经右胸小切口在二次心脏手术中的应用

The clinical application of Port-Access cardiac surgery in redo cardiac operations

目的:初步总结经右胸小切口在二次心脏病手术中临床应用的安全及有效性。方法:自2012年6月至2013年12月,在二次心脏手术中共完成经右胸小切口手术15例。其中男性8例,女性7例。平均年龄(41.9±12.9)岁,平均体质量(64.1±14.5)kg。手术方式包括二尖瓣置换(MVR)3例,主动脉瓣置换(AVR)1例,三尖瓣成形术(TVP)3例,三尖瓣置换术(TVR)2例,MVR+TVP1例;二尖瓣瓣周漏修补术3例;室间隔缺损(VSD)残余漏修补术2例。手术均在周围血管插管建立体外循环下完成。无1例转为传统胸正中切口开胸手术。结果:本组平均手术时间3~6小时,平均(4.0±0.8)小时,体外循环时间56~227分钟,平均(120.3±43.6)分钟。其中心脏不停跳下完成手术10例,其余5例,中位主动脉阻断时间70(66,76)分钟,心脏停跳术后自动复跳3例(3/5);气管插管时间8~42.5小时,中位时间17(12.5,20)小时,ICU时间10~73.5小时,中位时间20(17.5,40)小时,手术后住院时间4~17天,平均(7.1±3.5)天;切口长度5~7cm,平均(5.3±0.6)cm,术后第一天中位引流量300(200,1 000)m L,未输血患者9例;无围术期死亡;无明显并发症出现。出院时心功能Ⅰ级12例、Ⅱ级1例、Ⅲ级2例。结论:经右胸小切口在二次心脏手术中的近期手术效果良好,手术安全性高,适用于常见二次心脏手术;其创伤小,开胸简化,具有并发症和病死率低等特点。

Objective： To preliminarily summarize and Analysis the safety and efficiency of the Port-Ac- cess cardiac surgery in redo cardiac operations. Methods：From June, 2012 to December, 2013, 15 redo cardi- ac operations had been performed in our centre with Port-Access cardiac surgery via a right minithoracotomy, a- mong of which 8males and 7 females ; mean age （41.9 ＋ 12. 9 ） years old ; mean weight （ 64. 1 ＋ 14. 5 ） kg. These operations included mitral valve replacement （ MVR ） in 3 patients ; aortic valve replacement （AVR） in 1 pa- tient; tricuspid valve plasty（TVP） in 3 patients; tricuspid valve replacement（TVR） in 2 patients; mitral valve replacement concomitant with tricuspid valve plasty （ MVR ＋ TVP） in 1 patient; mitral valve periprosthetic leakage repair operations in 3 patients ; ventricular septal defect （VSD） residual shunt repair in 2 patients. All operations are performed with Peripheral cannulafion for cardiopulmonary bypass via the femoral arterial and ve- nous vessels, as well as the internal jugular vein. None of the cases was required to convert to median sternoto- my. Results：Mean operation time was （4. 0 ^-0. 8）hours; Cardiopulmonary bypass time was（ 120. 3 ~43.6 ） minutes ; 10 patients were performed on the beating heart ;5 patients were performed under heart ceased, aortic cross-clamp time was 70 （66,76） minutes, of which 3 patients recover to beat automatically after heart ceased operation. Mechanical ventilation time was17 （ 12. 5,20） hours; Intensive care unit stay was 20 （ 17.5,40） hours, Hospital stay post operative was （7. 1 ±3.5 ） days. Median incision length was （ 5. 3 ±0. 6） cm. Drai- ning volume was 300（200,1 000）mL in the first day after operation, No transfusion occurred in 9patients （9/15 ）. Early postoperative mortality was 0, No obvious clinical complications. When leaving hospital, 12 being of heart functional class Ⅰ , 1 of class Ⅱ ,2 of classlll. Conclusion： Port-Access cardiac surgery was associated with good operative effect in the near future, superior safety and broad application range in redo cardiac opera- tions; Furthermore, Port-Access cardiac surgery has minimally invasive, simplified open chest operation process. It may be safely performed with low postoperative mortality and morbidity in redo cardiac operations.