微创直视主动脉瓣置换术在主动脉瓣病变患者中的临床应用
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摘要
目的总结经右侧胸骨旁纵行小切口行微创直视主动脉瓣置换术的临床经验,并评价其安全性和疗效。方法 2014年12月-2016年3月,8例主动脉瓣病变患者接受了微创直视主动脉瓣置换术。男5例,女3例,年龄(45.12±9.09)岁。患者采用全身麻醉双腔气管插管,颈内静脉及股动、静脉插管建立体外循环右侧胸骨旁第2~3肋间隙纵行小切口(4~6 cm)进胸,直视下完成主动脉瓣置换术。结果全组无中转前正中开胸,无死亡,均痊愈出院。患者体外循环时间(102.87±29.88)min,主动脉阻断(69.00±20.98)min,手术时间(248.12±69.69)min,术后呼吸机辅助(10.42±3.08)h,术后重症监护病房(ICU)停留(17.56±3.19)h,术后住院(8.00±2.87)d。术中失血量(212.50±84.64)ml,术后24h胸腔引流量(195.46±60.38)ml,胸腔引流管留置时间(2.32±0.55)d;4例患者未输血,平均输血量(218.75±247.76)ml。切口平均长度(4.92±0.88)cm。出院前复查无瓣周漏及人工瓣膜功能障碍。8例随访(11.50±4.37)个月无死亡,心功能恢复至Ⅰ级,人工瓣膜未见异常。结论部分主动脉瓣病变患者采用外周血管插管建立体外循环,经右侧胸骨旁纵行小切口完成微创直视主动脉瓣置换术创伤小,出血和输血少并发症少术后恢复快,安全可靠,效果确切,值得临床推广。
Objective To summarize the clinical experience of minimally invasive aortic valve replacement(AVR) through right parasternal longitudinal small incision for patients with aortic valve disease,and to evaluate its safety and effect.Methods From December 2014 to March 2016,8 patients including 5 males and 3 femals underwent minimally invasive AVR in Cardiac Surgery Center of Sichuan Provincial People's Hospital were enrolled.The mean age was(45.12 ± 9.09) years.All patients were ventilated with a double lumen endotracheal tube after general anesthesia.Right internal jugular vein,right femoral artery and vein cannulation were used to establish cardiopulmonary bypass(CPB).Minimally invasive AVR was performed through the 2nd to 3rd intercostal space with a 4 to 6 centimeter right parasternal longitudinal incision.Results No patient was converted to anterior median thoracotomy.No death was found.All patients were cured and discharged from hospital.The mean CPB time,crossclamp time,operation time,postoperative ventilator support time,postoperative intensive care unit stay time and postoperative hospitalization time were(102.87 ± 29.88) minutes,(69.00 ±20.98) minutes,(248.12 ± 69.69) minutes,(10.42 ± 3.08) hours,(17.56 ± 3.19) hours,(8.00 ± 2.87) days respectively.The mean intraoperative blood loss was(212.50 ± 84.64) milliliter.The postoperative first 24 h thoracic drainage volume was(195.46 ± 60.38) milliliter.The drainage time of thoracic drainage tube was(2.32 ± 0.55)days.Tthe mean volume of blood transfusion was(218.75 ± 247.76) milliliter.The mean length of incision was(4.92 ± 0.88) centimeter.All patients were followed up for(11.50 ±4.37) months.During the following-up,no patient died,no perivalvular leakage and prosthetic valve dysfunction were found by ultrasound echocardiography.The heart function was improved to grade I.Conclusions Minimally invasive AVR through peripheral vascular can be used to establish CPB,and right parasternal longitudinal small incision with less invasive,less blood loss and blood transfusion,fewer complications,faster recovery,is safe and effective,and is suitable for some patients with aortic valve disease.
Objective To summarize the clinical experience of minimally invasive aortic valve replacement(AVR) through right parasternal longitudinal small incision for patients with aortic valve disease,and to evaluate its safety and effect.Methods From December 2014 to March 2016,8 patients including 5 males and 3 femals underwent minimally invasive AVR in Cardiac Surgery Center of Sichuan Provincial People's Hospital were enrolled.The mean age was(45.12 ± 9.09) years.All patients were ventilated with a double lumen endotracheal tube after general anesthesia.Right internal jugular vein,right femoral artery and vein cannulation were used to establish cardiopulmonary bypass(CPB).Minimally invasive AVR was performed through the 2nd to 3rd intercostal space with a 4 to 6 centimeter right parasternal longitudinal incision.Results No patient was converted to anterior median thoracotomy.No death was found.All patients were cured and discharged from hospital.The mean CPB time,crossclamp time,operation time,postoperative ventilator support time,postoperative intensive care unit stay time and postoperative hospitalization time were(102.87 ± 29.88) minutes,(69.00 ±20.98) minutes,(248.12 ± 69.69) minutes,(10.42 ± 3.08) hours,(17.56 ± 3.19) hours,(8.00 ± 2.87) days respectively.The mean intraoperative blood loss was(212.50 ± 84.64) milliliter.The postoperative first 24 h thoracic drainage volume was(195.46 ± 60.38) milliliter.The drainage time of thoracic drainage tube was(2.32 ± 0.55)days.Tthe mean volume of blood transfusion was(218.75 ± 247.76) milliliter.The mean length of incision was(4.92 ± 0.88) centimeter.All patients were followed up for(11.50 ±4.37) months.During the following-up,no patient died,no perivalvular leakage and prosthetic valve dysfunction were found by ultrasound echocardiography.The heart function was improved to grade I.Conclusions Minimally invasive AVR through peripheral vascular can be used to establish CPB,and right parasternal longitudinal small incision with less invasive,less blood loss and blood transfusion,fewer complications,faster recovery,is safe and effective,and is suitable for some patients with aortic valve disease.
引文
[1]GLAUBER M,FERRARINI M,MICELI A.Minimally invasive aortic valve surgery:state of the art and future directions[J].Ann Cardiothorac Surg,2015,4(1):26-32.
[2]MALAISRIE S C,BARNHART G R,FARIVAR R S,et al.Current era minimally invasive aortic valve replacement:techniques and practice[J].J Thorac Cardiovasc Surg,2014,147(1):6-14.
[3]PHAN K,XIE A,TSAI Y C,et al.Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement:a Bayesian network meta-analysis[J].Ann Cardiothorac Surg,2015,4(1):3-14.
[4]MAZZITELLI D,BEDDA W,PETROVA D,et al.Right parasternal approach for aortic valve replacement after retrosternal gastropexy[J].Eur J Cardiothorac Surg,2004,25(2):290-292.
[5]LEHMANN S,MERK D R,ETZ C D,et al.Minimally invasive aortic valve replacement:the Leipzig experience[J].Ann Cardiothorac Surg,2015,4(1):49-56.
[6]谢建将,黄达德,区景松,等.褥式与褥式外翻缝合法行主动脉瓣置换的临床对比[J].中国现代医学杂志,2009,19(22):3496-3499.
[7]TABATA M.Minimally invasive aortic valve replacement[J].Nihon Geka Gakkai Zasshi,2016,117(2):114-119.
[8]LUCIANI G B,LUCCHESE G.Minimal-access median sternotomy for aortic valve replacement[J].J Thorac Dis,2013,5(Suppl 6):S650-S653.
[9]ITO T,MAEKAWA A,HOSHINO S,HAYASHI Y.Right infraaxillary thoracotomy for minimally invasive aortic valve replacement[J].Ann Thorac Surg,2013,96(2):715-717.
[10]GLAUBER M,MICELI A,GILMANOV D,et al.Right anterior minithoracotomy versus conventional aortic valve replacement:a propensity score matched study[J].J Thorac Cardiovasc Surg,2013,145(5):1222-1226.
[11]MIHALJEVIC T,COHN L H,UNIC D,et al.One thousand minimally invasive valve operations:early and late results[J].Ann Surg,2004,240(3):529-534.
[12]GILMANOV D,BEVILACQUA S,MURZI M,et al.Minimally invasive and conventional aortic valve replacement:a propensity score analysis[J].Ann Thorac Surg,2013,96(3):837-843.
[13]COSGROVE D M 3RD,SABIK J F.Minimally invasive approach for aortic valve operations[J].Ann Thorac Surg,1996,62(2):596-597.
[14]MAEHARA T,KOKAJI K,YAMANO M,et al.Minimally invasive approach for mitral valve,aortic valve,and atrial septal defect surgery[J].Nihon Kyobu Geka Gakkai Zasshi,1997,45(10):1778-1781.
[15]TSUJII E,KOBAYASHI A,TAKEUCHI T,et al.Two surgical cases of right parasternal minimal incision for aortic valve replacement[J].Jpn J Thorac Cardiovasc Surg,1998,46(2):243-247.
[16]COHN L H.Minimally invasive aortic valve surgery:technical considerations and results with the parasternal approach[J].JCard Surg,1998,13(4):302-305.
[17]尤斌,高峰,李平,等.微创直视主动脉瓣替换术和传统开胸手术的比较[J].中华医学杂志,2012,92(40):2859-2861.
[18]高峰,尤斌,李平,等.微创主动脉瓣置换术及术后早期结果[J].中华胸心血管外科杂志,2012,28(6):349-351.
[2]MALAISRIE S C,BARNHART G R,FARIVAR R S,et al.Current era minimally invasive aortic valve replacement:techniques and practice[J].J Thorac Cardiovasc Surg,2014,147(1):6-14.
[3]PHAN K,XIE A,TSAI Y C,et al.Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement:a Bayesian network meta-analysis[J].Ann Cardiothorac Surg,2015,4(1):3-14.
[4]MAZZITELLI D,BEDDA W,PETROVA D,et al.Right parasternal approach for aortic valve replacement after retrosternal gastropexy[J].Eur J Cardiothorac Surg,2004,25(2):290-292.
[5]LEHMANN S,MERK D R,ETZ C D,et al.Minimally invasive aortic valve replacement:the Leipzig experience[J].Ann Cardiothorac Surg,2015,4(1):49-56.
[6]谢建将,黄达德,区景松,等.褥式与褥式外翻缝合法行主动脉瓣置换的临床对比[J].中国现代医学杂志,2009,19(22):3496-3499.
[7]TABATA M.Minimally invasive aortic valve replacement[J].Nihon Geka Gakkai Zasshi,2016,117(2):114-119.
[8]LUCIANI G B,LUCCHESE G.Minimal-access median sternotomy for aortic valve replacement[J].J Thorac Dis,2013,5(Suppl 6):S650-S653.
[9]ITO T,MAEKAWA A,HOSHINO S,HAYASHI Y.Right infraaxillary thoracotomy for minimally invasive aortic valve replacement[J].Ann Thorac Surg,2013,96(2):715-717.
[10]GLAUBER M,MICELI A,GILMANOV D,et al.Right anterior minithoracotomy versus conventional aortic valve replacement:a propensity score matched study[J].J Thorac Cardiovasc Surg,2013,145(5):1222-1226.
[11]MIHALJEVIC T,COHN L H,UNIC D,et al.One thousand minimally invasive valve operations:early and late results[J].Ann Surg,2004,240(3):529-534.
[12]GILMANOV D,BEVILACQUA S,MURZI M,et al.Minimally invasive and conventional aortic valve replacement:a propensity score analysis[J].Ann Thorac Surg,2013,96(3):837-843.
[13]COSGROVE D M 3RD,SABIK J F.Minimally invasive approach for aortic valve operations[J].Ann Thorac Surg,1996,62(2):596-597.
[14]MAEHARA T,KOKAJI K,YAMANO M,et al.Minimally invasive approach for mitral valve,aortic valve,and atrial septal defect surgery[J].Nihon Kyobu Geka Gakkai Zasshi,1997,45(10):1778-1781.
[15]TSUJII E,KOBAYASHI A,TAKEUCHI T,et al.Two surgical cases of right parasternal minimal incision for aortic valve replacement[J].Jpn J Thorac Cardiovasc Surg,1998,46(2):243-247.
[16]COHN L H.Minimally invasive aortic valve surgery:technical considerations and results with the parasternal approach[J].JCard Surg,1998,13(4):302-305.
[17]尤斌,高峰,李平,等.微创直视主动脉瓣替换术和传统开胸手术的比较[J].中华医学杂志,2012,92(40):2859-2861.
[18]高峰,尤斌,李平,等.微创主动脉瓣置换术及术后早期结果[J].中华胸心血管外科杂志,2012,28(6):349-351.