【摘要】：目的:微創(chuàng)二尖瓣手術在全球各大心臟外科中心已經常規(guī)開展,并取得了很好的手術效果。然而目前對于小切口二尖瓣手術的各項臨床研究,結果仍不盡相同。本研究總結了本中心胸腔鏡輔助下的右胸小切口二尖瓣手術經驗,通過傾向性評分匹配,將小切口和傳統(tǒng)正中切口二尖瓣手術進行對比。方法:本研究是一個單中心的回顧性隊列研究。2014年1月至2016年12月,在本中心共有49例患者行小切口二尖瓣成形術和54例患者行小切口二尖瓣置換術。在同期行正中切口二尖瓣成形和二尖瓣置換的患者中通過傾向性評分匹配,1:1選出47例二尖瓣成形和54例二尖瓣置換作為對照組,與小切口組對比分析研究。結果:1、二尖瓣成形術:兩組患者均無死亡病例,其中小切口組有2例(4.3%)出現(xiàn)術后并發(fā)癥與正中切口組4例(8.5%)無明顯差異。小切口組的平均體外循環(huán)時間和主動脈阻斷時間顯著長于正中切口組(108.7±29.4min vs.76.5±20.3min,p0.001;70.0±21.4min vs.49.6±17.1min,p0.001)。但是小切口組的平均術中出血量及術后引流量明顯較正中切口組少(144±82.9ml vs.238±72.4ml,p0.001;469.6±443.5mlvs.676.5±377.6ml,p=0.017)。同樣,小切口組患者的中位住院時間較正中切口組顯著低(7d vs.9d,p0.001)。2、二尖瓣置換術:兩組患者均無死亡病例,其中小切口組有7例(13%)出現(xiàn)術后并發(fā)癥與正中切口組5例(9.3%)無顯著差異。小切口組的平均手術時間、體外循環(huán)時間及主動脈阻斷時間較正中切口組顯著延長(188.7±43.0minvs.161.8±40.2min,p=0.001;104.7±-32.7min vs.73.8±15.5min,p0.001;66.9±25.6min vs.46.0±14.6min,p0.001)。然而小切口組患者的平均氣管插管時間(18.2±6.Oh)明顯低于正中切口組(24.5±14.1h),有統(tǒng)計學意義。同樣,小切口組的平均術中出血量和平均術后引流量比正中切口組明顯減少(141.7±98.9ml vs.240.7±71.4ml,p0.001;519.9±349.3ml vs.673.7±389.2ml,p=0.033)。類似的,小切口組患者的中位住院時間較正中切口組顯著低(7.5d vs.8.5d,p=0.004)。3、疼痛評估:對所有患者出院前進行疼痛等級評分發(fā)現(xiàn),小切口組患者手術傷口無痛的比例顯著高于正中切口組(62.4%vs.36.6%,p0.001),而小切口組患者傷口輕度疼痛的比例明顯低于正中切口組(33.7 vs.57.4%,p0.001)。4、學習曲線:2016年小切口二尖瓣手術的手術時間和術中出血量較2014年顯著降低(181.9±47.0min vs.207.1±41.9min,P0.05;123.8±79.6ml vs.211.7±108.3ml,p0.05)。結論:胸腔鏡輔助右胸小切口心臟二尖瓣手術是安全有效的,雖然較正中切口會延長體外循環(huán)及主動脈阻斷時間,但是其可明顯降低術中出血及術后引流量,縮短患者術后的住院時間,且具有良好的美容效果,患者術后疼痛少、恢復快,值得推廣。
[Abstract]:Objective: Minimally invasive mitral valve surgery has been routinely performed in major cardiac surgery centers around the world and has achieved good results. However, the results of various clinical studies on minimally invasive mitral valve surgery are still different. Methods: This study was a single center retrospective cohort study. From January 2014 to December 2016, 49 patients underwent mini-incision mitral valvuloplasty and 54 patients underwent mini-incision mitral valve replacement in our center. Mitral valvuloplasty and mitral valve replacement were matched by propensity score. 47 cases of mitral valvuloplasty and 54 cases of mitral valve replacement were selected as control group. Results: 1. Mitral valvuloplasty: There were no deaths in both groups, of which 2 cases (4.3%) had postoperative complications compared with the median incision group (4.3%). The mean cardiopulmonary bypass time and aortic occlusion time in the small incision group were significantly longer than those in the median incision group (108.7 65507 Similarly, the median hospitalization time in the small incision group was significantly lower than that in the median incision group (7 days vs. 9 days, P 0.001). Mitral valve replacement: There were no deaths in both groups, of which 7 (13%) had postoperative complications and 5 (9.3%) had no significant difference between the small incision group and the median incision group. The mean operative time, cardiopulmonary bypass time and aortic occlusion time in the incision group were significantly longer than those in the median incision group (188.7 (+ 43.0) min vs. 161.8 (+ 40.2) min, P = 0.001; 104.7 (- 32.7) min vs. 73.8 (+ 15.5) min, P 0.001; 66.9 (+ 25.6) min vs. 46.0 (+ 14.6) min, P 0.001). However, the mean tracheal intubation time in the small incision group was significantly shorter than that in the median incision group (18.2 (+ 6. Similarly, the mean intraoperative bleeding volume and average postoperative drainage volume in the small incision group were significantly less than those in the median incision group (141.7 Pain Assessment: Pain rating scores for all patients before discharge showed that the proportion of painless wounds in the small incision group was significantly higher than that in the median incision group (62.4% vs. 36.6%, p0.001), while the proportion of mild pain in the small incision group was significantly lower than that in the median incision group (33.7 vs. 57.4%, p0.001). Curve: In 2016, the operation time and intraoperative bleeding volume of mini-thoracotomy mitral valve surgery were significantly shorter than those in 2014 (181.9 (+ 47.0) min vs. 207.1 (+ 41.9) min, P 0.05; 123.8 (+ 79.6) ml vs. 211.7 (+ 108.3) ml, P 0.05). Conclusion: Thoracoscopic-assisted right mini-thoracotomy mitral valve surgery is safe and effective, although it may prolong cardiopulmonary bypass and main thoracotomy mitral valve surgery compared Arterial occlusion time, but it can significantly reduce intraoperative bleeding and postoperative drainage, shorten postoperative hospital stay, and has a good cosmetic effect, less postoperative pain, fast recovery, worthy of promotion.
【學位授予單位】：浙江大學
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R654.2

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