RU2738458C1 - Palliative infundibulectomy without closing the defect of the interventricular septum by accessing from the right atrium with severe cyanotic congenital heart defects combined with hypoplasia of the pulmonary artery system in elderly patients - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to cardiosurgery. In cyanotic congenital heart diseases (CHD) combined with hypoplasia of the pulmonary artery system in older patients, palliative infundibulectomy is performed without closing the defect of the interventricular septum by accessing the right atrium. That is ensured by opening the right atrium along the atrioventricular sulcus. Septal and parietal legs of the hypertrophied tapered partition are resected to the passage size.

EFFECT: method enables preserving cardiac myocardial integrity by avoiding the need for a right ventricular incision, avoiding hypervolemia of the pulmonary circulation.

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Description

The invention relates to medicine, namely to cardiac surgery of congenital heart defects (CHD), and can be used in the reconstruction of the right ventricular outflow tract without closure of the ventricular septal defect (VSD) as the first palliative stage in the correction of severe cyanotic congenital defects of conotruncus, combined with pronounced stenosis and hypoplasia of the pulmonary artery system.

The most common defects of this group are tetrad of Fallot and double passage of the aorta and pulmonary artery from the right ventricle in combination with hypoplasia of the pulmonary artery system and left ventricle. A characteristic feature is a large infundibular stenosis due to severe hypertrophy of the septal and parietal legs.

All patients with these defects are subject to early surgical treatment. The optimal method of treatment should be considered primary radical correction at the age of 3 to 6 months. The operation consists in closing the VSD and complete excision of the infundibular stenosis through the right ventriculotomy, followed by plasty of the right ventricular outflow tract and, if necessary, the pulmonary artery trunk with a patch. There is a method of radical correction of the defect by access from the right atrium without enlarging the outflow tract of the right ventricle, but this operation has not found widespread use due to the high frequency of residual pulmonary artery stenosis.

At the same time, in some patients, the anatomy of the defect is aggravated by pronounced hypoplasia of the pulmonary artery system, radical correction is contraindicated for them; as the first stage, palliative reconstruction of the right ventricular outflow tract (RVO) without closure of the VSD or the imposition of a systemic-pulmonary anastomosis can be performed.

Despite the advances in modern cardiac surgery, there are still severe age-related patients with advanced forms of cyanotic heart disease that require late surgical treatment. Severe hypoxemia, polyglobulia, hypoplasia of the pulmonary artery system and left ventricle require a special approach. Systemic-pulmonary anastomoses are ineffective, do not give the desired effect due to low blood flow through the pulmonary arteries. The operation of choice is RPOZH with the formation of a dosed antegrade pulsating blood flow from the right ventricle into the pulmonary artery by access through the outlet section of the right ventricle, followed by plasty with a patch.

However, the use of the "classical" method of prostate cancer is often accompanied by the development of a number of complications. In the early postoperative period, acute heart failure may develop due to dysfunction of the right ventricle as a result of surgical trauma - ventriculotomy, as well as bleeding associated with the eruption of sutures in the patch application area due to myocardial laxity in aged patients. The long-term period is often complicated by the formation of a false aneurysm of the outflow tract of the right ventricle. True aneurysm (bulging of the wall of the right ventricle of varying degrees) is not uncommon and is observed in 30-40% of patients. A pseudo-aneurysm is formed due to damage to the right ventricle and is a rare but rather formidable complication. A distinctive feature is progressive enlargement, which leads to compression of adjacent structures (trachea, bronchi, trunk and branches of the pulmonary artery, etc.). Pseudo-aneurysm is sometimes a complication of acute right ventricular myocardial infarction and, more often, of various surgical procedures, including right ventriculotomy and right ventricular repair with patch or conduit implantation.

Another problematic factor in right ventriculotomy is abnormal transection of the coronary arteries of the right ventricular outflow tract. The "problem" coronary arteries include the anterior interventricular artery and the only coronary artery, which is the third most common abnormality in Fallot's tetrad. Often, in aged patients, coronary arteries crossing the right ventricular outflow tract cannot be visualized due to massive epicardial fat, which is also associated with a high risk of damage during ventriculotomy.

One of the analogues of the developed method is the method described in the article by Airan B., Choudhary S.K., Kumar H.V.J., et al. Total transatrial correction of tetralogy of Fallot: no outflow patch technique. Ann. Thorac. Surg. 2006; 82: 1316-21.

The essence of the known method consists in the radical correction of the defect - complete excision of infundibular stenosis by access from the right atrium with simultaneous closure of the VSD. In our cases, this method is impossible due to the small size of the branches of the pulmonary artery, which will lead to increased pressure in the right ventricle after surgery. In addition, this operation has not become widespread due to the development of residual pulmonary artery stenosis in the long term.

In addition, there is a known method described in the work of A.A. Atmashkin. and others (Atmashkin A.A., Kim A.I., Didyk V.P., Rogova T.V., Metlin S.N., Erokhina O.V., Grigoryants T.R. Creation of adequate antegrade blood flow in patients with complex CHD using trans-atrial infundibulectomy Bulletin of the AN Bakulev Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Sciences "Cardiovascular Diseases". 2016; 17 (S3): 14.).

The essence of the known method is to perform an operation on children under the age of 1 year. The fundamental difference of this technique is that only one parietal pedicle of infundibular stenosis is excised from the right atrium without closure of the VSD. Given the small weight of the patients, this operation has a good short-term effect for several months, however, due to the rapid growth of the body of young children, they quickly outgrow the size of the hole created in the infundibular region. Therefore, these patients need to be taken quickly, within 5-6 months, for a second radical correction of the defect; in case of late treatment, a second palliative operation may be required.

The technical problem to be solved was to minimize the risk of developing intraoperative complications due to the violation of the integrity of the myocardium.

The achieved technical results of the developed method is the absence of the need for incision of the right ventricle, due to which the integrity of the heart myocardium is preserved. This leads to a number of benefits:

- the damaging factor on the myocardium and the development of acute heart failure in the immediate postoperative period are excluded;

- when performing the method, there is no bleeding from the incision on the right ventricle due to high pressure, respectively, there is no need for additional sutures on the spacers for hemostasis;

- prevention of the formation of a false aneurysm of the excretory part of the right ventricle in the patch area due to the lack of an incision;

- the need for accurate visualization of the coronary arteries crossing the excretory section of the right ventricle is eliminated, including due to the excessive presence of epicardial fat due to the fact that the compactness of the myocardium is not disturbed;

- dosed excision of the septal and parietal legs of the hypertrophied conical septum in adult patients allows to avoid hypervolemia of the pulmonary circulation in severe patients, to achieve the desired results of increasing blood oxygen saturation, improve the general condition of patients and prepare them for the next stage of radical correction in 1-2 years, when the branches of the pulmonary artery will expand to normal.

The advantage of keeping the right ventricle as intact as possible, especially in cases where transection of the pulmonary valve annulus is not required, leads to the achievement of good results in the immediate postoperative period in extremely severe patients. This is how the idea of eliminating infundibular stenosis by access through the right atrium and the opening of the tricuspid valve appeared, which makes it possible to reduce the traumatism of the operation and to perform reconstruction even if the coronary arteries cross the right ventricular outlet.

The technical result is achieved due to the following set of essential features that implement palliative infundibulectomy without closure of the VSD by access from the right atrium with cyanotic CHD in combination with hypoplasia of the pulmonary artery system in older patients:

- the right atrium is opened along the atrioventricular groove;

- perform resection of the septal and parietal legs of the hypertrophied conical septum to the size of the passage.

FIG. 1 shows a typical picture of Fallot's tetrad - large infundibular stenosis due to severe hypertrophy of the septal and parietal legs in combination with VSD.

FIG. 2 shows a scheme of radical correction of the defect - complete excision of infundibular stenosis by removing the septal and parietal legs to create an adequate outlet into the pulmonary artery with simultaneous closure of the VSD.

FIG. 3 shows the scheme of the operation in children under 1 year old - only one parietal pedicle of infundibular stenosis is excised without closure of the VSD.

FIG. 4 shows our technique - dosed partial resection of the septal and parietal legs of the hypertrophied conical septum by access from the right atrium, after which a 12 mm bougie began to pass into the outflow section of the right ventricle.

The figures show the following designations:

1 - pulmonary valve;

2 - aortic valve;

3 - VSD;

4 - tricuspid valve;

5 - septal pedicle of infundibular stenosis;

6 - parietal pedicle of infundibular stenosis.

In total, using this technique, we operated on two extremely severe adult patients with double vascular discharge from the right ventricle and tetralogy of Fallot at the age of 27 and 40 years.

Example 1. Patient O., 27 years old, diagnosis of double vascular discharge from the right ventricle, VSD, combined stenosis of the pulmonary artery, hypoplasia of the pulmonary artery system (pulmonary arterial index was 152 mm ² / m ² at a rate of 300 mm ² / m ² ), hypoplasia of the left ventricle, an accessory left-sided superior vena cava flowing into the coronary sinus, aorto-pulmonary collateral arteries from the descending aorta to both lungs. Severe polyglobulia (hemoglobin 230 g / l at a rate of 120-140 g / l, hematocrit 65% at a rate of 35-40 g / l) and cyanosis of the skin (blood oxygen saturation in capillaries 63% at a rate of 96-100%) were noted. Given the extremely grave condition of the patient, it was decided to carry out palliative surgery - reconstruction of the right ventricular outflow tract.

After opening the pericardium, it was noted that the excretory section of the right ventricle was crossed by a large branch of the coronary artery located in a thick layer of epicardial fat. The site for performing classical ventriculotomy was insufficient, and therefore it was decided to perform infundibulectomy by access from the right atrium.

According to the accepted technique, a heart-lung machine is connected through the ascending aorta, the appendage of the right atrium (superior vena cava) and parietally through the right atrium (inferior vena cava). Artificial blood circulation was started with cooling the patient's body to 28 ° C. The left heart is drained through the upper lobe pulmonary vein. Compressed aorta, pharmaco-cold cardioplegia (Custodiol) 1 time into the aortic root. The right atrium was widely opened along the atrioventricular groove. The accessory left superior vena cava is cannulated through the coronary sinus. A subaortic VSD with a diameter of 25 mm was found. Infundibular stenosis with a 4-5 mm opening was located near the defect.

Performed dosed partial resection of the septal and parietal legs of the hypertrophied conical septum (Fig. 4), after which a 12 mm bougie began to pass into the outflow section of the right ventricle. Warming the patient. The right atrium incision is sutured with a two-row continuous prolene suture 5.0-17. The aorta was released, which was clamped for 25 minutes. The restoration of cardiac activity is independent, sinus rhythm. Completed artificial circulation, which lasted 90 minutes. The measured pressure in the right pulmonary artery was 30 mm Hg. Art at a systemic pressure of 110 mm Hg. Art.

In the postoperative period, moderate heart failure was noted, hemodynamics were maintained at 0.1 μg / kg / min of epinephrine and 5 μg / kg / min. dobutamine. Oxygen saturation in arterial blood increased to 95-96%. With satisfactory blood gases, the patient was extubated after 8 hours.

After a course of conservative therapy, the general condition of the patient improved significantly, and on the 10th day after the operation she was discharged. Oxygen saturation in the capillaries in air at discharge was 90%.

Example 2. Patient C, 40 years old, with a severe form of Fallot's tetrad, dyspnea-cyanotic attacks, often squatted to improve general condition. A history of palliative surgery in 1983 - systemic-pulmonary anastomosis on the right. The condition improved temporarily, but after a few years the anastomosis became thrombosed and the condition worsened. There was also a pronounced polyglobulia (hemoglobin 210 g / l at a rate of 120-140 g / l, hematocrit 62% at a rate of 35-40 g / l) and acrocyanosis of the skin (blood oxygen saturation in capillaries 70% at a rate of 96-100%) ... Angiocardiography showed Fallot's tetrad with hypoplasia of the pulmonary artery system (pulmonary arterial index was 171 mm ² / m ² at a rate of 300 mm ² / m ² ) and hypoplasia of the left ventricle. Considering the initially extremely serious condition in an adult patient, as well as a successful example of a previous operation, it was decided to perform a palliative reconstruction of the right ventricular outflow tract by access from the right atrium.

According to the accepted methodology for connecting a heart-lung machine, the ascending aorta, the appendage of the right atrium (superior vena cava) and parietally through the right atrium (inferior vena cava) were cannulated. After the start of artificial circulation with cooling the patient's body to 28 ° C, the left heart was drained through the upper lobe pulmonary vein. Compressed aorta, pharmaco-cold cardioplegia (Custodiol) 1 time into the aortic root. The right atrium was widely opened along the atrioventricular groove. The anatomy is typical for the tetrad of Fallot-subortal VSD with a diameter of 21 mm; to the right, a pronounced infundibular stenosis with a 3-4 mm opening was visualized. By the same technique, a partial resection of the septal and parietal legs of the hypertrophied conical septum was dosed (Fig. 4), so that a 12 mm bougie would pass into the outlet section of the right ventricle. Warming the patient. The right atrium incision is sutured with a two-row continuous prolene suture 5.0-17. The aorta was released, which was clamped for 43 minutes.

The restoration of cardiac activity is independent, sinus rhythm. Completed artificial circulation, which lasted 124 minutes. The pressure in the right pulmonary artery was 30 mm Hg. Art. at a systemic pressure of 100 mm Hg. Art. The postoperative period was uneventful, with moderate heart failure, hemodynamics was maintained with small doses of cardiotonics - 0.05 μg / kg / min of epinephrine and 3 μg / kg / min of dobutamine. Oxygen saturation in arterial blood increased to 90-92%. With satisfactory blood gases, the patient was extubated after 10 hours.

After a course of conservative therapy, the patient's general condition improved significantly, and on the 12th day after the operation, she was discharged. Oxygen saturation in capillaries in air at discharge was 87%.

Thus, reconstruction of the right ventricular outflow tract by right atrial access has shown a number of advantages. This technique is more gentle, since the damaging factor of the right ventricular myocardium is excluded, the time of clamping the aorta and cardiopulmonary bypass decreases, respectively, after the operation, moderate heart failure develops, which makes it possible to activate patients more quickly on the first day (extubated 8 and 10 hours after removal to intensive care) , the duration of hospital stay in the postoperative period is reduced. The exclusion of the right ventricular incision greatly reduces the trauma of the operation, the duration of cardiopulmonary bypass, there is no need to impose additional sutures, which are mandatory when applying a patch to the flabby right ventricular myocardium, which has functioned for a long time under conditions of systemic arterial pressure, accordingly, the development of such formidable complications as false aneurysms is excluded ...

Claims (1)

The method of palliative infundibulectomy without closure of the ventricular septal defect by access from the right atrium with cyanotic congenital heart defects in combination with hypoplasia of the pulmonary artery system in older patients, including opening the right atrium along the atrioventricular sulcus, resection of the septal hypertrophy and parietal size of the septal cone of parietal size.

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