Surgical treatment of the dilated ascending aorta: When and how?
Surgical treatment of the dilated ascending aorta: When and how?
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DOI：
10.1016/s0003-4975(99)00439-7
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发表时间：
1999-06-01
影响因子：
4.6
通讯作者：
Griepp, RB
中科院分区：
文献类型：
--
作者：
Ergin, MA;Spielvogel, D;Griepp, RB
背景。如果升主动脉和主动脉根部的直径超过给定年龄和体型的标准，则认为主动脉病理性扩张。比正常直径增加 50% 被认为是动脉瘤样扩张。升主动脉的这种扩张经常导致明显的主动脉瓣膜关闭不全，即使存在其他正常的瓣膜。扩张或动脉瘤的升主动脉有自发破裂或夹层的风险。这种风险的大小与主动脉的大小和主动脉壁的潜在病理密切相关。即使在成功的紧急手术治疗后，破裂或夹层的发生也会不利地改变自然史和生存率。方法。在推荐升主动脉扩张的择期手术时，必须考虑患者的年龄、主动脉的相对大小、主动脉瓣的结构和功能以及主动脉壁的病理。马凡氏综合征、急性夹层、壁内血肿和伴环形破坏的心内膜炎患者更换升主动脉的指征得到了可靠的临床信息的支持。然而，由于缺乏自然史研究，干预升主动脉退行性扩张的手术指南，尤其是当其他心脏手术偶然发现其时，仍然主要是经验性的。二叶式主动脉瓣与升主动脉扩张的关联需要特别注意。结果。目前有多种手术恢复主动脉根部功能和解剖完整性的技术。手术的选择受到多种因素的仔细考虑，例如患者的年龄和预期生存时间；潜在的主动脉病变；与主动脉瓣叶、瓣环、窦和正弦管状脊相关的解剖学考虑因素；远端主动脉的状况；未来进行远端手术的可能性；抗凝治疗的风险；当然，还有外科医生的技术经验。目前，采用适当选择的技术进行选择性根部置换术的手术风险不应比常规主动脉瓣置换术高得多。主动脉瓣和升主动脉的复合置换，最初由 Bentall、DeBono 和 Edwards（经典 Bentall）描述，或由 Kouchoukos（按钮 Bentall）修改，仍然是最通用和广泛应用的方法。自 1989 年以来，Bentall 手术的按钮改良已在西奈山医疗中心的 250 名患者中使用，医院死亡率为 4%，长期生存率极好。在该组中，年龄是手术风险的唯一预测因素（年龄 > 60 岁，死亡率 7.3% [9/124]，而年龄 < 60 岁，死亡率 0.8% [1/126]，p = 0.02）。结论。 Bentall 手术的这一修改为评估最近引入的主动脉根部修复方法设定了标准。 (C) 1999 年，胸外科医师协会。
Background. The aorta is considered pathologically dilated if the diameters of the ascending aorta and the aortic root exceed the norms for a given age and body size. A 50% increase over the normal diameter is considered aneurysmal dilatation. Such dilatation of the ascending aorta frequently leads to significant aortic valvular insufficiency, even in the presence of an otherwise normal valve. The dilated or aneurysmal ascending aorta is at risk for spontaneous rupture or dissection. The magnitude of this risk is closely related to the size of the aorta and the underlying pathology of the aortic wall. The occurrence of rupture or dissection adversely alters natural history and survival even after successful emergency surgical treatment.Methods. In recommending elective surgery for the dilated ascending aorta, the patient's age, the relative size of the aorta, the structure and function of the aortic valve, and the pathology of the aortic wall have to be considered. The indications for replacement of the ascending aorta in patients with Marfan's syndrome, acute dissection, intramural hematoma, and endocarditis with annular destruction are supported by solid clinical information. Surgical guidelines for intervening in degenerative dilatation of the ascending aorta, however, especially when its discovery is incidental to other cardiac operations, remain mostly empiric because of lack of natural history studies. The association of a bicuspid aortic valve with ascending aortic dilatation requires special attention.Results. There are a number of current techniques for surgical restoration of the functional and anatomical integrity of the aortic root. The choice of procedure is influenced by careful consideration of multiple factors, such as the patient's age and anticipated survival time; underlying aortic pathology; anatomical considerations related to the aortic valve leaflets, annulus, sinuses, and the sine-tubular ridge; the condition of the distal aorta; the likelihood of future distal operation; the risk of anticoagulation; and, of course, the surgeon's experience with the technique. Currently, elective root replacement with an appropriately chosen technique should not carry an operative risk much higher than that of routine aortic valve replacement. Composite replacement of the aortic valve and the ascending aorta, as originally described by Bentall, DeBono and Edwards (classic Bentall), or modified by Kouchoukos (button Bentall), remains the most versatile and widely applied method. Since 1989, the button modification of the Bentall procedure has been used in 250 patients at Mount Sinai Medical Center, with a hospital mortality of 4% and excellent long-term survival. In this group, age was the only predictor of operative risk (age > 60 years, mortality 7.3% [9/124] compared with age < 60, mortality 0.8% [1/126], p = 0.02).Conclusions. This modification of the Bentall procedure has set a standard for evaluating the more recently introduced methods of aortic root repair. (C) 1999 by The Society of Thoracic Surgeons.