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!?77;?! Right Atrium=RA Left Atrium=LA Right Ventricle RV Left Ventricle LV
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=@0A>! B)-)6.5,!C!-/*/')!!! butterfly resection!
! ring! magic suture!
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! 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
! 24mm 22-23mm 20-21mm 19mm! 80 70 60 60
Patients 247 octogenarians and 10 nonagenarians (total 257) underwent elective SAVR or SAVR+CABG for severe AS from July 2004 through May 2014. These patients was divided to two groups Under 85 years old (85>) N=191 85 years of age or older (85 ) N=69 Sakakibara Heart Institute
A5-*5F)'#.G)!H/*65D)-! Sakakibara Heart Institute 1.0 06*/#'%#I!"/'G%G#I! Actuarial survival 0.8 0.6 0.4 0.2 "/'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%-$!'#.5R<4:8! 0.0 0 20 40 60 80 100 Months after surgery J!#*!'%-$!!!3K3!!!!!!!!!!!!!!!!!LK!!!!!!!!!!!!!!!!:8!!!!!!!!!!!!!!!!!88!!!!!!!!!!!!!!!!!!3:!!!!!!!!!!!!!!!!!!9!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!;;!!!!!!!!!!!!!!!!!7:!!!!!!!!!!!!!!!!!39!!!!!!!!!!!!!!!!!!:!!!!!!!!!!!!!!!!!!!!!7
30 25 Postop Mean Gradient (mmhg) 13.5 ± 4.8 11.9 ± 4.0 10.7 ± 4.2 8.3 ± 3.6 20 P=0.15 P=0.045 15 10 5 0 m p s t Mitroflow CEP Sapien Trifecta
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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 14-8-2 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)![)%1[*測定>! " 自己心膜パッチ 変性弁尖の補填 短縮弁尖の延長 欠損部分の補填! 心エコー 14-8-2 図 10 AFr73 -» Z Reimplantation (Davidnğ Remodeling 心エコー 14-8(Yacoubnğ 心エコー 14-8-2
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\/-F!D5.5,!!?\]?! 05 05 05 _` _` _` 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
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,!
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 0.8 0.6 0.4 0.2 0.0 0 24 48 72 96 120 Months after surgery Number at risk 164 106 38 23 5
Freedom rate from aortic reoperation 1.0 0.8 0.6 0.4 0.2 0.0 d'))25d!a'5d!#5'.6!')5f)'#.5,! 0 24 48 72 96 120 Months after surgery Number at risk 164 121 54 35 7
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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. 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 Class (Doctors assessment) 24 Improved No change Worsened Death AVA at 6 months f/u 1.0cm 2 79.2% (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')! 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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A'56)2/'#I!n/5'5!%D#1)-! \(H+\c!Hd!+^]cB`c^]+H^! 2014 AHA/ACC Guideline
T)6%-%5,!D#$%,1!5a!A#.),*!-)I)6.5,! YES YES NO NO YES NO
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Heart Team Sakakibara Heart Institute
(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.
Cross Training!
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