RU2618648C1 - Method of blood circulation correction in patients with functional single ventricle and general atroventricular valve insufficiency - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: at first, valve component is sutured with the highest hypoplasia ratio, and then it is closed with a synthetic patch. At first, the patch is fixed to the valve bridging leaflets with continuous suture at the level of interventricular septum crest projection, and then it is sutured along the perimeter to annulus fibrosus of the sutured valve component. Synthetic semiring is fixated with continuous suture to the fibrous ring of the remaining valve component, providing pleat compilation of the annulus fibrosus so that the diameter of the formed valve is not smaller than the size of the mitral valve according to the operated child age norm. While fixating the semiring, coronary sinus region is excluded from the suture region.

EFFECT: method enables to eliminate regurgitation due to separate plasty of two valve components, perform the prevention of complications caused by prolonged cardiac arrest, as well as complications associated with cardiac arrhythmia, as well as to create new anatomical conditions for general AV valve prosthesis.

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Description

The invention relates to medicine, namely to cardiovascular surgery, and can be used in the surgical treatment of congenital heart defects with one-ventricular hemodynamics.

One of the most important unresolved problems of hemodynamic correction in patients with different variants of the functionally unique ventricle of the heart remains the concomitant insufficiency of atrioventricular valves, which impedes the operation and worsens both immediate and long-term results. In the available literature, the experience of eliminating atrioventricular regurgitation in this category of patients is limited by small clinical material and unsystematic application of various techniques. The presented results are heterogeneous. The lack of a clear surgical approach, a wide variety of complications arising after the operation of a complete "bypass" of the right heart determines the relevance of the topic.

Combined interventions on a common atrioventricular valve (AV valve) can conditionally be divided into 2 options:

- suture annuloplasty of one of the components of the common AV valve according to Kay-Boyd in combination with valvuloplasty by applying individual sutures to the cleavage of the sash or according to commissures;

- De Vega semicircular annuloplasty of one of the components (mitral or tricuspid) of the common AV valve with suturing of the valves of the other component.

A known method for the correction of insufficiency of the common AV valve in patients with a functionally single ventricle of the heart, involving plastic surgery of the common AV valve while moving the collector of hepatic veins into the pulmonary artery. (Podzolkov V.P., Yurlov I.A., Zelenikin M.M., Kovalev D.V. et al. // Children's diseases of the heart and blood vessels. - 2006. - No. 3. - p. 46-51). The essence of the method was as follows: the first stage was the closure of the cusps of the mitral or tricuspid portion of the common AV valve, followed by closing it with a synthetic patch of PTFE. The purpose of plastic closure of one of the components (mitral or tricuspid) with a patch is not only to significantly reduce the area of the common atrioventricular opening, but also to stabilize the dilated fibrous ring. The next step was semicircular plastic surgery according to De Vega followed by strengthening of the fibrous ring with a soft supporting half-ring made of PTFE of the remaining component of the common AV valve. As a result, there is only one functioning atrioventricular valve.

The figure 1 presents a diagram of a combined annulovulvuloplasty of a common AV valve by a known method.

However, this method is performed in combination with the movement of the collector of the hepatic veins into the pulmonary artery, a different surgical operation, which is accompanied by the creation of other hemodynamic conditions different from the operation of a complete venous "bypass" of the right heart. In addition, the intervention includes two stages of plastic surgery of the remaining component of the common AV valve (De Vega plastic, reinforcing the fibrous ring with a soft support half-ring made of PTFE), which increases the time of surgery and, accordingly, the time of cardiac arrest.

There is a method of corrective intervention on a common AV valve in patients with a functionally single ventricle of the heart with complete extracardial "bypass" of the right heart, involving the execution of annuloplasty according to De Vega in combination with suture valvuloplasty (Ando M, Takahashi Y. Edge-to-Edge repair of common atrioventricular or tricuspid valve in patients with functionally single ventricle // Ann Thorac Surg., 2007; 84: 1571-1577) (prototype).

The figure 2 presents a diagram of a semicircular annuloplasty according to De Vega with suturing of the splitting of the anterior bridge-like valve of the common AV valve.

The disadvantages of the known prototype method are the high risk of suture erosion during valvuloplasty (especially with thin valve flaps) with the occurrence of repeated regurgitation, as well as the absence of stable stabilization and size of the fibrous ring.

We set the task to develop a method for eliminating the insufficiency of the common AV valve in patients with a functionally single ventricle during the operation of a complete extracardial "bypass" of the right heart, which allows reliably eliminating regurgitation and creating new anatomical conditions for prosthetics of one of the components of the common AV valve, if in remote the terms will develop a relapse of its insufficiency. The technical result achieved by the implementation of the proposed method is:

- reliable elimination of regurgitation due to the separate plasticity of the two components of the valve, while reducing the area of the common atrioventricular opening and stabilizing its dilated fibrous ring;

- prevention of complications caused by prolonged cardiac arrest by reducing the time of intraoperative cardiac arrest by performing plastic surgery of the remaining valve component and stabilizing the fibrous ring in one step;

- the creation of new anatomical conditions for prosthetics of the common AV valve in case of recurrence of its insufficiency due to reliable stabilization of the fibrous ring of the valve;

- prevention of complications associated with cardiac arrhythmias by improving the technique of surgical intervention by eliminating trauma to the coronary sinus region;

- prevention of the development of valve stenosis due to the formation of the optimal diameter of the corrected common AV valve under hemodynamic conditions created by the operation of complete venous "bypass" of the right heart.

The invention consists in the following.

To correct blood circulation in patients with a functionally single ventricle of the heart and a general atrioventricular valve insufficiency, a complete venous bypass of the right heart and combined annulovulvuloplasty of the common atrioventricular valve are performed. When performing the latter, the valve component with the highest degree of hypoplasia is first sutured, and then closed with a synthetic patch. The patch is first fixed with a continuous seam to the bridge-like valve cusps at the level of the projection of the ridge of the interventricular septum, and then is hemmed around the perimeter to the fibrous ring of the sutured valve component. Then they simultaneously perform semicircular annuloplasty of the remaining valve component and strengthen its fibrous ring, for which the synthetic half ring is fixed with a continuous suture to the fibrous ring of the remaining valve component so that the distance between the injections on the fibrous ring is 1.5-2 times greater than the distance between injections on a semicircle. At the same time, the fibrous ring is sorbed in such a way that the diameter of the formed valve is not less than the size of the mitral valve according to the age norm of the operated child. When fixing the half ring from the seam area exclude the area of the coronary sinus.

Additionally, the tricks of residual regurgitation, if necessary, eliminate the imposition of "Z" -shaped seams.

The method is as follows.

Access to the heart is via a mid sternotomy. According to the accepted method, an artificial blood circulation apparatus is connected (cannulas are installed in the ascending aorta, transverse vein and inferior vena cava) and perfusion begins in conditions of deep hypothermia.

To perform a complete venous bypass of the right heart, the following interventions are performed.

A bidirectional left-sided or right-sided cavopulmonary anastomosis is applied - an anastomosis between the superior vena cava and the left or right pulmonary artery, respectively (DCAP), the communication between the single ventricle and the pulmonary trunk is removed (for example, the pulmonary trunk is ligated), and the distal anastomosis is placed between the inferior vena cava (IVC) and a prosthesis, a proximal anastomosis between the prosthesis and the right or left pulmonary artery,

So, the technique of Fontaine’s operation in the modification of extracardiac conduit after previously performed DCPA includes several successive stages: the application of a distal anastomosis between the IVC and the prosthesis, for example, “Gore-Tech”, cardioplegia followed by an intracardiac stage with atrioventricular valve repair. Next - the application of a proximal anastomosis between the prosthesis, for example, Gore-Tech and the pulmonary artery system, as well as ligation or suturing of the pulmonary valve.

After the onset of cardiopulmonary bypass and clamping of the IVC by the turnstile on the cannula, the right atrium is squeezed in the region of the mouth of the IVC with a clamp so that the pulmonary veins, right coronary artery or coronary sinus do not fall into the clamp.

In order to increase the surgical field, the clamp is applied obliquely from the pulmonary veins towards the diaphragmatic surface of the heart. After applying the clamp, the IVC is cut off from the heart. Next, an anastomosis is applied between the distal end of the IVC and the Gore-Tech prosthesis using a Gore-Tech 5-0 thread with a continuous upset stitch.

This stage of the operation is performed on a working heart. After the formation of the anastomosis, the ascending aorta is squeezed between the conduit and the IVC and pharmacological cold cardioplegia is performed with the Custodiol solution in the aortic root. Remove the clamp from the right atrium (PP) and perform its incision.

Then, the intracardiac stage of the operation is performed - an intervention on the AV valve (combined annulovulvuloplasty of the common atrioventricular valve).

During the audit (determine the type of valve according to the classification of Rastelli) conduct a hydrodynamic test of the common AV-valve. Assess: the degree of dilatation of the fibrous ring.

The component of the common AV valve with the highest degree of hypoplasia is determined on the basis of instrumental research methods (echocardiography, angiocardiography, computed or magnetic resonance imaging) at the stage of prehospital examination.

After this, suturing of the component of the common AV valve, which is characterized by the highest degree of hypoplasia, is performed, followed by plastic closure with a patch of polytetrafluoroethylene (PTFE). The patch size is determined by the portion diameter of the common valve with the highest degree of hypoplasia. The patch is fixed with a continuous suture to the bridge-like valve cusps at the level of the projection of the ridge of the ventricular septum. After that, the patch is hemmed with a continuous seam to the fibrous ring of the valve.

The next step is to perform semicircular annuloplasty of the opposite valve component (the next step is combined annulovulvuloplasty): a soft support semicircle made of PTFE is hemmed with a continuous mattress suture to the fibrous ring of this component. The seam is imposed with a wider step on the fibrous ring and a smaller step on the support ring, due to which the diameter of the latter decreases.

The distance between the injections on the fibrous ring is 1.5-2 times greater than the distance between the injections on the half ring. At the same time, the fibrous ring is sorbed in such a way that the diameter of the formed valve is not less than the size of the mitral valve according to the age norm of the operated child. When fixing the half ring from the seam area exclude the area of the coronary sinus.

If necessary, the tricks of residual regurgitation are eliminated by the imposition of additional "Z" -shaped seams.

Monitoring the effectiveness of the operation is performed using a hydrodynamic test. The subsequent stages of the intervention are carried out in conditions of moderate hypothermia on a working heart. The atrial wall incision is closed with a two-row suture. The next step is to remove the clamp from the ascending aorta, restore cardiac activity, and sequentially, as shown above, suturing of the pulmonary valve and implantation of the tubular prosthesis from PTFE between the pulmonary artery and stump of the inferior vena cava are performed.

To reduce the time of ischemia of the heart, after filling the heart with blood and preventing air embolism, the clamp is removed from the aorta and cardiac activity is restored. The next step is to eliminate antegrade pulmonary blood flow, by ligation of the pulmonary trunk with two Mersilene 3-0 strings, one of which is applied circularly with suturing the walls of the pulmonary trunk, which prevents the threads from shifting towards the bifurcation of the trunk or in a more efficient way - suturing the valve opening from the lumen of the pulmonary trunk.

Anastomosis between the proximal end of the extracardiac conduit and the pulmonary artery is performed on a working heart. To do this, an incision is made on the lower aspect of the right or left branch of the pulmonary artery (depending on the formation and position of the heart and main vessels), observing the principle of separation of blood flows - the incision site on the right pulmonary artery should be removed as far as possible from the previously performed cavopulmonary anastomosis.

The distal end of the Gore-Tech prosthesis is sutured into the incision. In all cases, the anastomosis between the pulmonary artery system and the Gore-Tech prosthesis is superimposed with a Gore-Tech 5-0 thread with a needle No. 13 or No. 17. Extracardial conduit is laid along the lateral surface of the heart.

Anastomosis of the superior vena cava with the pulmonary artery can be performed during previous operations.

In figures 3, 4, 5 presents the stages of combined annulovulvuloplasty in accordance with the proposed method (intraoperative photographs): in FIG. 3 - suturing of the mitral hypoplastic component of the common AV valve; in FIG. 4 - plastic closure of the mitral hypoplastic component of the common AV valve with a PTFE patch; in FIG. 5 shows a semicircular annuloplasty of a common AV valve by suturing to the fibrous ring of the tricuspid component of the soft (PTFE strip) support half-ring.

Clinical example

Patient, 8 years old. Diagnosis: functionally the only ventricle of the heart; general atrioventricular valve with insufficiency of 3 degrees; valvular and subvalvular stenosis of the pulmonary artery; condition after applying a bidirectional cavapulmoral anastomosis (DKPA). Circulatory failure 3 FC according to NYHA. Upon admission to the ward, the patient complained of cyanosis, increased fatigue and shortness of breath with moderate physical exertion. Saturation of capillary blood with oxygen before surgery was 82%.

In 2006, the patient underwent Fontaine's surgery to modify eccardial conduit with plastic surgery of the common AV valve according to the proposed method in conditions of cardiopulmonary bypass, hypothermia (Trectum = 28C °) and pharmacological cold cardioplegia with Custodiol solution. The aortic clamping time was 58 minutes, the total IR time was 158 minutes. During surgery, a PP was opened on a stopped heart, the fibrous ring of the AV valve was expanded, the valves were moderately thickened, mobile. An examination revealed the highest degree of hypoplasia of the tricuspid component of the common AV valve. The valves in this area were sutured with a continuous suture, the tricuspid valve opening was closed with a PTFE synthetic patch fixed with a continuous prolene suture to the fibrous ring of the tricuspid component. A synthetic strip of PTFE is hemmed to the fibrous ring of the mitral component. The remaining valve hole in the measurement was 24 mm. A pulmonary valve was sutured from the lumen of the pulmonary artery at the stage of extracardiac conduit implantation in the right pulmonary artery. After the restoration of cardiac activity, the patient had a sinus rhythm. The early postoperative period was moderate heart failure. There have been episodes of pacemaker migration and supraventricular tachycardia. Saturation of capillary blood with oxygen after surgery was 95%. 5 years after the operation, the patient was examined at the age of 13 years. At rest and with moderate significant physical exertion, the patient did not complain, and with increased physical exertion there was moderate shortness of breath and fatigue. On the patient's ECG, a sinus rhythm was recorded, capillary blood saturation - 97%. On the echocardiography, the fibrous ring of the mitral component is 24 mm, there is no regurgitation, a thickened patch is noted in the projection of the tricuspid component, no discharge of blood into the right atrium was found on it.

According to the proposed technique, 5 successful operations were performed; in all cases, a significant decrease in regurgitation in the area of the AV valve was noted. The widespread introduction of this technique into clinical practice will make it possible to increase the effectiveness of surgical care for patients with a functionally single heart ventricle in combination with atrioventricular valve insufficiency, which will lead to a significant reduction in unsatisfactory results.

Claims (2)

1. A method for correcting blood circulation in patients with a functionally single ventricle of the heart and insufficiency of the general atrioventricular valve, characterized in that they perform a complete venous bypass of the right heart and combined annulovulvoplasty of the general atrioventricular valve, in which the valve component with the highest degree of hypoplasia is sutured, closed with a synthetic patch which is first fixed with a continuous suture to the bridge-like valve cusps at the level of the projection of the interventricular crest partitions, and then hem the perimeter to the fibrous ring of the sutured valve component, and then simultaneously perform semicircular annuloplasty of the remaining valve component and strengthen its fibrous ring, for which the synthetic half ring is fixed with a continuous suture to the fibrous ring of the remaining valve component so that the distance between the injections on the fibrous ring was 1.5-2 times greater than the distance between the injections on the half-ring, while ensuring that the fibrous ring was soared in such a way To diameter of the valve was not formed smaller than the size of the mitral valve according to the operated child age norm, and while fixing of the half rings seams region exclude the coronary sinus region. 2. The method according to p. 1, characterized in that the additional foci of residual regurgitation eliminate the imposition of "Z" -shaped seams.

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