RU2622598C1 - Method for heart valve prosthesis implantation in aortal position - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: pathologically altered aortic valve (AV) is dissected. The circumference of the fibrous ring (FR) of AV is divided into two semicircles, so that the middle of the first semicircle lies adjacent to the region of mitral-aortic contact. U-shaped stitches are applied along the first semicircle perimeter, puncturing both needles in from the ventricular, and out - from the aortic surface of AV FR. Next, U-shaped sutures are applied along the second semicircle perimeter. At that, both needles are punctured in from the aortic, and out - from the ventricular surface of AV FR. In the area of each boundary between the semicircles, a Z-shaped suture is applied. Parallel stitches of the Z-shaped suture are formed by passing needles through the AV FR similarly to the previously applied sutures. Then, the needles of all superimposed sutures are passed through the prosthesis cuff, beginning with its surface facing the ventricle. The prothesis is placed in the AV FR area, and the applied sutures are knotted.

EFFECT: method allows to reduce the number of complications caused by paraprosthetic fistula, coronary arteries overlapping by the prosthesis cuff of the with low position of coronary ostia, technical complexity of intervention under the conditions of small aortic window, and FR fusion due to the combination of supranualular and intranannular implantation techniques; to ensure the possibility of using prostheses with a large landing size by eliminating the rejection of larger diameter prostheses due to the impossibility of their location in the implantation area.

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Description

The invention relates to medicine, namely to cardiovascular surgery, and can be used for prosthetics of the aortic valve (AK).

After prosthetics of an AK with a prosthesis of an adequate diameter, the ejection barrier is reduced, the mass of the left ventricle is reduced, which reduces the risk of ischemia, dysfunction and electrical instability of the myocardium, and also significantly reduces the frequency of complications such as sudden death and congestive heart failure associated with left ventricular hypertrophy.

Currently, in practice, when implanting prosthetic heart valves into the aortic position, two methods of continuous suturing are used.

A known method of supraannular implantation, with the imposition of individual U-shaped sutures on the fibrous ring (FC) AK (Cardiac surgery: technique, Donald B. Doughty, John R. Doughty. / Ed. By R.S. Akchurin. 2014, p. 312 -313). Suture begins with the ventricular surface of FC AK. Both injections are made at a small distance from the FC AK from the ventricular surface, through the FC AK, and the injection occurs from the aortic surface of the FC also at a small distance from it. Then both needles are passed through the cuff of the valve prosthesis, starting from the lower surface facing the ventricle.

When using this method, there is a risk of para-prosthetic fistula, due to the fact that when tightening the sutures there is no visual control, i.e. there is a risk that the seam may not be stretched enough. This technique is not always reproducible with a low location of the mouths of the coronary arteries due to the possible overlap of the mouths of the coronary arteries with the cuff of the prosthesis.

A known method of intra-annular implantation, with the application of individual U-shaped sutures on the AK AK, we have chosen as a prototype (Cardiac surgery: technique, Donald B. Doughty, John R. Doughty. / Ed. R.S. Akchurin. 2014, p. . 312-313).

Suture begins with the aortic surface of the AK AK. Both injections are made, retreating a small distance from the AK AK, from the aortic surface, through the AK AK, and the injection occurs from the ventricular surface of the AK also at a small distance from it. Then both needles are passed through the cuff of the valve prosthesis, starting from the lower surface facing the ventricle.

This implantation method, having proved itself well, is considered simple and reliable, allows visual control at all stages of the implantation of the prosthesis, but there are a number of disadvantages, such as the complexity of the intra-annular arrangement of the prosthesis in a small aortic window, as well as the pairing of AK AK, which also leads to to reduce the landing hole.

We set the task to develop a method for implanting heart valve prostheses into the aortic position, providing a reduction in complications and shortcomings of both supraannular and intraannular implantation techniques, which allows the use of prostheses with a large landing size.

The technical result achieved by the invention is as follows:

- reducing the number of complications caused by the occurrence of a para-prosthetic fistula, overlapping of the coronary artery mouth with the prosthesis cuff with a low location of the coronary artery mouths, the technical difficulty of performing the intervention in the conditions of a small aortic window, and FC pairing due to the combination of supraannular and intraannular implantation techniques;

- providing the possibility of using prostheses with a large fit size by reducing the effect of suturing when suturing the FC, eliminating the rejection of larger prostheses due to the impossibility of their location in the implantation zone after flashing FC;

- obtaining a “gain” in the landing size of the FC (increasing the used landing size of the FC) while maintaining the reliability of implantation.

When performing implant implantation according to the proposed method, combining the techniques of supraannular and intraannular implantation, the prosthesis plane is placed at an angle of 10 ° -20 ° to the plane of the AK AK, which allows to increase the radius (size) of the implanted prosthesis. In this case, the “reorientation” of the MA contact occurs, the axis of the AK prosthesis frame shifts (changes in the implant implantation plane), which increases the prosthesis seat and improves hemodynamics. The proposed method allows the implantation of a larger diameter prosthesis in patients with a small narrowing of FC.

The invention consists in the following.

To implant a prosthetic heart valve into the aortic position, a pathologically altered AK is excised. The circle of FC AK is divided into two semicircles so that the middle of the first semicircle is adjacent to the area of mitral-aortic contact. U-shaped sutures are applied around the perimeter of the first semicircle, producing both injections from the ventricular side, and the punctures from the aortic surfaces of the AK AK. Next, impose U-shaped seams around the perimeter of the second semicircle. In this case, both injections are made from the aortic side, and punctures from the ventricular surfaces of the AK AK. In the area of each border between the semicircles impose a Z-shaped seam. Parallel stitches of the Z-shaped seam are formed by passing the needles through the AK AK in the same way as the adjacent stitches adjacent to them. Then, needles of all sutures are inserted through the cuff of the prosthesis, starting from its surface facing the ventricle. The prosthesis is placed in the area of the AK AK and the sutures are tied.

The method is as follows.

After excision of the altered AK tissues and preparation of the FC for suturing, the FC is divided into two equal semicircles so that the middle of one of them lies adjacent to the mitral-aortic contact. On this semicircle, U-shaped sutures that fix the prosthesis are applied supraannularly around the perimeter, that is, suturing begins from the ventricular surface of the AK AK. When each suture is applied, both injections are made from the gastric surface of FC AK (with different needles attached to one ligature), and the punctures are made from the aortic surface of FC AK.

The second semicircle is stitched around the perimeter, applying U-shaped sutures that fix the prosthesis, according to the intraannular technique, that is, suturing begins with the aortic surface of the AK AK. When each suture is applied, both injections are made from the aortic surface of FC AK (with different needles fixed on one ligature), and the punctures are made from the ventricular surface of FC AK.

In the area of contact (boundaries) of the semicircles (along their edges), that is, when one semicircle passes into another, transitional Z-shaped seams (one seam in the area of each transition) are applied to the AK AK. In this case, parallel stitches of the Z-shaped seam are imposed, stitching the AK AK similarly to the adjacent stitch of the previously applied U-shaped seam.

This condition can be fulfilled if, for example, they start puncture of the AK AK in the transition region next to one of the U-shaped seams laid on one semicircle of the AK AK using the supraannular technique, then the parallel stitch of the Z-shaped seam is also carried out through the AK AK, starting from its ventricular surface. For the application of a Z-shaped seam, two needles on the same ligature are also used. Then, AK AK is pierced with a second needle from the side of the aortic surface (intraannularly), and AK AK is stitched, imposing a second parallel stitch of a Z-shaped suture. The previously attached U-shaped suture of the second semicircle of the AK AK is also imposed with the stitching of the AK AK intranannularly.

After all the sutures are applied, the cuff of the valve prosthesis is sutured, starting the injection of each needle from the lower surface facing the ventricle, passing the threads of all the sutures through the cuff.

The prosthesis is seated and fixed in the area of the AK AK, tying the suture threads.

In FIG. 1 shows the suture areas on FC AK; in FIG. 2 - suturing techniques for FC AK, where indicated:

1 - semicircle of FC AK, stitched supraannularly,

2 - conditional line dividing the circle into two equal semicircles,

3 - the place of application of Z-shaped seams,

4 - semicircle FC AK, stitched intraannularly,

5 - fibrous ring of the aortic valve,

6 - fibrous ring of the mitral valve,

7 - mitral-aortic contact,

8 - method of supraannular suturing,

9 - the method of applying Z-shaped seams,

10 - method of intraannular suturing,

11 - wall of the aortic root,

12 - wall of the left ventricle.

To prove the possibility of realizing the claimed purpose and achieving the specified technical result, we provide the following data.

Clinical example

Patient I., 60. Diagnosis before surgery: Rheumatism. Aortic malformation: critical stenosis.

Aortic valve prosthetics was performed with Sorin No. 21 SlimLine mechanical prosthesis under conditions of cardiopulmonary bypass, hypothermia and pharmaco-cold cardoplegia according to the proposed method.

Operation protocol: Aseptic processing of the surgical field. Skin incision. Median sternotomy. The pericardium is opened T-shaped. The ascending aorta is not changed. Pouches on the aorta and vena cava. Bypass of the great vessels. Aortic cannulation. Separate cannulation of vena cava. Drainage of the left departments through the upper right pulmonary vein. IR started with hypothermia up to 28 degrees. The right atrium is opened. Pouch on the coronary sinus. The aorta is clamped and transversely opened. Retrograde cardioplegia with kustodiol in the coronary sinus of 1500 ml. Aortic valve: valves are roughly changed, pronounced fibrosis, soldered by commissures, pronounced calcification with the transition to FC and LV myocardium. The valves are excised. Decalcification was performed with the prevention of material embolism. The size of FC AK is 21 mm. A Sorin Bicarbon No. 21 SlimLine mechanical prosthesis was implanted into the aortic position supra-intraannularly at 18 U-shaped sutures (4 with spacers in the area of the non-coronary sash) in accordance with the proposed method. The aortic incision was sutured with a double-row twisted suture with 5/0 prolene suture. Warming up started. The right atrium was sutured with a prolen 5/0. Hollow veins released. Filling the heart chambers with the thorough prevention of air embolism. Clamp removed from the aorta. Recovery of cardiac activity after a single discharge of the defibrillator. Temporary epicardial electrodes were hemmed to the right ventricle in the avascular zone. The rhythm is imposed by pacing. Hemodynamic stabilization. End of IR. Decanulation. Careful hemostasis. The cavity of the pericardium and anterior mediastinum is washed with dioxidine. The pericardium is sutured. Drainages into the pericardial cavity and anterior mediastinum. The sternum is reduced by a metal wire. Suturing of soft tissues. Aseptic sticker. When observing the patient in the early and long-term postoperative periods, prosthetic dysfunction was not noted.

To correct the acquired pathology of the aortic valve, including with a narrow fibrous ring of AK, we performed 10 surgical interventions by the proposed method. The average age of the patients was 67 years. In determining the clinical effectiveness of surgical correction of defects, we assessed the dynamics of changes in the size and volume of heart cavities, as well as the dynamics of changes in the pumping function of the heart.

The following dynamics were observed in the group: final diastolic size (CRD) (cm) before / after operation 55/52, final systolic size (CRP) (cm) before / after operation 36/32, final diastolic volume (BWW) (ml) before / after operation 146/114, final systolic volume (CSR) (ml) before / after operation 54/45, ejection fraction (EF) (%) before / after operation 57/67.

In determining the hemodynamic properties of the valve, we evaluated the gradients, as well as the volume of residual transplant prosthesis.

In the group, the trans-prosthetic gradient was a peak gradient / sr. 18/9 mm Hg, and there was no residual trans-prosthetic regurgitation.

This technique of implantation of the aortic prosthesis has established itself as reliable and convenient. This avoids prosthesis dysfunction and ensures optimal prosthesis placement. Already in the early postoperative period, restoration of central hemodynamic parameters was observed with the development of reverse remodeling of the volume of cavities and normalization of the pumping function of the heart. In this case, moderate gradients on the prosthesis were noted.

Our proposed technique for implantation of an AK prosthesis can be used in cases where the optimal prosthesis size has a minimum excess of the size of the PK. It allows you to implant a prosthesis of the desired diameter, without resorting to complex methods of reconstruction of the aortic root. The technique proposed by us remains valid in difficult cases when, after the performed boring of the aortic root, the discrepancy between the dimensions of the PK and the diameter of the prosthesis remains.

Claims (1)

A method of implanting a heart valve prosthesis in an aortic position, characterized in that after excising a pathologically altered aortic valve (AK), the circumference of the fibrous ring (FC) of the AK is divided into two semicircles so that the middle of the first semicircle is adjacent to the area of mitral-aortic contact, impose P- shaped joints along the perimeter of the first semicircle, producing both injections from the ventricular side, and punctures from the aortic surfaces of the AK AK, then U-shaped joints along the perimeter of the second semicircle and, for which both injections are made from the aortic side, and the punctures from the ventricular surfaces of the AK AK, in the area of each border between the semicircles, a Z-shaped suture is applied, the parallel stitches of which are formed by passing the needles through the AK AK similarly to the previously applied sutures , then the needles of all the sutures are inserted through the cuff of the prosthesis, starting from its surface facing the ventricle; place the prosthesis in the area of the AK AK and tie the stitches in place.

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