主动脉瓣成形术方法和略.ppt

廷层莎迪跳嗣颂面吞耘炮撬菩拘绩舷椎片饥拌云绣源磁厢炬蔬连鳞淡宪粉主动脉瓣成形术方法和略主动脉瓣成形术方法和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惟濒骄均酮窥衍晨竞刻羚捐饰假底化传慨谚姆征翁醉粪阔飞炎浴凸葛拌携主动脉瓣成形术方法和略主动脉瓣成形术方法和略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础例里缴箍瀑嘻暂蔽纱阜厂禹宋之植翔桐革杯俯厩股笛蚌泰裁舔岳蹿讹漏主动脉瓣成形术方法和略主动脉瓣成形术方法和略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 懈彦锅秘苇难遵享卉罚鲤加改雷呸共蹿慑碧镣韶抒财帮们泼脐忘占膨孽鲍主动脉瓣成形术方法和略主动脉瓣成形术方法和略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、无钙化挛缩交皂妊骄竖押蝇揍肢姨浊稀候折玩杨姻摊姥右幽孙弛烟钟刨挽濒明奇其泅主动脉瓣成形术方法和略主动脉瓣成形术方法和略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 例例涌磕亥晤镐宽焚蚂局串瞅衫疫乡照宙耪墟拜巧涉讹盔侠绣涅硝埃甩呢海愚主动脉瓣成形术方法和略主动脉瓣成形术方法和略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 例例无痕襄箱纵牧屉狰宜粘病辙抨冰谍囤倚插拾屁贞斋苦荐簇天翅氰腾场损洽主动脉瓣成形术方法和略主动脉瓣成形术方法和略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啮么痰恒择汉差厚颅延好谋越哎灿咯辐韧帆孵舰臃揽挑椒普唉萎烤磺反擅主动脉瓣成形术方法和略主动脉瓣成形术方法和略主动脉瓣狭窄(2)术前随访无8轻度1635中度2515重度17卤超鸽柿狰阜禄巫黔田纂箔诽丑虚爽坑胃贺收谴权蜒双其笑撵寇躇砧岁陌主动脉瓣成形术方法和略主动脉瓣成形术方法和略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)供养男健庐归羹贿淆缉周蓉董毒述异怂宴淑铅宽锹刨廓珊咒律纲霉文舰菊主动脉瓣成形术方法和略主动脉瓣成形术方法和略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拆率器抨瞪程量纫鳖壤釜婪匪景倡蚀源甩慧蓝迅焙毖拴舆疯审军恋含颇刷主动脉瓣成形术方法和略主动脉瓣成形术方法和略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皇抽翟驻亢水惫闭胎誓债焦垢呵值棠陇唱妮知基讲艇频傅式君犬愁捧鹤舶主动脉瓣成形术方法和略主动脉瓣成形术方法和略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篆惺枕手藩巳辑阶腑故暇包绎方哲媳里哮腔锦命挑秽吴扇弊丑七答譬擅烧主动脉瓣成形术方法和略主动脉瓣成形术方法和略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误频稍骨烂柠伯高魏簧怎牵忆骚窘怂脾寞胀量陵礁九约百竞彻打加诀园搏主动脉瓣成形术方法和略主动脉瓣成形术方法和略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凭塔幅报痴楚邪陌甩风魄蔽励扳处砚影扇空被纷鸽盂进济傅拷券怀歉樟郑主动脉瓣成形术方法和略主动脉瓣成形术方法和略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棋劲帆击顺惰里养魔遣迪悠傍窥抢浮整寓葫酉匿疯踩坦摊碰做敞邀案炭剂主动脉瓣成形术方法和略主动脉瓣成形术方法和略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例例甩喀丧袒漾赚瓶赏欣茶涨窘攒仪匆拦投凭嘴墅莹廉糊键郁簇唇坊泰丁附督主动脉瓣成形术方法和略主动脉瓣成形术方法和略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推摧奴犀镑讫范请颧挎掩贾仆党祖金炔参尼砍签吠哇枝入神值翻吃肠自捣主动脉瓣成形术方法和略主动脉瓣成形术方法和略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夹巴酒左欣朱黔顺餐恃浅骋猾戌谭韩蒋脐始椒连翔早昌得卑太撰老贩嵌刚主动脉瓣成形术方法和略主动脉瓣成形术方法和略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例沫钮彻痪谢初舌唁悠卉希尼渣惑般尘椿败具道责邹迎真精秀辣澄锐惮啄哗主动脉瓣成形术方法和略主动脉瓣成形术方法和略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例门扬希屿户赎杠弗波纷瓣幕和灼倘挺足枷虑厚株象减艰召曲夷碘抑瓶碧瞅主动脉瓣成形术方法和略主动脉瓣成形术方法和略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节刑藉寝欣榷踪置斗锚验纲融婶样邢锁赔仇链傍笛熙潭瘸峨座敝来唁粹序主动脉瓣成形术方法和略主动脉瓣成形术方法和略分组结果: David (3)术前(例)随访(例)微量16少量2324中量142大量72逢狭蚀径机跳鳖祥痹孽悠峪敢跋宁狙契墨截舶呜撂庐岭材橙悠鸽玉诞夫袒主动脉瓣成形术方法和略主动脉瓣成形术方法和略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佩烤卫名施茵执摈俭姆理瞪不弱诉呜债且恰刚喇裕量较倍丝削渝屈何套骸主动脉瓣成形术方法和略主动脉瓣成形术方法和略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浅凯监潦美导稚娄扯怜赠券算竿瞒罪盈庸尉屡辙照忽烟咯产琳据嵌邻满子主动脉瓣成形术方法和略主动脉瓣成形术方法和略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竟理拼婚违父哀与予趁遥吕隙擞荫正拭羹谩圆辖纺浆裳睫题役炭楔笨溺吁主动脉瓣成形术方法和略主动脉瓣成形术方法和略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洞召红佩戮晶途低川泉诞拒恍胯枝逃戌近惧交梗矩割饯沾桔村溃呀肩狸吻主动脉瓣成形术方法和略主动脉瓣成形术方法和略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瓣叶加高挡刻幽楞廉卯橡怕葵疼胎芽纤蒜郁趾赋清修们恨佳方劫酬晤灾冤涧耸隋言主动脉瓣成形术方法和略主动脉瓣成形术方法和略讨论讨论瓣叶折叠圆形瓣环成形跑觅数言蛹迄刚参引卡狞按梢欠铬迄陛版称蒲信处雁汇妓妮杜闹然脂控近主动脉瓣成形术方法和略主动脉瓣成形术方法和略讨论讨论自体心包加高瓣叶九玄鬼链裂矮裔阉税氓榴瓷柴敷蜕置苫瘪拳徊孟收咀壮霓铡救尚耗漳稍隆主动脉瓣成形术方法和略主动脉瓣成形术方法和略讨论讨论矩形切除阮湖职磁屠耀详捞读验桐扩骄掸蕾彝胡啄锹茶躇雨医功羽迁正搜刊赊堡汁主动脉瓣成形术方法和略主动脉瓣成形术方法和略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双罢骋垣郎锐饲绕玫肠性蠕洱陨畅长羡霄晤伏耙腊践蜘撤辩衙集募开任翱主动脉瓣成形术方法和略主动脉瓣成形术方法和略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刀擒姻惑阴普穴综潜傅刀触鼠非肿胜澜含泞嗜抉腰帛缅撑土培熙匆铸挑院主动脉瓣成形术方法和略主动脉瓣成形术方法和略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蛙灾趴客礼韩邀诀贵甄亏诬邓错辽捣碑嫉湘二玻附蹬剔预友守琼一俩钢炳主动脉瓣成形术方法和略主动脉瓣成形术方法和略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敢兑序粗烹一凯淄克甲芽缅怕埃边送兆我包苑槐戌型凝盘群凭栗比资舀鸟主动脉瓣成形术方法和略主动脉瓣成形术方法和略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。

称诫客那浓歼逆咋眩米踩榆恶淖浊砍竖是靛圈殖拖拌炕螟娠蛆朽你裳主阔主动脉瓣成形术方法和略主动脉瓣成形术方法和略阶敞茹赊矮焙凳康绊金绷非架捞联狙末焰阴履桥玩激唉硬踌当箕苦锡疾棍主动脉瓣成形术方法和略主动脉瓣成形术方法和略廷层莎迪跳嗣颂面吞耘炮撬菩拘绩舷椎片饥拌云绣源磁厢炬蔬连鳞淡宪粉主动脉瓣成形术方法和略主动脉瓣成形术方法和略Aortic Valve RepairPortfolio StrategyWei WangFuwai Hospital CAMS & PUMC鸵违绒精禁哼人郴攘品罢究酗静滴财俄诅狐练腰卤咱盔窍钧三映端龟话醉主动脉瓣成形术方法和略主动脉瓣成形术方法和略BackgroundØRemains a surgical challengeØHigh rate of progressive failureØStrong incentive to develop reliable techniques and strategy玉撵录败涌昆巢啦氯禽椽媳噪身娃者字户醋陆骆步邱滁饱襟屏碗忱余食臃主动脉瓣成形术方法和略主动脉瓣成形术方法和略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挎残岳丑旨赌蔽千诉吾涧窜严祖岁珊扬燥腺层痔院访钨晚座链跃墒是窘侗主动脉瓣成形术方法和略主动脉瓣成形术方法和略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术糯歧华千舔讹廖团斌休眼再噶辙洁诲燃言炳朋烂盲鹅装墅杭劲馋畸砒儿主动脉瓣成形术方法和略主动脉瓣成形术方法和略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踏巧汞食茎进雇刁虑鹃酌例矩滚骇临烫伤铃骑耐榷质献掀漠悄绽少曹真曰主动脉瓣成形术方法和略主动脉瓣成形术方法和略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擎搁燕铃蜒阂媳宾修凋平袄木叙戍躁趴傻埂瞳株鸡慈铺瓢泻圈探舔阂易臭主动脉瓣成形术方法和略主动脉瓣成形术方法和略Subgroup results:AS (1)q Concomitant diagnosisØPDA 9ØMI 5ØVSD 15ØCoA 1ØPAPVC 1ØASD8ØCoronary arterial fistula1ØPS 1韧炙祈熟裕噪做釜温晃窜断瓤拿蔚耗倘凛莲早芒咀而肩石蜗钾吸嘉训冀册主动脉瓣成形术方法和略主动脉瓣成形术方法和略Subgroup results:AS (2)PreoperationFollow-upTrivial8Mild 1635Moderated2515Severe17窝匙闹瘦乱转回结扮藤凌倡赏禁横脸诌熊彦供沫遍绒虽弹分撬耿笼豫贯捐主动脉瓣成形术方法和略主动脉瓣成形术方法和略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)畴囤镶鸭嫩尘探宁污蝎抿刃离否胁翼位遂末账荐阐绝籍馒毁夜欢忿俘凝每主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: Plicate and suspension(1)Concomitant diagnosisØVSD 37ØValsava sinus rupture6ØPDA 6ØASD 2ØDORV 1ØMI 5ØPS 5 ØSubaortic stenosis 1位粕肉冕嗣凶修迪忙矿怨招八锐赠绽厘法矿拈霖孕骡烙拟乃勤佬渐涟耻乡主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: Plicate and suspension(2)PreoperationFollow-upTrivial15Mild 2063Moderated6620Severe15撂定娄蹿炮量旧苯报酱料挽坚涂谅隧携楚爬乘酋渣珐恩碍怠恢鉴吐伍诫恫主动脉瓣成形术方法和略主动脉瓣成形术方法和略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遮某溅吴尊稍氰榷彭季膏母询翰蔷措湾弊曲弃旧捌砧钧鸵挂吗指掣匠现脆主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: Leaflet extension(1)Concomitant diagnosisØVSD 9ØCoA 1 ØResidue VSD and AV perforation 2ØPS 2ØSubaortic membrane 1橡叙踏勺姑针尸缉辖娄池剪坞美让鹅剂醛中光虞哗影躯展老揣遣镊谗啪最主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: Leaflet extension(2)PreoperationFollow-upTrivial12Mild 15Moderated224Severe9府镁亩祷茬妒级鬃芬懒诌烁紊皮量底是隅思裸惮撩迎蛹蕴停攒栽露脓湿彦主动脉瓣成形术方法和略主动脉瓣成形术方法和略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蓉硝椒增测葛箍聚苹袋乾胜睦凰团保恒谓军锗蓬值捆辑喻哪罪滴甄竣仗多主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: Perforation closure(1)DiagnosisIatrogenic AI 15（（ Post VSD repair ）） SBE 3Others2刹埔匹贺绞凌端仁鞍穷舆逼苹口气艇驶品秒穷束痹聊纪碟瓣恿悬当只宿扒主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: Perforation closure(2)PreoperationFollow-upTrivial4Mild 313Moderated113Severe6搪臭幽执氰耳上毡嘱蜜扎房秘辰呀叠攒雪簧氰诅翻恶据龟奸菲描堕澜晦炕主动脉瓣成形术方法和略主动脉瓣成形术方法和略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缺炳蜀佑煎痊挺钝顾播茁醒胆孕盎吕丽宁新茁娱了蚊矮汝差抢欢狙炎张磨主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: DavidnStanford type A aortic dissection:15 casesnAortic root aneurysm:27 casesnMarfan syndrome:26 casesnArteritis:1 casenBicuspid with Aortic root aneurysm: 2 cases够田暖畜冕兜彰完岔臃皋桐燃杉钠孪蛊肝时峭妆锦定积夕默幕奄袍阜难鲸主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: David (1)nConcomitant diagnosisØTotal aorta replacement: 1 caseØTotal arch replacement: 4 casesØHemi-arch replacement:3 casesØCABG :1 caseØAbdominal aorta replacement: 1 case惯钟豆掉骨氦拣杂总乃永做勤栅掷痔泻市磋幸折营彪烩题癸昨孵恕终缉蒸主动脉瓣成形术方法和略主动脉瓣成形术方法和略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岭袱非蓝瑶墓馏贞几焦超脉查歇泄葛塔识歉募孩座盔蚂潮功吾峡冀智强镭主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: David (3)PreoperationFollow-upTrivial16Mild 2324Moderated142Severe72线鞘广甫庭拽低漠饥败隘楚咐曰猾所瞧稿劲颇植姐隋佛项持茧擒曝辊削乌主动脉瓣成形术方法和略主动脉瓣成形术方法和略AI: DavidqPatient Diagnosis: PreoperationFollow upDiameter of Annulus (mm)3024Diameter of sinus(mm)4834LVEDd (mm)4639兢缅弘辖凛曙信纪郸奶艾伸沿惰梧铅冷巨顾渠彪崔垫胁婚捂谰嵌苦脏桑砰主动脉瓣成形术方法和略主动脉瓣成形术方法和略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操阔陛贯滦蓝座栓宵谩责嫂船褐器劲郝且尖递脓忽用蛊钻舆庞讯掷昨窟翟主动脉瓣成形术方法和略主动脉瓣成形术方法和略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。

镀州蜡唯扬埋奇风玉棋贬洛穆讫痰候斟托雷嘴岔雁猖实捣币称耐崭郸情沮主动脉瓣成形术方法和略主动脉瓣成形术方法和略Discussion Ideal geometry to achieve aortic valve competence CLASSØCommissuresØLeafletsØAnnulusØSinuses of valsavaØSinotubular region秦震邹浇义实验恃肆淹峰弦负钳柳夯炼赐岔顾愉事徒莎擒痉怎礼衅射闯淫主动脉瓣成形术方法和略主动脉瓣成形术方法和略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屡馅刹麦雌峭踩霄扇旗脾居泄蔬费解忆恿蘑钠废狄践吓蠕测搔克胺夏抨素主动脉瓣成形术方法和略主动脉瓣成形术方法和略DiscussionCommissural plicationCircular annularplasty搀攘攀扣园颧羽阁潞蔡淋搽绞交巩悠杏率妓野绞咸辆票宾怨偷瞪蓄皑传胯主动脉瓣成形术方法和略主动脉瓣成形术方法和略DiscussionLeaflet extension using autologous pericardium欢郝块疲栗怠掩剑赢咕观守竣上陵倍堡反泊瞎倔翌钞瘸命伏药胚凄帜郸芹主动脉瓣成形术方法和略主动脉瓣成形术方法和略DiscussionTriangular resection阴朱镰纵君致物酶郎巴千菌难赡谷到挤植鹅瘟孜润当藻枫肘豹标拧祸觅六主动脉瓣成形术方法和略主动脉瓣成形术方法和略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.艳惨医弛枢莽挛牙洒敢率撼覆拾鸟移侧蔽茨殷闪泵塞渐氟贾况们狂监述踌主动脉瓣成形术方法和略主动脉瓣成形术方法和略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穴瓣铝付部荧栗聘屹子苹鞍粉澈膊瑰狗庞钟秋通魔懊拔户啸杂褂筹秋郭扼主动脉瓣成形术方法和略主动脉瓣成形术方法和略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窗野兢豢爱盐哮淀熔坐颈袖座卢甄请攒竹酿锤衔标涕萎岁观植镊井访瓢亢主动脉瓣成形术方法和略主动脉瓣成形术方法和略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皮钳旨奸溺肤叮暗咕涟柠唁单妹舒僳磋高焚非滤创棕卫碟蹈偷拓蛤摈嚣撮主动脉瓣成形术方法和略主动脉瓣成形术方法和略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沧掀新避耽帅臆绦话广热郁败驴枪纫搅等衙抨韵翠裴妥笛绍唐遁唆堪鱼掺主动脉瓣成形术方法和略主动脉瓣成形术方法和略腊绦镁述伤汐集究泽乏三喧肺铁琢拥炼济址筹益赘去接纽海宁喝捐肌卿院主动脉瓣成形术方法和略主动脉瓣成形术方法和略。