Name: full-root aortic valve replacement by stentless aortic xenografts in patients with small aortic roots
Uploaded: 2017-05-21T14:00:00.000+00:00
Duration: 12 min 17 s
Description: Watch this Scientific Journal Video about Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots at JoVE.com

Diese Arbeit wurde von einem Stipendium der Schweizerischen Herz-Kreislauf-Stiftung unterstützt.

<ol>
	<li>Bonow, R. O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Focused+update+incorporated+into+the+ACC/AHA+2006+guidelines+for+the+management+of+patients+with+valvular+heart+disease:+A+report+of+the+American+College+of+Cardiology/American+Heart+Association+Task+Force+on+Practice+Guidelines+(Writing+Committee+to+Revise+the+1998+Guidelines+for+the+Management+of+Patients+With+Valvular+Heart+Disease):+endorsed+by+the+Society+of+Cardiovascular+Anesthesiologists,+Society+for+Cardiovascular+Angiography+and+Interventions,+and+Society+of+Thoracic+Surgeons.">Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.</a> Circulation. 118 (15), e523-e661 (2008).</li><li>Rahimtoola, S. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+problem+of+valve+prosthesis-patient+mismatch.">The problem of valve prosthesis-patient mismatch.</a> Circulation. 58 (1), 20-24 (1978).</li><li>Pibarot, P., Dumesnil, J. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prosthesis-patient+mismatch:+definition,+clinical+impact,+and+prevention.">Prosthesis-patient mismatch: definition, clinical impact, and prevention.</a> Heart. 92 (8), 1022-1029 (2006).</li><li>Pibarot, P., Dumesnil, J. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemodynamic+and+clinical+impact+of+prosthesis-patient+mismatch+in+the+aortic+valve+position+and+its+prevention.">Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention.</a> J. Am. Coll. Cardiol. 36 (4), 1131-1141 (2000).</li><li>Kang, Y. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cardiac+hypertrophy:+a+risk+factor+for+QT-prolongation+and+cardiac+sudden+death.">Cardiac hypertrophy: a risk factor for QT-prolongation and cardiac sudden death.</a> Toxicol. Pathol. 34 (1), 58-66 (2006).</li><li>Castro, L. J., Arcidi, J. M., Fisher, A. L., Gaudiani, V. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Routine+enlargement+of+the+small+aortic+Root:+a+preventive+strategy+to+minimize+mismatch.">Routine enlargement of the small aortic Root: a preventive strategy to minimize mismatch.</a> Ann. Thorac. Surg. 74 (1), 31-36 (2002).</li><li>Kunihara, T., Schmidt, K., Glombitza, P., Dzindzibadze, V., Lausberg, H., Sch&#228;fers, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Root+replacement+using+stentless+valves+in+the+small+aortic+root:+A+propensity+score+analysis.">Root replacement using stentless valves in the small aortic root: A propensity score analysis.</a> Ann. Thorac. Surg. 82 (4), 1379-1384 (2006).</li><li>Yacoub, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fourteen-year+experience+with+homovital+homografts+for+aortic+valve+replacement.">Fourteen-year experience with homovital homografts for aortic valve replacement.</a> J. Thorac. Cardiovac. Surg. 110 (1), 186-194 (1995).</li><li>Sommers, K. E., David, T. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+valve+replacement+with+patch+enlargement+of+the+aortic+annulus.">Aortic valve replacement with patch enlargement of the aortic annulus.</a> Ann. Thorac. Surg. 63, 1608-1612 (1997).</li><li>El-Hamamsy, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rate+of+progression+and+functional+significance+of+aortic+root+calcification+after+homograft+versus+freestyle+aortic+root+replacement.">Rate of progression and functional significance of aortic root calcification after homograft versus freestyle aortic root replacement.</a> Circulation. 120 (Suppl 1), S269-S275 (2009).</li><li>Bach, D. S., Kon, N. D., Dumesnil, J. G., Sintek, C. F., Doty, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ten-year+outcome+after+aortic+valve+replacement+with+the+Freestyle+stentless+bioprosthesis.">Ten-year outcome after aortic valve replacement with the Freestyle stentless bioprosthesis.</a> Ann. Thorac. Surg. 80 (2), 480-487 (2005).</li><li>Ennker, I. C., Albert, A., Dalladaku, F., Rosendahl, U., Ennker, J., Florath, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Midterm+outcome+after+aortic+root+replacement+with+stentless+porcine+bioprostheses.">Midterm outcome after aortic root replacement with stentless porcine bioprostheses.</a> Eur. J Cardio-thorac. Surg. 40 (2), 429-434 (2011).</li><li>Tavakoli, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Full-root+aortic+valve+replacement+with+stentless+xenograft+achieves+superior+regression+of+left+ventricular+hypertrophy+compared+to+pericardial+stented+aortic+valves.">Full-root aortic valve replacement with stentless xenograft achieves superior regression of left ventricular hypertrophy compared to pericardial stented aortic valves.</a> J. Cardiothorac. Surg. 10, 15 (2015).</li><li>Kon, N. D., Cordell, A. R., Adair, S. M., Dobbins, J. E., Kitzman, D. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+root+replacement+with+the+Freestyle+stentless+porcine+aortic+root+bioprosthesis.">Aortic root replacement with the Freestyle stentless porcine aortic root bioprosthesis.</a> Ann. Thorac. Surg. 67 (6), 1609-1616 (1999).</li><li>Dapunt, O. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stentless+full-root+bioprosthesis+in+surgery+for+complex+aortic+valve-ascending+aortic+disease:+a+single+center+experience+of+over+300+patients.">Stentless full-root bioprosthesis in surgery for complex aortic valve-ascending aortic disease: a single center experience of over 300 patients.</a> Eur. J. Cardiothorac. Surg. 33 (4), 554-559 (2008).</li><li>Saxena, A., Dinh, D., Smith, J. A., Reid, C. M., Shardey, G., Newcomb, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+surgeon+status+is+not+associated+with+an+increased+risk+of+early+or+late+mortality+after+isolated+aortic+valve+replacement+surgery.">Training surgeon status is not associated with an increased risk of early or late mortality after isolated aortic valve replacement surgery.</a> Cardiol. J. 21 (2), 183-190 (2014).</li><li>D'Agostino, R. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Society+of+Thoracic+Surgeons+Adult+Cardiac+Surgery+Database:+2016+Update+on+Outcomes+and+Quality.">The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 Update on Outcomes and Quality.</a> Ann. Thorac. Surg. 101 (1), 24-32 (2016).</li><li>Fries, R., Wendler, O., Schieffer, H., Sch&#228;fers, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+rest+and+exercise+hemodynamics+of+23-mm+stentless+versus+23-mm+stented+aortic+bioprostheses.">Comparative rest and exercise hemodynamics of 23-mm stentless versus 23-mm stented aortic bioprostheses.</a> Ann. Thorac. Surg. 69 (3), 817-822 (2000).</li></ol>

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<html> Diese Studie berichtet über eine detaillierte Beschreibung der chirurgischen Technik des Vollwurzel-Aortenklappenersatzes mit stentlosen Aorten-Xenotransplantaten bei Patienten mit kleinen Aortenwurzeln. Frühe Morbidität und Mortalität sind sehr gering und vergleichen sich mit anderen Berichten gut. 7 . Stark verkalkte Koronarostien stellen eine anatomische Begrenzung dieser Technik dar. Ein weiterer Nachteil dieser Technik wird durch Patienten mit einem schlechten Allgemeinzustand darg...

Der biologische Aortenklappenersatz wird für Patienten empfohlen, die älter als 65 Jahre sind 1 . Bei Patienten mit kleinen Aortenwurzeln kann die Implantation eines gestrickten biologischen Ventilersatzes auf der Grundlage der vom Hersteller angegebenen Kennzeichnung nicht den funktionalen Bedürfnissen entsprechen. In dieser Situation beschrieb Rahimtoola zuerst die Prothesen-Patient-Mismatch (PPM) wie folgt: &quot; Mismatch kann als anwesend angesehen werden, wenn die wirksame prothetische Ventilfläche nach dem Einsetzen in den Patienten geringer ist als die eines normalen menschlichen Ventils &quot; 2 . Der effektive Öffnungsbereich der Ventilprothese soll mit der Körpergröße des Patienten und, häufiger, auf die Körperoberfläche des Patienten bezogen werden. Die hämodynamische Konsequenz eines zu kleinen Prothesenventils ist ein ungewöhnlich hoher transvalvaler Gradient 3 . Es wurde gezeigt, dass die Beziehung zwischen dem transvalvularen Gradienten und dem EffektivE-Öffnungsfläche, die auf die Körperoberfläche (EOAI) indiziert ist, ist krummlinig und die Gradienten steigen exponentiell an, wenn das indizierte EOA weniger als 0,8 bis 0,9 cm 2 / m 2 beträgt. Auf der Grundlage dieser Beziehung wird ein EOAI von weniger als 0,85 cm 2 / m 2 allgemein als die Schwelle für PPM in der Aortenposition 4 angesehen. Die Auswirkungen der PPM auf frühe und späte klinische Ergebnisse ist umstritten. Es wurde jedoch berichtet, dass PPM die Regression der linksventrikulären Hypertrophie negativ beeinflusst und damit die Normalisierung der linksventrikulären Funktion und die Linderung der Symptome 4 . Die anhaltende linksventrikuläre Hypertrophie ist mit einem erhöhten Risiko von Arrhythmien und einem plötzlichen Herztod verbunden. Es ist daher ratsam, PPM so weit wie möglich zu vermeiden 4 . Im Falle eines vorhersagbaren PPM für einen geplanten Aortenklappenersatz mit einem BiolOgischer Ventilersatz, die Optionen sind: 1) die PPM zu akzeptieren, die aus der Implantation eines gestielten Perikardventils resultiert, wenn Komorbiditäten des Patienten eine technisch anspruchsvollere operative Technik zum Implantieren einer größeren Prothese verbieten, 2), um die Aortenwurzel zu vergrößern Einen größeren versenkten Ventilersatz 6 oder 3), um ein stentloses biologisches Ventil 7 oder Homograft 8 zu implantieren. Aortenwurzelvergrößerung wurde berichtet, um perioperative Blutungen zu erhöhen, was eine Re-Sternotomie und eine zunehmende frühe Sterblichkeit erfordert 9 . Aorten-Homotransplantate können ausgezeichnete hämodynamische Profile und gute langfristige Ergebnisse haben, wenn sie von erfahrenen Chirurgen implantiert werden 8 . Allerdings machen ihre begrenzte Verfügbarkeit und die beschleunigte Verkalkungsrate Aorten-Homotransplantate weniger geeignete biologische Ventilersatzstoffe als ihre Gegenstücke, Schweine-Stentless-Aorta xEnografts 10 Der Mangel und die Nachteile von Homotransplantaten haben die Konzeption und Entwicklung von alternativen biologischen Ventilsubstituten veranlasst. Zu diesem Zweck wurden stentlose Aorten-Xenotransplantate in die klinische Praxis eingeführt 11 . Einerseits können dank der Beseitigung des umständlichen Nährings stentlose Aorten-Xenotransplantate die hämodynamischen Vorteile von Homograften reproduzieren. Andererseits wurde infolge der Anwendung der Anti-Verkalkungstechnologie die Haltbarkeit von stentless Aorten-Xenotransplantaten optimiert, um die Langlebigkeit der Homotransplantate zu übertreffen und sogar zu übertreffen 11 . Hämodynamische Vorteile von stentlosen Aorten-Xenotransplantaten werden durch die Vollwurzelimplantation vollständig erreicht. Im Gegensatz zu Subkoronar- und Wurzelintegrationstechniken platziert die Vollwurzelimplantation das stentlose Aorten-Xenotransplantat auf den Aortenkranz und nicht drinnen. Diese Tatsache undErkennt die Begründung für die Vollwurzelimplantationstechnik, die die Umsetzung des größten internen Funktionsdurchmessers des stentfreien Ventilsatzes ermöglicht. Darüber hinaus begünstigt die Erhaltung der Valsalva-Nebenhöhlen mit den Klappenblättern mehr physiologische Öffnungs- und Schließbewegungen und damit eine längere Lebenserwartung der Flugblätter. Dieser Vorteil trägt weiter zur Besserung der langfristigen Ergebnisse bei 12 . Die Besorgnis über das erhöhte Blutungspotential und für die mögliche Verzerrung von koronaren Ostia-Anastomosen hindert jedoch, dass eine Anzahl von Herzchirurgen von einem klassischen Aortenklappenaustausch mit einem gesungenen biologischen Ventil zu dem technisch anspruchsvolleren Verfahren, das durch den Vollwurzelersatz dargestellt wird, verlagert wird Stentlose Aorten-Xenotransplantate. Angesichts der potenziellen hämodynamischen Vorteile von stentless Aorten-Xenotransplantaten haben wir Full-Roo verabschiedetT Implantation zur Vermeidung von PPM bei Patienten mit kleinen Aortenwurzeln, die einen Aortenklappenersatz erfordern ( Tabelle 1 ). Bei diesen Patienten geht es darum, für die neu implantierte Aortenklappe eine projizierte EOAI von mehr als 0,85 cm 2 / m 2 zu erreichen. Diese Absicht beruht auf den Berichten von Pibarot und Mitarbeitern, die eine unannehmbar hohe transvalvuläre Gradienten für Ventilersatzstoffe mit einem projizierten EOAI von weniger als 0,85 cm 2 / m 2 mit der anschließenden unvollständigen Linderung der Symptome und dem anhaltenden Risiko von Nebenwirkungen zeigen 3 , 4 Nach der anfänglichen Identifizierung von erwachsenen Patienten mit einem Aortenringdurchmesser von weniger als 20 mm bei ihrer präoperativen Echokardiographie werden die Patienten ferner mit einer Körperoberfläche von mehr als 1,6 m 2 ausgewählt. In dieser Untergruppe der Patienten wurde die Implantation einer 19-mm-Stented-Pericardial-Aortenklappe (EOA: 1,28 cm 2 </Sup&gt;) zu einem projizierten EOAI von weniger als 0,85 cm 2 / m 2 führen würde . In diesem Protokoll sind diese Patienten Kandidaten für die Vollwurzelimplantation von stentless Aorten-Xenotransplantaten. Die endgültige Entscheidung wird nach der Entfernung der Aortenklappe intraoperativ getroffen. Wenn ein 19-mm-Ventil-Sizer für die gestielte Perikard-Aortenklappe zu eng durch den Aortenkranz hindurchtritt und der Patient hämodynamisch stabil ist und einen längeren Betrieb tolerieren kann, wird die Vollwurzelimplantation eines stentlosen Aorten-Xenotransplantats durchgeführt. Für die stentless Aorten-Xenotransplantate verwenden wir zwei handelsübliche Ventilsubstitute austauschbar (Details siehe Tabelle der Materialien ). Beide Ventile werden aus der Schildwurzel, die die Aortenklappe trägt, beschafft. Sie werden unter Verwendung eines Niederdruck- (0-2 mmHg) Fixierungsprozesses mit Anti-Verkalkung ( zB XenoLogiX) Behandlung für ein Ventil und Alpha-Amino-oleinsäure (AOA) anti-caVerfallbehandlung für den anderen. Bei den Patienten, für die der 19-mm-Sizer für die gestielten Perikardventile zu eng durch den Aortenkranz verläuft, bedeutet der 23 mm-Sizer für die stentless Aorten-Xenotransplantation, der gut im Aortenkranz passt, dass die stentless Aorten-Xenotransplantatgröße von 23 mm ist Gewählt werden. Dieses Protokoll beschreibt im Detail die Technik der Vollwurzelimplantation von stentlosen Aorten-Xenotransplantaten mit Schwerpunkt auf der Verwaltung der proximalen Nahtlinie und koronaren Anastomosen. Einschränkungen dieser Technik und alternative Optionen werden diskutiert.

<table><tbody><tr><td>&lt;strong&gt;Heart surgery infrastructure:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Heart Lung Machine</td><td>Stockert</td><td>SIII</td><td></td></tr><tr><td>EOPA 24Fr. arterial cannula</td><td>Medtronic</td><td>77624</td><td></td></tr><tr><td>Atrial caval venous cannula 34/48Fr.</td><td>Medtronic</td><td>93448</td><td></td></tr><tr><td>LV vent catheter 17Fr.</td><td>Edwards</td><td>E061</td><td></td></tr><tr><td>Antegrade 9Fr. cardioplegia cannula</td><td>Edwards</td><td>AR012V</td><td></td></tr><tr><td>Retrograde 14Fr. cardioplegia cannula&amp;nbsp;</td><td>Edwards</td><td>NPC014&amp;nbsp;</td><td></td></tr><tr><td>Coronary artery ostial cannula 90&amp;deg;</td><td>Medtronic</td><td>30155</td><td></td></tr><tr><td>Coronary artery ostial cannula 45&amp;deg;</td><td>Medtronic</td><td>30255</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Valve subsitutes:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Stentless aortic xenograft Prima Plus 23 mm</td><td>Edwards</td><td>2500P-23</td><td>anti-calcification XenoLogiX treatment</td></tr><tr><td>Stentless aortic xenograft Sizer 23 mm</td><td>Edwards</td><td>1170</td><td></td></tr><tr><td>Stentless aortic xenograft Freestyle 23 mm</td><td>Medtronic</td><td>FR995-23</td><td>alpha amino oleic acid (AOA) anti-calcification treatment</td></tr><tr><td>Stentless aortic xenograft Sizer 23 mm</td><td>Medtronic</td><td>7900</td><td></td></tr><tr><td>Electrocautery</td><td>Covidien</td><td>Force FX&lt;sup&gt;TM&lt;/sup&gt;</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Sutures:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Polypropylene 4/0</td><td>Ethicon</td><td>8871H</td><td></td></tr><tr><td>Polypropylene 5/0</td><td>Ethicon</td><td>8870H</td><td></td></tr><tr><td>Polypropylene 6/0</td><td>Ethicon</td><td>EH7400H</td><td></td></tr><tr><td>Braided polyesther 2/0 ligature with polybutylate coating&amp;nbsp;</td><td>Ethicon</td><td>X305H</td><td></td></tr><tr><td>Micro knife Sharpoint&amp;nbsp;</td><td>TYCO Healthcare PTY&amp;nbsp;</td><td>78-6900</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Drugs:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Midazolam</td><td>Roche Pharma</td><td>N05CD08</td><td></td></tr><tr><td>Rocuronium</td><td>MSD Merck Sharp &amp;amp; Dohme&amp;nbsp;</td><td>M03AC09</td><td></td></tr><tr><td>Propofol</td><td>Fresenius Kabi</td><td>N01AX10</td><td></td></tr><tr><td>Fentanil</td><td>Actavis</td><td>N01AH01</td><td></td></tr><tr><td>Heparin</td><td>Braun</td><td>B01AB01</td><td></td></tr><tr><td>Protamin</td><td>MEDA Pharmaceutical</td><td>V03AB14</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Instruments:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Cooley vascular aortic clamp</td><td>Delacroix-Chevalier</td><td>DC40810-16</td><td></td></tr><tr><td>Dissection forceps Carpentier</td><td>Delacroix-Chevalier</td><td>DC13110-28&amp;nbsp;</td><td></td></tr><tr><td>Scissors Metzenbaum</td><td>Delacroix-Chevalier</td><td>B351751</td><td></td></tr><tr><td>Needle holder Ryder</td><td>Delacroix-Chevalier</td><td>DC51130-20&amp;nbsp;</td><td></td></tr><tr><td>Dissection forceps DeBakey</td><td>Delacroix-Chevalier</td><td>DC12000-21&amp;nbsp;</td><td></td></tr><tr><td>Micro needle holder Jacobson</td><td>Delacroix-Chevalier</td><td>DC50002-21&amp;nbsp;</td><td></td></tr><tr><td>Micro scisors Jacobson</td><td>Delacroix-Chevalier</td><td>DC20057-21&amp;nbsp;</td><td></td></tr><tr><td>Lung retractor</td><td>Delacroix-Chevalier</td><td>B803990</td><td></td></tr><tr><td>Allis clamp</td><td>Delacroix-Chevalier</td><td>DC45907-25&amp;nbsp;</td><td></td></tr><tr><td>O&amp;rsquo;Shaugnessy Dissector</td><td>Delacroix-Chevalier</td><td>B60650</td><td></td></tr><tr><td>18 blade knife</td><td>Delacroix-Chevalier</td><td>B130180</td><td></td></tr><tr><td>Leriche haemostatic clamp</td><td>Delacroix-Chevalier</td><td>B86555</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Data analysis:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Mann-Whitney and Chi-square tests</td><td>GraphPad</td><td>Prism 7</td><td></td></tr></tbody></table>

full-root aortic valve replacement by stentless aortic xenografts in patients with small aortic roots

Bei Patienten mit kleinen Aortenwurzeln, die einen Aortenklappenaustausch mit biologischen Ventilersatzmitteln benötigen, kann die Implantation des gestampften Perikardventils nicht den funktionalen Bedürfnissen entsprechen. Die Implantation eines zu kleinen stented Perikardventils, das zu einer effektiven Blendenfläche führt, die auf eine Körperoberfläche von weniger als 0,85 cm 2 / m 2 indiziert ist, wird als Prothesen-Patient-Mismatch (PPM) angesehen. Ein PPM wirkt sich negativ auf die Regression der linksventrikulären Hypertrophie und damit auf die Normalisierung der linksventrikulären Funktion und die Linderung der Symptome aus. Die persistente linksventrikuläre Hypertrophie ist mit einem erhöhten Risiko von Arrhythmien und einem plötzlichen Herztod verbunden. Im Falle von vorhersagbarem PPM gibt es drei Möglichkeiten: 1) akzeptiere das PPM, das aus der Implantation eines gestielten Perikardventils resultiert, wenn Komorbiditäten des Patienten die technisch anspruchsvollere operative Technik der Implantation einer größeren Prothese verbieten, 2)Aortenwurzel, um einen größeren versenkten Ventilersatz aufzunehmen, oder 3) Implantieren Sie ein stentless biologisches Ventil oder ein Homograft. Im Vergleich zum klassischen Aortenklappenersatz mit gestrickten Perikardventilen bietet die Vollwurzelimplantation von stentless Aorten-Xenotransplantaten die Möglichkeit, ein 3-4 mm größeres Ventil bei einem gegebenen Patienten zu implantieren und damit eine signifikante Reduktion der transvalvalen Gradienten zu ermöglichen. Allerdings sind eine Reihe von Herzchirurgen zögern, einen klassischen Aortenklappenersatz mit verschnittenen Perikardventilen in die technisch anspruchsvollere Vollwurzelimplantation von stentlosen Aorten-Xenotransplantaten umzuwandeln. Angesichts der potenziellen hämodynamischen Vorteile von stentlosen Aorten-Xenotransplantaten haben wir eine Vollwurzelimplantation verabschiedet, um PPM bei Patienten mit kleinen Aortenwurzeln zu vermeiden, die einen Aortenklappenersatz erfordern. Hier beschreiben wir im Detail eine Technik für die Vollwurzelimplantation von stentlosen Aorten-Xenotransplantaten mit Schwerpunkt auf der Verwaltung der proximalen Nahtlinie anD koronare anastomosen Einschränkungen dieser Technik und alternative Optionen werden diskutiert.

statistische Analyse Die Werte der projizierten effektiven Blendenfläche, die auf die Körperoberfläche (EOAI, cm 2 / m 2 ) für implantierte stentless Aorten-Xenotransplantate mit einer Größe von 23 mm indiziert sind, werden als Mittelwerte ± SD ausgedrückt und verglichen mit dem berechneten EOAI der gestielten Perikardventile 4 mm kleiner ( Dh 19 mm) unter Verwendung des nichtparametrischen ...

Watch this Scientific Journal Video about Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots at JoVE.com

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

Vollwurzel-Aortenklappenersatz durch stentless Aorten-Xenotransplantat ist eine praktikable Option bei Patienten mit kleinen Aortenwurzeln. Wir beschreiben eine Technik für die Vollwurzelimplantation von stentlosen Aorten-Xenotransplantaten mit Schwerpunkt auf der Verwaltung der proximalen Nahtlinie und koronaren Anastomosen und diskutieren ihre Grenzen und Alternativen.

Vollwurzel Aortenklappenaustausch durch stentless Aortic Xenotransplantate bei Patienten mit kleinen Aortenwurzeln

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial ...

full-root-aortic-valve-replacement-stentless-aortic-xenografts

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

11.2K Aufrufe.  University of Zurich.  Vollwurzel-Aortenklappenersatz durch stentless Aorten-Xenotransplantat ist eine praktikable Option bei Patienten mit kleinen Aortenwurzeln. Wir beschreiben eine Technik für die Vollwurzelimplantation von stentlosen Aorten-Xenotransplantaten mit Schwerpunkt auf der Verwaltung der proximalen Nahtlinie und koronaren Anastomosen und diskutieren ihre Grenzen und Alternativen. 

Serie: Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

Orthotopic Aortic Transplantation in Mice for the Study of Vascular Disease

Vascular procedures involving anastomoses in the mouse are generally thought to be difficult and highly dependent on the skill of the individual surgeon. This is largely true, but there are a number of important principles that can reduce the difficulty of these procedures and enhance reproducibility. Orthotopic aortic transplantation is an excellent procedure in which to learn these principles because it involves only two end-to-end anastomoses, but requires good suturing technique and handling of the vessels for consistent success. This procedure begins with the procurement of a length of abdominal aorta from a donor animal, followed by division of the native aorta in the recipient. The procured aorta is then placed between the divided ends of the recipient aorta and sutured into place using end-to-end anastomoses. To accomplish this objective successfully requires a high degree of concentration, good tools, a steady hand, and an appreciation of how easily the vasculature of a mouse can be damaged, resulting in thrombosis. Learning these important principles is what occupies most of the beginner's time when learning microsurgery in small rodents. Throughout this protocol, we refer to these important points. This model can be used to study vascular disease in a variety of different experimental systems1-8. In the context shown here, it is most often used for the study of post-transplant vascular disease, a common long-term complication of solid organ transplantation in which intimal hyperplasia occurs within the allograft. The primary advantage of the model is that it facilitates quantitative morphometric analyses and the transplanted vessel lies contiguous to the endogenous vessel, which can serve as an additional control9. The technique shown here is most often used for mice weighing 18-25 grams. We have accumulated most of our experience using the C57BL/6J, BALB/cJ, and C3H/HeJ strains.

We describe a technique in which a section of the abdominal aorta from a mouse is transplanted orthotopically to just below the renal arteries in an allogeneic or syngeneic recipient. This technique can be useful in studies in which transplantation of large arteries of uniform size is deemed advantageous.

Orthotopen Aortic Transplantation in Mäuse für das Studium der Vascular Disease

Vascular procedures involving anastomoses in the mouse are generally thought to be difficult and highly dependent on the skill of the individual surgeon. ...

Forschung

Medizin

Transplantation of Pulmonary Valve Using a Mouse Model of Heterotopic Heart Transplantation

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed results. However, the cellular and molecular mechanisms of the neotissue development, valve thickening, and stenosis development are not researched extensively. To answer the above questions, we developed a murine heterotopic heart valve transplantation model. A heart valve was harvested from a valve donor mouse and transplanted to a heart donor mouse. The heart with a new valve was transplanted heterotopically to a recipient mouse. The transplanted heart showed its own heartbeat, independent of the recipient&#8217;s heartbeat. The blood flow was quantified using a high frequency ultrasound system with a pulsed wave Doppler. The flow through the implanted pulmonary valve showed forward flow with minimal regurgitation and the peak flow was close to 100 mm/sec. This murine model of heart valve transplantation is highly versatile, so it can be modified and adapted to provide different hemodynamic environments and/or can be used with various transgenic mice to study neotissue development in a tissue engineered heart valve.

In order to understand the cellular and molecular mechanisms underlying neotissue formation and stenosis development in tissue engineered heart valves, a murine model of heterotopic heart valve transplantation was developed. A pulmonary heart valve was transplanted to recipient using the heterotopic heart transplantation technique.

Transplantation von Pulmonalklappe Mit einem Maus-Modell der heterotopen Herztransplantation

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed ...

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

Standardisierte Technik der Aortenklappe erneute Implantation für Ventil-sparing Aortic Root Ersatz

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Technik und geduldige Auswahlkriterien der rechten vorderen Mini-Thorakotomie für Minimal Access Aortenklappenersatz

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

A Simplified Model for Heterotopic Heart Valve Transplantation in Rodents

There is an urgent clinical need for heart valve replacements that can grow in children. Heart valve transplantation is proposed as a new type of transplant with the potential to deliver durable heart valves capable of somatic growth with no requirement for anticoagulation. However, the immunobiology of heart valve transplants remains unexplored, highlighting the need for animal models to study this new type of transplant. Previous rat models for heterotopic aortic valve transplantation into the abdominal aorta have been described, though they are technically challenging and costly. For addressing this challenge, a renal subcapsular transplant model was developed in rodents as a practical and more straightforward method for studying heart valve transplant immunobiology. In this model, a single aortic valve leaflet is harvested and inserted into the renal subcapsular space. The kidney is easily accessible, and the transplanted tissue is securely contained in a subcapsular space that is well vascularized and can accommodate a variety of tissue sizes. Furthermore, because a single rat can provide three donor aortic leaflets and a single kidney can provide multiple sites for transplanted tissue, fewer rats are required for a given study. Here, the transplantation technique is described, providing a significant step forward in studying the transplant immunology of heart valve transplantation.

This protocol describes a simple and efficient method for the transplantation of aortic valve leaflets under the renal capsule to allow for the study of alloreactivity of heart valves.

Ein vereinfachtes Modell für die heterotope Herzklappentransplantation bei Nagetieren

There is an urgent clinical need for heart valve replacements that can grow in children. Heart valve transplantation is proposed as a new type of ...

A Rodent Model of The Ross Operation: Syngeneic Pulmonary Artery Graft Implantation in A Systemic Position

The Ross operation for aortic valve disease has regained new interest due to its outstanding long-term results. Nonetheless, when employed as freestanding root replacement, the possible dilation of the pulmonary autograft and subsequent aortic regurgitation is described. Several animal models have been proposed. However, these are usually limited to ex-vivo models or in-vivo experiments with relatively expensive large animal models. In this study, we sought to establish a rodent model of pulmonary artery graft (PAG) implantation in a systemic position. A total of 39 adult Lewis rats were included. Immediately after euthanasia, the pulmonary root was harvested from a donor animal (n=17). Syngeneic recipient (n=17) and sham-operated (n=5) rats were sedated and ventilated. In the recipient group, the PAG was implanted with an end-to-end anastomosis in infra-renal abdominal aortic position. Sham-operated rats underwent only transection and re-anastomosis of the aorta. Animals were followed with serial ultrasound studies for two months and post-mortem histological analysis. The median PAG diameter in the native position was 3.20 mm (IQR=3.18-3.23). At follow-up, the median diameter of the PAG was 4.03 mm (IQR=3.74-4.13) at 1 week, 4.07 mm (IQR=3.80-4.28) at 1 month, and 4.27 mm (IQR=3.90-4.35) at 2 months (p&lt;0.01). Peak systolic velocity was 220.07 mm/s (IQR=210.43-246.41) at 1 week, 430.88 mm/s (IQR=375.28-495.56) at 1 month, and 373.68 mm/s (IQR=305.78-429.81) at 2 months (p=0.02) and did not differ from the sham-operated group at the end of the experiment (p=0.5). Histological analysis did not show any sign of endothelial thrombosis. This study showed that rodent models may allow for the evaluation of the long-term adaptation of the pulmonary root to a high-pressure system. A systemically placed syngeneic PAG implantation represents a simple and feasible platform for the development and evaluation of novel surgical techniques and drug therapies to further improve the outcomes of the Ross operation.

We demonstrate how to establish a murine model of pulmonary root implantation into the descending aorta to simulate the Ross procedure. This model enables the medium/long-term evaluation of pulmonary autograft remodeling in a systemic position, representing the basis of developing therapeutic strategies to promote its adaptation.

Ein Nagetiermodell der Ross-Operation: Syngene Lungenarterientransplantatimplantation in einer systemischen Position

The Ross operation for aortic valve disease has regained new interest due to its outstanding long-term results. Nonetheless, when employed as freestanding ...

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from symptomatic severe aortic valve stenosis. This is also reflected in the recently updated international guidelines on managing patients with valvular heart disease. A transfemoral&#160;(TF) TAVI&#160;approach has proven superior to alternative access strategies. With the introduction of intravascular lithotripsy (IVL), patients with calcified iliofemoral vascular disease and borderline intraluminal diameters have also become candidates for percutaneous TF-TAVI. Moreover, IVL reduces the risk of major vascular complications by modifying the superficial and deep vascular calcium, thereby changing the vessel compliance and controlling luminal expansion. In this way, IVL has shown to safely facilitate TF delivery of TAVI devices in patients with calcified peripheral artery disease. The present article aims to provide a detailed step-by-step description on how to perform IVL-assisted TF-TAVI safely and efficiently. Furthermore, a literature review on the outcomes obtained with this technology is included, along with a concise discussion on this unique TAVI approach.

Transcatheter aortic valve implantation (TAVI) has been shown to generate the best clinical outcomes when performed by the percutaneous transfemoral approach. Intravascular lithotripsy (IVL) can facilitate a transfemoral process in patients with calcified iliofemoral vascular disease and borderline intraluminal diameters. The present protocol describes IVL-assisted transfemoral TAVI.

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from ...

Transcatheter Pulmonary Valve Replacement from Autologous Pericardium with a Self-Expandable Nitinol Stent in an Adult Sheep Model

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow tract or bioprosthetic valve dysfunction, with excellent early and late clinical outcomes. However, clinical challenges such as stented heart valve deterioration, coronary occlusion, endocarditis, and other complications must be addressed for lifetime application, particularly in pediatric patients. To facilitate the development of a lifelong solution for patients, transcatheter autologous pulmonary valve replacement was performed in an adult sheep model. The autologous pericardium was harvested from the sheep via left anterolateral minithoracotomy under general anesthesia with ventilation. The pericardium was placed on a 3D shaping heart valve model for non-toxic cross-linking for 2 days and 21 h. Intracardiac echocardiography (ICE) and angiography were performed to assess the position, morphology, function, and dimensions of the native pulmonary valve (NPV). After trimming, the crosslinked pericardium was sewn onto a self-expandable Nitinol stent and crimped into a self-designed delivery system. The autologous pulmonary valve (APV) was implanted at the NPV position via left jugular vein catheterization. ICE and angiography were repeated to evaluate the position, morphology, function, and dimensions of the APV. An APV was successfully implanted in&#160;sheep J. In this paper, sheep J was selected to obtain representative results. A 30 mm APV with a Nitinol stent was accurately implanted at the NPV position without any significant hemodynamic change. There was no paravalvular leak, no new pulmonary valve insufficiency, or stented pulmonary valve migration. This study demonstrated the feasibility and safety, in a long-time follow-up, of developing an APV for implantation at the NPV position with a self-expandable Nitinol stent via jugular vein catheterization in an adult sheep model.

This study demonstrates the feasibility and safety of developing an autologous pulmonary valve for implantation at the native pulmonary valve position by using a self-expandable Nitinol stent in an adult sheep model. This is a step toward developing transcatheter pulmonary valve replacement for patients with right ventricular outflow tract dysfunction.

Transkatheter-Pulmonalklappenersatz aus autologem Perikard mit einem selbstexpandierenden Nitinol-Stent in einem erwachsenen Schafmodell

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow ...

Aufsteigendes Aortenband zur Untersuchung der durch Drucküberlastung induzierten Herzinsuffizienz

A Minimally Invasive Model of Aortic Stenosis in Swine

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological similarities to humans. Efforts have been dedicated to creating a model of pressure-overload induced heart failure, and ascending aortic banding while still supra-coronary and not a perfect mimic of aortic stenosis in humans, closely resembling the human condition.
The purpose of this study is to demonstrate a minimally invasive approach to induce left ventricular pressure overload by placing an aortic band, precisely calibrated with percutaneously introduced high-fidelity pressure sensors. This method represents a refinement of the surgical procedure (3Rs), resulting in homogenous trans-stenotic gradients and reduced intragroup variability. Additionally, it enables swift and uneventful animal recovery, leading to minimal mortality rates. Throughout the study, animals were followed for up to 2 months after surgery, employing transthoracic echocardiography and pressure-volume loop analysis. However, longer follow-up periods can be achieved if desired. This large animal model proves valuable for testing new drugs, particularly those targeting hypertrophy and the structural and functional alterations associated with left ventricular pressure overload.

Autor im Rampenlicht: Entwicklung eines minimal-invasiven Großtiermodells für zuverlässige und reproduzierbare kardiovaskuläre Forschung 

This protocol describes a minimally invasive surgical procedure for ascending aortic banding in swine.

Ein minimal-invasives Modell der Aortenstenose beim Schwein

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological ...

Vollwurzel Aortenklappenaustausch durch stentless Aortic Xenotransplantate bei Patienten mit kleinen Aortenwurzeln

Zusammenfassung

Weitere Videos entdecken

Kapitel in diesem Video

Orthotopen Aortic Transplantation in Mäuse für das Studium der Vascular Disease

Transplantation von Pulmonalklappe Mit einem Maus-Modell der heterotopen Herztransplantation

Standardisierte Technik der Aortenklappe erneute Implantation für Ventil-sparing Aortic Root Ersatz

Technik und geduldige Auswahlkriterien der rechten vorderen Mini-Thorakotomie für Minimal Access Aortenklappenersatz

Ein vereinfachtes Modell für die heterotope Herzklappentransplantation bei Nagetieren

Ein Nagetiermodell der Ross-Operation: Syngene Lungenarterientransplantatimplantation in einer systemischen Position

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

Transkatheter-Pulmonalklappenersatz aus autologem Perikard mit einem selbstexpandierenden Nitinol-Stent in einem erwachsenen Schafmodell

Ein minimal-invasives Modell der Aortenstenose beim Schwein

Ein minimal-invasives Modell der Aortenstenose beim Schwein