RU2702468C1 - Method of surgical correction of ebstein abnormality - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, particularly to cardiovascular surgery. Tricuspid valve is made with its own tissues, for this purpose, the flaps are separated from the right ventricular wall, the right ventricular artificized portion is plicated. Tissue of the tricuspid valve is anchored to the true fibrous ring of the tricuspid valve with a clockwise rotation of the leaflets and a cone shaped valve is created. Separating the leaves is started from front-septal commissure from 10 o'clock with conditional application of dial-plate to tricuspid valve with transition to front leaf. At the same time maximally preserving the chords fixed to the edge of the front leaf in the area of the front-septal commissure.EFFECT: method enables avoiding intra- and postoperative complications: atrioventricular block, stenosis or insufficiency of the valve, avoiding valve prosthesis.1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to cardiovascular surgery.

Ebstein’s anomaly is a rare congenital heart pathology, the frequency of occurrence of which, according to various authors, is from 1 to 5 cases per 200,000 newborns, which is about 1% of all congenital heart defects. For the first time, this defect is Wilhelm Ebstein in 1866.

This pathology is a right ventricular myopathy, which leads to a varying degree of violation of the delamination of the valves of the tricuspid valve from the adjacent endocardium. Valve flaps have a modified shape and can be dysplastic. Often such cusps have shortened chords and papillary muscles that attach to the front edge of the cusp. The chord fixing the leaflets is small, while the leaflets are usually fenestrated. As the severity spectrum increases, the fibrous transformation of the cusps from their muscle precursors increases during embryogenesis. In this case, the septal leaflet is most strongly fused to the adjacent myocardium, and the anterior leaflet is least strongly fused to the myocardium and is more delaminated. As a result, there is a spiral displacement of the fixation point (functional ring of the valve) of the septal and posterior cusps spirally below the true fibrous ring of the tricuspid valve to the apex of the heart. The atrialized part of the right ventricle may have different thicknesses and the ability to contract, but most often it is thinned, dilated, and akinetic [1, 2].

Depending on the type of Ebstein's anomaly, a severe clinical picture may appear from the neonatal period, and in some cases may be absent for a long time. The average life expectancy, according to various sources, with the natural course of Ebstein's anomaly is about 30 years.

In 1988, A. Carpentier [3] proposed the following classification of the Ebstein anomaly consisting of 4 types: A, B, C, D. The correction is especially difficult with the E type of Ebstein anomaly, and with the extreme type D correction is almost impossible.

Surgical attempts to treat Ebstein's anomaly appeared in the early 1950s. J. Hopkins used the Blok-Taussig shunt, whose goal was to increase pulmonary blood flow and decrease cyanosis. In 1958, Hunter-Lillehei-Hardy proposed the first reconstructive procedure, consisting of the plastics of an incompetent tricuspid valve. In 1972, G. Danielson developed a correction method, which consists in transverse plication with U-shaped sutures of the atrialized part of the right ventricle towards the atrioventricular junction, sometimes with partial capture of the edge of the anterior cusp, thereby achieving monocuspidation of the valve. [four].

There is a known method of plasty according to Carpentier [7], in which the anterior leaflet is mobilized and moves to the true fibrous ring, the atrialized part of the right ventricle is plicated vertically, the support ring is fixed to the fibrous ring and narrows it to the normative size.

The da Silva method in 1989 is also known. da Silva and his colleagues developed a procedure for the restoration of the tricuspid valve with Ebstein's anomaly, called “conical reconstruction” [5, 6].

This method is the closest to the claimed technical essence and the achieved result and is selected as a prototype.

The disadvantages of the prototype method are incomplete mobilization of tissues of the valves of the tricuspid valve.

The aim of the invention is the prevention of intra- and postoperative complications.

The goal is achieved by a technical solution, which is a method of correcting the Ebstein anomaly. After connecting the heart-lung machine, the valve is accessed through the right atriotomy. The first stage is the mobilization of leaf tissue by separating them from the wall of the right ventricle starting from the anterior-septal commissure from 10 hours with the conditional application of the dial to the tricuspid valve with the transition to the front leaf. Delamination begins immediately below the fibrous ring of the tricuspid valve. Then, the anterior leaflet is delaminated, while the chords attached to the edge of the anterior leaflet in the region of the anterior-septal commissure are retained as much as possible. At the end of the separation of the anterior leaflet, they pass to the posterior leaflet, in case the tissue of the leaflet can be separated from the myocardium. The next step is plication of the atrialized part of the right ventricle. The main feature of this stage is the shallow injection of the needle into the myocardium in the projection of the right coronary artery and the prevention of artery deformation. The upper edge of the fabric is sutured to the true fibrous ring of the tricuspid valve with rotation of the valves in a clockwise direction, creating a valve in the form of a cone.

New in the proposed method is that they begin to separate the cusps from the anterior-septal commissure from 10 hours of conditional application of the dial to the tricuspid valve, and not from the front cusp of the tricuspid valve from 12 hours of conditional use of the dial to the tricuspid valve. This change will allow you to get more tissue to perform valve reconstruction.

The technical result of the invention is the ability to avoid intra- and postoperative complications: atrioventricular block, stenosis or insufficiency of the valve, to avoid prosthetics of the valve.

The essential features characterizing the invention showed in the inventive combination 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, by reducing early and long-term 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 figures attached to it.

In FIG. 1 shows a General view of the tricuspid valve through the right atriotomy, shows the location of the venous cannulas in the superior and inferior vena cava;

1 - front sash tricuspid valve;

2 - back cusp of the tricuspid valve;

3 - septal leaf;

4 - atrialized part of the right ventricle;

5 - true fibrous ring of the tricuspid valve;

6 - coronary sinus;

7 - atrial septal defect;

8 - the delamination line of the septal and anterior tricuspid valves;

9 - cannula of the superior vena cava;

10 - cannula of the inferior vena cava;

In FIG. 2 shows the view of the valve after delamination of the anterior and part of the septal leaf of the tricuspid valve. Raised by the edges of the sash at the retaining sutures are sutured to the true fibrous ring of the tricuspid valve, while the tissue rotates to the opposite edge of the septal sash.

In FIG. 3 shows the hemming of valve flaps to the fibrous ring:

11 - the point of attachment of the tricuspid valve leaf to the true fibrous ring

12 - suturing of the atrialized part of the right ventricle

13 - stitching of the rear valve of the tricuspid valve with septal

In FIG. 4 shows the final view of the valve after conical reconstruction:

14 - final view of the valve

15 - sutured atrialized part

16 - sutured atrial septal defect

The method is as follows: access to the heart and main vessels is carried out through the median sternotomy. By a standard technique, an heart-lung machine is connected. Establish drainage of the left ventricle. The aorta is squeezed, a cardioplegic solution is served anterograde. Access to the tricuspid valve is through the right atriotomy. The first stage is the mobilization of leaf tissue by separating them from the wall of the right ventricle starting from the anterior-septal commissure from 10 hours with the conditional application of the dial to the tricuspid valve with the transition to the front leaf. They begin to separate the valves immediately below the fibrous ring of the tricuspid valve. Then, the anterior leaflet is separated, while the chords attached to the edge of the anterior leaflet in the region of the anterior-septal commissure are retained as much as possible. At the end of the separation of the anterior leaflet, they pass to the posterior leaflet, in case the tissue of the leaflet can be separated from the myocardium. The next step is plication of the atrialized part of the right ventricle. The main feature of this stage is the shallow injection of the needle into the myocardium in the projection of the right coronary artery and the prevention of artery deformation when suturing the atrialized part of the right ventricle. The upper edge of the fabric is sutured to the true fibrous ring of the tricuspid valve with rotation of the valves in a clockwise direction, creating a valve in the form of a cone. Then, atrial septal defect is sutured. Suturing the right atrium. They stop the heart-lung machine. Remove the cannula from the aorta and vena cava. Modified ultrafiltration is carried out. The surgical wound with drainage of the pericardium, anterior mediastinum is sutured in layers.

Clinical example. Patient T., age 1 year, 9 months. Diagnosis: congenital heart disease Ebstein's anomaly type C. Atrial septal defect. Tricuspid valve insufficiency 3 degrees. Tax Code I Art. FC II (NYHA). The diagnosis was made on the basis of an ultrasound scan of the heart. Access - median, longitudinal sternotomy. Pericardiotomy On examination: the heart is enlarged due to the right departments. Introduced heparin. IR connection according to the “VPV-NPV - Aorta” scheme. The ascending aorta, cardioplegia to the root of the aorta, asystole are pinched. Hollow vein occlusion. Right atriotomy. Revision: atrial septal defect 13 mm, Ebstein type C anomaly. Delamination of the anterior, posterior and septal valves of the tricuspid valve was performed. The atrialized part of the pancreas was sutured with a continuous twisted suture with 5/0 prolene thread. The conical reconstruction of the tricuspid valve was performed with single interrupted sutures with 6/0 prolene thread. Completed suturing DMPP with a twisted seam with a prolet 6/0 thread. Hydrodynamic test - TK reg. up to 0-1 tbsp. Prevention of aeroembolism. Removing the clamp from the aorta. Self-restoration of cardiac activity with an outcome in sinus rhythm. Suturing of the right atrium with suture thread 6/0. End of vena cava occlusion. Measures to remove air from the heart and major vessels. Left ventricular drainage removed. AIK stopped. Intraoperative echocardiography - tricuspid valve insufficiency of 1 degree; the gradient on the tricuspid valve is 4/1 mm Hg, there are no interchamber shunts. Decanulation. Modified ultrafiltration. To the right atrium and right ventricle, electrodes are hemmed for the implementation of a temporary EX. Hemostasis. In the anterior mediastinum, an adhesive patch PRECLUDE was implanted. Osteosynthesis of the sternum by wire ligatures. Layered closure of the wound with drainage of the pericardium and anterior mediastinum, with one drainage. Kutasept. DERMOBOND.

After 4 hours, the patient was extubated, on the 2nd day transferred from the intensive care unit to the general ward. On the 13th day the patient was discharged from the hospital. At discharge according to echocardiography: tricuspid valve insufficiency up to 1 degree, gradient on the valve 5/2 mm Hg, systolic pressure of the right ventricle increased from 21 mm Hg to 38 mm Hg, the end-diastolic volume of the left ventricle increased from 14 cc to 17 cc and the ejection fraction of the left ventricle increased from 78% to 82%. There are no cardiac arrhythmias according to Holter monitoring.

The method proposed by the authors was applied in 32 patients. Complications when using this method during surgery, in the early and remote postoperative period was not observed. There was no mortality.

Thus, the application of the proposed method allows you to effectively correct the Ebstein anomaly of types B, C with the lowest surgical risk and satisfactory hemodynamic parameters of the tricuspid valve.

List of references

1. Constantine Mavroudis and Carl L. Backer. Pediatric cardiac surgery. - 4th ed., 571-586.

2. Anderson KR, Lie JT. (1979) The right ventricular myocardium in Ebstein's anomaly: a morphometric histopathologic study. Mayo Clin Proc 54, 181-184.

3. Carpentier A, Chauvaud S, Mace L, Relland J, Mihaileanu S, Marino JP, Abry B, Guibourt P. A new reconstructive operation for Ebstein's anomaly of the tricuspid valve // J Thorac Cardiovasc Surg. 1988.-Vol. 96.-P. 92-l01.

4. Ebstein's anomaly in newborns and children of the first year of life: principles of surgical treatment / L.A. Boqueria [et al.] // Children's diseases of the heart and blood vessels. - 2006.- No. 3.-C. 3-10.

5. da Silva J. P, Baumgratz J. F, da Fonseca L, et al. The cone reconstruction of the tricuspid valve in Ebstein's anomaly. The operation: early and midterm results // J. Thorac Cardiovasc Surg. 2007.-Vol. l33.-P. 215-223.

6. Francis Robicsek Wilhelm Ebstein and the History of Surgery for Ebstein's Disease // Thorac Cardiovasc Surg. 2013.-Vol. 61.-P. 286-292.

7. Jose Pedro da Silva, Luciana da Fonseca da Silva, Luiz Felipe P. Moreira, Lilian Maria Lopes2, Sonia Meiken Franchi ,. Cone Reconstruction in Ebstein's Anomaly Repair: Early and Longterm Results // Arq Bras Cardiol. 2011.-Vol. 97.-Is. 3. -P. 199-208.

Claims (1)

The method of surgical correction of Ebstein’s anomaly is that the tricuspid valve is made with its own tissues, for which the cusps are separated from the walls of the right ventricle, the atrialized part of the right ventricle is plicated, the tricuspid valve tissue is sutured to the true fibrous ring of the tricuspid valve with clockwise rotation of the cusps and create a valve in the form of a cone, characterized in that they begin the separation of the valves from the anterior-septal commissure from 10 hours under conditional applying the dial to the tricuspid valve with the transition to the anterior leaflet, while retaining the chords attached to the edge of the anterior leaflet in the area of the anterior-septal commissure.

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