RU2724871C1 - Method of artificial blood circulation in reconstructive operation on aortic arch - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to cardiovascular surgery, medical equipment. System comprising interconnected physiological and perfusion units is used. First, artificial blood circulation (ABC) is performed in parallel to antegrade pharmaco-cholera cardioplegia. Circulation reservoir is filled with cardioplegic solution, main line perfusion ports are connected to left coronary and right coronary arteries, and connection between physiological and perfusion units is blocked. That is followed by circulatory arrest and selective bilateral antegrade perfusion of the brain through a left common carotid artery (lCCA) and a brachiocephalic trunk (BCT), for which the arterial line is closed, a connection is opened between the physiological and perfusion units, the cardioplegic solution is displaced with the perfusate of the physiological unit, the circulation reservoir is disconnected, ports of main lines for perfusion of the main vessel are connected to the lCCA and BCT of the patient. Brain perfusion is performed at temperature 27–28 °C with separate delivery of oxygenated blood by lCCA and BCT, maintaining pressure of 50–70 mm Hg and cerebral perfusion rate of at least 250 ml/min separately along the main vessel perfusion lines. After the circulatory arrest is completed, the ABC is continued while the patient is warmed, and the cerebrum perfusion is continued at 27–28 °C, maintaining said perfusion parameters.EFFECT: method enables performing ABC with cardioplegia, perfusion of cerebrum using one universal system, provides prevention of neurological complications.1 cl, 4 dwg, 1 ex, 1 tbl

Description

The invention relates to medicine, namely to cardiovascular surgery, medical equipment, can be used when performing operations on the aortic arch and its branches, carried out under conditions of hypothermia and circulatory arrest with pharmacological cold cardioplegia.

Surgery on the aorta is usually accompanied by significant blood loss and neurological complications after circulatory arrest. This circumstance makes it particularly urgent to improve the methods of cardiopulmonary bypass during these surgical interventions.

Artificial blood circulation during reconstructive surgery on the aortic arch, usually includes the following steps:

1. cardiopulmonary bypass with pharmacological cold cardioplegia, providing myocardial protection;

2. cerebral perfusion under conditions of circulatory arrest (in which there is no blood supply to the lower floor of the patient's body), necessary for the prevention of complications caused by circulatory arrest;

3. cerebral perfusion during perfusion of the lower floor of the patient’s body under conditions of its warming.

Reconstructive operations on the aortic arch are performed under conditions of circulatory arrest with isolated perfusion of the brain. The “gold standard” for maintaining blood circulation in the brain is antegrade mono- or bigemisphere cerebral perfusion.

According to the recommendations of the American College of Cardiology (ACC) and the American Heart Association (AHA) for the diagnosis and treatment of patients with aortic pathology, these methods of protecting the brain and internal organs are considered optimal in aortic surgery (grade Pa, level evidence) (Belov Yu.V., Charchyan E.R., Axelrod B.A., Guskov D.A., Fedulova S.V., Eremenko A.A., Skvortsov A.A., Khachatryan Z.R. ., Medvedeva L.A., Oistrakh A.S. Protection of the brain and internal organs during reconstructive interventions on the aortic arch: features of intraoperative tactics and monitoring.Circulatory pathology and cardiac surgery. 2016; 20 (4), P. 34-44) .

A known system and method of cerebral antegrade perfusion of the brain during reconstructive operations on the aortic arch, which involve individually controlled and regulated cerebral and visceral perfusion in conditions of mild hypothermia (RU 2670006, C1).

However, the known method does not provide for controlling the volumetric perfusion rate in isolation in the arteries of each hemisphere of the brain, and also does not allow to accurately assess the perfusion pressure in the brachiocephalic trunk (BCC) and the left common carotid artery (VOCA). After the circulatory arrest is removed, pressure control in the BCS and VOCs is possible only with the help of an occluder on the cerebral perfusion line. The scheme does not allow for separate control and correction of the temperature of the brain and body of the patient.

In addition, the method is complicated, as it requires ultrasound dopplerography of BCS, VOC, left axillary artery, as well as transcranial dopplerography of the midbrain artery (twice).

A known system and method for selective cerebral perfusion of the brain during circulatory arrest during reconstructive operations on the aortic arch, (Selective Antegrade Cerebral Perfusion Attenuates Brain Metabolic Deficit in Aortic Arch Surgery: A Prospective Randomized Trial DK Harrington, AS Walker, H. Kaukuntla RM , T.N. Clutton-Brock, M. Faroqui, D. Pagano, and RS Bonser. Circulation. 2004; 110: II-231-II-236), the essence of which is as follows.

In the known system, between the cardiotomic reservoir and the oxygenator through a 10 mm line with a silicone fragment installed in the first pump, an arterial line of the physiological block comes out into which an arterial filter is implanted; then a 3 / 8-3 / 8-1 / 4 tee is installed, and a 6 mm line with a silicone fragment is connected to it, which is installed in the second pump. The system is filled with perfusate and before the circulatory arrest on the operating table, a 1 / 4-1 / 4-1 / 4 tee is implanted into the 6 mm highway, to which the VOCA perfusion line and the BCS perfusion line and cannulas for bilateral cerebral perfusion are connected.

The system used allows more precise control of the volumetric perfusion rate in the arteries of the brain, but does not provide for isolated control of the perfusion rate and pressure in the arteries of each hemisphere of the brain.

In addition, there is no separate control and correction of the temperature of the brain and body of the patient at the stage of warming. When the distal anastomosis to the aorta is completed and the reconstruction of the vessels of the aortic arch begins, it is necessary to begin perfusion and gradual warming of the lower floor, while maintaining the perfusion temperature of the brain 27-28 ° C.

In addition, there is no possibility of warming the patient after circulatory arrest with simultaneous selective perfusion of the brain under hypothermia at the stage of performing anastomoses in the area of the aortic arch.

There are various methods of cardioplegia necessary for performing cardiopulmonary bypass, which can be used including operations on the arc of the ortha (L.S. Lokshin et al. Artificial and auxiliary blood circulation in cardiovascular surgery, M, 1998, 50-52).

Known systems for cardioplegia do not imply control of speed and pressure when applying a plexic solution along each line in the coronary arteries. In known methods of cardioplegia, a tee is installed on the operating table for cardioplegia, to which cannulas for selective cardioplegia are inserted through the luer port, installed in the mouth of the left and right coronary arteries and a cardioplegic solution is supplied. (Ilyukhin M.A. Evaluation of the effectiveness of delivery methods in cardioplegia, abstract of thesis, Candidate of Medical Sciences, 2009, pp. 12-13).

In the literature, we could not find information about universal systems and methods of cardiopulmonary bypass in combination with perfusion of the brain and cardioplegia.

The technical problem is to create a simple, effective method of cardiopulmonary bypass with pharmacological cold cardioplegia, selective bilateral cerebral cerebral perfusion of the brain during reconstructive operations on the aortic arch, using one universal perfusion system and allowing reliable myocardial protection, separately controlling the perfusion speed and pressure in the arteries of each heme brain during cerebral perfusion, as well as conduct prolonged hypothermia of the brain at the stage of warming the patient.

The medical-technical result achieved by the implementation of the proposed group of inventions is

- providing convenience, ease of performing cardiopulmonary bypass, cerebral perfusion during reconstructive operations on the aortic arch through the use of a universal perfusion system;

- providing reliable selective myocardial protection, quick recovery of cardiac activity, minimizing manifestations of heart failure due to separate control of perfusion speed and pressure separately in the left and right coronary arteries during cardioplegia at a given temperature of a cardioplegic solution;

- reducing neurological complications, reducing the incidence of multiple organ failure, ensuring the possibility of early activation of the patient, reducing hospital mortality during operations on the aortic arch and its branches, performed under conditions of hypothermia and circulatory arrest with pharmacological cold cardioplegia due to prolonged cerebral hypothermia at the stage of patient warming , control the perfusion rate and pressure in the arteries of each hemisphere of the brain.

The present invention allows using one universal perfusion system, including physiological and perfusion blocks, to carry out cardiopulmonary bypass, pharmacological cold cardioplegia under the control of temperature, perfusion rate and pressure in the coronary arteries and selective bilateral cerebral perfusion, as well as to carry out a separate supply of oxygenated blood through BCC and VOCA with a given speed and temperature under the control of pressure in each line.

The proposed method provides for selective bilateral perfusion of the brain, isolated control and correction of the volume velocity of perfusion and perfusion pressure in both hemispheres of the brain, as well as independent thermoregulation of blood circuits of the brain and body of the patient.

The invention consists in the following.

During cardiopulmonary bypass during reconstructive surgery on the aortic arch, a system is used that includes a physiological unit interconnected, containing a cardiotome reservoir, an oxygenator, an arterial line, and a perfusion unit containing a circulation tank, a heat exchanger with a temperature sensor, two lines for perfusion of the main vessels, each of which contains a pump and a pressure sensor.

First, cardiopulmonary bypass is performed, followed by selective antegrade cardioplegia, for which the physiological block is filled with perfusate, the cardiotomic reservoir is connected to the right atrium or superior vena cava and inferior vena cava, the arterial port is connected to the aorta, the circulation reservoir is filled with cardioplegic solution, the ports of the perfusion mains connect with the left coronary and right coronary arteries, block the connection between physiological and perfusion blocks, administer a cardioplegic solution at a temperature of 4-5 ° C separately into the left and right coronary arteries, maintaining a pressure of 80-100 mm Hg and a perfusion rate of 110-200 ml / min separately for each line for perfusion of the main vessel.

After hypothermia reaches 27-28 ° C, a circulatory arrest is performed and selective bilateral antegrade perfusion of the brain through the left common carotid artery (VOCA) and the brachiocephalic trunk (BCC) is started. The arterial line is closed, the connection between the physiological and perfusion blocks is opened, the cardioplegic solution is displaced from the perfusion block with the perfusate of the physiological block, the circulation tank is turned off, the ports of the arteries for perfusion of the main vessel with VOC and BCC of the patient are connected. Brain perfusion is carried out at a temperature of 27-28 ° C with a separate supply of oxygenated blood through VOCs and BCC, maintaining a pressure of 50-70 mmHg and a brain perfusion rate of at least 250 ml / min separately along the main lines for perfusion of the main vessel.

After completion of the circulatory arrest by opening the arterial line, cardiopulmonary bypass continues while the patient is warming up, and cerebral perfusion at a temperature of 27-28 ° C, while maintaining the shutdown of the circulation tank, maintaining the above perfusion speed and pressure separately along the main lines for perfusion of the main vessel.

The invention is illustrated by the following figures.

In FIG. 1 shows a system for cardiopulmonary bypass, providing the ability to conduct cardioplegia and selective bilateral cerebral perfusion during reconstructive surgery on the aortic arch.

In FIG. 2 shows a cardiopulmonary bypass.

In FIG. Figure 3 shows the pattern of cerebral perfusion under conditions of circulatory arrest.

In FIG. 4 is a diagram of cerebral perfusion during perfusion of the lower floor of a patient’s body under conditions of its warming.

The figures show the following notation:

1 - cardiotomic reservoir;

2 - pump 1;

3 - oxygenator with integrated arterial filter;

4 - the first tee-splitter (arterial line);

5 - the first pressure sensor (arterial line);

6 - arterial highway;

7 - circulation tank;

8 - the second tee-splitter (connecting the arterial line with the perfusion unit);

9 - heat exchanger with built-in temperature sensor;

10 - the third tee-splitter (dividing the trunk for perfusion of the great vessels);

11 - pump 2;

12 - pump 3;

13 - the second pressure sensor (line for perfusion of the first main vessel);

14 - the third pressure sensor (line for perfusion of the second main vessel);

15 - the fourth tee-splitter (trunk for perfusion of the first main vessel);

16 - fifth tee-splitter (lines for perfusion of the second main vessel);

17 - the first highway for perfusion of the main vessel;

18 - the second highway for perfusion of the main vessel;

19 - blood concentrator;

20 - the sixth splitter tee.

In the proposed method, the following cardiopulmonary bypass system can be used, which includes a cardiotome reservoir 1, a first pump 2, an oxygenator 3 connected in series. The output of the oxygenator 3 is connected through the first tee splitter 4 and the first pressure sensor 5 to the port of the arterial line 6. Input circulation tank 7 using a second tee-splitter 8 is connected in series with the input of the heat exchanger 9. The first port of the first tee-splitter 4 is connected to the first port of the second tee-splitter 8. The output of the heat exchanger 9 through the third tee 10 is connected to the ports of the individual lines 17 and 18 for perfusion of the main vessel. Line 17 comprises a second pump 11 and a second pressure sensor 13. Line 18 comprises a third pump 12 and a third pressure sensor 14. The outlet of the circulation tank 7 is connected through the fourth tee-splitter 15 and the sixth tee-splitter 20 with the first line 17 for perfusion of the main vessel, and through the fifth tee-splitter 16 and the sixth tee-splitter 20 with the second line 18 for perfusion of the main vessel. A hemoconcentrator 19 is located between the cardiotomic reservoir 1 and the oxygenator 3.

In FIG. 1 shows a system that can be used in a cardiopulmonary bypass during reconstructive surgery on the aortic arch. The said system includes a cardiotome reservoir 1, a first pump 2, an oxygenator 3, the output of which is connected to the port of the arterial highway 6, connected in series to each other; port of the first line 17 for perfusion of the main vessel, port of the second line 18 for perfusion of the main vessel, the second pump 11, as well as the circulation tank 7, heat exchanger 9, the third 12 pump, the first 5, the second 13 and the third 14 pressure sensors, six 4, 8 , 10, 15, 16, 20 tee-splitters.

The output of the oxygenator 3 is connected in series with the port of the arterial highway 6 through the first tee-splitter 4 and the first pressure sensor 5, one of the ports of the first tee-splitter 4 is connected to the first port of the second tee-splitter 8, sequentially connecting the inputs of the circulation tank 7 and the heat exchanger 9.

The output of the heat exchanger 9 through the third tee 10 is connected to the ports of the lines 17 and 18 for perfusion of the main vessel with individual lines, one of which contains a second pump 11 and a second pressure sensor 13, and the other a third pump 12 and a third pressure sensor 14, while the circulation output reservoir 7 is connected through the fourth 15, fifth 16 and sixth 20 tees with highways 17 and 18 for perfusion of the main vessel.

The method is as follows.

At the preoperative stage, in a sterile room in compliance with aseptic and antiseptic rules, one-time physiological unit systems are assembled, providing cardiopulmonary bypass and hemoconcentration, which includes a cardiotome reservoir 1, first pump 2, oxygenator 3 with an integrated arterial filter, first tee 4 (3 (8-3 / 8-1 / 4) of the arterial line, the first pressure sensor 5 connected to the arterial line 6, and also a blood concentrator 19.

The perfusion unit includes a circulation tank 7, a second tee 8 (1 / 4-1 / 4-1 / 4) with a luer port, a heat exchanger 9 with an integrated temperature sensor, a 6 mm line with a third tee 10 (1 / 4-1 / 4- 1/4) and then two silicone fragments, the second pump 11, the third pump 12, the perfusion pressure sensor 13 on the first line 17 for perfusion of the main vessel, the perfusion pressure sensor 14 on the second line 18 for perfusion of the main vessel, fourth tee 15 (1 / 4-1 / 4-1 / 4) lines 17, the fifth tee 16 (1 / 4-1 / 4-1 / 4) lines 18, the first line 17 for perfusion of the main vessel, the second line 18 for perfusion of the main vessel.

The assembly of the cardiotomic reservoir 1 and oxygenator 3 is carried out using a set of sterile lines supplied with a physiological block for cardiopulmonary bypass. The patient’s venous blood enters the cardiotomic reservoir 1 and is pumped into the oxygenator 3 using the first pump 2. After the oxygenator 3, the arterial line 6 is removed from it, into which the first tee 4 and the first arterial pressure sensor 5, represented by adapter 3 / 8-, are installed 3/8 with a luer port and a line for measuring pressure, oxygenated blood enters the aorta.

The procedure for collecting a cardiopulmonary bypass block (physiological block) is described, for example, in the Clinical Evaluation of the Terumo Capiox ® FX05 Hollow Fiber Oxygenator with Integrated Arterial Line Filter. Joseph Deptula, MS, CCP, Melinda Valleley, MS, CCP, Kimberly Glogowski, MS, CCP, John Detwiler, BS, RRT, James Hammel, MD, and Kim Duncan, MD. J Extra Corpor Technol. 2009 Jul; 41 (4): 220-225.

с люер портом и линией для измерения давления, после которого имплантируют четвертый тройник 15 магистрали 17. Далее свободный порт магистрали 17 соединяют с канюлей для селективной кардиоплегии при выполнении кардиоплегии, а затем заменяют ее канюлей для ретроградной кардиоплегии (коронарного синуса) с раздуваемой манжетой 15 Fr при выполнении перфузии головного мозга (на фигурах не показано). После выхода из третьего насоса 12 в магистраль 18 имплантируют датчик 14 давления, представляющий собой переходник

с люер портом и линией для измерения давления, после которого устанавливают тройник 16 магистрали 18. Далее свободный порт магистрали 18 соединяют с канюлей для селективной кардиоплегии при выполнении кардиоплегии, а затем заменяют ее канюлей для ретроградной кардиоплегии (коронарного синуса) с раздуваемой манжетой 15 Fr при выполнении перфузии головного мозга (на фигурах не показано).The perfusion unit is a system of highways 6 mm in diameter with a circulation tank 7 connected in series, a second tee 8 with a luer port connecting the arterial highway 6 with the circulation tank 7 and a heat exchanger 9 with an integrated temperature sensor. After the heat exchanger 9, the line using the third tee 10 is divided into two separate lines 17 and 18. A second pump 11 is installed in the line 17. The third pump 12 is installed in the line 18. After exiting the second pump 11, a second pressure sensor 13 is installed in the line 17, representing an adapter

with a luer port and a pressure measuring line, after which the fourth tee 15 of the line 17 is implanted. Next, the free port of the line 17 is connected to a cannula for selective cardioplegia when performing cardioplegia, and then replaced by a cannula for retrograde cardioplegia (coronary sinus) with a 15 Fr inflated cuff when performing perfusion of the brain (not shown in the figures). After exiting the third pump 12, a pressure sensor 14, which is an adapter, is implanted into the highway 18

with a luer port and a pressure measuring line, after which a tee 16 of line 18 is installed. Next, a free port of line 18 is connected to a cannula for selective cardioplegia when performing cardioplegia, and then replaced by a cannula for retrograde cardioplegia (coronary sinus) with a 15 Fr inflated cuff at performing brain perfusion (not shown in the figures).

The fourth and fifth tees-splitters 15 and 16 are necessary for recycling in the perfusion unit to adequately deaerate and maintain the desired perfusion temperature by connecting lines 17 and 18 to the circulation tank 7.

After the assembly of the physiological block (block for cardiopulmonary bypass) and the perfusion block, they are connected through tee-splitters 4 and 8 with a 6 mm line.

Artificial blood circulation during reconstructive surgery on the aortic arch includes the following steps:

1. cardiopulmonary bypass with pharmacological cold cardiolegia;

2. cerebral perfusion in conditions of circulatory arrest (in which there is no blood supply to the lower floor of the patient's body);

3- perfusion of the brain during perfusion of the lower floor of the patient’s body under conditions of its warming.

The proposed system can be used at all three indicated stages of cardiopulmonary bypass.

At the first stage, a block for cardiopulmonary bypass can be used, and a perfusion block is used for pharmacological cold cardiolegia.

Cardiopulmonary bypass followed by selective antegrade cardioplegia. In the operating room, the physiological block is filled with perfusate, the cardiotome reservoir is connected to the right atrium or superior vena cava and inferior vena cava, and the arterial port is connected to the aorta.

As a perfusate of the physiological block, for example, perfusate of the following composition can be used: Plasmalit 250 ml, gelofusin 500 ml, mannitol 100 ml, sodium bicarbonate 100 ml with heparin 1 ml.

In this case, the ports of the highways 17, 18 are connected to the coronary arteries (for example, the port of the highway 17 is connected to the patient’s left coronary artery, the port of the highway 18 is connected to the patient’s right coronary artery) and the connection between the first 4 and second 8 branching tees is closed, i.e. the connection between the physiological and perfusion blocks, and the circulation tank 7 is filled with a cardioplegic solution, for example, Custodiol solution. Then the connection is closed between the fourth 15th and sixth 20, and also between the fifth 16th and sixth 20 branching tees, thus stopping the circulation of the cardioplegic solution (Fig. 2).

The introduction of a cardioplegic solution is carried out at a temperature of 4-5 ° C separately in the left and right coronary arteries, maintaining a pressure of 80-100 mm Hg and a perfusion rate of 110-200 ml / min separately for each line for perfusion of the main vessel. To control the pressure, pressure sensors 13 and 14 are used; to determine and control the perfusion rate, the second 11 and third 12 pumps are used. The temperature control at which the introduction of the cardioplegic solution is carried out using a temperature sensor of the heat exchanger 9.

Then, after hypothermia of 27-28 ° C is reached, circulatory arrest is performed and selective bilateral antegrade perfusion of the brain through the left common carotid artery (VOCA) and brachiocephalic trunk (BCC) is started (Fig. 3).

The arterial line 6 is blocked in front of the arterial line pressure sensor 5.

The connection between the physiological and perfusion blocks is opened (connection between the tees-splitters 4 and 8), the cardioplegic solution is forced out of the perfusion block with the perfusion solution of the physiological block.

The junction of the blocks from the side of the perfusion block is the middle of the highway with a diameter of 6 mm, going from the circulation tank to the heat exchanger. A second tee-splitter 8 is installed in the aforementioned junction of the blocks.

Before the perfusion of the brain, the circulation tank is turned off: the line is pressed between the circulation tank 7 and the fourth 15 and the fifth 16 tee-splitters, as well as between the circulation tank 7 and the tee-splitter 8.

Connect the ports of the lines for perfusion of the main vessel with the VOC and the patient’s BCC (for example, the port of the highway 17 is connected to the patient’s VOC, and the port of the highway 18 is connected to the patient’s BCC).

Brain perfusion is carried out at a temperature of 27-28 ° C with a separate supply of oxygenated blood through VOCs and BCC, maintaining a pressure of 50-70 mmHg and a brain perfusion rate of at least 250 ml / min separately along the lines 17 and 18 for perfusion of the main vessel .

Brain perfusion under conditions of circulatory arrest is carried out using 15 Fr inflated cuff cannulas implanted in OLSA and BCC.

If necessary, hemoconcentration is performed using a hemoconcentrator 19. In the process of hemoconcentration, the liquid part of the blood is removed and the shaped elements are left, returning them to the cardiotomic reservoir, thereby controlling the hematocrit.

The key point in the distribution of blood through the VOCs and BCC is to achieve the target pressure of 50-70 mm Hg in each of these vessels. Brain perfusion is carried out with a brain perfusion rate of at least 250 ml / min separately along the VOC and BCC highways.

To control the pressure, pressure sensors 13 and 14 are used; to determine and control the perfusion rate, the second 11 and third 12 pumps are used. Monitoring the temperature at which the perfusion of the brain is carried out using a temperature sensor of the heat exchanger 9.

The third stage of cardiopulmonary bypass - perfusion of the lower floor after the opening of the arterial highway 6 with gradual warming of the patient and selective perfusion of the brain at a temperature of 27-28 ° C is carried out according to the scheme shown in FIG. 4.

At the same time, parallel perfusion of the lower floor of the patient’s body and brain perfusion are performed. Brain perfusion is carried out at a temperature of 27-28 ° C, with a separate supply of oxygenated blood through VOC and BCC with a speed of at least 250 ml / min, a pressure of 50-70 mm Hg, maintaining these perfusion parameters separately along the VOC and BCC highways.

After the end of surgical procedures on the vessels, perfusion of the brain is stopped. After restoration of effective cardiac activity and warming of the patient to the target value of 37 ° C, cardiopulmonary arrest is performed.

We provide evidence of the possibility of realizing the claimed purpose and achieving the specified medical-technical result.

Clinical example.

Patient G. 31 years old with a diagnosis of Marfan syndrome. Exfoliating type I aortic aneurysm according to De Bakey, subacute stage. Aortic valve insufficiency 3 tbsp. Relative insufficiency of mitral and tricuspid valves. Pulmonary hypertension of 3 degrees. NK 2B. FC (functional class) 3. Height 185 cm, weight 70 kg. The surface area of the body is 1.92 m ² . Surgery Protocol: Median sternotomy. The pericardium is opened, taken on the holders, in its cavity about 200 ml of a clear liquid. The heart is enlarged due to the left ventricle, systolic-diastolic trembling above the aorta, the pulmonary artery is not strained. The aorta in the ascending section is expanded to 8 cm. The aneurysmal expansion of the aorta ends at the transition of the ascending section into the aortic arch. Further, the aorta is about 2 cm in diameter. Aortic arch and vena cava cannulated with bypassing the latter. Artificial blood circulation (IR) with hypothermia of 27 ° C started, after clamping the aorta, the myocardium was protected with a cooled cardioplegic solution “Custodiol” (3 liters) at the mouth of the coronary arteries (according to the proposed method), the cardioplegic solution was administered at a temperature of 4-5 ° C separately to the left and right coronary arteries, maintaining a pressure of 80 mmHg and a perfusion rate of 110 ml / min along the line for perfusion of the main vessel connected to the left coronary artery, as well as a pressure of 100 mmHg and a perfusion rate of 200 ml / min on the second line for perfusion of the main vessel connected to the right coronary artery.

Produced drainage of the heart through the upper right pulmonary vein.

After cardioplegia, longitudinal aortotomy was performed. On examination, the aortic wall is degeneratively altered, thinned. Stratification begins in the region of the Valsalva sinuses of the non-coronary and right coronary with separation of the mouth of the right coronary artery and leaves for the aortic clamp. The aortic wall is stratified circularly with multiple ruptures of intima in the ascending region. The aortic valve is a tricuspid valve, valves with an edge seal, sag into the cavity of the left ventricle along with exfoliated commissures, the fibrous ring of the aortic valve is about 3 cm.The decision was made on prosthetics of the ascending aorta according to the David technique. The ascending aorta was excised with the commissures of the aortic valve and the mouths of the coronary arteries on the sites. The 12th U-shaped sutures on the gaskets from the side of the ventricle with a puncture outwards sewn the fibrous ring of the aortic valve. The aortic root was reimplanted into the vascular prosthesis Gelweave-32Valsalva. 5-0 continuous commissural suture of the proletine aortic commissure is fixed to the prosthesis from the side of its lumen. A plurality of right coronary and non-coronary valves is made with several interrupted sutures. Anastomoses of the mouths of the left and right coronary arteries with a prosthesis of the end-to-side type were performed with a continuous entwining 5-0 proline suture. Against the background of hypothermia of 27 ° C, cardiopulmonary arrest (circular arrest) was stopped and bilateral selective perfusion of the brain through VOCs and BCC was started (according to the proposed method). LSA perfusion rate of 250 ml / min and BCC 300 ml / min at a temperature of 27 ° C. The pressure in this case is 50 mmHg and 70 mmHg in VOC and BCC, respectively. Clamp removed from the aorta. The aortic wall at the level of the arc is also stratified by 2/3 with ruptures of intima in several places and separation of the mouths of the BCS and VOC. The aortic arch is excised. A distal anastomosis of a multi-jaw prosthesis with a descending aorta and aortic wall plasty according to the “sandwich” type was formed by a continuous twisting suture. Cannulation of the additional jaw of the prosthesis. Perfusion of the distal sections with gradual warming of the patient’s body was started, selective brain perfusion was continued at a temperature of 28 ° C, a pressure of 50 mmHg and 70 mmHg in VOCA and BCC, respectively, the perfusion rate in VOC was 250 ml / min and BCC 290 ml / min. An anastomosis of the distal branch of the prosthesis with the left subclavian artery was formed with a continuous twisting suture of proline 5-0. Blood flow through the subclavian artery. A continuous upholstering suture of proline 5-0 formed an interdental anastomosis (an ascending aortic prosthesis and a multi-jaw prosthesis). Clamp removed from the aorta, coronary blood flow restored. An anastomosis of the middle jaw of the prosthesis with the spleen carotid artery was formed with a continuous twisting suture of proline 5-0. Blood flow was started along the VOCA. An anastomosis of the proximal jaw of the prosthesis with BCS was formed by a continuous upholstering suture of 5-0 prolen. Blood circulation has been started according to BCS. After warming the patient, cardiac activity was restored using two discharges of the defibrillator, almost immediately with a sinus rhythm. At the end of the operation, satisfactory hemodynamics against moderate doses of catecholamines (Dopamine 3 μg / kg / min and Dobutamine 2 μg / kg / min). Cardiopulmonary bypass, vena cava and aorta decanulation completed. The perfusion branch is tied up with firmware. An electrode is hemmed to the myocardium of the right ventricle. Hemostasis. The pericardial cavity and the anterior mediastinum are drained, the pericardium is sutured, the sternum is tightened with 5 wire sutures. The postoperative wound is sutured in layers tightly. Antiseptic treatment. Aseptic sticker. Cardiopulmonary bypass - 271 minutes, myocardial ischemia - 216 minutes, circulatory arrest - 40 minutes, selective cerebral perfusion - 110 minutes. 4600 ml ultrafiltration was performed. During all stages of the operation, blood pressure was monitored in the left and right radial and right femoral arteries, the volumetric rate of perfusion through the vessels of the brain under pressure was monitored, and the temperature was “cooling-warming”. The dynamics of laboratory data are presented in table No. 1. While in the intensive care unit 39 hours, the early postoperative period 4 days after the operation was complicated by hydrothorax - a puncture of the right pleural cavity was performed. The patient was discharged in satisfactory condition, in the hospital 19 bed days.

The result obtained using the proposed method is to improve and simplify the quality of all stages of artificial and auxiliary blood circulation in this pathology. Using the method leads to an increase in the number of reconstructive operations on the aortic arch, satisfactory neuroprotection, a decrease in the length of stay of patients in the intensive care unit, and a reduction in hospital days.

Claims (4)

A method of cardiopulmonary bypass during reconstructive surgery on the aortic arch, which uses a system comprising a physiological unit interconnected with a cardiotome reservoir, an oxygenator, an arterial line, and a perfusion unit containing a circulation tank, a heat exchanger with a temperature sensor, two lines for perfusion of the main vessel each of which contains a pump and a pressure sensor; first, artificial blood circulation is carried out followed by selective antegrade cardioplegia, for which the physiological block is filled with perfusate, the cardiotome reservoir is connected to the right atrium or superior vena cava and inferior vena cava, the arterial line port is connected to the aorta, the circulation tank is filled with cardioplegic solution, the ports of the perfusion mains connect with the left coronary and right coronary arteries, block the connection between the physiological and perfusion blocks and administer a cardioplegic solution at a temperature of 4-5 ° C separately into the left and right coronary arteries, maintaining a pressure of 80-100 mm RT. Art. and a perfusion rate of 110-200 ml / min separately for each line for perfusion of the main vessel; then, after hypothermia of 27-28 ° C is reached, a circulatory arrest is carried out and selective bilateral antegrade perfusion of the brain through the left common carotid artery (VOC) and the brachiocephalic trunk (BCC) is started, for which they block the arterial line, open the connection between the physiological and perfusion blocks, displace cardioplegic solution from the perfusion unit with the perfusate of the physiological unit, turn off the circulation tank, connect the ports of the lines for perfusion of the main vessel with the VOC and the BCC of the patient, and the brain is perfused at a temperature of 27-28 ° C with a separate supply of oxygenated blood through the VOC and the BCC, maintaining pressure 50-70 mmHg Art. and a brain perfusion rate of at least 250 ml / min separately for each trunk for perfusion of the great vessel; after completion of the circulatory arrest by opening the arterial line, artificial blood circulation is continued while the patient is warming up and the brain perfusion at a temperature of 27-28 ° С, keeping the circulating reservoir shut off, maintaining the above perfusion speed and pressure separately for each trunk for perfusion of the main vessel.

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