RU2457797C1 - Method of hemodynamic correction of congenital valvular defects with functionally single heart ventricle - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardio-vascular surgery. Excision of inferior vena cava from right auricle in the region of its orifice is performed. Through orifice of inferior vena cave interatrial septum is excised. Proximal anastomosis of "end-to-end" type is applied between inferior vena cava and linear prosthesis "Gore-tex". Right pulmonary artery is longitudinally cut from below, opposite earlier applied bidirectional cavapulmonary anastomosis, for 2-3 cm. Anastomosis of "end-to-side" type is applied between linear prosthesis Gore-tex" and right pulmonary artery. Fenestration with diameter 4-5 mm is formed in lateral side of prosthesis "Gore-tex", 1.5 cm above proximal anastomosis from the side adjacent to right atrium. External envelope of extracardial prosthesis is removed to the line of anastomosis between "ПП" and lateral wall of prosthesis "Gore-tex" in the region of fenestration. Anastomosis of "side-to-side" type is applied between right atrium and lateral wall of linear prosthesis "Gore-tex".

EFFECT: method makes it possible to reduce probability of stenosis of coronary sinus orifice, reduce probability of bleeding, reduce probability of thromboembolic complications.

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Description

The invention relates to medicine, namely to cardiovascular surgery.

In recent years, cardiac surgery has been marked by rapid growth in the treatment of complex congenital heart defects (CHD). It became possible to successfully operate on such defects as atresia of the tricuspid valve (TC), atresia of the mitral valve (MK), an unbalanced form of the complete atrioventricular canal (AVK), atresia of the pulmonary artery with an intact interventricular septum (ALA with UTI), Ebstein's anomaly, left ventricle LV), hypoplasia syndrome of the left corpus luteum hearth (GLOS). These CHD are combined into one general group called CHD with hemodynamics of a single ventricle of the heart or CHD with a functionally single ventricle of the heart (EJC). [12].

Surgical treatment of this group of defects consists in a phased hemodynamic correction.

Correction is performed in three stages, each of which can be performed separately. The first stage - with increased pulmonary blood flow - narrowing of the pulmonary artery, or with reduced pulmonary blood flow, application of a systemic-pulmonary anastomosis (modified Blok-Taussig shunt (MBTS)). The second stage is Glen's operation (blocking direct blood flow through the trunk of the pulmonary artery; excision of the valve cusps of the pulmonary artery; if necessary, excision of the interatrial septum (MPI); imposition of a bidirectional cavapulmonary anastomosis (DCAP)). The third and final stage is Fontaine’s operation [1, 2, 3, 4].

The present invention relates to the third stage of surgical correction of CHD with a functionally single ventricle of the heart.

There are several options for performing the Fontaine operation. Closest to the proposed method in its technical essence and the achieved result is an extracardial cavapulmonary anastomosis [3], and it is selected as a prototype.

The disadvantages of the prototype are, in the case of suturing of the right atrium (mouth of the IVC), the possibility of stenosis of the coronary sinus, the need to make an additional incision in the wall of the right atrium (PP) for applying the fistula between the prosthesis and the cavity of the PP, and further technical difficulties with endovascular closure of this fistula. Also, if the outer shell of the extracardiac prosthesis is not removed to the anastomosis line between the prosthesis and the lateral wall of the Gore-tex prosthesis in the fenestration area, then there may be a risk of thrombotic masses on the prosthesis wall and the development of thromboembolic complications.

The aim of the invention is to increase the safety of surgery and the prevention of intraoperative and postoperative complications.

The goal is achieved by a technical solution, which is a method of the third stage of hemodynamic correction of congenital heart defects with a functionally single ventricle of the heart, which is done by cutting off the inferior vena cava from the right atrium in the area of its mouth, through the mouth, if necessary, dissecting the interatrial septum. Then a proximal anastomosis is applied between the inferior vena cava and the Gore-tex linear prosthesis of the required diameter (the diameter should be comparable to the diameter of the inferior vena cava) according to the “end to end” type. Next, fenestration with a diameter of 4-5 mm is formed in the side wall of the Gore-tex prosthesis 1.5 cm above the proximal anastomosis from the side adjacent to the right atrium. The outer membrane of the extracardial prosthesis is removed to the line of the alleged anastomosis between the PP and the side wall of the Gore-tex prosthesis around the fenestration. Then, an anastomosis is placed around the fenestration (along the line of the removed external membrane) between the right atrium (the mouth of the inferior vena cava and the proximal part) and the lateral wall of the Gore-tex linear prosthesis, side-to-side. At the end of the operation, the right pulmonary artery is longitudinally dissected from below (opposite to the previously applied bi-directional cavapulmonary anastomosis) for 2-3 cm, anastomosis is applied between the Gore-tex linear prosthesis and the right pulmonary artery of the "end to side" type

New in the proposed method is that fenestration is formed in the side wall of the Gore-tex prosthesis 1.5 cm above the proximal anastomosis between the prosthesis and the inferior vena cava from the side adjacent to the right atrium. The outer membrane of the extracardial prosthesis is removed to the line of the alleged anastomosis between the PP and the side wall of the Gore-tex prosthesis around the fenestration. Then, an anastomosis is placed around the fenestration (along the line of the removed external membrane) between the right atrium (the mouth of the inferior vena cava and the proximal part) and the lateral wall of the Gore-tex linear prosthesis, side-to-side.

New signs can reduce the likelihood of stenosis of the mouth of the coronary sinus, reduce the likelihood of bleeding, further facilitate endovascular closure of fenestration and reduce the likelihood of thromboembolic complications.

The essential features characterizing the invention, showed in the claimed combination of new properties that are not explicitly derived from the prior art in this field and are not obvious to a specialist.

An identical set of features was not found in the study of patent and medical literature.

This invention can be used in practical health care to improve the quality of treatment, increase the safety of operations, reduce intra- and postoperative complications.

Based on the foregoing, the proposed method should be considered as relevant to the conditions of patentability of the invention “novelty”, “inventive step”, “industrial applicability”.

The proposed method will be clear from the following description and the attached figure.

Figure 1 shows a diagram of the method of the third stage of hemodynamic correction of congenital heart defects with a functionally single ventricle of the heart.

1a - cutoff of the inferior vena cava, application of an anastomosis between the inferior vena cava and the linear prosthesis “Gore-tex” of the “end to end” type, the formation of fenestration;

1 - aorta;

2 - bidirectional cavapulmonary anastomosis;

3 - the right pulmonary artery;

4 - the trunk of the pulmonary artery with a blocked direct flow;

5 - linear prosthesis "Gore-tex";

6 - the proximal part of the mouth of the inferior vena cava;

7 - fenestration;

8 - the boundary of the removal of the outer shell of the prosthesis "Gore-tex" around the fenestration;

9 - anastomosis between the inferior vena cava and the linear prosthesis "Gore-tex" type "end to end";

10 - the inferior vena cava;

1b - anastomosis between the right atrium and the lateral wall of the Gore-tex linear prosthesis, side to side, the anastomosis between the Gore-tex linear prosthesis and the right end-to-side pulmonary artery (general view of the operation third stage of hemodynamic correction);

1 - aorta;

2 - bidirectional cavapulmonary anastomosis;

3 - the right pulmonary artery;

5 - linear prosthesis "Gore-tex";

7 - fenestration;

9 - anastomosis between the inferior vena cava and the linear prosthesis "Gore-tex" type "end to end";

10 - the inferior vena cava;

11 - anastomosis between the linear prosthesis "Gore-tex" and the right pulmonary artery of the type "end to side";

12 - anastomosis between the right atrium and the lateral wall of the linear prosthesis "Gore-tex" on the type of "side to side";

The method is as follows.

Perform standard (median repeated sternotomy) access to the heart and major vessels. By a standard technique, an heart-lung machine is connected. Establish drainage of the left ventricle through the right upper pulmonary vein. Allocate the right and left pulmonary arteries, the trunk of the pulmonary artery (LA), superior vena cava. Pinch the aorta, perform cardioplegia. The inferior vena cava is cut off, an end-to-end anastomosis is applied between the Gore-tex linear prosthesis (the size of the prosthesis is selected depending on the diameter of the inferior vena cava). If necessary, dissect the interatrial septum through the mouth of the inferior vena cava. Then a fenestration with a diameter of 4-5 mm is formed in the side wall of the Gore-tex prosthesis 1.5 cm above the proximal anastomosis from the side adjacent to the right atrium, removed to the line of the alleged anastomosis between the prosthesis and the side wall of the Gore-tex prosthesis in In the area of fenestration, the outer shell of the extracardiac prosthesis, around the fenestration (along the line of the remote outer shell), an anastomosis is applied between the right atrium (the mouth of the inferior vena cava) and the lateral wall of the Gore-tex linear prosthesis, side to side (Fig. 1a). After that, the right pulmonary artery is longitudinally dissected from below (opposite to the previously applied bi-directional cavapulmonary anastomosis) for 2-3 cm, anastomosis is applied between the linear prosthesis "Gore-tex" and the right pulmonary artery of the type "end to side". Then the heart-lung machine is stopped. Remove the cannula from the superior and inferior vena cava. Audit for hemostasis. Carry out ultrafiltration. Remove the aortic cannula from the aorta. An anterior patch is implanted in the anterior mediastinum. Soft tissues of the surgical wound with drainage of the pericardium and anterior mediastinum are sutured in layers.

The final type of operation is shown in Figure 1b.

Clinical example. Patient I., 4 years old. Diagnosis: congenital heart disease. Two-leaf left ventricle of the heart. Pulmonary stenosis. Atrial septal defect. Condition after bi-directional cavapulmonary anastomosis at the age of 7 months. The diagnosis was made on the basis of ultrasound examination of the heart, sounding of the heart cavities. Access - median resternotomy. A cardiopulmonary bypass using a standard technique. Pinched aorta, cardioplegia. The inferior vena cava is cut off. An end-to-end anastomosis is applied between the Gore-tex linear prosthesis and the inferior vena cava. A fenestration with a diameter of 4 mm was formed in the lateral wall of the Gore-tex prosthesis 1.5 cm above the proximal anastomosis from the side adjacent to the right atrium, removed to the line of the alleged anastomosis between the prosthesis and the lateral wall of the Gore-tex prosthesis in the outer fenestration area an extracardiac prosthesis sheath, an anastomosis is placed around the fenestration (along the line of the removed external sheath) between the right atrium (the mouth of the inferior vena cava) and the lateral wall of the Gore-tex linear prosthesis, side-to-side. The right pulmonary artery is longitudinally dissected from below (opposite the previously applied bi-directional cavapulmonary anastomosis) for 2.5 cm, an anastomosis is placed between the Gore-tex linear prosthesis and the right pulmonary artery of the end-to-side type. The heart-lung machine is stopped. Decanulation. The blood flow through the prosthesis and bidirectional cavapulmonary anastomosis is satisfactory (according to transesophageal ultrasound). Ultrafiltration. Hemostasis. An epicardial electrode is hemmed to the ventricle for the implementation of a temporary EX. A Preclude patch has been hemmed to the edges of the dissected pericardium. Osteosynthesis of the sternum by wire ligatures. Layer wound closure with drainage of the pericardium and anterior mediastinum with a single drainage. Kutasept. Aseptic dressing. The postoperative period was uneventful. According to the ultrasound examination, there is no flow through the trunk of the aircraft, the cavapulmonary anastomosis and the anastomosis of the linear prosthesis with the right pulmonary artery function satisfactorily. After 2 hours, the patient was extubated, on the 3rd day transferred from the intensive care unit. On the 15th day the patient was discharged from the hospital.

The method proposed by the authors was applied in 7 patients. Complications when using this method during surgery, in the early and remote postoperative period was not observed.

Thus, the application of the proposed method allows you to effectively perform the third stage of hemodynamic correction with a functionally single ventricle of the heart with the lowest rates of surgical risk.

List of references

1. Podzolkov V.P., Chiaureli M.R. // Hemodynamic correction of congenital heart defects // M., 1994, 223 p.

2. Kirklin W.J. Cardiac surgery: Second ed. / W.J. Kirklin, G. Brian, Barratt-Boye // Churchill Livingstone Inc., 1993 .-- 185-525 p.

3. Constantin Mavrodis. Pediatric Cardiac Surgery: Second ed. / Constantin Mavrodis, Carl L. Backer. - Mosby-Year Book, Inc. 1994. - C.379-412.

4. Richard A. Jonas. Comprehensive Surgical Management of Congenital Heart Disease / Richard A. Jonas, James DiNardo, Peter C. Laussen, Robert Howe, Robert LaPierre, Gregory Matte. - Oxford University Press Inc. 2004 .-- S.185-525.

Claims (1)

The method of hemodynamic correction of congenital heart defects with a functionally single ventricle of the heart, which consists in cutting off the inferior vena cava from the right atrium (AP) in the area of its mouth, if necessary, dissect the atrial septum, apply a proximal anastomosis between the inferior vena cava and a linear prosthesis "Gore-tex" of the type "end to end", the right pulmonary artery is longitudinally dissected from below, opposite the previously imposed bidirectional cavapulmonary anastomosis for 2-3 cm give an anastomosis between the linear prosthesis "Gore-tex" and the right pulmonary artery of the type "end to side", characterized in that they form a fenestration with a diameter of 4-5 mm in the side wall of the prosthesis "Gore-tex" 1.5 cm above the proximal anastomosis from the side adjacent to the right atrium, the outer membrane of the extracardiac prosthesis is removed to the anastomosis line between the prosthesis and the lateral wall of the Gore-tex prosthesis in the fenestration area, an anastomosis is placed between the right atrium, at the cutoff of the inferior vena cava, and laterally side wall of the Gore-tex linear prosthesis, side-to-side.

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