全胸腔镜心脏手术在老年患者中的临床应用

Clinical application of totally video-assisted cardiac surgery to patients with heart disease over 60 years

摘要:

目的 总结全胸腔镜心脏手术在>60 岁心脏疾病患者中的临床应用经验，并评价其安全性和疗效。 方法 选取2014 年12 月-2016 年7 月于该院接受了全胸腔镜心脏手术治疗>60 岁心脏疾病患者14 例。患 者采用全身麻醉双腔气管插管，右侧股动、静脉+ 上腔静脉插管建立体外循环，右侧胸壁第3 ～ 5 肋间隙分 别戳孔1 个，全胸腔镜下完成房间隔缺损修补术、左心房黏液瘤切除术、三尖瓣成形术、二尖瓣成形或置换 术、单极射频消融术及左心耳内口缝闭术等手术操作。结果 全组无中转前正中开胸，无死亡，均痊愈出院。 患者体外循环时间为（130.71±34.32）min，主动脉阻断时间为（69.14±36.08）min，手术时间为（252.50± 80.14）min，术后呼吸机辅助时间为（8.93±5.40）h，术后ICU 停留时间为（24.93±16.08）h，术后住院时间 为（9.93±3.03）d。术中失血量为（160.71±84.10）ml，术后24 h 胸腔引流量为（108.57±55.59）ml，胸腔 引流管留置时间为（2.65±1.47）d，平均输血量为（375.00±183.71）ml。出院前复查心脏彩超未见异常。患 者随访（10.21±7.63）个月，无死亡，心功能恢复至Ⅰ、Ⅱ级，较术前改善（P <0.05）；心脏彩超提示左心房 内径和左心室舒张末期内径比术前缩小（P <0.05）。结论 在>60 岁心脏疾病患者中采用右侧股动、静脉+ 上腔静脉插管建立体外循环，右侧胸壁戳孔，全胸腔镜下完成心脏手术操作，创伤小，出血和输血少，并发症少， 术后恢复快，安全可靠，效果确切。

Abstract:

Objective To summarize the clinical experience of totally video-assisted cardiac surgery for the patients with heart disease over 60 years, and evaluate its safety and efficacy. Methods From December 2014 to July 2016, 14 patients including 6 males and 8 femals underwent totally video-assisted cardiac surgery in Cardiac Surgery Center of Sichuan Provincial People’s Hospital. Their mean age was (64.50 ± 4.62) years. All patients were ventilated with a double lumen endotracheal tube after general anesthesia. Superior vena cava, right femoral artery and vein cannulation were used to establish cardiopulmonary bypass (CPB). Three holes were poked respectively in the 3rd, 4th and 5th intercostal space at right chest wall. Intracardial procedures such as atrial septal defect repair, left atrial myxoma excision, tricuspid valve repair, mitral valve repair or replacement, unipolar radiofrequency ablation, direct suture of left atrial appendage inlet orifice were completed through totally video-assisted approach. Results No patient was converted to anterior median thoracotomy. No death was found. All patients were cured and discharged from hospital. The mean CPB time, aortic occlusion time, operation time, postoperative ventilator support time,postoperative intensive care unit stay time and postoperative hospitalization time were (130.71 ± 34.32) min, (69.14 ± 36.08) min, (252.50 ± 80.14) min, (8.93 ± 5.40) h, (24.93 ± 16.08) h, and (9.93 ± 3.03) d respectively. The mean intraoperative blood loss was (160.71 ± 84.10) ml. The thoracic drainage volume in 24 h after operation was (108.57 ± 55.59) ml. The thoracic drainage time was (2.65 ± 1.47) d. The mean blood transfusion volume was (375.00 ± 183.71) ml. No obvious abnormalities were found by ultrasound echocardiography before discharge. The patients were followed up for (10.21 ± 7.63) mon. During the follow-up period, no patient died. The heart function was improved to grade I or II which was better than that before operation (P < 0.05), left atrial dimension and left ventricular end diastolic dimension were also significantly reduced (P < 0.05). Conclusions In the patients over 60 years with heart disease, totally video-assisted cardiac surgery through poking holes at right chest wall and under CPB established through superior vena cava, right femoral artery and vein cannulation is safe and effective with little trauma, little blood loss and blood transfusion, few complications and faster recovery.