Name: standardized technique of aortic valve re-implantation for valve-sparing aortic root replacement
Uploaded: 2017-12-11T15:00:00
Description: Watch this Scientific Journal Video about Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement at JoVE.com

Dette arbeidet ble støttet av stipend (N ° 32117) av sveitsiske hjerte Foundation til RT.

Protokollen følger institusjonelle retningslinjene for menneskelig forskning etikk.
1. pre-utvalget av pasienten
<ol><li>Identifisere pasienter med utvidelse av bihulene for Valsalva ikke overskrider 60 mm bruker tomografi (CT) for pre-operative Datamaskinskanning.</li>
	<li>Deretter Velg blant disse pasientene en undergruppe med normal eller nesten normal vises Aortaklaff spisser på deres pre-operative echocardiography.</li>
	<li>Informere ansatte om muligheten for en ventil sparsom aorta...

<ol>
	<li>David, T. E., Feindel, C. M., Bos, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Repair+of+the+aortic+valve+in+patients+with+aortic+insufficiency+and+aortic+root+aneurysm.">Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm.</a> J Thorac Cardiovasc Surg. 109 (2), 345-352 (1995).</li><li>Yacoub, M. H., Gehle, P., Chandrasekaran, V., Birks, E. J., Child, A., Radley-Smith, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Late+results+of+a+valve-preserving+operation+in+patients+with+aneurysms+of+the+ascending+aorta+and+root.">Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root.</a> J Thorac Cardiovasc Surg. 115 (5), 1080-1090 (1998).</li><li>De Paulis, 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=One-year+appraisal+of+a+new+aortic+root+conduit+with+sinuses+of+Valsalva.">One-year appraisal of a new aortic root conduit with sinuses of Valsalva.</a> J Thorac Cardiovasc Surg. 123 (1), 33-39 (2002).</li><li>Rama, A., Rubin, S., Bonnet, N., Gandjbakhch, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+technique+of+aortic+root+reconstruction+with+aortic+valve+annuloplasty+in+ascending+aortic+aneurysm.">New technique of aortic root reconstruction with aortic valve annuloplasty in ascending aortic aneurysm.</a> Ann Thorac Surg. 83 (5), 1908-1910 (2007).</li><li>Richardt, D., Karluss, A., Schmidtke, C., Sievers, H. H., Scharfschwerdt, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+sinus+prosthesis+for+aortic+valve-sparing+maintaining+the+shape+of+the+root+at+systemic+pressure.">A new sinus prosthesis for aortic valve-sparing maintaining the shape of the root at systemic pressure.</a> Ann Thorac Surg. 89 (3), 943-946 (2010).</li><li>Schmidtke, C., 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=First+clinical+results+with+the+new+sinus+prosthesis+used+for+valve-sparing+aortic+root+replacement.">First clinical results with the new sinus prosthesis used for valve-sparing aortic root replacement.</a> Eur J Cardiothorac Surg. 43 (3), 585-590 (2013).</li><li>Stamou, S. C., Williams, M. L., Gunn, T. M., Hagberg, R. C., Lobdell, K. W., Kouchoukos, N. T. <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+surgery+in+the+United+States:+a+report+from+the+Society+of+Thoracic+Surgeons+database.">Aortic root surgery in the United States: a report from the Society of Thoracic Surgeons database.</a> J Thorac Cardiovasc Surg. 149 (1), 116-122 (2015).</li><li>David, T. E., Feindel, C. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+aortic+valve-sparing+operation+for+patients+with+aortic+incompetence+and+aneurysm+of+the+ascending+aorta.">An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.</a> J Thorac Cardiovasc Surg. 103 (4), 617-621 (1992).</li><li>Hopkins, R. A. <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+leaflet+sparing+and+salvage+surgery:+evolution+of+techniques+for+aortic+root+reconstruction.">Aortic valve leaflet sparing and salvage surgery: evolution of techniques for aortic root reconstruction.</a> Eur J Cardiothorac Surg. 24 (6), 886-897 (2003).</li><li>Mve Mvondo, C., 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=Surgical+treatment+of+aortic+valve+regurgitation+secondary+to+ascending+aorta+aneurysm:+is+adjunctive+subcommissural+annuloplasty+necessary?.">Surgical treatment of aortic valve regurgitation secondary to ascending aorta aneurysm: is adjunctive subcommissural annuloplasty necessary?.</a> Ann Thorac Surg. 95 (2), 586-592 (2013).</li><li>Aicher, D., Schneider, U., Schmied, W., Kunihara, T., Tochii, M., 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=Early+results+with+annular+support+in+reconstruction+of+the+bicuspid+aortic+valve.">Early results with annular support in reconstruction of the bicuspid aortic valve.</a> J Thorac Cardiovasc Surg. 145 (3 Suppl), S30-S34 (2013).</li><li>Lansac, 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=Aortic+prosthetic+ring+annuloplasty:+a+useful+adjunct+to+a+standardized+aortic+valve-sparing+procedure?.">Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure?.</a> Eur J Cardiothorac Surg. 29 (4), 537-544 (2006).</li><li>Tavakoli, R., Jamshidi, P., Gassmann, M. <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+by+stentless+aortic+xenografts+in+patients+with+small+aortic+root.">Full-root aortic valve replacement by stentless aortic xenografts in patients with small aortic root.</a> J Vis Exp. (123), e55632 (2017).</li><li>Zoghbi, W. A., 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=Recommendations+for+evaluation+of+the+severity+of+native+valvular+regurgitation+with+two-dimensional+and+Doppler+echocardiography.">Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.</a> J Am Soc Echocardiogr. 16 (7), 777-802 (2003).</li><li>Cohle, S. D., Delavan, J. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Coronary+artery+compression+by+teflon+pledget+granuloma+following+aortic+valve+replacement.">Coronary artery compression by teflon pledget granuloma following aortic valve replacement.</a> J Forensic Sci. 42 (5), 945-946 (1997).</li><li>Vallabhajosyula, P., 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=Geometric+orientation+of+the+aortic+neoroot+in+patients+with+raphed+bicuspid+aortic+valve+disease+undergoing+primary+cusp+repair+and+a+root+reimplantation+procedure.">Geometric orientation of the aortic neoroot in patients with raphed bicuspid aortic valve disease undergoing primary cusp repair and a root reimplantation procedure.</a> Eur J Cardiothorac Surg. 45 (1), 174-180 (2014).</li><li>David, T. E., David, C. M., Feindel, C. M., Manlhiot, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reimplantation+of+the+aortic+valve+at+20+years.">Reimplantation of the aortic valve at 20 years.</a> J Thorac Cardiovasc Surg. 153 (2), 232-238 (2017).</li><li>Zehr, K. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Form+ever+follows+function.">Form ever follows function.</a> J Thorac Cardiovasc Surg. 151 (1), 120-121 (2016).</li><li>De Paulis, 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=Long-term+results+of+the+valve+reimplantation+technique+using+a+graft+with+sinuses.">Long-term results of the valve reimplantation technique using a graft with sinuses.</a> J Thorac Cardiovasc Surg. 151 (1), 112-119 (2016).</li><li>Gleason, T. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+graft+formulation+and+modification+of+the+David+reimplantation+technique.">New graft formulation and modification of the David reimplantation technique.</a> J Thorac Cardiovasc Surg. 130 (2), 601-603 (2005).</li><li>Demers, P., Miller, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simple+modification+of+"T.+David-V"+valve-sparing+aortic+root+replacement+to+create+graft+pseudosinuses.">Simple modification of "T. David-V" valve-sparing aortic root replacement to create graft pseudosinuses.</a> Ann Thorac Surg. 78 (4), 1479-1481 (2004).</li><li>David, T. E., Maganti, M., Armstrog, S. <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+aneurysm:+principles+of+repair+and+long-term+follow-up.">Aortic root aneurysm: principles of repair and long-term follow-up.</a> J Thorac Cardiovasc Surg. 140 (6S), S14-S19 (2010).</li><li>Shrestha, 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=Long-term+results+after+aortic+valve-sparing+operation+(David+I).">Long-term results after aortic valve-sparing operation (David I).</a> Eur J Cardiothorac Surg. 41 (1), 56-61 (2012).</li></ol>

Hos pasienter med aorta roten aneurisme med normal eller nesten normal aorta spisser, ventil-sparing aorta roten er en mer fysiologiske og dermed attraktivt alternativ til sammensatte pode utskifting av aorta og aortic ventilen med mekanisk eller vev ventil. I denne protokollen, beskriver vi forenklet teknikk ventil-sparing aorta roten erstatning av re implantering av aortic ventilen. I motsetning til fleste tidligere rapportert teknikker3,8distribueres denne pro...

De siste tjue årene, kirurgisk behandling av aorta roten aneurisme med normal eller nesten normal aorta spisser har utviklet seg takket være en rekke kirurgiske prosedyrer sikte på bevaring av den opprinnelige Aortaklaff1,2, 3,4,5. Valve-sparing aorta roten erstatning oppnås i utgangspunktet ved re implantering av Aortaklaff inne en syntetisk pode1,3,4,6 eller en ombygging teknikk som gjenoppretter fysiologiske Anatomien av aorta roten2. Til tross for åpenbare fordelene ved bevaring av en normal Aortaklaff under aorta roten erstatning erstatte mange enkelte kirurger aortic ventilen med enten mekaniske eller biologiske ventil substitutter. Ifølge Society of Thoracic kirurger database mottok bare 14% av pasienter som gjennomgikk aorta roten erstatning i USA fra 2004 til 2010 en ventil-sparing prosedyre7.
I det opprinnelige re implantasjon teknikken Burrows aortic ventilen innenfor en rørformet vannrett crimped syntetiske pode8. Selv om denne teknikken stabiliserer aorta ringrommet, eliminerer bihulene for Valsalva. For å gjenskape bihulene for Valsalva, har denne teknikken gjennomgått flere endringer av oppfinneren samt andre forfattere9. En variant av denne teknikken har blitt foreslått av Rama et al., der restene av aorta veggen støtter commissures er sutured i langsgående åpninger i rørformede polyetylen terephthalate pode4.
Remodeling teknikken oppnår en mer anatomiske rekonstruksjon av aorta roten men forlater aorta ringrommet støttes ikke og utsatt for fremtidige dilatasjon. Ulike kirurgiske teknikker er utviklet for å skreddersy aorta ringformede base i aorta roten remodeling, inkludert sub-commissural aorta annuloplasty10, omkrets Sutur annuloplasty11og interne eller eksterne annuloplasty ring12av syntetisk delvis eller fullstendig.
Til tross for gode resultater rapportert av erfarne forfattere, kompleksitet og periodiske endringer av disse prosedyrene hemme deres reproduserbarhet av andre enkelte kirurger og dermed hindre en rekke egnede pasienter å nytte beholder sine egen Aortaklaff. For å styrke reproduserbarhet re implantasjon teknikk, har vi brukt et kommersielt tilgjengelige syntetiske pode med en uncrimped, pre-formet sinus del og forenklet implantasjon teknikken. Målet med denne protokollen er å beskrive i detalj denne standardisert og reproduserbar teknikken med særlig vekt på ledelse av den første raden i den proksimale Sutur linjen og plassering av commissures inne graftet og valg av graftet størrelse. Tidlige resultater og mellomlang sikt resultatene presenteres. Riktig valg av pasienter og begrensninger i denne fremgangsmåten er diskutert.

<table>
	<tbody>
		<tr>
			<td>Heart surgery infrastructure:</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&#160;</td>
			<td>Edwards</td>
			<td>NPC014&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Coronary artery ostial cannula 90&#176;</td>
			<td>Medtronic</td>
			<td>30155</td>
			<td></td>
		</tr>
		<tr>
			<td>Coronary artery ostial cannula 45&#176;</td>
			<td>Medtronic</td>
			<td>30255</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Pre-shaped sinus graft</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cardioroot 28 mm</td>
			<td>Maquet</td>
			<td>HEWROOT0028</td>
			<td></td>
		</tr>
		<tr>
			<td>Cardioroot 30 mm</td>
			<td>Maquet</td>
			<td>HEWROOT0030</td>
			<td></td>
		</tr>
		<tr>
			<td>Cardioroot 32 mm</td>
			<td>Maquet</td>
			<td>HEWROOT0032</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Electrocautery</td>
			<td>Covidien</td>
			<td>Force FX</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Sutures:</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&#160;</td>
			<td>Ethicon</td>
			<td>X305H</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Micro knife Sharpoint&#160;</td>
			<td>TYCO Healthcare PTY&#160;</td>
			<td>78-6900</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Drugs:</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 &#38; Dohme&#160;</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>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Instruments:</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&#160;</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&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Dissection forceps DeBakey</td>
			<td>Delacroix-Chevalier</td>
			<td>DC12000-21&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro needle holder Jacobson</td>
			<td>Delacroix-Chevalier</td>
			<td>DC50002-21&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro scisors Jacobson</td>
			<td>Delacroix-Chevalier</td>
			<td>DC20057-21&#160;</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&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>O&#8217;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>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Data analysis</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Kaplan Meier curves</td>
			<td>GraphPad</td>
			<td>Prism 7</td>
			<td></td>
		</tr>
	</tbody>
</table>

standardized technique of aortic valve re-implantation for valve-sparing aortic root replacement

Kompleksiteten i ventil sparsom prosedyrer forhindrer at en rekke enkelte kirurger innlemme dem i sin praksis til tross for åpenbare fordelene ved bevaring av en normal Aortaklaff under aorta roten erstatning. Målet med denne protokollen er å beskrive en aortic ventilen-sparing rot erstatning (VSRR) prosedyre forenklet og brukervennlig teknikk ved re implantering av aortic ventilen. Riktig valg av pasienter og begrensninger av teknikken er diskutert.
I 54 påfølgende pasienter var normalt vises aorta ventiler re implantert i en kommersielt tilgjengelig polyester protese Forbøyde bihulene av en forenklet og standardisert teknikk. Plasseringen av den første raden i den proksimale Sutur linjen, valg av protesen og justering av høyden på commissures av pasienten fast høyden på sinus delen av protesen var noe endret fra referanse teknikker med den sikte på å øke sin muligheten for bruk av andre enkelte kirurger. Tidlig dødelighet og sykelighet samt 5-års overlevelse, frihet fra Aortaklaff reoperation og frihet fra tilbakevendende moderat oppstøt ble samlet i alle pasienter.
Tretti dagers dødelighet, re-sternotomy for blødning, re-sternotomy for mediastinitis, og forekomsten av hjerneslag var svært lav, 1,8% for hver (1 av 54). Ingen pasient nødvendig permanent pace-maker implantasjon. På 5 år, overlevelse, frihet fra Aortaklaff reoperation og frihet fra tilbakevendende moderat oppstøt var 97,5% og 95,2% 91,6%, henholdsvis.
Mellomlang sikt resultatene av våre standardiserte teknikk re implantering av aortic ventilen for ventil-sparing aorta roten erstatning er veldig bra og sammenligne med mer komplekse teknikker rapportert av erfarne kirurger. Ved å følge stede protokollen av standardiserte re implantasjon teknikken, kan et større antall enkelte kirurger utføre denne prosedyren med sammenlignbare gode resultater.

Statistisk analyse:
Kontinuerlig variabler presenteres som gjennomsnittlig ± standardavvik og kategoriske variabler som prosenter. Kaplan-Meier kurver beregnet for overlevelse, frihet fra Aortaklaff reoperation og frihet fra tilbakevendende moderat gulpe opp ved hjelp av en kommersielt tilgjengelig programvarepakke.
Pasienten befolkningen:
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Watch this Scientific Journal Video about Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement at JoVE.com

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

Valve-sparing aorta roten erstatning har fordelen av å bevare pasientens egen aortic ventilen. Kompleksiteten i rapporterte teknikker hittil begrenser bruken til et begrenset antall enkelte kirurger. Denne protokollen beskriver trinnvis en standardisert teknikk reproduserbar av et større antall enkelte kirurger.

Standardisert teknikk av Aortaklaff re implantasjon for ventil-sparing aorta roten erstatning

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

The overall goal of this protocol is to describe in detail a Standardized and Reproducible Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement with particular emphasis on the management of the first row of the proximal suture. This method can help answer key questions regarding aortic valve preservation during aortic route replacement. The main advantage of this technique is that it uses a single graft with a pre-shaped sinus portion that helps standardization of the procedure.Begin this procedure with patient selection as detailed in the text protocol. Prepare the surgery suite and the patient for surgery as previously described. Access the heart through a median sternotomy as referenced in the text protocol.Then, prepare the aortic route for replacement by first grabbing the ascending aorta at the sinotubular junction with Carpentier dissection forceps. Then, make a horizontal opening with the 11 blade knife. Complete the aortotomy circumferentially and horizontally with Metzenbaum scissors.After having transected the aorta, verify the absence of calcifications of the cusps and/or thickening and retraction of their free margin. Check the coronary ostia. Dissect the outer aspect of the noncoronary sinus down to the roof of the left atrium, free from the surrounding tissue.Next, detach the right coronary ostium from the aortic wall with a generous circular patch, leaving five millimeters of the aortic wall remnant attached to the insertion of the cusps. Free the commissure between the noncoronary and right coronary sinus from the surrounding tissue. Dissect the outer aspect of the aortic wall remnant of the right coronary sinus free from the outflow tract of the right ventricle.Then, free the outer aspect of the commissure between the noncoronary and left coronary sinus down to the roof of the left atrium. Excise the aortic wall of the noncoronary sinus leaving five millimeters of the aortic wall remnant attached to the insertion of the cusp. Separate the outer aspect of the commissure between the right and left coronary sinus from the surrounding tissue.Take care not to injure the pulmonary artery. Then, detach the left coronary ostium from the aortic wall with the generous circular patch, leaving five millimeters of the aortic wall remnant attached to the insertion of the cusp. Mobilize the left main coronary artery over its first 10 millimeters.Dissect the outer aspect of the aortic wall remnant of the left coronary sinus free from the roof of the left atrium. Start the proximal implantation of the prosthesis as described in the text protocol. The single most difficult step of this procedure is the placement of the first row of the sutures by taking care not to injure the membranous septum and the anterior leaflet of the mitral valve.Place the fourth suture next to the third one in the direction of the commissure between the noncoronary and right coronary sinus. Avoid the base of the commissural triangle between the noncoronary and right coronary sinus, so as to not compromise the membranous septum. Start the first suture of the right coronary sinus two millimeters away from the base of the commissural triangle of the commissure between the noncoronary and right coronary sinus, thus skipping the membranous septum.Put the following sutures of the right coronary sinus in the direction of the commissure between the left and right coronary sinus. Place the fourth suture of the right coronary sinus at the base of the commissural triangle of the commissure between the left and right coronary sinus. Now pass the mattress sutures inside out into the prosthesis.Slide down the prosthesis, thus placing the valve inside it. Tie the mattress sutures gently and cut them. Start the second row of the proximal anastomosis as described in the text protocol.Finish the second row of the proximal anastomosis by fixing the remnant of the aortic wall in parallel to the insertion of the cusp up to the commissure, between the noncoronary and right coronary sinus. Tie the two suture ends together at each commissure. Check the absence of aortic regurgitation by filling the prosthesis with saline and applying suction to the vent placed to the right pulmonary vein and the mitral valve into the left ventricle.Reconnect the coronary ostia to the prosthesis by first creating a button hole in the left sinus of the prosthesis and placing the first stitch as detailed in the text protocol. Place the second stitch two millimeters to the right of the first one from inside out of the prosthesis and outside in of the left coronary ostium up to the mid height of the right ridge of the anastomosis. Put the suture end under light tension.Continue the running suture on the left ridge of the anastomosis from outside in the prosthesis and from inside out of the left coronary ostium to meet the other end. Tie the two ends together. After creating a button hole on the right sinus of the prosthesis and starting a suture as detailed in the text protocol, continue the suture to the mid height of the right ridge of the anastomosis and put the end under light tension.Complete the anastomosis by running the left ridge of the anastomosis to meet the other end. Tie the two ends together. Start the distal anastomosis as described in the text.Complete the distal anastomosis by running the suture on the left ridge to meet the other end. Tie the ends together. Tilt the operating table in the Trendelenburg position.Let the pump flow reduce to 50%of the full flow and slowly remove the aortic cross clamp under gentle aspiration of the left ventricular vent. After the procedure, resume the full flow of the cardiopulmonary bypass and check the operative field for undue surgical bleeding. Rewarm and separate the patient from the cardiopulmonary bypass.Finally, perform a post-operative patient care as referenced in the text protocol. The Kaplan Meier survival curve reveals that there were a total of three deaths in this series during the follow-up period. Thus, the five-year survival rate in this series was 97.5%and the 10-year survival rate was 92.5%Two of the four patients with recurrent moderate aortic regurgitation, underwent re-operation because of the progredient left ventricle dilatation.As a result, the freedom of re-operation for aortic valve replacement was 95.2%at five years and 93%at 10 years. For patients developed moderate aortic regurgitation during the follow up period. Therefore, their freedom from moderate aortic regurgitation was 91.6%at five years and 90%at 10 years.Once mastered, this technique can be done in 150 minutes if it is performed properly. While attempting this procedure, it is important to remember to entirely free the aortic route from the surrounding tissue. After watching this video, you should have a good understanding of how to avoid injury to the membranous septum during the procedure.Following this protocol, other surgical procedures on the aortic route can be performed to address different route pathologies. After its development, this technique opened the era of the preservation of the normal aortic valve during aortic route surgery. Don't forget that operating on the aortic route can be hazardous and gentle dissection of the tissue and placement of the sutures should always be taken while performing this procedure.

Research

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