摘要
目的 回顾性分析总结复旦大学附属中山医院施行的601例微创心脏瓣膜手术临床经验.方法 复旦大学附属中山医院自2009年7月至2012年11月实施胸腔镜辅助或直视微创心脏瓣膜手术601例,其中二尖瓣成形术174例,二尖瓣置换术262例,主动脉瓣置换术159例,二尖瓣+主动脉瓣置换术2例,升主动脉+主动脉瓣置换术4例,其中再次心脏瓣膜手术26例.二尖瓣手术径路为经第四肋间右胸前外侧切口(4～6 cm),主动脉瓣手术径路为经第三肋间右胸骨旁横切口(4 ～5 cm)或胸骨上段切口(6～8 cm),升主动脉+主动脉瓣置换术径路为经胸骨上段切口(6 ～8 cm),二尖瓣+主动脉瓣置换术径路为经第三肋间右胸骨旁横切口(6～8 cm).大部分手术采用股动静脉插管建立外周体外循环,部分胸骨上段切口手术采用升主动脉直接插管.结果 院内死亡6例,分别为3例二尖瓣置换术和3例主动脉瓣置换术患者,死亡原因分别为呼吸功能衰竭1例,心功能衰竭3例,肾功能衰竭2例.3例患者因术野暴露困难延长手术切口；3例因右侧胸腔粘连、l例因股动静脉插管失败、1例因出血难以控制导致中转胸骨正中切口.2例二尖瓣成形后术中食道超声提示残余中度以上二尖瓣反流,改行二尖瓣置换术,术后再次开胸止血8例,余患者手术顺利.平均手术时间(184.4±29.4) min,平均体外循环时间(82.6±23.4) min,平均主动脉阻断时间(47.8 +21.1)min,术后平均机械通气时间(7.4±6.4)h,术后24 h平均引流量(334.4 +316.4) ml,术后平均住院时间(6.3±4.1)d,75.8％(455/601)患者住院期间未接受任何血制品输注.术后随访2～38个月,随访率93.3％,因抗凝并发症导致脑血管意外死亡2例,2例二尖瓣成形术后出现中度二尖瓣反流,1例二尖瓣置换术后发现轻度瓣周漏,均保守治疗,另有1例主动脉瓣置换术后因感染性心内膜炎导致中重度瓣周漏,予行Bentall术,余患者恢复情况良好.结论 �
Objective Minimally invasive techniques are gaining popularity in cardiac valve surgery disciplines. This study reviewed our results of minimally invasive valve surgery( MIVS) in 601 patients.Methods From July 2009 to November 2012,a total of 601 patients underwent MIVS,including aortic valve replacement( AVR)( 26. 5%,159 /601),mitral valve repair( MVP)( 29. 0%,174 /601),mitral valve replacement( MVR)( 43. 6%,262/601),dual mitral and aortic valve replacement( DVR)( 0. 3%,2/601),ascending aorta and aortic valve replacement( Wheat surgery)( 0. 7%,4 /601). Twenty-six patients( 4. 3%,26 /601) had reoperative cardiac valve surgery. Surgical access was through a right antero-lateral throcotomy in the forth intercostal space( 4-6 cm,for MVR,MVP),right parasternal antero-lateral throcotomy in the third intercostal space( 5-8 cm,for AVR and DVR),upper ministernotomy( 6-8 cm,for AVR and Wheat surgery). Cardiopulmonary bypass( CPB) was established with a groin incision for femoral artery and vein connection in most patients. Results There were six( 1. 0%,6/601) operative deaths. Perioperative morbidity included incision expansion( 0. 5%,3/601),conversion to median sternotomy( 0. 5%,3 /601),reoperation for bleeding( 1. 3%,8 /601). Mean operation,cardiopulmonary bypass and aortic clamp time were( 184. 4 ± 29. 4) min,( 82. 6 ± 23. 4) min and( 47. 8 ± 21. 1) min. Mean length of intensive care unit( ICU) and hospital stay were( 19. 2 ± 8. 7) h and( 6. 3 ± 4. 1) d. Four hundred fifty-five patients( 75. 8%,455/601) did not receive any blood product transfusion in hospital. Follow-ups were performed in 93. 3%of patients. There were two( 0. 3%,2 /595) late deaths and two( 0. 3%,2 /595) paravalvular leak and one need to reoperation. A good recovery was obtained in all other patients. Conclusions MIVS with or without thoracoscopicassisted can be performed at very low levels of morbidity and mortality. All forms of valve repair and replacement operations can be performed,including dual mitral and aortic valve replacement and ascen
出处
《心血管外科杂志（电子版）》
2012年第1期17-22,共6页
Journal of Cardiovascular Surgery(Electronic Edition)
基金
上海市科委医学引导类项目资助(114119a9200)
卫生部行业科研专项项目资助(200902001)
关键词
心脏外科手术
外科手术
微创性
心脏瓣膜
Cardiac surgical procedures
Surgical procedures,minimally invasive
Heart valves
