低温室颤性停搏在胸腔镜辅助下再次二尖瓣置换术中的应用

Video-assisted thoracoscopic redo mitral valve replacement under hypothermic fibrillatory arrest in patients with previous sternotomy

目的:总结低温诱导室颤性停搏技术在胸腔镜辅助下再次二尖瓣置换术中的应用方法和近期疗效。方法:回顾性分析2017年10月至2019年12月浙江省人民医院收治的35例既往心脏手术后(PCS)接受胸腔镜辅助下再次二尖瓣置换手术患者的临床资料为PCS组。选取同期收治并接受胸腔镜辅助下首次二尖瓣置换手术的患者78例为对照组。术后随访6个月,比较2组患者围术期数据和近期随访结果。结果:2组患者在性别、年龄、三尖瓣病变、合并房颤等主要术前临床指标方面差异无统计学意义(均P>0.05)。PCS组手术时间和体外循环时间较对照组延长[(226.5±11.4)min vs.(189.6±17.7)min;(148.1±16.3)min vs.(105.3±15.3)min,均P<0.01];2组间术后24 h引流液量和围术期输血率差异无统计学意义[(205.8±27.8)mL vs.(195.3±26.3)mL;17.1%(6/35)vs.21.8%(17/78),均P>0.05]。术后心肌肌钙蛋白I和乳酸峰值指标差异无统计学意义[(3.0±1.1)μg/L vs.(2.5±1.3)μg/L;(3.0±0.9)mmol/L vs.(2.7±0.8)mmol/L,均P>0.05]。所有患者术后均无严重神经系统和呼吸系统并发症出现。术后随访6个月,2组均无心因性死亡或心功能衰竭再次住院者,2组间心功能分级及左心室射血分数指标差异无统计学意义(均P>0.05)。结论:应用低温诱导室颤停搏技术行胸腔镜辅助下经胸再次二尖瓣置换术是安全可行的。在提供良好术中显露的同时,可明显简化手术操作,并获得满意的近期随访效果。

Objective:To summarize the experience in minimally invasive redoing mitral valve replacement with hypothermic fibrillatory arrest technique in patients with a previous cardiac procedure performed through a sternotomy.Methods:The clinical data of 35 patients who underwent video-assisted thoracoscopic mitral valve replacement after previous cardiac surgery(PCS)from October 2017 to December 2019 in Zhejiang Provincial People’s Hospital were retrospectively analyzed.78 patients who underwent video-assisted thoracoscopic mitral valve replacement(first cardiac surgery,FCS)at the same time were assigned to the control group.All the 113 patients were followed up for 6 months,and their perioperative data and follow-up results were compared between the two groups.Results:There was no significant difference between the two groups in terms of gender,age,tricuspid valve disease,atrial fibrillation,and other major preoperative clinical indicators.The operation time and cardiopulmonary bypass time were longer in the PCS group compared with FCS group[(226.5±11.4)min vs.(189.6±17.7)min,(148.1±16.3)min vs.(105.3±15.3)min,both P<0.01].There was no significant difference between the two groups in 24-hour post-operative drain volume and perioperative blood transfusion rate[(205.8±27.8)mL vs.(195.3±26.3)mL,17.1%(6/35)vs.21.8%(17/78),both P>0.05].There was no significant difference in postoperative peak cardiac troponin I and blood lactate[(3.0±1.1)μg/L vs.(2.5±1.3)μg/L,(3.0±0.9)mmol/L vs.(2.7±0.8)mmol/L,both P>0.05].No serious neurological or respiratory complications occurred in all patients postoperatively.At 6-month postoperative follow-up,there was no cardiac death or rehospitalizations for heart failure in either group,and there was no significant difference in cardiac function classification or left ventricular ejection fraction between the two groups(both P>0.05).Conclusion:It is safe and feasible to redo mitral valve replacement using video-assisted thoracoscopy with hypothermic fibrillatory arrest technique in patients with a previous cardiac procedure.In addition to providing good intraoperative exposure,the technique can significantly simplify the operation and obtain satisfactory short-term follow-up results.