RU2206275C2 - Method for total by-pass of right cardiac departments - Google Patents

Abstract

FIELD: medicine, cardiosurgery. SUBSTANCE: artificial circulation is launched due to cannulation of aorta, cross-sectional vein and inferior vena cava at its bottom. Superior vena cava is crossed cross-sectionally at the level of right pulmonary artery. The latter is lanced longitudinally both along superior and inferior edges. Distal end of superior vena cava is anastomosed with superior edge of pulmonary artery by "the end-into-the side" technique. Proximal end of superior vena cava is anastomosed with inferior edge of pulmonary artery by the same technique. One should longitudinally lance right atrium and with the help of a patch form a tunnel between the bottoms of inferior vena cava and superior vena cava by keeping coronary sinus in left atrium. Exit from right ventricle is closed by ligating the trunk of pulmonary artery. Right ventricle is lanced in outflowing department in nonvascular area. One should carry out revision of interventricular septum defect to close it. At defect's size being below 1 cm it should be closed due to simple suturing by separate P-shaped sutures upon interlayers. At its size being above 1 cm - one should carry out defect's plasty due to applying a patch with separate P-shaped sutures. The suggested method enables to develop optimal conditions for functioning of left ventricle as a result of its isolation from lateral cavities. EFFECT: higher efficiency. 2 cl, 2 ex

Description

 The invention relates to medicine, namely to cardiac surgery.

 There is a method of bypassing the right heart, which consists in combining the right atrium (PP) with the pulmonary artery (LA) (Podzolkov VP, Chiaureli MR. Hemodynamic correction of congenital heart defects. -M .: Medicine, 1994, p.51 -67). The operation is performed from the middle access under cardiopulmonary bypass. Mobilize the trunk of the pulmonary artery or the right pulmonary artery. The right atrium is opened in the area where the anastomosis is supposed to be performed. In patients with atresia of the tricuspid valve, the atrial septal defect is closed; in patients with right ventricular hypoplasia syndrome, the tricuspid valve is also closed. The exit from the right ventricle is closed by ligation of the LA trunk at the base or by suturing the LA valve from the trunk lumen. Anastomosis is created between PP and LA by various surgical methods: by direct anastomosis of PP with LA using patches; by using the trunk of an aircraft without a valve or with a valve; using valve-containing or valveless conduits. This method is not currently used due to frequent complications.

 A known method of total cavapulmonary anastomosis (TKPA) (De Leval MR, Kilner P., Gewilling M. et. Al. Total cavopulmonary connection: a logical to atriopulmonary connection for complex Fontan operations. J. Thorac. Cardiovasc. Surg. 1988, Vol. 96, p. 682-695). The method is as follows (figure 1). Access the heart through a median sternotomy. Artificial blood circulation is connected by cannulation of the aorta 1, transverse vein and inferior vena cava (IVC) 2 at the mouth. The superior vena cava (ERW) 3 is crossed transversely at the level of the right pulmonary artery (LA) 4. The right pulmonary artery (LA) 4 is opened longitudinally along the upper and lower edges. The distal end of ERW 3 anastomose end-to-side with the upper edge of LA 4, the proximal end of ERW 3 anastomose with the lower edge of LA 4 end-to-side. Open longitudinally the right atrium (AP) 5 and with the help of a patch form a tunnel 6 between the mouths of the IVC 2 and the VPV 3, leaving the coronary sinus in the left atrium (LP) 7. The exit from the right ventricle (RV) 8 is closed by ligation of the trunk of the pulmonary artery (LA) ) 4.

 In the described methods of "bypassing" the right parts of the heart there is a negative side. In both cases, the interventricular septal defect (DMF) 9 does not close, through which the systemic ventricle, that is, the main, left ventricle (LV) 10, communicates with the cavity of the hypoplastic ventricle 8. This cavity, devoid of preload by suturing the tricuspid valve or ASD, is threatening factor. Directly communicating with the cavity of the systemic ventricle 10 through DMS 9 (often large), it acquires the effect of a false aneurysm. With simple dressing of the trunk of LA 4, the cavity of the false aneurysm increases due to the stump of the ligated trunk of LA 4. The degree of hemodynamic impairment and cardiac output in the early postoperative period depends on the size of the prostate cancer and the volume of the cavity of the hypoplastic ventricle. With each systole of the systemic ventricle, a part of the stroke volume (UO) is dumped into the cavity of the false aneurysm and vice versa. The side cavity violates the systolic and diastolic functions of the systemic ventricle, which results in an ineffective discharge. The patients immediately develop a clinic of acute heart failure, which requires intensive therapy with large doses of cardiotonics, including the use of phase compression of the anterior abdominal wall and often leads to death.

 The objective of the present invention is to create optimal conditions for the functioning of the main left ventricle of the heart.

 The problem is solved by isolating the main ventricle from side cavities, i.e. from the cavity of the hypoplastic ventricle in communication with the system through DMS.

 The method is as follows (figure 2).

 Access the heart through a median sternotomy. Artificial blood circulation is connected by cannulation of the aorta 1, transverse vein and inferior vena cava (IVC) 2 at the mouth. The superior vena cava (ERW) 3 is crossed transversely at the level of the right pulmonary artery (LA) 4. The right pulmonary artery (LA) 4 is opened longitudinally along the upper and lower edges. The distal end of ERW 3 anastomose end-to-side with the upper edge of LA 4, the proximal end of ERW 3 anastomose with the lower edge of LA 4 end-to-side. Open longitudinally the right atrium (AP) 5 and with the help of a patch form a tunnel 6 between the mouths of the IVC 2 and the VPV 3, leaving the coronary sinus in the left atrium (LP) 7. The exit from the right ventricle (RV) 8 is closed by ligation of the trunk of the pulmonary artery (LA) ) 4. In the excretory section in the avascular zone, pancreas 8 is opened, the ventricular septal defect (DMS) is revised 9. The defect is closed by simple suturing (with its small size - up to 1 cm) with separate U-shaped seams on the gaskets. With its large sizes, plastic defect is performed using a patch of 11 separate U-shaped seams.

 Thus, they create optimal conditions for the function of the systemic ventricle. In this case, the excess cavity that holds the "ballast" volume of blood and increases the residual volume and the final diastolic volume is isolated, the damping effect of this cavity during the systole and the leakage of part of the stroke volume into this cavity and, finally, the long-term effect of this additional "side" load on the systemic ventricle will not deplete its function.

 Indications for performing this operation are atresia of the tricuspid valve and pancreatic hypoplasia syndrome. A contraindication to this operation may be cases where the size of the proposed systemic ventricle is small and the cavities of both ventricles (both the main and hypoplastic) are communicated through a large ventricular septal defect. For example, the full form of atrioventricular communication (AVC) with hypoplastic ventricles, all forms of a single ventricle.

 A similar method can also be used in the operation of the atrial pulmonary anastomosis.

Claims (3)

 1. The method of total circumvention of the right heart, which consists in connecting artificial blood circulation by cannulation of the aorta, transverse vein and inferior vena cava at the mouth, the transverse intersection of the superior vena cava at the level of the right pulmonary artery, longitudinal opening along the upper and lower edges of the right pulmonary artery, anastomosis end-to-side of the distal end of the superior vena cava with the upper edge of the pulmonary artery and anastomosis of the proximal end of the superior vena cava with the lower edge of the pulmonary artery end-to-side, longitudinal opening the right atrium and forming with the help of a patch between the mouths of the inferior vena cava and the superior vena cava with the preservation of the coronary sinus in the left atrium, closing the exit from the right ventricle by ligation of the pulmonary artery, characterized in that the right one is opened in the excretory section of the avascular zone ventricle and produce an audit of a defect in the interventricular septum, after which the defect is closed.  2. The method according to claim 1, characterized in that when the size of the defect is less than 1 cm, it is closed by simply suturing individual U-shaped seams on the gaskets.  3. The method according to claim 1, characterized in that when the defect size is more than 1 cm, the defect is plasticized using a patch with separate U-shaped seams.

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