Vanermen H, Wellens F, De Geest R, Degrieck I, Van Praet F
Department of Cardiovascular and Thoracic Surgery, Onze-Lieve-Vrouw Clinic, Aalst, Belgium.
Semin Thorac Cardiovasc Surg. 1999 Jul;11(3):223-34. doi: 10.1016/s1043-0679(99)70063-8.
A right thoracotomy is a well-known alternative for midsternotomy to have access to the left atrium. The Port-Access (Heartport, Inc, Redwood City, CA) approach is an invaluable option to avoid cracking of ribs and cartilage. EndoCPB (Heartport, Inc) and Endo-Aortic Clamp (Heartport, Inc) allows installation of the extracorporeal circulation and cardiac arrest from the groin. Videoassistance and shafted instruments help the surgeon to perform the surgery through a 5 x 2-cm port and fulfill the main goals of minimally invasive cardiac surgery, comfort, cosmesis, and fast rehabilitation. From February 1997 to November 1998, 75 patients (40 men/35 women) had either Port-Access mitral valve repair (n = 41) or replacement (n = 33) for a variety of reasons: myxoid degeneration (n = 45), rheumatic disease (n = 21), chronic endocarditis (n = 4), annular dilatation (n = 2), and sclerotic disease (n = 2). One valve was replaced because of an ingrowing myxoma. There was one closure of a paravalvular leak. The mean age was 59.3 years of age (range, 32 to 83 years). Most patients had normal ejection fractions but different grades of mitral valve insufficiency and were in NYHA class II. One 71-year-old patient died after reoperation on postoperative day 1 for failed repair. Two patients had conversion to sternotomy and conventional ECC for repair of a dissected aorta. One patient died, one patient suffered a minor cerebrovascular deficit. Three patients had prolonged intensive care unit (ICU) stays for respiratory insufficiency, 5 patients underwent revision for bleeding. Mean ICU stay was 2.5 days; and mean hospital stay, 9 days (range, 4 to 36). A significant difference between the first 30 and last 38 patients in terms of length of stay in the ICU and the hospital was noticed. Two late mitral valve replacements for chronic endocarditis after repair occurred. One patient had medical therapy for endocarditis after mitral valve replacement. The debut of Port-Access mitral valve surgery may be nerve-racking; the routine is a smooth and sure surgery with maximum comfort, a very discrete scar, and a fast rehabilitation. There were no paravalvular leakages nor myocardial infarctions. Cerebrovascular accidents owing to thromboembolic phenomena, vascular lower limb or wound complications were not seen. Port-Access mitral valve surgery is a very important investment in the future of cardiac surgery. Some learning curve pitfalls were associated with the process of starting this revolutionary technique.
右胸切开术是一种众所周知的替代正中开胸术以进入左心房的方法。经皮端口入路（Heartport公司，加利福尼亚州红木城）是避免肋骨和软骨断裂的宝贵选择。体外循环（Heartport公司）和主动脉内阻断钳（Heartport公司）可经腹股沟建立体外循环和心脏停搏。视频辅助和杆状器械帮助外科医生通过一个5×2厘米的端口进行手术，实现微创心脏手术的主要目标：舒适、美观和快速康复。1997年2月至1998年11月，75例患者（40例男性/35例女性）因各种原因接受了经皮端口入路二尖瓣修复术（n = 41）或置换术（n = 33）：黏液样变性（n = 45）、风湿性疾病（n = 21）、慢性心内膜炎（n = 4）、瓣环扩张（n = 2）和硬化性疾病（n = 2）。1例因黏液瘤长入而进行瓣膜置换。有1例关闭了瓣周漏。平均年龄为59.3岁（范围32至83岁）。大多数患者射血分数正常，但二尖瓣关闭不全程度不同，心功能分级为纽约心脏病协会（NYHA）Ⅱ级。1例71岁患者术后第1天因修复失败再次手术死亡。2例患者转为正中开胸和传统体外循环以修复主动脉夹层。1例患者死亡，1例患者出现轻度脑血管功能缺损。3例患者因呼吸功能不全在重症监护病房（ICU）住院时间延长，5例患者因出血接受了再次手术。平均ICU住院时间为2.5天；平均住院时间为9天（范围4至36天）。注意到前30例患者和后38例患者在ICU住院时间和住院时间方面存在显著差异。出现2例二尖瓣修复术后因慢性心内膜炎进行晚期二尖瓣置换。1例患者二尖瓣置换术后接受了心内膜炎的药物治疗。经皮端口入路二尖瓣手术的初次尝试可能令人紧张不安；熟练后手术顺利可靠，患者舒适度高，疤痕非常不明显，康复快。未出现瓣周漏和心肌梗死。未见血栓栓塞现象、下肢血管或伤口并发症导致的脑血管意外。经皮端口入路二尖瓣手术是心脏手术未来的一项非常重要的进展。开展这项革命性技术的过程存在一些学习曲线陷阱。
