Clinical Application And Postoperative Quality Of Life Of Totally Thoracoscopic Atrial Myxoma Resection On Perfused Beating Heart

Part one:Clinical application of totally thoracoscopic atrial myxoma resection on perfused beating heartResearch BackgroundCardiac atrial myxoma(CAM)is the most common primary Cardiac tumor,and it accounts for approximately 50%-75%of all kinds of Cardiac tumors.Most of the CAM are benign and 90%of them are sporadic.Besides,they mainly originate in a specific location of the left atrium,with the location of oval fossa being the most common.According to some literature,CAM may be related to the potential multidirectional differentiation of endocardial mesenchymal stem cells in the corresponding position of ovale fossa on the left atrial surface.In addition,malignant CAM mostly has a variety of origins and some of them are featured by familial aggregation.CAM has complex and non-specific clinical manifestations.There can be no clinical symptoms when the tumor is small or does not block the internal channels of the heart.There are symptoms such as palpitation,suffocating and asthma,and even sudden death when the tumor falls off and the valve mouth is filled.Furthermore,there may be some atypical symptoms,such as low fever,arterial embolism(usually Carney Complex CAM),fatigue,syncope,vomiting,and angina.Surgical treatment has become the only effective means to treat CAM,and midsternal incision has also become the most common surgical treatment to remove myxoma.As minimally invasive cardiac surgery technology develops and the concept of minimally invasive cardiac surgery deepens,various kinds of minimally invasive cardiac surgery technology have been gradually applied to clinical practice.It is known that sternotomy and extracorporeal circulation can result in systemic inflammatory response syndrome after cardiac surgery,affecting the prognosis after cardiac surgery.Totally thoracoscopic atrial myxoma resection on perfused beating heart(TMB)avoid the huge trauma of thoracotomy,as well as the blockage of ascending aorta in extracorporeal circulation,cardiac arrest and myocardial protective fluid perfusion,and the ischemia and reperfusion injury of the heart.The study aims to verify the feasibility,safety,and effectiveness of TMB through experiment research.Research ObjectiveIn the study,the clinical data and follow-up of totally thoracoscopic atrial myxoma resection on perfused beating heart(TMB),totally thoracoscopic atrial myxoma resection on arrested heart(TMA)and median thoracotomy atrial myxoma resection(MTM)are compared so as to verify the feasibility,safety,and effectiveness of CAM resection under the totally thoracoscopic and perfused beating heart condition,and provide basis for the reasonable selection of surgical methods in clinical practice.Research MethodA total of 97 patients with CAM who received treatment in the Department of Cardiovascular Surgery,Qilu Hospital of Shandong University and The Department of Cardiovascular Surgery,Linyi People's Hospital Affiliated to Shandong University from January 2016 to June 2020 were selected.According to the type of surgery they received,all the cases were divided into TMB group,TMA group and MTM group.Patients in the TMB group underwent double-lumen endotracheal intubation,and they were taken with a pad height of 10-15° on the right side,with the right hand extending outsides after intravenous inhalation combined with anesthesia.Firstly,a hole was punched at the intersection point between the right axillary front and the median of sternum as the lens hole.A hole was punched between the second or third costal space and the median of the right clavicle as the left hand operating hole,and another hole was punched at the intersection of the 5th intercostal line and the lateral line of the right clavicle as the right hand operating hole.The obvious pulsation of the femoral artery below the abdominal sulcus dermatoglyph exposed the femoral artery and vein,where peripheral extracorporeal circulation was established.All the operations were finished with a beating heart.Patients in group TMA,operation was performed under cardiac arrest with ascending aorta blocked and Cardioprotective solution perfused,others are the same as TMB.As for MTM group,extracorporeal circulation was established according to ascending aorta intubation and routine cardiac arrest was conducted.The general information,operation duration,extracorporeal circulation time,aortic occlusion time,ventilator assisted time,ICU stay time,postoperative drainage volume,blood transfusion volume,postoperative hospital stay days and reexamination before discharge of the two groups were recorded.Besides,the data were input into IBM SPSS 20.0 software for analysis.ResultsThe 27 patients who received TMB had no perioperative death or major complications.Their extracorporeal circulation time was 50-168 minutes,with an average of(91.2±24.4)minutes.Their aortic occlusion time was 0,and the operation time was 100-218 minutes(averaging 158.8±34.7 minutes).Postoperative patients were assisted with ventilator for 2.9-16 hours,with an average of(6.4±3.2)hours.The treatment time in the ICU was 5-42 hours,averaging(17.2±8.8)hours.Besides,2 patients were injected with 2U suspended red blood cells respectively after the surgery,and the drainage volume was 10-500ml 24 hours after the surgery,averaging(76.0±92.0)ml.According to their echocardiography conducted by the postoperative care unit and cardiac echocardiography before discharge,there was no tumor residue and no aggravation of valve regurgitation.The short-term follow-up showed that there was no complication related to the surgery.Patients in the TMB group were significantly better than the MTM group in terms of operation time,aortic occlusion time,ICU stay time,postoperative hospital stay days and the first 24 hours of drainage;TMB group and TMA group had a significant difference in aortic block time.There is no significant difference between the three groups in terms of cardiopulmonary bypass time and ventilator assisted time.ConclusionTotally thoracoscopic atrial myxoma resection on perfused beating heart is feasible,safe and effective.The biggest advantage of group TMB is that it does not require longitudinal sternum sawing and cardiac arrest,avoids the trauma of median thoracotomy and heart ischemia-reperfusion injury.In addition,it is featured by small trauma,quick recovery,and good cosmetic effect of incision.According to the short-term follow-up,the patients undergoing TMB are satisfactory at the surgery results.Part Two:Post-operative quality of life of totally thoracoscopic atrial myxoma resection on perfused beating heartResearch BackgroundMinimally invasive cardiac surgery not only can reduce the trauma,but also guarantee the surgical effect.Totally thoracoscopic cardiac surgery technology on perfused beating heart is a novel minimally invasive cardiac surgery technique.Patients with CAM who undergo such surgery can recover more quickly.However,surgery is only the beginning of the treatment of diseases,and it still will have extensive and deep impact on patients after the completion of surgery.Due to postoperative impaired cardiac function,scar of incision,pain,impaired self-esteem,depressed mood,it is difficult for them to integrate into the surrounding environment,resulting in a series of negative results.For patients who undergo heart surgery,the surgery itself is only part of the treatment for their disease.The postoperative quality of life of patients is mainly assessed through SF-36 Scale(Item Short Form Health Survey),but it cannot effectively and thoroughly assess the impact of cardiac surgery on patients' physical health,mental health and other aspects.Quality of life(QoL)is defined by the World Health Organization as an individual's self-perception of his or her own living condition and satisfaction degree in the living environment,cultural background and value system.In the field of medicine,health-related Quality of Life(HRQoL)is defined as an individual's satisfaction and happiness with an important part of life that is affected by health,and it mainly reflects the quality of life affected by health,disease and treatment.With the improvement of human cognitive level,the range of health contains many aspects such as psychological,social relations and environmental adaptation instead of limiting to the disease-free state of body.The definition of health is constantly updating,and there is higher requirements for clinicians.Rather than limit to safety and effectiveness of treatment,the evaluation of a new treatment also included the improvement of the quality of life.Therefore,it is worthwhile to investigate whether patients undergoing TMB have a better quality of life than those undergoing TMA and MTM.Research ObjectiveIn the study,the follow-up results of patients undergoing TMB,TMA and MTM are compared so as to evaluate their quality of life,especially the differences in terms of physical health,mental health status,and then evaluate and analyze the possible reasons,and finally provide theoretical support for the application of TMB.Research MethodThe patients diagnosed with CAM in the Department of Cardiac Macrovascular Surgery,Qilu Hospital of Shandong University and Linyi People's Hospital Affiliated to Shandong University from January 2016 to June 2020,who received surgical treatment and had consistent postoperative pathological results with the diagnosis,were selected.According to the type of surgery they received,the subjects were divided into TMB group,TMA group and MTM group.The data were collected through online questionnaire,telephone follow-up and outpatient follow-up by using the following combined scales:1.Questionnaire for the General Information of Patients;2.Item Short Form Health Survey(SF-36);3.Patient Self-care Ability and Living Ability Assessment Scale(Barthel Assessment Scale);4.General Self-efficacy Scale(GSES)and Self Admission Questionnaire(SAQ).The subjects were asked to fill the scales more than 3 months after their operation treatment.The Scales were prepared with Changsha RanXing Information Technology Co.,Ltd.Questionnaire Star system(www.wjx.cn).Standard SF-36,Barthel Assessment Scale,GSES,SAQ were used.Personal general information was added,part of the operation data were filled in.besides,the subjects filled the scales online after scanning the related QR code through cell phone.To ensure the quality,some mandatory options were set and time limit of filling was controlled.The scales were summarized by the questionnaire star system to form a data table.The data were analyzed and compared by IBM SPSS Statistics 20.0 after finishing data collection.ResultsA total of 97 questionnaires were collected in the survey.There was no significant difference between the two groups in terms of gender,age distribution,marital status and personality.However,there were significant differences in terms of educational level.The statistics of preoperative and postoperative cardiac function showed that there was no significant difference in preoperative cardiac function classification between the two groups,suggesting that there was no obvious difference in preoperative cardiac function between the three groups.There were significant differences in the composition of cardiac function grades between the three groups after the surgery.TMB group had higher proportion(85.2%)of Grade I and II of cardiac function than TMA and MTM group,indicating that the subjects who had received TMB had better cardiac function recovery.Besides,the patients in the TMB and TMA group suffered obviously lower postoperative pain degree and lesspost-thoracotomy pain syndrome(PTPS).To be specific,48.2%patients in the TMB group and 56.0%patients in the TMA group suffered Grade 0 pain,while only 8.9%patients in the MTM group suffered Grade 0 pain;the proportion of TMB group and TMA group whose pain did not affect sleep and the proportion that needed to use painkillers were much lower than those of MTM group.The incidence of PTPS was 22.2%in TMB group,20.0%in TMA group and 66.7%in MTM group.According to the score analysis through Barthel Scale,70.3%of patients in the TMB group and 56.0%of patients in the TMA group had no dependence or mild dependence on self-care ability after the surgery,and 71.1%of patients in the MTM group had severe dependence,showing there was significant difference between the three groups.As shown in the SF-36 Scale,there were significant differences between the three groups in terms of physical component summary(PCS)and mental component summary(MCS),and the TMB group and MTA group scored higher in the two dimensions than the MTM group.After the surgery,the two groups had significantly different scores in general self-efficacy(GSE)and self admission(SA),showing that patients in the TMB group and TMA group had higher GSE and SA.ConclusionThe subjects undergoing TMB and TMA have better postoperative self-care ability,less postoperative pain,and lower incidence of PTPS.TMB group and TMA group have obviously higher quality of life(including PCS and MCS),self-efficacy and self-admission.Therefore,compared with conventional median thoracotomy,Thoracoscopic Heart Surgery has greater advantages in improving patients' self-care ability,reducing postoperative pain,and improving patients'quality of life,self-efficacy and self admission.The research results provide theoretical support to popularize the surgery technology.