经腋路微创孤立性主动脉瓣置换术的理念：1000例连续患者的结果

The transaxillary concept for minimally invasive isolated aortic valve replacement: results of 1000 consecutive patients.

作者信息

Wilbring Manuel, Arzt Sebastian, Taghizadeh-Waghefi Ali, Petrov Asen, Di Eusanio Marco, Matschke Klaus, Alexiou Konstantin, Kappert Utz

机构信息

Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.

Department of Cardiac Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden Heart Centre, Dresden, Germany.

出版信息

Eur J Cardiothorac Surg. 2024 Nov 28;66(6). doi: 10.1093/ejcts/ezae427.

DOI:10.1093/ejcts/ezae427

PMID:39602603

Abstract

OBJECTIVES

The transaxillary concept for minimally invasive cardiac surgery-aortic valve replacement is a new and versatile approach with nearly no visible scars. Due to its novelty, available data in literature are scarce. This study reports clinical outcomes of 1000 consecutive patients.

METHODS

Between 2019 and 2023, 4394 patients underwent elective isolated aortic valve procedures, with 2958 (67.5%) transcatheter aortic valve implantation's and 1436 patients surgical aortic valve replacement's (32.5%). Within this period, 1st consecutive 1000 transaxillary isolated minimally invasive cardiac surgery-aortic valve replacement were enrolled. Endocarditis, redo's or combined procedures were excluded. Mean age was 67.9 ± 8.3 years, STS-PROM 1.39 ± 2.89% and EuroScore II 1.65 ± 1.12%.

RESULTS

Use of the transaxillary access increased from 18.7% (2019) to 97.8% (2023). Mean procedure time was 127 ± 31 min, and average cross-clamp time was 43 ± 14 min. Used prostheses were rapid deployment (81.1%), sutured biologic (14.5%) or sutured mechanical valves (4.1%). Conversion rate was 1.9%. No patient died intraoperatively. Thirty-day major adverse cardiac and cerebrovascular event was 1.9% including 0.9% mortality, 0.8% perioperative stroke and 0.6% myocardial infarction. Multivariate factors for major adverse cardiac and cerebrovascular event are intraoperative conversion [OR 1.08 (1.00-1.16); P = 0.04], intraoperative transfusions [OR 1.21 (1.07-1.38); P < 0.01] and respiratory failure [OR 1.39 (1.30-1.49); P < 0.01]. Corresponding factors for mortality are diabetes on insulin [OR 1.02 (1.00-1.04); P = 0.03], pure aortic regurgitation for primary indication [OR 1.03 (1.01-1.05); P < 0.01], intraoperative conversion [OR 1.11 (1.07-1.16); P < 0.01], renal failure [OR 1.08 (1.05-1.10); P < 0.01] and respiratory failure [OR 1.22 (1.17-1.26); P < 0.01].

CONCLUSIONS

Transaxillary minimally invasive cardiac surgery-aortic valve replacement is a safe, effective and cosmetically convincing method for surgical aortic valve replacement, having the potential for >95.0% minimally invasive cardiac surgery rate in selected patients.

摘要

目的

经腋下入路进行微创心脏手术——主动脉瓣置换术是一种全新且通用的方法，几乎不会留下可见疤痕。由于其新颖性，文献中的可用数据较少。本研究报告了连续1000例患者的临床结果。

方法

2019年至2023年期间，4394例患者接受了择期单纯主动脉瓣手术，其中2958例（67.5%）接受经导管主动脉瓣植入术，1436例患者接受外科主动脉瓣置换术（32.5%）。在此期间，纳入了连续的1000例经腋下单纯微创心脏手术——主动脉瓣置换术患者。排除心内膜炎、再次手术或联合手术患者。平均年龄为67.9±8.3岁，胸外科医师协会预计风险（STS-PROM）为1.39±2.89%，欧洲心脏手术风险评估系统II（EuroScore II）为1.65±1.12%。

结果

经腋下入路的使用率从2019年的18.7%增至2023年的97.8%。平均手术时间为127±31分钟，平均主动脉阻断时间为43±14分钟。使用的人工瓣膜为快速植入型（81.1%）、缝合生物瓣（14.5%）或缝合机械瓣（4.1%）。中转开胸率为1.9%。术中无患者死亡。30天主要不良心脑血管事件发生率为1.9%，包括0.9%的死亡率、0.8%的围手术期卒中以及0.6%的心肌梗死。主要不良心脑血管事件的多因素分析显示，术中中转[比值比（OR）1.08（1.00 - 1.16）；P = 0.04]、术中输血[OR 1.21（1.07 - 1.38）；P < 0.01]和呼吸衰竭[OR 1.39（1.30 - 1.49）；P < 0.01]与之相关。死亡率的相关因素包括胰岛素依赖型糖尿病[OR 1.02（1.00 - 1.04）；P = 0.03]、以单纯主动脉瓣反流为主要适应证[OR 1.03（1.01 - 1.05）；P < 0.01]、术中中转[OR 1.11（1.07 - 1.16）；P < 0.01]、肾衰竭[OR 1.08（1.05 - 1.10）；P < 0.01]和呼吸衰竭[OR 1.22（1.17 - 1.26）；P < 0.01]。