Ross手术后行保留主动脉瓣主动脉根置换

Authors：Duke Cameron，.Luca Vricella

Video Description：

Ross手术很久以后，自身移植物出现扩张或者新主动脉瓣开始反流时有两种选择：应用机械假体或生物假体进行主动脉根置换；或者进行主动脉根置换的同时保留主动脉瓣(valve-sparing aortic root replacement, VSRR)。

该视频中，一名男性青少年在行Ross手术五年后，因主动脉根扩张和严重主动脉瓣反流到院就诊。患者升主动脉紧靠胸壁，在重新介入时被撕裂出血，将胸骨边缘重新对齐后出血得以控制。医生对其迅速进行股动脉插管，但由于主动脉瓣反流很严重，患者在心肺分流中持续射血。在患者左前胸处开小切口后置入左室心尖部有孔套管，并进行快速冷却。心脏纤维化后立即快速进行胸骨切开术，并在循环停止的6分钟内控制住升主动脉远端。从冠状动脉窦顺行灌注冷血停搏液后心搏停止。

新主动脉瓣似乎完好，主动脉返流被认为是继发于窦管交界处的扩张。作者认为，应用机械性人工瓣膜进行主动脉跟置换并不是最理想的；进行VSRR术也并不明智，因为这种方法本身就比较复杂。左心室扩张并未影响到心肌层，作者的这种推测很可能是正确的。所以作者最终决定缩小窦管交界处大小，以期保留主动脉瓣的功能。

在窦管交界处和升主动脉远端施置一个34mm的Dacron导管。患者在行十字钳闭31分钟后脱离心肺分流，伴新主动脉瓣轻微返流。第二天上午，患者的呼吸机设置为最低限度，神经完好，而且血液动力学功能和心脏动能良好。患者回到手术室进行VSRR。VSRR结束时新动脉瓣出现轻微返流。

 

When autograft dilation and neo-aortic valve regurgitation develop late after the Ross procedure, there are two surgical options: aortic root replacement with mechanical or biological prosthesis, or aortic valve preservation (valve-sparing aortic root replacement (VSRR)).

This video shows an adolescent male who presented with aortic root enlargement and severe aortic regurgitation five years following a Ross procedure. The ascending aorta, densely adherent to the sternum, was lacerated on reentry. Bleeding was controlled by re-approximation of the sternal edges. Femoral cannulation was expeditiously accomplished, but given the severity of aortic valve regurgitation, the patient continued to eject on cardiopulmonary bypass. An apical left ventricular vent was inserted via a limited left anterior thoracotomy, and instituted rapid cooling. As soon as the heart fibrillated, the sternotomy was rapidly completed, and control of the distal ascending aorta was obtained within six minutes of circulatory arrest. The heart was arrested with an antegrade intra-coronary infusion of cold blood cardioplegia.

The neo-aortic valve appeared intact, and the aortic regurgitation was deemed as secondary to the splaying of the sinotubular junction. The authors thought that an aortic root replacement with a mechanical prosthesis was not ideal. Proceeding with a VSRR procedure was also thought ill-advised because of its inherent complexity, as the authors were hopeful that the myocardium had not been injured by left ventricular distension. It was decided to downsize the sinotubular junction in the hope that competency of the aortic valve would be restored.

A 34 mm Dacron conduit was interposed between the sinotubular junction and the distal ascending aorta. The patient was weaned from cardiopulmonary bypass after a cross-clamp time of 31 minutes, with trivial neo-aortic valve regurgitation. By the following morning, the patient was on minimal ventilator settings, neurologically intact, and had excellent hemodynamic performance and cardiac function. The patient was then returned to the operating room, where a VSRR was performed. The VSRR yielded trivial neo-aortic valve regurgitation at completion of the procedure.