RU2604716C2 - Method for correction of partially abnormal drainage of right pulmonary veins in superior vein cava - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specialty - cardiovascular surgery. After connecting cardiopulmonary bypass manifold is created between abnormally drained upper pulmonary vein and interatrial septum defect in left atrium. Superior vein cava is transected at 5 mm above its return into right atrium and proximal end is closed. Then U-shaped flap is cut from right atrium eye and lower wall of anastomosis between distal end of superior vein cava and U-shaped flap of right atrium is formed. To form upper wall of anastomosis patch of autopericardium is used.

EFFECT: method allows reducing number of complications in early and in long postoperative period, as well as efficient correction of partially abnormal drainage of pulmonary veins in congenital heart disease with lowest surgical risk.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to cardiovascular surgery.

Partial abnormal pulmonary venous drainage (PADV) is one of the most common pathologies of pulmonary venous return [3].

The defect was first described by Winslow (1739). During pathological and anatomical examination, he found an abnormal drainage of the pulmonary vein of the upper lobe of the right lung into the superior vena cava. The most complete anatomy and clinic of this defect was studied by Brody (1942). We systematized the anatomical variants (types) of the defect R. Darling et al. (1957). In most cases (97.2%), drainage of the right pulmonary veins is observed, and in the remaining - of the left [4].

The incidence rate of this defect is at least 1.5% among all congenital heart defects (CHD) [4]. The average life expectancy of patients with CHADV does not exceed 37-40 years [1, 2].

The first successful operation for correcting CHADV using the closed method of “atrioseptopexy” was performed by W. Neptune in 1953.

The modern stage of the treatment of the defect began with the introduction of open heart surgery into clinical practice. Under hypothermia, F. Lewis was the first to perform the correction of abnormal pulmonary venous drainage into the right atrium and superior vena cava in 1955. In the future, artificial blood circulation was used to perform the operation.

Particularly difficult to correct is the option of partial abnormal drainage of the right superior pulmonary veins into the superior vena cava (CHAPLV in ERW) with or without atrial septal defect (ASD). Over the years, a significant number of methods have been developed in specialized clinics of far-abroad countries for correcting abnormal flow of the right pulmonary veins. All these methods have their positive and negative points.

The most common surgical treatment for CHADPV is to create a collector that moves abnormally draining pulmonary veins into the left atrium (LP), followed by xenopericardium, the anterior vena cava (CWP).

The disadvantages of this method are the impossibility of reliable prevention of damage to the conduction system of the heart and arteries of the sinus node, stenosis of the superior vena cava with the likelihood of thrombosis, hemodynamic disturbances in the area of the pulmonary vein collector and the mouth of the superior vena cava are possible [3].

A known method for surgical treatment of CHADPV is to move the abnormal drainage of the pulmonary veins into the left atrium, followed by the creation of an end-to-end anastomosis between the distal end of the ERW and the ear of the right atrium. This procedure was first described by Wardan et al. in 1984, the operation worked well, but like the previous version, it does not exclude damage to the sinus node and the formation of ERW stenosis in 20% of cases [1, 4, 5].

Thus, there is no optimal technique for surgical intervention for this type of partial abnormal drainage of the pulmonary veins.

An adequate prototype was not found in the analyzed literature.

The aim of the invention is the prevention of intra- and postoperative complications.

The goal is achieved by a technical solution, which is a way of correcting CHADPL in ERW. After connecting the cardiopulmonary bypass, the ERW is crossed 5 mm above the place where it flows into the right atrium (PP), the proximal end is sutured. With the help of a patch from the autopericardium, a collector is made between the mouth of the abnormally flowing right pulmonary vein (PLV) and DMPP, thus creating a tunnel of an abnormally draining superior pulmonary vein. A U-shaped flap is carved from the abalone of the PP, the lower wall of the anastomosis is formed between the distal end of the ERW and the U-shaped flap of the PP using a patch from the autopericardium as the upper wall of the anastomosis.

The technical result of the invention is the ability to avoid intra- and postoperative complications: weak sinus node, sinoatrial block, prevent the formation of distant stenosis and / or obstruction of the ERW in the area of the formed anastomosis.

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, by reducing early and long-term postoperative complications.

Based on the foregoing, the proposed method should be considered appropriate 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 figures attached to it.

In FIG. 1 shows a diagram of the allocation of the superior vena cava with its subsequent intersection, the right atrium in the context with the location of the abnormally flowing pulmonary veins and the atrial septal defect:

1 - the distal end of the cut superior vena cava;

2 - the proximal end of the cut superior vena cava;

3 - abnormally flowing right upper pulmonary vein into the right atrium;

4 - atrial septal defect.

In FIG. 2 shows a suturing scheme of the proximal end of the superior vena cava, the creation of a collector of abnormally flowing pulmonary veins using a patch from the autopericardium through an atrial septal defect into the left atrium:

1 - the distal end of the cut superior vena cava;

2 - sutured proximal end of the superior vena cava;

5 - created collector of abnormally flowing superior pulmonary veins through an atrial septal defect into the left atrium.

In FIG. 3 is a diagram of the formation of a U-shaped flap from the ear of the right atrium and the formation of the lower wall of the anastomosis:

1 - the distal end of the cut superior vena cava;

2 - sutured proximal end of the superior vena cava;

6 - the formation of a U-shaped flap from the ear of the right atrium with the implementation of the lower wall of the anastomosis.

In FIG. 4 is a diagram of the formation of the upper wall of the anastomosis:

2 - sutured proximal end of the superior vena cava;

7 - the upper wall of the anastomosis is formed by a patch from an autopericardium;

8 - the right atrium.

The method is as follows. In FIG. 1 shows the allocation scheme of ERW 1, 2 with subsequent intersection above the place of its confluence in PP 8 by 5 mm. Suturing of the proximal end of the ERW 2 (PrVPV) is performed. Using a patch from the autopericardium (Fig. 2), after pretreating it in glutaraldehyde, a pulmonary vein (LV) collector is performed through DMPP in LP 7 in order to move abnormally flowing pulmonary veins 3.

A U-shaped flap 6 is cut out from the abutment of PP 8 (Fig. 3). With its help, the lower wall of the anastomosis is made between the ear of the right atrium and the distal end of the ERW 6. From the remaining patch flap of the autopericardium, the upper wall of the anastomosis 7 is formed, as shown in FIG. four.

Clinical example. Patient M., 4 years 9 months. Diagnosis: Congenital heart disease. Partial abnormal drainage of the pulmonary veins. Atrial septal defect. NK 0 tbsp. LH 0 tbsp. FC I. The diagnosis was made on the basis of ultrasound examination of the heart. Access - median sternotomy. Pericardiotomy Autopericardium fence. On examination, the right pulmonary veins drain into the ERW. The heart is enlarged due to the right departments. Introduced heparin. IR connection according to the “VPV-NPV - Aorta” scheme. The ascending aorta, cardioplegia to the root of the aorta, asystole are pinched. Right atriotomy. The right upper and lower pulmonary veins with 2 mouths are drained in the ERW (Fig. 1). DMPP up to 20 mm. The movement of the right drug into the cavity of the PL with the plastic of the LSPP patch from the autopericardium (preliminary exposure in glutaraldehyde 15 minutes) with a continuous suture with 6/0 proline thread (Fig. 2) was performed. An anastomosis with ERW was performed with a flap of the front wall of the PP and a patch from the autopericardium (Fig. 3, 4). Prevention of aeroembolism. Removing the clamp from the aorta. Self-restoration of cardiac activity with outcome in SR. Suturing of the PP with a double-row seam with a prolet 6/0 thread. Measures to remove air from the heart and major vessels. End of vena cava occlusion. AIK stopped. Decanulation. A “Preclude” patch is 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 one drainage. Kutasept. Aseptic dressing. The postoperative period was uneventful.

According to the ultrasound examination: the flow in the formed anastomosis between the PP ear and the distal end of the ERW is adequate, the pressure gradient is less than 5 mm Hg, the pulmonary vein collector through the LSP in the LP functions satisfactorily. After 2 hours, the patient was extubated, on the 2nd day transferred from the intensive care unit to the general ward. On the 10th day the patient was discharged from the hospital.

The method proposed by the authors was applied in 10 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 correct CHAPPL in ERW with the lowest rates of surgical risk.

List of references

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

2. Modified Cavoatrial Anastomosis in Warden Procedure Kaiyu Tao, Wencheng Pan, Ke Lin, Yingkang Shi, Peiju Zhu, Yingqiang Guo, Changping Gan and Qi An Ann Thorac Surg 2010; 89: 2047-2048 DOI: 10.1016 / j.athoracsur. 2009.07.092.

3. 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 .-- C. 185-525.

4. Surgery for Congenital heart defects / [edited by] J. Stark, M. de Leval, illustrated by Michael Coutney - 2-nd ed. / W.B. Saunders Company 1994. - C. 712.

5. Anomalous pulmonary venous connection to superior vena cava: Brijesh P. Kottayil et al. / European Journal of Cardio-thoracic Surgery 39 (2011) 388-391.

Claims (1)

A method for surgical correction of partially abnormal drainage of the right pulmonary veins into the superior vena cava, characterized in that after connecting the cardiopulmonary bypass, a collector is created between the abnormally draining superior pulmonary vein and the atrial septal defect into the left atrium, for which the superior vena cava is crossed 5 mm higher the places of its confluence with the right atrium and the proximal end are sutured, then a U-shaped flap is cut from the ear of the right atrium and the lower wall of the anas is formed omoza between the distal end of the superior vena cava and the U-shaped flap of the right atrium and for forming the top wall of the anastomosis using the patch of autoperikarda.

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