Liu Rui, Rui Lu, Zhang Benqing, Lin Ye, Li Shoujun, Hua Zhongdong
Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 North Lishi Road, Xicheng District, Beijing, 100037, China.
Pediatr Cardiol. 2019 Aug;40(6):1247-1252. doi: 10.1007/s00246-019-02144-w. Epub 2019 Jul 23.
To evaluate the feasibility and efficacy of the right subaxillary vertical mini-incision (RAVI) used for the closure of doubly committed subarterial ventricular septal defect (SAVSD) through tricuspid approach only. From June 2015 to September 2016, 32 SAVSD patients (mean age 2.4 ± 1.9 years, range 0.7-8 years) underwent surgical repair with either RAVI (incision length 3-4 cm) through tricuspid (group A, n = 16) or conventional median sternotomy incision through the main pulmonary artery approach (group B, n = 16). A retrospective 1:1 matched-pair analysis was performed with the group B matched for defect size, body weight, gender, patching, and operation year. The demographic characteristics in both groups were similar. No patient died and only 1 patient in group B needed reoperation for sternal infection. The mean cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 48.6 ± 12.6 min, 29.3 ± 8.5 min in the group A and 57.8 ± 14.1 min (p = 0.03), 34.3 ± 12.1 min ( p = 0.18) in the group B. There was no significant difference between the two groups in the ICU stay (17.8 ± 8.9 h in group A, 18.7 ± 9.5 h in group B, p = 0.79), mechanical ventilation support time (2.7 ± 1.7 h in group A, 3.6 ± 1.5 h in group B, p = 0.11), postoperative hospital stay (6.3 ± 1.5 days in group A, 7.4 ± 1.7 days in group B, p = 0.06), and chest tube drainage (6.4 ± 4.3 ml/kg in group A, 8.5 ± 3.8 ml/kg in group B, p = 0.16). No significant residual defects were found in both groups. The post-operation pressure gradient across the right ventricular outflow tract (RVOT) was significantly different between the two groups with 4.6 ± 1.8 mmHg in group A and 10.0 ± 6.8 mmHg in group B (p = 0.004) even if no significant difference was found between both groups before operation. No arrhythmia was found after operation. All the patients or the parents (100%) in the group A were satisfied with the cosmetic results, while the number in B group was 7 (43.8%) in questionnaire. The RAVI through tricuspid approach to repair doubly committed subarterial ventricular septal defect is a safe and feasible procedure with better hemodynamic performance of RVOT and less CPB time because of keeping pulmonary artery intact comparing to conventional approach. More importantly, the RAVI through tricuspid approach can be performed with favorable cosmetic results.
仅通过三尖瓣入路评估右腋下垂直小切口（RAVI）用于闭合双动脉下室间隔缺损（SAVSD）的可行性和疗效。2015年6月至2016年9月，32例SAVSD患者（平均年龄2.4±1.9岁，范围0.7 - 8岁）接受手术修复，其中16例通过三尖瓣入路采用RAVI（切口长度3 - 4 cm）（A组），16例通过主肺动脉入路采用传统正中胸骨切开术（B组）。对B组进行回顾性1:1配对分析，匹配缺损大小、体重、性别、补片和手术年份。两组的人口统计学特征相似。无患者死亡，B组仅1例患者因胸骨感染需要再次手术。A组体外循环（CPB）时间和主动脉阻断时间分别为48.6±12.6分钟、29.3±8.5分钟，B组分别为57.8±14.1分钟（p = 0.03）、34.3±12.1分钟（p = 0.18）。两组在重症监护病房停留时间（A组17.8±8.9小时，B组18.7±9.5小时，p = 0.79）、机械通气支持时间（A组2.7±1.7小时，B组3.6±1.5小时，p = 0.11）、术后住院时间（A组6.3±1.5天，B组7.4±1.7天，p = 0.06）和胸腔引流（A组6.4±4.3 ml/kg，B组8.5±3.8 ml/kg，p = 0.16）方面无显著差异。两组均未发现明显残余缺损。两组术后右心室流出道（RVOT）的压力阶差有显著差异，A组为4.6±1.8 mmHg，B组为10.0±6.8 mmHg（p = 0.004），尽管术前两组无显著差异。术后未发现心律失常。A组所有患者或家长（100%）对美容效果满意，而问卷调查中B组为7例（43.8%）。与传统入路相比，通过三尖瓣入路的RAVI修复双动脉下室间隔缺损是一种安全可行的手术，RVOT血流动力学性能更好，CPB时间更短，因为肺动脉保持完整。更重要的是，通过三尖瓣入路的RAVI手术可获得良好的美容效果。
