Westhofen Sumi, Conradi Lenard, Deuse Tobias, Detter Christian, Vettorazzi Eik, Treede Hendrik, Reichenspurner Hermann
Department for Cardiovascular Surgery, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
Department for Cardiovascular Surgery, University Heart Center Hamburg-Eppendorf, Hamburg, Germany.
Eur J Cardiothorac Surg. 2016 Dec;50(6):1181-1187. doi: 10.1093/ejcts/ezw184. Epub 2016 Jun 3.
Advances in video-assistance lead to an increase in minimal access mitral valve surgery (MAMVS) with decreased incision size yet maintaining the same quality of surgery. Further reduction in surgical trauma and at the same time improved visual guidance can be achieved by a non-rib-spreading fully 3D endoscopic technique (NRS-3D). We compared patients who underwent MAMVS either through an NRS fully 3D endoscopic or rib-spreading (RS) access in a retrospective matched-pair analysis.
A matched pairs analysis was undertaken of retrospectively collected data of 284 consecutive patients having received an MAMVS between January 2011 and May 2015. Fifty patients with an RS procedure were compared with 50 patients with an NRS fully 3D endoscopic operation. For all patients, access was made through a 3-4 cm incision in the inframammary fold through the fourth intercostal space. In the NRS-3D group, only a soft-tissue protector, and no additional rib-spreader, was used. Operative visualization was provided by 3D endoscopy in the NRS-3D group.
The NRS as well as the RS procedure was successful in all patients without technical repair limitations. Mortality was 0% in both groups. Significant differences were seen for operation times (39.0 min mean shorter operation time in the NRS-3D group; P < 0.001), and length of stay on intensive care unit (1.0 day mean shorter stay in the NRS-3D group; P = 0.002) and in the hospital (1.4 days mean shorter stay in the NRS-3D group; P = 0.003). Postoperative analgesics doses were significantly lower in the NRS-3D group [P = 0.007 (paracetamol); P = 0.123 (metamizole); P = 0.013 (piritramide)]. Postoperative pain rated on a pain-scale from 0 to 10 was significantly lower in the NRS-3D group (mean difference of 1.8; P = 0.006). Patient satisfaction regarding cosmetic results was comparable in both the groups. Repair results, ejection fraction, perioperative morbidity and MACCE during follow-up showed no significant differences between both groups. Early postoperative and follow-up echocardiography showed sufficient repair in all patients of both groups with no case of >mild recurrent mitral regurgitation.
An endoscopic procedure supported by 3D-visualization enables superior depth perception, facilitating an excellent quality of repair results. 3D-visualization is a helpful tool especially for complex reconstruction cases and exact placement of artificial neochordae. With this, an experienced mitral valve surgeon takes shorter operation times. Patients benefit from shorter hospitalization with reduced postoperative pain and early mobilization.
视频辅助技术的进步使得微创二尖瓣手术（MAMVS）有所增加，切口尺寸减小的同时保持了相同的手术质量。通过非撑开肋骨的全三维内镜技术（NRS - 3D）可进一步减少手术创伤，同时改善视觉引导。我们在一项回顾性配对分析中比较了通过NRS全三维内镜或撑开肋骨（RS）入路接受MAMVS的患者。
对2011年1月至2015年5月期间连续接受MAMVS的284例患者的回顾性收集数据进行配对分析。将50例行RS手术的患者与50例行NRS全三维内镜手术的患者进行比较。所有患者均通过乳房下皱襞经第四肋间3 - 4厘米切口入路。在NRS - 3D组中，仅使用了软组织保护器，未使用额外的肋骨撑开器。NRS - 3D组通过三维内镜提供手术视野。
NRS组和RS组的所有患者手术均成功，无技术修复限制。两组死亡率均为0%。在手术时间（NRS - 3D组平均手术时间短39.0分钟；P < 0.001）、重症监护病房住院时间（NRS - 3D组平均住院时间短1.0天；P = 0.002）和医院住院时间（NRS - 3D组平均住院时间短1.4天；P = 0.003）方面存在显著差异。NRS - 3D组术后镇痛药剂量显著更低[对乙酰氨基酚：P = 0.007；安乃近：P = 0.123；哌替啶：P = 0.013]。NRS - 3D组术后0至10分疼痛评分显著更低（平均差异为1.8；P = 0.006）。两组患者对美容效果的满意度相当。修复结果、射血分数、围手术期发病率以及随访期间的主要不良心血管和脑血管事件（MACCE）在两组之间无显著差异。术后早期和随访超声心动图显示两组所有患者修复充分，无中重度以上二尖瓣反流复发病例。
由三维可视化支持的内镜手术能够提供卓越的深度感知，有助于获得优异的修复效果。三维可视化是一个有用的工具，尤其对于复杂重建病例和人工新腱索的精确放置。由此，经验丰富的二尖瓣外科医生手术时间更短。患者受益于住院时间缩短、术后疼痛减轻和早期活动。
