RU2624313C1 - Method of implantation of prosthesis of heart valve into aortal position in mitral-aortal prosthetics - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: when combined implantation of prostheses MK and AK, after first excision of pathologically altered MK, implant the prosthesis of the valve in the mitral position. Then, after excision of abnormally altered AK, the circumference of the CFR is divided into two semicircles so that the middle of the first semicircle adheres to the region of the 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 CFR. 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 CFR. 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 CFR 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 CFR area, and the applied sutures are knotted.

EFFECT: method allows to prevent the dysfunction of the occlusal element of the rotary-disc prosthesis AK in combined mitral-aortic prosthetics by providing an optimal interposition of implantable prostheses by combining the techniques of intrasupranulyarnoy technique with implantation of the valve prosthesis in the aortic position.

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Description

The invention relates to medicine, namely to cardiovascular surgery, can be used in prosthetics of the aortic valve in patients with mitral-aortic prosthetics.

The simultaneous surgical treatment of aortic and mitral valve defects (AK and MK) is an urgent problem of modern cardiac surgery. Moreover, the combination of AK and MK defects is quite large and sometimes amounts to up to a third of all cases of prosthetics. Currently, the main task for cardiac surgeons is to determine the method of surgical correction of the defect, the choice of prosthesis and implantation technique.

After adequate correction of two-valvular defect is performed, the mass of the left ventricle decreases, 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.

In patients who undergo simultaneous correction of MK and AK defects, after implantation of MK, it is often difficult to implant AK, which is associated with deformation of the mitral-aortic (MA) contact, especially in patients with initially hypoplastic MA contact.

A known method of implanting a prosthetic valve of the heart into the aortic position with mitral-aortic prosthetics, including the reconstruction of the MA contact, which we have chosen as a prototype

(Replacement of the aortic valve using the bentall-de bono technique and transaortic mitral valve replacement with reconstruction of the mitral-aortic contact during total calcification of the valves and aorta. Mironenko V.A., Aliev Sh.M., Perepelitsa A.A., Loginov D.T. ., Kuts E.V., Skopin I.I. Thoracic and cardiovascular surgery. 2005. No. 5. P. 66-68).

The operation of the prototype method includes plastic MA contact, which leads to an increase in the volume of surgical intervention.

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

The method of supraannular implantation with the application of individual U-shaped sutures on the fibrous ring (FC) AK is as follows.

Suture begins with the ventricular surface of the AK AK. Both injections are made by retreating a small distance from the AK AK from the ventricular surface, through the AK AK, and the injection occurs from the aortic 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. (Cardiac surgery: technique. Author: Donald B. Doughty, John R. Doughty; edited by R.S. Akchurin. 2014, pp. 312-313).

This method of implantation, having well-proven itself, is considered simple and reliable, however, there are a number of disadvantages, such as the risk of a para-prosthetic fistula due to the fact that when tightening the joints 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.

There is also known a method of intraannular implantation of a valve prosthesis with the application of individual U-shaped sutures on FC AK.

In this case, the suture begins with the aortic surface of FC AK. Both injections are made at 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 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. (Cardiac surgery: technique. Author: Donald B. Doughty, John R. Doughty; edited by R.S. Akchurin. 2014, pp. 312-313).

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

We set the task - to develop a method for implanting a prosthetic valve of the heart into the aortic position with the combined prosthetics of MK and AK in the conditions of a possible forward displacement of the MA contact due to implantation of the prosthesis MK.

The technical result achieved by the implementation of the invention is:

- reducing the invasiveness of the intervention by reducing its volume by eliminating additional reconstruction of the MA contact.

- prevention of dysfunction of the locking element of the AK rotary-disk prosthesis in case of combined mitral-aortic prosthetics due to the optimal interposition of implantable prostheses by combining intrasuprannular techniques when implanting a valve prosthesis into the aortic position;

- 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 AK 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 AK AK (increasing the used landing size of the AK) while maintaining the reliability of implantation of the AK prosthesis.

When performing AK implant implantation according to the proposed method, combining the methods 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, which is especially important for combined prosthetics after implantation of the MK prosthesis, accompanied by deformation of the MA contact, especially in patients with initially hypotrophic MA contact. The displacement of the axis of the prosthesis frame AK (changing the plane of implantation of the prosthesis) increases the seat of the prosthesis, improves hemodynamics. The proposed method allows to implant a prosthesis with a larger diameter AK in patients with a slight narrowing of the FC.

The proposed method provides the surgeon with “convenient” operation with two-valve prosthetics even for patients with a narrow and hypotrophic MA contact.

In cases where it is necessary to perform two-valve prosthetics in patients with a narrow or hypotrophic MA contact, the proposed method allows implantation of an AK prosthesis of the desired diameter without resorting to complex reconstruction in the intervention zone.

The invention consists in the following.

With the combined implantation of MK and AK prostheses, first after excision of the pathologically altered MK, implantation of the valve prosthesis into the mitral position is performed. Then, after excising a pathologically altered AK, the circumference of the AK 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 similar to the adjacent sutures adjacent to them. Then, the needles of all the 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.

For access to the mitral valve, the following accesses are used: left atrial access, interatrial and widened with transition to the dome of the left atrium (according to Giradon). As a rule, for prosthetics, mechanical (rotary disc and / or double-wing, as well as prostheses with improved hemodynamics) or biological (frame, frameless prostheses and allografts) heart valve prostheses are used.

With the combined implantation of MK and AK prostheses, first after excision of the pathologically altered MK, implantation of the valve prosthesis into the mitral position is performed.

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 goes into another, transitional z-shaped seams are applied to the AK AK (one seam in the area of each transition). At the same time, parallel stitches of the z-shaped seam are imposed, stitching the AK AK similar to the adjacent stitch of the previously applied U-shaped seam.

This condition can be fulfilled if, for example, they begin 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, FC AK is punctured with a second needle from the side of the aortic surface (intraannularly), FC AK is stitched, imposing a second parallel stitch of the 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 shows the methods of suturing on FC AK, where

1 - semicircle of FC AK, stitched supraannularly,

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

3 - 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 K., 75, diagnosis before surgery: Rheumatism. Aortic malformation: grade 3 insufficiency. Mitral defect: grade 3 insufficiency. Relative insufficiency of the tricuspid valve. Operated in accordance with the proposed method.

Aortic valve replacement was performed with Sorin No. 23 SlimLine mechanical prosthesis; mitral valve replacement with Sorin No. 29 FitLine mechanical prosthesis while preserving the subvalvular structures of the posterior mitral valve under conditions of cardiopulmonary bypass, hypothermia, and pharmaco-cold cardoplegia.

Operation protocol: Aseptic processing of the surgical field. Skin incision. Median sternotomy. The pericardium is opened T-shaped. The ascending aorta is spindle-shaped expanded to 45 mm. 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 GTVLV. IK started with hypothermia up to 28 gr. 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 700 ml and antegrade in the mouth of the coronary arteries of 400 ml, additionally 500 ml after 90 min retrograde. Aortic valve: sashes thin, moderate fibrosis. FC AK 26 mm. The non-coronary leaf sags, coaptation is impaired. The valves are excised. Access to the mitral valve by Gyrodon. Mitral valve: myxomatous valves, moderate fibrosis, commissure commissure, subvalvular structures thickened. The posterior mitral valve (ZMS) is drawn into the cavity of the left ventricle (LV). The valves are excised with the preservation of part of the ZMS. A mechanical prosthesis Sorin Bicarbon No. 29 FitLine was implanted into the mitral position at 19 U-shaped sutures (6 with gaskets - in the ZMS region closer to the anterior-lateral commissure and in the region of the mitral-aortic contact). A Sorin Bicarbon No. 23 SlimLine mechanical prosthesis was implanted into the aortic position supraintraunularly at 18 U-shaped sutures (2 with spacers - supraannularly in the LKS area), 1 additional suture with a spacer for fixing the prosthesis in the middle of the base of the NSC. The dome of the LP and MPP are sewn. The aortic incision was sutured with a double-row twisted suture with 5/0 prolene suture. Warming up started. Sewn down by PP with proline 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 EX. 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 processing. Aseptic sticker.

In order to correct acquired valvular pathology and conduct a clinical hemodynamic assessment of the method of implanting a heart valve prosthesis into the aortic position with mitral-aortic prosthetics, we performed 15 surgical interventions.

In this case, prostheses of the following sizes were used: AK 21-1, 23-9, 25-5, MK 27-11, 29-4, the average age of the patients was 54 years.

There was no general hospital mortality.

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 was observed in the group: CRD (cm) before / after 57/52 KSR (cm) before / after 38/34 BWW (ml) before / after 156/134 KSO (ml) before / after 58/50 PV (%) before / after 60/63.

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 is minimal, and the amount of residual trans-prosthetic regurgitation was absent.

This technique of implantation of the aortic prosthesis has proven to be reliable and convenient, which allowed us to avoid prosthesis dysfunction and ensure optimal relative positioning of prostheses with two-valve prosthetics. 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.

Claims (1)

The method of combined implantation of prostheses of the mitral and aortic valves of the heart, characterized in that first, after excision of the pathologically altered mitral valve, the prosthesis is implanted into the mitral position, then, after excision of the 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, U-shaped sutures are applied around the perimeter of the first semicircle, n making both injections from the ventricular side, and the punctures from the aortic surfaces of the AK AK, then U-shaped sutures are applied along the perimeter of the second semicircle, for which both injections are made from the aortic side, and the punctures are from the ventricular surfaces of the AK AK, in the area of each the boundaries between the semicircles are imposed by a Z-shaped seam, the parallel stitches of which are formed by passing the needles through the AK AK similar to the adjacent sutures adjacent to them, then the needles of all the sutures are inserted through the cuff of the prosthesis, starting from surface facing the ventricle; place the prosthesis in the area of the AK AK and tie the stitches in place.

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