RU2718265C1 - Method for pericardial drainage after open cardiosurgical interventions - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to cardiovascular surgery. Active flexible four-channel silicone pericardial drainage is installed. Draining is looped along the perimeter of the pericardial membrane. It is performed above an inferior vena cava, passed in a pocket between a right pericardial wall and a right atrium, arched above the right atrium. Then drainage is inserted into a transverse sinus pericardium and brought out in the left half of the pericardial cavity for 1–2 cm.

EFFECT: method provides effective and uniform drainage of all parts of pericardial cavity, as well as prevention of cardiac tamponade after open cardiosurgical operations.

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Description

The invention relates to medicine, namely to cardiovascular surgery, and can be used to prevent cardiac tamponade after most open cardiac surgery performed through median sternotomy.

About 60 thousand open cardiac surgical interventions are performed annually in the Russian Federation [1]. All of them end with drainage of the pericardial cavity, which is necessary for postoperative monitoring of the intensity of bleeding and the prevention of such a life-threatening condition as cardiac tamponade.

The traditional approach to pericardial drainage is to conduct a single-lumen drainage tube through a separate incision puncture in the epigastric region (subxiphoidally) along the diaphragmatic surface of the pericardium to the deepest point of the oblique pericardial sinus and connect the drainage tube to the vacuum aspiration device [2]. “Syndrome of blood retention in the pericardium” after open cardiac surgery with the traditional method of pericardial drainage develops in 13.8–22.7% of patients [7]. The frequency of repeated interventions to remove blood and clots from the pericardial cavity reaches 9.2% [6]. Repeated operations significantly increase the risk of developing deep sternal infection and mediastinitis, increase the incidence of postoperative acute renal failure, extend the length of stay in intensive care units and inpatient departments, and increase 30-day mortality [6]. Dissatisfaction with the results of the traditional method of pericardial drainage has led to the development of alternative methods for evacuating the postoperative contents of the pericardial cavity.

The method proposed by D. A. Basarab et al. [3] is aimed at improving drainage of the oblique pericardial sinus by increasing the duration of drainage in the pericardium up to 5 days after surgery. At the same time, the authors recommend that during the first three days the traditional PVC pipe be removed and replaced with a tube of a smaller diameter. The disadvantages of this method are the prolonged standing of pericardial drainage, as well as the need to introduce a rehabilitation suction catheter and a new drainage microtube into the lumen of the primary drainage. All this increases the risk of secondary infection of the pericardium and anterior mediastinum. In addition, the method cannot be used after coronary artery bypass surgery, since the complicated procedure for replacing pericardial drainage in the absence of direct visual control is potentially associated with coronary artery bypass grafting and bleeding.

The method developed by K.A. Petlin et al. [4] also improves drainage of the left pericardial only: blood from the oblique pericardial sinus flows through the created pericardial opening into the left pleural cavity and is taken from there by the working part of the drainage from the pericardium to the left pleura. As in the previous method, the authors propose using a single-lumen drainage tube. However, more successful prevention of cardiac tamponade in this prototype is achieved due to additional surgical trauma: pericardial fenestration and opening of the pleural cavity are required. In addition, the use of this method is difficult for operations on a working heart, since pericardial fenestration is performed during cardiopulmonary bypass.

A method for simultaneous drainage of the retrosternal space and the left half of the pericardium in children using a single drainage that envelopes the heart in the sagittal plane was proposed by A.Yu. Podoxenov et al. [5]: a drainage tube was made between the posterior surface of the sternum and the anterior sheet of the pericardium to the middle of the trunk of the pulmonary artery, directed down into the pericardial cavity between the left pulmonary artery and the ear of the left atrium, placed behind the left ventricle in the oblique pericardial sinus, and then performed along the diaphragmatic surface of the pericardium to its anterior leaf. This approach for pericardial drainage was used in a standard situation with unopened pleural cavities. The authors proposed the drainage of the right pericardium only as a supplement to the drainage of the right pleural cavity: the drainage introduced through the incision in the VII-VIII intercostal space along the anterior axillary line was carried out through the right pleural cavity to the unnamed vein, and then it was directed to the pericardial cavity on the right and side from the right atrium. The disadvantage of this method of drainage of the right pleura and pericardium is the need to perform an intercostal incision-puncture, which increases the risk of pneumothorax, subcutaneous emphysema and bleeding into the pleural cavity after drainage is removed. Blake® silicone thoracic drains (Ethicon Inc.) with a diameter of 15F and 19F were used as drainage tubes.

Thus, most of the existing methods for pericardial drainage are aimed at optimizing the outflow of blood and clots from the left pericardium and do not take into account the adequacy of drainage of the right pericardial cavity. Especially in the area of the natural pocket-recess, which is laterally limited by the right wall of the pericardial cavity, and medially by the superior vena cava, right pulmonary veins, right atrium, inferior vena cava and duplicatures of the visceral pericardium spreading through these formations. It is in this section of the pericardial cavity, in our experience, the most frequent accumulation of blood and clots leads to compression of the compliant right atrium, a decrease in its diastolic filling and the development of clinical manifestations of heart hemotamponade.

The objective of the invention is the prevention of cardiac tamponade after open cardiac surgery due to the effective evacuation of blood and clots from all departments of the pericardial sac (pericardium). This problem is solved by the proposed method of drainage of the pericardial cavity, which consists in a special S-shaped positioning of the drainage tube, taking into account the anatomical features of the pericardium. Drainage is looped along the perimeter of the diaphragmatic surface of the pericardium, carried out over the inferior vena cava, passed in a pocket between the right wall of the pericardium and the right atrium, placed arcuately over the right atrium, inserted into the transverse sinus of the pericardium and brought to the left half of the pericardial cavity by 1-2 cm. A flexible thoracic four-channel silicone drainage having a cross-section and a diameter of 19 FR (6.3 mm) is assumed to be a drainage tube. Factory-made Blake® or Meding® drains meet these requirements. Compared with known analogues, this method provides a more uniform and complete drainage of all departments and pockets of the pericardial cavity. Thanks to the proposed method, a more effective removal of blood and hemorrhagic discharge from the pericardial cavity is achieved, which is of great importance for the prevention of cardiac tamponade. This method of pericardial drainage is applicable as a standard for any open cardiac surgery, regardless of the integrity of the pleural cavities. It avoids the development of life-threatening complications, reduces the need for repeated sanitation and drainage interventions, and thereby improves the results of surgical treatment of patients.

The method is as follows. In the epigastric region 3-5 cm below the xiphoid process of the sternum and to the right of the midline, a skin incision is made corresponding to the diameter of the drainage. A horizontal U-shaped seam is applied to the edges of the incision for subsequent sealing of the exit site and fixation of the drainage. Through a skin incision at an acute angle to the front surface of the body, Kocher clamp is inserted from front to back and it is bluntly passed through the subcutaneous fat and rectus muscle to the apex of the angle between the anterior and diaphragmatic walls of the pericardium. On the pericardial side, the tubular end of the four-lumen silicone drainage is gripped by a clamp and pulled out through a previously formed channel. The placement of the drainage tube in the pericardium is performed under direct visual control through sternotomy surgical access. S-shaped drainage is laid through all the recesses and pockets of the pericardial cavity (Fig. 1). Drainage is looped along the perimeter of the diaphragmatic surface of the pericardium (along the borders of its transition into the anterior, left lateral and posterior walls of the pericardium), carried out over the inferior vena cava, passed through a pocket between the right pericardial wall and the right atrium, placed arcuately above the right atrium, transverse the sinus of the pericardium and output into the left half of the pericardial cavity by 1-2 cm (Fig. 2). The positioning of the drainage arc when moving from the right pericardial pocket to the transverse sinus should be avoided by touching the area of the sinoatrial node of the cardiac conduction system (the presence of the sinus rhythm is controlled by the ECG curve on the anesthetic monitor). During shunt operations, it is also necessary to exclude contact of the tube with coronary shunts. After the drainage is installed in the pericardial cavity, a single node is tightened on a previously applied sealing U-shaped skin suture, multiple multidirectional winding of the drainage by the ends of the fixing thread (as close to the place of its exit to the skin as possible) and the final fixation of the drainage by three surgical nodes are tightened. After the installation of pericardial drainage is completed, the pericardial leaves can be sutured with single sutures, or the pericardium can be left not sutured (at the surgeon's discretion). Drainage of the pericardium is always supplemented by drainage of the retrosternal space by installing parallel or behind the sternum of a four-channel or single-lumen multicarrier tube of the same diameter. In the case of opening the pleural cavity, additional pleural drainage is established through an incision in the epigastrium. All drains are connected to a vacuum aspiration apparatus. Drainage removal, as a rule, is carried out for 2-3 days with a volume of separated less than 50 ml / day. The wound is sealed after drainage is removed by tightening the U-shaped seam with the loose ends of the fixing thread.

Clinical example. Patient K., 62 years old, underwent elective mammary coronary artery bypass grafting, autovenous coronary artery bypass grafting of the obtuse margin of the envelope artery and posterior interventricular artery under extracorporeal circulation. Intervention was performed under multicomponent general anesthesia with mechanical ventilation. The pleural cavities did not open. Myocardial ischemia time was 28 minutes, cardiopulmonary bypass time was 35 minutes, and the total operation time was 2 hours and 40 minutes. The operation is completed by pericardial drainage (drainage is installed according to the above method) and retrosternal space. Extubation took place 2 hours after leaving the operating room. Hemodynamics remained stable. Cardiotonic and vasopressor support was not required. On the survey x-ray of the chest organs signs of hemopericardium, hemothorax was not detected (Fig. 2A). The boundaries of the shadow of the heart were not expanded, the waist of the heart was clearly traced, signs of ventilation or congestive disorders in both lungs were not detected. The total volume of discharge by drainage reached 350 ml on the first day, 100 ml on the second day, and 50 ml on the 3rd day. On day 3, drainage was removed. According to echocardiography, the maximum discrepancy of the pericardial leaves in the first day after the operation was 0.9 cm; on the second day - 0.8 cm; on the fifth day, 0.5 cm. Normal diastolic filling of the right and left chambers of the heart was observed. No tendency to hypotension and tachycardia was noted. Healing of postoperative wounds occurred by primary intention, without wound complications. The patient was discharged in satisfactory condition on the 7th day after surgery.

The new method of pericardial drainage was successfully applied during 132 operations of isolated coronary artery bypass grafting and 38 combined interventions (coronary artery bypass grafting with plastic surgery or prosthetic heart valves). All patients had stable hemodynamics without x-ray and ultrasound signs of blood retention in the pericardium. In 5 patients (2.9%), in the first hours after the operation, there was an active flow of blood through the drains at a speed of more than 200 ml / h, in connection with which he underwent an urgent restotomy and elimination of the sources of bleeding. In patients operated repeatedly, clinical and instrumental signs of cardiac hemotamponade were also absent. On the first, second and fifth days after the initial or repeated operation, a planned echocardiography was performed, on which the maximum discrepancy of the pericardial leaves did not exceed 1 cm (0.9 ± 0.16 cm). There were no ultrasonic signs of compression of the heart chambers by intrapericardial contents. All patients were discharged in satisfactory condition. The absence of cases of cardiac hemotamponade in the observations presented indicates the effectiveness of the proposed method for pericardial drainage. The method is easily reproducible in the presence of anatomical knowledge and basic skills in the field of cardiovascular surgery.

The proposed method is illustrated by 2 figures:

• In FIG. 1 shows the pericardial drainage scheme (for perception, the anterior wall of the pericardium and the heart are removed): 1 - aorta; 2 - bifurcation of the pulmonary artery; 3 - drainage in the transverse sinus of the pericardium; 4 - pulmonary veins; 5 - oblique sinus of the pericardium; 6 - diaphragmatic surface of the pericardium; 7 - pericardial drainage in the area of exit to the surface of the body; 8 - pericardium (visceral and parietal leaflets); 9 - the inferior vena cava; 10 - drainage in the right pocket of the pericardium; 11 - superior vena cava.

• In FIG. Figure 2 shows an overview x-ray of the chest organs of a patient with an S-shaped pericardial drainage (performed 12 hours after surgery): A - an x-ray, on which an x-ray positive drainage contour is traced; B - the same X-ray pattern on which the light line of the drainage has a black line.

List of references

1. Cardiovascular Surgery - 2017. Diseases and congenital malformations of the circulatory system / L.A. Boqueria, E.B. Milievskaya, Z.F. Kudzoeva, V.V. Gingerbread man. - M: NIICSSH them. A.N. Bakuleva Ministry of Health of the Russian Federation, 2018 .-- 252 p.

2. Cardiovascular surgery: a guide / V.I. Burakovsky [et al.]; Ed .: V.I. Burakovsky, L.A. Boqueria. - 2nd ed., Ext. - M .: Medicine, 1996 .-- 768 p.

3. A method for the prevention and treatment of exudative-inflammatory complications after median sternotomy: US Pat. 2467706 Russian Federation: IPC А61В 17/00 / D.A. Basarab, V.A. Mithish, A.L. Yarosh, V.F. Kulikovsky, A.N. Prikhodko; Applicant and patent holder, Belgorod State National Research University. - No. 20111134182/14; application 08/12/2011; publ. 11/27/2012, Bull. No. 33.

4. A method for the prevention of cardiac tamponade during cardiac surgery: Pat. 2647626 Russian Federation: SPK А61В 17/00; A61M 27/00 / K.A. Petlin, A.S. Pryakhin, M.S. Kuznetsov, B.N. Kozlov, V.M. Shipulin; Applicant and patent holder of the Tomsk National Research Medical Center of the Russian Academy of Sciences (Tomsk Scientific and Technical Center). - No. 2017118304; declared 05/25/2017; publ. 03/16/2018, Bull. Number 8.

5. Methods of drainage of the pericardium, anterior mediastinum / A.Yu. Podoxenov [et al.] // Siberian Medical Journal. - 2012. - Volume 27, No. 4. - S. 25-29.

6. Outcome after procedures for retained blood syndrome in coronary surgery / Tauriainen T. [et al.] // Eur. J. Cardiothoracic Surg. - 2017 .-- Vol. 51, No. 6. - P. 1078-1085.

7. Retained blood syndrome after cardiac surger: a new look at an old problem / E.M. Boyle [et al.] // Innovations (Phila). - 2015. - Vol. 10, No. 5. - P. 296-303.

Claims (1)

A method of pericardial drainage after open cardiac surgery, including the installation of an active flexible four-channel silicone pericardial drainage, characterized in that the drainage is looped along the perimeter of the diaphragmatic surface of the pericardium, carried out over the inferior vena cava, passed in the pocket between the right pericardial wall and the right atrium, placed in an arcuate the right atrium, lead into the transverse sinus of the pericardium and lead to the left half of the pericardial cavity by 1-2 cm.

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