单中心全胸腔镜微创手术治疗先天性心脏病2543例临床分析

Clinical experience of 2 543 cases of congenital heart diseases undergoing totally thoracoscopic cardiac surgery in a single center

目的探讨全胸腔镜微创手术治疗先天性心脏病的疗效。方法回顾性分析2000年4月至2016年3月连续2 543例在第四军医大学西京医院心血管外科接受全胸腔镜微创心脏手术治疗的先天性心脏病患者资料。男性957例，女性1 586例，年龄0.5-66.0岁，平均年龄（21±18）岁，体重6-118 kg，平均（49±30）kg。术前均经超声心动图或经食管超声心动图确诊为无法行经皮介入治疗的复合或复杂型先天性心脏畸形。采用胸壁3孔入路，建立外周心肺转流，阻断升主动脉，冷血心脏停搏液顺行灌注保护心肌，完成心脏手术。选择技术成熟阶段（2013年1月至2015年12月）的787例全胸腔镜手术患者（腔镜组）与同期710例在同一医院接受开胸手术的患者进行比较（开放组），分别采用t检验、t＇检验、秩和检验、χ^2检验和Fisher确切概率法对两组数据进行比较。结果总体手术病死率为0.35%（9/2 543），术后并发症发生率为2.28%（58/2 543）。存活患者中2 521例获得随访，随访时间1-190个月，平均（75±34）个月，无残余分流和明显瓣膜关闭不全，心功能明显好转。腔镜组与开放组的升主动脉阻断时间、术后呼吸机使用时间、ICU停留时间、手术病死率相似（P〉0.05），而心肺转流时间[（31±20）min比（40±17）min，t＇＝9.407，P＝0.001]、手术时间[（91±27）min比（102±64）min，t＇＝4.251，P＝0.000]和住院天数[（5.3±2.2）d比（13.0±4.0）d，t＇＝45.463，P＝0.000]明显缩短，术后胸腔引流量[M（QR）：33（17）ml比121（53）ml，T＝2.632，P＝0.000]和主要并发症发生率明显减少（7/787比23/710，χ^2＝10.49，P＝0.001），术后无胸骨畸形发生（0比192/710，χ^2＝244.10，P＝0.000），但住院费用略高[（2.4±0.4）万元比（2.0±0.4）万元，t＝19.320，P＝0.000]。结论全胸腔镜微创心脏手术治疗先天性心脏病安全可靠，较常规开胸手术创伤小，并发症少，恢复快，具有较好的中远期效果。

ObjectiveTo summarize the experience of totally thoracoscopic cardiac surgical （TTCS） at congenital heart diseases （CHD） treatment.MethodsFrom April 2000 to March 2016, 2 543 patients with CHD underwent TTCS in Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, including 957 male and 1 586 female patients. The age ranged from 0.5 to 66.0 years with a mean age of （21±18） years. The body weight ranged from 6 to 118 kg with a mean of （49±30） kg. Patients were diagnosed with echocardiography or transesophagel echocardiography as complex or complicated CHD which was unsuitable for percutaneous procedure. Surgical procedures were performed through 3 holes inserted at the right chest wall, and catheters were placed in the right femoral artery and vein to set up cardiopulmonary bypass.The ascending aorta was cross-clamped with long tailor-made forceps and the myocardium was protected by coronary perfusion with cold crystalloid（blood）cardioplegia. There were 787 cases （from January 2013 to December 2015） were selected to compare with 710 cases underwent conventional thoracotomy over the same period. Statistical analysis was performed by t test, t＇ test, rank-sum test, χ^2 test and Fisher exact test, respectively.ResultsThe total death rate and the major complication rate of the operation were 0.35% （9/2 543） and 2.28% （58/2 543）, respectively. All patients were followed up 1 to 190 months and the average follow-up time was （75±34） months. No residual shunt or obvious mitral/tricuspid regurgitation was observed, and the patients gained better cardiac function as level Ⅰ to Ⅱ （New York Heart Association classification）. There was no significant difference in aorta clamp time, ICU stay, hospital cost, and surgical fatality rate between 787 patients underwent TTCS and 710 conventional thoracotomy. The cardiopulmonary bypass time （（31±20） minuets vs. （40±17） minuets, t＇=9.407, P=0.001）, operation time （（91±27） minuets vs. （ 102±64） minuets, t＇=4.251, P=0.000）, hospital stay （（5.3±2.2） d vs. （13.0±4.0） d, t＇=45.463, P=0.000）, postoperative drainage （M（QR）： 33（17） ml vs. 121（53） ml, T=2.632, P=0.000） and major complications （7/787 vs. 23/710, χ^2=10.49, P=0.001） were significantly reduced and no sternal deformation occurrence （0 vs. 192/710, χ^2=244.10, P=0.000） in TTCS group. While the cost was higher in TTCS group （（24 000±400） yuan vs. （20 000±400） yuan, t=19.320, P=0.000）.ConclusionTTCS is feasible, safe, and minimal invasive for patients with CHD, resulting in quick recovery and good median-long term outcomes.