7. 大動脈基部再置換術

Clinical Outcomes of Aortic Root Reoperation

本邦においては，近年の胸部大動脈手術の件数増加および成績向上に伴い1），胸部大動脈の再手術を必要とする症例も増加している．大動脈基部手術は，胸部大動脈手術の中でも上行大動脈近位部，Valsalva洞，冠状動脈，大動脈弁といった多くの構成要素がかかわってくる領域であり，必然的に手術手技は複雑となる．さらに大動脈基部再置換術となると，胸骨正中切開，癒着組織の剝離や人工心肺の確立，心筋保護法，冠状動脈再建法といった多くの手技があり，通常の初回基部置換術とは異なる配慮が必要となる．本稿では当院における大動脈基部再置換術（初回手術は大動脈基部置換術，上行または弓部置換術，大動脈弁置換術を含む）の経験を報告するとともに，文献的な考察を加えて近年の大動脈基部再置換術の適応，手術手技，成績や遠隔期の注意点などについて概説する．

We presented our experiences of reoperative aortic root replacement and technical details. Between April 2000 and February 2021, 80 patients underwent reoperative aortic root replacement （60 male, mean age 59.3±14.4 years）. The previous procedures were ascending or arch replacement in 36, aortic valve replacement （AVR） in 32, and aortic root replacement in 12. Surgical indications for reoperation included infective endocarditis or graft infection （n＝31）, root dilation/dissection （n＝26）, pseudoaneurysm （n＝13）, aortic valve regurgitation （n＝7）, and structural valve dysfunction （n＝3）. Mean interval from 1st operation was 6.7±6.1 years. Reoperative procedures were composed of modified Bentall （n＝27）, reimplantation technique （n＝25）, root replacement with stentless valve （n＝16）, partial remodeling/patch plasty （n＝5）, Commando operation （n＝5）, and Ross operation （n＝2）. In-hospital mortality was 8.8％（7/80 patients）. The causes of mortality were sepsis in 3, pneumonia in 2, bowel perforation in 1, and anastmotic rupture with mediastinitis in 1. Freedom from 3rd time aortic root related operation was 90.8±4.8％ at 10 years. Actuarial survival after reoperation was 67.3±6.6％ at 10 years.

In conclusion, the clinical short-and long-term outcomes of reoperative aortic root replacement were reasonable even in patients with complicated aortic pathologies.