Sharony Ram, Grossi Eugene A, Saunders Paul C, Schwartz Charles F, Ursomanno Patricia, Ribakove Greg H, Galloway Aubrey C, Colvin Steven B
Department of Cardiothoracic Surgery, New York University School of Medicine, New York, NY, USA.
J Card Surg. 2006 May-Jun;21(3):240-4. doi: 10.1111/j.1540-8191.2006.00271.x.
Minimally invasive, nonsternotomy approaches for valve procedures may reduce the risks associated with cardiac surgery after prior sternotomy and may improve outcomes. We analyzed our institutional experience to test this hypothesis.
Between 1995 and 2002, 498 patients with previous cardiac operations via sternotomy underwent isolated valve surgery: 337 via median sternotomy (aortic = 160; mitral = 177) and 161 via mini-thoracotomy (aortic = 61; mitral = 100). Data were collected prospectively using the New York State Cardiac Surgery Report Form.
Preoperative incidences of congestive heart failure, renal disease, and nonelective procedures were higher in the sternotomy group. Hospital mortality was significantly lower with the minimally invasive approach, 5.6% (9/161) versus 11.3% (38/337) (univariate, p = 0.04). However, multivariate analysis (odds ratio: 95% confidence intervals, p value) revealed that chronic obstructive pulmonary disease (6.6: 1.4 to 3.1, p = 0.001), renal disease (4.1: 1.52 to 11.2, p = 0.01), cerebrovascular disease (2.2: 1.03 to 4.78, p = 0.04), and ejection faction <30% (1.5: 0.96 to 5.5, p = 0.06) were associated with increased mortality. While mean bypass time, cross-clamp times, and stroke rates were comparable between groups, patients undergoing minimally invasive valve surgery had no deep wound infections (0% vs 2.4%, p = 0.05), less need for blood products (p = 0.02), and shorter hospital stays (p = 0.009). Five-year survival was higher with minimally invasive techniques as compared to a sternotomy approach (92.4 +/- 2% and 86.0 +/- 2%, respectively, p = 0.08).
Reoperative valve surgery can be safely performed using a nonsternotomy, minimally invasive approach, with at least equal mortality, less hospital morbidity, decreased hospital length of stay, and slightly favorable mid-term survival as compared to sternotomy.
瓣膜手术采用微创、非胸骨切开术式可能会降低既往胸骨切开术后心脏手术相关风险，并可能改善预后。我们分析了我们机构的经验以验证这一假设。
1995年至2002年间，498例既往通过胸骨切开术进行过心脏手术的患者接受了单纯瓣膜手术：337例通过正中胸骨切开术（主动脉瓣手术 = 160例；二尖瓣手术 = 177例），161例通过小切口开胸术（主动脉瓣手术 = 61例；二尖瓣手术 = 100例）。使用纽约州心脏手术报告表前瞻性收集数据。
胸骨切开术组充血性心力衰竭、肾病和非择期手术的术前发生率较高。微创方法的医院死亡率显著较低，分别为5.6%（9/161）和11.3%（38/337）（单因素分析，p = 0.04）。然而，多因素分析（比值比：95%置信区间，p值）显示，慢性阻塞性肺疾病（6.6：1.4至3.1，p = 0.001）、肾病（4.1：1.52至11.2，p = 0.01）、脑血管疾病（2.2：1.03至4.78，p = 0.04）和射血分数<30%（1.5：0.96至5.5，p = 0.06）与死亡率增加相关。虽然两组间平均体外循环时间、主动脉阻断时间和卒中发生率相当，但接受微创瓣膜手术的患者无深部伤口感染（0%对2.4%，p = 0.05），对血制品需求较少（p = 0.02），住院时间较短（p = 0.009）。与胸骨切开术式相比，微创技术的五年生存率更高（分别为92.4±2%和86.0±2%，p = 0.08）。
再次瓣膜手术可通过非胸骨切开的微创方法安全进行，与胸骨切开术相比，死亡率至少相当，医院发病率更低，住院时间缩短，中期生存率略优。
