Byrne J G, Mitchell M E, Adams D H, Couper G S, Aranki S F, Cohn L H
Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, MA 02115, USA.
Semin Thorac Cardiovasc Surg. 1999 Jul;11(3):212-22. doi: 10.1016/s1043-0679(99)70062-6.
We reviewed our experience with minimally invasive direct-access mitral valve surgery in 207 patients through February 1999. Three patients underwent associated procedures, a coronary artery bypass graft (CABG) with right internal mammary artery to right carotid artery (RIMA-RCA), a left ventricular outflow tract (LVOT) debridement for endocarditis, and a primum atrial septal defect (ASD) repair, and were excluded from analysis. Of the 204 remaining patients, 120 (59%) patients were men, aged 58.7 +/- 13.2 years, functional class of 2.3 +/- 0.5. The cause was myxomatous in 162 (79%) patients, rheumatic in 28 (14%) patients, endocarditis in 8 (4%) patients, congenital in 3 (2%) patients, and ischemic in 3 (2%) patients. Mean preoperative EF was 60% +/- 10%, with 184 (90%) patients showing ejection fraction (EF) greater than 50%. The valve was approached through a 5- to 8-cm right parasternal (n = 180, 88%) or right inframammary (n = 24, 12%) incision. One hundred nineteen (58%) patients had open femoral artery-femoral vein cannulation, and 85 (42%) patients had direct cannulation of the aorta and percutaneous cannulation of the femoral vein. One hundred seventy (83%) patients underwent successful valve repair, and 34 (17%) patients required valve replacement. The mean duration of aortic clamping and cardiopulmonary were, respectively, 100 +/- 34 and 146 +/- 44 minutes. There were 2 (1%) surgical deaths. Nonfatal perioperative complications included 3 (1.5%) ascending aortic complications, 3 (1.5%) reoperations for bleeding, 4 (2%) strokes, 2 (1%) transient ischemic attacks (TIAs), 2 (1%) myocardial infarctions, 3 (1.5%) pericardial effusions requiring drainage, 9 (4.5%) vascular complications, and 3 (1.5%) wound complications. Mean length of stay (LOS) was 6.1 +/- 3 days, with 63 (31%) patients being discharged in less than 5 days. One hundred twenty-nine (63%) patients did not require blood transfusions. Follow-up was complete in 165 (81%) patients, with mean follow-up of 13.2 +/- 8 months. Late complications included 1 (0.5%) myocardial infarction, 3 (1.5%) reoperations, all converting repairs to replacements, 3 (1.5%) wound hernias requiring reoperation and repair with mesh, 5 (2.5%) thromboembolic events, and 3 (1.5%) deaths of suicide, pneumonia, and sudden death, respectively. Mean follow-up New York Heart Association (NYHA) functional class was 1.2 +/- 0.5. We conclude that minimally invasive direct-access mitral valve surgery is safe, effective, and applicable for most patients presenting for isolated mitral valve surgery. We now consider it the standard of care for selected patients.
我们回顾了截至1999年2月对207例患者进行微创直接入路二尖瓣手术的经验。3例患者接受了相关手术，分别是右乳内动脉至右颈动脉的冠状动脉旁路移植术（CABG）、因心内膜炎进行的左心室流出道（LVOT）清创术以及原发孔房间隔缺损（ASD）修复术，这3例被排除在分析之外。在其余204例患者中，120例（59%）为男性，年龄58.7±l3.2岁，心功能分级为2.3±0.5级。病因方面，黏液瘤样病变162例（79%），风湿性28例（14%），心内膜炎8例（4%），先天性3例（2%），缺血性3例（2%）。术前平均射血分数（EF）为60%±10%，184例（90%）患者的射血分数大于50%。通过5至8厘米的右胸骨旁切口（n = 180，88%）或右乳房下切口（n = 24，12%）显露瓣膜。119例（58%）患者采用开放股动脉 - 股静脉插管，85例（42%）患者采用主动脉直接插管和股静脉经皮插管。170例（83%）患者瓣膜修复成功，34例（17%）患者需要瓣膜置换。主动脉阻断和心肺转流的平均持续时间分别为100±34分钟和146±44分钟。有2例（1%）手术死亡。非致命性围手术期并发症包括3例（1.5%）升主动脉并发症、3例（1.5%）因出血再次手术、4例（2%）中风、2例（1%）短暂性脑缺血发作（TIA）、2例（1%）心肌梗死、3例（1.5%）需要引流的心包积液、9例（4.5%）血管并发症以及3例（1.5%）伤口并发症。平均住院时间（LOS）为6.1±3天，63例（31%）患者在5天内出院。129例（63%）患者无需输血。165例（81%）患者完成随访，平均随访时间为13.2±8个月。晚期并发症包括1例（0.5%）心肌梗死、3例（1.5%）再次手术（均为将修复术转为置换术）、3例（1.5%）需要再次手术并用补片修复的伤口疝、5例（2.5%）血栓栓塞事件以及3例（1.5%）分别因自杀、肺炎和猝死导致的死亡。平均随访时纽约心脏协会（NYHA）心功能分级为1.2±0.5级。我们得出结论，微创直接入路二尖瓣手术安全、有效，适用于大多数单纯二尖瓣手术患者。我们现在将其视为特定患者的治疗标准。
