经右前小切口主动脉瓣置换术与标准胸骨切开术的比较：492例患者的倾向评分分析
A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients.
作者信息
Bowdish Michael E, Hui Dawn S, Cleveland John D, Mack Wendy J, Sinha Raina, Ranjan Rupesh, Cohen Robbin G, Baker Craig J, Cunningham Mark J, Barr Mark L, Starnes Vaughn A
机构信息
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
出版信息
Eur J Cardiothorac Surg. 2016 Feb;49(2):456-63. doi: 10.1093/ejcts/ezv038. Epub 2015 Mar 6.
OBJECTIVES
Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy.
METHODS
Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed.
RESULTS
Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups.
CONCLUSION
Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.
目的
右前小切口开胸并进行中心动脉插管是我们进行微创主动脉瓣置换术（AVR）的首选技术。我们将采用该技术的围手术期结果与经胸骨切开术的结果进行了比较。
方法
1999年3月至2013年12月期间，我院492例患者接受了单纯AVR手术，其中经胸骨切开术（SAVR，n = 198）或微创右前开胸术（MIAVR，n = 294）。对两组进行单因素比较以评估总体结果和不良事件。为控制治疗选择偏倚，根据患者核心特征构建倾向评分。然后对结果和不良事件进行倾向评分分层分析。
结果
SAVR组和MIAVR组的总体死亡率分别为2.5%和1.0%。MIAVR组的住院时间和重症监护病房（ICU）停留时间更短，术中血液制品使用量更少，伤口感染更少。在包括中风在内的其他不良事件方面没有差异。MIAVR组存活且无不良事件的复合终点明显更常见（83%对74%，P = 0.002）。在调整倾向评分后，MIAVR组的住院时间和ICU停留时间仍然更短，术中血液制品使用量仍然更少。两组之间的死亡率、中风或其他不良事件没有差异。
结论
通过右前开胸并主要采用中心插管进行的微创AVR手术，其发病率和死亡率与胸骨切开术相似。与胸骨切开术相比，这种微创方法在减少术中血液制品使用量、降低伤口感染率和缩短住院时间方面似乎具有优势。如果将死亡率和不良事件的发生综合考虑，MIAVR可能会带来更好的结果。随着微创AVR变得越来越普遍，需要进一步的长期随访，前瞻性多中心随机试验是必要的。
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