RU2197898C2 - Method for tricuspidal circular purse- string annuloplasty in patients with acquired valvular defects of left cardiac departments - Google Patents

Abstract

FIELD: medicine, cardiosurgery. SUBSTANCE: one should apply a purse- string suture along the whole perimeter of fibrous ring. Conditional line is established coming along fibrous ring of tricuspidal valve, along superior edge of membranous part of interatrial septum and to the front against coronary sinus descending again towards fibrous ring. Suture is applied along this line. The method enables to achieve the best juncture of valvular folds without their deformation and prevent trauma of conducting system of heart. EFFECT: higher efficiency of operation. 1 dwg, 1 ex

Description

 The invention relates to medicine and can be used in cardiac surgery.

Two large groups of tricuspid annuloplasty (TAP) techniques are known:
- supporting-ring, consisting in the implantation of the so-called support rings, narrowing the diameter of the fibrous ring of the valve (Carpentier ring, Duran), [Kirklin John W. Cardiac surgery. 2nd ed. 1993.], not without drawbacks, such as technical complexity, high cost, the fact that a foreign body is implanted, as a result of which the patient is required to be treated as after a prosthetic valve with an artificial prosthesis.

 - suture (De Vega, Boyd, Kay, Soloviev), when the fibrous ring of the valve is narrowed by applying various types of sutures [G.M.Soloviev, S.P. Ivanov, A.S. Prokhorov. Defects of the tricuspid valve and plastic surgery on it. M .: Medicine. 1988; 252].

 The most widely used suture method of plastic surgery (by the method of De Vega) is the closest to the claimed method according to its technical nature and is selected as a prototype.

 Its disadvantages include the asymmetry of the suture, which entails the deformation of the valves and the fibrous ring of the valve, resulting in unstable results.

 The purpose of the invention is to achieve the best closure of valve flaps without deformation and to prevent injury to the conduction system of the heart.

 The goal is achieved by a technical solution, which is a method of circular purse-string annuloplasty in patients with acquired valvular defects of the left heart by applying a single-row circular purse-string suture along the entire perimeter of the tricuspid valve fibrous ring, bypassing the "danger zone" in the anterior septal commissure, where the atrioventricular node is located bundle of His.

 For this, we have identified a conditional line running along the fibrous ring of the tricuspid valve, along the upper (muscle) edge of the membranous part of the atrial septum and anteriorly from the coronary sinus again descending to the fibrous ring.

 New in the proposed method is the suturing around the entire perimeter of the fibrous annulus of the valve, bypassing the "danger zone" in the area of the anterior septal commissure, which ensures the most complete closure of the valves without deformation and avoids injury to the conduction system of the heart.

The essence of the proposed operation will be clear from the following description and drawing, which shows a scheme for applying a circular purse string suture along the fibrous ring of the tricuspid valve, where
1 - suture line;
2 - tricuspid valve;
3 - membranous part of the atrioventricular septum;
4 - coronary sinus;
5 - atrioventricular node.

 The circular purse string suture is applied as follows: the suture (1) is applied along the fibrous ring of the tricuspid valve (2), along the upper (muscle) edge of the membranous part of the atrioventricular septum (3), anteriorly from the coronary sinus (4), the suture again descends to the fibrous ring, thus enveloping the atrioventricular node (5).

 EXAMPLE: Patient Ya-va, 44g. Diagnosis: Rheumatism. Inactive phase. Condition after surgery of closed mitral commissurotomy (1966, 1974, 1988). Mitral valve restenosis. Paroxysmal atrial fibrillation. H-IIA-B.

 The patient underwent surgery: mitral valve prosthetics with the MIX-MDM-27 mono-wing disc prosthesis, tricuspid circular purse-string purse-string annuloplasty, radiofrequency isolation of the left atrium. Immediately at the end of the main stage of the operation and the restoration of cardiac activity, a sinus rhythm was obtained, which persisted both in the early and late postoperative period. The patient was discharged on the 30th day after surgery with a sinus rhythm.

The study included 3 stages:
1) Experimental
2) Morphological
3) Clinical
At the first stage, paraffin casts of the fibrous ring of the tricuspid valve, narrowed according to the De Vega method with an oncoming half-net seam, were studied. We studied the shape of the fibrous ring, the zone of coaptation of the valve cusps, the configuration of the mouth of the coronary sinus.

 It was found that the fibrous ring is not uniformly deformed, the zone of coaptation of the valves is displaced from the center, the mouth of the coronary sinus acquires an oval configuration instead of a round one. At the second stage, we identified the suture line: along the fibrous ring, approximately from the middle of the septal valve along the entire circumference of the fibrous ring to the membranous septum, then along the upper edge of the membranous part of the interatrial septum, then a fold is formed in its upper part, from where the suture descends downward.

 During a morphological study of the seam circumference, elements of the cardiac conduction system were not found in the seam area.

 Since 1989 In the Department of Cardiovascular Surgery, Research Institute of Cardiology, TNTs SB RAMS according to the proposed method, 33 patients with acquired defects of the left heart complicated by pulmonary hypertension and tricuspid valve insufficiency (TK), accompanied by both moderate (I-II st.) and severe (III-IV st.) Regurgitation. The average age of the patients was 46 ± 1.23 years. Along with TKAP, the following procedures were performed for patients: mitral valve prosthetics - 29 people, aortic valve prosthetics - 1 person, two-valve prosthetics (aortic and mitral valves) - 3 people. The degree of regurgitation on TC in these patients before surgery was 3.5 ± 0.14 (III-IV art.), In the long-term postoperative period it decreased significantly and significantly -1.5 ± 0.5 (I-II art .; p <0.05). Systolic pressure in the pulmonary artery (SDLA) was 46.5 ± 7.07 mm Hg before surgery. Art. , during the control examination - 37.6 ± 5.4 mm RT. Art. (p <0.05). The ejection fraction of the left ventricle (VVlzh) before surgery was 57.2 ± 2.3%, with a follow-up examination - 53.8 ± 3.3% (p <0.05).

 For comparison, we used a group of patients (44 people), identical in age and sex composition and central hemodynamics, who used the tricuspiad annuloplasty method according to the De Vega method. In patients of this group, preoperative regurgitation on the TC was 1.9 ± 0.17 (I-III art.), In the control study, 1.2 ± 0.16 (I-II art .; p> 0.05).

 It should also be noted that, in the patients of the main group, initially, in the preoperative period, a significantly higher degree of regurgitation in the TC was observed (3.5 ± 0.14; III-IV stages) than in the patients of the control group (1.9 ± 0, 17; I-II Art.), P <0.05. In patients with TCAP, no cases of progression of tricuspid regurgitation were noted. Also, in this group there were no cases of violation of atrioventricular conduction.

 The mean follow-up was 120.7 ± 12.4 months. for patients of the main group and 59.1 ± 15.6 months. for patients in the control group (p <0.05).

 From each group, one patient died in the long-term postoperative period (long-term mortality in the main group was 3.1%, in the control group - 2.5% (p> 0.05).

The application of the proposed TKAP method allows to ensure
- adequate correction of tricuspid insufficiency in patients with acquired defects of the left heart, complicated by pulmonary hypertension and TK insufficiency;
- technical simplicity of the operation;
- lack of progression of tricuspid insufficiency in the postoperative period;
- the safety of the conduction system of the heart.

Claims (1)

 The method of tricuspid circular purse-string annuloplasty in patients with acquired valvular defects of the left heart, which consists in the fact that along the entire perimeter of the fibrous ring of the tricuspid valve a single-row circular purse-string suture is sutured, characterized in that the suture is applied bypassing the “danger zone” in the anterior-septal region commissures - from the middle of the septal valve to the membranous septum, then - along the upper edge of the membranous part of the atrial septum so that in its upper part hand, from where the seam goes down.