01),2#! 34+,*'52/6.5,! :4
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1 -.//% *,!!!"#$%&'()%*+&,% 01),2#! 34+,*'52/6.5,! :4 ;4
2 01),2#! 34+,*'52/6.5,! :4
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4 !?77;?! Right Atrium=RA Left Atrium=LA Right Ventricle RV Left Ventricle LV
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11 B)-)6.5,!C!-/*/')!!! butterfly resection!
12 ! ring! magic suture!
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16 ! Valve selection (Oct.2013-Dec.2014) CEP: 35 Trifecta: 24 7EDD 23mm 19mm 25mm 19mm Sapien: 58 21mm 23mm 21mm 7;DD 23mm 19mm Mitroflow: 13 21mm 23mm
17 ! 24mm 22-23mm 20-21mm 19mm!
18 Patients 247 octogenarians and 10 nonagenarians (total 257) underwent elective SAVR or SAVR+CABG for severe AS from July 2004 through May These patients was divided to two groups Under 85 years old (85>) N= years of age or older (85 ) N=69 Sakakibara Heart Institute
19 A5-*5F)'#.G)!H/*65D)-! Sakakibara Heart Institute */#'%#I!"/'G%G#I! Actuarial survival "/'G%G#I!!!L:M!!!!!!!!!L:N! 3?O)#'!P!!K:4EQ!!!!!K84:Q! 8?O)#'!P!!K34:Q!!!!!L94LQ!! :?O)#'!P!!LE4;Q!!!!!EL47Q!!!!!B%-$!'#.5R<4:8! Months after surgery J!#*!'%-$!!!3K3!!!!!!!!!!!!!!!!!LK!!!!!!!!!!!!!!!!:8!!!!!!!!!!!!!!!!!88!!!!!!!!!!!!!!!!!!3:!!!!!!!!!!!!!!!!!!9!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!;;!!!!!!!!!!!!!!!!!7:!!!!!!!!!!!!!!!!!39!!!!!!!!!!!!!!!!!!:!!!!!!!!!!!!!!!!!!!!!7
20 30 25 Postop Mean Gradient (mmhg) 13.5 ± ± ± ± P=0.15 P= m p s t Mitroflow CEP Sapien Trifecta
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22 a remodeling Yacoub 法 a remodeling Yacoub 法 自己弁温存基部再建 大動脈弁形成術! b modified Yacoub 法 S適応M! 大動脈解離 大動脈弁輪拡張症による大動脈閉鎖不全症! 単独大動脈弁閉鎖不全症! 有意な大動脈弁狭窄症 弁尖変性のあるものは除外! a remodeling Yacoub 法 c reimplantation David 法 S術式M! " B)%DFI#,*#.5,!=RT#G%2>手術! " " " b modified Yacoub 法 b modified Yacoub 法 B)D52)I%,1!=RU#65/&>手術! b modified Yacoub 法 D52%V)2!U#65/&手術!=U#65/&!W!弁輪縫縮X外固定>! 心エコー 図 10 単独大動脈弁形成術!=Y弁輪縫縮X外固定>! S大動脈弁形成M! c 法reimplantation David 法 c reimplantation David c reimplantation David 法 " 6),*'#I!FI%6#.5,!P!弁尖逸脱の矯正=)Z)6.G)
23 !
![\/-F!D5.5,!!?\]?](/docs-images/92/109511821/images/24-0.jpg "! 05 05 05 _` _` _` B\\!")
24 \/-F!D5.5,!!?\]?! _` _` _` B\\!P!F'5I#F-) ^\\!P!F#'.#I!&),2%,1 _\\!P!,5'D#I B\\ ;9!O454!!a)D#I)! T2XT-!E7X;3b!cd!8:Qb!-)G)')!0B!=00cW6/-F!F'5I#F-)>! _\\ ^\\ ed52%v)2!u#65/&!f%*[!0`a 9E F5-*5F)'#.G)!6/-F!65,V1/'#.5,! RCC LCC RCC and LCC were performed central plication Perioperative eh of all cusp were more than 9mm NCC It was possible to evaluate in detail cusp configuration
25 0`g!D)#-/'%,1!?A[Oh%52O,#D%6-?! mod. Yacoub David Systolic phase Systolic phase H/'!%,2%6#.5,!a5'!05'.6!`#IG)!"F#'%,1!! 01)!SE:!O)#'-!5I2! ^5'D#I!5'!')F#%'#&I)!#5'.6!G#IG)!6/-F-! +-5I#*)2!0B! cg)'o!f#*[5i51op!/,%b!&%b!*'%b!i/! 066)F*#&I)!j(! B55*!5'!0-64!05'*#!2%I#*#.5,! 0,)/'O-D!! B55*!-%k)P!M=9<?>9:DD! 06/*)!05'.6!T%--)6.5,!
26 clf#,2%,1!*[)!%,2%6#.5,!a5'!#5'.6!g#ig)!-f#'%,1! 01)!ME:!O)#'-!5I2! 0&5'D#I!#5'.6!G#IG)!6/-F-!?!d),)-*'#.5,b!")G)')!F'5I#F-)b!\/-F!')-*'%6.5,! +-5I#*)2!0B! cg)'o!f#*[5i51op!/,%b!&%b!*'%b!i/! 066)F*#&I)!j(! _`!2O-a/,6.5,! d'))25d!a'5d!')6/''),*!d52)'#*)x-)g)')!0b! 1.0 Freedom rate from recurrent moderate/severe AR Months after surgery Number at risk
27 Freedom rate from aortic reoperation d'))25d!a'5d!#5'.6!')5f)'#.5,! Months after surgery Number at risk
28 01),2#! 34+,*'52/6.5,! :4!
29 # - - # # - - ASD, VSD - - Maze 1 3
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31 # # # #! #!=_)#',%,1!6/'G) >! # # 65,G)'-%5,
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34
![A0B]^cB!m" \5[5'*!0 ]0`B!G-!0`B! 0II?\#/-)!@5'*#I%*O!#*!3!U)#'! 0.5 0.4 0.3 TAVR AVR 26.8 HR [95% CI] = 0.93 [0.71, 1.22] P (log rank) = 0.62 0.2 0.1 24.2 0 0No.](/docs-images/92/109511821/images/35-1.jpg "at Risk 6 12 18 24 Months TAVR 348 298 260 147 67 AVR 351 252 236 139 65 Secondary Endpoint -Physician based NYHA Improvement- Transapical Approach Matrix Analyzable number of patient NYHA Functional")
35 A0B]^cB!m" \5[5'*!0 ]0`B!G-!0`B! TAVR AVR 26.8 HR [95% CI] = 0.93 [0.71, 1.22] P (log rank) = No. at Risk Months TAVR AVR Secondary Endpoint -Physician based NYHA Improvement- Transapical Approach Matrix Analyzable number of patient NYHA Functional Class (Doctors assessment) 24 Improved No change Worsened Death AVA at 6 months f/u 1.0cm % (19/24) 1.0cm 2 < 0% (0/24) 0% (0/24) 0% (0/24) 0% (0/24) 0% (0/24) 20.8% (5/24) Improvement Rate* 95%CI [57.8, 92.9]
![TAVR -)G)')!0"0`B!!! "]"!-65') c/'5-65')!](/docs-images/92/109511821/images/36-0.jpg "d'#%i*o=w> = 0T_!! \#-)! L3!O5!a)D#I)!f%*[!-)G)')!")
36 TAVR -)G)')!0"0`B!!! "]"!-65') c/'5-65')! d'#%i*o=w> = 0T_!! \#-)! L3!O5!a)D#I)!f%*[!-)G)')!0"! ^U(0!6I#--!++!! (%-*5'O!5a![OF)'*),-%5,!#,2!1#-*'%6!/I6)'! "]"!-65')!948Q! A5-%.G)!a'#%I*O! 3976Db!9;$1!
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38 A'56)2/'#I!%D#1)! A'56)2/'#I!n/5'5!%D#1)-!
39 A'56)2/'#I!n/5'5!%D#1)-! A'56)2/'#I!n/5'5!%D#1)-!
40 A'56)2/'#I!n/5'5!%D#1)-! \(H+\c!Hd!+^]cB`c^]+H^! 2014 AHA/ACC Guideline
41 T)6%-%5,!D#$%,1!5a!A#.),*!-)I)6.5,! YES YES NO NO YES NO
![]0`+!F'51'#Dbo44!](/docs-images/92/109511821/images/42-1.jpg "TCT2011 Sakakibara Heart")
42 01),2#! 34+,*'52/6.5,! :4 ;4 "*#'.,1!*[)!]0`+!F'51'#Dbo44! TCT2011 Sakakibara Heart L9! Institute
43 Heart Team Sakakibara Heart Institute
44 (O&'%2!-/'1)5,!! Optimal skill set in TAVI, endovascular interventions and new catheter-based technology Least biased decision maker Still needs intensive collaboration with other surgical and interventional experts. Sakakibara Heart Institute Hybrid skill is optional. Hybrid thinking is essential.
45 Cross Training!
46 \'5--!*'#%,%,1! Thank you!! 0(121310)45#63763#1$896: );<=>>#63763#1$896:>%
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症例報告 37 急性大動脈解離に対する上行大動脈置換術後の大動脈基部拡張 大動脈弁閉鎖不全に対する自己弁温存基部置換術 (remodeling 手術 ) 概要 : mm remodeling 索引用語 : remodeling Remodeling technique for aneurysm of aortic root and moderate aortic valve regurgitation
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