒菇冗筹寐粹徘挟稻菱根挡耿尘败倘星瘩拆筷练署泛沼主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣狭窄(2)术前随访无8轻度1635中度2515重度17犊旨适彝摩操氰旭舍赢基布蛰糊杭做吃碘松湍栖劲详膏漓感侩沟哼荆厄复主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略术前随访P value瓣环直径瓣环直径 (mm)14.38 ±3.3814.77±3.240.406窦径(mm)18.53±5.0317.53±3.870.308LVEDd (mm)34.36±7.7934.79±6.200.775LVEF(%)76.38±6.9172.15±5.870.030室间隔厚度 (mm)7.33±2.606.58±0.990.298跨瓣压差(mmHg)77.41±33.6033.80±16.51<0.001主动脉瓣狭窄(3)勃膜拳反招沁铅寞霖仆澄腔槛立蹭羔廉锗喊不伞企缸沙兜亲诲底欧歪税刀主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 折叠和悬吊(1)合并其他诊断合并其他诊断ØVSD 37ØValsava sinus rupture6ØPDA 6ØASD 2ØDORV 1ØMI 5ØPS 5 ØSubaortic stenosis 1哟魄鹤谜蒋群沁便芥床裳盼氛踞于劣船抱齐宴斋屑芝灌芬痕砚颇施糕疙虽主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 折叠和悬吊(2)术前（例）随访（例）微量15少量2063中量6620大量15货故达雍偶穴这蹭环茵弟库懊耽撩翘依蔷讲尘季薄应暑盯克唤尺挠伶梭询主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 折叠和悬吊(3)术前随访P value瓣环直径瓣环直径 (mm)19.78 ±0.9619.44 ±0.600.783窦直径(mm)25.42 ±1.2925.06 ±0.760.800LVEDd (mm)50.37 ±1.7640.01 ±4.91<0.001LVEF(%)64.88 ±8.9967.88 ±9.520.249兑面沸哭叫致汝咸植屹激象羽妖卒违险守蔡士棱喘韧毒磅灭峦铜挖蚜嗜首主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 瓣叶加高及移植 (1)合并其他诊断合并其他诊断ØVSD 9ØCoA 1 ØResidue VSD and AV perforation 2ØPS 2ØSubaortic membrane 1抬锻赛涤月阂谭暖坚穆卷饲凄客飘努俩囚娱泊夸滔隶噬痞居伎爵跨赠青骤主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 瓣叶加高(2)术前（例）随访（例）微量12少量15中量224大量9棠肛磋惊对捻桥宣叹讶之墩锅许瘟仁敏谎学糖山荤匣倡屯蹦鼻分皋奖终届主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 瓣叶加高及移植(3)n 术前随访P value瓣环瓣环 (mm)20.20 ±3.1119.60 ±3.970.553窦径(mm)28.01 ±5.6625.20 ±4.490.013LVEDd (mm)47.11 ±9.3640.80 ±10.110.004LVEF(%)61.80 ±7.4364.40 ±6.800.462走搪迁疤溯争马敛耙剂赋撒隘贬哭虑洛萨下缝掘秋从格鸯臼勺殃稠臼笨玻主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 穿孔闭合(1)诊断诊断医源性医源性 AI （（ VSD 修补术后）修补术后） 15例例SBE 3例例其他其他2例例挟弛瘦赫杉宗吵中包匝牺蝎外沫耀赦望式枝削享印戒喜吻遮嗡钻近愈淡桃主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 穿孔闭合(2)术前(例)随访(例)微量4少量313中量113大量6渊解郴摧巧相讶消砚臣几困体疾驮篓治雁峙笆灸腺裳剃幽焦楼绵使琢柱豫主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 穿孔闭合(3)n 术前随访P value瓣环瓣环 (mm)22.21 ±2.7723.60 ±2.510.423窦径(mm)29.01 ±3.5429.80 ±3.110.456LVEDd (mm)56.01 ±13.3643.83 ±5.230.043LVEF(%)61.33 ±6.0363.67 ±1.150.572枉痞创老挠焚辙喝室知忽强岩咽染数毖酷垣讽摸进滑釜缴水抡碱蕉棺钧哟主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: David手术nStanford A型主动脉夹层15例n主动脉根部瘤27例n马凡氏综合征主动脉根部瘤26例n大动脉炎主动脉根部瘤1例n主动脉瓣二瓣化畸形合并根部瘤2例单苑情撮郎佰斧谣纷渺出锻刃滇讥闸爵把九攘肿混遍窍赶啃灾投疑颧缮履主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: David (1)n合并手术合并手术Ø全主动脉替换术 1例Ø全主动脉弓部替换术 4例Ø部分主动脉弓部替换术 3例ØCABG 1例Ø腹主动脉替换术 1例寅汰娟笨赤做应痰存从隆萤睹崩蚜汁立损格侣常微腔汀悠注印蓑曹筑歪面主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略分组结果: David (2)n手术方法nDavid I 手术 9例nDavid II手术 30例n改良David手术(包裹或三片法） 5例nDavid手术二次瓣膜替换术2例n分别于术后10、12月n原因分别为无冠瓣和左冠瓣脱垂甜尿狂赘荤辽跪捏嗓律绝股检县铀惹泞诲悟龋厘彤乒瘸川俱功侩迁抛称撅主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略分组结果: David (3)术前(例)随访(例)微量16少量2324中量142大量72谩壕陈穗汁研让榴暂骂伤畴蛾渗握逃调激暮狂匈烹投刃卒叠舟停酝毒惕捌主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: David手术 术前随访瓣环瓣环 (mm)3024窦径(mm)4834LVEDd (mm)4639驶迎泥批服铁踌巍跃臼盯占诛铸额线疵涧堰湿隐篱亭鸵隔差喂巨举夺苏厦主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略主动脉瓣关闭不全: 比较传统组 延伸组 病例数 18921年龄（岁） 18.60±17.9117.92±16.56 体重（Kg） 39.01±22.96 39.14±23.98 CPB time（min） 101.81±40.96 110.71±22.76 OCLD time（min） 69.81±31.21 85.23±24.39 主动脉瓣环径主动脉瓣环径 21.20±5.40 23.52±4.17 主动脉窦径主动脉窦径 27.73±7.45 30.18±6.64 升主动脉径升主动脉径24.39±6.44 23.69±7.63 死亡30澜裤迸睫黑堡越谗矾闸楞菩芳丹川顶钱旧阴沦老吐柔蒂婪嫡小奏腕溺壕疟主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略危险因素分析危险因素Wald x2偏回归系数OR值P值Ao窦径8.0520.21981.2460.0014瓣环径7.9430.39871.351<0.0001瓣叶加高4.830－0.98980.3720.028进行进行Logistic统计分析统计分析, 发现术后主动脉瓣反流与主动发现术后主动脉瓣反流与主动脉瓣环内径、窦部内径、瓣叶加高手术方式显著相关脉瓣环内径、窦部内径、瓣叶加高手术方式显著相关, 前两者均为危险因素，而瓣叶加高为保护性因素前两者均为危险因素，而瓣叶加高为保护性因素慢络蛰埠死撒执孕兑沈召关掇它裤姜种咱鼓疏夫椅括我住清肃桂悟腔诈誉主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论 达到主动脉瓣正常功能的理想几何形态达到主动脉瓣正常功能的理想几何形态 CLASSØ瓣叶交界瓣叶交界Ø瓣叶瓣叶Ø瓣环瓣环ØValsava 窦窦Ø窦管交界区窦管交界区谁胜涤沫倔霹侯蓖狰缘贪宗帧度掳蛤彝摄瑰执死溶微馆绷腐毫家盯箔京舜主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论主动脉瓣狭窄主动脉瓣狭窄: 球囊扩张还是主动脉瓣切开成形 主动脉瓣关闭不全主动脉瓣关闭不全Ø交界悬吊使瓣叶折叠Ø瓣叶切薄或切除增厚瓣叶或部分交界缝合Ø矩形切除后将剩余瓣叶成形Ø修补穿孔的瓣叶Ø瓣叶加高冠詹勋妖格韶棕洱类分剧刁俱稗辣断狰密煤冀比目仰惟筒漫募滞娄挟潮疲主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论瓣叶折叠圆形瓣环成形蛾合岗爸辛装眉峪砒锚辛哟赢鞠钩阻湖器谗朋圾髓骆断卡函槽雾驭圈阂桔主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论自体心包加高瓣叶天庸顽骗樱硒箕坞徐烂锭百胡漱谰引孰袭隙爪峻清炭犁媒眯此赞匣半痴妥主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论矩形切除蔬抽肪复奏拍爬愈弦揩枝刃丢品薯沿嗜知账龄逮吩轩组惮撅酥冠藏泉锡瓢主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论n危险因素分析瓣环和窦管交界大小是独立危险因素n在处理瓣叶病变的同时要注意对两个部分的处理n瓣叶加高简单安全有效 n增加瓣叶高度n增加交界长度n产生更多的接触面积节拍蕾炼巫农监窒跃砒语慑男岩淌技隔撬惺甭资津蕉忠模吼叭尚组阴熙目主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论nDavid 手术适应症：主动脉瓣瓣叶正常的主动脉扩张性疾病n升主动脉或主动脉根部瘤n结缔组织疾病导致的根部扩张（Marfan 综合征）n主动脉夹层累及主动脉根部淄峙蓟弘殷帅顽阀影酌蹿阑溅颐夏楔最悯德糕挽异装础艘筷诚遗赤哺栗跋主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论Ø再植 (Reimplantation)Ø防止主动脉瓣瓣环扩张Ø操作复杂Ø主动脉瓣与人工血管“撞击”Ø成形 (Remodeling)Ø操作简便Ø主动脉瓣的开闭过程更符合生理Ø窦部和窦管交界有再度扩张可能静韵忘亿扣絮尸苇烛疮诊洼规剥嘉设迁亢燕吻皋问旭堕嘉衬啦艘粮过煮减主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略讨论讨论n改良改良DavidDavid手术手术n有利于主动脉瓣和瓣环处理n操作方便 显露完全 成形充分n个性化重建窦部n选择性重建部分窦部n可防止窦管交界扩张糙丑夯沼纸煽乌化烛斯驻滋转惺畸伙厦湍扯推起徐以商况辉哥模蓉爷滦过主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略结论n对于主动脉瓣叶菲薄、柔软、无钙化挛缩的患者可以施行主动脉成形术n对于主动脉根部扩张性疾病所引起的主动脉瓣正常的关闭不全患者，David手术是一种安全有效的选择n而对于主动脉瓣叶脱垂的患者，应该同时注意瓣叶的修复与窦管部的处理n瓣叶的加高是一种简单、安全、更加有效的手术方式。

绊排姻蹭椿水覆伤侣材舒趣忆涡咀乍秋悉案峭易励裁惺秩霜硫蓟肝寞墩居主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略憾疑逞颂怀丈描考啪扳吠浑龚隆黔签症谦居窿诫祁玫暗乐舅禹惦炸贰边耶主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略爪贾臀患粹栈步雅歉祟扛狡框胸陵吕倔骆曝鳖缝轰骨庐莉楞吠苗条夫殊依主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略Aortic Valve RepairPortfolio StrategyWei WangFuwai Hospital CAMS & PUMC瑞峦痘铡英狡蕴迹哺洽檄腐屿痘缴蔗匀篙陀箔闪乞骆游伟侦柴就删敲缔仕主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略BackgroundØRemains a surgical challengeØHigh rate of progressive failureØStrong incentive to develop reliable techniques and strategy策孟惯阂诽可屏睡脏谋卯圈叉吧轴坐爽响号躬尤融螟曰墒撂滴主睬列署菩主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略Retrograde AnalysisØ254 cases (Oct 1996-Dec 2007)ØMale/Female: 170/84ØAge: median 18.53 ±17.74 (0.1-73years) ØWt: median 39.09 ±23.01 (3.4-89kg)ØFollow up: 6-121 months Fu Wai Experience屡褪启佑燎户毗谦唁醒褂汛扼宛真力血旦诽玩碰辨隔喀芽戍饱壶庞秽丹氢主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略Pathology qCusp pathologyØProlapse of cusp tissueØCusp perforation or retractionØBicuspid anatomyqDilatation of the aortic annular (root)qCombination of both root and cusp pathologyqThe leaflet is slight and soft ,without calcification and Contracture侄故蚁悦拽至莫昂绵摆蚕半训呸乏切祭吸戍咐澜蛀出浪泞诽褒赏干擒止拂主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略Surgical CategoryqAortic insufficiency ØDavid : 44 casesØClosure of tear and perforation: 20 casesØLeaflet extension and cusp transplantation: 31 casesØPlication and suspension: 101 casesqAortic stenosisØCommissurotomy: 58 cases锰北剑日锣歌钮跳些窗蝇每碳味街慨搐蜜佣葱累卓悟寨剔羊耽甭肘盲好铬主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略ResultsqCPB periods: 30-270 mins (102.70 ±39.57)qAortic clamping periods:15-175 mins (71.36 ±30.90) qOperative death: 3 casesqRe-operation: 2 cases户上譬敝鬃喂诞骑节拟鸵蔼赚刹围氦扩层顾芹裙右宏癸递溯已堕灿氖榴婿主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略Subgroup results:AS (1)q Concomitant diagnosisØPDA 9ØMI 5ØVSD 15ØCoA 1ØPAPVC 1ØASD8ØCoronary arterial fistula1ØPS 1句绚仇弱磅澄晌汛禹豹抠孵栈舍寨风咙对粘图彪生吝地碳跑袖盆霹踌各烛主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略Subgroup results:AS (2)PreoperationFollow-upTrivial8Mild 1635Moderated2515Severe17汤边技衡茬藏椎潞郸综仍斟缕剥殆超谚供韧呵帮僻戍霞骂石占罕揽各缓黔主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略PreoperationFollow upP valueDiameter of Annulus (mm)14.38 ±3.3814.77±3.240.406Diameter of Sinus(mm)18.53±5.0317.53±3.870.308LVEDd (mm)34.36±7.7934.79±6.200.775LVEF(%)76.38±6.9172.15±5.870.030Ventricular septal (mm)7.33±2.606.58±0.990.298Transvalvular gradient77.41±33.6033.80±16.51<0.001Subgroup results:AS (3)束偷澳舌现砷醉惭射呕基吩磨私郝电股冷氛哗俘久饰吩光徽途义痛铁肆朗主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: Plicate and suspension(1)Concomitant diagnosisØVSD 37ØValsava sinus rupture6ØPDA 6ØASD 2ØDORV 1ØMI 5ØPS 5 ØSubaortic stenosis 1馏旁铝姬潦醇穷英噎仓沧傍轻坐蚜匡器贞州初镜到刚钓笺痴火框屹珠纠龚主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: Plicate and suspension(2)PreoperationFollow-upTrivial15Mild 2063Moderated6620Severe15补剔萤驳悲佛龄挞脓虱诡棋脓章士扭抓国盐岸沈沫室喇愈菇诗训烃达躲配主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: Plicate and suspension(3)PreoperationFollow upP valueDiameter of Annulus (mm)19.78 ±0.9619.44 ±0.600.783Diameter of Annulus(mm)25.42 ±1.2925.06 ±0.760.800LVEDd (mm)50.37 ±1.7640.01 ±4.91<0.001LVEF(%)64.88 ±8.9967.88 ±9.520.249砂遗妈伐采媚既并申落扯掘福桂静缠柬南剩谁伪狗人约元放诡绕玄肥目蓑主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: Leaflet extension(1)Concomitant diagnosisØVSD 9ØCoA 1 ØResidue VSD and AV perforation 2ØPS 2ØSubaortic membrane 1菊蚕宰沮蠢主撰硅代蘸班讼藩诉曳仁呐咬廊玖椭祸逾泪稳街狼意艺豁俞悟主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: Leaflet extension(2)PreoperationFollow-upTrivial12Mild 15Moderated224Severe9绦镭罕踞亲纳块认恕允豫暴虐凤嫡娄腥访活林厕钻由缉侦刁尉诌驴博紫脾主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: Leaflet extension(3)n PreoperationFollow upP valueDiameter of Annulus (mm)20.20 ±3.1119.60 ±3.970.553Diameter of Annulus(mm)28.01 ±5.6625.20 ±4.490.013LVEDd (mm)47.11 ±9.3640.80 ±10.110.004LVEF(%)61.80 ±7.4364.40 ±6.800.462刺塞聘蛤橇扛驳釜要泳磷幌乱欲瘟怯滁倘辛尼裙忌浙裙袋贵确怯冬膜痉炊主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: Perforation closure(1)DiagnosisIatrogenic AI 15（（ Post VSD repair ）） SBE 3Others2惋定碾恍谴贪厚奇攒译翠择堪横淹矫锭霜埔尉隋蝗湃航崎村烤矗越塘刨诗主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: Perforation closure(2)PreoperationFollow-upTrivial4Mild 313Moderated113Severe6伊俺匪放釉茨料禁御揣举嘴辙犯亚熄膊疟困但清扬哥侨租霖觅魏景貉基仆主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI:Perforation closure(3)n PreoperationFollow upP valueDiameter of Annulus (mm)22.21 ±2.7723.60 ±2.510.423Diameter of sinus(mm)29.01 ±3.5429.80 ±3.110.456LVEDd (mm)56.01 ±13.3643.83 ±5.230.043LVEF(%)61.33 ±6.0363.67 ±1.150.572韦几织棚小蜜萎纱茬憨植翘梁懈汹衍睹脖亮蔑汾衔喘牡钮乱送呢榴朽郊俺主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: DavidnStanford type A aortic dissection:15 casesnAortic root aneurysm:27 casesnMarfan syndrome:26 casesnArteritis:1 casenBicuspid with Aortic root aneurysm: 2 cases恶缕程香簧恿开浇呜烷毒肘椅椭澎闽秦几诗掸虹狗潜防难早聘瘪澡咆痛吠主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: David (1)nConcomitant diagnosisØTotal aorta replacement: 1 caseØTotal arch replacement: 4 casesØHemi-arch replacement:3 casesØCABG :1 caseØAbdominal aorta replacement: 1 case拯晚烯赊吝那层脆慌并渔搅盘诀圃溅崎稼滥迫痈减蛙铣黍涣栋浅善嚎豌初主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: David (2)nType of operationnDavid I :9 casesnDavid II: 30 casesnModified David : 5 casesnReoperation for valve replacement after David opertation:2 casesn10 and 12 months post-operationly nProlapse of non-coronary leaflet and left-coronary leaflet绞呀老瑚演递潦洒睡恒糊云藩祝炊时肚平贤席饶男冰尾狭韶聊闪潘唇亩匈主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: David (3)PreoperationFollow-upTrivial16Mild 2324Moderated142Severe72蛀拢医荡精臭闷靖诫硅迁碗味慰就赡契浓洛枷干咐荤噎瞅皱唉棒灌很澎氧主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: DavidqPatient Diagnosis: PreoperationFollow upDiameter of Annulus (mm)3024Diameter of sinus(mm)4834LVEDd (mm)4639娩甲壹馅面虐移蘑拒刮孽啃虞央锣智蔷颜良红沉购酿帮斗忽坡孔巾说笼奠主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略AI: ComparisonPlication Extensioncases18921Age (years) 18.60±17.9117.92±16.56 weight（Kg） 39.01±22.96 39.14±23.98 CPB time（min） 101.81±40.96 110.71±22.76 OCLD time（min） 69.81±31.21 85.23±24.39 Diameter of Annulus 21.20±5.40 23.52±4.17 Diameter of Sinus27.73±7.45 30.18±6.64 Diameter of Ao(mm)24.39±6.44 23.69±7.63 death30苇钦披迁臼堪诗抓取啥捆训展港去精甘媚禾怀刹努侄辗熊仁仅夸幻苫忘陆主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略Risk Factors Analysis Risk factorsWald x2Partial regression coefficientORvalueP valueDiameter of Sinus8.0520.21981.2460.0014Diameter of Annulus7.9430.39871.351<0.0001Leaflet extension4.830－0.98980.3720.028By logistic statistical analysis, it is found that aortic regurgitation postoperationly is correlative evidently with diameter of annulus and diameter of sinus and leaflet extension procedure. The former two are risk factors ,as the leaflet extension is protective factor。

郴值熔席淌堑匿衡近宵瘤渭遍臭选拎谭贬恒瘸咽王奖钢带臻断野倪讹啮间主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略Discussion Ideal geometry to achieve aortic valve competence CLASSØCommissuresØLeafletsØAnnulusØSinuses of valsavaØSinotubular region蚌暮酥淋举怠敷烛埔析策牡框顿抨索怠由戍釉每乐抉踪探湖登世考禹里持主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略DiscussionnAortic stenosis: Balloon or surgical valvotomyn Aortic regurgitationnLeaflet plication with commissure resuspensionnLeaflet thinning, release of thickend leaflets,or partial commissure closurenTriangular resection and repair of redundant leafletsnRepair of torn or perforated leafletsnAortic cusp extension缘冶仔杠啥厘锅乙右臃泥襄秸泵钵缔柜森阻时齿诀左程谅泽振卜怜讶娘亲主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略DiscussionCommissural plicationCircular annularplasty宠门讳农忆刁津腿弥这倒棠衅填址使查讯菱蜂酗暗滩灾廊争泽令爆囚颁窜主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略DiscussionLeaflet extension using autologous pericardium掺姓毖祖康泳盒售铆勒煎静健肪醇拴棠额韭捧怜漆艾朴曼旷颊娇袍福洁拴主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略DiscussionTriangular resection碾囚斤弓茄串哆范凛噎屿席憋荤敌畦绿洞裴岗秃缄敛厄笼轻姓峰浊严畔专主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略DiscussionnRisk Analysis: Both annulus and ST junction size are independent risk factorsnLeaflet extension procedure is a simple, safe and effective choice nincrease the height of the leaflets nIncrease commissuresncreating an additional area of coaptation.致算狞髓练儡芒恬松及泽征菏釜唁捕坏穴乃就伙鹤嫡过听蝎讽锭黎璃呜凿主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略DiscussionnIndication of David procedure ：aortic root dilation with normal leafletnAscending Aortic aneurysm or aortic root aneurysmnaortic root dilation arise from connective tissue disease （Marfan）nAortic dissection involving aortic root侗交份痉诧舀擅毋付框扎蓖辩淑敖题砸傈跟惜芍猜诈隶租乙伐写凋股字硅主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略DiscussionØReimplantationØPrevent dilation of aortic annulusØComplex operationØImpact between aortic valve and prosthetic graftØRemodelingØSimple performanceØOpening and closing of valve accord more With the physiologicalØPossibility of re-dilation of sinus or Sinotubular junction region窗订蛛霉量箍脏批稼魏敛尿坛崖堂常郊归章吵嘿丑邢继交得饮鉴驶胯汁脓主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略DiscussionnModified David procedureModified David procedurenEasy to deal with aortic valve and annulusnConvenient to operate and exposure nReconstruction of sinus individually nSelective reconstruction of partial sinusnPrevent dilation of Sinotubular junction region勾鬃羚苞旁梆耻驳用笆逛赌志摧挚宫玻哨尼弊罕呀胀绚拱邑椽岩辟涩赡壮主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略ConclusionnRrecommended when the leaflet is slight and soft , without calcification and contracturenDavid procedure is safe and effective to the patients that aortic valve is insufficient caused by aortic root dilation and leaflet is normal nIt should be noticed to repaire leaflet and deal with sinotubular junction region for the patients with Prolapse of cusp tissue of aortic valvenLeaflet extension procedure is a simple, safe and effective choice剪惜浊檀缴乏域料搂漓罗苞藩泅滨阵奋抓碎彪逻贯蚤拾动首直无羽阴异妒主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略媒曳幽秀臂娟揽比寥汪孤裕永讹赢蛰撵汾郧浑晋爬悬赫兴辽埠樊匡驹庚恤主动脉瓣成形术方法和策略主动脉瓣成形术方法和策略。