14929 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.
German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.
Innovations (Phila). 2021 Jul-Aug;16(4):358-364. doi: 10.1177/15569845211004265. Epub 2021 Apr 20.
An accepted landmark to assess feasibility of surgical aortic valve replacement (SAVR) via right anterolateral minithoracotomy (RALT) is the aortic-midpoint to right-sternal-edge distance. We aimed to evaluate single left lung positive-end-expiratory-pressure (SLL-PEEP) ventilation inducing an intraoperative rightward shift of the ascending aorta to improve exposure.
Nineteen patients with aortic stenosis undergoing SAVR via RALT were prospectively analyzed. SLL-PEEP ventilation (20,395 cmHO) via a double-lumen endotracheal tube was applied immediately before transthoracic aortic cross-clamping, thereby inducing rightward shift of the ascending aorta to enhance exposure. We analyzed preoperative computed tomography (CT) reconstructions and intraoperative video recordings. Primary endpoint was extent of rightward shift induced by SLL-PEEP ventilation; secondary endpoints were procedure times and safety events.
Mean age was 61 ± 14.8 years and 6 of 19 (31.6%) were female. Mean EuroSCORE II was 0.81% ± 0.04%, STS-PROM was 1.13% ± 0.74%, and mean aortic rightward shift induced by SLL-PEEP ventilation was 10.32 ± 4.14 mm (4 to 17 mm; = 0.003). Median shift in the group considered suitable for the RALT approach by preoperative CT-scan evaluation was 14.2 mm (IQR 11) and in the less suitable group 11.5 mm (IQR 5). Mean procedure time was 167 ± 28.9 min, CPB time was 105.7 ± 18.4 min, and cross-clamp time was 64.5 ± 13 min. Fifteen patients (79%) received SAVR via RALT with implantation of a bioprosthesis, whereas a rapid-deployment-prosthesis was used in 4 patients (21%). Ten of 19 (53%) patients who were classified as less suitable preoperatively received SAVR via RALT after SLL-PEEP ventilation. No strokes were observed.
The SLL-PEEP ventilation maneuver during SAVR via RALT significantly enhances aortic exposure. There were no safety events associated with this maneuver and we were able to demonstrate significant rightward aortic shift in every single patient.
通过右前外侧小开胸术（RALT）评估主动脉瓣置换术（SAVR）可行性的公认标志是主动脉中点至右胸骨缘距离。我们旨在评估单肺正呼气末压（SLL-PEEP）通气引起升主动脉向右侧移位以改善显露。
前瞻性分析 19 例接受 RALT 下 SAVR 的主动脉瓣狭窄患者。在经胸主动脉阻断前立即通过双腔气管内导管给予 SLL-PEEP 通气（20，395cmHO），从而引起升主动脉向右侧移位以增强显露。我们分析了术前计算机断层扫描（CT）重建和术中视频记录。主要终点是 SLL-PEEP 通气引起的右侧移位程度；次要终点是手术时间和安全事件。
平均年龄为 61±14.8 岁，19 例中有 6 例（31.6%）为女性。平均 EuroSCORE II 为 0.81%±0.04%，STS-PROM 为 1.13%±0.74%，SLL-PEEP 通气引起的平均主动脉右侧移位为 10.32±4.14mm（4-17mm；=0.003）。术前 CT 扫描评估认为适合 RALT 方法的患者组中，中位数的移位为 14.2mm（IQR 11），不太适合组为 11.5mm（IQR 5）。平均手术时间为 167±28.9min，CPB 时间为 105.7±18.4min，阻断时间为 64.5±13min。15 例（79%）患者接受 RALT 下生物瓣 SAVR，4 例（21%）患者接受快速部署假体。19 例患者中，术前分类为不太适合的患者中有 10 例（53%）在 SLL-PEEP 通气后接受 RALT 下 SAVR。未观察到中风。
在 RALT 下进行 SAVR 时，SLL-PEEP 通气操作可显著增强主动脉显露。该操作无安全性事件发生，且我们能够证明每位患者均有明显的主动脉向右侧移位。
