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

この研究は、Swiss Cardiovascular FoundationからRTへの助成金によって支えられました。

<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>

著者は何も開示することはない。

<html>本研究では大動脈根の小さい患者のステントレス大動脈異種移植を用いた大動脈弁置換術の外科的手法の詳細を報告している。早期の罹患率と死亡率は非常に低く、他の報告書と比較して優れている7 。高度に石灰化された冠動脈口がこの技術の解剖学的制限を構成する。この技術のもう一つの欠点は、より長い手術時間を許容しない一般的でない状態の患者であるこ?...

65歳以上の患者には、生物学的大動脈弁置換術が推奨される1 。小さな大動脈根を有する患者では、製造業者によって与えられた標識されたサイズに基づくステント付生物学的弁置換術の移植は、機能的な必要性を満たさない可能性がある。この状況では、Rahimtoolaはまず、プロテーゼ患者ミスマッチ（PPM）を次のように記述しました。「 患者への挿入後の有効な人工弁領域が正常なヒト弁の面積よりも小さい場合、ミスマッチが存在すると考えることができます。 。弁プロテーゼの有効オリフィス面積は、患者の体の大きさ、より一般的には患者の体表面積に関連するものでなければならない。小さすぎる人工弁の血行力学的帰結は、異常に高い経皮的勾配3である。経皮的勾配とエフェクトとの関係は、身体表面積（EOAI）に指数化された開口面積は曲線であり、その勾配は、指数化されたEOAが0.8〜0.9cm 2 / m 2未満で指数関数的に増加する。この関係に基づいて、0.85cm 2 / m 2未満のEOAIは、大動脈位4の PPMの閾値と一般にみなされる。初期および後期の臨床転帰に及ぼすPPMの影響は議論の余地がある。しかし、PPMは左室肥大の退行に負の影響を与え、したがって左室機能の正常化および症状の軽減に影響することが報告されている4 。持続性の左心室肥大は、不整脈および突然の心臓死のリスク増加と関連している5 。 したがって、可能な限りPPMを避けることが望ましい4 。計画された大動脈弁置換術のための予測可能なPPMの場合選択肢は、1）患者の合併症がより大きいプロテーゼを埋め込むために技術的に要求される手術技法を禁じる場合、2）大動脈根を拡大して収容するためにステント付き心膜弁の移植に起因するPPMを受け入れる場合ステントレス生体弁7または同種移植片8を移植するために、より大きなステント弁置換術6または3）を使用する。 大動脈根の拡張は、周術期の出血を増強し、再胸骨切開術を必要とし、早期死亡率を増加させると報告されている9 。大動脈同種移植片は、経験豊富な外科医によって移植された場合、優れた血行動態プロファイルおよび良好な長期結果を有し得る。しかし、それらの利用可能性が限られており、石灰化の速度が速いため、大動脈同種移植片は、対応するブタのステントレス大動脈よりも適さない生物学的弁置換物である人工血管10 。 同種移植片の不足と欠点は、代替の生物学的弁代替物の概念と発達を促した。この目的のために、ステントレス大動脈異種移植を臨床診療11に導入した 。一方では、厄介な縫合リングの除去により、ステントレス大動脈異種移植は、同種移植の血行力学的利点を再現することができる。他方、抗石灰化技術を適用した結果、ステントレス大動脈異種移植片の耐久性は、同種移植片11の寿命に適合し、さらにそれを超えるように最適化されている11 。ステントレス大動脈異種移植片の血行力学的利点は、完全根移植によって完全に達成される12 。副冠動脈および根の包埋技術とは対照的に、完全根移植は、ステントレス大動脈異種移植を大動脈弁輪の上部に配置し、内部には配置しない。この事実とステントレス弁代替物の最大の内部機能径の実施を可能にするフルルート植え込み技術を選択することの根拠を説明している。さらに、バルサルバ洞を弁小葉と共に一括して保存することは、より生理学的な開閉運動に有利であり、したがって小葉の平均余命がより長くなる。この利点は、長期的な結果の改善にさらに寄与する12 。 しかしながら、出血の可能性の増大および冠状動脈吻合術の歪みの可能性に関する懸念は、多くの心臓外科医が、ステント付生体弁を用いた古典的な大動脈弁置換から、フルルート置換で代表されるより技術的に要求される手順に移行することを防止するステントレス大動脈異種移植片。 ステントレス大動脈異種移植の潜在的な血行動態上の利点を考慮して、我々はフルロ大動脈弁置換術を必要とする小大動脈の根を有する患者においてPPMを回避するための移植（ 表1 ）。これらの患者では、新たに移植された大動脈弁について、0.85cm 2 / m 2より大きい投影EOAIを達成することが目的である。この意図は、0.85cm 2 / m 2未満の投影されたEOAIを有する弁置換術用の容認できないほど高い経橈骨勾配を示すPibarotおよび共同研究者の報告に基づいており、その後症状の不完全な軽減および有害な結果3,4 。術前心エコー検査で20mm未満の大動脈輪径を有する成人患者を最初に同定した後、患者はさらに1.6m 2より大きい体表面積を有するように選択される。この患者のサブグループでは、19mmステント心膜大動脈弁（EOA：1.28cm 2 </0.85cm 2 / m 2未満の投影EOAIをもたらすであろう。このプロトコルでは、これらの患者は、ステントレス大動脈異種移植の完全根移植の候補である。大動脈弁を切除した後、術中に最終決定を下す。ステント付き心膜大動脈弁用の19mmバルブサイザーが大動脈弁輪を過度にしっかりと通過し、患者が血行力学的に安定であり、より長い操作に耐えることができれば、ステントレス大動脈異種移植の完全根移植が行われる。 ステントレス大動脈異種移植片の場合、市販の2つの弁代用品を同じ意味で使用しています（詳細は表の表を参照 ）。両方の弁は、大動脈弁を有するブタ大動脈根から調達される。これらは、低圧（0〜2mmHg）の固定プロセスを用いて調製され、1つのバルブおよびαアミノオレイン酸（AOA）抗caに対して抗石灰化（ 例えば、 XenoLogiX）もう一方のための石化処理。ステント留置された心膜弁の19mmサイザーが大動脈弁輪を過度にしっかりと通過する患者では、大動脈弁輪内のステントレス大動脈異種移植片の23mmサイザーは、23mmの大動脈外ステントレス異種移植片が、選択される。このプロトコルは、ステントレス大動脈異種移植の完全根移植の技術を詳細に説明し、近位縫合線および冠動脈吻合の管理に重点を置いている。この手法と代替オプションの制限について説明します。

<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

小動脈の根が大動脈弁置換術を必要とする大動脈弁置換術を受けている患者では、ステント留置した心膜弁の埋め込みは、機能的な必要性を満たさない可能性がある。 0.85cm 2 / m 2未満の体表面積に指数化された有効オリフィス面積につながる小さすぎるステント付き心膜弁の埋め込みは、プロテーゼ - 患者ミスマッチ（PPM）とみなされる。 PPMは、左心室肥大の退行、したがって左心室機能の正常化および症状の緩和に悪影響を与える。持続性の左心室肥大は、不整脈および突然の心臓死のリスクの増加と関連している。予測可能なPPMの場合、3つの選択肢がある：1）患者の併存疾患がより大きなプロテーゼを移植する技術的に要求の厳しい手術技法を禁ずるときに、ステント付き心膜弁の移植に起因するPPMを受け入れる、2）より大きいステント弁置換術を受け入れるための大動脈根、または3）ステントレス生体弁または同種移植片を移植する。ステントレス大動脈異種移植の完全根移植は、ステント留置した心膜弁による古典的大動脈弁置換術と比較して、所与の患者に3〜4mmのより大きな弁を移植する可能性を提供し、経皮的勾配を著しく減少させる。しかしながら、多くの心臓外科医は、ステントレス心臓弁を用いた古典的な大動脈弁置換術を、ステントレス大動脈異種移植の技術的に困難なフルルート移植に変えることには消極的である。ステントレス大動脈異種移植の潜在的な血行動態上の利点を考慮して、我々は大動脈弁置換術を必要とする小動脈の根を有する患者においてPPMを避けるためにフルルート移植を採用した。ここでは、ステントレス大動脈異種移植片の完全根移植のための技術を詳細に説明し、近位縫合線の管理に重点を置き、d冠動脈吻合である。この手法と代替オプションの制限について説明します。

統計分析 23mmのサイズの移植されたステントレス大動脈異種移植片の体表領域（EOAI、cm 2 / m 2 ）に指標付けされた投影有効面積の平均値を平均±SDとして表し、ステント付心膜弁の計算されたEOAI すなわち、 19mm）を、ノンパラメトリックマンホイットニー検定を用いて評価した。表2において、連続変数...

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

ステントレス大動脈異種移植による大動脈弁の大動脈置換術は、小動脈の根が小さい患者では実行可能な選択肢である。近位縫合線および冠状動脈吻合の管理に重点を置いて、ステントレス大動脈異種移植片の全ルート移植のための技術を説明し、その限界および代替選択肢について論じる。

小型大動脈瘤患者におけるステントレス大動脈異種移植による全大動脈弁置換術

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 ビュー.  University of Zurich. ステントレス大動脈異種移植による大動脈弁の大動脈置換術は、小動脈の根が小さい患者では実行可能な選択肢である。近位縫合線および冠状動脈吻合の管理に重点を置いて、ステントレス大動脈異種移植片の全ルート移植のための技術を説明し、その限界および代替選択肢について論じる。 

ビデオ: 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.

血管疾患の研究のためのマウスにおける同所性大動脈移植

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

医学

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.

血管内大動脈瘤の修復の新しいマウスモデル

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.

異心臓移植のマウスモデルを用いた肺動脈弁の移植

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.

弁温存大動脈の大動脈弁再置換術の標準化された技術のルート交換

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.

技術と最小限のアクセス大動脈弁置換のミニ開胸右前の患者選択基準

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.

げっ歯類におけるヘテロトピック心臓弁移植のための簡略モデル

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.

ロス手術のげっ歯類モデル:全身位置における同系肺動脈移植移植

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>血管内砕石術補助経大腿経カテーテル大動脈弁留置術

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.

血管内砕石術補助経大腿経カテーテル大動脈弁留置術

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.

成体ヒツジモデルにおける自己拡張性ニチノールステントを有する自家心膜からの経カテーテル肺弁置換

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

小型大動脈瘤患者におけるステントレス大動脈異種移植による全大動脈弁置換術

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血管疾患の研究のためのマウスにおける同所性大動脈移植

血管内大動脈瘤の修復の新しいマウスモデル

異心臓移植のマウスモデルを用いた肺動脈弁の移植

弁温存大動脈の大動脈弁再置換術の標準化された技術のルート交換

技術と最小限のアクセス大動脈弁置換のミニ開胸右前の患者選択基準

げっ歯類におけるヘテロトピック心臓弁移植のための簡略モデル

ロス手術のげっ歯類モデル:全身位置における同系肺動脈移植移植

血管内砕石術補助経大腿経カテーテル大動脈弁留置術

血管内砕石術補助経大腿経カテーテル大動脈弁留置術

成体ヒツジモデルにおける自己拡張性ニチノールステントを有する自家心膜からの経カテーテル肺弁置換