全胸腔镜下二尖瓣手术97例经验总结
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摘要
目的:探讨经胸壁三孔完全胸腔镜下二尖瓣手术的治疗效果及安全性。方法:回顾性分析2012-02-2018-02在兰州大学第二医院心脏外科接受完全胸腔镜下二尖瓣成形或置换手术患者的临床资料。男56例,女41例;年龄20～73岁,平均(58±17)岁。所有患者患有二尖瓣中-重度狭窄和(或)关闭不全,其中鲁登巴赫综合征3例,合并心房颤动19例,合并重度肺动脉高压18例,合并三尖瓣关闭不全40例。手术采用股动脉、静脉插管建立体外循环,阻闭升主动脉,冷血心脏停跳液顺行灌注行心肌保护,完全胸腔镜下行二尖瓣成形或置换术。结果:本组97例患者均顺利完成手术,无手术死亡。全组无术后残余漏、瓣周漏,6例发生术后早期并发症,分别为肾功能不全4例,经治疗后均恢复正常,二次开胸止血1例,术中扩大切口1例,均顺利恢复。平均体外循环时间(165±45) min;平均升主动脉阻断时间(102±41) min;平均手术时间(238±57) min。平均术后呼吸机辅助时间(19±11) h,平均ICU停留时间(28±13) h,术后平均引流量(278±86) ml,平均住院时间(9.5±3.8) d。术后左室射血分数较术前无明显降低(P=0.112),术后左心房明显缩小(P=0.046);其中,二尖瓣关闭不全患者术后左心室内径明显缩小(P=0.039)。置换后的人工瓣膜和成形后的自体瓣膜均正常关闭,无瓣周漏,无狭窄或关闭不全。随访3～72个月,全部病例中,5例有轻度肾功能不全表现,余无其他并发症或死亡。结论:完全胸腔镜下二尖瓣手术的手术操作安全,创伤小,疗效确切,在二尖瓣疾病的外科治疗方面有着良好的应用价值。
Objective:To summarize the clinical outcome of totally thoracoscopic cardiac surgery for mitral valve operation.Method:Clinical data of 97 cases undergoing totally thracoscopic cardiac surgery for mitral valve repair or replacement from Feb 2012 to Feb 2018 in Department of Cardiacvascular Surgery,2 nd Hospital,Lanzhou University was analyzed retrospectively.There were 56 male and 41 female patients,aged from 20 to 73 with a mean of(58±17) years.All the 97 patients had moderate-severe mitral vavle stenosis and(or) regurgitation,3 patients had Lutembacher Syndrome,19 patients had atrial fibrillation,18 patients had severe pulmary artery hypertension,and 40 patients had moderate-severe tricuspid valve regurgitation.Cardiopulmonary bypass was established with right femoral artery and a single 2 stage venus cannula in the right atrium.The ascending aorta was cross-clamped and myocardium was protected by coronary perfusion with cold crystalloid cardioplegia.Totally thoracoscopic mitral valve repair or replacement were performed.Result:The 97 patients were all operated successfully without death during operation.There was no perivalvular leakage postoperation.Postoperative complications occurred in 6 cases,including 4 cases of acute renal failure who were recovered by CRRT treatment,1 case of reoperation for bleeding,1 case of incision expandation.These patients were all recovery.Cardiopulmonary bypass and aortic cross-clamp time were(165±45) minutes and(102±41) minutes respectively.Operation time was(238±57) minutes.Mechanical ventilation time and intensive care unit stay were(19±11) hours and(28±13) hours respectively.Postoperation drainage quantity was(278±86) ml.The hospital stay was(9.5±3.8) days.The duration of follow-up was 3 to 72 months.The postoperative heart function of all patients was no significant decrease than preoperative(P=0.112).The diameter of left atrium postoperative was smaller than preoperative(P=0.046) in the patients with mitral valve stenosis.The diameter of left atrium postoperative and left ventricle was smaller than preoperative(P=0.039 and P=0.044) in the patients with mitral valve regurgitation.There was no perivalvular leakage and the function of prosthesis was normal postoperation in the patients performed mitral vavle replacement.There was no prolapse,rupture of chordae tendineae or annulus laceration postoperation in the patients performed mitral vavle plasty.The 5 cases had mild renal dysfunction as late complication.There was no other complication or death in the others.Conclusion:The thoracoscopic cardiac surgery for mitral valve operation is safe and effective.
Objective:To summarize the clinical outcome of totally thoracoscopic cardiac surgery for mitral valve operation.Method:Clinical data of 97 cases undergoing totally thracoscopic cardiac surgery for mitral valve repair or replacement from Feb 2012 to Feb 2018 in Department of Cardiacvascular Surgery,2 nd Hospital,Lanzhou University was analyzed retrospectively.There were 56 male and 41 female patients,aged from 20 to 73 with a mean of(58±17) years.All the 97 patients had moderate-severe mitral vavle stenosis and(or) regurgitation,3 patients had Lutembacher Syndrome,19 patients had atrial fibrillation,18 patients had severe pulmary artery hypertension,and 40 patients had moderate-severe tricuspid valve regurgitation.Cardiopulmonary bypass was established with right femoral artery and a single 2 stage venus cannula in the right atrium.The ascending aorta was cross-clamped and myocardium was protected by coronary perfusion with cold crystalloid cardioplegia.Totally thoracoscopic mitral valve repair or replacement were performed.Result:The 97 patients were all operated successfully without death during operation.There was no perivalvular leakage postoperation.Postoperative complications occurred in 6 cases,including 4 cases of acute renal failure who were recovered by CRRT treatment,1 case of reoperation for bleeding,1 case of incision expandation.These patients were all recovery.Cardiopulmonary bypass and aortic cross-clamp time were(165±45) minutes and(102±41) minutes respectively.Operation time was(238±57) minutes.Mechanical ventilation time and intensive care unit stay were(19±11) hours and(28±13) hours respectively.Postoperation drainage quantity was(278±86) ml.The hospital stay was(9.5±3.8) days.The duration of follow-up was 3 to 72 months.The postoperative heart function of all patients was no significant decrease than preoperative(P=0.112).The diameter of left atrium postoperative was smaller than preoperative(P=0.046) in the patients with mitral valve stenosis.The diameter of left atrium postoperative and left ventricle was smaller than preoperative(P=0.039 and P=0.044) in the patients with mitral valve regurgitation.There was no perivalvular leakage and the function of prosthesis was normal postoperation in the patients performed mitral vavle replacement.There was no prolapse,rupture of chordae tendineae or annulus laceration postoperation in the patients performed mitral vavle plasty.The 5 cases had mild renal dysfunction as late complication.There was no other complication or death in the others.Conclusion:The thoracoscopic cardiac surgery for mitral valve operation is safe and effective.
引文
[1] 宋鹏,梁志强,郑向阳,等.左心系统瓣膜替换术后远期三尖瓣关闭重度不全治疗新策略[J].临床心血管病杂志,2015,31(6):684-686.
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[10] Folkkmann S,Seeburger J,Garbade J,et al.Minimally invasive mitral valve surgery for mitral valve infective endocarditis[J].Thorac Cardiovasc Surg,2018,66(7):525-529.
[11] Ward AF,Grossi EA,Galloway AC.Minimally invasive mitral surgery through right mini-thoracotomy under direct vision[J].J Thorac Dis,2013,5 Suppl(6):S673-679.
[12] Sakaguchi T,Totsugawa T,Kuinose M,et al.Minimally invasive mitral valve repair through right minithoracotomy-11-year single institute experience[J].Circ J,2018,82(6):1705-1711.
[13] Glauber M,Miceli A,Canarutto D,et al.Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy:a 10-year experience in 1604 patients[J].J Cardiothorac Surg,2015,10:181-181.
[14] Holzhey DM,Seeburger J,Misfeld M,et al.Learning minimally invasive mitral valve surgery:a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center[J].Circulation,2013,128(5):483-491.
[15] Vollroth M,Seeburger J,Garbade J,et al.Conversion rate and contraindications for minimally invasive mitral valve surgery[J].Ann Cardiothorac Surg,2013,2(6):853-854.
[16] Hysi I,Rebet O,Gautier L,et al.A standardized loop technique for mitral valve repair[J].Ann Thorac Surg,2017,103(1):e105-e106.
[17] Tiwari KK,Gasbarri T,Bevilacqua S.Right-sided minithoracotomy as a surgical approach for the concomitant treatment of atrial fibrillation[J].Res Cardiovasc Med,2016,5(2):e31374.
[2] 兰怀,程云阁,贾宝成,等.完全胸腔镜下二尖瓣置换术634例临床分析[J].中华外科杂志,2016,54(8):609-612.
[3] 刘健,郭惠明,高强,等.三维胸腔镜下二尖瓣成形术60例临床分析[J].中华外科杂志,2016,54(8):605-608.
[4] 杨新超,柳德斌,徐学增.全胸腔镜下心脏外科手术95例[J].中华胸心血管外科杂志,2014,30(9):564-565.
[5] Lei Q,Zeng QS,Zhang XS,et al.Bilateral subclavian vein sheaths for superior vena cava drainage during thoracoscopic repair of atrial septal defects:cosmetic outcomes,safety and effectiveness[J].Perfusion,2016,31(3):240-246.
[6] 董念国,胡行健.微创心脏外科发展现状及思考[J].临床心血管病杂志,2015,31(4):362-366.
[7] Goldstone AB,Woo YJ.Is minimally invasive thoracoscopic surgery the new benchmark for treating mitral valve disease?[J].Ann Cardiothorac Surg,2016,5(6):567-572.
[8] Fleibner F,Salman J,Naqizadah J,et al.Minimally invasive surgery in mitral valve endocarditis[J].Thorac Cardiovasc Surg,2018,doi:10.1055/s-0038-16753422018.
[9] Mcclure RS,Athanasopoulos LV,Mcgurk S,et al.One thousand minimally invasive mitral valve operations:early outcomes,late outcomes,and echocardiographic follow-up[J].J Thorac Cardiovasc Surg,2013,145(5):1199-1206.
[10] Folkkmann S,Seeburger J,Garbade J,et al.Minimally invasive mitral valve surgery for mitral valve infective endocarditis[J].Thorac Cardiovasc Surg,2018,66(7):525-529.
[11] Ward AF,Grossi EA,Galloway AC.Minimally invasive mitral surgery through right mini-thoracotomy under direct vision[J].J Thorac Dis,2013,5 Suppl(6):S673-679.
[12] Sakaguchi T,Totsugawa T,Kuinose M,et al.Minimally invasive mitral valve repair through right minithoracotomy-11-year single institute experience[J].Circ J,2018,82(6):1705-1711.
[13] Glauber M,Miceli A,Canarutto D,et al.Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy:a 10-year experience in 1604 patients[J].J Cardiothorac Surg,2015,10:181-181.
[14] Holzhey DM,Seeburger J,Misfeld M,et al.Learning minimally invasive mitral valve surgery:a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center[J].Circulation,2013,128(5):483-491.
[15] Vollroth M,Seeburger J,Garbade J,et al.Conversion rate and contraindications for minimally invasive mitral valve surgery[J].Ann Cardiothorac Surg,2013,2(6):853-854.
[16] Hysi I,Rebet O,Gautier L,et al.A standardized loop technique for mitral valve repair[J].Ann Thorac Surg,2017,103(1):e105-e106.
[17] Tiwari KK,Gasbarri T,Bevilacqua S.Right-sided minithoracotomy as a surgical approach for the concomitant treatment of atrial fibrillation[J].Res Cardiovasc Med,2016,5(2):e31374.