Ribeiro Igo B, Ruel Marc
1 Division of Cardiac Surgery, University of Ottawa Heart Institute, Canada.
Innovations (Phila). 2019 Aug;14(4):321-329. doi: 10.1177/1556984519844745. Epub 2019 May 14.
A stepwise approach for right anterior minithoracotomy aortic valve replacement (RAT-AVR), without sutureless valves, special instruments, or preoperative imaging, was developed. We report our experience with this widely applicable, simplified approach.
Patients with a history of previous chest surgery, documented PVD, severe COPD, LVOT size <2.0 cm, and root size <2.8 cm were excluded. Chest CT was not mandatory. The stepwise surgical approach consists of 1) tolerability of single-lung ventilation; 2) 5-cm long incision on third right anterior ICS; 3) small pericardial opening to localize the aortic valve annular plane by digital palpation; 4) shingling of the correct rib to create a box field; 5) optimizing exposure with stay sutures; 6) femoral or central cannulation with right superior pulmonary vein venting and usual antegrade cardioplegia; 7) performing a standard AVR without adjunct instruments; and 8) reconstructing 1 costochondral cartilage.
Fifty-five patients were operated. The mean age was 68.5 years (SD 10.4); 29.1% were female. Median STS PROM was 1.18 (0.4 to 6.6). Pump and cross-clamp times were 104.8 minutes (SD 27.9) and 73.2 minutes (SD 22.8), respectively. There was no need for a knot pusher. There was 1 conversion, 1 reopening for bleeding, and 1 pacemaker insertion. No patient had a stroke, MI, or death at 30 days. The median LOS was 6 days (3 to 19).
RAT-AVR can be applicable and performed safely in a wide range of patients by adopting a simple, stepwise approach with intraoperative assessment, without the need for special imaging, instrumentation, or advanced training.
开发一种用于右前外侧小切口主动脉瓣置换术（RAT-AVR）的分步方法，该方法无需使用无缝合瓣膜、特殊器械或术前影像学检查。我们报告了我们在这种广泛适用的简化方法方面的经验。
排除有既往胸部手术史、记录在案的周围血管疾病、严重慢性阻塞性肺疾病、左心室流出道直径<2.0 cm和根部直径<2.8 cm的患者。胸部CT不是必需的。分步手术方法包括：1）单肺通气的耐受性；2）在右前第三肋间做5厘米长的切口；3）做小的心包切口，通过手指触诊确定主动脉瓣环平面；4）将正确的肋骨重叠以形成一个盒状区域；5）用牵引缝线优化暴露；6）经股动脉或中心插管，同时经右上肺静脉排气并采用常规顺行性心脏停搏液；7）不使用辅助器械进行标准的主动脉瓣置换术；8）重建一块肋软骨。
55例患者接受了手术。平均年龄为68.5岁（标准差10.4）；29.1%为女性。STS PROM中位数为1.18（0.4至6.6）。体外循环时间和主动脉阻断时间分别为104.8分钟（标准差27.9）和73.2分钟（标准差22.8）。无需使用打结推送器。有1例中转手术、1例因出血再次开胸和1例植入起搏器。30天时无患者发生中风、心肌梗死或死亡。住院时间中位数为6天（3至19天）。
通过采用简单的分步方法并进行术中评估，RAT-AVR可在广泛的患者中安全应用，无需特殊影像学检查、器械或高级培训。
