Name: full-root aortic valve replacement by stentless aortic xenografts in patients with small aortic roots
Uploaded: 2017-05-21T14:00:00.000+00:00
Duration: 12 min 17 s
Description: Watch this Scientific Journal Video about Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots at JoVE.com

Bu çalışma İsviçre Kardiyovasküler Vakfı&#39;ndan RT&#39;ye verilen bir hibe ile desteklendi.

<ol>
	<li>Bonow, R. O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Focused+update+incorporated+into+the+ACC/AHA+2006+guidelines+for+the+management+of+patients+with+valvular+heart+disease:+A+report+of+the+American+College+of+Cardiology/American+Heart+Association+Task+Force+on+Practice+Guidelines+(Writing+Committee+to+Revise+the+1998+Guidelines+for+the+Management+of+Patients+With+Valvular+Heart+Disease):+endorsed+by+the+Society+of+Cardiovascular+Anesthesiologists,+Society+for+Cardiovascular+Angiography+and+Interventions,+and+Society+of+Thoracic+Surgeons.">Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.</a> Circulation. 118 (15), e523-e661 (2008).</li><li>Rahimtoola, S. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+problem+of+valve+prosthesis-patient+mismatch.">The problem of valve prosthesis-patient mismatch.</a> Circulation. 58 (1), 20-24 (1978).</li><li>Pibarot, P., Dumesnil, J. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prosthesis-patient+mismatch:+definition,+clinical+impact,+and+prevention.">Prosthesis-patient mismatch: definition, clinical impact, and prevention.</a> Heart. 92 (8), 1022-1029 (2006).</li><li>Pibarot, P., Dumesnil, J. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemodynamic+and+clinical+impact+of+prosthesis-patient+mismatch+in+the+aortic+valve+position+and+its+prevention.">Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention.</a> J. Am. Coll. Cardiol. 36 (4), 1131-1141 (2000).</li><li>Kang, Y. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cardiac+hypertrophy:+a+risk+factor+for+QT-prolongation+and+cardiac+sudden+death.">Cardiac hypertrophy: a risk factor for QT-prolongation and cardiac sudden death.</a> Toxicol. Pathol. 34 (1), 58-66 (2006).</li><li>Castro, L. J., Arcidi, J. M., Fisher, A. L., Gaudiani, V. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Routine+enlargement+of+the+small+aortic+Root:+a+preventive+strategy+to+minimize+mismatch.">Routine enlargement of the small aortic Root: a preventive strategy to minimize mismatch.</a> Ann. Thorac. Surg. 74 (1), 31-36 (2002).</li><li>Kunihara, T., Schmidt, K., Glombitza, P., Dzindzibadze, V., Lausberg, H., Sch&#228;fers, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Root+replacement+using+stentless+valves+in+the+small+aortic+root:+A+propensity+score+analysis.">Root replacement using stentless valves in the small aortic root: A propensity score analysis.</a> Ann. Thorac. Surg. 82 (4), 1379-1384 (2006).</li><li>Yacoub, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fourteen-year+experience+with+homovital+homografts+for+aortic+valve+replacement.">Fourteen-year experience with homovital homografts for aortic valve replacement.</a> J. Thorac. Cardiovac. Surg. 110 (1), 186-194 (1995).</li><li>Sommers, K. E., David, T. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+valve+replacement+with+patch+enlargement+of+the+aortic+annulus.">Aortic valve replacement with patch enlargement of the aortic annulus.</a> Ann. Thorac. Surg. 63, 1608-1612 (1997).</li><li>El-Hamamsy, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rate+of+progression+and+functional+significance+of+aortic+root+calcification+after+homograft+versus+freestyle+aortic+root+replacement.">Rate of progression and functional significance of aortic root calcification after homograft versus freestyle aortic root replacement.</a> Circulation. 120 (Suppl 1), S269-S275 (2009).</li><li>Bach, D. S., Kon, N. D., Dumesnil, J. G., Sintek, C. F., Doty, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ten-year+outcome+after+aortic+valve+replacement+with+the+Freestyle+stentless+bioprosthesis.">Ten-year outcome after aortic valve replacement with the Freestyle stentless bioprosthesis.</a> Ann. Thorac. Surg. 80 (2), 480-487 (2005).</li><li>Ennker, I. C., Albert, A., Dalladaku, F., Rosendahl, U., Ennker, J., Florath, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Midterm+outcome+after+aortic+root+replacement+with+stentless+porcine+bioprostheses.">Midterm outcome after aortic root replacement with stentless porcine bioprostheses.</a> Eur. J Cardio-thorac. Surg. 40 (2), 429-434 (2011).</li><li>Tavakoli, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Full-root+aortic+valve+replacement+with+stentless+xenograft+achieves+superior+regression+of+left+ventricular+hypertrophy+compared+to+pericardial+stented+aortic+valves.">Full-root aortic valve replacement with stentless xenograft achieves superior regression of left ventricular hypertrophy compared to pericardial stented aortic valves.</a> J. Cardiothorac. Surg. 10, 15 (2015).</li><li>Kon, N. D., Cordell, A. R., Adair, S. M., Dobbins, J. E., Kitzman, D. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+root+replacement+with+the+Freestyle+stentless+porcine+aortic+root+bioprosthesis.">Aortic root replacement with the Freestyle stentless porcine aortic root bioprosthesis.</a> Ann. Thorac. Surg. 67 (6), 1609-1616 (1999).</li><li>Dapunt, O. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stentless+full-root+bioprosthesis+in+surgery+for+complex+aortic+valve-ascending+aortic+disease:+a+single+center+experience+of+over+300+patients.">Stentless full-root bioprosthesis in surgery for complex aortic valve-ascending aortic disease: a single center experience of over 300 patients.</a> Eur. J. Cardiothorac. Surg. 33 (4), 554-559 (2008).</li><li>Saxena, A., Dinh, D., Smith, J. A., Reid, C. M., Shardey, G., Newcomb, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+surgeon+status+is+not+associated+with+an+increased+risk+of+early+or+late+mortality+after+isolated+aortic+valve+replacement+surgery.">Training surgeon status is not associated with an increased risk of early or late mortality after isolated aortic valve replacement surgery.</a> Cardiol. J. 21 (2), 183-190 (2014).</li><li>D'Agostino, R. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Society+of+Thoracic+Surgeons+Adult+Cardiac+Surgery+Database:+2016+Update+on+Outcomes+and+Quality.">The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 Update on Outcomes and Quality.</a> Ann. Thorac. Surg. 101 (1), 24-32 (2016).</li><li>Fries, R., Wendler, O., Schieffer, H., Sch&#228;fers, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+rest+and+exercise+hemodynamics+of+23-mm+stentless+versus+23-mm+stented+aortic+bioprostheses.">Comparative rest and exercise hemodynamics of 23-mm stentless versus 23-mm stented aortic bioprostheses.</a> Ann. Thorac. Surg. 69 (3), 817-822 (2000).</li></ol>

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<html> Bu çalışma, küçük aort köklü hastalarda stentless aortik ksenogreftleri kullanarak tam kök aort kapak replasmanı cerrahi tekniğinin detaylı bir tanımını bildirmektedir. Erken morbidite ve mortalite çok düşüktür ve diğer raporlar ile olumlu karşılaştırılmalıdır 7 . Ağır kalsifiye koroner ostia, bu tekniğin anatomik bir kısıtlılığını oluşturmaktadır. Bu tekniğin diğer bir dezavantajı, genel operasyon süresi daha uzun süre dayanamayan fakir bir gene...

65 yaşından büyük hastalar için biyolojik aort kapak replasmanı önerilmektedir 1 . Küçük aort köklü hastalarda, üretici tarafından verilen etiketli büyüklüğe dayalı stentli bir biyolojik supap ikamesi implantasyonu fonksiyonel ihtiyaçları karşılamayabilir. Bu durumda, Rahimtoola önce protez-hasta uyumsuzluğunu (PPM) şöyle tanımladı : &quot; uyumsuzluk, etkili protez kapak alanı hastaya yerleştirildikten sonra normal bir insan kapağından daha az olduğunda görülüyor &quot; 2 . Vana protezinin efektif delik alanı, hastanın vücut ölçüsüne ve daha yaygın olarak hastanın vücut yüzey alanına bağlı olmalıdır. Çok küçük bir protez kapağının hemodinamik sonucu anormal yüksek transvalvüler gradienttir 3 . Transvalvüler gradient ve efektif arasındaki ilişkiVücut yüzey alanına (EOAI) endekslenmiş açıklık alanı eğrisel olup, endekslenmiş EOA 0.8 ila 0.9 cm 2 / m 2&#39;den düşük olduğunda bu degradeler katlanarak artmaktadır. Bu ilişkiye dayanarak, aortik pozisyon 4&#39;te , 0.85 cm2 / m2&#39;den daha düşük bir EOAI genellikle PPM için eşik olarak kabul edilmektedir. PPM&#39;nin erken ve geç klinik sonuçlara etkisi tartışmalıdır. Bununla birlikte, PPM&#39;nin sol ventrikül hipertrofisinin gerilemesini ve dolayısıyla sol ventrikül fonksiyonunun normalleşmesini ve semptomların hafifletilmesini olumsuz etkilediği bildirilmiştir4. Kalıcı sol ventrikül hipertrofisi artmış aritmi ve ani kardiyak ölüm riski ile ilişkilidir 5 . Bu nedenle, PPM&#39;yi olabildiğince önlemeniz önerilir 4 . Bir biyol ile planlanan aort kapak replasmanı için öngörülebilir bir PPM durumundaOpsiyonel olarak şunlardır: 1) stentli bir perikard kapısının implante edilmesinden kaynaklanan PPM&#39;yi kabul etmek, hastanın komorbiditeleri, daha büyük bir protezin implantasyonu için daha teknik olarak zorlayıcı bir ameliyat tekniğini yasakladığında, 2) aort kökünü yerleştirmek için büyütmektir Stentsiz bir biyolojik valf 7 veya homograft 8&#39;i yerleştirmek için daha geniş stentli bir valf yerine 6 veya 3). Aort kökü genişlemesinin, perioperatif kanamayı arttırdığı, yeniden sternotomi yapılması ve erken mortalitenin arttığı bildirilmiştir ( 9) . Aortik homogreftler, deneyimli cerrahlar tarafından implante edildiğinde mükemmel hemodinamik profiller ve uzun süreli iyi sonuçlar alabilirler 8 . Bununla birlikte, kalsifikasyon oranlarının sınırlı olması ve hızlandırılmış kalsifikasyon oranı, aortik homogreftleri, muadilleri olan domuz stentless aortik x&#39;e göre biyolojik kapak ikamelerini daha az uygun hale getirirEnogreftler 10 . Homogreftlerin eksikliği ve dezavantajları, alternatif biyolojik kapak ikamelerinin gelişimine ve gelişimine neden olmuştur. Bu amaçla, stentless aortik ksenograftlar klinik uygulamaya sokulmuştur11. Bir taraftan, hantal dikiş halkasının ortadan kaldırılması sayesinde, stentless aortik ksenograftlar homograftların hemodinamik avantajlarını çoğaltabilir. Öte yandan, anti-kalsifikasyon teknolojisinin uygulanmasının bir sonucu olarak, stentless aortik ksenograftların dayanıklılığı homogreflerin 11 uzunluğunu karşılamak ve hatta aşmak için optimize edilmiştir. Stentless aortik ksenograftların hemodinamik avantajları tam kök implantasyon ile sağlanır 12 . Subkoroner ve kök inklüzyon tekniklerinin aksine, tam kök implantasyon, stentless aortik ksenogrefti aort anülüsünün üzerine yerleştirir ve içinde bulunmaz. Bu gerçek veStentsiz supap yerine en büyük iç işlevsel çapın uygulanmasını sağlayan tam kök implantasyon tekniğini tercih etme gerekçesini eritebilir. Buna ek olarak, Valsalva sinüslerin kapak broşürleri ile en-blok halinde korunması, daha fazla fizyolojik açma ve kapama hareketine ve dolayısıyla broşürlerin ömrünün uzamasına neden olur. Bu avantaj, daha uzun vadeli sonuçların iyileştirilmesine katkıda bulunur 12 . Bununla birlikte, artan kanama potansiyeli ve olası koroner ostia anastomoz distorsiyonu ile ilgili endişeler, bir takım kalp cerrahlarının stentli bir biyolojik kapak ile klasik bir aort kapak replasmanından tam kök replasman ile temsil edilen daha teknik olarak talep eden prosedüre geçmesini önler Stentless aortik ksenograftlar. Stentless aortik ksenograftların olası hemodinamik avantajları göz önüne alındığında, tam rooAort kapak replasman&gt; n&gt; gerektiren küçük aort köklü hastalarda PPM&#39;yi önle- mek için ( Tablo 1 ). Bu hastalarda, yeni implante aort kapağı için 0,85 cm 2 / m 2&#39;den daha yüksek bir EOAI elde etmek amaçlanmaktadır. Bu niyet, Pibarot ve arkadaşlarının raporlarında, 0.85 cm2 / m 2&#39;den daha düşük projeksiyona tabi tutulmuş bir EOAI değerine sahip olan kapak ikame maddeleri için kabul edilemez derecede yüksek transvalvüler gradyanlar gösteren ve daha sonra semptomların hafifletilmesiyle ve yan etkilerin kalıcı riskini gösteren raporlara dayanmaktadır 3 , 4 . Ameliyat öncesi ekokardiyografide aortik anulus çapı 20 mm&#39;den az olan yetişkin hastaların ilk tanımlanmasının ardından, hastalar 1.6 m2&#39;den daha fazla bir vücut yüzey alanına sahip olmak için seçilir. Bu hasta alt grubunda, 19 mm stentli bir perikardiyal aort kapağının (EOA: 1.28 cm2 </0.85 cm2 / m2&#39;den daha düşük bir EOAI tahmini ile sonuçlanacaktır. Bu protokolde, bu hastalar stentless aortik ksenograftların tam kök implantasyonu için adaydır. Aort kapağının çıkarılmasından sonra nihai karar intraoperatif olarak verilir. Stentli perikardiyal aort kapağı için 19 mm&#39;lik bir valf ölçme cihazı aort halkasında aşırı sıkı geçerse ve hasta hemodinamik olarak kararlıysa ve daha uzun bir ameliyatı tolere edebilirse, stentless aortik ksenograftın tam kök implantasyonu gerçekleştirilir. Stentless aortik ksenograftlar için piyasada bulunan iki vana ikamesini birbirinin yerine kullanıyoruz (ayrıntılar için , Malzeme Tablosuna bakınız ). Her iki valf aort kapağını taşıyan domuz aort kökünden temin edilir. Bir kapak için anti-kalsifikasyon ( örn. XenoLogiX) ve antioksidan alfa amino oleik asit (AOA) ile düşük basınçlı (0-2 mmHg) fiksasyon işlemi kullanılarak hazırlanırlarDiğeri için laksifikasyon tedavisi. Stentli perikard kapakçıkları için 19 mm boyutlu kemiğin aortik anülüsten çok sıkı geçtiği hastalarda aortik anülüste stentless aortik ksenograft uydurma için 23 mm boyutlayıcı, 23 mm stentless aortik xenograft boyutunun Seçilmeli. Bu protokol, proksimal sütür hattının ve koroner anastomozların tedavisine vurgu yapılarak, stentless aortik ksenograftların tam kök implantasyon tekniğini detaylı olarak tarif eder. Bu tekniğin sınırlamaları ve alternatif seçenekler tartışılmıştır.

<table><tbody><tr><td>&lt;strong&gt;Heart surgery infrastructure:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Heart Lung Machine</td><td>Stockert</td><td>SIII</td><td></td></tr><tr><td>EOPA 24Fr. arterial cannula</td><td>Medtronic</td><td>77624</td><td></td></tr><tr><td>Atrial caval venous cannula 34/48Fr.</td><td>Medtronic</td><td>93448</td><td></td></tr><tr><td>LV vent catheter 17Fr.</td><td>Edwards</td><td>E061</td><td></td></tr><tr><td>Antegrade 9Fr. cardioplegia cannula</td><td>Edwards</td><td>AR012V</td><td></td></tr><tr><td>Retrograde 14Fr. cardioplegia cannula&amp;nbsp;</td><td>Edwards</td><td>NPC014&amp;nbsp;</td><td></td></tr><tr><td>Coronary artery ostial cannula 90&amp;deg;</td><td>Medtronic</td><td>30155</td><td></td></tr><tr><td>Coronary artery ostial cannula 45&amp;deg;</td><td>Medtronic</td><td>30255</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Valve subsitutes:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Stentless aortic xenograft Prima Plus 23 mm</td><td>Edwards</td><td>2500P-23</td><td>anti-calcification XenoLogiX treatment</td></tr><tr><td>Stentless aortic xenograft Sizer 23 mm</td><td>Edwards</td><td>1170</td><td></td></tr><tr><td>Stentless aortic xenograft Freestyle 23 mm</td><td>Medtronic</td><td>FR995-23</td><td>alpha amino oleic acid (AOA) anti-calcification treatment</td></tr><tr><td>Stentless aortic xenograft Sizer 23 mm</td><td>Medtronic</td><td>7900</td><td></td></tr><tr><td>Electrocautery</td><td>Covidien</td><td>Force FX&lt;sup&gt;TM&lt;/sup&gt;</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Sutures:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Polypropylene 4/0</td><td>Ethicon</td><td>8871H</td><td></td></tr><tr><td>Polypropylene 5/0</td><td>Ethicon</td><td>8870H</td><td></td></tr><tr><td>Polypropylene 6/0</td><td>Ethicon</td><td>EH7400H</td><td></td></tr><tr><td>Braided polyesther 2/0 ligature with polybutylate coating&amp;nbsp;</td><td>Ethicon</td><td>X305H</td><td></td></tr><tr><td>Micro knife Sharpoint&amp;nbsp;</td><td>TYCO Healthcare PTY&amp;nbsp;</td><td>78-6900</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Drugs:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Midazolam</td><td>Roche Pharma</td><td>N05CD08</td><td></td></tr><tr><td>Rocuronium</td><td>MSD Merck Sharp &amp;amp; Dohme&amp;nbsp;</td><td>M03AC09</td><td></td></tr><tr><td>Propofol</td><td>Fresenius Kabi</td><td>N01AX10</td><td></td></tr><tr><td>Fentanil</td><td>Actavis</td><td>N01AH01</td><td></td></tr><tr><td>Heparin</td><td>Braun</td><td>B01AB01</td><td></td></tr><tr><td>Protamin</td><td>MEDA Pharmaceutical</td><td>V03AB14</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Instruments:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Cooley vascular aortic clamp</td><td>Delacroix-Chevalier</td><td>DC40810-16</td><td></td></tr><tr><td>Dissection forceps Carpentier</td><td>Delacroix-Chevalier</td><td>DC13110-28&amp;nbsp;</td><td></td></tr><tr><td>Scissors Metzenbaum</td><td>Delacroix-Chevalier</td><td>B351751</td><td></td></tr><tr><td>Needle holder Ryder</td><td>Delacroix-Chevalier</td><td>DC51130-20&amp;nbsp;</td><td></td></tr><tr><td>Dissection forceps DeBakey</td><td>Delacroix-Chevalier</td><td>DC12000-21&amp;nbsp;</td><td></td></tr><tr><td>Micro needle holder Jacobson</td><td>Delacroix-Chevalier</td><td>DC50002-21&amp;nbsp;</td><td></td></tr><tr><td>Micro scisors Jacobson</td><td>Delacroix-Chevalier</td><td>DC20057-21&amp;nbsp;</td><td></td></tr><tr><td>Lung retractor</td><td>Delacroix-Chevalier</td><td>B803990</td><td></td></tr><tr><td>Allis clamp</td><td>Delacroix-Chevalier</td><td>DC45907-25&amp;nbsp;</td><td></td></tr><tr><td>O&amp;rsquo;Shaugnessy Dissector</td><td>Delacroix-Chevalier</td><td>B60650</td><td></td></tr><tr><td>18 blade knife</td><td>Delacroix-Chevalier</td><td>B130180</td><td></td></tr><tr><td>Leriche haemostatic clamp</td><td>Delacroix-Chevalier</td><td>B86555</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Data analysis:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Mann-Whitney and Chi-square tests</td><td>GraphPad</td><td>Prism 7</td><td></td></tr></tbody></table>

full-root aortic valve replacement by stentless aortic xenografts in patients with small aortic roots

Aort kapak replasmanları ile aort kapak replasmanına ihtiyaç duyan küçük aort köklerine sahip hastalarda, stentli perikart valfinin implantasyonu fonksiyonel ihtiyaçları karşılamayabilir. 0.85 cm2 / m2&#39;den daha düşük bir vücut yüzey alanına endeksli etkili bir delik alanına yol açan çok küçük stentli bir perikard valfinin implantasyonu protez hastası uyuşmazlığı (PPM) olarak kabul edilir. Bir PPM, sol ventrikül hipertrofisinin gerilemesi ve dolayısıyla sol ventrikül fonksiyonunun normale dönmesi ve semptomların hafifletilmesini olumsuz etkiler. Kalıcı sol ventrikül hipertrofisi artmış aritmi ve ani kardiyak ölüm riski ile ilişkilidir. Öngörülebilir PPM durumunda üç seçenek vardır: 1) stentli bir perikard kapısının implante edilmesiyle elde edilen PPM&#39;yi kabul etmek, hastanın eştanısı olan hastalar daha teknik olarak daha büyük bir protezi yerleştirme operatif tekniklerini yasakladığında, 2)Aort kökünün daha büyük bir stent kapak ikamesi yerine getirmesi, veya 3) stentsiz bir biyolojik vana veya bir homograft yerleştirilmesi. Stentli perikart kapaklı klasik aort kapak replasmanı ile karşılaştırıldığında, stentless aortik ksenograftların tam kök implantasyonu, belirli bir hastaya 3-4 mm&#39;lik daha büyük bir vana yerleştirme imkanı sunar, bu nedenle transvalvüler gradyanlarda önemli düşüşe izin verir. Bununla birlikte, bir takım kalp cerrahları, klasik bir aort kapak replasmanını stentli perikard vana ile stentless aortik ksenograftların tam kök implantasyonuna dönüştürmek konusunda isteksizdirler. Stentless aortik ksenograftların olası hemodinamik avantajları göz önüne alındığında, aort kapak replasmanı gerektiren küçük aort köklerine sahip hastalarda PPM&#39;yi önlemek için tam kök implantasyonu uyguladık. Burada, stentsiz aortik ksenograftların tam kök implantasyonu için bir teknik ayrıntılı olarak, proksimal dikiş çizgisinin yönetimine vurgu ile veKoroner anastomozlar. Bu tekniğin sınırlamaları ve alternatif seçenekler tartışılmıştır.

istatistiksel analiz 23 mm boyutlu implante stentless aortik ksenograftlar için vücut yüzey alanına (EOAI, cm 2 / m 2 ) endekslenen projektif efektif delik alanının değerleri, ortalama ± standart sapma olarak ve hesaplanan stearli perikard kapakçıklarının EOAI&#39;sı ile 4 mm daha küçük olarak ( Yani 19 mm) parametrik olmayan Mann Whitney testi kullanıldı. Tablo 2&#39;de sürekli d...

Watch this Scientific Journal Video about Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots at JoVE.com

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

Stentless aortik ksenogreft ile kök aort kapak replasmanı, küçük aort köklü hastalarda uygulanabilir bir seçenektir. Proksimal dikiş çizgisinin ve koroner anastomozların önemini vurgulayan, stentless aortik ksenograftların tam kök implantasyonu için bir teknik tanımlıyoruz ve sınırlamalarını ve alternatif seçeneklerini tartışıyoruz.

Küçük Aort Köklü Hastalarda Stentless Aortik Xenograftlarla Tam Kök Aort Kapak Replasmanı

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial ...

full-root-aortic-valve-replacement-stentless-aortic-xenografts

Research

JoVE Journal

Medicine

11.2K Görüntüleme.  University of Zurich.  Stentless aortik ksenogreft ile kök aort kapak replasmanı, küçük aort köklü hastalarda uygulanabilir bir seçenektir. Proksimal dikiş çizgisinin ve koroner anastomozların önemini vurgulayan, stentless aortik ksenograftların tam kök implantasyonu için bir teknik tanımlıyoruz ve sınırlamalarını ve alternatif seçeneklerini tartışıyoruz. 

Video: Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

Orthotopic Aortic Transplantation in Mice for the Study of Vascular Disease

Vascular procedures involving anastomoses in the mouse are generally thought to be difficult and highly dependent on the skill of the individual surgeon. This is largely true, but there are a number of important principles that can reduce the difficulty of these procedures and enhance reproducibility. Orthotopic aortic transplantation is an excellent procedure in which to learn these principles because it involves only two end-to-end anastomoses, but requires good suturing technique and handling of the vessels for consistent success. This procedure begins with the procurement of a length of abdominal aorta from a donor animal, followed by division of the native aorta in the recipient. The procured aorta is then placed between the divided ends of the recipient aorta and sutured into place using end-to-end anastomoses. To accomplish this objective successfully requires a high degree of concentration, good tools, a steady hand, and an appreciation of how easily the vasculature of a mouse can be damaged, resulting in thrombosis. Learning these important principles is what occupies most of the beginner's time when learning microsurgery in small rodents. Throughout this protocol, we refer to these important points. This model can be used to study vascular disease in a variety of different experimental systems1-8. In the context shown here, it is most often used for the study of post-transplant vascular disease, a common long-term complication of solid organ transplantation in which intimal hyperplasia occurs within the allograft. The primary advantage of the model is that it facilitates quantitative morphometric analyses and the transplanted vessel lies contiguous to the endogenous vessel, which can serve as an additional control9. The technique shown here is most often used for mice weighing 18-25 grams. We have accumulated most of our experience using the C57BL/6J, BALB/cJ, and C3H/HeJ strains.

We describe a technique in which a section of the abdominal aorta from a mouse is transplanted orthotopically to just below the renal arteries in an allogeneic or syngeneic recipient. This technique can be useful in studies in which transplantation of large arteries of uniform size is deemed advantageous.

Damar Hastalığı Çalışmaları Farelerde Ortotopik Aort Nakli

Vascular procedures involving anastomoses in the mouse are generally thought to be difficult and highly dependent on the skill of the individual surgeon. ...

Tıp

A New Murine Model of Endovascular Aortic Aneurysm Repair

Endovascular aneurysm exclusion is a validated technique to prevent aneurysm rupture. Long-term results highlight technique limitations and new aspects of Abdominal aortic aneurysm (AAA) pathophysiology. There is no abdominal aortic aneurysm endograft exclusion model cheap and reproducible, which would allow deep investigations of AAA before and after treatment. We hereby describe how to induce, and then to exclude with a covered coronary stentgraft an abdominal aortic aneurysm in a rat. The well known elastase induced AAA model was first reported in 19901 in a rat, then described in mice2. Elastin degradation leads to dilation of the aorta with inflammatory infiltration of the abdominal wall and intra luminal thrombus, matching with human AAA. Endovascular exclusion with small covered stentgraft is then performed, excluding any interactions between circulating blood and the aneurysm thrombus. Appropriate exclusion and stentgraft patency is confirmed before euthanasia by an angiography thought the left carotid artery. Partial control of elastase diffusion makes aneurysm shape different for each animal. It is difficult to create an aneurysm, which will allow an appropriate length of aorta below the aneurysm for an easy stentgraft introduction, and with adequate proximal and distal neck to prevent endoleaks. Lots of failure can result to stentgraft introduction which sometimes lead to aorta tear with pain and troubles to stitch it, and endothelial damage with post op aorta thrombosis. Giving aspirin to rats before stentgraft implantation decreases failure rate without major hemorrhage. Clamping time activates neutrophils, endothelium and platelets, and may interfere with biological analysis.

Histological and biochemical modifications after aneurysm endograft exclusion are still unclear. We describe a new model of endograft implantation on a murine aneurysm. Through thrombus analysis with and without persistant circulating blood stream interface, and new endovascular biomaterials evaluation, this model will help to better understand endovascular aneurysm exclusion pathobiology.

Endovasküler Aort Anevrizma Onarımı Yeni Bir murin Modeli

Endovascular aneurysm exclusion is a validated technique to prevent aneurysm rupture. Long-term results highlight technique limitations and new aspects of ...

Transplantation of Pulmonary Valve Using a Mouse Model of Heterotopic Heart Transplantation

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed results. However, the cellular and molecular mechanisms of the neotissue development, valve thickening, and stenosis development are not researched extensively. To answer the above questions, we developed a murine heterotopic heart valve transplantation model. A heart valve was harvested from a valve donor mouse and transplanted to a heart donor mouse. The heart with a new valve was transplanted heterotopically to a recipient mouse. The transplanted heart showed its own heartbeat, independent of the recipient&#8217;s heartbeat. The blood flow was quantified using a high frequency ultrasound system with a pulsed wave Doppler. The flow through the implanted pulmonary valve showed forward flow with minimal regurgitation and the peak flow was close to 100 mm/sec. This murine model of heart valve transplantation is highly versatile, so it can be modified and adapted to provide different hemodynamic environments and/or can be used with various transgenic mice to study neotissue development in a tissue engineered heart valve.

In order to understand the cellular and molecular mechanisms underlying neotissue formation and stenosis development in tissue engineered heart valves, a murine model of heterotopic heart valve transplantation was developed. A pulmonary heart valve was transplanted to recipient using the heterotopic heart transplantation technique.

Heterotopik Kalp Nakli bir Fare Modeli Kullanarak Pulmoner Vana Nakli

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed ...

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

Aort kapak yeniden implantasyon Vana-tutumlu aort için standart tekniği kök değiştirme

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Teknik ve en az düzeyde erişim aort kapak replasmanı için hemen ön Mini Torakotomi hasta seçimi kriterleri

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

A Simplified Model for Heterotopic Heart Valve Transplantation in Rodents

There is an urgent clinical need for heart valve replacements that can grow in children. Heart valve transplantation is proposed as a new type of transplant with the potential to deliver durable heart valves capable of somatic growth with no requirement for anticoagulation. However, the immunobiology of heart valve transplants remains unexplored, highlighting the need for animal models to study this new type of transplant. Previous rat models for heterotopic aortic valve transplantation into the abdominal aorta have been described, though they are technically challenging and costly. For addressing this challenge, a renal subcapsular transplant model was developed in rodents as a practical and more straightforward method for studying heart valve transplant immunobiology. In this model, a single aortic valve leaflet is harvested and inserted into the renal subcapsular space. The kidney is easily accessible, and the transplanted tissue is securely contained in a subcapsular space that is well vascularized and can accommodate a variety of tissue sizes. Furthermore, because a single rat can provide three donor aortic leaflets and a single kidney can provide multiple sites for transplanted tissue, fewer rats are required for a given study. Here, the transplantation technique is described, providing a significant step forward in studying the transplant immunology of heart valve transplantation.

This protocol describes a simple and efficient method for the transplantation of aortic valve leaflets under the renal capsule to allow for the study of alloreactivity of heart valves.

Kemirgenlerde Heterotopik Kalp Kapağı Transplantasyonu için Basitleştirilmiş Bir Model

There is an urgent clinical need for heart valve replacements that can grow in children. Heart valve transplantation is proposed as a new type of ...

A Rodent Model of The Ross Operation: Syngeneic Pulmonary Artery Graft Implantation in A Systemic Position

The Ross operation for aortic valve disease has regained new interest due to its outstanding long-term results. Nonetheless, when employed as freestanding root replacement, the possible dilation of the pulmonary autograft and subsequent aortic regurgitation is described. Several animal models have been proposed. However, these are usually limited to ex-vivo models or in-vivo experiments with relatively expensive large animal models. In this study, we sought to establish a rodent model of pulmonary artery graft (PAG) implantation in a systemic position. A total of 39 adult Lewis rats were included. Immediately after euthanasia, the pulmonary root was harvested from a donor animal (n=17). Syngeneic recipient (n=17) and sham-operated (n=5) rats were sedated and ventilated. In the recipient group, the PAG was implanted with an end-to-end anastomosis in infra-renal abdominal aortic position. Sham-operated rats underwent only transection and re-anastomosis of the aorta. Animals were followed with serial ultrasound studies for two months and post-mortem histological analysis. The median PAG diameter in the native position was 3.20 mm (IQR=3.18-3.23). At follow-up, the median diameter of the PAG was 4.03 mm (IQR=3.74-4.13) at 1 week, 4.07 mm (IQR=3.80-4.28) at 1 month, and 4.27 mm (IQR=3.90-4.35) at 2 months (p&lt;0.01). Peak systolic velocity was 220.07 mm/s (IQR=210.43-246.41) at 1 week, 430.88 mm/s (IQR=375.28-495.56) at 1 month, and 373.68 mm/s (IQR=305.78-429.81) at 2 months (p=0.02) and did not differ from the sham-operated group at the end of the experiment (p=0.5). Histological analysis did not show any sign of endothelial thrombosis. This study showed that rodent models may allow for the evaluation of the long-term adaptation of the pulmonary root to a high-pressure system. A systemically placed syngeneic PAG implantation represents a simple and feasible platform for the development and evaluation of novel surgical techniques and drug therapies to further improve the outcomes of the Ross operation.

We demonstrate how to establish a murine model of pulmonary root implantation into the descending aorta to simulate the Ross procedure. This model enables the medium/long-term evaluation of pulmonary autograft remodeling in a systemic position, representing the basis of developing therapeutic strategies to promote its adaptation.

Ross Operasyonunun Kemirgen Modeli: Sistemik Pozisyonda Singeneik Pulmoner Arter Greft İmplantasyonu

The Ross operation for aortic valve disease has regained new interest due to its outstanding long-term results. Nonetheless, when employed as freestanding ...

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from symptomatic severe aortic valve stenosis. This is also reflected in the recently updated international guidelines on managing patients with valvular heart disease. A transfemoral&#160;(TF) TAVI&#160;approach has proven superior to alternative access strategies. With the introduction of intravascular lithotripsy (IVL), patients with calcified iliofemoral vascular disease and borderline intraluminal diameters have also become candidates for percutaneous TF-TAVI. Moreover, IVL reduces the risk of major vascular complications by modifying the superficial and deep vascular calcium, thereby changing the vessel compliance and controlling luminal expansion. In this way, IVL has shown to safely facilitate TF delivery of TAVI devices in patients with calcified peripheral artery disease. The present article aims to provide a detailed step-by-step description on how to perform IVL-assisted TF-TAVI safely and efficiently. Furthermore, a literature review on the outcomes obtained with this technology is included, along with a concise discussion on this unique TAVI approach.

<meta charset="utf8"></head><body>İntravasküler Litotripsi Yardımlı Transfemoral Transkateter Aort Kapak İmplantasyonu

Transcatheter aortic valve implantation (TAVI) has been shown to generate the best clinical outcomes when performed by the percutaneous transfemoral approach. Intravascular lithotripsy (IVL) can facilitate a transfemoral process in patients with calcified iliofemoral vascular disease and borderline intraluminal diameters. The present protocol describes IVL-assisted transfemoral TAVI.

İntravasküler Litotripsi Yardımlı Transfemoral Transkateter Aort Kapak İmplantasyonu

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from ...

Transcatheter Pulmonary Valve Replacement from Autologous Pericardium with a Self-Expandable Nitinol Stent in an Adult Sheep Model

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow tract or bioprosthetic valve dysfunction, with excellent early and late clinical outcomes. However, clinical challenges such as stented heart valve deterioration, coronary occlusion, endocarditis, and other complications must be addressed for lifetime application, particularly in pediatric patients. To facilitate the development of a lifelong solution for patients, transcatheter autologous pulmonary valve replacement was performed in an adult sheep model. The autologous pericardium was harvested from the sheep via left anterolateral minithoracotomy under general anesthesia with ventilation. The pericardium was placed on a 3D shaping heart valve model for non-toxic cross-linking for 2 days and 21 h. Intracardiac echocardiography (ICE) and angiography were performed to assess the position, morphology, function, and dimensions of the native pulmonary valve (NPV). After trimming, the crosslinked pericardium was sewn onto a self-expandable Nitinol stent and crimped into a self-designed delivery system. The autologous pulmonary valve (APV) was implanted at the NPV position via left jugular vein catheterization. ICE and angiography were repeated to evaluate the position, morphology, function, and dimensions of the APV. An APV was successfully implanted in&#160;sheep J. In this paper, sheep J was selected to obtain representative results. A 30 mm APV with a Nitinol stent was accurately implanted at the NPV position without any significant hemodynamic change. There was no paravalvular leak, no new pulmonary valve insufficiency, or stented pulmonary valve migration. This study demonstrated the feasibility and safety, in a long-time follow-up, of developing an APV for implantation at the NPV position with a self-expandable Nitinol stent via jugular vein catheterization in an adult sheep model.

This study demonstrates the feasibility and safety of developing an autologous pulmonary valve for implantation at the native pulmonary valve position by using a self-expandable Nitinol stent in an adult sheep model. This is a step toward developing transcatheter pulmonary valve replacement for patients with right ventricular outflow tract dysfunction.

Yetişkin Bir Koyun Modelinde Otolog Perikarddan Transkateter Pulmoner Kapak Replasmanı

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow ...

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