左心瓣膜置换术后再次胸腔镜下右胸小切口三尖瓣手术

Redo tricuspid valve surgery under thoracoscopic-assisted minimally invasive right thoracotomy after left heart valve replacement

目的探索左心瓣膜置换术后再次胸腔镜下右胸小切口心脏不停跳下行三尖瓣手术的治疗效果。方法2018年5月~2020年7月我院收治的胸腔镜辅助下右胸小切口行三尖瓣成形或置换的再次手术病人28例,9例病人接受三尖瓣成形术,19例接受三尖瓣置换术。所有病人均使用全麻双腔气管插管,右侧抬高位,右侧锁骨中线至右侧腋前线第4肋间5 cm切口为主操作孔,右侧腋中线第5肋间1 cm切口为观察孔,通过股动静脉插管建立体外循环,所有三尖瓣手术均在心脏不停跳下完成。结果所有手术均在外周体外循环支持、心脏不停跳下进行,无术中转正中切口,术中无股动静脉插管并发症。体外循环时间(78±15)分钟,术后ICU拔除气管插管时间(20.3±8.6)小时,术后住院时间(8.5±3.0)天。围手术期死亡1例,该病人三尖瓣置换术后出现急性肾功能衰竭合并肺部感染,其余病人术后恢复良好。随访12~30个月,术后均存活,心功能均较术前有明显改善。结论左心瓣膜置换术后再次胸腔镜下右胸小切口行三尖瓣手术是安全可行的优选手术方式。胸腔镜下右胸小切口可简化手术过程,降低术后死亡率及术后并发症发生率。

Objective To explore the effect of thoracoscopic-assisted tricuspid valve surgery with minimally invasive right thoracotomy after left heart valve replacement.Methods A retrospective analysis of 28 patients with tricuspid valve surgery with minimally invasive right thoracotomy after left heart valve replacement was conducted in the First Affiliated Hospital with Nanjing Medical University from May 2018 to July 2020.Nine patients underwent tricuspid valve repair and 19 patients underwent tricuspid valve replacement.All the patients underwent double-lumen tracheal intubation under general anesthesia,with the right chest elevated,the main operating hole of 5 cm from the right midclavicular line to the right midaxillary line at the 4 th intercostal space,and the observation hole of 1 cm at the 5 th intercostal incision at the right midaxillary line.Cardiopulmonary circulation was established through right femoral artery and vein cannulation,and tricuspid valve surgery was completed under heart beating.Results Only one patient died during the perioperative period,the patient developed acute renal failure combined with pulmonary infection,and the rest patients recovered well after the operation.All the operations were performed under cardiopulmonary bypass with continuous heart beating,no patients were converted to sternotomy,and there was no intraoperative complication.The cardiopulmonary bypass time was(78±15)min,postoperative ICU extubation time(20.3±8.6)h,postoperative hospital stay(8.5±3.0)days,no postoperative third-degree atrioventricular block,postoperative echocardiography showed no paravalvular leakage.The patients were followed up for 12 to 30 months,no death was found,and the cardiac function was improved compared with that before the operation.Conclusion Tricuspid valve surgery with thoracoscopic-assisted minimally invasive right thoracotomy after left heart valve replacement is a safe and feasible surgical method,which can significantly simplify the surgical process and reduce postoperative mortality and complications.