直视微创技术在二次及多次心脏手术中的应用

Clinical application of minimally invasive cardiac surgery in secondary or multipal heart surgery

目的 总结我院微创心脏外科近年开展的微创心脏手术在二次及多次心脏手术患者中的应用情况，探讨该术式的应用范围，注意事项。方法 2012年6月至2016年12月进行直视微创下二次或多次心脏手术23例。常规建立闭式体外循环，根据病情不同，分别以右锁骨中线至腋前线第4肋间或右胸骨旁第3肋间为切口，根据诊断不同进行相应的手术。结果 再次心脏手术患者23例，男13例，女10例，年龄20-69岁，平均41.43岁，其中二尖瓣置换术后瓣周漏患者4例，卡瓣1例，二尖瓣成形术后二尖瓣关闭不全3例，室缺修补及主动脉瓣成形术后主动脉瓣关闭不全1例，房室缺修补术后二尖瓣关闭不全1例，室缺修补术后残余漏3例，双瓣置换术后三尖瓣关闭不全1例，左心房黏液瘤切除术后三尖瓣关闭不全1例，Bentall术后三尖瓣关闭不全1例。二尖瓣置换术后三尖瓣关闭不全2例，室缺修补加二尖瓣成形术后二尖瓣关闭不全1例，Ebstein畸形矫治术后三尖瓣关闭不全2例。分别进行瓣周漏修补术，二尖瓣置换术，主动脉瓣置换术，二尖瓣成形术，三尖瓣成形术，室缺残余漏修补术，再次Ebstein畸形矫治术。全组手术效果满意，无手术死亡及严重并发症。全部患者均在体外循环下手术，其中5例行主动脉阻断，18例采用并行循环。从手术时间、术后伤口引流量，输血比例上统计表明手术可行。结论 采用闭式体外循环下微创心脏手术的方法，对二次或多次心脏手术的患者施行手术，可以避开经原切口进胸所导致的因组织粘连而导致的出血，损伤等并发症，缩短了手术时间，减少了手术风险，减少了患者的输血率，可以在部分二次或多次心脏手术的患者中应用。

Objective To review and analyze minimally invasive right thoracotomy and peripheral cannulation as an al- ternative strategy in redo heart surgery. Methods From June 2012 to December 2016, 23 reoperative heart procedures were performed through a right lateral thoraeotomy with about 5 cm in the third or fourth intercostal space, according to the different diagnosis with the corresponding operations. Results We performed 23 redo heart surgeries, there were 10 female and 13 male patients with a mean age of 41.43 years（ range,20 to 69 years）. 4 mitral perivalvular leakage, 1 prosthetic valve dysfunction, 3 mitral insufficiency after mitral valvuloplasty, 1 aortic insufficiency after ventricular septal defect and aortic repair, 1 mitral insufficiency after ventricular and atrial septal defect repair, 3 residual fistula after surgery repair of ventricular septal defect, 1 tricuspid insufficiency after mitral and aortic valve replacement, 1 tricuspid insufficiency after left atrial myxoma removal, 1 tri- cuspid insufficiency after Bentall surgery, 2 tricuspid insufficiency after mitral valve replacement, 1 mitral insufficiency after ventricular septal defect and mitral valvuloplasty, 2 tricuspid insufficiency after the repair of Ebstein abnormality. We respec- tively carried out repair of valve leakage, mitral valve replacement, aortic valve replacement, mitral valve repair, tricuspid val- vuloplasty, postoperative repair of residual shunt of ventricular septal defect, redo repair of Ebstein abnormality. The effect of the whole group operation of operation was satisfactory, no death during operation and severe complications. All patients were under cardiopulmonary bypass,three patients＂ ascending aortas were bloked, and nine patients were with cardiopulmonary by- pass. It indicated tha the operation was possible at operation time, total blood loss and the frequency of blood transfusion. Con- chlsiOn The application of closed thoracic cardiopulmonary bypass and minimally invasive right thoracotomy in redo or multi- ple cardiac surgery, can avoid reoperative sternotomy risk such as hemorrhage, tissue damage and so on. It shortened the opera- tion time, reduced the risk of surgery and blood transfusion rate, can be used in some of the heart surgery patients again and re- peatedly.