Sanad Mohammed, Beshir Hatem
Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University Hospitals, D17, F5. 60, El Gomhoria Street, Qism 2, Mansoura, Dakahlia 35516 Egypt.
Department of Cardiothoracic Surgery, Egypt Ministry of Health and Population, Nasser Institute for Research and Treatment, Cairo, Egypt.
Cardiothorac Surg. 2020;28(1):9. doi: 10.1186/s43057-020-00019-y. Epub 2020 Mar 6.
Minimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding. However, few centers have started using these approaches with standard equipment because of the limited resources. We sought to report intra- and postoperative clinical outcomes and address health resource utilization after MIAVR.
A total of 102 eligible patients who had aortic valve replacement were enrolled in a prospective, multicenter cohort study conducted from June 2015 to December 2017. Fifty patients underwent aortic valve surgery via upper inverted T-shaped hemi-sternotomy (MS), and 52 patients were operated using full sternotomy (FS) in two centers in a developing country. Central cannulation was performed in all cases. Major adverse cardiac events, pain, and wound complications were compared. A cost analysis was performed, and exposure and feasibility for cannulation were assessed. The mean length of MS skin incision was 5.82 ± 0.67 cm. Cumulative cross-clamp time was insignificant between both groups (91.87 ± 34.41 versus 94.91 ± 33.96 min; = 0.66). MS exhibited shorter ventilation time (6.18 ± 1.86 versus 10.68 ± 12.78 h; = 0.029) and intensive care stays (33.27 ± 19.75 versus 49.42 ± 47.1 h; = 0.037). Major adverse cardiac events (MACEs) were compared, and MS group exhibited fewer transfusions (1.18 ± 0.89 versus 1.7 ± 0.97 units; = 0.002), fewer pulmonary complications (1 (2%) versus 2 (3.8%); < 0.001), and less sternotomy wound infection (1 (2%) versus 5 (9.6%); = 0.048). Total operative mortality of 4.46% was recorded ( = 5). Significant cost reduction was recorded favoring MS; central cannulation saved $907.16 and carried a total cost reduction of $580 (9.3%) when compared with the FS approach ( < 0.0001).
With a lack of logistics in developing countries, MIAVR not only has a cosmetic advantage but carries a significant reduction in blood use, respiratory complications, pain, and cost. MIAVR can be feasible, with a rapid learning curve in developing centers.
主动脉瓣置换术的微创方法在技术和后勤保障方面要求较高。然而，由于资源有限，很少有中心开始使用这些方法及标准设备。我们试图报告微创主动脉瓣置换术（MIAVR）的术中和术后临床结果，并探讨其卫生资源利用情况。
在2015年6月至2017年12月进行的一项前瞻性多中心队列研究中，共纳入了102例符合条件的接受主动脉瓣置换术的患者。在一个发展中国家的两个中心，50例患者通过上倒T形半胸骨切开术（MS）进行主动脉瓣手术，52例患者采用全胸骨切开术（FS）进行手术。所有病例均采用中心插管。比较主要不良心脏事件、疼痛和伤口并发症。进行了成本分析，并评估了插管的暴露情况和可行性。MS皮肤切口的平均长度为5.82±0.67厘米。两组之间的累计主动脉阻断时间无显著差异（91.87±34.41对94.91±33.96分钟；P=0.66）。MS组的通气时间较短（6.18±1.86对10.68±12.78小时；P=0.029），重症监护停留时间较短（33.27±19.75对49.42±47.1小时；P=0.037）。比较主要不良心脏事件（MACE），MS组输血较少（1.18±0.89对1.7±0.97单位；P=0.002），肺部并发症较少（1例（2%）对2例（3.8%）；P<0.001），胸骨切开伤口感染较少（1例（2%）对5例（9.6%）；P=0.048）。记录的总手术死亡率为4.46%（n=5）。记录到MS组成本显著降低；与FS方法相比，中心插管节省了907.16美元，总成本降低了580美元（9.3%）（P<0.0001）。
在发展中国家缺乏后勤保障的情况下，MIAVR不仅具有美容优势，而且在血液使用、呼吸并发症、疼痛和成本方面显著降低。MIAVR在发展中中心可能是可行的，且学习曲线较快。
