胸腔镜单操作孔在左心瓣膜术后单纯三尖瓣中重度反流的手术疗效分析

Surgical efficacy analysis of thoracoscopic single operating hole in patients with moderate-to-severe tricuspid regurgitation after left heart valve surgery

目的 研究左心瓣膜术后中远期出现单纯三尖瓣中重度反流时行胸腔镜单操作孔三尖瓣生物瓣置换的安全性及中远期疗效。方法 选取2009年3月至2017年12月左心瓣膜术后继发三尖瓣中重度反流行生物瓣置换的患者30例作为研究对象。其中,选取2014年2月至2017年12月行胸腔镜单操作孔三尖瓣生物瓣置换术13例患者纳入腔镜组,选取2009年3月至2016年7月行原胸骨正中切口三尖瓣生物瓣置换的17例患者纳入对照组,回顾性比较两组患者的手术时间、体外循环时间、术后出血量、红细胞悬液输血量、术后呼吸机辅助时间、ICU停留时间、术后住院时间、血管活性药物用量,观察围手术期并发症发生情况及致死率,并随访两组患者术后心功能情况及生存情况。结果 两组均无手术死亡。围手术期腔镜组死亡1例,对照组死亡3例。腔镜组较对照组手术时间显著缩短,术后出血量及输血量显著减少(P<0.05),术中右心损伤减少(P=0.052)。而在体外循环时间、ICU滞留时间、呼吸机使用时间、住院时间、术后并发症方面,两组比较差异均无统计学意义(P>0.05)。两组随访1年内心脏事件再次入院率均为50%,心功能提高1~2级。腔镜组12例,心功能恢复至Ⅰ级3例、Ⅱ级6例、Ⅲ级3例;对照组14例,心功能恢复至Ⅰ级4例、Ⅱ级6例、Ⅲ级4例,均较术前显著改善。一年后超声提示,右心较术前比较明显减小(P<0.05)。结论 左心瓣膜术后继发单纯三尖瓣中重度反流患者行胸腔镜单操作孔三尖瓣生物瓣置换术较正中开胸手术创伤小,出血少,手术时间短;该术式安全可靠,中远期疗效满意,可作为该患者的常规治疗方式。

Objective To study the safety and medium and long term efficacy of thoracoscopic tricuspid valve replacement with single operating hole when simple tricuspid valve regurgitation occurs in the middle and long term after left heart valve surgery.Methods A total of 30 patients who underwent bioprosthetic valve replacement with moderate-to-severe tricuspid valve regurgitation secondary to left heart valve surgery from March 2009 to December 2017 were selected as the research subjects.Among them, 13 patients who underwent thoracoscopic tricuspid valve replacement with single operating hole from February 2014 to December 2017 were selected and included in the endoscopic group, and 17 patients who underwent midsternal incision tricuspid biological valve replacement from March 2009 to July 2016 were selected and included in the control group.The operation time, extracorporeal circulation time, postoperative blood loss, red blood cell suspension transfusion volume, postoperative ventilator assistance time, ICU stay time, postoperative hospitalization time, and vasoactive drug dosage, the perioperative complications, and mortality were retrospectively compared between the two groups, and the postoperative cardiac function and survival of the two groups were followed up.Results There were no operative deaths in either group.In the perioperative period, one patient died in the endoscopic group and three patients died in the control group.Compared with the control group, the operation time of the endoscopic group was significantly shortened, the postoperative bleeding volume and blood transfusion volume were significantly reduced(P<0.05),and the intraoperative right heart injury was reduced(P=0.052).There were no significant differences between the two groups in the duration of cardiopulmonary bypass, ICU stay time, ventilator use time, hospital stay, and postoperative complications(P>0.05).Within one year of follow-up, the readmission rate of cardiac events in both groups was 50%,and cardiac function improved by 1-2 grades.Among the 12 patients in the endoscopic group, cardiac function recovered to grade I in three cases, grade II in six cases, and grade Ⅲ in three cases.In the control group of 14 cases, cardiac function recovered to grade I in four cases, grade Ⅱ in six cases, and grade Ⅲ in 4 cases, all of which were significantly improved compared with those before operation.One year later, the ultrasound showed that the right heart was significantly smaller than that before surgery(P<0.05).Conclusion Compared with median thoracotomy, thoracoscopic tricuspid valve replacement with single operating hole is less traumatic, less bleeding, and has shorter operation time for patients with simple tricuspid regurgitation after left heart valve operation.The operation is safe and reliable, with satisfactory mid-and long-term efficacy, and can be used as a routine treatment for this patient.