低温室颤下全胸腔镜再次二尖瓣手术的早期临床结果

Early clinical results of totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation

目的比较低温室颤下全胸腔镜再次二尖瓣手术与正中开胸常规再次二尖瓣手术的围手术期结果,探讨全胸腔镜再次二尖瓣手术的安全性。方法回顾性纳入2018年1月至2022年1月在解放军总医院第一医学中心心脏大血管外科由同一术者收治的再次二尖瓣手术患者。根据手术方式分为低温室颤下全胸腔镜组(全胸腔镜组)和常规正中开胸组(正中开胸组),收集患者术前基线资料及围手术期结果,应用SPSS 22.0软件进行统计学分析。结果91例患者符合标准纳入研究,全胸腔镜组25例,正中开胸组66例。两组患者术前基线资料差异无统计学意义。全胸腔镜组在二尖瓣成形率(32.0%对7.6%,P=0.008)、输血率(72.0%对98.5%,P<0.001)、机械通气[(19.0±27.8)h对(43.3±58.3)h,P=0.009]、术后胸腔引流量[(489.6±319.1)ml对(913.6±568.4)ml,P=0.001]、胸腔引流管留置[(2.2±1.9)天对(3.7±2.4)天,P=0.004]、术后住院时间[(8.0±2.7)天对(13.9±12.8)天,P=0.026]等方面具有优势。全胸腔镜组具有更长的体外循环[(180.8±41.7)min对(143.2±39.7)min,P<0.001],术中室颤时间为(100.2±42.5)min。两组患者在术后并发症发生率(12.0%对21.2%,P=0.481)和病死率(4.0%对4.5%,P=1.000)方面差异无统计学意义。结论全胸腔镜入路相比正中开胸入路具有创伤小、恢复快的特点。低温室颤相比常规阻断升主动脉,简化了升主动脉处操作的同时可减少心肌损伤。低温室颤下全胸腔镜再次二尖瓣手术是一种安全可靠的微创技术。

Objective The aim of this study was to compare the perioperative outcomes of a totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation with those of a conventional median sternotomy approach for repeat mitral valve surgery and to explore the safety of the totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation.Methods Patients requiring repeat mitral valve surgery admitted by the same surgeon at Cardiovascular Surgery,First Medical Center,Chinese PLA General Hospital from January 2018 to January 2022 were retrospectively enrolled.The patients were divided into the totally thoracoscopic group under hypothermic ventricular fibrillation and the conventional median sternotomy group according to the procedure,and the preoperative baseline data and perioperative outcomes were collected and statistically analyzed using SPSS 22.0.Results A total of 91 patients matched the criteria for study enrollment,25 in the totally thoracoscopic group and 66 in the median sternotomy group.There was no statistical difference in the preoperative baseline data between the two groups.The totally thoracoscopic group has advantages in mitral valvuloplasty rate(32.0%vs.7.6%,P=0.008),transfusion rate(72.0%vs.98.5%,P<0.001),mechanical ventilation time[(19.0±27.8)h vs.(43.3±58.3)h,P=0.009],chest drainage tube time[(2.2±1.9)days vs.(3.7±2.4)days,P=0.004],postoperative chest drainage volume[(489.6±319.1)ml vs.(913.6±568.4)ml,P=0.001],postoperative discharge time[(8.0±2.7)days vs.(13.9±12.8)days,P=0.026].The totally thoracoscopic group had a longer cardiopulmonary bypass time[(180.8±41.7)min vs.(143.2±39.7)min,P<0.001],and it had an intraoperative ventricular fibrillation time of(100.2±42.5)min.There were no statistically significant differences in the postoperative complication rate(12.0%vs.21.2%,P=0.481)and mortality(4.0%vs.4.5%,P=1.000)between the two groups.Conclusion The totally thoracoscopic approach has the characteristics of less invasion and faster recovery compared with the median sternotomy approach.Hypothermic ventricular fibrillation simplifies the procedure at the ascending aorta while reducing myocardial injury than conventional occlusion of the ascending aorta.Totally thoracoscopic mitral valve surgery under hypothermic ventricular fibrillation is a safe minimally invasive technique.