RU2721820C1 - Method of surgical correction of ebstein abnormality - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, particularly to cardiovascular surgery. Right ventricular flaps are mobilized starting from a front-piece commissure from 10 o'clock with a conditional application of the clock face to the three-leaf valve with transition to the front flap. Flaps are started to be separated immediately below the tricuspid valve fibrous ring. Then the front flap is separated, at the same time the chords are kept as much as possible, which are fixed to the edge of the front flap in the area of the front-piece commissure. After the separation of the anterior fold is completed, the rear flap is moved, if the fold tissue can be separated from the myocardium. Next step involves the atrialisation of the right ventricle. In the projection of the atrioventricular node, the suture line is displaced 0.5 cm below the true fibrous ring of the tricuspid valve, and the tissue of the set off flap is sutured with single interrupted suture to the interventricular septum.EFFECT: method enables preventing an intra- and postoperative complication in the form of an atrioventricular block and avoiding the implantation of a cardiac pacemaker.1 cl, 1 ex, 1 dwg

Description

The invention relates to medicine, namely to cardiovascular surgery.

Ebstein’s anomaly is a congenital pathology of the right ventricle and tricuspid valve, the frequency of occurrence of which is about 1% of all congenital heart defects. This defect belongs to the blue type of congenital pores of the heart. Wilhelm Ebstein made the morphological description of vice for the first time in 1866.

Ebstein’s anomaly is characterized by five anatomical features. The first feature is the fusion of the valves with the ventricular myocardium. As a rule, the anterior cusp is delaminated more from the ventricular wall, while the posterior and septal cusps are delaminated minimally. In the most severe cases, the septal leaf is a comb of connective tissue. Secondly, there is an antero-apical displacement of the functional ring of the tricuspid valve (the place of transition of the atrialized part of the ventricle to the true right ventricle with normal delamination of the valves) towards the excretory section of the right ventricle. The third characteristic feature is the redundancy of the tissue of the anterior leaflet (sail-shaped leaflet), its fenestration and limitation of mobility between the valve leaflet and the right ventricle due to chordal connection. The fourth feature is the presence of a thinned, dilated and akinetic part of the right ventricle (atrialized part), with the number of myocardial fibers in this area being significantly less than normal. And the fifth sign is the expansion of the true (anatomical) fibrous ring of the tricuspid valve [1,2].

The life expectancy of patients with this congenital heart disease is 30-40 years. The severity of the patient's condition directly depends on the ratio of the volume of the atrialized and functional parts of the right ventricle. The larger the volume of the atrialized part and the smaller the functional part, the worse the condition of the patient. The most used in practical work was the classification of the French cardiac surgeon A. Carpentier [3], developed in 1988 and consisting of 4 types: A, B, C, D.

Surgical attempts to treat Ebstein's anomaly began in the early 1950s. J. Hopkins used the Blok-Taussig shunt, which aimed 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 of the atrialized part of the right ventricle with U-shaped sutures towards the atrioventricular junction, sometimes with a partial capture of the edge of the anterior cusp, thereby achieving monocuspidation of the valve. [4].

There is also a method of plasty according to A. 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.

A known method of the Brazilian cardiac surgeon da Silva, developed in 1989. This method is based on the A. Carpentier technique. da Silva and colleagues developed a tricuspid valve repair procedure 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 authors report the occurrence of complete atrioventricular block after conical reconstruction, if the leaf tissue was sutured to the fibrous in the projection of the atrioventricular node and damaged it. In an article by Chinese author Bin Li et al. 4 cases of complete atrioventricular blockade after tricuspid valve repair and 3 cases after prosthesis of the tricuspid valve are reported [10]. A multicenter study described by Joseph A. Dearani et al. shows implantation of a pacemaker in 11 cases out of 494 surgical interventions [9]. da Silva et al. describe the occurrence of complete atrioventricular blockade in the distant postoperative period, which required the implantation of a pacemaker [7]. The experience of Russian authors given in the article by V.A. Bolsunovsky and sovt. also showed complete transverse blockade in 1 patient out of 19 patients operated using the “cone reconstruction” method [8].

The disadvantages of the prototype method is the possibility of damage to the atrioventricular node.

The aim of the invention is to prevent complete atrioventricular block.

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 in the area of the atrioventricular node, the suture line is mixed 0.5 centimeters below the true fibrous tricuspid valve and the tissue of the separated sash is sutured to the interventricular septum with single interrupted sutures.

This change will avoid damage to the atrioventricular node.

The technical result of the invention is the ability to avoid intra- and postoperative complications: atrioventricular block and implantation of a pacemaker.

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 the early 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 the final view of the valve after conical reconstruction

1 - suture line of valve leaf tissue to the fibrous ring

2 - sutured atrialized part of the right ventricle

3 - projection of the atrioventricular node

4 - coronary sinus

5 - inferior vena cava

6 - suture line to the interventricular septum

7 - the displacement point of the suture from the fibrous ring of the tricuspid valve to the interventricular septum

8 - superior vena cava

The method is as follows: access to the heart and main vessels is carried out through the median longitudinal 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. In the area of the atrioventricular node, the suture line is shifted 0.5 cm below the fibrous ring of the tricuspid valve and the leaf tissue is sutured with single nodal sutures to the interventricular septum. Then, atrial septal defect is sutured. Suture 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 11 years. Diagnosis: congenital heart disease Ebstein's anomaly type C. Atrial septal defect. Tricuspid valve insufficiency 3 degrees. Tax Code I Art. FC I (NYHA). The diagnosis was made on the basis of an ultrasound scan of the heart. According to electrocardiography before surgery: sinus rhythm, P-0.08 s, PQ-0.16c, QRS-0.10c RR-0.76c, QT-0.38c, heart rate-84 per minute. 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 - TC per. 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 up to 1 degree; gradient on the tricuspid valve 9/5 mm. Hg. Art, there are no inter-chamber shunts. Decanulation. Modified ultrafiltration. Electrodes are sewn to the right atrium and right ventricle for the implementation of a temporary EX. Hemostasis. In the anterior mediastinum, an anti-adhesive patch PRECLUDE was implanted. Osteosynthesis of the sternum by wire ligatures. Layer wound closure with drainage of the pericardium and anterior mediastinum, with one drainage. Kutasept. DERMOBOND.

After 17 hours, the patient was extubated, on the 3rd day he was transferred from the intensive care unit to the general ward. On the 21st day the patient was discharged from the hospital. At discharge according to echocardiography: tricuspid valve insufficiency up to 1 degree, gradient on the valve 6/2 mm. Hg. Art., systolic pressure of the right ventricle increased from 21 mm. Hg. St up to 28 mm. Hg. century, the end-diastolic volume of the left ventricle increased from 58 cc to 72 cc and the ejection fraction of the left ventricle increased from 67% to 75%. According to electrocardiography after surgery: sinus rhythm, P-0.08 s, PQ-0.14c, QRS-0.10c RR-0.72c, QT-0.36c, heart rate-92 per minute. According to Holter monitoring, there were no cardiac arrhythmias before and after surgical treatment.

The method proposed by the authors was applied in 32 patients. Complications and rhythm disturbances 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 without damaging the atrioventricular node and the development of atrioventricular block.

List of used literature.

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

2. Anderson K.R., Lie J.T. The right ventricular myocardium in Ebstein's anomaly: a morphometric histopathologic study // Mayo Clin Proc. 1979. - Vol. 54. - P. 181-184.

3. Carpentier A., Chauvaud S., Mace L., Relland J., Mihaileanu S., Marino J.P., Abry B., Guibourt P. A new reconstructive operation for Ebstein's anomaly of the tricuspid valve // J Thorac Cardiovasc Surg. 1988. - Vol. 96. - P. 92-101.

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. - S. 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. 133. - 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. da Silva J.P., da Silva L.F., Moreira L.P., Lopes L.M., Franchi S.M. Cone Reconstruction in Ebstein's Anomaly Repair: Early and Longterm Results // Arq Bras Cardiol. 2011. - Vol. 97. - Is.3. - P. 199-208.

8. Bolsunovsky B.A., Khubulava G.G., Novik G.A., Zhdanova M.V., Movsesyan P.P., Shorokhov S.E., Khokhlunov M.S., Bolsunovsky A.V. Ebstein’s anomaly: a cone reconstruction operation is the first experience of anatomical correction. Attending doctor. - 2017. - No. 1; - S. 7.

9. Hoist K.A., Dearani JA, Said SM, Davies RR, Pizarro C, Knott-Craig C, Kumar S., Starnes VA, Kumar SR, Pasquali SK, Thibault DP, Meza JM, Hill KD, Chiswell K. , Jacobs JP, Jacobs ML Surgical Management and Outcomes of Ebstein Anomaly in Neonates and Infants: A Society of Thoracic Surgeons Congenital Heart Surgery Database Analysis // Ann Thorac Surg. 2018; - Vol. 106 - P. 785-791.

10. Li B., Sun H.S., Pan S.W., Xu J.P. Outcomes of Ebstein's Anomaly Patients Treated with Tricuspid Valvuloplasty or Tricuspid Valve Replacement: Experience of a Single Center // Chin Med J. 2018; - Vol. 131. - P. 1067-1074.

Claims (1)

A method of surgical correction of Ebstein’s anomaly by the method of conical reconstruction, namely, 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 rotation clockwise and create a valve in the form of a cone, characterized in that in the area of the atrioventricular node, the suture line is shifted 0.5 centimeters below the true fibrous ring of the tricuspid valve, and the tissue of the separated leaflet is sutured to the interventricular septum with single interrupted sutures.

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