RU2562104C1 - Method for replacing endocardial electrodes of implanted antiarrhythmic devices after orthotopic cardiac transplantation by biatrial technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: endocardial electrodes of a deimplanted antiarrhythmic device are cross-sectioned. A recipient's heart is removed together with proximal segments of the sectioned endocardial electrodes. Distal segments of the sectioned endocardial electrodes and a generator of the antiarrhythmic device are left in an original projection. They are removed and replaced simultaneously with re-implanting a new stimulation system not earlier than three weeks after the cardiac transplantation. The new endocardial electrodes are implanted with the use of stiletto holes of the distal segment of the endocardial electrodes, wherein a guide wire is delivered up to a point of the expected implantation of the endocardial electrode; thereafter, the distal segment of the sectioned electrode is removed by traction along the guide wire.

EFFECT: method enables increasing safety and increasing the number of complications accompanying replacing the endocardial electrodes of the implanted antiarrhythmic devices.

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Description

The invention relates to medicine, namely to cardiovascular surgery, and can be used in interventional arrhythmology for the treatment of life-threatening rhythm disturbances in patients after orthotopic heart transplantation using a biatrial technique.

Currently, considerable attention is being paid to the problem of replacing pacemakers and deimplantation of compromised endocardial electrodes (EEs), this is also associated with an increase in the total number of implants, which exceeded 1 million in the world, and an increase in the number of two- and three-chamber EXs. Complications of ECS replacement include infection, electrode damage, and asystole during the switch from the old to the new generator. Moreover, to date, the American College of Cardiology (ACC), together with the American Heart Association (AHA), have developed recommendations for the removal of EE EX.

A known method of surgical removal of endocardial electrodes for continuous pacemaking (L. Bokeria. Experience of surgical removal of endocardial electrodes for continuous pacing / L.A. Bokeria, A.Sh. Revishvili, A.A.Dyuzhikov, G.V. Chudinov // Annals arrhythmology. - 2006. - No. 2. - P.78-81), in which, under conditions of cardiopulmonary bypass using open coronary access, the electrodes are excised along with the fibrous perielectrode capsule. The disadvantage of this method is a significant increase in the risk of bleeding and fatal thromboembolic complications.

A known method of interventional mechanical deobliteration of endocardial electrodes (Byrd CL Is there an optimal method of lead extraction? // Cardiac Pacing: New advances / Ed. M. Rosenqvist. - Philadelphia: WB Saunders Co., 1997. - P.293-317) . The method includes the use of an active tip of the telescopic system that destroys the fibrous perielectrode tissue by laser irradiation, after which the extraction of the electrodes is carried out by counter-attraction through the telescopic system.

The disadvantage is that the clinical application of this method is accompanied by the development of life-threatening complications, such as injuries of the heart chambers and blood vessel walls, accompanied by hemopericardium and hemothorax, in addition, detachment of electrode fragments is possible during traction. Finally, the efficiency of using telescopic systems is not more than 89%.

At the same time, issues of replacing EE in a patient with rhythm disturbances after orthotopic heart transplantation are not well understood and require a special approach. When performing heart transplantation using a biatrial technique, on average three weeks after surgery, approximately 30-35% of patients require re-implantation of permanent endocardial systems, mainly due to bradyarrhythmias. This is due to the fact that the main pacemaker (sinus node) of the recipient is electrically isolated from the right atrium of the donor heart by a seam connecting the right atrium of the hearts of the donor and the recipient.

Closest to the claimed one is a method of removing electrodes for continuous pacemaking, in which, under the conditions of normothermic parallel cardiopulmonary bypass (IR), a right-sided transverse atriotomy is performed and, under direct visual control, the intra-atrial part of the endocardial electrode is mobilized from the cicatricial fusion and intersected, separating the proximal (Chudinov G.V. A method for removing electrodes for continuous pacing using parallel of cardiopulmonary bypass / G.V. Chudinov, A.V. Ponomarev, A.S. Dodonov // Bulletin of Arrhythmology. - 2013. - No. 73. - p. 64), after which the distal part of the EE together with the EX is removed by traction through a wound in the projection of the ECS bed, and the proximal segments of the right ventricular EE are removed using mechanical traction. A segment of the proximal end of the EE is passed through a specially made wire loop, while simultaneously pulling the electrode, immersing the loop in the right ventricle, shifting it to the point of electrode-endocardial contact.

The disadvantage of the prototype is that on the background of immunosuppressive therapy in the postoperative period, the healing of the postoperative wound is much worse, the risk of developing local infectious complications associated with leaving an empty bed of the antiarrhythmic device after removing the latter is increased. In addition, with the subsequent reimplantation of a new stimulation system in the process of conducting EE through altered tissues of the subclavian region, complications such as bleeding, arteriovenous fistulas, pneumothorax, etc. may develop.

The technical result of the invention is to increase safety and reduce the number of complications when replacing EE of implantable antiarrhythmic devices after orthotopic heart transplantation using a biatrial technique.

The technical result is achieved due to the fact that during the cardiectomy of the recipient, the endocardial electrodes of the deimplantable antiarrhythmic device cross at the mouth of the superior vena cava and the heart is removed along with the proximal segments of the electrodes. The distal segments of the dissected electrodes and the generator are left in the initial position, and their removal or replacement is carried out after three weeks of the postoperative period.

A method is proposed for replacing EE of implantable antiarrhythmic devices after orthotopic heart transplantation using a biatrial technique, including transverse dissection of EE of a deimplantable antiarrhythmic device at the level of the superior vena cava vein, removing the recipient’s heart along with the proximal segments of the dissected endocardial electrodes and performing donor allograft implantation.

The difference is that the distal segments of the dissected endocardial electrodes and the generator of the antiarrhythmic device are left in the original projection, and their removal and replacement is performed no earlier than three weeks after heart transplantation, while reimplantation of the new stimulation system is carried out simultaneously with the removal of the distal segments of the endocardial electrodes and generator antiarrhythmic device. New endocardial electrodes are conducted along conductors inserted through the stylet shaft inside the distal segments of the left endocardial electrodes.

The early postoperative period is the most difficult and responsible in adapting the donor heart to new conditions of functioning. Despite the apparent effectiveness and power of the transplanted organ, almost all patients in the postoperative period show rhythm disturbances (supraventricular in 81.2% and ventricular in 87.5%). Along with abnormalities in the rhythm of the donor heart, patients quite often register arrhythmias of the remaining part of the recipient's atria, weak sinus syndrome. Some patients may need reimplantation of regular pacemakers.

If a patient develops life-threatening rhythm and / or conduction disturbances after heart transplantation, the implantation of a new stimulation system is carried out simultaneously with the removal of the distal segments of the left endocardial electrodes. Before removing the old system, the generator of the antiarrhythmic device is first disconnected from the distal segments of the dissected endocardial electrodes. New endocardial electrodes are installed along conductors inserted through stylet shafts inside the distal segments of the endocardial electrodes.

The invention is illustrated by drawings, where in FIG. 1 shows the arrangement of elements of the antiarrhythmic device in the heart of the recipient before performing the method, where 1 is the generator of the antiarrhythmic device, 2 is the heart of the recipient, 3 is the endocardial electrodes; in FIG. 2 shows a dissection of endocardial electrodes 3 into distal 4 and proximal 5 segments; in FIG. 3 shows an arrangement diagram of an antiarrhythmic device 1 with distal 5 segments of EE and a donor heart 6; in FIG. 4 shows a diagram of a distal 4 EE segment, where 7 is a conductor, 9 is a shaft for a stylet; in FIG. 5 shows the introduction of the conductor 7 into the distal 4 segment of the EE to the right ventricle of the transplanted donor heart 6; in FIG. 6 shows the installation of a replaceable endocardial electrode 10 along conductor 7; in FIG. 7, a replaceable electrode 10 is installed in the right ventricle of an allograft 6.

The method for replacing the endocardial electrodes of implantable antiarrhythmic devices after orthopedic heart transplantation consists of two time-delayed stages.

At the first stage, during cardioectomy in the recipient, the endocardial electrodes 3 of the antiarrhythmic device 1 intersect at the level of the mouth of the superior vena cava, thus dividing them into distal 4 and proximal 5 segments. The heart of the recipient 2 is removed together with the proximal segments of the endocardial electrodes 5 of the deimplantable antiarrhythmic device 1.

After this, transplantation of the donor heart is performed 6. The distal segments 4 of the dissected endocardial electrodes 3 and the antiarrhythmic device 1 are left in the same place, completing the surgical stage of transplantation. In the postoperative period, the patient is corrected for hemodynamics, immunosuppressive therapy and antibiotic therapy are prescribed.

Three weeks after transplantation, the second stage is performed. If there is no need for re-implantation of the antiarrhythmic device with electrodes, the antiarrhythmic device 1 is removed together with the distal segments 4 of the dissected endocardial electrodes 3.

In the case of a positive decision on the need for reimplantation of a new stimulation system, the antiarrhythmic device 1 is removed by first disconnecting it from the distal segments 4 of the dissected endocardial electrodes 3.

The subsequent implantation of new endocardial electrodes 10 is carried out using shafts 9 for the stylet of the distal segment 4 of the endocardial electrodes 3, along which the conductor 7 is guided to the site of the implanted endocardial electrode 10. Then, the distal segment 4 of the dissected electrode is removed by traction along the conductor 7 (technique also known like "over-the-wire"), leaving the latter in the same position. Next, implantation of a new endocardial electrode 10 is carried out by conducting it along conductor 7 using the over-the-wire technique with or without a bursting introducer, also pre-installed along conductor 7.

After implantation of the electrode 10 with passive fixation, the conductor 7 is removed by traction. In the case when an endocardial electrode 10 with active fixation is implanted, its screw tip extends, after which the conductor 7 is removed by traction.

Thus, the introducer sheath and the new endocardial electrode 10 are guided along the previously formed bed, eliminating the need for repeated catheterization of the subclavian vein and the introduction of the introducer sheath and endocardial electrode 10 through fibrously altered and calcified subclavian tissue. Due to this, the risk of local complications (bleeding, arteriovenous fistula, pneumothorax, etc.) is reduced. If it is necessary to implant more than one endocardial electrode, the rest are implanted in the same way. In the future, the connection of newly implanted endocardial electrodes to the antiarrhythmic device is carried out in the usual way; the generator of the antiarrhythmic device is also implanted in a previously formed bed.

The technique can be used in all patients, allowing to improve the healing of the postoperative wound, reduce the risk of developing local infectious complications after removing the antiarrhythmic device with endocardial electrodes, and also reduce the risk of complications of subsequent re-implantation of the antiarrhythmic device with endocardial electrodes.

Example 1. Patient 3., 52 years old, was in the department of cardiovascular surgery from 01/14/2013 to 03/14/2013 with the terminal stage of chronic heart failure on the background of dilated cardiomyopathy. Earlier, for the purpose of primary prevention of sudden cardiac death, she underwent implantation of a single-chamber cardioverter-defibrillator with an endocardial electrode in the right ventricle.

01/15/2013, the patient underwent orthotopic heart transplantation according to a biatrial technique in conditions of cardiopulmonary bypass and anterograde crystalloid cardioplegia. Right before transplantation of the recipient’s heart, a right-sided transverse atriotomy was performed, an intraatrial section of the endocardial electrode from the cicatricial fusion was mobilized under direct visual control and divided, thus dividing it into the proximal and distal segments. After that, the distal part of the EE together with the cardioverter-defibrillator is removed by traction through the wound in the projection of the bed of the antiarrhythmic device. The proximal segment of EE, since it was not necessary to separate it from the recipient's heart, was explanted with the latter.

Then, the implantation of a donor heart was performed, disruption of cardiopulmonary bypass, hemming to the right atrium and right ventricle of the electrodes for temporary pacemaking, reduction of the edges of the pericardium and layer-by-layer suturing of the sternotomy wound with sternum osteosynthesis and drainage of the pericardium. At once, the bed of the previously implanted antiarrhythmic device was sutured tightly.

Due to the adequate chronotropic function of the transplant, the electrodes for temporary pacing were removed on the third day after the operation. However, by the end of the second week of the postoperative period, the patient noted the development of sinus bradycardia, which was an indication for implantation of a permanent endocardial EX. However, in the process of catheterization of the left subclavian vein, damage to the artery of the same name occurred, which led to the development of a hematoma in the left supraclavicular and subclavian region, despite the preventive measures taken. It was decided to refrain from continuing implantation on the right side. A decision was made to implant the device from the “unsuccessful” right side (the patient was right-handed).

In the process of catheterization of the right subclavian vein for implantation of new endocardial electrodes, pleura was damaged in the apex of the lung, resulting in the onset of intense pneumothorax. In this regard, puncture drainage of the right pleural cavity was carried out urgently, after which the EX was nevertheless implanted in the right subclavian region.

In the immediate postoperative period, local inflammatory events were noted in the area of the bed of the implanted EX, requiring repeated puncture drainage and the appointment of combined antibacterial therapy.

The patient was discharged 03/14/2013 due to the fact that the complications that occurred required an extension of hospitalization for three weeks compared with the planned discharge date.

Six months after the reimplantation of EX, the patient suffered an injury to the right lower limb, and therefore was forced to walk for more than six months, resting her right hand on a cane. This led to myopotential inhibition of ECS, which was resolved by adjusting the device program.

In this clinical case, the implementation of the reimplantation of EX using the prototype method led to four sequentially developing complications (hematoma, pneumothorax, bed inflammation, myopotential inhibition), which required an extension of hospitalization and then correction of the EX program.

Example 2. Patient P., 45 years old, was in the department of cardiovascular surgery from 12/30/2012 to 01/28/2013 with the terminal stage of chronic heart failure on the background of ischemic cardiomyopathy. Earlier, for the purpose of primary prevention of sudden cardiac death, he underwent implantation of a two-chamber cardioverter-defibrillator with endocardial electrodes in the right ventricle and right atrium.

12/31/2012 the patient underwent orthotopic heart transplantation according to a biatrial technique in conditions of cardiopulmonary bypass and anterograde crystalloid cardioplegia. Immediately prior to the implantation of the recipient’s heart, a transverse dissection of the endocardial electrodes of the previously implanted cardioverter-defibrillator at the mouth of the superior vena cava was performed with further removal of the recipient’s heart along with the proximal segments of the dissected endocardial electrodes. Then, the implantation of a donor heart was performed, disruption of cardiopulmonary bypass, hemming to the right atrium and right ventricle of the electrodes for temporary pacemaking, reduction of the edges of the pericardium and layer-by-layer suturing of the sternotomy wound with sternum osteosynthesis and drainage of the pericardium.

In the immediate postoperative period, chronotropic incompetence was observed against the background of low cardiac output syndrome (the stroke volume of the donor heart turned out to be half that of the recipient's heart) with a relatively normal function of the natural pacemaker. The decrease in the minute volume of blood circulation and cardiac output was compensated by the operation of the temporary pacemaker system at a frequency of 90-100 pulses per minute. On the second day, drainage was removed. Within a week, the pumping function of the heart, adequate to the needs of the body, was achieved against a background of spontaneous atrial rhythm, in connection with which the electrodes for temporary pacing were removed. At the end of the second week of the postoperative period, bradycardia began to progress, for which 01/21/2013 simultaneous deimplantation of a cardioverter-defibrillator was performed along with distal segments of dissected endocardial electrodes and simultaneous implantation of a permanent cardiac pacing system with endocardial electrodes into the right ventricle and the right atrium according to the proposed method.

In the postoperative period, no complications were observed, the wounds healed by first intention, on January 28, 2013 the patient was discharged in satisfactory condition.

Over the next year, the observation of complications, including local ones, was not recorded. Twice, the function of the implanted endocardial system of constant pacing was tested, which showed its normal functioning.

In this clinical case, the implementation of the proposed method made it possible to effectively replace the endocardial electrodes of implantable antiarrhythmic devices after orthotopic heart transplantation using a biatrial technique, while avoiding local complications.

The proposed method was used on 6 patients, as a result of which data were obtained on its high efficiency and safety.

Claims (1)

A method for replacing endocardial electrodes of implantable antiarrhythmic devices after orthotopic heart transplantation using a biatrial technique, including transverse dissection of endocardial electrodes of a deimplantable antiarrhythmic device, removing the recipient’s heart together with proximal segments of dissected endocardial electrodes and performing implantation of allocardial donor endografts, which differ antiarrhythmic mouth generator the moles are left in the initial projection, and their removal and replacement is performed simultaneously with the reimplantation of a new stimulation system no earlier than three weeks after heart transplantation; wherein, the replaceable endocardial electrodes of the reimplanted device are conducted along conductors installed through the stylet shaft inside the distal segments of the left endocardial electrodes.

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