右前小切口开胸术与正中胸骨切开术治疗原发性二尖瓣感染性心内膜炎的对比

Right anterior minithoracotomy versus median sternotomy surgery for native mitral valve infective endocarditis.

作者信息

Mihos Christos G, Santana Orlando, Pineda Andres M, Lamas Gervasio A, Lamelas Joseph

出版信息

J Heart Valve Dis. 2014 May;23(3):343-9.

Abstract

BACKGROUND AND AIM OF THE STUDY

While concomitant medical and surgical therapy has improved the treatment of infective endocarditis (IE), mortality and postoperative complications remain high. A minimally invasive approach to mitral valve surgery has been associated with decreased morbidity and mortality in high-risk populations. The study aim was to analyze the feasibility of a minimally invasive approach to valve surgery for native mitral valve IE.

METHODS

All heart operations performed between January 2008 and April 2013 at the authors' institution were reviewed retrospectively. The operative times, intensive care unit (ICU) and hospital lengths of stay, postoperative complications, and in-hospital mortality of patients who underwent minimally invasive surgery via a right anterior minithoracotomy for native mitral valve IE were compared to those of a cohort which underwent median sternotomy. A Kaplan-Meier analysis was performed to compare long-term survival between the cohorts.

RESULTS

A total of 50 patients was identified (22 minithoracotomy, 28 median sternotomy). The baseline characteristics, mitral valve pathology and disease burden (annular abscess, cusp perforation, vegetation size, chordal rupture) were similar between the groups. There was no difference in the rate of active versus healed disease. Patients who underwent a minithoracotomy had fewer postoperative composite complications (41% versus 75%, p = 0.02), mainly driven by a decreased incidence of sepsis (0% versus 21%, p = 0.02), as well as less use of intraoperative blood products (59% versus 93%, p = 0.004), higher rates of mitral valve repair (55% versus 25%, p = 0.03), and a shorter ICU length of stay (56 versus 114 h, p = 0.009). Repair of the mitral valve was associated with a decreased risk of postoperative composite complications (OR 0.16, 95% CI 0.04-0.71, p = 0.02). At 2.5 years postoperatively, survival was estimated at 80% and 68% in the minithoracotomy and median sternotomy groups, respectively (p = 0.33).

CONCLUSION

A right anterior minithoracotomy approach for native mitral valve IE provides a safe and feasible alternative to conventional median sternotomy surgery, with improved outcomes conferred by valve repair compared to replacement.

摘要

研究背景与目的

虽然药物与手术联合治疗已改善了感染性心内膜炎（IE）的治疗效果，但死亡率和术后并发症仍然很高。二尖瓣手术的微创方法已使高危人群的发病率和死亡率有所降低。本研究的目的是分析针对原发性二尖瓣IE进行瓣膜手术的微创方法的可行性。

方法

回顾性分析2008年1月至2013年4月在作者所在机构进行的所有心脏手术。将经右前小切口进行原发性二尖瓣IE微创手术患者的手术时间、重症监护病房（ICU）住院时间、住院时间、术后并发症及院内死亡率，与接受正中胸骨切开术的队列患者进行比较。采用Kaplan-Meier分析比较两组队列的长期生存率。

结果

共纳入50例患者（22例行小切口手术，28例行正中胸骨切开术）。两组间的基线特征、二尖瓣病变及疾病负担（瓣周脓肿、瓣叶穿孔、赘生物大小、腱索断裂）相似。活动性疾病与愈合性疾病的发生率无差异。接受小切口手术的患者术后综合并发症较少（41%对75%，p = 0.02），主要原因是脓毒症发生率降低（0%对21%，p = 0.02），术中血制品使用较少（59%对93%，p = 0.004），二尖瓣修复率较高（55%对25%，p = 0.03），以及ICU住院时间较短（56小时对114小时，p = 0.009）。二尖瓣修复与术后综合并发症风险降低相关（OR 0.16，95%CI 0.04 - 0.71，p = 0.02）。术后2.5年，小切口手术组和正中胸骨切开术组的生存率分别估计为80%和68%（p = 0.33）。