RU206049U1 - Papillary muscle retractor hook - Google Patents

Abstract

The useful model relates to the field of cardiac surgery, namely to surgical instruments for abduction of the papillary muscles. The technical result is to ensure optimal efficiency of the surgical intervention and the elimination of operational complications. The technical result is achieved by the fact that the hook-retractor for the papillary muscles consists of a handle connected to a rod, ending in two arms of equal length, bent into a semicircle in a plane perpendicular to the plane of the rod.

Description

Technology area

The useful model relates to the field of cardiac surgery, namely to surgical instruments for abduction of papillary muscles.

State of the art

Hypertrophic cardiomyopathy (HCM) is a hereditary heart disease characterized by hypertrophy of the ventricular myocardium, lack of enlargement, other cardiac or systemic pathology. The frequency of occurrence in the population in humans is 1: 500, while the mortality rate in the natural course of the disease reaches 1-2% per year. Mortality during surgical treatment is less than 1% [1].

The defining symptom of the disease is ventricular hypertrophy. However, along with technical progress and an increase in the resolution of diagnostic methods for visualizing the anatomical structures of the heart, other structural abnormalities inherent in this pathology were revealed. These include: pathology of papillary muscles (hypertrophy, adhesion, displacement, accessory muscle, fibrosis), anterior mitral valve leaflet (increase in length and area, fibrosis), mitral annulus fibrosus (calcification, decreased systolic mobility), mitral valve chords (fibrosis, elongation, rupture) [2].

Structural and functional abnormalities of the papillary muscles in HCM, limiting their mobility and disrupting the adequate functioning of the mitral valve, occur in most cases due to the presence of fibrous connective tissue cords between the papillary muscle and the wall of the left ventricle, the interventricular septum or a nearby muscle. To achieve optimal results of surgical treatment of HCM, this structural pathology requires surgical correction - dissection of fibrous cords. This procedure is performed as a simultaneous intervention in addition to resection of part of the interventricular septum (septal myoectomy).

In HCMP surgery, dissection of the ascending aorta by 1/2 of its circumference in the oblique direction is used as an operative approach. Evaluation of ventriculoarchitectonics, revision of structural abnormalities and surgical manipulations are performed through the surgical field limited by the aortic fibrous ring, the average diameter of which does not exceed 2.5 cm. The conditions of a "narrow" field of view and space sharply limited by the cavity of the left ventricle make standard movements with surgical instruments extremely difficult and increase the risk iatrogenic complications, and the presence of an additional instrument (tweezers) in the area of surgical interest makes manipulations practically impracticable.

The intersection of the connective tissue fibrous cords with scissors is performed after the papillary muscle is abducted with tweezers to the side opposite to the location of the cord. Due to the limitation of the visual field and space, this technique does not always allow detecting and dissecting all connective tissue cords, which can limit the mobility of the papillary muscles, not completely eliminate their abnormal displacement, thereby compromising the optimal functioning of the mitral valve and impairing the results of surgical treatment. A number of surgeons use nerve hooks for retraction (retraction) for revision of the papillary muscles.

A number of nerve hooks are known [3, 4, 5].

Common features of known nerve hooks are the presence of a handle and a shaft terminating in a curved tip.

Specialists in the field of surgery understand that the known hooks, in contrast to the proposed hook-retractor for the papillary muscles, are used for revision of the papillary muscles by bringing the mitral valve attached to the papillary muscles under the chords and pulling up behind them, while the papillary muscles are minimally displaced , which often does not allow a complete adequate revision and dissection of the fibrous connective tissue strands fixing them. Performing manipulations directly on the papillary muscle with such hooks is not possible due to the extremely high risk of iatrogenic damage.

Disclosure of the essence of the utility model

The essence of the useful model is the creation of a retractor hook for the papillary muscles, which allows a controlled complete gradual revision and direct abduction of the papillary muscles.

The technical result is to ensure the optimal efficiency of the surgical intervention and the elimination of operational complications.

The technical result is achieved in that the hook-retractor for papillary muscles, consisting of a handle connected to a rod, ending in two arms of equal length, curved into a semicircle in a plane perpendicular to the plane of the rod.

Brief Description of Drawings

FIG. 1 shows an embodiment of a papillary muscle retractor hook.

The retractor hook is made in the form of a rod, consisting of a handle 1 connected to a rod 2 inserted into the heart cavity, at the end of which there are hooks 3. Hooks 3 are two arms of equal length, bent into a semicircle in a plane perpendicular to the plane of the rod. Handle 1 can have a grooved or rough surface for better grip and to avoid slipping out of the hand.

FIG. 2 shows a variant of using a retractor hook for papillary muscles.

The retractor hook works as follows. After performing septal myoectomy through the incision of the ascending aorta 4 and the aortic valve 5, a retractor hook for the papillary muscles is inserted into the cavity of the left ventricle 6, placing the upper part of the papillary muscle 7 in a semicircle bounded by its shoulders 3, then by pressing the shoulders 3 onto the papillary muscle 7 it is withdrawn from nearby anatomical structures (walls of the left ventricle, interventricular septum or nearby papillary muscle), carrying out revision of fibrous connective tissue strands 8, fixing it, then the found strands 8 are crossed with scissors when papillary muscle 7 is retracted in the direction opposite to strand 8, in the same way when By moving the retractor hook for the papillary muscles along the length (from the top to the base) and the circumference of the papillary muscles, their full mobilization is gradually carried out.

Implementation of the utility model

The following clinical example illustrates the use of the proposed papillary muscle retractor hook.

Clinical example

Patient V., 48 years old. Diagnosis: Obstructive hypertrophic cardiomyopathy. From the anamnesis: has been ill since the beginning of 2018, when shortness of breath and dizziness appeared after eating and during exercise. Complaints progressed, exercise tolerance decreased. Since the onset of the disease, repeated episodes of loss of consciousness. In November 2019, the patient was examined in a cardiological hospital, obstructive hypertrophic cardiomyopathy was revealed. According to echocardiography and MRI of the heart, hypertrophy of the left ventricle (the thickness of the interventricular septum in the basal section is 28 mm), mitral insufficiency of the 3rd degree due to the anterior systolic movement of the anterior cusp of the mitral valve. The peak pressure gradient in the outflow tract of the left ventricle at rest is 93/52 mm Hg, with the Valsalva test - 181/45 mm Hg, with physical activity - 195/115 mm Hg. Fibrous ring of the aortic valve - 24 mm. On 03.12.2019, a planned operation was performed: septal myoectomy, mobilization of papillary muscles in conditions of artificial circulation and blood cardioplegia.

In the course of the operation, the following were sequentially performed: median sternotomy, connection of the heart-lung machine, the onset of cardiopulmonary bypass, clamping of the ascending aorta, non-selective blood cardioplegia, oblique aortomy, septal myoectomy. After that, a retractor hook for the papillary muscles was inserted into the cavity of the left ventricle through the incision of the ascending aorta and the aortic valve into the cavity of the left ventricle, placing the upper part of the papillary muscle in a semicircle bounded by its shoulders. Then, pressing the shoulders on the papillary muscle, they took away its interventricular septum, carrying out a revision and finding a fibrous connective tissue cord fixing it. The strand was crossed with scissors when the papillary muscle was abducted in the direction opposite to the strand. Similarly, when the retractor hook for the papillary muscles was moved along the length (from the top to the base) and the circumference of the papillary muscles, their complete mobilization was gradually carried out. Revealed and crossed 5 connective tissue strands.

Further stages of the operation are performed in a standard way. The pressure gradient in the LV outflow tract after surgery at rest was 6/3 mm Hg. Art., with the Valsalva test and physical activity - 8/4 mm Hg, there is no anterior systolic movement of the anterior mitral valve leaflet and mitral insufficiency.

The postoperative period was uneventful. The patient was discharged on the 7th day after surgery.

On examination after 6 months, the patient did not actively complain, was active, his ability to work was fully restored, dizziness and shortness of breath did not bother him, there were no episodes of loss of consciousness, and exercise tolerance was high. Echocardiography was performed, according to which the pressure gradient in the LV outflow tract at rest was 5/3 mm Hg. Art., during the Valsalva test and physical activity - 7/4 mm Hg, anterior systolic movement of the anterior mitral valve leaflet and mitral insufficiency were not detected.

Thus, the inventive hook-retractor for papillary muscles is easy-to-use, it allows to perform a controlled complete gradual revision of the papillary muscles, to ensure the optimal efficiency of the surgical intervention and to avoid operational complications.

Sources of information:

1. Kotkar KD, Said SM, Dearani JA, Schaff HV. Hypertrophic obstructive cardiomyopathy: the Mayo Clinic experience. Ann Cardiothorac Surg. 2017; 6 (4): 329-336. doi: 10.21037 / acs.2017.07.03.

2. Silbiger JJ. Abnormalities of the Mitral Apparatus in Hypertrophic Cardiomyopathy: Echocardiographic, Pathophysiologic, and Surgical Insights. J Am Soc Echocardiogr. 2016; 29 (7): 622-639. doi: 10.1016 / j.echo.2016.03.003.

3. Catalog of the firm "Aesculap", 1999, section of surgical instruments, p. 359, model BT081R, brand name Caspar.

4. Microhook Roton from the catalog of Surtex Instruments, 18.5 cm, article NS-591-10, p. 36.

Claims (2)

1. Hook-retractor for papillary muscles, containing a handle and a rod connected to the handle, characterized in that the rod can be inserted into the cavity of the ventricle of the heart and at its end contains two arms of equal length, curved to form a semicircle in a plane perpendicular to the plane of the rod. 2. The retractor hook according to claim 1, wherein the handle comprises a grooved coating.

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