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右胸骨旁横切口和胸骨上段切口行微创主动脉瓣置换术的临床对比研究

Comparison of anterolateral minithoracotomy versus partial upper hemisternotomy in aortic valve replacement

摘要:

目的 比较右胸骨旁横切口和胸骨上段切口行微创主动脉瓣置换术的手术效果.方法 回顾性分析2009年7月至2016年3月复旦大学附属中山医院胸外科完成的297例微创主动脉瓣置换术患者的临床资料,男性174例,女性123例,年龄15~73岁,平均年龄(51±13)岁.根据手术人路分为右胸骨旁横切口组(右胸组)132例、胸骨上段切口组(胸骨组)165例,采用t检验、t'检验、秩和检验、x2检验比较两组患者的手术效果.结果 右胸组和胸骨组分别有4例和1例院内死亡.两组手术时间类似,右胸组心肺转流时间[(92±27)min比(76±18)min,t'=5.848,P=0.000]和主动脉阻断时间[(56±21)min比(43±12)min,t'=6.333,P=0.000]较长,但术后机械通气时间[M(QR):5(4)比9(10)d,Z=4.548,P=0.000]较短,输血率[20.4%比39.4%,x2=12.303,P=0.001]较低,引流量[250(307)ml比570(370)ml,Z=8.161,P=0.000]较少.结论 经右胸骨旁横切口和胸骨上段切口行微创主动脉瓣手术均安全有效.经胸骨上段切口人路术野暴露更好,手术适应证更广,更适合拟开展微创主动脉瓣手术的心脏中心.对于有经验的术者,经右胸骨旁横切口适合有更高美容要求的选择性患者,且有胸切口避免胸骨劈开有助于术后康复.

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abstracts:

Objective To compare the results of aortic valve replacement through anterolateral minithoracotomy(RT)and partial upper hemistemotomy(PS)approaches.Methods This was a retrospective,observational,cohort study of collected data on 297 patients undergoing isolated primary aortic valve replacement between July 2009 and March 2016 at Department of Cardiovascular Surgery,Zhongshan Hospital,Fudan University.There were 174 male and 123 female patients,aging from 15 to 73 years with a mean age of(51±13)years.Of these,132 were performed through right RT and 165 through PS.Outcomes of the two groups were compared by t test,t'test,rank-sum test and x2 test,respectively.Results The overall in-hospital mortality was 1.7%(5/297),with no difference between the 2 groups(3.0%,4/132 vs.0.6%,1/165,P=0.175).Patients in the RT group had longer cardiopulmonary bypass((92±27)minutes vs.(76±18)minutes,t'=5.848,P=0.000)and crossclamping((56±21)minutes vs.(43±12)minutes,t'=6.333,P=0.000)times.Three patients in the RT group and two patients required intraoperative conversion.Patients by way of RT was associated with a lower incidence of blood transfusions(20.4%vs.39.4%,x2=12.303,P=0.001)and less drainage(250(307)ml vs.570(370)ml,Z=8.161,P=0.000).In addition,patients in RT group had a shorter postoperative lengthof stay(5(4)days vs.9(10)days,Z=4.548,P=0.000).Conclusions Aortic valve replacement via RT and PS are both safe and feasible.The approach through PS is associated with better exposure,more extensive indication for surgery,and more suitable to heart centers which intend to carry out miminally invasive aortic valve replacement.While,for an experienced surgeon,the approach through right RT is worthy of clinical selective application for patients concern more about good cosmetic result,and patients have faster recovery by avoid sternotomy through RT approach.

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