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完全胸腔镜下二尖瓣置换术634例临床分析

Clinical outcome of totally thoracoscopic cardiac surgery for mitral valve replacement:a series of 634 cases

摘要:

目的 探讨经胸壁3孔完全胸腔镜下二尖瓣置换术的疗效及安全性.方法 回顾性分析2004年5月至2016年2月上海远大心胸医院腔镜科连续634例行完全胸腔镜下二尖瓣置换术的患者资料.男性292例,女性342例;年龄17~68岁,平均(45±13)岁.所有患者原发病为二尖瓣中重度狭窄和(或)关闭不全;合并三尖瓣中重度关闭不全263例,心房颤动356例,左心房血栓46例.手术采用股动脉、股静脉插管建立外周心肺转流,阻闭升主动脉,冷血心脏停跳液顺行灌注行心肌保护,完全胸腔镜下行二尖瓣置换术.结果 本组634例患者中,术中扩大切口13例,中转正中开胸8例.平均心肺转流时间(89±18)min,平均主动脉阻断时间(51±12)min,平均手术时间(3.1±1.2)h,平均术后ICU停留时间(27±8)h,平均机械通气辅助时间(17±6)h,平均术后胸腔引流量(390±70)ml,平均术后住院时间(9.2±2.1)d.住院死亡5例.术后早期发生并发症42例(6.6%),包括右侧血气胸18例,二次开胸止血12例,瓣周漏3例(其中1例二次手术),低心排血量综合征3例,急性肾功能不全2例,下腔静脉损伤2例,肝脏损伤1例,股动脉血栓形成1例.608例(96.7%,608/629)患者获得随访,随访时间2~141个月,平均(58±9)个月.随访期间死亡3例,2例死于心力衰竭,1例死于脑卒中.37例发生远期并发症,包括瓣周漏1例,三尖瓣中度关闭不全32例,脑卒中3例,感染性心内膜炎1例.无二次手术患者.结论 完全胸腔镜下二尖瓣置换术,手术操作安全,疗效确切,临床可选择性应用.

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abstracts:

Objective To summarize the clinical outcome of totally thoracoscopic cardiac surgery for mitral valve replacement.Methods Clinical data of 634 cases undergoing totally thoracoscopic cardiac surgery for mitral valve replacement from May 2004 to February 2016 in Department of Thoracoscopic Cardiacsurgery,Shanghai Yodak Cardiothoracic Hospital was analyzed retrospectively.There were 292 male and 342 female patients,aged from 17 to 68 years with a mean of(45±13)years.All the 634 patients had moderate-severe mitral valve stenosis and(or)incompetence,263 patients had moderate-severe tricuspid valve incompetence,356 patients had atrial fibrillation,46 patients had left atrium thrombosis.Cardiopulmonary bypass was established with right femoral artery and a single 2 stage venus cannula in the right atrium.The ascending aorta was cross-clamped and the myocardium was protected by coronary perfusion with cold crystalloid cardioplegia.Totally thoracoscopic mitral valve replacement were performed.Results Thirteen cases had incision expanded and 8 cases had conversions to sternotomy.Cardiopulmonary bypass and aortic cross-clamp time were(89±18)minutes and(51±12)minutes,respectively.Operation time was(3.1±1.2)hours.Mechanical ventilation time and intensive care unit stay were(17±6)hours and(27±8)hours,respectively.Postoperation drainage quantity was(390±70)ml.The hospital days was(9.2±2.1)days.There were 5 cases in-hospital deaths.Postoperative complications occurred in 42 cases(6.6%),including 18 cases of right hemoneumothorax,12 cases of reoperation for bleeding,3 cases of perivalvular leakage(reoperation was done in 1 patient),3 cases of low cardiac output syndrome,2 cases of acute renal failure,2 cases of inferior vena cava injury,1 case of right femoral artery thrombosis and liver injury,respectively.The mean duration of follow-up was(58±9)months in 608 cases,with a follow-up rate of 96.7%(608/629).Three patients had died during the period of follow-up caused by congestive heart failure(2 patients)and stroke(1 patient).Late complication among 605 survivors were 37 cases,including 32 cases of moderate tricuspid valve insufficiency,3 cases of stroke,1 case of perivalvular leakage and infective endocarditis,respectively.There was no reoperation during the period of follow-up.Conclusion Totally thoracoscopic cardiac surgery for mitral valve replacement is safe and effective,with unique superiority and clinical feasible.

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