RU2465834C1 - Method for prosthetic valve implantation in tricuspid position - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely cardiosurgery. A prosthetic valve is fixed in a tricuspid position on the basis of the use of a mark-reinforcing suture (MRS). The MRS is applied on an implanted auricular surface along the line of a fibrous ring in a projection of anterior and posterior flappers of the tricuspid valve. In a projection of a septal leaflet, the MRS is applied along a medial wall of a right auricle outside of a Koch triangle area. A reinforcing ring is formed along the full length of the valve. The MRS filaments are left to be free. Then prosthetic valve braiding is fixed with a continuous blanket suture. Then the MRS filaments are tightened with pulling tissues to the fixed prosthetic valve, and then drawn tight on the implanted prosthetic valve and fastened.

EFFECT: method enables preventing suture cutting fixing the prosthetic valve braiding with paraprosthetic fistulas, reducing a length of myocardial ischemia - aortic occlusion due to increasing a rate of prosthetic valve fixation by a marking suture, improving effects of surgical interventions for the patients.

2 cl, 2 ex

Description

The invention relates to medicine, namely cardiac surgery, and can be used in the treatment of tricuspid valve defects.

There are various methods of sutures for implantation of a valve prosthesis into the tricuspid position: individual knotted, separate U-shaped, separate eight-shaped sutures, continuous twisted seam. The suture through the true fibrous ring of the tricuspid valve in the projection of the Koch triangle is associated with the threat of deformation or damage to the structures of the conduction system of the heart, leading to atrioventricular block after surgery. To prevent this complication, the stitches fixing the prosthesis are displaced relative to the projection of the Koch triangle: either “apically” to the ventricular region or “atrially” to the atrium.

The METHOD FOR IMPLANTING A VALVE PROSTHESIS IN A TRICUSPIDAL POSITION is according to which the sutures that fix the prosthesis are displaced relative to the projection of the Koch triangle “apically”, thereby preventing damage to the structures of the conduction system of the heart, and a “marking-reinforcing suture” is used to prevent their eruption (1). The disadvantage of this method is that as a result of the "apical" displacement of the prosthesis design, a decrease in the cavity of the right ventricle occurs, which is relatively safe in adult patients, but can become a pathological factor in children.

The METHOD FOR IMPLANTATION OF A VALVE PROSTHESIS IN A TRICUSPIDAL POSITION, according to which the stitches fixing the prosthesis are displaced relative to the projection of the Koch triangle “atrially”.

The method allows to eliminate the possibility of damage to the conductive system of the heart and at the same time increase the cavity of the right ventricle. At the same time, the imposition of U-shaped sutures with a wide base allows you to adapt the expanded entrance to the right ventricle to the prosthesis sleeve (2).

However, the imposition of structurally coarse U-shaped sutures with a wide base, designed to tighten the excess live atrial tissue in an attempt to adapt the expanded entrance to the right ventricle to the prosthesis sleeve at the time of tying, can lead to impaired myocardial trophism, deformations, and excessive stresses in within the tightened U-shaped suture on a wide base, which can cause it to erupt with the formation of a para-prosthetic fistula.

The METHOD FOR FIXING IN-CARDIARY IMPLANTS BY A METHOD-REINFORCING SEAM (3), in which the suture threads are pulled, the suture is lifted and the sutures are tied, forming a support ring to which an intracardiac implant is fixed.

The proposed method for implanting the prosthesis into the tricuspid position using the intracardiac marking-reinforcing suture (RAS) is new, not described in the patent and scientific literature.

The purpose of the invention is the prevention of iatrogenic reduction in the volume of the cavity of the right ventricle, reducing the risk of damage, compression or deformation of the conduction paths of the heart by the braid of the prosthesis and its surgical sutures fixing it by additionally fixing the heart tissue to the prosthesis. The method prevents the eruption of sutures that fix the braid of the prosthesis with the occurrence of para-prosthetic fistulas, reduces the time of myocardial ischemia - aortic occlusion due to an increase in the rate of fixation of the prosthesis along the marking suture, improves the results of surgical intervention for the patient.

The method of fixing the prosthesis in the tricuspid position is based on the use of a marking-reinforcing seam (RAS).

During valve replacement, the operating surgeon performs three consecutive steps. The first method produces an overlay of the RASH, but does not tie its ends. The second step is the fixation of the braid of the prosthesis with a continuous twisting seam, conducted around the RASH thread. In the third trick, the surgeon pulls the RASH by both ends of his thread, additionally attracting tissue to the fixed frame of the prosthesis, and then connects both ends of the RASH thread.

For the first dose, suture material is needed - a monofilament atraumatic thread (2 / 0-5 / 0) with two pricking needles at the ends - from 9 to 17 mm long. A thin, bright strip corresponding to the true fibrous ring of the valve is visualized on the implanted atrial surface. RASH is applied strictly along this line in the projection of the anterior and posterior cusps of the tricuspid valve. In the projection of the displaced septal valve, the suture is formed along the medial wall of the right atrium: outside the zone of the Koch triangle. The result is a closed line of a continuous seam, in which the stitches located outside the fabric have a length of 0.5-1.0 mm, and the stitches going inside the fabric and at a depth of 3-3.5 mm have a length of 4-5 mm. And so they sew through the entire circumference of the valve until a reinforcing suture ring is formed along a precision trajectory. At the same time, the RASH threads do not stretch and do not bind, leaving them free.

The next step is to implant a valve prosthesis.

To do this, the braid of the prosthesis is fixed by continuous curling suture, passing the needle under the thread of the first suture, the tissue of the heart is fixed to the prosthesis over the sections of the fibrous tissue of the implantation rim indicated by RAS.

The final stage additionally fixes the prosthesis using the purse-string properties of the Rush, which is tightened with little effort until the first signs of resistance appear, and the threads are tied. In this case, the extended entrance to the right ventricle is uniformly adapted to the prosthesis frame along the entire perimeter of the implantation line.

Clinical example 1

Patient I.G.V. 15 years old, IB No. 3639, operated on March 30, 2011 regarding tricuspid valve insufficiency. During the audit of the tricuspid valve, the impossibility of valve-saving operation was ascertained. The fibrous ring of the tricuspid valve is stitched with a marking-reinforcing suture (3/0 prolene), in the area of the septal cusp, outside the zone of the Koch triangle: 10 mm above the mouth of the coronary sinus, the UniLine bioprosthesis No. 28 is sewn in with a continuous twisted suture, after which it is pulled by the thread RASH and tying the prosthesis frame additionally “squeezed” the implantation rim tissues. Aortic occlusion time 40 minutes. In the postoperative period, there is a sinus rhythm, there are no parasthetic fistulas. The volume of the right ventricle is not reduced: the end-diastolic size is 3.1 cm, the end-diastolic volume of the right ventricle is 62 ml, which corresponds to the age norm.

Clinical example 2

Patient K.T.A. - 5 years. IS No. 2282, operated on March 4, 2011, regarding the Ebstein anomaly. During intracardiac revision, Ebstein's type C anomaly is determined: the septal cusp is displaced by 30 mm to the apex of the right ventricle, is located almost vertically, across the output section of the right ventricle, is flattened along the interventricular septum, attached to it with short chords. The anterior leaflet has sufficient windage only 1/3 closer to the “conditional” anterior-septal commissure, the remaining 2/3 of the leaflet body, as well as the entire posterior leaflet, are flattened along the MJP, pulled to it by short chords, and the posterior leaflet is displaced by 25 mm in pancreatic cavity. When performing a hydraulic test, the closing function of the valve is unsatisfactory - a pronounced back stream. The anterior papillary muscle is absent. The cavity of the functioning part of the right ventricle is visually small. Valve-saving operation is recognized impossible.

A 30 mm UniLine biological prosthesis was implanted into the supraannular position, leaving the coronary sinus in the right ventricle. Pre-formed marking-reinforcing seam (RATTT) with monofilament thread Premilen 5/0 with atraumatic needles using synthetic gaskets at the beginning and at the end of the seam. Due to the supraannular implantation of the prosthesis, the NAB is displaced atrially and performed in the region of the lower limb of the oval fossa outside the conduction system of the heart, from the coronary sinus to the edge of the anterior cusp of the tricuspid valve. The valve was implanted further: in the projection of the anterior leaflet, the valve is fixed with a continuous twisting seam, along the rest of the circumference with separate p-shaped seams on synthetic gaskets; in the RAS area, the seams were held with the capture of threads of a marking-reinforcing seam. After that, pulling the RASH threads and tying them, the prosthesis frame is additionally “squeezed” by the tissues of the implant rim. Aortic occlusion time 43 minutes. In the postoperative period, there is a sinus rhythm, there are no parasthetic fistulas. The volume of the right ventricle is not reduced: the end-diastolic size is 2.3 cm, the end-diastolic volume of the right ventricle is 43 ml, which corresponds to the age norm.

Thus, the use of the claimed method of implanting the prosthesis into the tricuspid position eliminates the risk of damage or deformation of the conduction pathways of the heart, prevents the formation of paraclavicular fistulas, prevents a decrease in the volume of the cavity of the right ventricle, reduces the time of myocardial ischemia-occlusion of the aorta and cardiopulmonary bypass, which together contributes to a more favorable outcome surgical intervention for the patient.

Literature

1. RU 2371116 C2, 10.27.2009, Bull. Number 36.

2. Cardiovascular Surgery./ Ed. V.I. Burakovsky and L.A. Bokeria. - 1989. - P.265.

3. RU 2290090 C2, 12/27/2006, Bull. Number 36.

Claims (2)

1. The method of implantation of a valve prosthesis in a tricuspid position, including the use of a marking-reinforcing suture (RAS), characterized in that on the implanted atrial surface of the RASH is applied along the line of the fibrous ring of the valve in the projection of the anterior and posterior valves of the tricuspid valve; in the projection of the septal cusp, the Rush is imposed along the medial wall of the right atrium outside the zone of the Koch triangle; get a closed line of a continuous seam and form a reinforcing suture ring around the entire circumference of the valve, while leaving the RASH threads free; then, the continuous braiding of the prosthesis is fixed over the sections of the fibrous tissue of the implantation rim, passing it around the RASH thread, after which the heart tissue is additionally fixed to the prosthesis with the RASH thread, pressing the heart tissue to the prosthesis frame by pulling the free RASH threads, both ends of the RASH thread are tightened to implanted prosthesis and knotted. 2. The method according to claim 1, characterized in that when fixing the prosthesis, the pouch properties of the Rush are used, allowing the threads to be tightened, while tightening is performed until the first signs of tissue resistance appear.