RU2512745C1 - Method for prevention of low cardiac output syndrome and complications thereof following cardiac valve replacement - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to anaesthesiology and resuscitation, and concerns the prevention of low cardiac output syndrome (LCOS) and complications thereof following a cardiac valve replacement. For this purpose, the completion of a main phase of the surgical intervention and the termination of bypass are followed by an infusion of Levosimendan in a dose of min. 12.5 mg for 6-8 hours; thereafter a session of 12-hour veno-venous hemofiltration in an average replacement volume of 35-40 mg/kg.

EFFECT: method provides the effective prevention of LCOS, including in the patients suffering functional call II-IV chronic heart failure by maintaining the cardiac contractility, correcting dyshydrosis and systemic complications of LCOS.

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Description

The invention relates to medicine, namely to anesthesiology and intensive care, and can be used in patients with dysfunction of prosthetic heart valves, complicated by chronic heart failure.

Repeated heart valve prosthetics are associated with an increased risk of postoperative mortality, which exceeds the risk of primary surgery and reaches 8.6-12.8%. The leading predictor of the adverse outcome of repeated surgery is the high functional class of heart failure (HF). So, with HF II-III of the functional class, perioperative mortality is 3.8%, while with HF IV of the functional class, mortality reaches 21.7%.

The main mechanism for the development of postoperative complications in heart failure is the syndrome of small cardiac output (CMSV), which leads to the development of a cascade of complications, primarily multiple organ failure (POR) with signs of a systemic inflammatory response (SVR): dyshydria, fermentemia, hyperglycemia, signs of a detoxification disorder, synthetic liver function and nitrogen excretory function of the kidneys. The earliest possible start of intensive care for such patients with initially severe heart failure and, therefore, a high risk of developing low cardiac output syndrome should be aimed at the prevention and correction of homeostasis.

A known method for the prevention of low cardiac output syndrome through the use of preventive preoperative intra-aortic balloon counterpulsation (VABK) (Lomivorotov V.V. Experience of the preventive use of intra-aortic balloon counterpulsation in patients with a low ejection fraction of the left ventricle operated on under extracorporeal circulation / V.V. Lomivorotov , I.L.Kornilov, A.M. Cherniavsky, etc. // Anesthesiology and intensive care. - 2009. - No. 6. - P.51-54). The disadvantage of this method is the high risk of acute heart failure due to a change in intracardiac hemodynamics during the operation of the IABP before surgery in conditions of uncorrected valvular defects.

Closest to the claimed is a method for preventing the development of low cardiac output syndrome during operations of prosthetic aortic valve of the heart in patients with left ventricular hypertrophy (Järvelä K, Maaranen P, Sisto T, Ruokonen E. Levosimendan in aortic valve surgery: cardiac performance and recovery. J Cardiothorac Vase Anesth. 2008 Oct; 22 (5): 693-8), which consists in the infusion of levosimendan upon induction into anesthesia and the continued administration of levosimendan after surgery for 24 hours. The disadvantage of this method is that the infusion of levosimendan during anesthesia leads to a decrease in the average arterial and nonfusion organ pressure due to vasodilation, which makes it necessary to increase the volume of the volemic load and dosages of vasopressors.

The objective of the proposed invention is to preventive organoprotective intensive care aimed at the prevention of low cardiac output syndrome and its complications in patients with heart valve dysfunction complicated by chronic heart failure II-IV FC, received for reprosthesis of heart valves, due to a set of measures aimed at mechanical and pharmacological support for contractility, correction of dyshidria and systemic effects of MSV.

The task is achieved in that patients who received repeated surgery for dysfunction of prosthetic heart valves and having a high functional class of HF, during the induction of anesthesia, catheterize the femoral artery and install an introducer for IABC, and mechanical circulation is performed after surgical correction of valve function apparatus. Immediately after the anesthetic period, when the patient is transferred to the intensive care unit, an infusion of levosimendan is started for 6-8 hours, after which an extended veno-venous hemofiltration session is performed for 12 hours.

The essence of the method lies in the fact that a patient with valve prostheses dysfunction complicated by chronic heart failure II-IV FC, received for the purpose of reprosthesis, during the water period of anesthesia, catheterize the femoral artery and install an introducer for conducting IABC. The balloon is introduced and the start of counterpulsation is carried out after the completion of the main stage of surgical intervention with adequate surgical valve correction, which avoids the negative intracardiac hemodynamic effects characteristic of counterpulsation. The need to start IABP is determined during the period of departure from cardiopulmonary by the parameters of central hemodynamics and the data of transesophageal echocardiography characterizing the contractile function of the myocardium. In this case, the main indications for starting IABC are the index of the cardiac index (SI) ≤2.2 l / min / m ² , the expulsion fraction (FI) ≤35%. At the end of anesthesia and transferring the patient to the intensive care unit, levosimendan is infused at a dose of at least 12.5 mg for 6-8 hours.The start of levosimendan infusion at the end of anesthesia avoids the excessive combination of the vasodilation effect of the drug and limits the need for infusion and vasopressor hemodynamic correction. After 6-8 hours from the start of the infusion, in the absence of excessive drainage losses, patients undergo an extended veno-venous hemofiltration session in a medium-volume replacement mode of 35-40 ml / kg, using balanced bicarbonate substitute and dosed anticoagulation with heparin (at the level of activated blood coagulation time 180-200 s). The duration of hemofiltration is determined by indications of the relief of signs of systemic inflammation, the stabilization of homeostasis and the alignment of the water sectors. Effective minimum duration of at least 12 hours

The proposed method allows the prevention of low cardiac output syndrome in patients at high risk, while correcting both systolic and diastolic myocardial functions. The preventive therapy of the syndrome of small cardiac output is multicomponent and consists of mechanical and pharmacological support for the contractile function of the myocardium and correction of the hydrodynamic status. Correction of the systemic consequences of the syndrome of small cardiac output begins in the immediate postoperative period at the stage of organ and system dysfunction by early initiation of prolonged veno-venous hemofiltration and is aimed at correcting dysmetabolic disorders and dyshidria, and not at replacing the already formed organ failure. The combination of targeted therapy, supporting adequate myocardial contractility, and correction of homeostasis allows the patient to successfully tolerate the period of hemodynamic remodeling after reprosthesis of heart valves.

Thus, this method is used in the clinic of anesthesiology and resuscitation FGBI “NII KISSS” SB RAMS and allows to prevent the development of postoperative multiple organ failure in patients at high risk.

Example 1. Patient D., 49 years old, was admitted for surgical treatment with a diagnosis of Rheumatic heart disease, stenosis and aortic valve insufficiency with a predominance of insufficiency, 3 tbsp .; condition after mitral bioprosthetics and tricuspid valve repair 4 years ago. Dysfunction of the prosthesis in the mitral position - para-prosthetic fistula; insufficiency of the tricuspid valve 3-4 tbsp .; FC 3, NK 3. Concomitant diseases: coronary heart disease, angina pectoris 2, NYHA II, PIX, stenosis of PKA 75%; type 2 diabetes mellitus, subcompensation; chronic pyelonephritis, without exacerbation, CRF 0-1; duodenal ulcer, remission. After standard preoperative preparation, an operation was performed: reprosthesis of the myral valve, prosthesis of the aortic valve with mechanical prostheses, bioprosthesis of the tricuspid valve, coronary artery bypass grafting (PCA). The duration of the operation is 435 minutes, the aortic pinched 140 minutes, cardiopulmonary bypass (IR) 280 minutes.

Entrance to anesthesia and the main stage of the operation proceeded without technical and hemodynamic problems; at the introductory stage, an introducer was installed in the right femoral artery for possible IABC. At the stage of restoration of cardiac activity, according to the data of transesophageal echocardiography and according to monitoring of central hemodynamics, signs of HF are detected with a predominance of right ventricular failure with a decrease in cardiac index (SI) below 2 l / min / m ² , expulsion fractions (PI) of not more than 30%, restrictive type diastolic dysfunction. IK was continued with 50% productivity, an intra-aortic balloon was performed and IABC was performed, which allowed stabilizing hemodynamics. Upon reaching the SI indicators of 2.4 l / min / m ² , FI up to 40%, it was decided to complete the IC and transfer the patient to the intensive care unit, where the infusion of 12.5 mg of levosimendan was started, which lasted for 5 hours. At the end of the infusion, the SI level was 2.8 l / min, PI 42% according to the transtorocal echocardiography, which allowed us to diagnose the hypertonic type of diastolic myocardial dysfunction. According to the results of monitoring the indicators of central hemodynamics, the phenomena of hyperhydration and acute lung damage were revealed - CVP 12 mmHg; DZLA 34 mmHg, extravascular lung water index (EVLWI) 16 ml / kg; venous desaturation of 49% with forced ventilation modes, at the same time there was an increase in the manifestations of SVR: hyperthermia up to 38.8 ° C, leukocytosis 18 × 10 ⁹ , metabolic acidosis BE-11.6, hyperglycemia 16 g / l. Given the minimal drainage losses (less than 2 ml / kg / h) with satisfactory hemostasis, 6 hours after the operation, extended veno-venous hemofiltration (PVVHF) was started at a rate of 35 ml / kg with dosed heparinization with an ultrafiltration volumetric rate of 100 ml / h. After 12 h, the procedures of the phenomenon of overhydration were stopped (CVP 5 mmHg, DZLA 21 mmHg. EVLWI 8 ml / kg, standard ventilation). In this case, inotropic support in the therapeutic range (dobutamine 6 μg / kg / min, dopmin 3 μg / kg / min), IABC mode 1: 2 provide SI 2.8 l / min with a PI of 40%. After 24 hours, IABC was discontinued, the patient was extubated, and after 5 days transferred to the surgical department, and was subsequently discharged in satisfactory condition.

Example 2. Patient K., 52 years old, was admitted for surgical treatment with a diagnosis of Primary prosthetic endocarditis - bioprosthesis insufficiency in the mitral position, 3-4 tbsp .; secondary insufficiency of the tricuspid valve 3 tbsp., NK 3. Concomitant diseases: coronary heart disease, angina pectoris 2 FC (PN stenosis 35% and VTK 40%); type 2 diabetes mellitus first detected, compensation, COPD, DN 2; peptic ulcer, remission. After standard preoperative preparation, an operation was performed: reprosthesis of the mitral valve with a mechanical prosthesis, plastic tricuspid valve. Duration of operation 265 min, aortic clamping 90 min, IR 110 min. Entering anesthesia and the main stage of the operation without technical and hemodynamic features, at the introductory stage, an introducer was installed in the right femoral artery for possible IABC. 20 minutes after the end of the main ethane of surgical intervention and the termination of IR, signs of SI were recorded (SI 1.6 l / min, FI 24%). At high doses of inotropic support (dobutamine 18 mg / kg / min, adrenaline 0.15 μg / kg / min, dopmin 7 μg / kg / min with a total hydrobalance of 25 ml / kg) IABC started in 1: 1 mode, upon reaching stable hemodynamic parameters, the patient was transferred to resuscitation, where a 6-hour infusion of 12.5 mg of levosimendan was performed. At the end of the infusion, with reduced dosages of inotropic support (dobutamine 10 mg / kg / min, adrenaline 0.07 mg / kg / min) SI 2.0 l / min, with transthocal echocardiography - FI 35%. The effects of hyperhydration and acute lung damage persist (CVP 10 mmHg; DZLA 28 mmHg, EVLWI 12 ml / kg; forced ventilation), manifestations of SVR are expressed (hyperthermia up to 39 ° C, leukocytosis 14.4 × 10 ⁹ , metabolic acidosis BE-12 , 1, hyperglycemia 18 g / l). When registering minimal drainage losses (less than 1 ml / kg / h) against the background of satisfactory hemostasis, 8 hours after surgery, PVVHF was started in the regime of 45 ml / kg with dosed heparinization with a volumetric rate of ultrafiltration of 55 ml / h. After 10 hours of the procedure, the phenomena of overhydration were stopped (CVP 6 mmHg, DZLA 15 mmHg, EVLWI 6 ml / kg, standard ventilation). Inotropic support in the therapeutic range (dobutamine 5 μg / kg / min, dopmin 3 μg / kg / min) and IABC 1: 2 regimen provide SI 3 l / min with a PI of 46%. In the next 12 hours, IABC was discontinued, the patient was extubated, and after 3 days transferred to the surgical department, was subsequently discharged in satisfactory condition.

Claims (1)

A method for the prevention of low cardiac output syndrome and its complications in patients after surgery for heart valve re-prosthetics, including balloon counterpulsation and infusion of a solution of levosimendan at a dose of at least 12.5 mg, characterized in that the infusion of levosimendan begins immediately after the completion of the main stage of surgical correction of heart valves and stopping cardiopulmonary bypass, the duration of the infusion is 6-8 hours, after which a veno-venous hemofiltration session is carried out for 12 hours, in an average volumetric mode of substitution of 35-40 mg / kg.