不同入路行二尖瓣修复术治疗Barlow综合征所致复杂二尖瓣反流的效果比较

Effect comparison of mitral annuloplasty by different approaches in the treatment of complex mitral valve regurgitation caused by Barlow syndrome

目的评价经右胸微创入路行二尖瓣修复术治疗Barlow综合征所致复杂二尖瓣反流的安全性和有效性。方法选择2010年4月~2014年12月于复旦大学附属中山医院行二尖瓣修复手术的Barlow综合征患者52例,其中19例经右胸微创入路（微创组）,33例经正中胸骨入路（正中切口组）。比较两组手术、围术期及随访资料。结果全组无手术死亡。微创组体外循环时间长于正中切口组[（105.3±33.7）比（86.7±30.0）min],差异有统计学意义（P〈0.05）;微创组主动脉阻断时间长于正中切口组[（61.4±19.2）比（52.0±22.0）min],但差异无统计学意义（P〉0.05）。微创组术后24 h伤口引流量[（411.0±446.7）比（550.0±293.6）m L]、重症监护时间[（1.5±2.3）比（1.8±1.3）d]及住院时间[（5.6±2.2）比（7.2±3.1）d]均低于正中切口组,但差异均无统计学意义（P〉0.05）。微创组全部修复成功,正中切口组3例术中转行二尖瓣置换术。微创组1例住院死亡,正中切口组无住院死亡（P〉0.05）。术后随访3~70个月,平均（25±19）个月。微创组及正中切口组术后5年生存率分别为100%和88%（P〉0.05）,再次二尖瓣手术豁免率分别为100%和82%,中度以上二尖瓣反流复发豁免率分别为92%和75%,差异均无统计学意义（P〉0.05）。结论采用微创入路实施二尖瓣修复术治疗Barlow综合征所致二尖瓣反流的手术难度相对较大,但经过一定训练和经验积累,微创入路亦可获得与传统正中入路相似的手术安全性和良好疗效。

Objective To evaluate the safety and efficacy of mitral annuloplasty by right breast minimally invasive approach in the treatment of complex mitral valve regurgitation caused by Barlow syndrome. Methods 52 cases of patients with Barlow syndrome underwent mitral valve repair surgery in Zhongshan Hospital, Fudan University from April 2010 to December 2014 were selected. 19 cases were given minimally invasive operation（MI group）, and 33 cases were given classical median sternotomy（MS group）. Operative data, perioperative data and follow-up details were reviewed. Results No operative death was observed. The cardiopulmonary bypass time was significantly longer in the MI group than in MS group [（105.3 ±33.7） vs（86.7 ±30.0） min]（P〈 0.05）. The aortic cross-clamp time [（61.4 ±19.2） vs（52.0 ±22.0）min], the amount of drainage in the first 24 postoperative hours [（411.0±446.7） vs（550.0±293.6） m L], intensive care unit stay [（1.5±2.3） vs（1.8±1.3） d], and hospital stay [（5.6±2.2） vs（7.2±3.1） d] were comparable between the two groups,without statistically significant differences（P〉 0.05）. Mitral valve repair was 100% completed in the MI group and 3patients in MS group required a conversion to mitral valve replacement intraoperatively. 1 case had died in hospital in the MI group, no operative death in the MS group（P〉 0.05）. Patients were followed up for 3-70 months, average of（25±19） months. The 5 years survival rate was 100% in MI group and 88% in MS group（P〉 0.05）; freedom from reoperation for mitral valve at 5 years was 100% and 82% in MI group and MS group（P〉 0.05）; freedom from moderate mitral regurgitation at 5 years was 92% and 75% in MI group and MS group（P〉 0.05）. Conclusion The difficulty of mitral annuloplasty by minimally invasive approach in the treatment of complex mitral valve regurgitation caused by Barlow syndrome is relatively large. After a substantial training and experience accumulation,minimally invasive approach can also provide equivalent safety and curative effect for these complex surgical repair in comparison with median sternotomy.