单操作孔全胸腔镜治疗左心瓣膜术后三尖瓣关闭不全临床分析

Uni-port totally thoracoscopic surgery in tricuspid insufficiency patients after previous left-sided valve surgery

目的探讨单操作孔全胸腔镜手术治疗左心瓣膜术后三尖瓣关闭不全的效果.方法回顾性分析2017年9月至2019年6月36例在解放军总医院第一医学中心心血管外科接受全胸腔镜三尖瓣手术治疗的左心瓣膜术后单纯三尖瓣关闭不全患者的临床资料.男性13例,女性23例,年龄(56±11)岁(范围:43-79岁).所有患者为左心瓣膜术后重度三尖瓣关闭不全,不合并严重肺动脉高压及严重的左心室功能或瓣膜功能障碍.手术经右胸前外侧第4肋间长约4 cm的操作孔完成,通过股动静脉插管建立心肺转流,上腔静脉不插管,下腔静脉不阻断并应用负压吸引辅助引流,在心脏跳动下完成三尖瓣手术.结果7例患者实施三尖瓣成形,29例患者实施三尖瓣生物瓣置换,手术时间(2.9±0.3)h(范围:2.5-3.6 h).无中转胸骨切开患者.术中无患者发生室性心律失常等严重并发症和股动静脉插管相关并发症.心肺转流建立时间为(22±5)min(范围:12-24 min),心肺转流时间为(82±16)min(范围:62-93 min),术后住院时间为(9±3)d(范围:5-13 d).无术后早期死亡.随访3~22个月,无患者死亡.结论单操作孔全胸腔镜三尖瓣手术治疗左心术后的单纯三尖瓣关闭不全安全可行,效果可靠.下腔静脉单独插管不行上下腔静脉游离阻断的心肺转流方式可降低此类患者手术的复杂程度.

Objective To examine minimally invasive tricuspid valve operations applied in tricuspid valve insufficiency patients with previous left-sided valve surgery.Methods Between September 2017 and June 2019,thirty-six consecutive patients received minimally invasive totally thoracoscopic tricuspid surgery through right thoracotomy at Department of Cardiovascular Surgery,Fisrt Medical Center,People′s Liberation Army General Hospital.There were 13 males and 23 females,aging(56±11)years(range:43 to 79 years).All the patients had isolated significant tricuspid regurgitation after previous left-sided cardiac surgeries.A right anterolateral thoracotomy incision about 4 cm was made from the fourth intercostal space as main operating port.The arterial cannula was placed in femoral artery.The venous cannula was placed in femoral vein using Seldingger technique.Tricuspid valve operation was performed on beating heart by assist of vena vacuum.Results Tricuspid valve repair was performed in 7 patients.Tricuspid valve replacement with bioprosthesis was performed in 29 patients.The operation time was(2.9±0.3)hours(range:2.5 to 3.6 hours).There was no conversion to sternotomy during operation.There was no severe complications during operation period.There were no complications related to this cannulation technique.The time of cardiopulmonary bypass establishment was(22±5)minutes(range:12 to 24 minutes)and pump time was(82±16)minutes(range:62 to 93 minutes).The length of hospital stay was(9±3)days after operation(range:5 to 13 days).There was no early death in hospital.All patients were followed up for 3 to 22 months.No patient died.Conclusions One single port-based minimally invasive approach seems to be safe,feasible,and reproducible in case of redo tricuspid valve operations.Only cannulation of inferior vena cava significantly simplified the complexity of isolated redo tricuspid surgery.