Babliak Oleksandr, Lazoryshynets Vasyl, Demianenko Volodymyr, Babliak Dmytro, Marchenko Anton, Revenko Katerina, Melnyk Yevhenii, Stohov Oleksii
Division of Cardiac Surgery, Diagnostic and Treatment Center for Children and Adults of the Dobrobut Medical Network, Kyiv, Ukraine.
National Academy of Medical Sciences, National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine.
JTCVS Tech. 2023 Dec 6;24:57-63. doi: 10.1016/j.xjtc.2023.11.015. eCollection 2024 Apr.
We have developed a new technique for accessing the mitral valve through the left anterior minithoracotomy. This approach has been used in patients requiring both mitral valve surgery and coronary artery bypass grafting.
From October 2020 to September 2022, we performed 24 concomitant mitral valve procedures and coronary artery bypass grafting through the left anterior minithoracotomy. The average age of the patients was 65.5 years, and the mean left ventricular ejection fraction was 44.5%. Computed tomography angiography was routinely performed preoperatively. The surgical technique included a left anterior minithoracotomy in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic crossclamping using a transthoracic clamp through the additional port in the left second intercostal space, the administration of cold blood cardioplegia, a right atrial transseptal approach to the mitral valve, and special surgical exposure maneuvers. These maneuvers were designed to displace the heart into the left pleural space by pulling the inferior vena cava tape and the ascending aorta tape to the left. Conventional mitral valve surgical techniques were used. The mitral valve repair or replacement was performed after the distal anastomoses to the right and circumflex coronary system were completed. Subsequently, after the mitral valve procedure, coronary anastomosis to the left anterior descending artery was performed.
The mitral valve was effectively visualized, and a planned procedure was successfully completed in all patients. There was no need for conversion to a sternotomy. mitral valve repair was performed in 22 patients (91.7%), and mitral valve replacement was performed in 2 patients (8.3%). Conventional surgical instruments were used in 10 cases (41%), and long-shafted instruments were used in 14 cases (59%). A knot-pusher was required in 9 cases (37.5%). A computed tomography distance from the skin level to the mitral valve posterior annulus of more than 14 cm was identified as a technical difficulty marker, necessitating the use of long-shafted instruments. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomoses was 2.54 ± 0.7 (1; 4). Total operation time was 341 ± 41 (285; 420) minutes, cardiopulmonary bypass time was 231 ± 38 (172; 316) minutes, and the crossclamp time was 127 ± 23 (80; 169) minutes. Patients had a mean intensive care unit stay of 1.87 ± 0.69 (1; 4) days, and their total hospital stay averaged 6.54 ± 1.86 (4; 10) days. There were no reoperations due to bleeding, no occurrences of strokes, and no other major complications. There were no instances of hospital mortality or mortality within 30 days after the procedures.
Mitral valve repair or replacement through the left anterior thoracotomy and transseptal approach is a valuable and effective technique that can be used for concomitant procedures performed through a single minithoracotomy incision in selected patients.
我们开发了一种通过左前小切口进入二尖瓣的新技术。该方法已用于需要同时进行二尖瓣手术和冠状动脉旁路移植术的患者。
2020年10月至2022年9月，我们通过左前小切口进行了24例二尖瓣手术联合冠状动脉旁路移植术。患者的平均年龄为65.5岁，平均左心室射血分数为44.5%。术前常规进行计算机断层扫描血管造影。手术技术包括在第四肋间进行左前小切口、外周体外循环、通过左第二肋间的额外切口使用经胸夹进行主动脉阻断、给予冷血心脏停搏液、经右心房房间隔入路至二尖瓣以及特殊的手术暴露操作。这些操作旨在通过将下腔静脉带和升主动脉带向左牵拉，将心脏移入左胸腔。采用传统的二尖瓣手术技术。在完成右冠状动脉和回旋支冠状动脉系统的远端吻合后进行二尖瓣修复或置换。随后，在二尖瓣手术后，进行左前降支冠状动脉吻合。
所有患者均能有效显露二尖瓣，且成功完成了计划的手术。无需转为胸骨正中切开术。22例患者（91.7%）进行了二尖瓣修复，2例患者（8.3%）进行了二尖瓣置换。10例（41%）使用了传统手术器械，14例（59%）使用了长柄器械。9例（37.5%）需要使用打结器。计算机断层扫描显示皮肤水平至二尖瓣后环的距离超过14 cm被确定为技术困难指标，需要使用长柄器械。所有病例均实现了完全血运重建。远端吻合的平均数量为2.54±0.7（1；4）个。总手术时间为341±41（285；420）分钟，体外循环时间为231±38（172；316）分钟，阻断时间为127±23（80；169）分钟。患者在重症监护病房的平均住院时间为1.87±0.69（1；4）天，总住院时间平均为6.54±1.86（4；10）天。无因出血进行再次手术的情况，无中风发生，也无其他重大并发症。术后无医院死亡或30天内死亡病例。
通过左前开胸房间隔入路进行二尖瓣修复或置换是一种有价值且有效的技术，可用于在选定患者中通过单一小切口进行联合手术。
