胸骨上段小切口在主动脉病变微创手术中的应用

Application of Partial Upper Sternotomy in Minimally Invasive Aortic Surgery

目的探讨胸骨上段小切口在主动脉病变微创手术中的安全性和疗效。方法2018年3月~2022年6月我科对15例主动脉病变采用胸骨上段J型或L型小切口,体外循环通过中心插管或股动、静脉插管建立,直视下完成主动脉成形或置换手术。结果15例手术均顺利完成,其中升主动脉成形术2例,升主动脉置换术13例,同期行主动脉瓣成形术1例,主动脉瓣置换术11例,窦部置换+左、右冠脉移植术5例(Bentall手术4例,改良Cabrol手术1例),右半弓置换术1例,全弓置换+胸降主动脉术中支架植入术(孙氏手术)1例。手术时间225~365 min,(293.0±38.6)min;体外循环时间93~209 min,(149.1±36.7)min;主动脉阻断时间53~158 min,(100.8±32.2)min;术后呼吸机辅助时间4~23 h,(11.7±5.5)h;ICU时间15~42 h,(29.3±8.8)h。术中出血量300~600 ml,(410.0±82.8)ml;术后3~4 d拔除引流管,(3.4±0.5)d;总引流量250~930 ml,(614.0±183.4)ml;总输血量600~1200 ml,(736.7±166.3)ml。手术切口长8~10 cm,(9.0±0.8)cm;术后无胸骨裂开和切口愈合不良。术后住院时间8~14 d,(10.3±1.7)d。15例随访2~53个月,中位随访时间33个月,无死亡和再次手术,心功能明显改善[NYHA心功能Ⅰ级占93.3%(14/15),Z=-3.452,P=0.000]。心脏彩超提示主动脉瓣膜未见明显异常13例、轻度关闭不全2例,升主动脉内径和左室舒张末期内径较术前明显缩小[(29.5±4.9)mm vs.(46.3±4.8)mm,t=10.088,P=0.000;(46.6±5.6)mm vs.(52.2±10.6)mm,t=4.039,P=0.001]。主动脉CTA提示升主动脉直径较术前明显缩小[(29.1±4.1)mm vs.(49.6±6.7)mm,t=9.665,P=0.000]。结论对主动脉根部、升主动脉、主动脉弓部病变的患者,通过胸骨上段小切口完成微创主动脉成形或置换手术,创伤相对较小,安全、有效。

Objective To investigate the safety and efficacy of partial upper sternotomy in minimally invasive aortic surgery.Methods From March 2018 to June 2022,15 patients with aortic lesions received minimally invasive surgical treatment in our department.Aorticplasty or replacement for all patients was performed under direct vision through J-shaped or L-shaped partial upper sternotomy,and cardiopulmonary bypass was established through central cannulation or femoral artery and vein cannulation.Results All the operations were successfully performed,including 2 cases of ascending aorta plasty and 13 cases of ascending aorta replacement.Simultaneously,aortic valvoplasty was performed in 1 case,aortic valve replacement in 11 cases,aortic sinus replacement combined with left and right coronary artery ostium reconstruction in 5 cases(Bentall procedure in 4 cases and modified Cabrol procedure in 1 case),partial aortic arch replacement in 1 case,and total arch replacement combined with stent implantation in descending thoracic aorta(Sun’s procedure)in 1 case.The operation time was 225-365 min(mean,293.0±38.6 min),the cardiopulmonary bypass time was 93-209 min(mean,149.1±36.7 min),and the aortic cross-clamping time was 53-158 min(mean,100.8±32.2 min).The postoperative ventilator support time was 4-23 h(mean,11.7±5.5 h),and the postoperative intensive care unit stay time was 15-42 h(mean,29.3±8.8 h).The intraoperative blood loss was 300-600 ml(mean,410.0±82.8 ml),and the drainage tube was removed 3-4 d(mean,3.4±0.5 d)after the operation.The total drainage volume was 250-930 ml(mean,614.0±183.4 ml),and the total blood transfusion volume was 600-1200 ml(mean,736.7±166.3 ml).The length of chest incision was 8-10 cm(mean,9.0±0.8 cm),and there was no sternal staphyloma or poor wound healing.All the patients recovered and were discharged from hospital,and the postoperative hospital stay was 8-14 d(mean,10.3±1.7 d).All the 15 patients were followed up for 2-53 months,with a median of 33 months.There was no death or re-operation,and the cardiac function improved significantly[cardiac function gradeⅠaccording to New York Heart Association(NYHA)accounting for 93.3%(14/15),Z=-3.452,P=0.000].The color Doppler echocardiography showed no obvious abnormality in 13 cases and mild aortic insufficiency in 2 cases.The diameter of ascending aorta and end diastolic diameter of left ventricle were significantly smaller than those before operation[(29.5±4.9)mm vs.(46.3±4.8)mm,t=10.088,P=0.000;(46.6±5.6)mm vs.(52.2±10.6)mm,t=4.039,P=0.001].The CT angiography of the aorta showed that the diameter of ascending aorta was also significantly smaller than that before operation[(29.1±4.1)mm vs.(49.6±6.7)mm,t=9.665,P=0.000].Conclusions Minimally invasive aortic plasty or replacement can be performed through partial upper sternotomy for patients with aortic root,ascending aorta,and aortic arch lesions.The trauma is relatively small.It is safe and effective,being worthy of application in appropriate patients.