Ito Toshiaki, Maekawa Atsuo, Hoshino Satoshi, Hayashi Yasunari, Sawaki Sadanari, Yanagisawa Junji, Tokoro Masayoshi
Eur J Cardiothorac Surg. 2017 May 1;51(5):913-918. doi: 10.1093/ejcts/ezw430.
Totally endoscopic minimally invasive mitral valve surgery (MIMVS) is technically demanding and often performed with robotic assistance. We hypothesized that three-port video-assisted thoracic surgery (VATS) would facilitate endoscopic MIMVS and evaluated its feasibility and safety.
From October 2010 to June 2016, we performed first-time MIMVS in 250 consecutive patients (122 male), with median age of 65 years (54-73 years, 25-75 percentile). The thoracic access ports comprised one small (3-5 cm) thoracotomy without a rib spreader plus two trocars (one for the endoscope and one for left-handed instruments), thus establishing triangular three-port VATS. Cannulas, an aortic clamp, and a left atrial retractor were inserted through the thoracotomy, and right-handed instruments were inserted through the remaining space. Cardiopulmonary bypass was established through a groin incision.
The etiology of the mitral valve lesion was myxomatous degeneration in 70% of patients, rheumatic disease in 9%, infectious endocarditis in 6%, and other conditions in 15%. Mitral valve repair was performed in 233 patients and replacement in 27. Two patients underwent conversion to replacement after attempted repair. Forty-nine patients underwent tricuspid annuloplasty, and 45 underwent the Maze procedure. One in-hospital death occurred within 30 days. Two patients developed stroke, three underwent re-exploration for bleeding, one developed low output syndrome, and one required new haemodialysis. The aortic clamp, bypass, and total operation times were 119 (94-149), 166 (134-200) and 237 (204-285) min, respectively, median (25-75%). The 5-year survival and reoperation-free rates were 98.3% ± 0.9% and 96.9% ± 1.2%, respectively.
Three-port endoscopic MIMVS appears reproducible and safe.
完全内镜下微创二尖瓣手术（MIMVS）技术要求高，通常在机器人辅助下进行。我们推测三端口电视辅助胸腔镜手术（VATS）将有助于内镜下MIMVS，并评估其可行性和安全性。
2010年10月至2016年6月，我们对250例连续患者（122例男性）首次进行MIMVS，中位年龄65岁（54 - 73岁，第25 - 75百分位数）。胸部切口包括一个不使用肋骨撑开器的小（3 - 5厘米）开胸切口加两个套管针（一个用于内镜，一个用于左手器械），从而建立三角形三端口VATS。套管、主动脉夹和左心房牵开器通过开胸切口插入，右手器械通过剩余空间插入。通过腹股沟切口建立体外循环。
二尖瓣病变的病因在70%的患者中为黏液瘤样变性，9%为风湿性疾病，6%为感染性心内膜炎，15%为其他情况。233例患者进行了二尖瓣修复，27例进行了置换。2例患者在尝试修复后转为置换。49例患者进行了三尖瓣环成形术，45例进行了迷宫手术。1例患者在30天内发生院内死亡。2例患者发生中风，3例因出血进行再次手术探查，1例发生低心排血量综合征，1例需要进行新的血液透析。主动脉夹闭、体外循环和总手术时间分别为119（94 - 149）、166（134 - 200）和237（204 - 285）分钟，中位数（第25 - 75百分位数）。5年生存率和无再次手术率分别为98.3%±0.9%和96.9%±1.2%。
三端口内镜下MIMVS似乎具有可重复性且安全。
