RU2718308C1 - Method for preventing reperfusion myocardial damage in congenital heart disease surgery - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, particularly to cardiovascular surgery. Retrograde reperfusion of the coronary vascular bed is performed immediately before resuming the coronary blood flow stopped at the cardioplegia stage. For this purpose, venous blood is injected from the cardiotomy reservoir through the venous main line of the pulmonary circulation circuit through an ultrafiltration pump into the coronary sinus by passing it through an ultrafilter column of an artificial circulation circuit.EFFECT: method enables reducing the rate of postoperative complications caused by myocardial dysfunction in the patients with congenital heart defects after correction in the conditions of artificial blood circulation and prolonged blood cardioplegia, increasing the rate of self-sustained cardiac rhythm perfusion.1 cl, 1 dwg, 2 ex

Description

The invention relates to medicine, namely to a method for protecting the myocardium in cardiopulmonary bypass. The need for such protection is associated with negative clinical effects due to ischemia-reperfusion syndrome after cardioplegic cardiac arrest.

The objective of the invention is to provide a method aimed at reducing the degree of myocardial damage at the stage of reperfusion, limiting the negative clinical consequences of prolonged myocardial ischemia in patients with congenital heart defects after correction in conditions of blood cardioplegia.

The problem is solved by retrograde reperfusion of the coronary vascular bed with venous blood from the cardiotomic reservoir, which is taken through the venous line of the circuit of the cardiopulmonary bypass immediately before resuming coronary blood flow stopped at the stage of cardioplegia. Venous blood is pumped by an ultrafiltration pump sequentially through the supply line of the ultrafilter, the column of the ultrafilter, the outlet line of the ultrafilter into the cardioplegic cannula of retrograde reperfusion. which immediately before reperfusion is installed in the coronary sinus. Retrograde reperfusion of the coronary vascular bed with venous blood corresponds in duration to the time of deaeration of the heart cavities.

The technical result of this invention is to reduce the incidence of postoperative complications due to myocardial dysfunction in patients with congenital heart defects after correction in conditions of cardiopulmonary bypass and prolonged cardioplegia.

cardioprotection methods of adaptation methods in clinical practice, their effective adaptation in cardiac surgery [16, 17, 18].

There is a method of short-term preparation for reperfusion - "terminal" normothermic cardioplegic blood perfusion, performed immediately before the restoration of cardiac activity [9]. The purpose of this clinical procedure is the controlled delay of reperfusion and the preparation of the myocardium for it, its recovery after cardioplegic ischemia. The technique is carried out by retrograde reperfusion from the arterial line of the heart-lung machine. In the first minutes, the perfusate contains an increased concentration of potassium. Then, normal blood is pumped into the coronary vessels from the aortic cannula of the extracorporeal kennel IR. After restoration of cardiac activity, aortic occlusion is stopped, removing the clamp from it.

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

The disadvantage of this method is the direct use of oxygenated perfusate from the arterial line of the circuit of the heart-lung machine. Arterial reperfusion is characterized by a high partial oxygen pressure and an uncontrolled concentration of inflammatory mediators, which are known factors of oxidative stress, which reduces the effectiveness of the prevention of reperfusion injury.

The objective of the invention is to provide a method aimed at reducing the degree of myocardial damage at the stage of reperfusion, limiting the negative clinical consequences of prolonged myocardial ischemia in patients with congenital heart defects after correction in conditions of cardioplegia.

The problem is solved by retrograde reperfusion of the coronary vascular bed with venous blood from the cardiotomic reservoir through the venous line of the circuit of the heart-lung machine immediately before resuming coronary blood flow stopped at the stage of cardioplegia. Venous blood is pumped by the ultrafiltration pump sequentially through the supply line of the ultrafilter, the column of the ultrafilter, the outlet line of the ultrafilter and the cardioplegic cannula of retrograde reperfusion, which is installed immediately before reperfusion into the coronary sinus. Retrograde reperfusion of the coronary vascular bed with venous blood corresponds in duration to the time of deaeration of the heart cavities.

New in the proposed method is the use of venous blood for reperfusion of the coronary vascular bed, which is taken through the venous line of the circulatory apparatus, ultrafiltration of this blood and its hemoconcentration with a decrease in the concentration of inflammatory factors in the ultrafilter column, followed by retrograde injection into the coronary sinus.

The technical result of this invention is to reduce the incidence of postoperative complications due to myocardial dysfunction in patients with congenital heart defects after correction in conditions of cardiopulmonary bypass and prolonged cardioplegia.

Distinctive features showed in the inventive combination of new properties that are not explicitly derived from the prior art in this field and are not obvious to a specialist. No identical set of features was found in the analyzed literature. Proposed as an invention, the method can be used in healthcare to increase the effectiveness of treatment.

Based on the foregoing, this technical solution should be considered relevant to the conditions of patentability: "novelty", "inventive step", "industrial applicability".

The invention will be clear from the following description and the attached figure. In FIG. 1 shows a diagram of the proposed method, where:

1 - arterial line of the circuit of the heart-lung machine

2 - cardiotomy reservoir

3 - venous trunk circuit of the heart-lung machine

4 - shunt between venous and arterial arteries

5 - supply line ultrafilter

6 - ultrafiltration pump

7 - filtrate

8 - vacuum suction ultrafilter

9 - ultrafilter column

10 - output line ultrafilter

11 - crane switching the direction of blood after passing through an ultrafilter

12 - cardioplegic cannula of retrograde reperfusion through the coronary sinus

The method is as follows. Immediately before the resumption of coronary blood flow, stopped at the stage of cardioplegia. switch the shunt between the venous and arterial arteries of the cardiopulmonary bypass 4 and the valve switching the blood direction after passing through the ultrafilter 11 to stop pumping blood from the arterial arteries of the arteries of the cardiopulmonary bypass 1 to the ultrafilter 9. Start collecting venous blood from the cardiotomy reservoir 2 through the venous arteries heart-lung machine 3, a shunt between the venous and arterial highways 4, the supply line of the ultrafilter 5 and pumping it into the ultrafilter 9. Blood is pumped by the ultrafiltration pump 6. The filtrate 7 is removed from the blood through the ultrafilter 9. The vacuum for ultrafiltration is created by vacuum suction of the ultrafilter 8. After filtration in the ultrafilter 9, blood is pumped through the outlet line of the ultrafilter 10, the blood direction switching tap after passing through an ultrafilter 11 and a cardioplegic cannula of retrograde reperfusion 12 into the coronary sinus.

Clinical example 1.

Patient P., 3 g. Main disease: Congenital heart disease. Ebstein's anomaly (type C). Tricuspid valve insufficiency 3 degrees. Atrial septal defect. NK I. FC II (Ross). The patient underwent surgery: Cone reconstruction of the tricuspid valve, suturing of the interatrial septal defect under normothermic IR from median thoracotomy under endotracheal anesthesia (sevoran) of central analgesia (fentanyl 10 μg / kg). After connecting the IR, before performing the main stage, for the purpose of cardioplegia, a cold blood solution was induced at a temperature of 12 degrees C. From the aortic root at the rate of 30 ml / kg, dystolic asystole was achieved. Repeated cardioplegia sessions were performed at 25 min and 50 min after aortic occlusion. At the 76th minute of aortic occlusion, retrograde reperfusion of venous blood was performed, injected through an ultrafilter for 4 minutes according to the proposed method, followed by the resumption of coronary blood flow after the cardioplegia stage. The duration of the IC was 98 minutes, the time of aortic occlusion was 82 minutes. Self-restoration of cardiac activity with an outcome in sinus rhythm. In 10 minutes. AIK reperfusion stopped. Decanulation. The total duration of the operation is 200 minutes Inotropic therapy adrenaline 0.03 mcg / kg / min, milrinone 0.5 mcg / kg min. Extubation after 8 hours. Observation in the intensive care unit for 36 hours. Echocardus 24 after surgery: Left ventricular contractility, contractility, and pumping function are normal. No complications were observed in the early postoperative period.

Clinical example 2. Patient I., newborn 1 day.

Main disease: Congenital heart disease. D-Transposition of the great vessels. Restrictive open oval window. Open ductus arteriosus. FC II (Ross). The patient underwent surgery: Arterial switching, suturing of the atrial septal defect, clipping, ligation, intersection of the open arterial duct under normothermic IR from median thoracotomy under conditions of central analgesia (fentanyl 20 μg / kg) and endotracheal anesthesia (sevoran). After connecting the IR, before performing the main stage for the purpose of cardioplegia, an induction of a cold blood solution with a temperature of 12 degrees was performed. From the aortic root at the rate of 30 ml / kg, dystolic asystole was achieved. Repeated cardioplegia sessions were performed for 20 min, 40 min, 66 min after aortic occlusion. The total aortic occlusion time was 89 minutes. From 83 minutes of aortic occlusion within 5 minutes, retrograde reperfusion was performed with blood pumped through an ultrafilter from a cardiotomic reservoir by the proposed method, followed by restoration of antegrade blood flow after removing the clamp from the aorta. The duration of the IR was 117 minutes, the time of aortic occlusion was 89 minutes. Self-restoration of cardiac activity with an outcome in sinus rhythm. In 20 minutes. AIK reperfusion stopped. Decanulation. The total duration of the operation is 200 minutes Inotropic therapy dopamine 6 mcg / kg / min. No cardiac arrhythmias were observed in the postoperative hours, inotropic support was disabled after 6 hours, and there was no increase in the level of low cardiac output markers (lactate) and myocardial damage (troponin). Extubation after 18 hours. Observation in the intensive care unit for 36 hours. Echocardus 6 and 24 after surgery: Left ventricular contractility, contractility and pumping function are normal. No complications were observed in the early postoperative period. The child was discharged on the 14th day.

The method proposed as an invention was tested in 18 children operated on for congenital heart defects (Ebstein's anomaly - 4, Fallot tetrad 6, Transposition of the main arteries - 6, total abnormal pulmonary venous drainage - 2) with a duration of intraoperative cardioplegic myocardial ischemia from 62 to 102 minutes . The method allows to increase the frequency of self-recovery of heart rate during reperfusion, to reduce the number of postoperative complications caused by a decrease in myocardial contractility and to improve the results of cardiac surgery in this category of patients.

List of references

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Claims (1)

A method for the prevention of reperfusion damage to the myocardium in the surgery of congenital heart defects by retrograde reperfusion of coronary bloodstream immediately before resuming coronary blood flow, stopped at the stage of cardioplegia, characterized in that the coronary sinus is pumped from the cardiotomy reservoir through the venous arterial circulation pump passing it through an ultrafilter column of a cardiopulmonary bypass I am.

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