经胸骨上段小切口行主动脉手术的学习曲线及临床疗效

Learning curve and clinical efficacy of aortic surgery through upper hemisternotomy

目的探讨经胸骨上段小切口行主动脉夹层手术和非夹层主动脉手术的学习曲线和临床疗效。方法回顾分析同一手术团队经胸骨上段小切口行主动脉夹层和非夹层主动脉手术的围术期资料。根据体外循环时间和主动脉阻断时间,采用累计求和(CUSUM)分析法及拟合曲线分别绘制夹层手术组和非夹层手术组的学习曲线,根据所得曲线的临界点将整个过程分为提高期和熟练期,对比两个阶段的围术期各项指标随时间的变化趋势分析学习曲线,验证临界点是否为度过学习曲线所需的手术例数,并明确熟练掌握胸骨上段小切口主动脉手术后的安全性和近期疗效。结果共107例患者纳入研究,根据完善的术前检查分为两组:主动脉夹层组47例,术式为升主动脉置换+弓部置换+降主动脉支架植入和/或主动脉根部处理;非夹层组60例,术式为主动脉根部手术和/或升主动脉置换。夹层组中男37例、女10例,体外循环时间和主动脉阻断时间的最佳拟合方程分别为y=-0.019x^(3)+0.251x^(2)+28.852x-6.076(x为手术例数,最优拟合系数R^(2)=0.918,P<0.05)和y=-0.015x^(3)-0.093x^(2)+34.799x-27.316(R^(2)=0.92,P<0.05),以27例为界将夹层组分为提高期和熟练期,两阶段术前基线资料差异无统计学意义(P>0.05);熟练期的围术期指标明显优于提高期,该临界点为度过学习曲线所需的手术例数。非夹层主动脉组中男45例、女15例,体外循环时间和主动脉阻断时间的最佳拟合方程分别为y=0.013x^(3)-1.826x^(2)+62.353x+193.189(R^(2)=0.906,P<0.05)和y=0.009x^(3)-1.416x^(2)+49.389x+177.335(R^(2)=0.90,P<0.05),以22例为界将非夹层主动脉组分为提高期和熟练期,两阶段术前基线资料除二次开胸例数[8(36.36%)vs 1(2.63%),P<0.001]外差异无统计学意义;熟练期的围术期指标同样优于提高期,该临界点为度过学习曲线所需的手术例数。经胸骨上段小切口行夹层和非夹层手术在度过学习曲线后安全性和近期疗效好。结论经胸骨上段小切口行主动脉夹层和非夹层主动脉手术过程安全,夹层手术经约30例后可熟练掌握此技术;非夹层主动脉手术经约20例后可熟练掌握,与夹层手术相比学习曲线较短。两组熟练掌握后均可提高术后近期疗效。

Objective To investigate the learning curve and clinical efficacy of aortic dissection and non-dissection aortic surgeries through upper hemisternotomy.Methods We retrospectively analyzed the perioperative data of aortic dissection and non-dissection surgeries through upper hemisternotomy performed by the same surgical team.Based on cardiopulmonary bypass time and aortic cross-clamping time,the learning curves were plotted using cumulative(CUSUM)analysis and the fitting curve,and the learning process was divided into the improvement period and proficiency period.We compared the perioperative parameters in the two stages,and verified whether the critical point was the number of operations required to overcome the learning curve.The safety and short-term efficacy of the aortic surgeries were analyzed after achieving proficiency.Results A total of 107 patients were analyzed,including 47 undergoing aortic dissection(ascending aorta replacement+arch replacement+descending aorta stent implantation and/or aortic root treatment)and 60 undergoing non dissection surgeries(artery root surgery and/or ascending aorta replacement).The optimal fitting equation was y=-0.019x^(3)+0.251x^(2)+28.852x-6.076(R^(2)=0.918,P<0.05)for CPB time and y=-0.015x^(3)-0.093x^(2)+34.799x-27.316(R^(2)=0.92,P<0.05)for aortic cross clamping time.In the dissection group,with 27 cases as the boundary,the perioperative parameters were significantly better in the proficiency stage than in the improvement stage,and the critical point was the number of surgeries needed to overcome the learning curve.The best fitting equation was y=0.013x^(3)-1.826x^(2)+62.353x+193.189(R^(2)=0.906,P<0.05)for CPB time and y=0.009x^(3)-1.416x^(2)+49.389x+177.335(R^(2)=0.90,P<0.05)for aortic cross-clamping time.In the non-dissecting aorta group,where 22 cases served as the boundary,the perioperative parameters were also better in the proficiency period than in the improvement period.Conclusion Both aortic dissection and non-dissection surgeries through upper hemisternotomy are safe and can significantly improve the short-term postoperative efficacy after achieving proficiency,but the latter approach has a shorter learning curve.