【摘要】：目的:微創(chuàng)二尖瓣手術(shù)在全球各大心臟外科中心已經(jīng)常規(guī)開展,并取得了很好的手術(shù)效果。然而目前對(duì)于小切口二尖瓣手術(shù)的各項(xiàng)臨床研究,結(jié)果仍不盡相同。本研究總結(jié)了本中心胸腔鏡輔助下的右胸小切口二尖瓣手術(shù)經(jīng)驗(yàn),通過傾向性評(píng)分匹配,將小切口和傳統(tǒng)正中切口二尖瓣手術(shù)進(jìn)行對(duì)比。方法:本研究是一個(gè)單中心的回顧性隊(duì)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(shù)和54例患者行小切口二尖瓣置換術(shù)。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(píng)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(duì)照組,與小切口組對(duì)比分析研究。結(jié)果:1、二尖瓣成形術(shù):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(shù)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(shí)間和主動(dòng)脈阻斷時(shí)間顯著長(zhǎng)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(shù)中出血量及術(shù)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(shí)間較正中切口組顯著低(7d vs.9d,p0.001)。2、二尖瓣置換術(shù):兩組患者均無死亡病例,其中小切口組有7例(13%)出現(xiàn)術(shù)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(shù)時(shí)間、體外循環(huán)時(shí)間及主動(dòng)脈阻斷時(shí)間較正中切口組顯著延長(zhǎng)(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(shí)間(18.2±6.Oh)明顯低于正中切口組(24.5±14.1h),有統(tǒng)計(jì)學(xué)意義。同樣,小切口組的平均術(shù)中出血量和平均術(shù)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(shí)間較正中切口組顯著低(7.5d vs.8.5d,p=0.004)。3、疼痛評(píng)估:對(duì)所有患者出院前進(jìn)行疼痛等級(jí)評(píng)分發(fā)現(xiàn),小切口組患者手術(shù)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(xué)習(xí)曲線:2016年小切口二尖瓣手術(shù)的手術(shù)時(shí)間和術(shù)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(jié)論:胸腔鏡輔助右胸小切口心臟二尖瓣手術(shù)是安全有效的,雖然較正中切口會(huì)延長(zhǎng)體外循環(huán)及主動(dòng)脈阻斷時(shí)間,但是其可明顯降低術(shù)中出血及術(shù)后引流量,縮短患者術(shù)后的住院時(shí)間,且具有良好的美容效果,患者術(shù)后疼痛少、恢復(fù)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(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R654.2

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1 程實(shí);谷天祥;修宗誼;吳立民;高銳;高雅;;真空輔助靜脈引流技術(shù)在微創(chuàng)心臟手術(shù)中的應(yīng)用[J];中國(guó)醫(yī)療器械雜志;2011年06期

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