RU2202959C2 - Method for setting ascending aorta segment and aortic valve prosthesis in extra-aortic way - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves building in an aortal valve by suturing. The sutures fixing the prosthesis are taken outwards in extra-aortic way along fibrous ring perimeter of the aortic valve. Aneurysm resection is carried out. Aortorrhaphy is carried out. Synthetic fabric is placed around the aorta and joined by sewing in creating extra-aortic cut in the aorta. The proximal end of the extra-aortic aorta prosthesis is fixed with sutures brought out in extra-aortic way from the aortic valve prosthesis creating the secondary supporting ring for the aortic valve prosthesis on the synthetic fabric base. The distal part of the extra-aortic prosthesis of the aorta is fixed with separate sutures below brachiocephalic arterial exits to pericardium around the aorta. EFFECT: reduced risk of traumatic complications; low blood losses; reduced risk of coronary artery kink. 4 dwg

Description

 The invention relates to medicine, namely to methods for treating acquired heart defects.

 Known methods for prosthetics of the ascending aorta during its aneurysm, which include prosthetics of the aorta with a synthetic or biological prosthesis using a valve-containing conduit with reimplantation of the coronary arteries into the aortic prosthesis (I).

 The negative sides of the operation of aortic root prosthetics are expressed in the invasiveness of the intervention, the danger of kink of the coronary arteries, the development of a false aneurysm of the mouths of the coronary arteries in the presence of altered intima of the mouths of the coronary arteries; implantation of synthetic tissue into the vascular bed of the ascending aorta increases the risk of developing septic complications; preservation of the aortic-right atrial discharge through the formed anastomosis between the para-prosthetic space and the right atrium (Tsukerman G.I. et al., 1996).

 The aim of the proposed method is to reduce the morbidity of the operation and blood loss, eliminate the danger of kinks in the coronary arteries, the need for a fistula between the prosthetic space, preserve the native tissue in the vascular bed of the ascending aorta and reduce the risk of developing septic complications, increase the reliability of fixation of the aortic valve prosthesis.

 The essence of the proposed method for extra-aortic prosthetics of the ascending aorta with aneurysm in combination with damage to the aortic valve is as follows.

 Perform longitudinal aortotomy within the aortic aneurysm. Excise the affected aortic valve. Then the fibrous ring of the aortic valve is stitched with separate U-shaped sutures, which are passed through the braid of the aortic valve prosthesis. The valve is lowered into the projection of the fibrous ring, and the threads are removed through the aortic wall and tied together extraaortally (Figs. 1, 2).

 The next step is to perform a linear longitudinal resection of the aortic aneurysm, suturing the linear section of the aorta with a mechanical suture, reducing the diameter of the aortic expansion to 40 mm.

 Then the synthetic tissue is brought under the aorta, the aorta is wrapped and the synthetic tissue is sutured over the ascending aorta with the UKL 60 apparatus. The proximal part of the formed synthetic tube is fixed with threads previously brought to the outer wall of the aorta in the projection of the mechanical prosthesis ring, creating an extra-aortic support ring for the aortic valve prosthesis ( figure 3, 4).

 The distal part of the synthetic tube is fixed with separate sutures below the mouth of the brachiocephalic vessels to the pericardium around the aorta, preventing the dislocation of the synthetic tube (Fig. 4).

 Example. Patient P., 29 years old, medical history 202-82. Admitted to the department of septic endocarditis with complaints of cardiac arrhythmias, fatigue, pain in the heart.

 Heart disease was diagnosed at the age of 18 years. Progressive deterioration since 1979.

 The condition at admission is serious. The skin is pale. The area of the heart is not changed. The left border of the heart is 1.5 cm outward from the midclavicular line, the right is on the right edge of the sternum. Above the aorta is a diastolic and very short systolic murmur with irradiation to the vessels of the neck. A / D 110/30 mm Hg The liver is not enlarged, the spleen is not palpable.

 ECG - sinus bradycardia, impaired intraventricular conduction, moderate left ventricular hypertrophy, signs of myocardial malnutrition by the type of hypoxia in the region of the left ventricular lateral wall.

 Chest x-ray - pulmonary pattern close to the norm of SLK 52%. Significantly enlarged left ventricle. The aorta is dilated mainly in the ascending region with a significant protrusion of the anterior wall and intense pulsation of this zone.

 Hemoculture - Staphylococcus aureus twice isolated.

 10.21.82 g. - operation. Extrapleural thoracotomy. The pericardium is opened. The ascending aorta is expanded to 120 mm, the aneurysm extends from the fibrous ring of the aortic valve distally to the mouth of the brachiocephalic trunk. On the aortic wall fibrinous overlay. Systolic and diastolic trembling is palpated above the fibrous ring of the aortic valve.

 Occlusion of the vena cava and the aorta is 1 cm proximal to the mouth of the brachiocephalic trunk. The aorta is opened longitudinally. The aortic valve opening is about 20 mm, the valves are fibrous at the edges. Destruction of the posterior commissure and fibrous ring, occupying 20% of the perimeter of the fibrous ring. There is a thickening of the intima of the aorta throughout the aneurysm. There is no exfoliation of intimacy.

 The affected aortic valve cusps and the destroyed part of the fibrous ring were excised, the defect of the fibrous ring was sutured with two U-shaped sutures, and a mechanical prosthesis AKCh-4 was implanted at 14 sutures. The most modified part of the wall of the anterior aortic wall is resected. The aorta is longitudinally squeezed, as a result of which its diameter is reduced to 40 mm. Then, aortic flashing was performed with two UKL-60 devices. Aortic occlusion was 30 minutes. Cardiac activity restored. Synthetic tissue has been brought under the aorta, tissue has been wrapped around the aorta from the fibrous ring of the aortic valve to the brachiocephalic trunk. The tissue above the aorta is sutured with the UKL-60 device, as a result of which a synthetic extraaortic prosthesis of the ascending aorta is formed. The sutures removed during implantation of the aortic prosthesis, the extra-aortic synthetic prosthesis is fixed around the fibrous ring of the aortic valve outside the mouth of the coronary arteries. The distal part of the extraaortic prosthesis is fixed to the pericardium with interrupted sutures.

 The postoperative period was uneventful.

 Histology: disorganization of the connective tissue of the aortic wall, its gross fibrosis and sclerosis. There are areas of atherosclerotic plaques with deposition of calcification, around which there is an active process of sclerosis and focal histiolymphocytic infiltration.

 Examined in 1991. No complaints. Engaged in heavy physical labor in agriculture. Functional Class I according to NYNA.

 ECG - sinus bradycardia, incomplete blockade of the right leg of the bundle of His, signs of left ventricular hypertrophy. Moderate diffuse changes in the myocardium.

 X-ray - pulmonary vascular pattern is not changed, SLK - 52%. 4 arches are elongated, on the right contour a shadow of an expanded ascending contour with a clear intense density due to metal sutures of the synthetic extraaortic aortic prosthesis. In the position of the aortic valve, an artificial valve.

 ECHO: LV DAC 3.4; LVcdr 5.7; diastolic volume of the LV cavity 160 ml; systolic volume of the LV cavity 54 ml; shock volume 106 ml. The base of the aorta is 4.8 cm. The function of the prosthesis is not impaired.

LITERATURE
1. Bentall H., Do BonoA: A technigue for complete replacement of the ascendind aorta. Thorax 1988,23; 338.

 2. Zuckerman G.I., Malashenkov A.I., Hassan Ali and others. Surgery of ascending aortic aneurysms: retrospective assessment. Thoracic and cardiovascular surgery, 1996, 3, p. 68-72.

Claims (1)

 A method for extra-aortic prosthetics of the ascending aorta and the aortic valve, including prosthetics of the aorta and the aortic valve, characterized in that after suturing the aortic valve, sutures that fix the prosthesis are removed extraaortally around the perimeter of the fibrous ring of the aortic valve, then the aorta is sutured, synthetic tissue is brought around the aorta which is stitched together to create an extraaortic aortic prosthesis, while the proximal end of the extraaortic aortic prosthesis is fixed with sutures removed aortic from the aortic valve prosthesis, creating a secondary support ring for the aortic valve prosthesis based on synthetic tissue, after which the distal part of the extraaortic prosthesis of the aorta is fixed with separate sutures below the mouths of the brachiocephalic arteries to the pericardium around the aorta.

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