Byrne J G, Adams D H, Couper G S, Rizzo R J, Cohn L H, Aranki S F
Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, MA 02115, USA.
Heart Surg Forum. 1999;2(4):326-9.
We retrospectively analyzed our early results with minimally invasive aortic root replacement.
Between August 1996 and April 1999, our center performed 137 aortic root replacements. Thirty-seven (27%) were accomplished through a 5 to 8 cm minimally invasive upper hemi-sternotomy incision. All minimally invasive operations were elective. The mean age for this cohort was 46 +/- 12 yrs. Thirty one (84%) of the patients were male and 3 (8%) were reoperations. The average preoperative NYHA classification was 2.4 +/- 0.6 and ejection fraction (EF) was 58% +/- 12%. Valve pathology was congenitally bicuspid in 19 (51%), endocarditis (SBE ) in 5 (14%), calcific degeneration in 4 (11%), annuloaortic ectasia in 3 (8%), rheumatic in 2 (5%) and other etiologies in 4 (11%). Nine patients (24%) had associated ascending aortic or arch aneurysms.
The surgical techniques performed through mini-hemisternotomy consisted of 1) full root replacement in 31 (84%), 2) subcoronary replacement in 4 (11%), and 3) hemiroot in 2 (5%). Valve implants consisted of a homograft in 30 (81%), "Freestyle" bioprosthesis in 4 (11%) and a St Jude valved conduit in 3 (8%). Mean cardiopulmonary bypass duration was 193 +/- 47 min. and aortic cross-clamp duration was 157 +/- 40 min. Myocardial protection included systemic hypothermia in all (24 +/- 4 degrees C), antegrade cardioplegia (CP) in 35 (95%) with supplemental retrograde CP in 23 (62%). Three patients (8%) experienced postoperative low cardiac output syndrome (LCO). There was one operative death (3%). There was one (3%) reoperation for bleeding and 13 patients (35%) required blood transfusions. New onset atrial fibrillation occurred in 7 patients (19%) and there were 3 (8%) minor complications. Hospital length of stay (LOS) was 6.7 +/- 4.3 days and LOS was less than 7 days in 29 patients (78%).
Minimally invasive aortic root replacement is feasible for a broad range of aortic valve pathology, can incorporate full root, hemiroot and subcoronary techniques, can be used for homografts and "Freestyle" valves as well as valved conduits, and can be accomplished with acceptable morbidity and mortality. However, the operation takes longer through the smaller incision and therefore requires more careful attention to myocardial protection.
我们回顾性分析了微创主动脉根部置换术的早期结果。
1996年8月至1999年4月间，我们中心进行了137例主动脉根部置换术。其中37例（27%）通过5至8厘米的微创上半胸骨切开术切口完成。所有微创手术均为择期手术。该队列患者的平均年龄为46±12岁。31例（84%）患者为男性，3例（8%）为再次手术。术前纽约心脏协会（NYHA）分级平均为2.4±0.6，射血分数（EF）为58%±12%。瓣膜病变中，先天性二叶瓣19例（51%），感染性心内膜炎（SBE）5例（14%），钙化性退变4例（11%），主动脉瓣环扩张3例（8%），风湿性2例（5%），其他病因4例（11%）。9例（24%）患者合并升主动脉或主动脉弓动脉瘤。
通过微创半胸骨切开术实施的手术技术包括：1）全根部置换31例（84%），2）冠状动脉下置换4例（11%），3）半根部置换2例（5%）。瓣膜植入物包括同种异体移植物30例（81%），“Freestyle”生物假体4例（11%），以及带瓣管道3例（8%）。平均体外循环时间为193±47分钟，主动脉阻断时间为157±40分钟。心肌保护措施包括全部患者采用全身低温（24±4℃），35例（95%）患者采用顺行心脏停搏液（CP），其中23例（62%）补充逆行CP。3例（8%）患者术后发生低心排综合征（LCO）。有1例手术死亡（3%）。有1例（3%）因出血再次手术，13例（35%）患者需要输血。7例（19%）患者出现新发房颤，3例（8%）出现轻微并发症。住院时间（LOS）为6.7±4.3天，29例（78%）患者住院时间少于7天。
微创主动脉根部置换术对于多种主动脉瓣病变是可行的，可采用全根部、半根部和冠状动脉下技术，可用于同种异体移植物、“Freestyle”瓣膜以及带瓣管道，且发病率和死亡率可接受。然而，通过较小切口进行手术耗时更长，因此需要更仔细地关注心肌保护。
