Department of Cardiothoracic Surgery, New York University Medical Center, New York, New York 10016, USA.
Ann Thorac Surg. 2010 Mar;89(3):723-9; discussion 729-30. doi: 10.1016/j.athoracsur.2009.11.061.
A recent report suggested that a thoracotomy approach for reoperative mitral valve (MV) procedures was associated with an equivalent mortality and an unacceptable risk of stroke. We assessed these outcomes in a single institution's experience.
From 1992 through 2007, 905 patients underwent reoperative MV procedures. The approach was a median sternotomy in 612 (67.6%), right anterior thoracotomy in 242 (26.7%), and left posterior thoracotomy in 51 (5.6%). Concomitant procedures in 411 patients (67.6%) included aortic procedures in 189, tricuspid procedures in 170, and coronary artery bypass grafting in 90. Hypothermic fibrillation was used in 65 patients. Logistic analysis was used to analyze risk factors and outcomes.
Overall mortality was 12.7% (115 of 905), 6.7% (25 of 371) for first time isolated MV reoperations, and 10.1% (50 of 494) for all isolated MV operations. Overall incidence of stroke was 3.8% (34 of 905); 10.9% (9 of 82) with retrograde arterial perfusion and 3.0% (25 of 824) with central aortic cannulation (p < 0.001). For isolated MV reoperations, the incidence of stroke was 4.3% (21 of 494): 2.9% (7 of 241) for antegrade perfusion and 5.5% (14 of 253) for retrograde perfusion (p = 0.15). Risk factors for death were age (p < 0.001), renal failure (p < 0.01), tricuspid valve disease (p < 0.001), chronic obstructive pulmonary disease (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8 to 4.9; p < 0.001), emergency procedure (OR, 2.9; 95% CI, 1.2 to 6.9; p = 0.02), and ejection fraction less than 0.30 (OR, 1.9; 95% CI, 1.1 to 3.3, p = 0.018). Risk factors for stroke were retrograde perfusion (OR, 4.4; 95% CI, 1.8 to 10.3; p < 0.01) and ejection fraction below 0.30 (OR, 2.1; 95% CI, 0.9 to 5.0; p = 0.09).
The incidence of stroke in reoperative MV operations is associated with perfusion strategies, not with the incisional approach. Reoperative sternotomy and minithoracotomy with central cannulation are both useful for reoperative MV procedures and are associated with low stroke rates.
最近的一份报告表明，开胸手术入路治疗二尖瓣（MV）再次手术与相当的死亡率和不可接受的中风风险相关。我们评估了一家机构的这些结果。
1992 年至 2007 年间，905 例患者接受了二尖瓣再次手术。手术入路为 612 例（67.6%）经正中胸骨切开术，242 例（26.7%）经右前胸切开术，51 例（5.6%）经左后胸切开术。411 例（67.6%）同时进行了其他手术，其中 189 例主动脉手术、170 例三尖瓣手术和 90 例冠状动脉旁路移植术。65 例患者采用低温纤维颤法。采用逻辑分析分析危险因素和结果。
总死亡率为 12.7%（905 例中的 115 例），首次孤立性 MV 再次手术的死亡率为 6.7%（371 例中的 25 例），所有孤立性 MV 手术的死亡率为 10.1%（494 例中的 50 例）。总中风发生率为 3.8%（905 例中的 34 例）；逆行动脉灌注的发生率为 10.9%（82 例中的 9 例），主动脉中央插管的发生率为 3.0%（824 例中的 25 例）（p<0.001）。对于孤立性 MV 再次手术，中风的发生率为 4.3%（494 例中的 21 例）：顺行灌注的发生率为 2.9%（241 例中的 7 例），逆行灌注的发生率为 5.5%（253 例中的 14 例）（p=0.15）。死亡的危险因素是年龄（p<0.001）、肾衰竭（p<0.01）、三尖瓣疾病（p<0.001）、慢性阻塞性肺疾病（比值比[OR]，2.9；95%置信区间[CI]，1.8 至 4.9；p<0.001）、急诊手术（OR，2.9；95%CI，1.2 至 6.9；p=0.02）和射血分数小于 0.30（OR，1.9；95%CI，1.1 至 3.3，p=0.018）。中风的危险因素是逆行灌注（OR，4.4；95%CI，1.8 至 10.3；p<0.01）和射血分数低于 0.30（OR，2.1；95%CI，0.9 至 5.0；p=0.09）。
二尖瓣再次手术中风的发生率与灌注策略有关，而与切口入路无关。再次开胸和经胸骨正中切开术联合中心插管对二尖瓣再次手术均有效，且中风发生率较低。
