心脏黏液瘤合并缺血性卒中的手术方式和术后管理

Surgical modalities and postoperative management of cardiac myxoma combined with ischemic stroke

目的探讨心脏黏液瘤合并缺血性卒中(cardiac myxoma combined with ischemic stroke,CM-IS)的手术方式、术后并发症及术后抗栓治疗,为心脏黏液瘤导致的心源性卒中的手术方式和术后管理提供依据。方法心脏黏液瘤分别采用传统胸骨正中开胸手术和经胸骨右侧第四肋间微创手术两种手术方式。回顾性收集了2010年1月1日至2020年12月31日于北京安贞医院住院治疗的全部心脏黏液瘤患者,并将患者分为心脏黏液瘤合并缺血性卒中组和非卒中组,对部分患者进行短期随访。分析心脏黏液瘤合并缺血性卒中的手术方式、术后并发症,术后抗栓治疗及短期预后。结果共有387例患者纳入分析,其中包括45例缺血性卒中患者和342例非卒中患者。缺血性卒中患者在胸骨正中切开术中,体外循环阻断时间(62.7 min±23.7 min vs.63.2 min±27.4 min,P=0.921)、住院天数(10.2±3.0 vs.10.0±3.5,P=0.596)和术后并发症(15.0%vs.9.5%,P=0.283),与非卒中患者均无显著差别,缺血性卒中患者同时行冠脉搭桥手术的比例更高(17.5%vs.5.6%,P=0.005),同时行心脏瓣膜手术的比例较低(2.5%vs.16.8%,P=0.018)。缺血性卒中患者在微创手术中,体外循环阻断时间(66.6 min±27.5 min vs.69.7 min±29.9 min,P=0.460)、住院天数(9.1±1.8 vs.11.2±4.3,P=0.268)和术后并发症(20.0%vs.13.2%,P=0.678),与非卒中患者亦无显著差别。缺血性卒中患者术后使用抗栓治疗的比例(37.8%vs.39.8%,P=0.471),与非卒中患者无显著差别;随访期间无脑卒中复发,死亡(4.3%vs.2.0%,P=0.481)和黏液瘤复发(2.2%vs.1.8%,P=0.825)的比例,两组亦无显著差别。缺血性卒中患者3年生存率为95.7%(95%CI:94.9~96.5)。结论心脏黏液瘤合并缺血性卒中患者在黏液瘤切除手术方法中,无论采取胸骨正中切除术,还是微创手术,都是安全、有效的,术后并发症少。卒中患者在黏液瘤切除术后无需常规给予抗栓治疗,预后良好,生存率高。

Objective To investigated surgical modalities and postoperative complications and postoperative antithrombotic therapy of cardiac myxoma combined with ischemic stroke(CM-IS),and to offer further support for therapy and postoperative management of cardiogenic stroke caused by cardiac myxoma.Methods Surgical procedures including median sternotomy and minimally invasive.Cardiac myxoma was treated with two surgical methods:traditional median sternotomy and minimally invasive through the right fourth intercostal space of the sternum.We performed a retrospective analysis of data from all CM patients at Beijing Anzhen Hospital and conducted follow-up examination from January 1,2010 to December 31,2020.Patients were divided into CM-IS group and CM without stroke(Non-stroke)group.The surgical modalities,postoperative complications,postoperative antithrombotic therapy and survival of CM-IS were analyzed by cohort study.Results A total of 387 patients were recruited for analysis,including 45 patients with CM-IS and 342 patients without stroke(Non-stroke).There was no significant difference in cardiopulmonary bypass time(62.7 min±23.7 min vs.63.2 min±27.4 min,P=0.921),hospital days(10.2 min±3.0 min vs.10.0 min±3.5 min,P=0.596)and postoperative complications(15.0%vs.9.5%,P=0.283),compare with Non-stroke patients underwent median sternotomy,and the proportion of coronary bypass surgery was significantly higher in CM-IS patients(17.5%vs.5.6%,P=0.005),while the proportion of valvular cardiac surgery was significantly lower(2.5%vs.16.8%,P=0.018).There was no significant difference in cardiopulmonary bypass time(66.6 min±27.5 min vs.69.7 min±29.9 min,P=0.460),hospital days(9.1±1.8 vs.11.2±4.3,P=0.268)and postoperative complications(20.0%vs.13.2%,P=0.678),compare with Non-stroke patients underwent minimally invasive.There was no difference in postoperative antithrombotic therapy between the two groups(37.8%vs.39.8%,P=0.471).There was no stroke recurrence during the follow-up period and no significant differences between groups in death(4.3%vs.2.0%,P=0.481)and myxoma relapse(2.2%vs.1.8%,P=0.825)either.The three-year survival rate of stroke patients was 95.7%(95%CI:94.9~96.5).Conclusions Both median sternotomy and minimally invasive are safe and efficacious in patients with CM-IS,with less postoperative complications.Routine postoperative antithrombotic therapy is unnecessary,the prognosis is favorable and the survival rate is high.