RU2639030C1 - Method for distal anastomosis formation during right ventricle department outlet reconstruction by extracardiac conduit in children with congenital heart disease, causing stenosis of pulmonary arteries mouths - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: starting from the edge of the conduit end connected to the area of pulmonary trunk bifurcation, longitudinal and transverse incisions are performed. The conduit segments obtained by the transverse incision are diverted in different directions, giving T shape to the indicated end of the conduit. A vascular incision is performed through the area of pulmonary trunk bifurcation with a transition to the right and left pulmonary arteries to the mouths of their lobar branches. The conduit is directed so that the diverted conduit segments coincide with the length of the vascular incision, and the conduit is stitched in this incision.

EFFECT: method allows to adequately expand the mouths of the pulmonary arteries and prevent conduit dysfunction caused by distal stenosis in distal terms after operation.

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Description

The invention relates to medicine, namely to cardiac surgery, can be used in the surgical treatment of complex congenital heart defects, requiring reconstruction of the excretory section of the right ventricle using extracardial conduit and accompanied by stenosis of the mouth of the pulmonary arteries.

To date, the application of a distal anastomosis during implantation of conduits (in particular, from the jugular vein of a bull) is made in the form of a circle or oval (in the latter case, with a continuation of the incision into the left pulmonary artery) [1-3]. These lines of anastomoses are circularly closed in two-dimensional space and limit the round and oval planes, respectively. With the simultaneous presence of wellhead stenosis of both pulmonary arteries, their plastic surgery is performed using the implantation of additional materials (biological or synthetic).

In the case of the development of neointimal proliferation, which is a morphological substrate for the development of distal stenosis (an actual clinical event in the long term after implantation), the latter will develop along the “traces” of the superimposed anastomosis, that is, in a circularly closed circuit.

Closest to the proposed method is a method of applying a distal anastomosis oval type, used in the reconstruction of the excretory section of the right ventricle after a U-shaped cut of the outflow segment using the example of a conduit from the jugular vein of a bull [4], which we selected as a prototype. The prototype method involves the implementation of a special cut conduit and T-shaped incision in the area of pulmonary bifurcation. The stages of application of the anastomosis are presented in FIG. one.

The disadvantages of this method are the need to perform an additional perpendicular incision on the trunk of the pulmonary artery, the complex technique of suturing, and the inability to use for atresia of the pulmonary trunk.

The technical problem is the creation of a distal anastomosis during reconstruction of the output section of the right ventricle in children with heart defects complicated by stenosis of the mouth of the pulmonary arteries, which allows correcting the mentioned stenosis while preventing the narrowing of the anastomosis in the postoperative period.

Based on this, it seems reasonable to create a fundamentally new form of distal anastomosis, which, along with conduit implantation, can simultaneously perform plastic surgery of the mouths of the pulmonary arteries without the use of additional plastic materials, and also eliminates the principle of "circular closure" of the anastomosis zone.

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

- adequate expansion of the mouths of the pulmonary arteries without implantation of additional materials;

- prevention of conduit dysfunction due to neointimal proliferation along the limited conduit diameter of the anastomosis line, in the long term after surgery;

- reducing the invasiveness of the intervention by eliminating additional incisions on the pulmonary trunk using the original technique of cutting the outflow end of the conduit.

The invention consists in the following.

When a distal anastomosis is formed during reconstruction of the excretory section of the right ventricle with extracardial conduit in children with congenital heart defects accompanied by stenosis of the mouths of the pulmonary arteries, the bifurcation of the pulmonary trunk and one of the ends of the conduit are connected. Why on the conduit, starting from the edge of the end of the conduit, connected with the bifurcation region of the pulmonary trunk, a longitudinal section is made, which is placed along the conduit, and a transverse section. The length of the longitudinal section corresponds to the size of the adequate increase in the mouth of both the right and left pulmonary arteries. The length of the cross section corresponds to half the circumference of the conduit. The segments obtained at the end of the conduit are turned in different directions, giving the end of the conduit the shape of an inverted letter "T". After that, a vascular incision is made through the bifurcation region of the pulmonary trunk with transition to the right and left pulmonary arteries to the mouths of their lobar branches on each side. The lateral lateral ends of the segments are symmetrically shortened, ensuring that their width is consistent with the length of the vascular incision. The resulting conduit is oriented so that the diluted conduit segments coincide with the length of the vascular incision. Then form the posterior lip of the anastomosis. In this case, the lower half of the lateral edge of the first segment, the lower edge of the first segment, the conduit semicircle bounded by the medial edges of the lower sides of the segments, the lower edge of the second segment and the lower half of the lateral edge of the second segment are sequentially connected to the lower edge of the vascular section in a continuous seam. Then, the anastomosis anterior lip is formed, for which the upper half of the lateral edge of the second segment, the upper edge of the second segment, the conduit semicircle bounded by the medial edges of the upper sides of the segments, the upper edge of the first segment, the upper half of the lateral edge of the first segment are sequentially connected to the upper edge of the vascular incision with a continuous suture. .

In a particular case, before performing a vascular incision, a conduit semicircle is located located in the region of its edge and bounded by the medial ends of the lower sides of the segments, performing a half-moon incision along its entire length with a maximum axial depression of 3–8 mm.

After shortening the segments, their lateral edges can be modeled to give each of them a semicircle or trapezoid shape. Segment modeling provides “smoothing” of the anastomosis line.

For the technical convenience of performing the intervention, the segment farthest from the surgeon is selected as the first.

The advantages of the proposed method are:

- the possibility of expanding the gaps of the right and left pulmonary arteries due to segments with their wellhead stenosis without the use of additional plastic materials;

- the absence of two-dimensional circular closure of the anastomosis line, preventing conduit dysfunction with the development of distal stenosis in the long period after surgery, which occurs with the classic round and oval types of anastomosis;

- the ability to manipulate the angle of connection of the conduit with pulmonary bifurcation in order to minimize the bend of its outflow segment, depending on the choice of the location of the vascular incision in the pulmonary arteries.

The method is illustrated by the following figures.

In FIG. 1 presents the methodology for the operation of the prototype method.

In FIG. 2 presents a conduit cutting technique, where:

1 - longitudinal component of the section; 2 - transverse component of the section; 3 - expanded segments; 4 - a half-moon section of the end (located in the region of the edge of the conduit) semicircle of the conduit bounded by the medial ends of the lower sides of the segments.

In FIG. 3 shows a view of the conduit after its cutting, where:

5 - the first segment (left); 6 - the second segment (right); 7 - the upper edge of the segment; 8 - lateral edge of the segment; 9 - the lower edge of the segment; 10 - end (located in the region of the edge of the conduit) semicircle of the conduit, bounded by the medial ends of the lower sides of the segments; 11 - conduit semicircle bounded by the medial ends of the upper sides of the segments.

In FIG. 4 shows a simulation of the lateral edges of the segments in the form of a semicircle, where: 12 is the upper half of the lateral edge of the segment; 13 - the lower half of the lateral edge of the segment.

In FIG. 5 shows the stages of the anastomosis between the end of the conduit and the vascular incision: Figure A shows the points of correspondence between the stitched portions of the conduit and the lower edge of the vascular incision; Figure B shows the hemming of the first segment to the corresponding part of the lower edge of the vascular incision; Figure B shows the completion of the formation of the posterior lip of the anastomosis; on the diagram D - the implementation of the anterior lip of the anastomosis.

In FIG. Figure 6 shows a heart with estuarial stenosis of the pulmonary arteries (A) and after reconstruction of the excretory section of the right ventricle with extracardial conduit after its cutting (B).

The method is as follows.

The proposed method can be used in the surgical treatment of the following congenital heart defects in children requiring reconstruction of the excretory section of the right ventricle with extracardial conduit and accompanied by stenosis of the mouth of the pulmonary arteries:

• transposition of the main vessels with stenosis of the pulmonary artery and a defect in the interventricular septum (including the corrected form);

• atresia of the pulmonary artery with a defect in the ventricular septum;

• tetralogy of Fallot;

• double passage of vessels from the right ventricle;

• common arterial trunk.

When extracardiac conduit is implanted to reconstruct the right ventricular excretory section in children with congenital heart defects, a proximal anastomosis is placed between one end of the conduit and a ventriculotomic incision in the excretory section of the right ventricle.

In the formation of a distal anastomosis, the bifurcation region of the pulmonary trunk and the other (outflow) end of the conduit are connected. The end of the conduit, anastomosed with the pulmonary arteries, should be considered as perfect.

The outflow end of the conduit is cut as shown in FIG. 2 and 3.

Starting from the edge of the end of the conduit, perform a longitudinal section, placing it parallel to the axis of the conduit. The length of the longitudinal section is selected individually and corresponds to the size of an adequate increase in the mouth of both the right and left pulmonary arteries, that is, depends on the degree of stenosis of the mouths of the pulmonary arteries. The surgeon chooses a cut length that will allow sufficiently expanding the mouth of the pulmonary arteries in accordance with age norms.

The length of the longitudinal section necessary to adequately increase the lumen of the narrowed pulmonary artery can be determined as follows. The difference in values between the age norm of the diameter of the pulmonary artery and the diameter of the narrowed pulmonary artery is calculated. The resulting difference is multiplied by the number π.

The length of the transverse section corresponds to half the circumference of the lumen of the conduit. Moreover, the middle of the transverse section corresponds to the end of the longitudinal section, that is, both halves of the transverse section are symmetrical with respect to the longitudinal section.

After conducting transverse and longitudinal sections at the end of the conduit, rectangular fragments are obtained - segments, each of which is connected to the conduit with its medial side. The segments obtained at the end of the conduit are turned outward in different directions.

The conduit cutting can be explained as follows: on the back semicircle of the outflow part of the conduit, a vertical (longitudinal) cut is made along the midline, from the completion point of which two additional horizontal (transverse) cuts are made in opposite directions to 1/4 of the conduit circumference, each at right angles to the vertical section.

The formed right and left segments (corresponding to the right and left pulmonary arteries) are turned in different directions, after which the end of the conduit takes the form of the letter “T”.

The length of the vertical section is defined individually according to the degree of stenosis of the pulmonary arteries, as well as the fact that it forms a width segments, which should be of sufficient size to prevent full engagement seam line segments.

The width of the span of the segments (or the span of the segments) is the maximum distance between their lateral lateral edges after a turn. It is equal to the circumference of the conduit. The deployment of the segments is made in such a way that they are located in the same plane.

In a particular case, before performing a vascular incision, a conduit semicircle is located located in the region of its edge and bounded by the medial ends of the lower sides of the segments, performing a half-moon incision along its entire length with a maximum axial depression of 3–8 mm. In other words, they simulate the semicircle of the conduit located along its edge formed after the deployment of the segments.

Then, a linear vascular incision is made through the bifurcation region of the pulmonary trunk with transition to the right and left pulmonary arteries to the mouths of their lobar branches. The edge of the incision closest to the right ventricle is lower, the other edge is upper.

A vascular incision is performed as long as possible (from the lobar branches of the left pulmonary artery to the corresponding branches of the right pulmonary artery). The lateral (lateral) ends of the segments are symmetrically shortened, ensuring that their width is consistent with the length of the vascular incision.

Thus, after shortening the segments, the total length of the semicircle of the conduit and the double length of the larger side of the segment should correspond to the length of the vascular incision.

Next, the lateral edges of the segments are modeled, giving each of them a semicircle or trapezoid shape to smooth the anastomosis line (Fig. 4).

To prevent kink of the posterior lip of the anastomosis and its keeled bulging into the conduit lumen, the latter’s semicircle (limited by the medial ends of the lower sides of the segment) is modeled by cutting the half-moon shape over its entire length with a maximum axial depression of 3-8 mm.

After finishing the end of the conduit and modeling its segments, they proceed to the stage of applying a distal anastomosis between the conduit and pulmonary arteries in the bifurcation area. The preformed conduit is oriented so that the diluted conduit segments coincide with the length of the vascular incision. Anastomosis begins with the formation of the posterior lip. The lower half of the lateral edge of the first segment, the lower edge of the first segment, the conduit semicircle bounded in front by the medial edges of the lower edges of the segment, the lower edge of the second segment and the lower half of the lateral edge of the second segment are sequentially connected to the lower edge of the vascular incision with a continuous suture.

The edges of the segment located closer to the right ventricle are lower, and those removed from it are upper. In other words, the lower edges (sides) of the segment are the long sides of the segments remote from the edge of the end of the conduit anastomosed with the region of pulmonary bifurcation, and the upper edges (sides) of the segments are the long sides of the segments located in the region of the edge of the end of the conduit anastomosed with area of pulmonary bifurcation. The lateral lateral edges of the segments correspond to the edges of the longitudinal section.

The segment farthest from the surgeon can be selected as the first. This provides technical convenience for the surgeon when applying an anastomosis.

Then form the front lip of the anastomosis. The upper half of the lateral edge of the second segment, the upper edge (upper side) of the second segment, the conduit semicircle bounded by the medial edges of the upper sides (upper edges) of the segments, the upper edge (upper side) of the first segment, the upper half are sequentially connected to the upper edge of the vascular incision with a continuous suture. the lateral edge of the first segment (Fig. 5). The final view of the operation is shown in FIG. 6.

To confirm the feasibility of implementing the stated purpose and achieving the specified technical result, we present the following data.

Clinical example. Patient K., 2 years 2 months old, was admitted to a specialized surgical hospital for planned surgical treatment of congenital heart disease. Diagnosed with tetralogy of Fallot, combined stenosis of the pulmonary artery, wellhead stenosis of the right and left pulmonary arteries (diameters of 6 and 7 mm, respectively), a large branch of the coronary artery in the output section of the right ventricle, an open oval window, tricuspid valve insufficiency with regurgitation of 1.5 ( +), circulatory failure 2A Art. A decision was made to perform a radical correction of the defect in conditions of cardiopulmonary bypass, hypothermia and pharmacological cold cardioplegia. After suturing of the open oval window and plastic surgery of the interventricular septal defect, the stage of reconstruction of the excretory section of the right ventricle by extracardial conduit from the jugular vein of the bull (Contegra No. 16; Medtronic) was started. Conduit was washed by standard methods in physiological saline. Conduit modeling began with the longitudinal and transverse sections on the conduit in accordance with the proposed method. A longitudinal section of the conduit wall was made in the axial direction with a length of 13 mm, from the end point of which two symmetrical transverse sections were made with a total length 1/2 of the circumference of the conduit. The circumference of conduit No. 16 is calculated by the formula 16π and is equal to 50.24 mm. Since the total length of the symmetrical transverse sections corresponds to half the circumference of the conduit, it is 25.12 mm. Therefore, the length of each transverse section is 12.56 mm, i.e. 1/4 conduit circumference. The span length of the formed segments is equal to the circumference of the conduit, i.e. 50.25 mm. On the back semicircle, limited by the medial edges of the lower sides of the segments, a half-moon shaped section was made over its entire length with a maximum axial depression of 5 mm. An incision in the pulmonary arteries began in the area of the bifurcation of the pulmonary trunk with transition to the left and right pulmonary arteries through the narrowed areas until the lobar branches depart. The length of the vascular incision was 38 mm. In order to adapt the length of the span of the segments to the length of the vascular incision, each of the segments is shortened by 6 mm, after which their side edges in the form of a semicircle are modeled. At the end of the cut, the conduit was again washed, after which it was implanted.

The resulting conduit is oriented so that the diluted conduit segments coincide with the length of the vascular incision. Conduit implantation began with the posterior lip of the distal anastomosis being performed with a continuous upholstery of Premilene 6.0-13.0 (B Braun). The application of anastomoses was performed from the farthest angle from the surgeon to the near one. The lower edge of the vascular section was successively connected to the lower half of the lateral edge of the first segment, the lower edge of the first segment, the posterior conduit semicircle bounded by the medial edges of the lower sides of the segments, the lower edge of the second segment and the lower half of the lateral edge of the second segment. After the completion of the posterior lip, the anastomosis proceeded to the execution of the anterior lip by the other end of the thread. The upper edge of the vascular section was connected with the upper half of the lateral edge of the second segment, the upper edge of the second segment, the conduit semicircle bounded by the medial edges of the upper sides of the segment, the upper edge of the first segment, and the upper half of the lateral edge of the first segment. At the end of the lines of the anastomosis, both ends of the thread were tied. Next, a proximal anastomosis was performed with the excretory section of the right ventricle according to a standard technique. The total time of cardiopulmonary bypass and clamping of the aorta was 175 and 89 minutes, respectively.

The early postoperative period was uneventful. Cardiotonic support: dopamine - 10 mcg / kg / min. The total time of mechanical ventilation is 26 hours. The total time spent in the intensive care unit is 60 hours. In connection with the positive dynamics, the patient was discharged from the hospital on the twelfth day after surgery. According to the control echocardiography study before discharge: left ventricular ejection fraction - 60%; conduit valve insufficiency with regurgitation 1 (+), the gradient on the conduit valve is 9 mm RT. Art.

Literature

1. Boudjemline Y., Bonnet D., Massih T., Agnoletti G., Iserin F., Jaubert F. et al. Use of bovine jugular vein to reconstruct the right ventricular outflow tract: early results Journal of Thoracic and Cardiovascular Surgery. 2003; 126: 490-497.

2. Dave H., Kadner A., Bauersfeld U., Berger F., Turina M., Pretre R. Early results of using the bovine jugular vein for right ventricular outflow tract reconstruction during the Ross procedure. 2003. The Heart Surgery Forum.

3. Fiore A., Brown J., Turrentine M., Ruzmetov M., Huynh D., Hanley S. et al. A bovine jugular vein conduit: A ten-year bi-institutional experience. Annals of Thoracic Surgery. 2011; 92: 183-192.

4. Boething D., Thies W., Hecker H., Breymann T. Mid term course after pediatric right ventricular outflow tract reconstruction: a comparison of homografts, porcine xenografts and Contegras. Europen Journal of Cardiothoracic Surgery. 2005; 27: 58-66.

Claims (4)

1. A method for the formation of a distal anastomosis during reconstruction of the excretory section of the right ventricle with extracardial conduit in children with congenital heart defects accompanied by stenosis of the mouths of the pulmonary arteries, comprising connecting the bifurcation region of the pulmonary trunk and one of the ends of the conduit, characterized in that starting from the edge of the end of the conduit to be connected with the region of the bifurcation of the pulmonary trunk, perform a longitudinal section, placing it parallel to the axis of the conduit, and a transverse section, the length of which corresponds to the floors Other than the circumference of the conduit lumen, the conduit segments obtained by cross-section are bred in different directions, giving the indicated end of the conduit the shape of the letter “T”, a vascular incision is made through the bifurcation region of the pulmonary trunk with transition to the right and left pulmonary arteries to the mouths of their lobar branches, and the conduit is oriented so that the diluted conduit segments coincide with the length of the vascular incision made, and the conduit is sutured into the indicated incision. 2. The method according to p. 1, characterized in that before performing a vascular incision, a conduit semicircle is limited, limited by the medial ends of the lower sides of the segments, making a half-moon incision along its entire length with a maximum axial recess of 3-8 mm. 3. The method according to p. 1, characterized in that they model the lateral edges of the segments, giving each of them a semicircle shape. 4. The method according to p. 1, characterized in that they model the lateral edges of the segments, giving each edge a trapezoid shape.

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