目的 传统的正中开胸手术（CFS）被认为是治疗二尖瓣反流（MR）的最佳方法。但其手术创伤巨大。通过右侧小开胸微创（MI）二尖瓣（MV）修复MR,可以减少手术创伤;然而,其安全性和有效性尚未确定。在本研究中,比较MR患者与MI或CFS患者之间的临床结果。方法 收集同期以MR为主的96例患者的资料。51例患者接受CFS （CFS组）,45例患者接受MI （MI组）。两组患者的一般资料、手术资料、术前和术后心肺参数进行对比研究。术后总生存期、再手术和复发MR,生存分析采用Kaplan-Meier法,组间比较采用log-rank检验进行分析。结果 所有患者均顺利完成手术。MI组切口长度明显缩短。与CFS组比较,MI组术中出血量、术后输血、胸腔引流量均较CFS组少。两组患者均行房颤消融。CFS组房颤消融效果较好,而MI组术后新发房颤发生率较低。MI组出现较多肺部并发症。CFS组在术后第1、2天时炎症反应较轻。术后2 d MI组炎症反应明显减轻。两组在总生存率、无再手术生存率和无复发MR生存率上无统计学差异。结论 MI治疗MR与CFS具有同样的手术效性和安全性。绝大多数MR患者都可以进行MI治疗。
Objective Conventional full sternotomy （CFS） is considered the best treatment for mitral regurgitation （MR）. But the surgical trauma of CFS is great. Minimal invasive （MI） mitral valve （MV） repair for MR through right mini-thoracotomy has been developed to decrease operative trauma; however, the safety and efficacy are not defined yet. In the present study, clinical outcomes were compared between patients with MR who received MI or CFS. Methods The data of 96 patients who mainly suffered from MR during the same period were collected. Among them, 51 patients received CFS （CFS group）, and 45 patients received MI （MI group）. Patients' demographics, surgical data, pre- and post-operative cardiopulmonary parameters were compared between the two groups. Postoperative overall survival, reoperation, and recurrent MR survival were estimated using the Kaplan-Meier method, and comparisons between groups were performed by log-rank test. Results The procedures were successfully performed in all patients. The incision length was significantly shorter in the MI group. Compared with the CFS group, intraoperative blood loss, postoperative blood transfusion, and thoracic drainage were less in the MI group. Atrial fibrillation ablation was performed in the two groups. In the CFS group, a better result of atrial fibrillation ablation was achieved; however, a lower incidence rate of new-onset postoperative atrial fibrillation was observed in the MI group. More pulmonary complications were found in the MI group. The inflammatory response was lighter in the CFS group on post operative day（POD） 1 and 2. On postoperative day 2, the inflammatory response in the MI group reduced significantly. No statistical difference was found in overall survival, reoperation-free survival, and recurrence-free survival. Conclusion The efficacy and safety of MI for MR are the same as CFS. MI could be performed in the vast majority of patients with MR.
[1] Coutinho GF, Antunes MJ.Mitral valve repair for degenerative mitral valve disease: surgical approach, patient selection and long-term outcomes[J]. Heart, 2017,103(21):1663-1669.
[2] Gammie JS, Sheng S, Griffith BP, et al.Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database[J]. Ann Thorac Surg, 2009,87(5):1431-1437.
[3] Brown LJ, Mellor SL, Niranjan G, et al.Outcomes in minimally invasive double valve surgery[J]. J Card Surg, 2020,35(12):3486-3502.
[4] Falk V, Cheng DCH, Martin J, et al.Minimally invasive versus open mitral valve surgery: a consensus statement of the international society of minimally invasive coronary surgery (ISMICS) 2010[J]. Innovations, 2011,6(2):66-76.
[5] Vollroth M, Seeburger J, Garbade J, et al.Conversion rate and contraindications for minimally invasive mitral valve surgery[J]. Ann Cardiothorac Surg, 2013,2(6):853-854.
[6] Watt DG, Horgan PG, McMillan DC. Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review[J]. Surgery, 2015, 157(2):362-380.
[7] Sündermann SH, Sromicki J, Rodriguez Cetina Biefer H, et al. Mitral valve surgery: right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis[J]. J Thorac Cardiovasc Surg, 2014,148(5):1989-1995.
[8] Akowuah E, Burdett C, Khan K, et al.Early and late outcomes after minimally invasive mitral valve repair surgery[J]. J Heart Valve Dis, 2015,24(4):470-477.
[9] Mohr FW, Onnasch JF, Falk V, et al.The evolution of minimally invasive valve surgery-2 year experience[J]. Eur J Cardiothorac Surg, 1999,15(3):233-238.
[10] Nakayama T, Nakamura Y, Yasumoto Y, et al.Early and mid-term outcomes of minimally invasive mitral valve repair via right mini-thoracotomy: 5-year experience with 129 consecutive patients[J]. Gen Thorac Cardiovasc Surg, 2021,69(8):1174-1184.
[11] Algarni KD, Suri RM, Schaff H.Minimally invasive mitral valve surgery: does it make a difference[J]? Trends Cardiovasc Med, 2015,25(5):456-465.
[12] Atluri P, Stetson RL, Hung G, et al.Minimally invasive mitral valve surgery is associated with equivalent cost and shorter hospital stay when compared with traditional sternotomy[J]. J Thorac Cardiovasc Surg, 2016,151(2):385-388.
[13] Badhwar V, Rankin JS, Damiano RJ, et al.The Society of Thoracic Surgeons 2017 Clinical Practice guidelines for the surgical treatment of atrial fibrillation[J]. Ann Thorac Surg, 2017,103(1):329-341.
[14] Iribarne A, DiScipio AW, McCullough JN, et al. Surgical atrial fibrillation ablation improves long-term survival: a multicenter analysis[J]. Ann Thorac Surg, 2019,107(1):135-142.
[15] Waldron NH, Cooter M, Piccini JP, et al.Predictive ability of perioperative atrial fibrillation risk indices in cardiac surgery patients: a retrospective cohort study[J]. Can J Anaesth, 2018,65(7):786-796.
[16] Hirai K, Kawakami R, Nogi M, et al.Impact of atrial fibrillation on the prognosis of acute decompensated heart failure with and without mitral regurgitation[J]. Circ Rep, 2021,3(7):388-395.
[17] Murtuza B, Pepper JR, Stanbridge RD, et al.Does minimal-access aortic valve replacement reduce the incidence of postoperative atrial fibrillation[J]? Tex Heart Inst J, 2008,35(4):428-438.
[18] Rezaei Y.Anti-inflammatory role of statins in preventing postoperative atrial fibrillation[J]. Am J Cardiol, 2016,117(2):314.
[19] Ishii Y, Schuessler RB, Gaynor SL, et al.Postoperative atrial fibrillation: the role of the inflammatory response[J]. J Thorac Cardiovasc Surg, 2017,153(6):1357-1365.
[20] Raiten JM, Ghadimi K, Augoustides JG, et al.Atrial fibrillation after cardiac surgery: clinical update on mechanisms and prophylactic strategies[J]. J Cardiothorac Vasc Anesth, 2015,29(3):806-816.
