大血管外科课件

,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,主动脉根部扩张病变的外科治疗,主动脉根部扩张病变的外科治疗,主动脉根部病变的病因,继发于升主动脉瘤的主动脉根部扩张,结缔组织病如Marfan综合征和Ehlers-Danlos综合征：病变可累及主动脉窦、主动脉瓣环以及窦管交界，但瓣叶较少累及。受累部位可导致主动脉根部扩张,主动脉根部、升主动脉夹层,合并有退行性变的老年患者，尤其是合并动脉粥样硬化者,先天性疾病如主动脉瓣二叶化畸形、主动脉瓣上狭窄,其他：如大动脉炎、外伤、感染等,主动脉根部病变的病因继发于升主动脉瘤的主动脉根部扩张,主动脉根部解剖结构,主动脉根部解剖结构,Ascending aortic replacement with remodeling of the sinotubular junction Aortic insufficiency can occur in the setting of either isolated ascending aortic aneurysms or,due to aortic root aneurysms.,Typically these patients are older and have a large ascending aortic aneurysm and aortic insufficiency.,The preoperative echocardiogram will demonstrate loss of STJ definition, minimal dilation of the sinuses and central aortic insufficiency due to lack of cusp coaptation.,Ascending aortic replaceme,大血管外科课件,常见的主动脉,根部外科治疗方法,Wheat,手术,Carbrol,手术,Bentall,手术,David,手术,Ross,手术,常见的主动脉根部外科治疗方法Wheat手术,适 应 症,症状,主动脉直径,三叶瓣患者：直径5.5cm,二叶瓣、 Marfan 综合征、Ehlers-Danlos、Turner 综合征或动脉瘤家族史 ：直径 75mm,LV end-systolic dimension of 55mm,declining exercise tolerance,When operating for a valvular indication or aortic dissection, concomitant aortic root or ascending replacement is recommended at aortic diameters 4.5cm.,适 应 症 symptoms of congestive h,Bentall 手术,1969年经典手术：可重复、安全、效果持久,手术的指征：瓣叶形态不对称或瓣叶穿孔造成的严重主动脉瓣反流；主动脉瓣二瓣化畸形，合并有明显狭窄、瓣叶增厚、脱垂或穿孔的升主动脉瘤,需终生抗凝治疗。与抗凝治疗相关的血栓或出血并发症的年发生率在2-4左右,生活质量,妊娠风险,Bentall 手术1969年经典手术：可重复、安全、效果,Bentall 手术,Bentall 手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,1992年，David及Feindel发表文章，David I型,1993年，Sarsam与Yacoub提出 “主动脉瓣环成形术”,1995年，David提出了适用于无主动脉瓣环扩张患者的“成形法”，David II型,1996年，David在David II的基础上，利用特氟龙毡条对主动脉瓣环进行了加固，David III型,将原David I术式中所用涤纶管道的直径增加4mm，并增加了对新窦管交界的皱缩操作，David IV型术式,将原David I术式中所用涤纶管道的直径增加8mm，并增加了对新窦管交界和根部的皱缩操作，从而形成一个人造的假瓣窦，David V型,保留瓣膜的主动脉瓣根部置换手术1992年，David及Fei,适 应 症,Significant calcification of the annulus and cusps are generally considered prohibitive of an AVS operation.,Severe free margin thickening has also been demonstrated to limit long term valve durability following AVS operations.,Stress fenestrations and free margin elongation are not contraindications to a valve sparing procedure, and valve repair techniques are often added to an AVS operation.,适 应 症Significant calcification,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,保留瓣膜的主动脉瓣根部置换手术,Remodeling or reimplantation,remodeling procedure maintains the independent mobility of the individual sinus segments. Sinus segment mobility is crucial to facilitating changes in aortic root distensibility throughout the cardiac cycle. Root expansion and contraction is thought to maximize blood flow through the valve apparatus while minimizing stress and strain on the leaflets.,The remodeling procedure fails to stabilize the annulus, which is important in preventing future annular dilatation,Remodeling or reimplantationre,Remodeling or reimplantation,Remodeling of the aortic root is ideal for patients with primarily ascending aortic aneurysm and AI with or without aortic sinuses aneurysm, or aortic root aneurysms with normal aortic annulus.,Reimplantation of the aortic valve is ideal for patients with primarily aortic root aneurysm because of inherited connective tissue disorders such as Marfan syndrome, and familial aneurysms in whom dilation of the aortic annulus is common.,A recent collective review of 14 published series totaling 1338 patients concluded that current evidence is in favor of reimplantation rather than remodeling “in pathologies such as Marfan syndrome, acute type A aortic dissection, and excessive annular dilatation that may impair aortic root integrity.”,Remodeling or reimplantationRe,Remodeling or reimplantation,Most surgeons recommend that patients with annuloaortic ectasia, Marfan syndrome and other connective tissue disorders are best served by a reimplantation procedure.,The remodeling procedure should be reserved for older patients with a normal aortic annulus (25mm woman, 27mm man),Remodeling or reimplantation,Bentall or AVS operation,二者的手术指征并不相同：主动脉瓣是否可以保留是选择两类术式的关键之一,两类术式病情严重程度不同：前者的患者常有较为严重的主动脉瓣关闭不全（3+/4+），更容易出现主动脉夹层，更容易以急诊手术的形式出现,由于使用了机械瓣膜，Bentall术后发生血栓事件或出血事件的可能性也会更大，而行保留瓣膜的主动脉根部置换手术的患者如果要再次手术，其原因无一例外的都是因为主动脉瓣关闭不全,由于术者常常倾向于为年轻的患者保留自身瓣膜，因此Bentall手术人群的年龄相比较而言，都会更大一些,Bentall or AVS operation二者的手术指,后面内容直接删除就行,资料可以编辑修改使用,资料可以编辑修改使用,后面内容直接删除就行,主要经营：网络软件设计、图文设计制作、发布广告等,公司秉着以优质的服务对待每一位客户，做到让客户满意！,主要经营：网络软件设计、图文设计制作、发布广告等,致力于数据挖掘，合同简历、论文写作、,PPT,设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求,致力于数据挖掘，合同简历、论文写作、PPT设计、计划书、策划,感谢您的观看和下载,The user can demonstrate on a projector or computer, or print the presentation and make it into a film to be used in a wider field,感谢您的观看和下载The user can demonstr,