대흉외지 2007;40:825-830 임상연구 승모판성형술에있어최소침습적수술방식과고전적정중흉골절개술을통한접근방식의비교 조원철 * ㆍ이재원 * ㆍ제형곤 * ㆍ김정원 ** Comparison of Mitral Valve Repair between a Minimally Invasive Approach and a Conventional Sternotomy Approach Won-chul Cho, M.D.*, Jae-Won Lee, M.D.*, Hyoung-Gon Je, M.D.*, Jeong Won Kim, M.D.** Background: Minimally invasive cardiac surgery appears to offer certain advantages such as earlier postoperative recovery and a greater cosmetic effect than that achieved through conventional sternotomy. However, this approach has not yet been widely adopted in Korea to replace complex open heart surgery such as mitral valve reconstruction. This study compared the results of robot assisted minimally invasive mitral valve repair with those results of conventional sternotomy. Material and Method: From December 1993 to December 2005, 520 consecutive patients underwent mitral valve reconstruction for mitral regurgitation in our institution. These patients were subdivided according to those whose surgery used the conventional sternotomy approach (Group S, n=432) and those who underwent minimally invasive right anterior thoracotomy (Group M, n=88); we then compared the clinical results of both groups. When we performed minimally invasive right thoracotomy, we used a robot (AESOP 3000) and made an incision less than 5 cm. Result: Our study patients in both groups were similar for their age, gender and preoperative ejection fraction. There were two hospital mortalities in group S. but there was no mortality in the group M patients. Significant reductions in the ICU stay and the postoperative hospital stay were observed in the group M patients compared with the group S patients. However, both the bypass time and the aortic cross-clamp time were significantly longer in the group M patients. In spite of the confined incision in the group M patients, there were no limitations on the mitral valve repair techniques. There was a similar frequency of postoperative significant residual mitral regurgitation in both groups. Conclusion: In this study, the minimally invasive mitral valve repair showed comparable early results with the conventional sternotomy patients. We will now need long-term follow-up of these patients who underwent minimally invasive mitral valve repair, but we anticipate that based on the results of this study, we will begin to routinely perform minimally invasive cardiac surgery as our primary approach for mitral valve reconstruction. Key words: 1. Mitral valve, repair 2. Mitral valve insufficiency 3. Minimally invasive surgery (Korean J Thorac Cardiovasc Surg 2007;40:825-830) * 울산대학교의과대학서울아산병원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine ** 울산대학교의과대학울산대학교병원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Ulsan University Hospital, University of Ulsan College of Medicine 본논문은대한흉부외과학회제 38 차추계학술대회에서구연되었음. 논문접수일 :2007 년 7 월 27 일, 심사통과일 :2007 년 9 월 29 일책임저자 : 이재원 (138-736) 서울시송파구풍납동 388-1, 서울아산병원흉부외과 (Tel) 02-3010-3580, (Fax) 02-3010-6811, E-mail: jwlee@amc.seoul.kr 본논문의저작권및전자매체의지적소유권은대한흉부외과학회에있다. 825
대흉외지 2007;40:825-830 서론최소침습적인수술방식은최근수년간여러외과분야에서비약적인발전을보였으며, 심혈관외과분야에서도역시예외는아니었다. 이는새로운수술기술및심폐기가동방법의발달로인해심장외과의로하여금전통적인정중흉골절개술을하지않고도심장판막수술을가능하게하였다 [1-3]. 수술후환자의빠른회복, 짧은입원기간, 수술후통증감소, 우수한미용적인효과등의많은장점으로인해최소침습적수술에대한요구도는점차커져가고있다 [4]. 수술용로봇을이용한심장수술에대한국내의연구는심방중격결손증등의치료에대해매우제한적으로보고되고있으나, 승모판막성형술과같이복잡한개심술에서의성적은아직국내에보고된바없다. 따라서, 본연구에서는승모판막폐쇄부전증환자군에서로봇을이용하여최소침습적우측개흉술을통해시행한승모판막성형술의유용성을정중흉골절개술과비교하여알아보고자하였다. 대상및방법 1) 대상환자 1993년 12월부터 2005년 12월까지본원에서승모판막성형술을시행한환자들은모두 948명이었다. 이중대동맥판막및관상동맥질환등이같이있는경우와승모판성형술을받은환자중수술전경흉부심초음파검사상승모판개구부의면적 (mitral valve area) 이 1.5 cm 2 미만이거나평균경승모판막압력차 (mean transmitral pressure gradient) 가 8 mmhg 이상으로승모판막협착의소견이있는환자는연구대상에서제외하였다. 따라서순수한승모판막폐쇄부전으로승모판막성형술을시행받은 520명의환자를연구대상으로하였다. 승모판막성형술과동반되어시행된삼첨판막성형술, 메이즈술식, 심방중격결손의첩포봉합술등의술식은승모판막성형술의성적에영향을주지않을것으로판단되어연구대상에포함하였다. 모든자료는후향적으로연구되었으며모든수술은단일술자에의해시행되었다. 연구대상인 520명의환자중정중흉골절개술을통하여승모판막성형술을시행받은 432명을 S군 (sternotomy group), 최소침습적우측개흉술을이용하여승모판막성형술을시행받은 88명을 M 군 (mini-thoracotomy group) 으로나누어비교하였다. Table 1. Preopertive characteristics Characteristic S (n=432) M (n=88) p value Incision Sternotomy Rt. minithoracotomy Age (yr) 47.1±14.7 44.9±14.8 NS Male:Female 207:225 41:47 NS EF (preoperative) 60.8±9.4 60.9±7.9 NS LVIDs (mm) 41.0±7.7 39.3±7.5 NS F/U duration (mth) 65.2±32.6 13.2±8.0 <0.01 MR+3 33 13 NS MR+4 399 75 NS S=Sternotomy; M=Mini-thoracotomy; EF=Ejection fraction; LVIDs= Systolic left ventricle dimension; F/U=follow up; MR=Mitral regurgitation; NS=Non-specific. 2) 최소침습적수술방법 본연구에사용된최소침습적수술방법의상세한방법은이미보고된바와동일하다 [5]. 두환자군의체외순환을위해사용된심폐기및막형산화기는동일하였다. 체외순환을위하여 S군에서는상행대동맥및상대정맥하대정맥에삽관하였으며, M군에서는대퇴동맥에동맥관을삽관하고, 정맥환류를위해서우측내경정맥및대퇴정맥에삽관하였다. 우측경정맥캐뉼라삽입은숙련된마취과의에의해경피적방법으로시술이되었고, 술후중환자실에서캐뉼라제거후단순압박으로지혈을시행하였다. 대퇴동맥및정맥의캐뉼라삽입을위해서는제한된피부절개 (2 2.5 cm) 로동맥과정맥을노출시킨후동맥관과정맥관을삽입하였고, 심폐기이탈후쌈지봉합술로동맥과정맥을지혈및보완하였다. 동ㆍ정맥관삽입시발생할수있는신경학적합병증예방을위해서수술전환자평가시경식도초음파상대동맥의석회화침착의정도가경증이하의경우만최소침습적수술을시행하였고, 중증이상인경우는정중흉골절개를통해수술하였다. 본연구는로봇을이용한최소침습적수술을시행한첫예부터연속적으로시행한 88예의환자에서자료를수집하였다. 3) 추적관찰 모든환자군에서승모판성형술후 1주이내에경흉부심초음파검사를시행하였고, 술후 6개월, 1년그리고이후매년경흉부심초음파로추적관찰하였다. 수술후 826
조원철외 Minimally Invasive Mitral Valve Repair Table 2. Postoperative characteristics S (n=432) M (n=88) p value M-1 (n=44) M-2 (n=44) p value* p value CPB time (min) 119.2±41.9 139.0±39.8 <0.01 151.7±37.7 126.3±38.1 <0.01 NS ACC time (min) 85.1±31.0 95.0±27.3 <0.01 100.9±24.7 89.1±28.7 <0.01 NS ICU stay (d) 3.3±2.2 1.9±1.6 <0.01 LOS (d) 11.4±8.4 7.0±3.3 <0.01 *p value=the comparison between group M-1 and group M-2; p value=the comparison between group M-2 and group S; S=Sternotomy; M=Mini-thoracotomy; M-1=The 1st half of group M; M-2=The 2nd half of group M; CPB=Cardiopulmonary bypass; ACC=Aortic cross clamp; ICU=Intensice care unit; LOS=Length of stay; NS=Non-specific. Table 3. Immediative follow-up echocardiographic data after the operation F/U immediate S (n=432) M (n=88) p value EF (%) 50.3±11.0 51.6±10.3 NS LA (mm) 44.6±8.4 43.6±8.3 NS LVIDs (mm) 39.1±8.2 37.8±7.4 NS LVIDd (mm) 53.5±7.6 53.3±6.6 NS S=Sternotomy; M=Mini-thoracotomy; NS=Non-specific; LA=Left atrium; LVIDs=Systolic left ventricle dimension; LVIDd=Diastolic left ventricle dimension. Table 4. Last follow-up echocardiographic data after the operation F/U Last S (n=432) M (n=88) p value EF (%) 57.8±8.6 58.2±6.8 NS LA (mm) 45.8±8.7 42.2±8.1 <0.01 LVIDs (mm) 34.0±7.4 33.9±5.8 NS LVIDd (mm) 50.7±6.7 50.7±6.1 NS S=Sternotomy; M=Mini-thoracotomy; NS=Non-specific; LA=Left atrium; LVIDs=Systolic left ventricle dimension; LVIDd=Diastolic left ventricle dimension. 최종심초음파관찰시점까지의간격을추적관찰기간으로정의하였으며, 잔존하는승모판막폐쇄부전은최근추적한심초음파검사상 2도를초과하는판막역류가있는경우를의미있는것으로보았다. 4) 통계분석본연구의통계학적분석은 SPSS 12.0 (SPSS Inc., Chicago, IL, USA) 을이용하였다. 양군간의연속변수자료는평균값 ± 표준편차로표시하였고, 독립표본 T-검정 (independent T-test) 으로비교하였으며, 범주형변수의비교를위하여 Chi-Square 혹은 Fisher의정확한검정을이용하였다. 유의수준이 0.05 이하일때통계학적으로유의한차이가있는것으로하였다. 결과양군간의나이, 성별, 수술전좌심실구출률등은서로차이가없었고, 추적관찰기간은 S군에서유의하게길었다 (Table 1). S군에서 2예의조기사망이있었으나 M군에서는사망예가없었다. S군에서발생한 2예의조기사망은모두수술후저심박출증후군이사망원인이었다. M군의 환자중수술중원하지않는문제가발생하여정중흉골절개술로전환하였던경우는없었다. 추적관찰기간은 S 군이 65.2±32.6개월, M군이 13.2±8.0개월이었다. M군이대동맥차단 (aortic cross clamp) 시간과심폐기가동 (cardiopulmonary bypass) 시간은 S군에비해길었지만, 중환자실재원기간과수술후재원일수는 S군에비해유의하게짧았다 (Table 2). M군에서숙련도에따른수술시간을비교하기위하여전반기 44명 (the 1st half of group M: M-1) 과후반기 44명 (the 2nd half of group M: M-2) 의대동맥차단시간과체외순환시간을비교했을때, M-2군에서대동맥차단시간과체외순환시간이유의하게감소하였다. 또한 M-2군의대동맥차단시간및체외순환시간은 S군과유의한차이를보이지않았다 (Table 2). 수술직후에시행한심초음파검사와최종심초음파에서양군간의좌심구출률, 좌심방의직경, 좌심실의수축시직경및좌심실의이완기시직경등에서유의한차이는보이지않았다 (Table 3, 4). 잔존승모판막폐쇄부전은, 수술직후시행한심초음파상 S군에서 5예 (1.2%), M군에서 2예 (2.3%) 가관찰되었으며, 술후 6개월에시행한초음파검사상 S군에서 17예 (4.8%), M군에서 2예 (2.5%) 가관찰되었고, 술후 1년째시 827
대흉외지 2007;40:825-830 Table 5. Residual mitral regurgitation after mitral valve repair MR>Mild S M p value After 1 week 5 (1.2%) 2 (2.3%) NS n=432 n=88 After 6 months 17 (4.8%) 2 (2.5%) NS n=349 n=80 After 12 months 20 (9.6%) 2 (5.8%) NS n=209 n=34 MR=Mitral regurgitation; S=Sternotomy; M=Mini-thoracotomy; NS=Non-specific. 행한초음파검사에서는 S군에서 20예 (9.6%), M군에서 2 예 (5.8%) 가관찰되었지만, 양군간에유의한차이를보이지않았다 (Table 5). 잔존승모판막폐쇄부전으로재수술을시행한경우는 S군은 7예 (1.6%), M군에서는 1예 (1.1%) 였다. 잔존승모판막폐쇄부전으로재수술을한경우에서, 근본적인승모판막폐쇄부전증의원인을살펴보면, S군에서발생한 7예중 5예는승모판막폐쇄부전의원인이퇴행적 (degenerative) 이었고 2예는류마티스성이었으며, M군에서 1예는폐쇄부전의원인이 cleft였다. 재수술까지의평균기간은 S군은 44개월 (10 101개월) 이고 M군은 24개월이었다. 승모판막성형술시에사용한술식에서판막륜성형술 (annuloplasty) (S군:84%, M군 :97%) 과신건삭형성술 (new chorda formation) (S군:17%, M군 :51%) 은 S군에비해 M군에서유의하게많았다. 승모판막사각및삼각절제술 (Q/T resection), 승모판막교련절개술 (commissurotomy), Alfieri법및건삭전이술 / 단축술 (chordae transfer/shortening) 등의술식은양군에서유사한정도로시행되었다 (Table 6). M군에서말초삽관과관련된신경학적손상및혈관적인손상은없었으나, M군환자중 1예에서수술후통증관리목적으로수술전경막외마취카테터를삽입한후경막주변에혈종으로인해양하지의부분적마비가있었다. 하지마비는경막외혈종의감소에따라회복되어잔존하는후유증없이퇴원할수있었다. 이후환자의통증감소를위해경막외마취가아닌늑간신경냉동차단술과정맥내통증조절기를이용하고있다. 고 기존의심장수술은정중흉골절개를통한접근법이주종을이루고있는데이방법은상처를많이남길뿐아니 찰 Table 6. The techniques of mitral valve repair Technique S (n=432) M (n=88) p value Annuloplasty 366 (84%) 86 (97%) <0.01 Commissuroplasty 43 (9%) 18 (20%) NS NCF 73 (17%) 45 (51%) <0.001 Q/T resection 97 (22%) 24 (27%) NS Alfieri 2 (0.4%) 2 (2.2%) NS Chordae transfer/ shortening 29 (7%) 3 (3%) NS S=Sternotomy; M=Mini-thoracotomy; NS=Non-specific; NCF= New chorda formation; Q/T=Quadrangular/Triangular. 라수술후회복과관련하여흉골상처의감염이나종격동염등으로병원재원일수를연장시키는원인이되기도한다 [6]. 이에반해 1996년이후시행되고있는최소침습적심장수술방법들은상처감염의감소, 입원기간의단축, 빠른회복, 미용효과의증진등의만족스러운결과를보여주고있다 [4,7,8]. 1997년등장한심장수술로봇 AESOP 3000은술자의음성을인식한로봇이수술내시경을이동시켜, 안정적인수술시야를제공하는장비로고식적인수술방법에비해작은상처만으로만족할만한수술결과들을가져다주었다 [9-12]. 본저자들은국내최초로수술용로봇을이용하여승모판막질환, 대동맥판막질환, 심방중격결손증에대한수술및최소침습적관상동맥우회술 (MIDCAB) 을시행하여그초기결과를이미보고하였다 [5]. 최소침습적우측개흉술은소아또는젊은사람들에서심방중격결손증의수술을위해처음으로제안되었다 [8]. 심장수술에서최소침습적우측개흉술의목적은수술후유병율을줄이고조기퇴원을증진시키는데있는데, 몇몇의저자들이판막수술에있어최소침습적수술과정중흉골절개술을비교연구하여이런주장을뒷받침하였다 [13,14]. 본연구에서도 M군이중환자실재원기간과수술후재원일수가 S군에비해유의하게짧았으며, 수술후의결과도 S군과비교하여유의하게다른차이를보이지않았다. 그러나로봇을이용한최소침습적수술의남아있는문제점들중하나로증가된대동맥차단시간과체외순환시간을들수있다. 즉최소침습적수술의경우수술적방법이복잡하고시간이많이걸린다는견해들이있다 [4,15]. 그렇지만또다른저자들은수술이숙련됨에따라대동맥차단시간과체외순환시간은감소될것이라고 828
조원철외 Minimally Invasive Mitral Valve Repair 주장하고있다 [16]. 본연구에서도 M군을 S군과비교해보았을때대동맥차단시간및체외순환시간이 10 20분정도길었으나최소침습적우측개흉술의도입초기부터모든환자를대상으로한연구인점을감안하면수긍할만한수치라고생각한다. 또한본연구에서 M-1군과 M-2 군을비교했을때 M-1군에서대동맥차단시간과체외순환시간이유의하게감소하였으며, M-2군과 S군을비교해보았을때유의한차이가없는것으로보아숙련된최소침습적승모판막성형술은대동맥차단시간및체외순환시간을증가시키지는않을것으로생각한다. 제한된절개를통한최소침습적수술방법과고전적인절개를통한수술방법을비교하였을때, 최소침습적수술방법을통해서도승모판막성형술의여러술식을제한없이시행할수있는지에의구심을갖는주장도있다 [17]. 그러나몇몇의보고자들은최소침습적수술방법으로도승모판막성형술식에제한이없다고주장하였다 [17]. 본연구에서도양군간에승모판막성형술에시행된술식에는차이가없었으며오히려 M군에서신건삭형성술과같이기술적인숙련도가요구되며수술시간을연장시킬수있는성형술식이더많이시행되었다. 따라서로봇을이용한최소침습적승모판막성형술은정중흉골절개술과비교하였을때제한이없다고생각한다. 몇몇보고자들의연구를분석하면최소침습적수술을하는데있어여성보다는흉곽이더큰남성을, 나이가많은사람보다는젊은사람을선호하는경향을나타내기도하였으나 [18,19], 본연구결과를살펴보면양군간의성별, 나이가서로유사하여 (Table 1) 최소침습적승모판막성형술의대상으로젊은환자나남자환자를선호하지는않는것을알수있다. 본원에서는승모판막성형술시최소침습적심장수술을일차적인수술방법으로적용하고있으며, 유일한제외대상으로대동맥판막수술이나관상동맥우회술을필요로하는경우나술전경식도심초음파상중등도이상의하행대동맥죽상경화증이발견된경우를들수있다. 최소침습적심장수술을시행함으로인하여과도한의료비의상승의우려할수있으나본연구결과에서처럼중환자실재원기간을 1일이상단축시키고, 수술후재원기간을 4일이상단축시켜최소침습적심장수술과관련된의료비의상승요인을상쇄할수있다. 나아가환자의빠른회복및재원기간의단축은제한된병상하에서병상회전율을상승시키는장점이있다. 본연구는정중흉골절개술을시행받은대조군 (S군) 에 비해실험군인최소침습적우측개흉술 (M군) 의환자수가현저하게적으며, 단일술자에의한연대기적수술방법간의비교라는제한점이있다. 그러나앞으로최소침습적심장수술을시행받는환자군은증가할것이고, 수술의숙련도를요하는승모판막성형술식의특수성을고려해볼때단일술자에의해시행된수술결과를비교하는것이접근방법에따른차이를규명하는데가장적합한연구모델일것이다. 결 로봇을이용한최소침습적승모판막성형술은정중흉골절개술에비해대동맥차단시간과심폐기가동시간은더길었지만이는숙련됨에따라개선되었고, 중환자실재원기간과총재원일수는유의하게짧았다. 절개를최소화하여우측개흉술을통한승모판막성형술을시행하더라도술식의구사에는제한이없었으며수술의성적은유사하여만족할만한조기성적을보였다. 향후최소침습적승모판막성형술의중-장기성적의관찰을요하며본연구를바탕으로승모판막성형술의일차적인접근방법으로최소침습적개흉술이보다폭넓게시행될수있을것으로기대한다. 론 참고문헌 1. Gulielmos V, Wagner FM, Waetzig B, et al. Clinical experience with minimally invasive coronary artery and mitral valve surgery with the advantage of cardiopulmonary bypass and cardioplegic arrest using the port access technique. World J Surg 1999;23:480-5. 2. Gillinov AM, Cosgrove DM. Minimally invasive mitral valve surgery: mini-sternotomy with extended transseptal approach. Semin Thorac Cardiovasc Surg 1999;11:206-11. 3. Glower DD, Komtebedde J, Clements FM, Debruijn NP, Stafford-Smith M, Newman MF. Direct aortic cannulation for port-access mitral or coronary artery bypass grafting. Ann Thorac Surg 1999;68:1878-80. 4. Cohn LH, Adams DH, Couper GS, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg 1997;226:421-8. 5. Cho SW, Chung CH, Kim KS, et al. Initial experience of robotic cardiac surgery. Korean J Thorac Cardiovasc Surg 2005;38:366-370. 6. Gummert JF, Barten MJ, Hans C, et al. Mediastinitis and cardiac surgery: an updated risk factor analysis in 10,373 829
대흉외지 2007;40:825-830 consecutive adult patients. Thorac Cadiovasc Surg 2002; 50:87-91. 7. Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-7. 8. Navia JL, Cosgrove DM. Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542-4. 9. Mohr FW, Falk V, Diegeler A, Walther T, van Son JA, Autschbach R. Minimally invasive port access mitral valve surgery. J Thorac Casrdiovasc Surg 1998;115:567-74. 10. Falk V, Walther T, Austschbach R, Diegeler A, Battellini R, Mohr FW. Robotic-assisted minimally invasive solo mitral valve operation. J Thorac Casrdiovasc Surg 1998; 115:470-1. 11. Felger JE, Chitwood WR Jr, Nifong LW, Holbert D. Evolution of mitral valve surgery: toward a totally endoscopic approach. Ann Thorac Surg 2001;72:1203-9. 12. Vanerman H, Wellens F, De Geest R, et al. Video-assisted port-access mitral valve surgery. Will trocar-portaccess cardiac surgery ultimately lead to robotic cardiac surgery? Semin Thorac Cardiovasc Surg 1999;3:223-34. 13. Grossi EA, LaPietra A, Ribakove GH, et al. Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate-term results. J Thorac Cardiovasc Surg 2001;121:708-13. 14. De Vaumas C, Philip I, Daccache G, et al. Comparison of minithoracotomy and conventional sternotomy approaches for valve surgery. J Cardiothorac Vasc Anesth 2003;17:325-8. 15. Loulmet DF, Carpentier A, Cho PW, et al. Less-invasive techniques for mitral valve surgery. J Thorac Cardiovasc Surg 1998;115:772-9. 16. Jones BA, Krueger S, Howell D, Meinecke B, Dunn S. Robotic mitral valve repair. Tex Heart Inst J 2005;32: 143-6. 17. Greelish JP, Cohn LH, Leacche M, et al. Minimally invasive mitral valve repair suggests earlier operations for mitral valve disease. J Thorac Cardiovasc Surg 2003;126: 365-73. 18. Mishra YK, Malhotra R, Mehta Y, Sharma KK, Kasliwal RR, Trehan N. Minimally invasive mitral valve surgery through right anterolateral minithoracotomy. Ann Thorac Surg 1999;68:1520-4. 19. Aybek T, Dogan S, Risteski PS, et al. Two hundres forty minimally invasive mitral operations through right minithoracotomy. Ann Thorac Surg 2006;81:1618-24. = 국문초록 = 배경 : 최소침습적심장수술은전통적인정중흉골절개술에비해수술후조기회복및우수한미용적효과등의장점이있지만승모판막성형술과같이복잡한개심술에서의성적은아직국내에보고된바없다. 본연구에서는승모판폐쇄부전증의환자군에서로봇을이용한최소침습적승모판성형수술의유용성에관해정중흉골절개술과비교하여알아보고자하였다. 대상및방법 : 1993 년 12 월부터 2005 년 12 월까지승모판막폐쇄부전으로승모판막성형술을시행받은 520 명의환자를연구대상으로하였다. 이중정중흉골절개술을통하여승모판성형술을시행한군을 S 군 (n=432), 최소침습적우측개흉술을이용한환자군을 M 군 (n=88) 으로하여임상결과를비교하였다. 우측개흉술시에는 AESOP (Automated Endoscopic System for Optimal Positioning) 3000 이라는로봇을이용하여 5 cm 이하의절개로수술을시행하였다. 결과 : 양군간의나이, 성별, 수술전좌심실구출률등은양군간의차이는없었다. S 군에서 2 예의조기사망이있었으나 M 군에서는수술사망예가없었다. M 군이대동맥차단시간과심폐기가동시간은 S 군에비해유의하게길었지만, 중환자실재원기간과수술후재원일수는 S 군에비해유의하게짧았다. 제한된절개에도 M 군에서승모판막성형술식에사용된수술술기는제한이없었으며, 술후의미있는잔존승모판막폐쇄부전증의빈도는양군에서유사하였다. 결론 : 최소침습적우측개흉술을통한승모판막성형술을시행하더라도조기성적은차이가없었다. 향후최소침습적승모판막성형술의중 - 장기성적의관찰을요하며본연구를바탕으로승모판막성형술의일차적인접근방법으로최소침습적개흉술이보다폭넓게시행될수있을것으로기대한다. 중심단어 :1. 승모판막성형술 2. 승모판막폐쇄부전증 3. 최소침습적수술 830