完全胸腔镜下体外循环心脏瓣膜手术279例

Thoracoscopic cardiac surgical valve procedures:a report of 279 cases

目的 探讨经胸腔镜体外循环心脏瓣膜手术的疗效和安全性.方法 于2012年1月至2014年6月在广东省人民医院经胸腔镜体外循环施行心脏瓣膜手术279例.包括二尖瓣换瓣201例,二尖瓣整形78例.合并三尖瓣整形98例,三尖瓣换瓣3例,清除左心房血栓19例,合并先天性心脏病房间隔修补5例,卵圆孔封闭术3例.使用30°胸腔镜及配套手术器械,股动脉插供血管,股静脉和（或）上腔静脉插引流管行体外循环,胸腔内操作均在胸腔镜下进行,以30°胸腔镜显示屏为手术野.结果 本组279例患者手术成功276例,成功率98.9％,术中转为正中开胸2例,术后行正中开胸止血1例.体外循环时间（144.3±44.4）min,升主动脉阻断时间（92.4±30.7） min,术后呼吸机辅助时间11（2～88）h,术后住院时间（8.2±4.6）d,术后24 h胸腔闭式引流量100（20～800） mL.全部患者无死亡.38例发生并发症,发生率13.6％;包括术中转正中开胸2例,术后二次止血14例,右侧气胸2例,肺炎9例,泌尿系统感染2例,消化道出血1例,心脏骤停1例,术后低心排血量综合征3例,伤口感染1例,伤口愈合不良2例,出现股静脉穿刺处血栓1例.术后随访复查心脏B超,时间为2～25个月,57例出现轻度二尖瓣反流（反流面积＜4 cm2）,5例出现中度二尖瓣反流（4 cm2≤反流面积＜8 cm2）,其中1例伴有二尖瓣中度梗阻.结论 完全胸腔镜下二尖瓣换瓣或整形术及三尖瓣换瓣或整形术是安全可行的.

Objectives To evaluate the efficacy and safety of thoracoscopic cardiac valve surgical procedures under extracorporeal circulation.Methods From Junany 2012 to June 2014,279 patients received thoracoscopic cardiac valve surgery under extracorporeal circulation.These procedures include mitral valve replacement for 201 patients,mitral valve annuloplasty for 78 patients; combining with tricuspid valve annuloplasty for 98 patients,tricuspid valve replacement for 3 patients,remove of left atrial thrombus for 19 patients,atrial septal defect occlusion for 5 patients and foramen ovale closure for 3 patients.Thirty degree thoracoscopes and femoral extracorporeal circulation were used.The aorta was crossclamped and the myocardium was protected by coronary perfusion with cold crystal or blood cardioplegie.Result The operation successded in 276 patients （98.9%,276/279）.Median sternotomy in surgery was performed in 2 patients,median stemotomy after operation was performed in 1 patient.Cardiopulmonary bypass duration of the patients was （144.3±44.4） min.Aortic cross clamp duration was （92.4±30.7） rmin.Duration of postoperative mechanic rentilation assistance was 11 （2-88） hours.Duration of in-hospital was （8.2±4.6）days.Volume of chest drainage was 100（20-800） mL.None postoperative death occurred.Postoperative complications occurred in 38 cases （13.6%）,including median sternotomy in surgery in 2 patients,bleeding in 14 patients,pneumothorax in 2 patients,pneumonia in 9 patients,urinary tract infection in 2 patients,gastrointestinal bleeding in 1 patient,cardicac arrest in 1 patient,low cardiac output syndrome in 3 patients,wound infection in 1 patient,poor wound healing in 2 patients,femeral venous puncture site thrombosis in 1 patient.Follow-up duration was 2-25 months.Cardiac ultrasound was rechecked during follow-up,the results showed that mild mitral regurgitation （regurgitant area〈4 cm2） in 57 patients,moderate mitral regurgitation （4 cm2≤regurgitant area〈8 cm2） in 5 patients,and 1 patients with moderate mitral obstraction.Conclusions Thoracoscopic cardiac surgical procedures for mitral replacement or annuloplasty with tricuspid replacement or annuloplasty is feasible and safe.