Thompson M J, Behranwala A, Campanella C, Walker W S, Cameron E W J
Department of Cardiothoracic Surgery, Royal Infirmary NHS Trust, 1 Lauriston Place, Edinburgh EH3 9YW, UK.
Eur J Cardiothorac Surg. 2003 Jul;24(1):47-51; discussion 51. doi: 10.1016/s1010-7940(03)00188-x.
Repeat median sternotomy is a potentially dangerous technique providing variable but mainly poor access to the mitral valve. Right thoracotomy is an alternative route previously used to access the mitral valve in the early years of cardiac surgery that offers the advantage of a fresh surgical field in the context of redo surgery. We have reviewed our experience with mitral prosthetic replacement undertaken via a right thoracotomy in order to determine the immediate and long-term results obtained with this approach.
The operation was carried out on a beating heart using normothermic bypass without cross-clamping the aorta. Arterial inflow was achieved via the femoral artery or ascending aorta and venous drainage with bi-caval cannulae. Pre-, intra- and postoperative data were documented from case note review. Long-term follow-up was established from the UK Heart Valve Registry, referring Cardiologist, direct patient contact and the Scottish Registry for births and deaths. Statistical analysis was undertaken using a desktop computer package.
One hundred and twenty-five patients (mean age 63 years) underwent mitral prosthetic replacement by this technique. One hundred and eleven patients (86%) were in NYHA grades III or IV preoperatively. Twenty-two patients (16.6%) had also undergone previous CABG. Thirty-five patients (28%) had undergone two or more sternotomies. Mean bypass time was 83.6 min (SD 43.1). Postoperatively, mean duration of ventilation was 44 h; mean ITU stay was 4 days (SD 5.3) and mean inpatient total stay was 12 days. Thirty-six patients (28.8%) required inotropic support postoperatively. Complication rates were low: pleuro-pulmonary, 30 patients (24%), re-operation for bleeding, four patients (3.2%) and CVA, two patients (1.6%). Eight patients (6.4%) died within 30 days. Ten-year survival figures (Kaplan-Meier) were: 47% for all causes of mortality and 82.9% when only valve related causes of death were considered. Most of the patients (97.5%) had not required re-operation at 10 years.
Mitral prosthetic replacement via a right thoracotomy on beating heart under normothermic bypass offers a safe alternative to redo median sternotomy in this high-risk group. Operative access is facilitated and procedural time reduced. Complication rates are low and perioperative mortality is lower than that generally reported with conventional surgery.
再次正中开胸是一种潜在危险的技术，对二尖瓣的显露效果不一，但总体较差。右胸切口是心脏外科早期用于显露二尖瓣的一种替代途径，在再次手术中具有提供新鲜手术视野的优势。我们回顾了经右胸切口进行二尖瓣人工瓣膜置换的经验，以确定该方法的近期和远期效果。
手术在心脏跳动下进行，采用常温体外循环，不阻断主动脉。通过股动脉或升主动脉实现动脉灌注，使用双腔静脉插管进行静脉引流。通过病例记录回顾记录术前、术中和术后数据。通过英国心脏瓣膜注册中心、转诊心脏病专家、直接与患者联系以及苏格兰出生和死亡注册中心进行长期随访。使用桌面计算机软件包进行统计分析。
125例患者（平均年龄63岁）通过该技术进行了二尖瓣人工瓣膜置换。111例患者（86%）术前处于纽约心脏协会（NYHA）III或IV级。22例患者（16.6%）此前还接受过冠状动脉旁路移植术（CABG）。35例患者（28%）接受过两次或更多次开胸手术。平均体外循环时间为83.6分钟（标准差43.1）。术后，平均通气时间为44小时；平均重症监护病房（ITU）停留时间为4天（标准差5.3），平均住院总停留时间为12天。36例患者（28.8%）术后需要使用血管活性药物支持。并发症发生率较低：胸膜肺部并发症，30例患者（24%）；因出血再次手术，4例患者（3.2%）；脑血管意外（CVA），2例患者（1.6%）。8例患者（6.4%）在30天内死亡。10年生存率（Kaplan-Meier法）为：全因死亡率47%，仅考虑瓣膜相关死亡原因时为82.9%。大多数患者（97.5%）在10年内无需再次手术。
在常温体外循环下经右胸切口对跳动心脏进行二尖瓣人工瓣膜置换，为该高危组患者再次正中开胸提供了一种安全的替代方法。便于手术显露，减少手术时间。并发症发生率低，围手术期死亡率低于传统手术通常报道的水平。
