Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Aalst, Belgium.
Eur J Cardiothorac Surg. 2018 Aug 1;54(2):288-293. doi: 10.1093/ejcts/ezy027.
This study reports the factors that contribute to sternotomy conversions (SCs) and adverse intraoperative events in minimally invasive aortic valve surgery (MI-AVS) and minimally invasive Endoscopic Port Access™ atrioventricular valve surgery (MI-PAS).
In total, 3780 consecutive patients with either aortic valve disease or atrioventricular valve disease underwent minimally invasive valve surgery (MIVS) at our institution between 1 February 1997 and 31 March 2016. MI-AVS was performed in 908 patients (mean age 69.2 ± 11.3 years, 45.2% women, 6.2% redo cardiac surgery) and MI-PAS in 2872 patients (mean age 64.1 ± 13.3 years, 46.7% women, 12.2% redo cardiac surgery).
A cumulative total of 4415 MIVS procedures (MI-AVS = 908, MI-PAS = 3507) included 1537 valve replacements (MI-AVS = 896, MI-PAS = 641) and 2878 isolated or combined valve repairs (MI-AVS = 12, MI-PAS = 2866). SC was required in 3.0% (n = 114 of 3780) of MIVS patients, which occurred in 3.1% (n = 28 of 908) of MI-AVS patients and 3.0% (n = 86 of 2872) of MI-PAS patients, respectively. Reasons for SC in MI-AVS included inadequate visualization (n = 4, 0.4%) and arterial cannulation difficulty (n = 7, 0.8%). For MI-PAS, SC was required in 54 (2.5%) isolated mitral valve procedures (n = 2183). Factors that contributed to SC in MI-PAS included lung adhesions (n = 35, 1.2%), inadequate visualization (n = 2, 0.1%), ventricular bleeding (n = 3, 0.1%) and atrioventricular dehiscence (n = 5, 0.2%). Neurological deficit occurred in 1 (0.1%) and 3 (3.5%) MI-AVS and MI-PAS conversions, respectively. No operative or 30-day mortalities were observed in MI-AVS conversions (n = 28). The 30-day mortality associated with SC in MI-PAS (n = 86) was 10.5% (n = 9).
MIVS is increasingly being recognized as the 'gold-standard' for surgical valve interventions in the context of rapidly expanding catheter-based technology and increasing patient expectations. Surgeons need to be aware of factors that contribute to SC and adverse intraoperative outcomes to ensure that patients enjoy the maximum potential benefit of MIVS and to apply effective risk reduction strategies that encourage safer and sustainable MIVS programmes.
本研究报告了微创主动脉瓣手术（MI-AVS）和微创经胸小切口经食管房室瓣手术（MI-PAS）中导致胸骨切开术（SC）和术中不良事件的因素。
1997 年 2 月 1 日至 2016 年 3 月 31 日期间，共有 3780 例连续的主动脉瓣或房室瓣疾病患者在我院接受微创瓣膜手术（MIVS）。908 例患者接受 MI-AVS（平均年龄 69.2±11.3 岁，45.2%女性，6.2%再次心脏手术），2872 例患者接受 MI-PAS（平均年龄 64.1±13.3 岁，46.7%女性，12.2%再次心脏手术）。
共进行了 4415 例 MIVS 手术（MI-AVS=908，MI-PAS=3507），其中 1537 例为瓣膜置换术（MI-AVS=896，MI-PAS=641），2878 例为单纯或联合瓣膜修复术（MI-AVS=12，MI-PAS=2866）。3.0%（n=3780）的 MIVS 患者需要进行 SC，其中 MI-AVS 患者为 3.1%（n=28 of 908），MI-PAS 患者为 3.0%（n=86 of 2872）。MI-AVS 中 SC 的原因包括可视化不足（n=4，0.4%）和动脉插管困难（n=7，0.8%）。对于 MI-PAS，54 例（2.5%）单纯二尖瓣手术需要 SC（n=2183）。MI-PAS 中 SC 的原因包括肺粘连（n=35，1.2%）、可视化不足（n=2，0.1%）、心室出血（n=3，0.1%）和房室瓣分离（n=5，0.2%）。MI-AVS 和 MI-PAS 分别有 1 例（0.1%）和 3 例（3.5%）发生神经功能缺损。MI-AVS 中转 SC （n=28）无手术或 30 天死亡病例。MI-PAS 中转 SC（n=86）30 天死亡率为 10.5%（n=9）。
微创瓣膜手术日益被认为是在导管技术迅速发展和患者期望不断提高的背景下进行瓣膜介入治疗的“金标准”。外科医生需要了解导致 SC 和术中不良结果的因素，以确保患者能够从 MIVS 中获得最大的潜在益处，并应用有效的风险降低策略，以鼓励更安全和可持续的 MIVS 项目。
