The surgical treatment of aortic valve lesions with severe root stenosis Han Lin Xu Zhiyun Department of Thoracic Surgery, Shanghai Changhai Hospital The matching of the aortic valve opening area with the patient’s body surface area affects the long-term clinical outcome of the surgery, so for patients with aortic root stenosis, aortic sinus or annulus widening is often required to replace the prosthetic valve with a larger opening area. From January 1995 to July 2006, we performed 39 cases of small aortic root widening and aortic valve replacement or aortic mitral valve double valve replacement, and achieved satisfactory clinical results. Han Lin, Department of Thoracic Surgery, Shanghai Changhai Hospital Clinical Data and Methods There were 39 cases in this group, 21 males and 18 females, age 4~71 years (32±18 years), weight 13~78 kg (53±16 kg), height 101~180 cm (161±13 cm), body surface area BSA. Congenital aortic diaphyseal valve malformation combined with aortic valve stenosis in 15 cases, rheumatic aortic valve lesions in 9 cases, combined rheumatic aortic and mitral valve valvulopathy in 6 cases, ventricular septal defect with acute endocarditis of the aortic valve in 1 case, bacterial endocarditis of the aortic valve in 2 cases, age-related calcific lesions of the aortic valve in 5 cases, and congenital subvalvular aortic stenosis with aortic valve closure insufficiency in 1 case. There were 1 case of descending aortic constriction, 1 case of arteriovenous stenosis and right ventricular outflow tract stenosis and descending aortic constriction, 1 case of arteriovenous stenosis and pulmonary valve stenosis and descending aortic constriction, 1 case of coronary artery disease, 12 cases of cardiac function (NYHA) class II, 24 cases of class III, 3 cases of class IV, 15 cases of ECG suggestive of left ventricular wall hypertrophy, and 3 cases of atrial fibrillation; cardiac echocardiography was performed except for 3 cases of bacterial In addition to 3 cases of bacterial endocarditis with simple aortic valve incompetence, the aortic valves of the remaining 36 cases had different degrees of stenosis, and 22 cases had valve calcification in combination, and the transvalvular pressure difference was 53-110 mmHg (87±17 mmHg, 1 kPa=7.5 mmHg). The internal diameter of the aortic root ranged from 13 to 21 mm (15.1±1.8 mm). The aortic incision was chosen 1 cm above the opening of the right coronary artery, an oblique incision was made, the aortic valve leaflet was removed, calcified spots were carefully removed, the diameters of the aortic sinus and the aortic annulus were measured, and different widening methods were chosen according to the different stenosis sites and degrees. Different widening methods were chosen according to the different stenosis sites and degrees, and autologous pericardial slices treated with 0.25% glutaraldehyde were used. (1) simple aortic sinus junction widening, applied to patients with supra-aortic stenosis and normal aortic annulus, extending the aortic incision to the left-coronary junction off the left coronary valve, widening with a shuttle-shaped pericardial piece, and aortic valve replacement as in conventional surgery, using this method to widen the aortic root in 7 cases; (2) modified Manouguian method, that is, cutting the aortic wall and aortic annulus perpendicular to the junction of the left coronary valve and the coronary valve without (2) modified Manouguian method, in which the aortic wall and aortic annulus are cut perpendicular to the junction of the left coronary and uncoronary valves, and extended downward to the aortic mitral annular junction, and the aortic annulus is widened with a shuttle-shaped pericardial piece. (3) aortic valve-micuspid fibrous annulus widening, this method is suitable for aortic valve-micuspid valve double valve replacement with narrow aortic root, that is, extending the aortic incision to the right of the junction of the left coronary valve and coronary valve, aortic coronary valve annulus up to the anterior mitral annulus, incising the top of the left atrium, simultaneously performing an atrial septal incision and extending the incision with the top incision of the left atrium, widening the anterior mitral annulus and the aortic valve annulus with a rectangular autologous pericardial slice. The prosthetic valve was replaced in the following order: first, intermittent mattress sutures with spacers were placed along the mitral valve annulus and passed through the prosthetic valve suture ring without seating, then the aortic valve sutures were passed through the aortic valve annulus, and the appropriate prosthetic valve was seated and tied first, then the mitral valve prosthetic valve was seated and tied, and the left atrial incision was repaired with autologous pericardial slices to avoid bleeding due to excessive tension. This method was used in all patients with combined valve disease. In this group, the aortic block time ranged from 73 min to 154 min (93.5±25.6 min), and all patients in this group used mechanical valves, replacing 17 mm supra-annular valve in 1 case, 19 mm valve in 9 cases, 21 mm valve in 17 cases, 23 mm valve in 12 cases, coronary artery bypass grafting in 1 case, descending aortic widening angioplasty in 2 cases, descending and ascending aortic bypass in 1 case, and PDA ligation in 2 cases. PDA ligation was performed in 2 cases, pulmonary stenosis was dissected in 1 case, and the right ventricular outflow tract was widened in 1 case. Results: There were 2 cases of early death after surgery in this group of 39 cases, with a mortality rate of 4.9%. 1 case was a patient with aortic bileaflet malformation, in which implantation failed again after initial implantation of a 21-mm valve, and implantation of a 21-mm valve only after widening again, and died postoperatively from severe hypoventricular row and ventricular arrhythmia because of prolonged aortic block; the other case was a 4-year-old child with severe aortic valve prolapse, and widening of the root The other case was a 4-year-old child with severe aortic valve prolapse who was implanted with a 17-mm supra-annular valve and died of heart failure postoperatively. The other case was a 4-year-old child with severe aortic valve prolapse who was implanted with a 17-mm supra-annular valve after root widening and died of heart failure after surgery. One case was reopened after surgery due to bleeding from the aortic suture. The echocardiogram of the heart was repeated 6 months after surgery, and no perivalvular leak of the aortic valve was found. 15~32 mmHg (19±8) mmHg of the prosthetic aortic valve transvalvular pressure difference was found. 2 months~10 years of postoperative follow-up with an average of 4.3 years, no distant death, no infective endocarditis, 23 cases of class I and 14 cases of class II cardiac function. Discussion: Aortic root stenosis poses some difficulty in selecting a prosthetic valve with the appropriate valve opening area for aortic valve replacement, and although there is still debate about the long-term efficacy of replacement of a small prosthetic heart valve causing a mismatch between the aortic valve opening area and body surface area index (prosthesis-patient mismatch PPM), most long-term follow-up results suggest that Since the choice of a smaller valve opening area has a variable effect on postoperative LV myocardial weight and coronary flow recovery as well as postoperative LV functional decline, Rizzo et al. found in a long-term follow-up of 1103 patients with AVR that postoperative LV weight decreased by only 4.5% in the PPM group compared with a 23% decrease in the matched group, the authors noted that regardless of the presence of postoperative PPM The authors noted that, regardless of the presence of postoperative PPM, aortic replacement surgery resulted in hemodynamic improvement and that the optimal outcome is to avoid PPM, which increases the mean transvalvular pressure difference due to the small effective valve opening area, thereby affecting long-term outcomes. Nowadays, aortic root widening is no longer a technically complex surgical technique due to the increasing maturity of extracorporeal circulation and myocardial protection methods as well as surgical techniques, and a total of 27 cases, including 5 cases of combined aortic-micuspid valve replacement, have been performed since 2002 without surgical death or serious surgical complications. Therefore, we advocate that aortic root widening should be performed in patients with narrow aortic roots to select an appropriate size prosthetic valve based on the relationship between their body surface area and the prosthetic valve. Since 2002, we have used an indexed EOA of less than 0.85 cm2/m2 as a reference standard for PPM during aortic valve replacement surgery, calculated the body surface area BAS based on the patient’s height and weight, and used the calculated BAS×0.85 to select the appropriate valve with reference to the opening area of various types of prosthetic valves (Tables 1 and 2). If the measured aortic root and annular internal diameters do not match the corresponding valve type selected, widening surgery is required. Aortic root stenosis includes aortic sinus canal and aortic annular internal diameter stenosis. In seven cases in this group with aortic sinus canal stenosis and appropriate annular size, only the aortic sinus portion of the valve is widened, which facilitates valve seating, avoids excessive aortic suture tension, and postoperative supravalvular stenosis, and the pericardial slice can be widened in the sinus portion without the midpoint of the coronary valve. The Manouguian method has the advantage that the widened pericardial slices are The advantage of the Manouguian approach over the Nick method is that the widened pericardial piece is sutured to the middle part of the anterior mitral leaflet, thus avoiding mitral valve insufficiency due to deformation of the anterior mitral leaflet. According to our surgical experience, the following aspects should be noted when widening the aortic annulus: (1) In most cases, as long as the aortic sinus is separated from the top of the left atrium, a more satisfactory result can be obtained without cutting the top of the left atrium, and only when the inner diameter needs to be widened or the mitral valve is replaced at the same time, the top of the left atrium is cut, and when the left atrial incision is sutured closed, the pericardial piece should be used to repair it to avoid bleeding caused by excessive tension in the incision. (2) The spacer of the suture line at the pericardial patch should be placed outside the aortic wall, and the suture line at the junction of the pericardium and aortic annulus should span the aortic annulus and pericardial piece, and the suture needle sewn to the pericardial piece is slightly higher than the suture needle on the side of the aortic annulus, that is, the level of the suture line at the pericardial patch is slightly higher, so that the artificial valve is seated at a certain inclination, thereby enlarging the annulus accordingly; (3) Mitral-aortic joint valve replacement requires reconstruction of the The fibrous connection is reconstructed by extending along the aortic incision toward the junction of the left coronary and noncoronary valves and cutting the top of the left atrium, then cutting the septum from the top of the left atrium downward, and after removal of the aortic and mitral valves, the fibrous connection is reconstructed with a rectangular pericardial slice (Figure 1). (4) In addition to fine suturing techniques to prevent bleeding, it is critical to avoid tension in the suture opening and in the prosthetic valve when it is seated downward, so it is especially critical to cut the appropriate size pericardial slice, rather large than small. References: 1. P Pibatot and JG Dumesnil: Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart, 2006; 92:10022~1029 2. L Castro, JM Arcidi, AL Fisher,et al. Routine Enlargement of the small Aortic Root: A Preventive Strategy to Minimize Mismatch. Ann Thorac Surg 2002; 74:31~6 3. TM Sundt. Patch Enlargement of the Aortic Annulus using the Manouguian Technique. Operative Techniques in Thoracic and Cardiovascular Surg2006 Spring 16 ~21. 4, T David, CM Feindel, S Armstrong, et al. Reconstruction of the Mitral Anulus, A ten-year experience. J Thorac Cardiovasc Surg 1995; 110:1323~32.