更少是否更好？比较正中开胸和胸腔镜手术入路在左心室辅助装置植入术后结果和瓣膜病方面的影响。
Less is better? Comparing effects of median sternotomy and thoracotomy surgical approaches for left ventricular assist device implantation on postoperative outcomes and valvulopathy.
机构信息
Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY.
Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY.
出版信息
J Thorac Cardiovasc Surg. 2024 Feb;167(2):731-743.e3. doi: 10.1016/j.jtcvs.2022.04.036. Epub 2022 May 17.
OBJECTIVE
Our objective was to compare outcomes after left ventricular assist device implantation performed via median sternotomy or lateral thoracotomy.
METHODS
We retrospectively analyzed 222 adult patients with the HeartMate3 (Abbott Lab) left ventricular assist device implanted between November 2014 and November 2021. Outcomes stratified by surgical approach were evaluated in propensity score-matched groups. The primary outcome was 1-year survival. Secondary outcomes included in-hospital morbidity and mortality, readmissions, and significant valvular regurgitation.
RESULTS
Our cohort consisted of 60 patients (27%) who underwent lateral thoracotomy and 162 patients (73%) who underwent median sternotomy. Propensity score matching compared 45 patients who underwent lateral thoracotomy with 68 patients who underwent median sternotomy. There were no differences in intensive care unit or hospital stay duration (median, 10 vs 11 days, P = .58; 46 vs 40 days, P = .279), time to extubation (median, 2 days, P = .627), vasoactive-inotropic scores at intensive care unit arrival (18.20 vs 16.60, P = .654), or in-hospital mortality (2 [5%] vs 4 [6.1%] patients, P = 1). One-year survival (95.56% vs 90.61%, P = .48) and all-cause hospital readmission rate (Gray's test: P = .532) were also comparable. Patients who underwent lateral thoracotomy had significantly less early right ventricular failure (24.4% vs 53.7%, P = .004), although they had more follow-up tricuspid regurgitation (17.6% vs 0%, P = .030) and volume overload readmissions (Gray's test: P = .0005).
CONCLUSIONS
Our data suggest that lateral thoracotomy is a safe although not necessarily superior alternative to median sternotomy for HeartMate 3 implantation in the perioperative and postoperative periods, because it precludes concomitant tricuspid valve repairs and may be associated with increased risk of late tricuspid regurgitation and volume overload readmissions.
目的
我们的目的是比较通过正中胸骨切开术或侧开胸进行左心室辅助装置植入后的结果。
方法
我们回顾性分析了 2014 年 11 月至 2021 年 11 月期间植入 HeartMate3（雅培实验室）左心室辅助装置的 222 例成年患者。通过倾向性评分匹配组评估按手术途径分层的结果。主要结果是 1 年生存率。次要结果包括院内发病率和死亡率、再入院和严重瓣膜反流。
结果
我们的队列包括 60 例（27%）接受侧开胸手术和 162 例（73%）接受正中胸骨切开术的患者。倾向性评分匹配比较了 45 例接受侧开胸手术的患者和 68 例接受正中胸骨切开术的患者。重症监护病房或住院时间（中位数，10 天 vs 11 天，P=0.58；46 天 vs 40 天，P=0.279）、拔管时间（中位数，2 天，P=0.627）、入住重症监护病房时的血管活性-正性肌力评分（18.20 vs 16.60，P=0.654）或院内死亡率（2[5%] vs 4[6.1%]患者，P=1）均无差异。1 年生存率（95.56% vs 90.61%，P=0.48）和全因医院再入院率（格雷检验：P=0.532）也相当。接受侧开胸手术的患者早期右心室衰竭发生率明显较低（24.4% vs 53.7%，P=0.004），尽管他们在随访中三尖瓣反流更多（17.6% vs 0%，P=0.030）和容量超负荷再入院率更高（格雷检验：P=0.0005）。
结论
我们的数据表明，虽然侧开胸术在围手术期和术后期间对于 HeartMate 3 植入可能不是更好的替代方法，但它是一种安全的选择，因为它可以避免同时进行三尖瓣修复，并且可能与晚期三尖瓣反流和容量超负荷再入院风险增加相关。
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