再次心脏房室瓣手术的微创化探索

Minimally invasive cardiac surgery for cardiac atrioventricular valve reoperation

目的总结近10年来再次心脏房室瓣微创手术的经验。方法回顾性分析2009—2019年在安徽医科大学第一附属医院施行再次心脏房室瓣微创手术32例患者的临床资料,其中男13例、女19例,平均年龄(51.0±12.6)岁。所有患者均采用股动、静脉插管或联合经皮上腔静脉插管建立外周体外循环,不阻断升主动脉,分别采用单纯右胸前外侧小切口,或胸腔镜辅助下右胸前外侧小切口,或完全胸腔镜下行再次瓣膜成形或置换术。并与同期24例常规正中开胸再次手术患者围术期指标进行比较。结果单纯三尖瓣置换术21例、单纯三尖瓣成形术4例、三尖瓣置换+房间隔缺损修补术1例、二尖瓣置换+三尖瓣成形术6例。27例患者在并行循环下完成手术,5例患者在心室颤动下完成手术。微创手术患者手术时间[(3.23±1.56)h vs.(5.46±2.13)h,P<0.001]、术后机械通气时间[(9.19±5.40)h vs.(43.23±21.74)h,P<0.001]、重症监护室滞留时间[(35.03±18.26)h vs.(79.15±22.43)h,P<0.001]及住院时间[(9.35±6.43)d vs.(15.85±7.56)d,P=0.001]均短于正中开胸患者,且体外循环时间没有明显延长。微创手术患者围术期发生并发症4例,术后院内死亡1例。结论微创方法行再次心脏房室瓣手术可以有效地改善手术疗效,而全胸腔镜下不停跳再次房室瓣手术更具优势,有利于减少创伤,并减少心肌缺血-再灌注损伤,术后恢复快,并发症少。这种手术方式可能是将来微创化的发展方向,但要注意解决和避免术中外周循环所带来的相关问题。

Objective To summarize the clinical experiences of minimally invasive cardiac surgery(MICS)for cardiac atrioventricular valve reoperation.Methods Perioperative data of 32 patients who underwent MICS for cardiac atrioventricular valve reoperation from 2009 to 2019 in the First Affiliated Hospital of Anhui Medical University were retrospectively reviewed,including 13 males and 19 females with a mean age of 51.0±12.6 years.All patients were given combined intravenous and inhalation anesthesia,and a double-lumen tube for mechanical ventilation.Cardiopulmonary bypass was established in all patients by femoral artery and venous cannulation or combined with percutaneous superior vena cava cannulation,without aortic cross-clamping.The MICS approaches included right anterolateral small incision surgery,thoracoscopic assisted small incision surgery and total thoracoscopic surgery.The clinical data of the 32 patients were compared with the perioperative indicators of 24 patients undergoing reoperation with conventional median thoracotomy during the same period.Results Among them,21 patients underwent isolated tricuspid valve replacement,4 isolated tricuspid valvuloplasty,1 combined tricuspid valve replacement and atrial septal defect repair and 6 combined mitral valve replacement and tricuspid valvuloplasty.Twenty-seven patients completed the operation in a beating heart,and 5 under the condition of ventricular fibrillation.Operation time(3.23±1.56 h vs.5.46±2.13 h,P<0.001),postoperative mechanical ventilation time(9.19±5.40 h vs.43.23±21.74 h,P<0.001),ICU stay(35.03±18.26 h vs.79.15±22.43 h,P<0.001)and hospital stay of patients with minimally invasive surgery(9.35±6.43 d vs.15.85±7.56 d,P=0.001)were shorter than those with median thoracotomy.And the extracorporeal circulation time was not significantly prolonged.There were 4 perioperative complications in patients with minimally invasive surgery,and 1 died in hospital after operation.Conclusion MICS for cardiac atrioventricular valve reoperation can avoid the risk of median sternotomy and separation of cardiac scar adhesion.Especially,total thoracoscopic surgery has more advantages when compared with other operations,including less trauma,less myocardial ischemia reperfusion injury,more rapid recovery and fewer postoperative complications.Total thoracoscopic surgery may be the development direction of MICS for cardiac atrioventricular valve reoperation.However we should take effective and feasible measures to solve the problems caused by cardiopulmonary bypass.