RU2704218C1 - Method for reimplantation of the pulmonary artery mouths with the impossibility of their direct connection using the extracardiac conduit into the pulmonary artery position - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardiosurgery. There is a connection of the mouth of the existing pulmonary artery with a distal part of the missing pulmonary artery by reimplantation thereof into a side wall of the formed outflow segment of the extracardiac conduit. For this purpose, two vertical incisions in the caudal direction are made on the end of the outflow segment of the extracardiac conduit on opposite sides. Then the conduit outflow end is closed tightly, leaving the side holes intact.

EFFECT: method enables creating confluent pulmonary blood flow in reimplantation of pulmonary artery mouths in case of impossibility of their direct connection using an extracardiac conduit into a pulmonary artery position.

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Description

The invention relates to cardiac surgery and can be used for surgical treatment of patients with congenital heart defects who require the connection of the right and left pulmonary arteries at their remote location from each other in cases where extracardiac conduit implantation is necessary for prosthetics of the pulmonary trunk with conotruncus defects.

There are a number of congenital heart defects, in which one of the concomitant anatomical features is the absence of the proximal part of one of the pulmonary arteries, while its distal part (the so-called chylous artery), as a rule, moves away from the ipsilateral open arterial duct. This defect in about 60-70% of cases is combined with other intracardiac defects, the most common of which is Fallot tetrad. But regardless of the anatomy of the concomitant defect, the main idea of surgical intervention in the pulmonary arteries in this pathology is the combination of both pulmonary arteries in order to create a confluent blood flow.

There is a method of creating confluence of the pulmonary arteries with a combination of tetralogy of Fallot and the absence of the proximal part of the left pulmonary artery, in which the distal part of the left pulmonary artery is pulled to the mouth of the right pulmonary artery and expands with a pericardial patch [1]. The disadvantages of this method are the tension of the distal part of the left pulmonary artery, the use of additional plastic material to connect and expand the pulmonary arteries, as well as the additional suture line necessary for this. In the developed method, tension in the pulmonary artery does not occur, because the distance between the chylus artery (the blood flow in which needs to be restored) and the normal contralateral pulmonary artery is compensated by the diameter of the outflow segment of the conduit, which is positioned between these pulmonary arteries.

There is a method of creating confluence of the pulmonary arteries, in which the distal part of the absent pulmonary artery is directly connected to the pulmonary trunk [2]. The disadvantage of this method is the inability to perform direct reimplantation of the distal part of the absent pulmonary artery with the pulmonary trunk in each case, since often the distance between them is relatively significant for performing this procedure without significant vessel tension, which is a substrate for the formation of subsequent pulmonary restenosis.

A known method of creating confluence of the pulmonary arteries, in which the distal part of the absent pulmonary artery and the mouth of the existing pulmonary artery are connected using a tube of synthetic or biological material [3, 4]. The disadvantages of this method are the fact that the child overgrows the diameter of the tube over time, the risk of tube obstruction, the need for implantation of additional plastic material, and the need for additional lines of anastomoses.

The technical problem to be solved is the creation of confluence of the pulmonary arteries without tension of the pulmonary arteries, which leads to the development of their restenosis.

Achievable technical result is the creation of confluent pulmonary blood flow during reimplantation of the mouths of the pulmonary arteries if it is impossible to directly connect them using extracardial conduit to the position of the pulmonary artery.

The specified technical result is achieved due to the following set of essential features: the mouth of the existing pulmonary artery is connected to the distal part of the absent pulmonary artery by reimplantation into the side wall of the formed outflow segment of the extracardial conduit. To do this, at the end of the outflow segment of the extracardial conduit from opposite sides, two vertical incisions are made in the caudal direction. Then the outflow (outlet) end of the conduit is sutured tightly, while leaving the side openings intact.

The method is as follows.

The mouth of the existing pulmonary artery is connected to the distal part of the absent pulmonary artery by reimplantation into the wall of the outflow segment of the extracardiac conduit without the use of additional plastic material acting as an “insert” between the pulmonary arteries to connect them. Why the outlet end of the conduit is cut in accordance with the required length for implantation. After that, on its lateral sides (along the right and left edges of the conduit relative to the surgeon after fitting the prosthesis between the right ventricle and pulmonary arteries), two vertical descending incisions are made in the caudal direction. Moreover, to eliminate the risk of narrowing of the mouth of the pulmonary artery, the diameter of the formed lateral openings should exceed the diameter of the corresponding pulmonary artery. After that, the outlet end of the conduit is sutured tightly.

The method is illustrated by the following figures:

Figure 1: 1 is a cut line along the edge of the outflow segment of extracardiac conduit on one side;

Figure 2: 2 - suturing of the outflow end of the extracardial conduit;

Figure 3: 3 - formed side openings on the outflow segment of the extracardiac conduit.

Example.

A patient of 1 year 1 month was admitted to a cardiosurgical hospital for planned surgical treatment of congenital heart disease. Diagnosis at admission: tetralogy of Fallot, absence of the proximal part of the left pulmonary artery, a branch of the coronary artery crosses the excretory section of the right ventricle.

The results of angiocardiography and echocardiography (Echocardiography) established the possibility of radical correction of the defect. Due to the impossibility of performing transanular plastic surgery of the excretory section of the right ventricle due to the presence of a large branch of the right coronary artery, it was decided to reconstruct the excretory section of the right ventricle with extracardial conduit from the jugular vein of bull No. 14.

The operation was performed under cardiopulmonary bypass, pharmacological cold cardioplegia and moderate hypothermia (32 ° C). Prior to the cannulation stage, a wide isolation of the right pulmonary artery and the distal part of the left pulmonary artery was performed for their maximum mobility. The distal part of the left pulmonary artery is cut off from the open arterial duct, from which it departed, with preliminary clipping of the latter with two tantalum clips. After clamping the aorta and cardioplegic cardiac arrest, the right atrium was opened. After revision of the interventricular septal defect, an incision of about 20 mm was performed through the tricuspid valve in the avascular zone of the right ventricular excretory section, and massive infundibular stenosis was excised. Through ventriculotomic and partially atrial access, plastic of the interventricular septum was patched with a xenopericardium.

Then we proceeded to implant extracardiac conduit. At the first stage, the prosthesis was tried on between the ventriculotomy incision and the conditional site of the conduit bifurcation, after which the excess length of the outflow segment was cut off. Two vertical sections in the caudal direction are made along the right and left edges of the outflow segment of the conduit. The length of each section was previously calculated. For the calculation, the following formula was used (in this case, other methods for determining the cut length can be used):

Given that the diameter of the mouth of the right pulmonary artery and the diameter of the distal part of the absent left pulmonary artery were 8 mm, the length of the vertical sections was:

After this, the outflow end of the extracardial conduit was sutured tightly using a 6.0-10.0 polypropylene yarn.

Reimplantation of the distal part of the left pulmonary artery was performed primarily (as the point farthest from the surgeon) with the corresponding lateral opening on the outflow segment of the conduit using a continuous twisted polypropylene suture with a thread of 6.0-10.0.

In a similar way, reimplantation of the mouth of the right pulmonary artery was performed.

The operation ended with the imposition of a proximal anastomosis between the conduit and the excretory section of the right ventricle.

The total time of cardiopulmonary bypass and clamping of the aorta is 190 and 115 minutes, respectively. Cardiotonic support at the time of leaving the operating room: norepinephrine - 0.08 mcg / kg / min, adrenaline - 0.08 mcg / kg / min.

The early postoperative period proceeded with the phenomena of right ventricular failure. The total time spent in the ICU department is 6 days. Ventilation time - 3 days.

On the 17th day after the operation, the child was discharged from the hospital. According to echocardiography before patient discharge: left ventricular ejection fraction 64%, pressure gradient on both pulmonary arteries - up to 26 mm Hg

Dynamic observation of the patient 2 years after the operation did not reveal the development of significant stenosis of reimplanted pulmonary arteries (the gradient of systolic pressure in the area of the mouths of the pulmonary arteries is up to 20 mm Hg).

Bibliography

1. Giamberti A., Huseinov F., Yuzbashova M., Musayev S., Piazza L., Mahmudov R. Tetralogy of Fallot with left pulmonary artery discontinuity and totally anomalous pulmonary venous drainage to the azygos vein. World Journal for Pediatric and Congenital Heart Surgery. 2016; 7 (4): 506-8.

2. Welch K., Hanley F., Johnston T., Cailes C, Shah M.J. Isolated unilateral absence of right proximal pulmonary artery: surgical repair and follow-up. Annals of Thoracic Surgery. 2005; 79: 1399-402.

3. Moreno-Cabral R.J., McNamara J.J., Reddy V.J., Caldwell P. Unilateral absent pulmonary artery: surgical repair with a new technique. Journal of Thoracic and Cardiovascular Surgery. 1991; 102: 463-5.

4. Hiramatsu T., Komori S., Okamura Y., Suzuki H., Takeuchi T., Shibuta S. Surgical correction of isolated unilateral absence of right pulmonary artery. Heart Vessels. 2010; 25: 353-5.

Claims (1)

The method of reimplantation of the mouths of the pulmonary arteries when it is impossible to directly connect them using extracardiac conduit to the position of the pulmonary artery, comprising connecting the mouth of the existing pulmonary artery with the distal part of the absent pulmonary artery by reimplanting them into the lateral wall of the formed outflow segment of the extracardiac conduit, for which purpose at the end of the outflow segment of the extracardial conduit the conduit from opposite sides perform two vertical incisions in the caudal direction, then about the exact end of the conduit is sutured tightly, while leaving intact the lateral openings.

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