华西医院成功实施胸腔镜下经肋间小切口免缝合主动脉瓣置换联合升主动脉成形术

2022-07-30 四川大学华西医院 网络

本例老年患者主动脉瓣重度狭窄,还伴随主动脉瓣严重钙化,基础心脏功能差且合并升主动脉瘤样扩张改变,都极大地增加了手术难度。

近日,我院胡佳教授团队为一名71岁高龄女性患者成功实施胸腔镜下肋间小切口免缝合主动脉瓣置换联合升主动脉成形术,患者术后恢复顺利。该手术的成功开展,为患者及心脏外科同行提供了一个全新的微创瓣膜手术技术方法,标志着华西医院心脏大血管外科心脏瓣膜微创技术处于国内先进水平。经文献检索,目前国内尚未见类似病例报道。

患者李女士(化名)2个多月前活动后出现心悸、气紧、胸闷等不适,后症状日益加重,逐渐开始出现夜间无法平卧。患者辗转多家医院后,到我院心脏大血管外科胡佳教授门诊就诊。检查显示患者先天性主动脉瓣二叶式畸形主动脉瓣重度狭窄伴轻中度关闭不全,左室明显增大(LV 60),心功能测值降低(EF% 48%),同时合并升主动脉瘤样扩张(AAO 45)。

主动脉瓣病变是心脏大血管外科常见病种之一,手术治疗是此类疾病的首选治疗方法。考虑到患者年龄较大,常规手术创伤大,术后胸骨愈合缓慢,易出现术后肺部感染等并发症,胡佳教授对患者进行了全面评估后建议患者实施胸腔镜下肋间小切口免缝合主动脉瓣置换+升主动脉成形术。

相较于传统开胸瓣膜置换手术,胸腔镜辅助下肋间小切口不损伤胸骨,同时免缝合主动脉瓣术中仅需缝置三根引导线,避免瓣环逐一缝合打结,大大缩短体外循环和心脏阻断时间,降低手术风险。经导管主动脉瓣膜置换(transcatheter aortic valve implantation,TAVI)虽然微创,但无法解决患者合并的升主动脉瘤样扩张性病变,远期存在主动脉持续扩张甚至发生主动脉夹层或血管破裂的风险。相较于TAVI,免缝合主动脉瓣置换可以在处理瓣膜病变的同时同期处理升主动脉病变。

在完善相关术前检查后,胡佳教授团队选择右侧胸骨旁第二肋间切口作为主操作孔显露手术视野,经股动静脉插管建立体外循环,纵行切开升主动脉探查主动脉瓣。

充分显露主动脉瓣为Type I型二叶式主动脉瓣,无冠瓣瓣膜钙化明显,瓣口重度狭窄。

团队切除病变主动脉瓣,仔细清除钙化,测量瓣环径并选择合适型号的人工瓣膜。

选择瓣膜型号为“L”,体外组装瓣膜进行压瓣。

主动脉瓣瓣环均匀缝置三根引导线,经引导线将瓣膜输送至合适位置,确认位置后释放瓣膜。

球囊扩张人工生物瓣瓣环,撤出三针引导线。

最后,切除部分扩张的升主动脉行升主动脉成形,关闭主动脉切口,停机,撤除体外循环,止血后关闭手术切口,手术切口约5cm。

在胡佳教授外科团队、麻醉科余海教授、术中食道超声宋海波教授和体外循环谭赵霞教授的通力合作下,手术过程十分顺利。术中主动脉阻断时间40分钟,术后食道超声评估瓣膜开闭正常,无瓣周漏,平均跨瓣压差3mmHg。手术结束后,患者转至心外重症监护室。在重症监护室及病房医护团队的共同努力和细心照料下,患者术后恢复良好,顺利出院。

由于主动脉根部、主动脉瓣解剖及病理生理的特殊性,微创腔镜下主动脉瓣置换术存在较高的技术难度,而且腔镜下操作难度大,技术要求高,是制约微创腔镜下主动脉瓣置换术发展的重要因素。随着免缝合主动脉瓣的出现,微创腔镜下主动脉瓣置换得到进一步发展。据胡佳教授介绍,根据最新国际多中心长期随访数据显示,免缝合主动脉瓣置换术具有创伤小、植入易、康复快、耐久佳等优点。

本例老年患者主动脉瓣重度狭窄,还伴随主动脉瓣严重钙化,基础心脏功能差且合并升主动脉瘤样扩张改变,都极大地增加了手术难度。胡佳教授团队开创性地完成胸腔镜下经肋间小切口免缝合主动脉瓣置换联合升主动脉成形术,充分体现了其团队对高风险复杂病例实施个体化微创治疗的能力,也展现出我院心脏大血管外科作为西南地区心脏大血管疑难重症中心的实力。

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    2022-08-05 yxch48
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    2022-07-29 fengyqf

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