微创右胸切口与常规胸骨正中切口主动脉瓣置换术的对比研究

Right Anterior Minithoracotomy Versus Conventional Median Sternotomy for Aortic Valve Replacement

目的对比研究微创右胸切口与常规胸骨正中切口施行单纯主动脉瓣置换术的安全性及疗效。方法2006年3月至2013年3月,上海交通大学医学院附属新华医院心胸外科共施行首次单纯主动脉瓣置换术169例,其中微创右胸切口42例(微创手术组),男30例、女12例,平均年龄(59.31±8.30)岁;常规胸骨正中切口行主动脉瓣置换127例(常规手术组),男89例、女38例,平均年龄(60.02±5.93)岁。病变类型:主动脉瓣狭窄75例,关闭不全42例,狭窄伴关闭不全52例。微创手术组经右锁骨中线第3肋间、胸骨旁切口(6 cm)进胸,股动、静脉插管建立体外循环;常规手术组经胸骨正中切口进胸,常规升主动脉及上、下腔静脉插管建立体外循环。阻断升主动脉后,施行主动脉瓣置换术。结果两组患者术前临床资料差异无统计学意义。全组患者均顺利完成手术。术中置换主动脉瓣机械瓣153例,生物瓣16例,21 mm瓣52例,23 mm瓣117例。微创手术组术中体外循环时间及主动脉阻断时间较常规手术组长(P<0.001),但术后呼吸机辅助通气时间、术后住ICU时间及术后住院时间均较常规手术组明显缩短(P<0.001),且术后24 h胸腔引流量及术中、术后输血量明显少于常规手术组(P<0.001)。术后早期常规手术组开胸探查止血2例,切口感染2例。全组术后早期死亡2例,均为常规手术组,1例为术后低心排血量综合征导致多器官功能衰竭,另1例为胸骨感染并发人工瓣膜心内膜炎。结论与常规胸骨正中切口相比,微创右胸切口可安全、有效地应用于主动脉瓣置换术,两组患者手术疗效相似,但微创手术组创伤更小、恢复更快,且具有良好的美容效果。

Objective To compare the safety and clinical outcomes of isolated aortic valve replacement （AVR） through right anterior minithoracotomy （RAMT） and conventional median sternotomy. Methods From March 2006 to March 2013, 169 patients underwent isolated AVR in Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine. Among them, 42 patients received AVR via RAMT （RAMT group ） including 30 males and 12 females with their age of 59.31±8.30 years. And 127 patients received AVR via conventional median stemotomy （conventional surgery group）including 89 males and 38 females with their age of 60.02±5.93 years. There were 75 patients with aortic valve stenosis （AS）, 42 patients with aortic regurgitation （AR） and 52 patients with AS＋AR. Postoperative outcomes were compared between the 2 groups. Results There was no statistical difference in preoperative clinical characteristics between the 2 groups. All the patients successfully received isolated AVR. 153 patients received mechanicalprosthesis and 16 patients received bioprosthetic valves. Fifty-two patients received 21 mm valves, and 117 patients received 23 mm valves. Cardiopulmonary bypass time and aortic cross-clamping time of RAMT group were significantly longer than those of conventional surgery group （P 〈 0.001 ）. But mechanical ventilation time, length of postoperative ICU stay and hospital stay of RAMT group were significantly shorter than those of conventional surgery group （P 〈 0.001 ）. Postoperative thoracic drainage, intraoperative and postoperative blood transfusion of RAMT group were significantly less than those of conventional surgery group （P 〈 0.001 ）. In conventional surgery group, 2 patients underwent reexploration for bleeding and 2 patients had wound infection postoperatively. Two patients died postoperatively, both in conventional surgery group, including 1 patient with low cardiac output syndrome and multiple organ dysfunction syndrome, and another patient with prosthetic valve endocarditis secondary to sternal wound infection. Conclusion Compared with conventional median sternotomy, RAMT is safe and efficacious for patients undergoing isolated AVR with minimal surgical injury, better postoperative recovery and cosmetic outcomes.