高龄Stanford A型急性主动脉夹层患者的外科手术治疗

目的回顾性研究高龄(≥70岁)Stanford A型急性主动脉夹层行改良主动脉弓置换手术的优势并总结其经验。方法自2011年1月至2013年12月该中心共收治≥70岁Stanford A型急性主动脉夹层患者27例,经充分术前准备,均行急诊手术,手术均在全麻、中度深低温停循环加选择性脑灌注下完成。术式为升主动脉置换术、改良主动脉弓部置换术、支架象鼻术,其中合并有瓣膜病变或冠状动脉粥样硬化的病人行瓣膜置换及冠状动脉旁路移植术。结果围术期死亡2例,1例因肾功能不全、感染死亡,1例因多脏器衰竭死亡。肾功能不全5例,低氧血症2例,手术切口感染3例,一过性脑神经功能障碍3例。结论对70岁以上Stanford A型主动脉夹层病人行改良主动脉弓置换手术,能大大缩短体外循环时间、停循环时间、手术时间,并降低高龄患者术后并发症,使手术存活率明显高于保守治疗。     

急性主动脉夹层的腔内修复术治疗现状与展望

急性主动脉夹层是一组威胁患者生命的急危重症。主动脉腔内修复术在一些局限于升主动脉的Stanford A型主动脉夹层(A型主动脉夹层)个案报道中尝试使用;其与外科升主动脉置换联合进行的杂交手术在适宜的A型主动脉夹层患者中应用获得了较理想的临床效果。在急性Stanford B型主动脉夹层(B型主动脉夹层)患者治疗中,腔内修复术有望成为替代外科血管置换术的治疗方式。B型主动脉夹层患者在内科治疗基础上行腔内修复术可能优于单纯内科保守治疗,但有待更进一步临床研究证实。     

主动脉右弓右降合并Stanford B型主动脉夹层的外科治疗

目的:总结主动脉右弓右降合并Stanford B型主动脉夹层的外科治疗经验。方法:3例右位主动脉弓、右位降主动脉、迷走左锁骨下动脉(迷走左锁骨下动脉型)合并Stanford B型主动脉夹层的患者经胸部右后外切口行胸降主动脉置换术、迷走左锁骨下动脉缝扎术。结果:3例患者均痊愈出院,住院天数7～10 d,无左上肢缺血症状及神经系统并发症。结论:主动脉右弓右降合并Stanford B型主动脉夹层患者行胸降主动脉置换术方法可行,临床疗效满意,术中判断后行迷走左锁骨下动脉缝扎术,可简化手术方式,但应避免术后左上肢缺血坏死。     

马凡综合征主动脉根部瘤的外科治疗

目的总结马凡综合征主动脉根部瘤的外科治疗经验。方法2002年1月至2006年12月,手术治疗马凡综合征主动脉根部瘤34例,年龄16～54(29.5±4.1)岁。其中合并急性I型主动脉夹层(DeBakey分型)7例,急性Ⅱ型主动脉夹层2例,慢性Ⅱ型主动脉夹层2例。术前心功能分级(NYHA)Ⅱ级17例,Ⅲ级15例,Ⅳ级2例。共行Bentall手术27例,Bentall及右半弓置换1例,Bentall及全弓置换加“象鼻”手术6例,同期行二尖瓣成形术6例,胸骨翻转1例。结果全组术后死亡1例,死亡率2.9%。33例随访1个月至5年,2例接受二次手术,其余恢复良好,心功能I～Ⅱ级,无晚期死亡。结论Bentall手术是治疗马凡综合征主动脉根部瘤的首选方法,合并I型主动脉夹层的病例应行Bentall及全弓置换加支架“象鼻”手术。     

保留主动脉根部及升主动脉后壁的新术式在急性Stanford A型主动脉夹层中的应用及早期临床效果分析

目的：总结保留主动脉根部及升主动脉后壁的新术式治疗急性Stanford A型主动脉夹层的手术效果，并对早期临床效果进行分析。方法：回顾性分析2021年1月至2022年6月，新乡医学院第三附属医院及商丘市第一人民医院接受保留主动脉根部及升主动脉后壁的新术式治疗的28例急性Stanford A型主动脉夹层患者的临床资料，其中男20例，女8例，年龄30～74岁。患者夹层均未累及升主动脉后壁，所有患者均采用深低温体外循环下行保留主动脉根部及升主动脉后壁的外科新术式。结果：全组28例患者手术顺利，其中25例痊愈出院，2例术后因心包填塞死亡（死亡率7.1%）,1例术后因多器官衰竭自动放弃出院，术后随访22例，患者生命质量均较好，复查胸腹联合CTA均未发生内漏及再发夹层现象，术后主动脉瓣均无中到重度反流。结论：应用保留主动脉根部及升主动脉后壁的外科新术式治疗急性Stanford A型主动脉夹层可以缩短手术时间、降低死亡率、简化手术方式等，具有较好的近期临床疗效，远期临床效果仍需要大量样本的跟踪及随访。     

急性Stanford A型主动脉夹层再手术治疗分析

摘要 目的：探讨急性A型主动脉夹层再手术治疗的效果,总结其外科治疗经验。方法 ：回顾分析2007年1月-2017年5月16例Stanford A型主动脉夹层再手术患者的临床资料。首次手术包括升主动脉替换术1例,Wheat手术 (升主动脉+主动脉瓣替换术)1例,升主动脉+次全弓替换+主动脉瓣成形术1例,升主动脉替换+孙氏手术（全弓替换及降主动脉支架象鼻人工血管置入）2例,升主动脉替换+孙氏手术+主动脉窦部成形术4例,Bentall手术(带瓣人工血管升主动脉替换替换术)3例,Bentall+孙氏手术4例。再次手术方式包括孙氏手术5例,全主动脉置换术1例,全胸腹主动脉替换2例,主动脉瓣周漏修补术1例,主动脉根部吻合口漏修补术2例（其中1例并行主动脉根部假性动脉瘤切除术）,主动脉覆膜支架腔内隔绝术7例。结果：1例患者在围术期死亡,术后并发症共8例。其中再次开胸2例,伤口感染2例,低心排综合症1例,神经系统并发症1例,肺部感染2例,以上并发症均于出院前治愈。结论：急性A型主动脉夹层再手术临床效果满意,因弓部病变再次行孙氏手术亦安全、有效;孙氏术后远端主动脉病变行常温非体外循环下全胸腹主动脉替换术亦是一种安全、有效的外科策略。     

急性Stanford A型主动脉夹层的外科治疗

目的探讨急性Stanford A型主动脉夹层的急诊外科治疗经验。方法分析急诊手术治疗16例急性Stanford A型主动脉夹层。按主动脉根部术式,分为Bentall术7例,单纯升主动脉置换术3例,David+升主动脉置换术2例,全弓置换术+支架象鼻术4例。涉及主动脉弓部手术患者采用深低温停循环,选择性脑灌注。结果全组16例手术患者,围手术期并发急性肾功能衰竭3例,胸腔积液2例,呼吸功能不全2例,住院死亡2例,均死于术后并发急性肾功能衰竭,1例经过透析治愈,无手术死亡,无精神症状发生,无二次开胸止血。生存出院者随防0.5～8年,期间失防3例,晚期死亡1例,余生活质量良好。结论急性Stanford A型主动脉夹层及时准确作出诊断,准确掌握手术适应证,积极手术治疗,术中采用最佳术式及合适的脑保护,术后及时处理并发症,可以取得良好的效果。     

Stanford A型主动脉夹层患者术后消化道出血的临床分析

目的：测探讨Stanford A型主动脉夹层患者术后消化道出血的临床因素及治疗。方法：回顾分析我中心自2018年1月至2021年6月，Stanford A型主动脉夹层患者术后消化道出血的患者12例（男7例，58.3%），平均年龄（60.6±10.4）岁，和同期Stanford A型主动脉夹层患者共249例为对比组（男188例，75.5%），平均年龄（50.0±13.5）岁，全部行开放性主动脉修复术。对患者围术期重要的临床变量进行统计，对差异有统计学意义的单变量纳入多因素Logistic回归模型，对Stanford A型夹层患者术后消化道出血的临床因素进行分析。结果：两组患者的单因素对比中，年龄、术前SPO2<95%、术中停循环时间、术后低心排血量综合征、术后摄氧浓度≥50%、连续肾替代疗法（CRRT）、感染、住院时间、在ICU时间及死亡率方面，差异有统计学意义（P均<0.05）。将有意义的单变量纳入Logistic回归模型，其术前SPO2<95%及术后CRRT为Stanford A型夹层患者术后消化道出血的危险因素。结论：Stanford A型主动脉夹层即使不累及肠系...     

应用腔内隔绝术治疗胸腹主动脉夹层及随访

目的:总结应用腔内隔绝术治疗Stanford B型主动脉夹层经验并报道中期随访结果。方法:22例急性和2例慢性Stanford B型主动脉夹层患者接受腔内隔绝术治疗,术后1、6、12个月,以后每年随访胸部X线平片与螺旋CT检查。结果:24例患者中23例技术成功,1例因支架故障技术失败,技术成功率95·8%。临床随访:23例技术成功患者中22例假腔内完全血栓形成,1例患者部分血栓形成,1例术后1周死于脑栓塞,1例术后3个月囊性动脉瘤形成需行外科血管置换术。临床成功率87·5%。结论:腔内隔绝术治疗急慢性胸腹主动脉夹层技术可行,中期疗效满意,远期疗效需要进一步随访观察。     

A型夹层孙氏术后再发胸腹主动脉夹层1例

马方综合征(Marfan syndrome,MFS)A型夹层行孙氏手术后因结缔组织病变对自身大动脉的影响,远端残余主动脉常发生瘤变和再次出现夹层,需再次手术治疗.我们收治了1例MFS孙氏术后再发胸腹主动脉巨大夹层动脉瘤的患者,行胸腹主动脉置换,术后康复出院.     

Asymptomatic chronic traumatic aortic valve perforation with severe aortic regurgitation

Here, we present a young asymptomatic male patient incidentally diagnosed to have aortic regurgitation (AR). The patient had a history of a blunt trauma to the thorax two years back but did never have any symptoms. Transthoracic echocardiography showed a moderately dilated left ventricle with normal systolic function and severe AR with normal nondilated aortic root and tri-leaflet aortic valve. To diagnose the etiology of the AR, a transesophageal echocardiogram (TEE) was done, which revealed a perforation in the nonadjacent leaflet (NAL) and confirmed severe AR with two AR jets being clearly visualized, one through the point of incomplete coaptation and other one through the perforated area in the NAL. The patient was treated with aortic valve replacement and was doing well on follow-up.     

同种异体带瓣主动脉行主动脉根部置换的临床效果

目的 :探讨应用低温保存的同种异体带瓣主动脉行主动脉根部重建手术的临床效果。方法 :85例主动脉瓣膜病变患者行同种主动脉根部置换手术 ,术后随访观察临床结果。结果 :随访 39± 13（1.5～ 91）个月。早期手术死亡率 1% （1/ 85 ） ,远期手术死亡率 6 % （5 / 85 ） ;与术前比较心功能明显改善 （P<0 .0 5 ） ;术后随访心内膜炎发生率占2 % （2 / 85 ） ;生存者中瓣膜无或有轻度返流 84 % （6 6 / 79） ,中度返流 16 % （13/ 79）。结论 :同种异体带瓣主动脉根部重建手术效果可靠 ,且并发症少。     

Difficulties with horizontal aortic root in transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) emerged to be a viable treatment option for failing bioprosthesis in the aortic position. Transfemoral approach is the most common access route for TAVI and associated with most favorable clinical outcome. However, in the presence of unfavorable aortic root anatomy, TAVI via transfemoral approach provides inadequate support for device manipulation during valve positioning, particularly performed for the indication of severe aortic regurgitation. We report our experience on TAVI utilizing CoreValve for a patient with regurgitant failing bioprosthesis with horizontal aortic root where we encountered difficulties during implantation and retrieval of valve delivery system. © 2012 Wiley Periodicals, Inc.     

Transfemoral transcatheter aortic valve implantation after aortic valve repair with HAART 300 device

We report the first successful case, to our knowledge, of CoreValve Evolut R (Medtronic, Minneapolis, MN) implantation into a failed HAART 300 aortic annuloplasty device (BioStable Science & Engineering, TX). An 81‐year‐old man presented with severe symptomatic aortic regurgitation secondary to failure of the 21 mm HAART 300 device, which had been implanted 45 days previously. Transthoracic echocardiography (TTE) revealed grade 3 aortic regurgitation with central jet, without aortic valve stenosis. Because of the high risk for redo surgery, the heart team proceeded with femoral transcatheter aortic valve implantation. The 26 mm CoreValve Evolut R was deployed into the 21 mm HAART 300 device without difficulty or complications. There were no intraoperative or postoperative complications. The patient was discharged after 5 days. TTE showed a mean aortic valve gradient of 18 mmHg, with minimal paravalvular leak. Our experience suggests that CoreValve Evolut R implantation may be an attractive option in patients with failed HAART 300 aortic annuloplasty.     

Mixed aortic valve disease treated with transcatheter aortic valve replacement in a high risk patient presenting with acute decompensated heart failure

Mixed aortic valve disease refers to the combination of aortic regurgitation (AR) and aortic stenosis (AS). Commonly etiologies include a bicuspid aortic valve, rheumatic heart disease, and endocarditis superimposed upon a stenotic aortic valve. Treatment depends upon the severity of disease, the presence of symptoms and the size and function of the left ventricle. We present a case of a young patient that presented with new onset acute decompensated heart failure with mixed aortic valve disease that was successful treated with transcatheter aortic valve replacement (TAVR). Invasive hemodynamics at baseline and following TAVR provide an insight into the characteristic features of mixed aortic valve disease. TAVR represents a new treatment option for critically ill patients deemed high risk or nonoperable for surgical aortic valve replacement.     

Severe aortic regurgitation with intimal intussusception secondary to Debakey type I aortic dissection

Aortic regurgitation (AR) with intimal intussusception, secondary to aortic dissection, is relatively rare and the images are interesting findings. We report a typical case of severe AR with intimal intussusception, secondary to DeBakey type I aortic dissection, detected by contrast-enhanced computed tomography (CECT) and transesophageal echocardiography (TEE). Since there are three types of aortic regurgitation with aortic dissection, it is imperative to consider the most appropriate intervention for AR. The combination of CECT, TEE, and surgical findings may play an important role in determining the optimum surgical procedure for AR with aortic dissection.     

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文章论述主动脉夹层(AD)、主动脉壁间血肿(出血)、主动脉穿透性溃疡的影像学诊断的进展,并讨论三者的关系,提出影像学检查在诊断和鉴别诊断中具有重要的作用。