Shrestha Malakh, Krueger Heike, Umminger Julia, Koigeldiyev Nurbol, Beckmann Erik, Haverich Axel, Martens Andreas
Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Ann Cardiothorac Surg. 2015 Mar;4(2):148-53. doi: 10.3978/j.issn.2225-319X.2014.08.04.
Even though minimally invasive cardiac surgery may reduce morbidity, this approach is not routinely performed for aortic root replacements. The purpose of this pilot study was to assess the safety and feasibility of valve sparing aortic root replacement via an upper mini-sternotomy up to the 3(rd) intercostal space.
Between April 2011 and March 2014, 26 patients (22 males, age 47.6±13 years) underwent elective minimally invasive aortic valve sparing root replacement (David procedure, group A). Twelve patients underwent additional leaflet repair. Concomitant procedures were: four proximal aortic arch replacements and one coronary artery bypass grafting (CABG) to the proximal right coronary artery (RCA). During the same time period, 14 patients (ten males, age 64.2±9.5 years) underwent elective David procedure via median full sternotomy (group B). Concomitant procedures included six proximal aortic arch replacements. Although the patient cohorts were small, the results of these two groups were compared.
In group A, there were no intra-operative conversions to full sternotomy. The aortic cross-clamp and cardiopulmonary bypass (CPB) times were 115.6±30.3 and 175.8±41.9 min, respectively. One patient was re-opened (via same access) due to post-operative bleeding. The post-operative ventilation time and hospital stay were 0.5±0.3 and 10.4±6.8 days, respectively. There was no 30-day mortality. The patient questionnaire showed that the convalescence time was approximately two weeks. In group B: the cross-clamp and CPB times were 114.1±19.9 and 163.0±24.5 min, respectively. One patient was re-opened (7.1%) due to post-operative bleeding. The post-operative ventilation time and hospital stay were 0.6±0.7 and 14.2±16.7 days, respectively. There was no 30-day mortality.
Minimally invasive valve sparing aortic root replacement can be safely performed in selected patients. The results are comparable to those operated via a full sternotomy. The key to success is a 'step by step' technique of moving from minimally invasive aortic valve replacements (AVR) to more demanding aortic root replacements. Meticulous hemostasis & attention to surgical details is of utmost importance to prevent perioperative complications.
尽管微创心脏手术可能降低发病率，但这种方法在主动脉根部置换术中并未常规应用。本前瞻性研究的目的是评估经第3肋间上半胸骨切开术进行保留瓣膜的主动脉根部置换术的安全性和可行性。
2011年4月至2014年3月期间，26例患者（22例男性，年龄47.6±13岁）接受了择期微创保留主动脉瓣根部置换术（David手术，A组）。12例患者接受了额外的瓣叶修复。同期手术包括：4例近端主动脉弓置换术和1例右冠状动脉近端冠状动脉搭桥术（CABG）。同一时期，14例患者（10例男性，年龄64.2±9.5岁）通过正中全胸骨切开术接受了择期David手术（B组）。同期手术包括6例近端主动脉弓置换术。尽管患者队列较小，但对这两组的结果进行了比较。
A组中，无术中转为全胸骨切开术的情况。主动脉阻断和体外循环（CPB）时间分别为115.6±30.3分钟和175.8±41.9分钟。1例患者因术后出血再次手术（通过相同入路）。术后通气时间和住院时间分别为0.5±0.3天和10.4±6.8天。无30天死亡率。患者问卷调查显示康复时间约为两周。B组中：主动脉阻断和CPB时间分别为114.1±19.9分钟和163.0±24.5分钟。1例患者因术后出血再次手术（7.1%）。术后通气时间和住院时间分别为0.6±0.7天和14.2±16.7天。无30天死亡率。
在选定的患者中，微创保留瓣膜的主动脉根部置换术可以安全进行。结果与通过全胸骨切开术手术的结果相当。成功的关键是从微创主动脉瓣置换术（AVR）逐步过渡到要求更高的主动脉根部置换术的“循序渐进”技术。细致的止血和对手术细节的关注对于预防围手术期并发症至关重要。
