右胸前外侧小切口微创主动脉瓣置换的倾向评分匹配研究

A propensity score matched study of minimally invasive aortic valve replacement through right anterior minithoracotomy

目的总结右胸前外侧小切口微创主动脉瓣置换的技术和结果。方法回顾性研究我院2010年1月至2017年6月单纯主动脉瓣置换患者资料，分为微创组（n=65）和常规组（正中开胸，n=182），胸骨上段小切口患者予以排除。微创组采用股动静脉插管建立体外循环，右侧第3肋间胸骨旁小切口，直视下置换主动脉瓣。采用Logistic模型对患者的性别、年龄、体重指数、主动脉瓣病变类别、心脏射血分数、心功能等级进行倾向评分匹配（propensity score matching），匹配比例1：1；研究微创主动脉瓣置换技术对临床结局的影响。结果全组患者3例死亡，均为常规组患者（3／182，1．6％）。微创组无中转开胸、无二次手术。进行倾向评分匹配显示，新的常规对照组（n=65）术前资料与微创组无差异；与该组相比，微创组体外循环时间和主动脉阻断时间显著延长[（103．6±37．2）min比（88．3±27．2）min，P=0．01，（68．3±18．6）min比（48．8±18．9）min，P〈0．01]；微创组术后ICU停留时间和住院天数均显著低于常规组[（1．9±0．4）d比（2．4±0．9）d，（8．4±1．8）d比（10．6±3．2）d，P〈0．01]；微创组术后第一天引流量较少[（281±53）ml比（432±88）ml，P〈0．01]。两组间死亡率、深部切口感染率及输血率比较未见统计学差异（0％比1．5％，P=0．32，0％比3．1％，P=O．15，23．1％比35．4％，p=0．13）。结论经右胸前外侧小切口微创主动脉瓣置换技术安全可行。该技术尽管增加体外循环时间和主动脉阻断时间，但可减少引流，加速术后康复。

Objective To summarize the techniques and results of minimally invasive aortic valve replacement（AVR） through right anterior minithoracotomy. Methods Patients with isolated aortic valve replacement from January 2010 to June 2017 were retrospectively reviewed. They were divided into two groups, the minimally invasive AVR group through right anterior minithoracotomy （MIAVR, n=65）, and conventional AVR group from sternotomy （CAVR, n=182）. Patients with ministernotomy were excluded. In MIAVR group, the cardiopulmonary bypass was established by peripheral cannulatian from femoral artery and vein, A right parasternal transverse incision from the third intercostal space was used, and the aortic valve replacement was performed through the small incision. A logistic model was used in the propensity score matching（PSM ） methods; gender, age, etiology of aortic valve, ejection fraction, and NYHA heart function were adjusted in the model. The matching ratio is one to one. The influence of minimally invasive techniques in the clinical outcomes of AVR was evaluated. Results There were 3 deaths, and all of them belonged to CAVR group （3/182, 1.6%）. There was no transition to sternotomy and no reoperation in the MIAVR group. After propensity score matching, the new control group （PSM-CAVR group） contained 65 patients, who had similar pre-operative baseline data as the MIAVR group. When compared to PSM-CAVR group, the cardiopulmonary bypass time and cross clamp time were significantly longer [ （ 103.6±37.2 ）rain vs. （88.3±27.2）min, P=0.01, （68.3± 18.6 ）rain vs. （48.8± 18.9 ）min, P〈0.01 ]. In the MIAVR group, the length of ICU stay was （1.9±0.4）days, and the post-operative hospital stay time was （8.4±1.8）days, which were significantly lower than PSM-CAVR group [（2.4±0.9）d vs. （10.6±3.2）d, P〈0.01]. The pleural drainage during the first post-operative day was less in MIAVR group than that in PSM-AVR group [（281±53）ml vs. （432±88）ml, P〈0.01 ]. No differences of mortality, deep wound infection and transfusion rate were found be- tween the groups（0% vs. 1.5%, P=0.32, 0% vs. 3.1%, P=0.15; 23.1% vs. 35.4%, P=0.13）. Conclusion Min- imally iuvasive aortic valve replacement from right anterior mkdthoracotomy is feasible attd safe. Despite the proce- dure increases cardiopulmonary bypass time and cross clamp time, it can reduce drainage and facilitate post-opera- tive recovery.