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

这项工作得到了瑞士心血管基金会向RT提供的资助。

该议定书遵循人类研究伦理委员会的机构准则。 1.预选患者<ol><li>使用术前超声心动图，确定估计主动脉环直径小于20 mm的患者。请注意，在严重钙化的主动脉瓣和瓣膜中，术前超声心动图有时可能会误导。 </li><li>从这些患者中选择身体表面积大于1.6平方米的亚组。 </li><li>在阀门制造商提供的图表上验证，标记为19 mm的支架式心包主动脉瓣置换的有效孔面积为1.28 cm 2 。 </li><li>确保在上述亚组患者中植入置入19 mm的支架置入的心包主动脉瓣置换术将导致EOAI小于0.85 cm 2 / m 2 （1.28 cm 2除以1.6 m 2 = 0.8cm 2 / m 2 ）。 </li><li>告知工作人员全根无支架主动脉异种移植植入的可能性。 </li><li>取出主动脉瓣后，在术中做出最终决定。检查冠状动脉口腔是否没有钙化，而用于支架置入的心包主动脉瓣置换器的19 mm阀门尺寸调节器通过过大的主动脉瓣环太紧。 </li></ol> 2.手术准备注意:手术准备遵循成人心脏手术患者的制度指南和建议。 <ol><li>以典型的方式清洁并准备手术套件。为了方便外科医生和灌肠者之间的沟通，将心脏肺机器放置在患者左侧，与外科医生相对。 </li><li>在诱导麻醉前30-60分钟口服5mg咪达唑仑，预先给予患者治疗。 </li><li>莫根据标准指导，病人按照麻醉师的直接动脉和中心静脉压力进入。使用0.5-1.5mg / kg丙泊酚，1-2μg/ kg芬太尼和0.6mg / kg罗库溴铵的初始静脉内注射诱导麻醉。 </li><li>根据需要进行气管插管，然后通过静脉滴注丙泊酚100-150μg/ kg / min，芬太尼0.015 - 0.03μg/ kg / min和罗库溴铵0.6 - 1.2μg/ kg / min进行麻醉。 </li><li>将患者安置在仰卧位，以无菌的方式悬挂她/他，使手术区域的胸部，腹部和腹股沟自由。 </li></ol> 3.手术<ol><li> 通过中位胸骨切开术进入心脏。 <ol><li>使用18刀刀将皮肤纵向切开超过15厘米，开始于上胸部切口1厘米处。注意留在胸骨宽度的中间。 </li><li>用振荡器看见胸骨tory看见注意留在胸骨宽度的中间。 </li><li>用Carpentier解剖镊子抓住心包并用Metzenbaum剪刀切开心包。继续使用电烙术将心包切开上升主动脉的反射线。 </li><li>通过IV线给予300IU的肝素/ kg（浓度:5000U / mL）。 </li><li>使用市售的动脉插管13插管远端升主动脉。 </li><li>使用市售的心房静脉插管13插入右心房。 </li><li>开始体外循环。将患者冷却至32°C。 </li><li>将市售的通气孔通过右上肺静脉和左心室的二尖瓣放出左心脏13 。用聚丁烯涂层的编织聚酯2/0结扎固定。 </li><li>插入市售逆行心脏停搏套管穿过冠状窦。用聚丁烯涂层的编织聚酯2/0结扎固定。 </li><li>将市售的顺行性心脏停搏插管插入主动脉根部，在中肠管结。用聚丁烯涂层的编织聚酯2/0结扎固定。 </li><li>夹紧动脉插管部位下方的远端升主动脉。 </li><li>通过主动脉根部的顺行插管提供顺行的冷血心麻痹，每20分钟反复重复一次。在完成冠状动脉吻合术后，使用市售的冠状动脉心脏停搏套管将顺行的冷血心麻痹症直接重复进入冠状动脉门静脉。 </li></ol></li><li> 准备主动脉根植入。 <ol><li>去除顺行的心脏停搏套管。使用Carpentier解剖镊子抓住上升主动脉，左侧开口左侧的左侧椭圆形的心脏停跳套管。 </li><li>用18刀刀放大开口。用Metzenbaum剪刀完成主动脉横断。验证右冠状动脉口和左冠状动脉口的存在。 </li><li>用Carpentier解剖钳抓住Valsalva左窦顶部，并用Metzenbaum剪刀从主动脉壁解剖患者左侧冠状动脉和近端主左冠状动脉，周围的斑块为5mm。将5/0聚丙烯保持缝线穿过左冠状动脉口周围的补片顶部。 </li><li>用Carpentier解剖镊子抓住Valsalva右窦顶部，并用Metzenbaum剪刀从主动脉壁解剖右侧冠状动脉和患者近端右冠状动脉，周围的斑块为5mm。将5/0聚丙烯保持缝线穿过右侧冠状动脉口的补片顶部。 </li><li>确认病态主动脉瓣叶片的变化。 </li><li>用Carpentier解剖钳抓住右冠状动脉瓣，并用Metzenbaum剪刀切除。用Carpentier解剖镊子抓住非冠状动脉小叶，并用Metzenbaum剪刀切除。 </li><li>用Carpentier解剖镊子抓住左冠状动脉瓣，并用Metzenbaum剪刀切除。用Carpentier解剖钳抓住非冠状动脉Valsalva窦壁，并从顶部到窦底部进行垂直切口。距离主动脉环1厘米。 </li><li>使用市售的分流器校准主动脉瓣环。确保用于支架式心包瓣的19 mm尺寸调节器通过主动脉环通过得太紧，而用于无支架主动脉异种移植物的23 mm尺寸适配器适用于主动脉环的顶部。 </li><li>一旦其尺寸确定，请打开阀门的包装。 </li><li>通过将阀门放置在750以下来开始冲洗阀门mL无菌，生理盐水溶液。确保盐水溶液完全覆盖阀门。轻轻地将阀门来回旋转至少1分钟。丢弃冲洗溶液。重复此过程至少两次，使用新的盐水溶液，总共三次冲洗，每次1分钟。 </li><li>通过将无支架主动脉异种移植物的原位左冠状动脉口腔或结扎左冠状动脉扩张到左冠状动脉和非冠状动脉窦之间的连合处，在无支架主动脉异种移植物中创建左冠状动脉新腔。根据患者左侧冠状动脉口腔及其周围的斑块，调整这种新口腔的大小。 </li><li>让助手握住拇指和食指之间的无支架主动脉异种移植壁，使得移植物的左侧新冠状动脉口向上取向。 </li></ol></li><li> 开始用近端缝线植入无支架主动脉异种移植物。 <ol><li>在每个主动脉结膜上方放置4/0聚丙烯保持缝合线。拉起这些牵引缝线以更好地暴露患者的主动脉环。 </li><li>使用4/0聚丙烯缝合线，在左冠状动脉新腔下方的无支架主动脉异种移植物左冠状动脉缝的中间开始近端吻合的第一缝合。将这种第一种从异种移植物的外部方面传递到内部。 </li><li>将左冠状窦中部的第一只睾丸穿过患者的主动脉环，从心室向外，使用Ryder针架和Carpentier解剖钳。确保异种移植物的左冠状动脉孔正好面对病人的左冠状面。 </li><li>用Carpentier解剖镊子小心地抓住无支架主动脉异种移植物的缝合环的脊。将第二只睾丸穿过第二颗2毫米，从第二只异种移植物的外部到内部方面。将缝合线轻轻地穿过移植物以获得其全长。 </li><li>抓住左侧冠状动脉窦和非冠状动脉窦之间的连接顶部的主动脉壁（用Carpentier解剖钳），并将其拉起以拉伸患者主动脉环的左窦部分。 </li><li>将患者的主动脉环的左冠状窦的第二个静脉穿过第一个左侧的左侧，从心室向外。使用莱德针架和Carpentier解剖钳。 </li><li>通过轻轻拉动第一缝合线的两端，向下滑动无支架主动脉异种移植物。将第一条缝合线的右端放在牵引力上。 </li><li>用Carpentier解剖镊子抓住无支架主动脉异种移植物的左冠状窦和右冠状窦之间的连接顶部的主动脉壁，并向右轻轻拉动移植物以暴露患者左冠状窦左半部分。 </li><li>通过第三在第二个左侧，从无外支架主动脉异种移植物的外部方面到内部两侧的距离为2毫米。 </li><li>让第一助手紧紧握住第一缝合线的左端，并使用Carpentier解剖镊子抓住病人左右冠状窦之间的合并顶端的主动脉壁。让第二助手使用肺牵开器轻轻展开患者的右冠状窦。 </li><li>将患者主动脉环的左冠状窦内的第三个睾丸穿过第二个左心室的左侧，从心室向外。使用莱德针架和Carpentier解剖钳。 </li><li>将第一条缝合线连接到病人左侧和右侧冠状动脉窦之间的连接处。将第一缝合线的左端放在牵引力上。 </li><li>通过将第一个针脚2毫米放在无支架主动脉x的缝合环的最后一针的一侧，开始第二个4/0聚丙烯运行缝合从外向内移植。 </li><li>将第二次运行缝合线的第一根刺针穿过患者的主动脉瓣环的右冠状窦，右侧最后一个，从心室向外，使用莱德针架和Carpentier解剖钳。 </li><li>将第二个4/0聚丙烯运行缝合线的第二线圈放置在无支架主动脉异种移植物的缝合环中，距离第一个2mm侧。让第一名助手宽松地握住缝线的跑步。 </li><li>将第二个4/0聚丙烯运行缝合线的第二针缝合到病人主动脉环的右冠状窦上，距离第一个2 mm右心室从心室向外。使用莱德针架和Carpentier解剖钳。 </li><li>将第二个4/0聚丙烯运行缝合线的第三个针迹放在无支架主动脉异种移植物的缝合环中，向第二个侧面移动2mm。让第一个助手松散地ld缝合线的运行端。 </li><li>将第二个4/0聚丙烯运行缝合线的第三针缝合到病人主动脉环的右冠状窦上，距离第二个心室的右侧2mm，从心室向外。使用莱德针架和Carpentier解剖钳。 </li><li>将第二条缝合线运送到患者主动脉环的右冠状窦的中部。缓慢拉动第二条运动缝合线的两端，将移植物和主动脉环带紧密连在一起。将第二条缝合线的两端放置在牵引力上。 </li><li>将第三个4/0聚丙烯运行缝合线的第一针缝合2毫米从无支架主动脉异种移植物的缝合环的最后一个针迹的一侧，从外部到内部。让第一名助手宽松地握住缝线的跑步。 </li><li>将第三个4/0聚丙烯运行缝合线的第一针穿过2mm右侧冠状动脉的最后一针我们的病人的主动脉环。 </li><li>运行第三个4/0聚丙烯运行缝合线到病人的右冠状动脉和非冠状动脉窦之间的连合处。将第三根缝线的两端放在牵引力上。 </li><li>放置第四个4/0聚丙烯运行的缝合线，在移植物和主动脉环侧上有2mm的空间，从右冠状动脉窦和非冠状动脉窦之间的连接处开始，并行进到非冠状窦的中间。最初，让第一助手宽松地握住缝线。 </li><li>慢慢地拉动第四条运行缝合线的两端，将患者的移植物和主动脉环带紧紧连在一起。让第一名助手用Carpentier解剖镊子抓住移植物，并将其带到患者的主动脉环。将第四条缝合线的两端放在牵引上。 </li><li>放置第五个4/0聚丙烯运行缝合线，在移植物和主动脉环面两侧有2mm的空间，开始在非冠状动脉窦的中间，并且运动到非冠状动脉和左冠状窦之间的并发症。最初，让第一助手宽松地握住缝线。 </li><li>缓慢拉动第五条缝合线的两端，将患者的移植物和主动脉环带紧紧连在一起。让第一名助手用Carpentier解剖镊子抓住移植物，并将其带到患者的主动脉环。将第五条缝合线的两端放在牵引力上。 </li><li>放置第六个4/0聚丙烯运行的缝合线，在移植物和主动脉瓣环两侧有2毫米的空间，从非冠状动脉和左冠状动脉窦的连接开始，并行驶到左冠状动脉窦的中部，以满足第一个4/0聚丙烯运行缝合的右端。最初，让第一助手宽松地握住缝线。 </li><li>缓慢拉动第六条缝合线的两端，紧紧接合移植物患者的主动脉瓣环。让第一名助手用Carpentier解剖镊子抓住移植物，并将其带到患者的主动脉环。将第六条缝合线的两端放在牵引力上。 </li><li>将相邻的运行缝合线的两端绑在一起。验证在近端缝合线和冠状动脉口附近抽吸后叮咬之间没有任何间隙。 </li></ol></li><li> 将患者的左冠状动脉重新连接到移植物的左冠状动脉新腔。 <ol><li>将6/0聚丙烯运行缝合线的第一针缝合在移植物左冠状动脉新腔的最深处，从内到外。使用微针架和DeBakey解剖镊子。 </li><li>将6/0聚丙烯运行缝合线的第一针穿过患者左侧冠状口的最深处，从外部到内部。缓慢拉动6/0聚丙烯的两端运行缝合物将患者左侧冠状动脉新生口和左冠状动脉口吻合在一起。 </li><li>将缝合线的第二线圈放置在第一根缝线的右侧，从移植物的内侧到外侧。 </li><li>将缝合线插入左冠状动脉吻合口右脊的中间。将缝合线的这一端放在牵引力上。 </li><li>继续通过将缝合线的左端穿过移植物的左冠状动脉新腔，从外部到内部，然后进入患者的左冠状面，从内到外。 </li><li>轻轻地抓住左冠状动脉口的移植物和脊，以便每次缝合线穿过时将它们聚集在一起。 </li><li>带缝线满足另一端。然后把两端连在一起。 </li></ol></li><li> 将患者的右冠状动脉孔重新连接到移植物的右冠状动脉新生口。 <ol><li>抓用DeBakey解剖镊子连接右冠状动脉口。通过切除移植物的结扎右冠状动脉并在水平方向扩大开口，使用手术刀（ 例如，尖锐的）在移植物的右冠状动脉和非冠状动脉窦之间的连合处，在移植物中创建右冠状动脉新口。 </li><li>将6/0聚丙烯运行缝合线的第一线圈放置在患者右冠状动脉口的下脊的左端，从内向外。使用微针架和DeBakey解剖镊子。 </li><li>将6/0聚丙烯运行缝合线的第一针缝合在移植物右冠状动脉新腔的下端左侧，从外侧到内侧。缓慢拉动6/0聚丙烯运行缝合线的两端，将右侧冠状动脉新生口和患者右冠状动脉口吻合。 </li><li>放置苏打的第二针e右侧第一个，右侧冠状动脉内侧至外侧的病人，然后从外侧移至右侧冠状动脉新生口内侧。 </li><li>将缝合线插入右冠状动脉吻合口右脊的中间。将缝合线的这一端放在牵引力上。 </li><li>通过将缝线从外部放置到患者右冠状动脉的内侧并从移植物的右冠状动脉的内侧到外侧，继续缝合左端。 </li><li>让第一助手用肺牵开器轻轻收回右心室流出道，以改善手术区的展现。 </li><li>将缝合线的左端朝向右端，并将它们绑在一起。 </li><li>冠状动脉吻合完成后，将冠状动脉口腔插管置于左冠状动脉口45°，右冠状动脉插管90°病人的冠状口。将顺行的冷血心麻痹直接重复进入冠状动脉。 </li></ol></li><li> 完成远端吻合。 <ol><li>将5/0聚丙烯运行缝合线的第一针缝合在移植物下缘的左端，从内到外，然后从外部到内部进入面向远端的升主动脉。 </li><li>在吻合的右侧面留下一个泵吸盘，用于相对无血的手术区域。 </li><li>把下一个针脚放在前一个针脚的右边。使用微针夹持器和Carpentier解剖镊子，继续缝合从内侧到外侧的移植物和远端升主动脉的外部到内部。 </li><li>使用Carpentier解剖镊子，抓住远端升主动脉下缘右端的外膜，并将其水平向右拉以展开a的下部nastomosis。从外侧到大主动脉内侧的每个通道重复此操作。 </li><li>按照并将每个针迹从内侧放置在吻合的后缘上，使得所有针脚定期坐在距离彼此2mm的距离处。将缝合线缝合到吻合口右边缘的中间。将缝合线的末端放在牵引力上。 </li><li>继续缝合左端。同时，开始逆行温血心脏停搏。将缝线等距放置在吻合的前方，从无支架移植物的外侧到内侧，以及远端升主动脉的内侧和外侧。 </li><li>将缝合线的左端朝向右端，并将它们绑在一起。 </li><li>让手表在Trendelenburg位置倾斜。让泵流量减少到全流量的50％。在左心室排气口温和抽吸的情况下缓慢移除主动脉夹钳。 </li><li&gt;恢复心肺循环的全流程。取出右心室流出道上的肺牵开器。检查手术部位是否出现过度的手术出血。 </li><li>将患者重新装到37°C，并将患者与心肺旁路分开。当达到稳定的血压时，以1:1的比例（3mg / kg对应于300U / kg肝素）以质子蛋白注射的IV中和肝素。检查止血，并根据需要使用胸腔引流。以标准方式关闭胸部。 </li></ol></li></ol> 4.术后患者护理<ol><li>将患者转移到重症监护病房。 </li><li>根据需要静脉输注丙泊酚100-150μg/ kg / min，芬太尼0.015-0.03μg/ kg / min，罗库溴铵0.6-1.2μg/ kg / min，使患者静脉麻醉。 </li><li>当病人的核心温度达到37°C时，减少麻醉。 </li><li>拔除pati当氧气的动脉分压大于9kPa，并且在0.3的启发氧分数下，CO 2的动脉分压小于5kPa。 </li><li>通过检查前3小时（小于100 mL / h）和6,12和24 h（全球排水量小于30 mL / h）的小管引流，确保不出现过度出血。 </li><li>通过在到达重症监护室后6,12和24小时检查心电图和心肌酶，确保没有心肌缺血。 </li><li>一旦没有出血和心肌缺血就记录下来，就可以动员拔管的病人。 </li><li>在达到稳定的血液动力学的时候将患者转移到病房。 </li></ol>

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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>

作者没有什么可以披露的。

<html>本研究报告了具有小主动脉根部病人的无支架主动脉异种移植物全根主动脉瓣置换术的详细描述。早期发病率和死亡率非常低，与其他报告相比有优势7 。重度钙化冠状动脉口腔构成对这种技术的解剖限制。这种技术的另一个缺点是由总体状况差的患者表现出来，不能耐受较长的手术时间。在这些情况下，标准的支架置入的心包主动脉瓣置换术，有或没有主动脉根部扩大应优于更严格的全根无支架主动脉异种移植植入6 。 该协议要求六个运行的4/0聚丙烯缝线用于近端吻合。类似于其他作者使用的多个中断缝线14 ，s ="xref"&gt; 15，这种近端吻合技术导致近端吻合的张力分布更好，从而避免了缝合线的打褶。与多个中断缝合线相比，使用六个半连续运行的缝合线稍微节省时间。此外，它通过心包或聚四氟乙烯条使用缝合线的加固来控制术后出血7,12,14不必要。在这些患者中，出血不需要再切开术。一些作者7,12提出的用于近端吻合术的单次运行缝合线的潜在缺点是瓣膜替代物和左心室流出道打褶的风险。 除了术后出血增多的可能性外，冠状动脉吻合问题另一个主要关心的心脏外科医生谁不愿意使用全根技术植入无支架主动脉异种移植物。可能出现冠状动脉吻合问题，因为病人的冠状动脉在重新植入后与吻合过度紧张相关的组织撕裂。为了使移植物冠状动脉新生的位置适应患者的冠状动脉口，左冠状动脉新腔首先通过将现有的左冠状动脉孔或结扎动脉延伸到左侧和右侧的连接处而在移植物中产生非冠状动脉窦的无支架移植物。在完成近端缝合线并重新连接左冠状动脉吻合后，根据移植物的右冠状窦调整患者右冠状动脉口的重新连接位置。为了做到这一点，右冠状动脉新生口在移植物中是通过扩展现有的右冠状动脉孔或结扎动脉<html>对于无支架移植物的右冠状动脉和非冠状窦之间的连合。主动脉冠状动脉超过1-2cm的近端动员进一步有助于消除冠状动脉吻合的过度紧张，从而有助于组织撕裂和出血。这种技术避免了其他作者提出的无支架移植物的旋转12 。 预期这种技术的交叉夹钳，心肺 - 肺旁路手术和手术时间要长于带支架瓣膜16的标准主动脉瓣置换术。然而，它们与Kunihara 等人报道的相当。 7用于全根植入无支架主动脉异种移植物。尽管我们的患者手术时间延长，但与STS成人心脏手术数据库中报道的相比，围手术期的发病率和死亡率没有受到不利影响lass ="xref"&gt; 17用于隔离主动脉瓣置换。特别是，出血重新发生的发生率，完全性心脏阻塞需要确定性的起搏器植入，中风，深部胸骨感染或早期死亡率很低，与Kunihara 等报道的相似。 7用于全根植入无支架主动脉异种移植物，并由我们自己用于通过支架式心包瓣膜13隔离主动脉瓣置换。 所有可商购的机械和生物阀替代品的标记尺寸表示阀的全局（外径）直径。然而，对于包括机械和生物支架式心包瓣膜在内的支架瓣膜替代品，阀门的缝合环占阀门全局（外径）的3至4 mm，并相应地降低了功能上有用的内径。生物无支架主动脉Xenog木筏没有类似的阻塞缝环。因此，这些阀替代品的功能上有用的内径非常接近它们的全局（外部）直径，如商业标记的。结果，对于给定的标记尺寸，生物无支架阀提供比生物支架式心包瓣膜更大的功能上有用的内径。更大的功能上有用的内径允许阀的更大的开口面积被称为阀的有效孔口面积。阀门的更好的开口面积，被调整为身体表面积，被称为指数有效孔面积，提供优异的血液动力学，并有助于更好的功能缓解患者。在这方面，通过全根技术植入的23mm支架和无支架瓣膜之间的比较显示，在跨瓣度梯度方面，后者的血液动力学更好。因此，根据le的回归观察到更好的患者结果心室肥厚18 。 根据预计的（ 即术前预期）EOAI ，选择全根无支架主动脉异种移植植入的小型主动脉根的成年患者。具体来说，在术前超声心动图估计的主动脉环直径小于20mm的患者中，确定了体表面积大于1.6m 2的亚组。如果患者接受支架置入的心包瓣膜，其有效孔面积为1.28厘米2 ，那么这些患者处于PPM的危险之中，所得到的孔隙面积为0.8cm 2 / m 2 。已经显示，小于0.85cm 2 / m 2的预测EOAI预测PPM，对术后，长期跨瓣梯度和患者结果有不利影响3,4 。 accommo的另一个选择将较大的主动脉瓣假体变为小主动脉根，由主动脉环6的斑块扩大表示。然而，这种技术并没有缺点，即使在经验丰富的手中。 Sommers和David 9报道，增加术后出血需要重新切开术和增加主动脉环扩张后的早期死亡率。 总之，对于小主动脉根部的患者，我们建议全根植入无支架的主动脉异种移植物以避免PPM。这种技术可以在不影响早期发病率或死亡率的情况下进行。因此，与植入心包支架瓣膜相比，全根植入无支架瓣膜所需的额外时间因此对早期临床结果并不有害，可以通过更好的中期和长期疗效来获得回报。对此技术的限制e由高度钙化的冠状动脉口腔和一般状况不佳的患者表现为不能耐受更长的手术时间。

65岁以上的患者推荐使用生物主动脉瓣置换术1 。在小主动脉根部的患者中，植入根据制造商提供的标签尺寸的支架生物瓣膜替代物可能不符合功能需求。在这种情况下，Rahimtoola首先描述了假体和患者不匹配（PPM），如下所示:" 插入患者后有效的假体瓣膜面积小于正常人体瓣膜 " 2 时，可以认为不匹配存在 。瓣膜假体的有效孔口面积与患者的身体尺寸有关，并且更常见于患者的体表面积。太小的人工瓣膜的血流动力学结果是异常高的跨瓣叶梯度3 。已经表明，跨瓣度梯度与效应之间的关系指向体表面积（EOAI）的孔口面积为曲线，当指数的EOA小于0.8至0.9cm 2 / m 2时，梯度呈指数增长。在这种关系的基础上，小于0.85cm 2 / m 2的EOAI通常被认为是主动脉位置4中PPM的阈值。 PPM对早期和晚期临床结果的影响是有争议的。然而，据报道，PPM负面影响左心室肥大的退化，从而影响左心室功能的正常化和症状缓解4 。持续的左心室肥大与心律失常和心源性猝死的风险增加有关5 。 因此建议尽量避免PPM 4 。在使用生物体计划的主动脉瓣置换可预测的PPM的情况下选择是:1）接受患者的合并症时植入支架置入的心包瓣膜造成的PPM，禁止更技术要求较高的手术技术植入较大的假体，2）扩大主动脉根部以适应更大的支架置换阀6或3）植入无支架生物瓣膜7或同种移植物8 。 据报道主动脉根部肿大增加围手术期出血，需要重新切开胸腔，并增加早期死亡率9 。有经验的外科医生植入时，主动脉同种异体移植物可能具有优异的血液动力学特征和良好的长期疗效。然而，它们有限的可用性和加速的钙化率使得主动脉同种异体移植物不如其对应的生物瓣膜替代物，猪无支架主动脉移植物10 。 同种异体移植物的短缺和缺点促使替代生物瓣膜替代品的构想和发展。为此，将无支架的主动脉异种移植物引入临床实践11 。一方面，由于消除麻烦的缝合环，无支架主动脉异种移植物可以再现同种移植物的血液动力学优势。另一方面，由于应用抗钙化技术，无支架主动脉异种移植物的耐久性已被优化，以匹配甚至超过同种移植物的寿命11 。无支架主动脉异种移植物的血流动力学优势完全通过全根植入获得12 。与亚冠状和根夹入技术相比，全根植入将无支架主动脉异种移植物放置在主动脉环的顶部，而不在其内。这个事实和推翻了全根植入技术的理由，从而实现了无支架阀替代品的最大内功能直径。此外，与瓣膜传单一起保存的瓦萨尔瓦鼻窦有利于更多的生理开闭运动，从而延长传单的预期寿命。这一优势进一步有助于改善长期成果12 。 然而，对增加的出血潜力和冠状动脉口吻合的可能扭曲的担忧防止了许多心脏外科医生从具有支架的生物瓣膜的经典主动脉瓣置换转变为以全根替代为代表的技术要求更高的方法，无支架主动脉异种移植物。 鉴于无支架主动脉异种移植物的潜在血液动力学优势，我们采用了全身性t植入以避免PPO在需要主动脉瓣置换的小主动脉根部的患者（ 表1 ）。在这些患者中，目的是为新植入的主动脉瓣获得大于0.85cm 2 / m 2的预计EOAI。该意图是基于Pibarot及其同事的报告显示，具有小于0.85 cm 2 / m 2的预计EOAI的瓣膜替代品的不可接受的高跨度梯度，随后症状的不完全缓解以及不良结局的持续风险3，4 。在手术后超声心动图初步鉴定主动脉瓣环直径小于20 mm的成年患者后，进一步选择患者身体表面积大于1.6平方米。在这一亚组患者中，植入19 mm支架的心包主动脉瓣（EOA:1.28 cm 2 </sup&gt;）将导致小于0.85cm 2 / m 2的预计EOAI。在该方案中，这些患者是全根植入无支架主动脉异种移植物的候选者。最终决定是在手术切除主动脉瓣后进行的。如果用于支架式心包主动脉瓣的19 mm阀门尺寸调节器通过主动脉瓣环过紧，患者血液动力学稳定并能耐受更长时间的手术，则可进行全根植入无支架主动脉异种移植。 对于无支架的主动脉异种移植物，我们可以互换使用两种市售的瓣膜替代物（详见材料表 ）。两个阀均采用主动脉瓣主动脉根部。它们使用低压（0-2 mmHg）固定过程制备，具有抗钙化（ 如 XenoLogiX）治疗一个瓣膜和α氨基油酸（AOA）抗ca对另一方进行化疗。在那些用于支架式心包瓣膜的19 mm尺寸调整器通过主动脉环过紧的患者中，主动脉瓣环中较好的无支架主动脉异种移植物的23 mm尺寸测量仪表示23 mm的无支架主动脉异种移植物尺寸为被选中。该方案详细描述了全根植入无支架主动脉异种移植物的技术，重点是近端缝合线和冠状动脉吻合的管理。讨论这种技术和替代选项的局限性。

<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

在需要主动脉瓣置换术的小型主动脉根部患者中，采用生物瓣膜置换术，支架置入的心包瓣膜的植入可能不能满足功能需要。植入太小的支架式心包瓣膜，导致指向小于0.85cm 2 / m 2的体表面积的有效孔面积被认为是假体 - 患者不匹配（PPM）。 PPM负面影响左心室肥大的退化，从而影响左心室功能的正常化和症状的缓解。持续的左心室肥大与心律失常和心源性猝死风险增加有关。在可预测的PPM的情况下，有三个选择:1）接受患者的合并症时植入支架置入的心包瓣膜造成的PPM，禁止植入较大假体的技术要求更高的手术技术，2）放大主动脉根部容纳更大的支架置换阀，或3）植入无支架生物瓣膜或同种移植物。与具有支架式心包瓣膜的经典主动脉瓣置换相比，全根植入无支架主动脉异种移植物提供了在给定患者中植入3-4mm更大的瓣膜的可能性，从而允许跨瓣膜梯度显着降低。然而，一些心脏外科医生不愿意将具有支架的心包瓣膜的经典主动脉瓣置换转换为更无技术上具有挑战性的全根植入无支架主动脉异种移植物。鉴于无支架主动脉异种移植物的潜在血液动力学优势，我们采用全根植入术，以避免需要主动脉瓣置换的小主动脉根部病人的PPM。在这里，我们详细描述了全根植入无支架主动脉异种移植物的技术，重点是近端缝合线的管理冠状动脉吻合术。讨论这种技术和替代选项的局限性。

统计分析植入的无支架主动脉异种移植物（23毫米）的体表面积（EOAI，cm 2 / m 2 ）的预计有效孔面积的值表示为平均值±SD，并与计算出的4 mm较小的支架式心包瓣膜的EOAI值进行比较即 19 mm），使用非参数Mann Whitney检验。在表2中，使用非参数Mann Whitney检验和通过卡方检验的分类变量来比较连续变量。使用市售软件进行统计学分析，统计学显着性设置为p &lt;0.05。 有效孔面积指数在小主动脉根部的患者（ 图1 ），植入一个19毫米的大小的stenTED心包瓣将导致中度至重度PPM 4的EOAI为0.7±0.09（范围0.55 - 0.84）cm 2 / m 2 （ 图1 ）。使用这种技术，在这些患者中植入无支架的主动脉异种移植物产生的显着更高的EOAI为1.09±0.14cm 2 / m 2 （范围为0.87-1.31cm 2 / m 2 ，p &lt;0.0001），从而消除任何PPM 2 ）。 术中和术后早期数据如预期的那样，在我们的患者中，无夹层主动脉异种移植物的全根植入的交叉钳夹，心肺旁路手术和手术时间比用支架瓣膜13,14分离的主动脉瓣置换报告长。然而，围手术期的发病率死亡率非常低，不会因手术时间延长而受到不利影响（ 表2 ）。 <img alt="图1" src="/files/ftp_upload/55632/55632fig1.jpg" /> 图1:心脏内部解剖学。心脏的前方部分被去除以描绘四个心脏腔室和瓣膜。二尖瓣的前叶与主动脉瓣的左冠状动脉和非冠状动脉相连通。 <a href="https://ecsource-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/55632/55632fig1large.jpg" target="_blank">请点击此处查看此图的较大版本。</a> <img alt="图2" src="/files/ftp_upload/55632/55632fig2.jpg" /> 图2:有效孔径指数。在小主动脉根部（N = 22）的患者中，预计有效孔面积指数d为23 mm的植入式无支架主动脉异种移植物的体表面积（EOAI，cm 2 / m 2 ）显着高于计算的EOAI，如果他们接受了4 mm更小（ 即 19 mm）的支架式心包瓣膜。通过将制造商提供的阀门替代物的有效孔面积（cm 2 ）除以患者的体表面积（m 2 ）来计算预计的EOAI。这些值表示为平均值±标准偏差。 <table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always"><tbody><tr><td></td><td> 全根无根异种移植物 </td></tr><tr><td> ñ </td><td> 22 </td></tr><tr><td>年龄，年龄（平均值±SD） </td><td> 63±10 </td></tr><tr><td>女性</td><td> 18（82％） </td></tr><tr><td>体表面积m 2 （平均值±SD） </td><tD&gt; 1.85±0.24 </td></tr><tr><td>喷射分数（％）（平均值±SD） </td><td> 53±11 </td></tr><tr><td>主动脉瓣反流</td><td> 5（22％） </td></tr></tbody></table> 表1:患者特征患者的特征在本表中描述。植入全根无支架主动脉异种移植物的决定是基于体表面积，以避免小于&lt;0.85cm 2 / m 2的预计有效孔面积，被认为是假体 - 患者不匹配。 <table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always"><tbody><tr><td></td><td> 全根无牙异种移植物23毫米 </td><td> 用支架式心包瓣隔离主动脉瓣置换1 </td><td> p </td></tr><tr><td> ñ </td><td><strong&gt; 22 </td><td> 36 </td><td></td></tr><tr><td>交叉钳位时间（min） </td><td> 83±9 </td><td> 62.3±9.4 </td><td> 0.0001 </td></tr><tr><td> CPB时间（分钟） </td><td> 134±32 </td><td> 101±27.2 </td><td> 0.0001 </td></tr><tr><td> OP时间（分钟） </td><td> 242±48 </td><td> 191.7±53.2 </td><td> 0.0001 </td></tr><tr><td>重新探查出血</td><td> 0 </td><td> 1（3％） </td><td> NS </td></tr><tr><td>起搏器制造商</td><td> 0 </td><td> 0 </td><td> NS </td></tr><tr><td>行程</td><td> 1（4.5％） </td><td> 1（3％） </td><td> NS </td></tr><tr><td>胸骨感染</td><td> 0 </td><td> 0 </td><td> NS </td></tr><tr><td>早期死亡率</td><td> 0 </td><td> 1（3％） </td><td> NS </td></tr><tr><td> 1符合生物医学中心许可，参考13 </td><td></td><td></td><td></td> &lt;/ TR&gt; <tr><td> ns =不重要</td><td></td><td></td><td></td></tr></tbody></table> 表2:术前数据与30天发病率和死亡率与以前报告数据的比较。报告了夹钳，心肺旁路（CPB）和手术时间（平均值±标准偏差），以及所呈现的组患者的30天发病率和死亡率，并与先前报道的支架置入心包数据进行比较主动脉瓣。参考13，适应生物中心的许可。

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

通过无支架主动脉异种移植的全根主动脉瓣置换术是小主动脉根部病人的可行选择。我们描述了一种全根植入无支架主动脉异种移植物的技术，重点是近端缝合线和冠状动脉吻合的管理，并讨论其局限性和替代选择。

全根主动脉瓣置换主动脉瓣狭窄主动脉异种移植患者小主动脉根

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

Nanyang Technological University

Research

JoVE Journal

Medicine

11.2K 次观看.  University of Zurich. 通过无支架主动脉异种移植的全根主动脉瓣置换术是小主动脉根部病人的可行选择。我们描述了一种全根植入无支架主动脉异种移植物的技术，重点是近端缝合线和冠状动脉吻合的管理，并讨论其局限性和替代选择。 

视频: 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.

原位主动脉瓣移植在小鼠血管疾病的研究

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

科研

医学

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.

肺动脉瓣使用异位心脏移植小鼠模型移植

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.

主动脉瓣重置术治疗瓣膜备用主动脉根置换的规范化技术

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.

右前小切口主动脉瓣置换术的技术及患者选择标准

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.

啮齿动物异位心脏瓣膜移植的简化模型

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.

罗斯手术的啮齿动物模型:全身位置的同源肺动脉移植植入

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.

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.

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.

成年绵羊模型中自体心包经导管肺动脉瓣置换术，使用自扩展镍钛诺支架

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

用于研究压力超负荷诱发的心力衰竭的升主动脉束带

A Minimally Invasive Model of Aortic Stenosis in Swine

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological similarities to humans. Efforts have been dedicated to creating a model of pressure-overload induced heart failure, and ascending aortic banding while still supra-coronary and not a perfect mimic of aortic stenosis in humans, closely resembling the human condition.
The purpose of this study is to demonstrate a minimally invasive approach to induce left ventricular pressure overload by placing an aortic band, precisely calibrated with percutaneously introduced high-fidelity pressure sensors. This method represents a refinement of the surgical procedure (3Rs), resulting in homogenous trans-stenotic gradients and reduced intragroup variability. Additionally, it enables swift and uneventful animal recovery, leading to minimal mortality rates. Throughout the study, animals were followed for up to 2 months after surgery, employing transthoracic echocardiography and pressure-volume loop analysis. However, longer follow-up periods can be achieved if desired. This large animal model proves valuable for testing new drugs, particularly those targeting hypertrophy and the structural and functional alterations associated with left ventricular pressure overload.

作者聚焦:开发用于可靠且可重复的心血管研究的微创大型动物模型 

This protocol describes a minimally invasive surgical procedure for ascending aortic banding in swine.

猪主动脉瓣狭窄的微创模型

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological ...

全根主动脉瓣置换主动脉瓣狭窄主动脉异种移植患者小主动脉根

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此视频中的章节

原位主动脉瓣移植在小鼠血管疾病的研究

肺动脉瓣使用异位心脏移植小鼠模型移植

主动脉瓣重置术治疗瓣膜备用主动脉根置换的规范化技术

右前小切口主动脉瓣置换术的技术及患者选择标准

啮齿动物异位心脏瓣膜移植的简化模型

罗斯手术的啮齿动物模型:全身位置的同源肺动脉移植植入

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

成年绵羊模型中自体心包经导管肺动脉瓣置换术，使用自扩展镍钛诺支架

猪主动脉瓣狭窄的微创模型

猪主动脉瓣狭窄的微创模型