الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 116 |  |  |
| | | from | 116 | | |
Abstract
Median sternotomy has been well established as a standard access for mitral valve operations, but it is also associated with some complication including deep bone infection, wound dehiscence, delayed recovery and increased hospital stay. Cosmetic and psychological implications of surgery have assumed increasing importance in the same time frame and a variety of minimally invasive cardiac surgical techniques have been developed, including parasternal incision, right thoracotomy, port-access surgery, and video-as¬sisted methods. Minimally invasive mitral valve surgery does not refer to a single approach but rather to a collection of new techniques and operation-specific technologies, of these, right anterolateral thoracotomy approach which was strongly recommended as an alternative approach to standard median sternotomy for patients undergoing mitral valve replacement. This is an observational prospective study included a total of 40 patients undergoing mitral valve replacement. Patients were selected from departments of cardiothoracic surgery in Assiut and Al-Minia university hospitals during the period from January 2016 to August 2018 after being approved by the local ethical committee of research at Assiut University. Patients were randomly assigned to two age and sex matched groups, group (I) which included 20 patients underwent conventional median sternotomy approach and group (II) which included 20 patients underwent right anterolateral thoracotomy with the complete cannulation and aortic cross-clamping conducted through the same incision. The aim of this study was to evaluate the clinical safety and efficacy of mitral valve replacement through a right anterolateral thoracotomy and to compare the results of this approach with the conventional median sternotomy approach. The obtained results are summarized as follows there were no statistical significant differences between groups regarding age and sex distribution. Also, there were no significant differences between groups as regard NYHA classification. Regarding the preoperative assessment, no significant differences were recorded between the studied groups the results showed that the right anterolateral thoracotomy group had significantly higher cannulation time, cross-clamp time and total bypass time compared to median sternotomy group (P. ≤ 0.01). The mean total operative time was significantly higher in right anterolateral thoracotomy approach compared to median sternotomy approach (287 ± 41 min. vs. 231 ± 36 min., P. ≤ 0.01). The mean skin incision length was significantly higher in median sternotomy approach (21.7 ± 2.2 cm) compared to right anterolateral thoracotomy approach (7.06 ± 1.1 cm) (P. ≤ 0.01). All patients in both groups required post-operative mechanical ventilation. Ventilation time mean in median sternotomy group was 6.1 ± 1.84 hrs. This was significantly higher than that of the right anterolateral thoracotomy group ”4.2 ± 1.51 hrs??” (P. ≤ 0.01). The mean blood loss was significantly higher in median sternotomy approach group compared to that of the right anterolateral thoracotomy approach group (335 ± 137 ml vs. 229 ± 85 ml, P. ≤ 0.01). The present results demonstrated that group (I) required significantly higher amount of blood transfusion (2.19 ± 1.1 units) compared to group (II) (1.41 ± 0.6 units) (P. ≤ 0.01). Patients of median sternotomy group had significantly higher ICU stay duration mean compared to those of right anterolateral thoracotomy group (2.78 ± 0.82 vs. 2.11 ± 0.49 days) (P. ≤ 0.01). The results showed that two patients (10.0%) in group (I) required re-exploration for bleeding due to excessive blood drainage (> 4 ml / Kg/ hour), while no patients required re-exploration for bleeding in group (II). At 1st day post-operative, group (II) had significantly lower pain score (pain was less) compared to group (I), (7.65 ± 0.56 vs. 9.77 ± 0.61, P. ≤ 0.01), also, the same trend of results was found at 2nd day post-operative and pre-discharge (P. ≤ 0.01). Obviously, the pain score was decreased in both groups along with time from 1st to 2nd day postoperative and the lowest value was pre-discharge. In general, 10 cases (50.0%) in group (I) suffered from postoperative complications versus 6 cases (30.0%) in group (II) with no significant difference between groups, this may be due to limited number of studied cases. In the present study, there were no mortality among all included patients. The results demonstrated that the mean total hospital stay duration was significantly higher in median sternotomy group compared to right anterolateral thoracotomy group (8.4 ± 1.6 vs. 7.2 ± 1.3 days, P.=0.013). Patient satisfaction was significantly higher right anterolateral thoracotomy group compared to sternotomy group (only 6 patients (30.0%) in group (I) was satisfied about their wound, while 19 patients (95.0%) in group (II) was satisfied with highly statistical significance difference, P. ≤ 0.01). The result of the X-ray findings and pericardial effusion 3 months post-operative in both groups showed that only 2 patients (10.0%) had mild pleural effusion in group (I) compared to 3 patients (15.0%) in group (II) with no statistical significance differences between both groups (P=0.632). Pericardial effusion was recorded in 4 cases in group (I) versus 6 cases in group (II) also with no significant difference (P=0.465). The results demonstrated that trans-thoracic echocardiography variables means (EF%, LA, LVED, LVES and PAP) were significantly decreased at 3 months postoperative compared to preoperative values in both groups (both approaches). However, no significant differences were noticed between both groups regarding pre and post-operative echocardiography variables.