RU2621953C1 - Method for aortic coarctation and re-coarctation plastic combined with hypoplastic aortic arch - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: heart and great vessels are approached through a median sternal incision. The patient is connected to a cardiac pump. The patient is cooled to the target level of hypothermia. That is followed by separation of the aortic arch, branches and a descending aorta in the distal direction from a stenosis. That is followed by separation of the aortic arch, branches and a descending aorta in the distal direction from a stenosis. After clamping of the ascending aorta, aortic arch branches, the descending aorta in the distal direction from a stenosis, the descending aorta is dissected along the right lateral surface, starting distally to the stenosis area, and then passing to the lower surface of the distal and proximal portion of the aortic arch, and terminating the incision along the left lateral surface of the distal third of the ascending aorta on the left. Next, a patch of the necessary size is cut out of the synthetic material, after which the patch is sewn into the section of the dissected aorta with a continuous blanket suture. Actions are taken to prevent air embolism; the aorta and its branches are unclamped. The patient is heated to normal temperature.

EFFECT: method allows to increase surgery safety and to prevent intraoperative and postoperative complications.

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Description

The invention relates to medicine, namely to cardiovascular surgery.

The need to use additional plastic material during reconstructive procedures on the aorta in patients with coarctation (CoAo) and rearctation of the aorta (reCoAo) is found in cases of rigidity of the tissue of the aortic wall, reCoAo with a pronounced adhesion process, the inability to sufficiently mobilize the aorta due to anatomical features, calcification of the aorta, especially with a combination of CoAo and reCoAo with hypoplasia of the aortic arch [1, 2, 3]. In such cases, there is a need for the use of additional plastic material in the form of patches or vascular prostheses. When using vascular prostheses, unlike patches, the reconstructed section of the aorta will never grow, thereby creating the prerequisites for the development of reKoAo [1, 2, 3].

A known method of surgical treatment of CoAo, reCoAo using a patch at the site of aortic stenosis and the distal part of the aortic arch [4]. This method is the closest to the claimed technical essence and the achieved result. It is selected as a prototype.

The disadvantage of the prototype is the inability to eliminate concomitant hypoplasia of the aortic arch in the proximal segment of the aortic arch, which leads to the likelihood of a residual gradient and the development of reKoAo with subsequent growth of the patient.

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 plasty of KoAo and reKoAo in combination with hypoplasia of the aortic arch, for which, after access to the heart and great vessels through median sternotomy and connecting the heart-lung machine (AIK), cooling of the patient to the target level of hypothermia begins. Then, the aortic arch, its branches and the descending aorta are distal to the narrowing. After clamping the ascending aorta, branches of the aortic arch, descending aorta distal to the narrowing, dissect the aorta along the right lateral surface of the descending aorta, starting distal to the stenosis site, followed by transition to the lower surface of the distal and proximal part of the aortic arch, and complete the incision along the left lateral surface of the distal third ascending aorta to the left. If there is a membrane in the region of CoAo, it is resected. Next, a patch of the required size is cut out of synthetic material, after which the patch is sewn into the section of the dissected aorta with a continuous twisting seam. Prevent airborne embolism, remove the clamps from the aorta and its branches. The patient begins to warm up to normothermia.

New in the proposed method is that the aorta is dissected, starting distal to the stenosis site along the right lateral surface of the descending aorta, followed by transition to the lower surface of the distal and proximal part of the aortic arch, and the incision is completed along the left side surface of the distal third of the ascending aorta to the left, after which stitching the patch of the required diameter into the section of the dissected aorta is performed.

New signs make it possible to increase the safety of surgery and to prevent intraoperative and postoperative 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 peri-and 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 drawings attached to it.

FIG. 1 is a view of aortic coarctation in combination with arch hypoplasia;

1 - ascending aorta;

2 - brachiocephalic trunk;

3 - left common carotid artery;

4 - the left subclavian artery;

5 - aortic arch;

6 - plot of aortic stenosis;

7 - the descending aorta.

FIG. 2 - view of the main stage of the operation;

8 - clamps;

9 - section of the aorta;

10 - patch.

FIG. 3 - final view;

10 - patch.

The method is as follows.

Access through the median sternotomy to the heart and major vessels. Connect AIK. The patient begins to cool to 30 ° Celsius. Allocate the ascending aorta - 1, the aortic arch - 5, its branches - 2, 3, 4, the site of aortic stenosis - 6 and the descending aorta - 7 (Fig. 1). The aortic pouch is relaxed, the aortic cannula is advanced into the lumen of the brachiocephalic trunk - 1 (BCC), and the aortic pouch is tightened. Squeeze the ascending aorta - 1, perform cardioplegia in the aortic root, achieve asystole. The mouth of the BCS is compressed - 8. The volumetric perfusion rate (OSP) is reduced to 30% of the standard value. Clips are applied to the branches of the aortic arch - 8, the descending aorta is distal to the narrowing - 8, after which the aorta is cut, starting distal to the stenosis site along the right lateral surface of the descending aorta, followed by transition to the lower surface of the distal and proximal part of the aortic arch, and the incision is completed on the left the lateral surface of the distal third of the ascending aorta to the left is 9. In the presence of a membrane in the region of CoAo, it is resected. Next, a patch of the required size is cut out of synthetic material, after which the patch is sewn into the dissected aorta site with a continuous twisting suture - 10 (Fig. 2). They carry out the prophylaxis of aeroembolism, let the blood flow through BCS - 1, remove the clamps - 8 from the branches of the arch - 3, 4 and the descending aorta - 7. Relax the pouch on the ascending aorta, move the aortic cannula into the lumen of the ascending aorta, and tighten the aortic pouch. OSB increase to 100%. Remove the clamp from the ascending aorta. Begin warming to normothermia. Then stop the AIK. Perform ultrafiltration, and then carry out decanulation. The final result is shown in FIG. 3. The soft tissues of the surgical wound are sutured in layers with drainage of the pericardium and anterior mediastinum.

Clinical example. Patient G., 14 years old. Diagnosis: Congenital heart disease. Hypoplasia of the aortic arch. Coarctation of the aorta. Bicuspid aortic valve. NK 0 tbsp. FC I.

The diagnosis was made on the basis of complaints, medical history, objective examination, ultrasound of the heart, multispiral computed tomography with contrasting of the thoracic aorta. Access - median sternotomy. Connected AIK according to the scheme “aorta-vena cava”. Installed drainage of the left ventricle through the right upper pulmonary vein. Hypothermia up to 30 ° Celsius. The aortic arch, its branches, and the descending aorta are distal to the narrowing. The ascending aorta, cardioplegia to the root of the aorta, asystole are pinched. The aortic cannula is moved to the lumen of the BCS. BCC is pinched, OSB is reduced to 30%. The descending aorta is distal distal to the narrowing, branches of the aortic arch. The aorta is dissected, starting distal to the stenosis on the right side of the aortic of the descending aorta with the transition to the lower surface of the distal and proximal part of the aortic arch and to the distal third of the ascending aorta on the left side. Next, a patch of the required size from polytetrafluoroethylene (PTFE) was cut out, the patch was sewn into the dissected section of the aorta with a twisted suture. Prevention of aeroembolism was performed, clamps were removed from the descending aorta and its branches. Blood flow through the BCC was started, the aortic cannula was moved to the aortic lumen, the OSB was increased to 100%. Clamp removed from the ascending aorta. Recovery of cardiac activity with an outcome in sinus rhythm. Warming up to normothermia. Measures to remove air from the heart and major vessels. AIK stopped. Modified ultrafiltration. Decanulation. An electrode is attached to the right ventricle for the implementation of a temporary EX. Hemostasis. The pericardium is sutured. Osteosynthesis of the sternum by wire ligatures. Layered closure of the wound with drainage of the pericardium, anterior mediastinum with a single drainage. Kutasept. Aseptic dressing.

The postoperative period was uneventful. During the first day, the patient is extubated, on the 2nd day transferred from the intensive care unit. The postoperative course is smooth. On the 9th day after the operation, the patient was discharged from the hospital.

Clinical example. Patient K., 12 years old. Diagnosis: Congenital heart disease. Recoarctation of the aorta. Hypoplasia of the aortic arch. NK 0 tbsp. FC I. The diagnosis was made on the basis of complaints, medical history, objective examination, ultrasound of the heart, multispiral computed tomography with contrasting the thoracic aorta. Performed median sternotomy. Connected AIK according to the scheme "aorta-right atrium." Installed drainage of the left ventricle through the right upper pulmonary vein. Hypothermia up to 30 ° Celsius. The aortic arch, its branches, and the descending aorta are distal to the narrowing. The ascending aorta, cardioplegia to the root of the aorta, asystole are pinched. The aortic cannula is moved to the lumen of the BCS. BCC is pinched, OSB is reduced to 30%. The descending aorta is distal distal to the narrowing, branches of the aortic arch. The aorta is dissected, starting distal to the stenosis on the right side of the aortic of the descending aorta, with the transition to the lower surface of the distal and proximal part of the aortic arch and to the distal third of the ascending aorta on the left side. Next, a patch of the required size from PTFE was cut out, the patch was sewn into the dissected section of the aorta with a twisted suture. Prevention of aeroembolism was performed, clamps were removed from the descending aorta and its branches. Blood flow through the BCC was started, the aortic cannula was moved to the aortic lumen, the OSB was increased to 100%. Clamp removed from the ascending aorta. Recovery of cardiac activity with an outcome in sinus rhythm. Warming up to normothermia. Measures to remove air from the heart and major vessels. AIK stopped. Modified ultrafiltration. Decanulation. An electrode is attached to the right ventricle for the implementation of a temporary EX. Hemostasis. The pericardium is sutured. Osteosynthesis of the sternum by wire ligatures. Layered closure of the wound with drainage of the pericardium, anterior mediastinum with a single drainage. Kutasept. Aseptic dressing.

The postoperative period was uneventful. During the first day, the patient is extubated, on the 2nd day transferred from the intensive care unit to the children's department. The postoperative course is smooth. On the 12th day the patient was discharged from the hospital.

The method proposed by the authors was applied in 9 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 can effectively eliminate CoAo and reCoAo and concomitant hypoplasia of the aortic arch with the lowest rates of surgical risk.

List of references

1. Jonas S. Comprehensive surgical management of congenital heart disease / S. Jonas; 2 ^nd ed., Taylor and Francis group, LLC. - 2013 .-- 679 p.

2. Mavrodis C, Backer C. Pediatric Cardiac Surgery: Fourth ed. / Blackwell Publishing Ltd. - 2013 .-- C. 256-282.

3. Kouchoukos N. et al. Kirklin / Barratt-Boyes cardiac surgery: morphology, diagnostic criteria, natural history, techniques, results, and indications / Nicholas T. Kouchoukos. - 2013 .-- 4th ed; - C. 1718-1779.

4. Mery C., Fraser C. Anatomic repair of recurrent aortic arch obstruction // Operative Techniques in Thorac and Cardiovasc Surg. - 2012. - Vol. 17, issue 4. - P. 271-279.

Claims (1)

The method of plasticity of coarctation and rearctation of the aorta in combination with hypoplasia of the aortic arch, which consists in the fact that after performing a mid sternotomy, connecting the cardiopulmonary bypass, the ascending aorta, the arch and the descending aorta are distal to the stenosis, the ascending aorta, the branches of the aortic arch and the descending aorta are squeezed , after which the aorta is dissected, then the patch of the required size is cut out of the synthetic material, after which the patch is sewn into the section of the dissected aorta with an upholstered suture, aeroembolism is prevented, clamps are removed from the aorta and its branches, characterized in that the aorta begin to dissect distal to the stenosis along the right lateral surface of the descending aorta with the subsequent transition to the lower surface of the distal and proximal parts of the aortic arch and complete the incision along the left lateral surface the distal third of the ascending aorta to the left.

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