胸骨上段小切口心脏瓣膜置换术的临床研究
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摘要
目的总结经胸骨上段小切口行主动脉瓣或二尖瓣置换术的临床经验,并评价其安全性和疗效。方法选取经胸骨上段小切口行主动脉瓣或二尖瓣置换术的9例瓣膜性心脏病患者为微创组;选择同期经胸骨正中切口进行相应手术的9例患者为传统组。比较两组患者的临床资料,评价经胸骨上段小切口心脏瓣膜置换术的安全性和疗效。结果微创组9例患者手术全部成功,其中主动脉瓣置换术7例(2例使用生物瓣),二尖瓣置换术1例,二尖瓣置换+三尖瓣成形+主动脉瓣环扩大+主动脉瓣置换术1例,植入主动脉瓣膜型号19～25 mm,无1例延长手术切口。术后无死亡患者,无出血及胸部切口愈合不良,术后出现右侧胸腔积气和右侧胸腔积液各1例,均经胸腔引流后治愈出院。与传统组相比,微创组手术时间、体外循环(CPB)时间和主动脉阻断(ACC)时间稍延长(P <0. 05),但并不延长术后呼吸机辅助时间和ICU入住时间(P> 0. 05),且术后引流量和总输血量减少(P <0. 05),皮肤切口长度及术后住院时间缩短(P <0. 05)。两组患者术后并发症发生率比较,差异无统计学意义(P> 0. 05)。微创组患者术后随访1～13个月,心脏彩超提示人工瓣膜未见明显异常,心功能恢复至Ⅰ级。结论经胸骨上段小切口行主动脉瓣或二尖瓣置换术可以取得与经胸骨正中切口同样的效果,但创伤更小,失血和输血更少,术后恢复更快。
Objective To summarize the clinical experience of aortic or mitral valve replacement with upper sternal mini-incision,and to evaluate its safety and efficacy. Methods Nine patients with valvular heart diseases underwent aortic or mitral valve replacement with upper sternal mini-incision,and were enrolled as minimally invasive group. Another 9 patients with cardiac valve diseases underwent corresponding operations with median sternal incision during the same period and were enrolled as traditional group. The clinical data were compared between the two groups. The safety and efficacy of cardiac valve replacement with upper sternal mini-incision were assessed. Results In the minimally invasive group,the operation was successfully completed in all of the 9 cases including 7 cases with aortic valve replacement(biological valve was applied to 2 cases),1 case with mitral valve replacement and 1 case with mitral valve replacement +tricuspid annuloplasty + aortic annulus enlargement + aortic valve replacement. The model of the aortic valve implanted was 19-25 mm. No lengthening of incision occurred in any cases. No death,hemorrhage and poor healing of sternal incision were observed after operation. Right aerothorax and right pleural effusion were found in one case separately,and the patients were cured then were discharged after therapy with chest drainage. Compared to the traditional group,the durations of operation,cardiopulmonary bypass and aortic cross clamp were slightly longer(P < 0. 05),but the duration for postoperative assisted mechanical ventilator and ICU stay were not prolonged(P > 0. 05),the volume of postoperative drainage and total volume of transfusion decreased(P < 0. 05),and the length of skin incision and postoperative hospital stay were shorten in the minimally invasive group(P < 0. 05). There was no significant difference in the incident rate of postoperative complications between the patients in both groups(P > 0. 05). Postoperative follow-up of1-13 months was performed in the patients of the minimally invasive group,no obvious abnormality in the artificial valves was found by echocardiography, and the cardiac function was improved to grade Ⅰ.Conclusion Aortic or mitral valve replacement with upper sternal mini-incision can obtain a similar efficacy as replacement with median sternal incision,but achieves less trauma,blood loss and blood transfusion,and faster postoperative recovery.
Objective To summarize the clinical experience of aortic or mitral valve replacement with upper sternal mini-incision,and to evaluate its safety and efficacy. Methods Nine patients with valvular heart diseases underwent aortic or mitral valve replacement with upper sternal mini-incision,and were enrolled as minimally invasive group. Another 9 patients with cardiac valve diseases underwent corresponding operations with median sternal incision during the same period and were enrolled as traditional group. The clinical data were compared between the two groups. The safety and efficacy of cardiac valve replacement with upper sternal mini-incision were assessed. Results In the minimally invasive group,the operation was successfully completed in all of the 9 cases including 7 cases with aortic valve replacement(biological valve was applied to 2 cases),1 case with mitral valve replacement and 1 case with mitral valve replacement +tricuspid annuloplasty + aortic annulus enlargement + aortic valve replacement. The model of the aortic valve implanted was 19-25 mm. No lengthening of incision occurred in any cases. No death,hemorrhage and poor healing of sternal incision were observed after operation. Right aerothorax and right pleural effusion were found in one case separately,and the patients were cured then were discharged after therapy with chest drainage. Compared to the traditional group,the durations of operation,cardiopulmonary bypass and aortic cross clamp were slightly longer(P < 0. 05),but the duration for postoperative assisted mechanical ventilator and ICU stay were not prolonged(P > 0. 05),the volume of postoperative drainage and total volume of transfusion decreased(P < 0. 05),and the length of skin incision and postoperative hospital stay were shorten in the minimally invasive group(P < 0. 05). There was no significant difference in the incident rate of postoperative complications between the patients in both groups(P > 0. 05). Postoperative follow-up of1-13 months was performed in the patients of the minimally invasive group,no obvious abnormality in the artificial valves was found by echocardiography, and the cardiac function was improved to grade Ⅰ.Conclusion Aortic or mitral valve replacement with upper sternal mini-incision can obtain a similar efficacy as replacement with median sternal incision,but achieves less trauma,blood loss and blood transfusion,and faster postoperative recovery.
引文
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[11] Brinkman WT,Hoffman W,Dewey TM,et al. Aortic valve replacement surgery:comparison of outcomes in matched sternotomy and PORT ACCESS groups[J]. Ann Thorac Surg,2010,90(1):131-135.
[12] Perreas KG,Hunter S. Aortic valve replacement with a stentless pericardial valve through minimal access surgery[J]. J Card Surg,2006,21(2):176-177.
[13] Little S,Flynn M,Pettersson GB,et al. Revisiting the dome approach for partial sternotomy/minimally invasive mitral valve surgery[J]. Ann Thorac Surg,2009,87(3):694-697.
[14] Di Eusanio M,Vessella W,Carozza R,et al. Ultra fast-track minimally invasive aortic valve replacement:going beyond reduced incisions[J]. Eur J Cardiothorac Surg,2018,53(suppl 2):ii14-ii18.
[2] Goh SSC. Post-sternotomy mediastinitis in the modern era[J]. J Card Surg,2017,32(9):556-566.
[3]谢晓勇.微创心脏瓣膜外科手术治疗的研究进展[J].微创医学,2016,11(2):220-222,225.
[4]刘胜中,谭今,向波,等.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[J].中国现代医学杂志,2017,27(5):73-77.
[5] Bouhout I,Morgant MC,Bouchard D. Minimally Invasive Heart Valve Surgery[J]. Can J Cardiol,2017,33(9):1129-1137.
[6] Easterwood RM,Bostock IC,Nammalwar S,et al. The evolution of minimally invasive cardiac surgery:from minimal access to transcatheter approaches[J]. Future Cardiol,2018,14(1):75-87.
[7] Konertz W,Waldenberger F,Schmutzler M,et al. Minimal access valve surgery through superior partial stemotomy:a preliminary study[J]. J Heart Valve Dis,1996,5(6):638-640.
[8] Johnston DR,Atik FA,Rajeswaran J,et al. Outcomes of less invasive J-incision approach to aortic valve surgery[J]. J Thorac Cardiovasc Surg,2012,144(4):852-858. e3.
[9]孙立忠,刘宁宁,常谦,等.经胸骨小切口主动脉根部置换术[J].中华胸心血管外科杂志,2004,20(2):78-80.
[10]谢斌,郭慧明,卢聪,等.胸骨上段正中小切口在心脏外科手术中的应用[J].实用医学杂志,2010,26(20):3755-3757.
[11] Brinkman WT,Hoffman W,Dewey TM,et al. Aortic valve replacement surgery:comparison of outcomes in matched sternotomy and PORT ACCESS groups[J]. Ann Thorac Surg,2010,90(1):131-135.
[12] Perreas KG,Hunter S. Aortic valve replacement with a stentless pericardial valve through minimal access surgery[J]. J Card Surg,2006,21(2):176-177.
[13] Little S,Flynn M,Pettersson GB,et al. Revisiting the dome approach for partial sternotomy/minimally invasive mitral valve surgery[J]. Ann Thorac Surg,2009,87(3):694-697.
[14] Di Eusanio M,Vessella W,Carozza R,et al. Ultra fast-track minimally invasive aortic valve replacement:going beyond reduced incisions[J]. Eur J Cardiothorac Surg,2018,53(suppl 2):ii14-ii18.