胸骨下段正中小切口在心脏外科的应用

Application of lower median ministernotomy in heart surgery

目的总结460例胸骨下段正中小切口心脏手术的经验. 方法 1997年1月～2003年8月,我院共进行各类胸骨下段小切口心脏手术460例,包括先天性心脏病手术100例,瓣膜手术178例,冠状动脉手术168例,动脉瘤手术12例,其它2例.术中未使用任何特殊的手术器械. 结果院内死亡4例(0.9%),再次手术3例(0.7%),术后并发症29例(6.3%).73例非体外循环手术.387例体外循环时间25～1 115 min,中位数80 min;主动脉阻断时间0～164 min,(55.8±31.9) min.460例术后气管插管时间0～364 h,中位数10 h.术后胸腔引流量20～3 290 ml,中位数350 ml;按体重计算,胸腔引流量0.3～42.2 ml/kg,中位数5.8 ml/kg.术后280例需要输血,输血量(951.1±644.6) ml.术后ICU时间1～28 d,中位数2 d.术后住院1～60 d,(11.6±6.0) d.371例随访7～80个月,(59.2±29.6)月.无远期死亡,症状均明显改善.心功能Ⅰ级169例,Ⅱ级135例,Ⅲ级67例,明显好于术前(Z=-12.57,P＝0.000).心胸比率0.50±0.11(0.41～0.67),与术前相比无显著差异(t=-1.63,P＝0.104).左心室射血分数0.36～0.71(0.606±0.113),明显高于术前(t=3.43,P＝0.001).结论胸骨下段正中小切口心脏手术创伤小,安全可靠;皮肤切口小,美观;无须特殊器械,操作简单易行,在特定病例可获得良好的手术效果.

Objective To review the experience of 460 cases of cardiac operations through a lower median ministernotomy. Methods A total of 460 cardiac operations via a lower median ministernotomy route were carried out between January 1997 and August 2003 in this hospital, involving 100 operations for congenital heart diseases, 178 valve operations, 168 coronary operations, 12 operations for aneurysms, and 2 other operations. On operation no special instruments were required. Results Within the hospitalization period 4 patients died (0.9%) and 3 underwent a re-operation (0.7%). Postoperative complications occurred in 29 patients (6.3%). Off-pump operations were employed in 73 patients, while in the remaining 387 patients the cardiopulmonary bypass time was 25~1 115 min (median, 80 min) and the aortic cross-clamp time was 0~164 min (55.8±31.9 min). Of the 460 patients, the length of postoperative tracheal intubation was 0~364 h (median, 10 h), and the postoperative chest drainage was 20~3 290 ml (median, 350 ml), or 0.3~42.2 ml/kg (median, 5.8 ml/kg). Blood transfusion were required after surgery in 280 patients with an amount of 951.1±644.6 ml. The postoperative ICU and hospital stay were 1~28 d (median, 2 d) and 1~60 d (11.6±6.0 d), respectively. A follow-up for 7~80 months (59.2±29.6 months) in 371 patients was conducted. No long-term deaths were noted and symptoms were significantly improved. Heart function was classified as grade Ⅰ in 169 patients, grade Ⅱ in 135 patients, and grade Ⅲ in 67 patients, respectively, with significant difference as compared with that in pre-operation ( Z =-12.57 , P =0.000). No significant difference was observed in the cardiothoracic ratio (0.50±0.11, 0.41~0.67) between postoperative and preoperative period ( t =-1.63, P =0.104). The left ventricular ejection fraction was significantly higher postoperatively (0.36~0.71, 0.606±0.113) than preoperatively ( t =3.43, P =0.001). Conclusions In properly selected cases, heart operations through a lower median ministernotomy provides many advantages including mini-invasion, high reliability, excellent cosmetic results, simplicity to performance, and good surgical outcomes.