RU2770982C1 - Method for eliminating additional cavity of left ventricle during its reconstruction - Google Patents

Abstract

FIELD: medicine; cardiovascular surgery.

SUBSTANCE: opening of the left ventricle (hereinafter – LV) cavity is performed by a longitudinal incision in the area of scar-altered, dyskinetic myocardium. Boundaries for suturing a patch are determined. The patch is implanted in the LV cavity by a continuous wrapping suture. In this case, the sealing of a residual cavity is performed in the following way. Opposite LV walls are sutured from the inside with a continuous inner Z-shape suture, 5 mm higher the patch, along the entire length of LV. Then, thread is taken out and tightened. A continuous wrapping outer suture capturing the thickness of scar tissues is applied to half the length of the ventricular incision in the reverse direction by the end of thread taken out. A continuous wrapping outer suture is applied to the second half of the length of the ventricular incision by the second – free – end of thread, tightened and tied in a knot with the first end.

EFFECT: method allows for elimination of the possibility of formation of an additional LV cavity with preserved altered blood flow and partial thrombosis, which leads to the reduction in the risk of the development of thromboembolic complications and improvement of the results of surgical treatment of a group of patients with postinfarction LV aneurysm.

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Description

The invention relates to medicine, namely to cardiovascular surgery, and can be used in the geometric reconstruction of the left ventricle (LV) in the surgical treatment of postinfarction LV aneurysms.

There is a known method for LV reconstruction according to Dor in patients with postinfarction LV aneurysm by applying a patch and suturing the ventriculotomy incision with two rows of sutures (Menicanti L., Di Donato M. The Dor procedure: What has changed after fifteen years of clinical practice? J. Thorac. Cardiovasc Surg 2002; 124 (5): 886-89).

In addition, a method is known for eliminating an additional LV cavity after aneurysm resection, including excision of the fibrosed endocardium, implantation of an endoventricular patch by suturing it to the visually normal myocardium of the inner surface of the LV of the heart and an endoventricular purse-string suture placed along the border between the unchanged myocardium and the scar. In this case, the endoventricular patch is oriented along the long axis of the LV, and its central part is fixed to the inner surface of the remnants of the aneurysmal sac, for which 2 U-shaped sutures are applied to it with monofilament threads, which are brought to the surface of the epicardium through the interventricular septum (IVS) to the right of the anterior descending artery 1.5 cm and tied on synthetic pads after removing the clamp from the aorta and restoring cardiac activity (RU 2620049 05/22/2017). This method can be chosen as a prototype.

The disadvantage of the prototype is the lack of complete sealing of the residual LV cavity located between the patch and the LV wall with a sutured ventriculotomy incision, which retains the possibility of residual blood flow and the formation of blood clots in it with subsequent thromboembolism.

The technical problem solved by the claimed method is the risk of developing intra- and postoperative complications in the form of thromboembolism due to the presence of a cavity with residual blood flow between the patch and the aneurysmically altered outer wall of the left ventricle (the so-called "third ventricle"), which is formed as a result of reconstruction of the left ventricle according to Dor .

The technical result of the claimed method is to exclude the possibility of forming an additional LV cavity with preserved altered blood flow and partial thrombosis, which reduces the risk of thromboembolic complications and improves the results of surgical treatment of a group of patients with post-infarction LV aneurysm.

The technical result is achieved in the following way: the LV cavity is opened with a longitudinal incision in the area of the scar-modified, dyskinetic myocardial area; determine the boundaries for sewing on the patch; patches are implanted into the LV cavity with a continuous twist suture (geometric reconstruction of the LV according to Dor); seal the residual cavity by suturing. 5 mm above the patch, the opposite walls of the left ventricle are sutured from the inside with a continuous internal Z-shaped suture along its entire length, after which the thread is brought out and tightened. scar tissue thickness; With the second free end of the thread, a continuous external external suture is applied to the second half of the length of the ventriculotomy incision, tightened and tied into a knot with the first end.

Thus, one thread is used to apply a sealing suture and an external suture for suturing the ventriculotomy incision.

As a result, the consistent use of continuous Z-shaped and upholstered sutures ensures hermetic suturing of the LV ventriculotomy incision, preventing the formation of an additional LV cavity and a thrombus in it.

The standard course of the operation using a sealing suture is as follows. A catheter is punctured into the radial artery. Combined anesthesia (endotracheal in combination with IV). The operating field is treated with antiseptics three times. Perform median sternotomy. At the same time, conduits are taken to perform direct myocardial revascularization (autoveins, mammary arteries). The pericardium is opened in a T-shape. Perform a revision of the heart - visually determine the size and localization of the LV aneurysm, the place of imposition of distal anastomoses with the coronary arteries.

Perform heparinization of the body. Then, under the conditions of a beating heart, direct myocardial revascularization is carried out - the imposition of distal and proximal anastomoses between the conduits, coronary arteries and aorta. Starts blood flow through the shunts.

Next, a dose of heparin calculated for a particular patient is administered to continue the operation under conditions of cardiopulmonary bypass.

According to the standard technique, the aorta and the right atrium are cannulated (two-level venous cannula). Parallel perfusion begins.

On a beating heart, under conditions of parallel perfusion and normothermia, a left ventriculotomy is performed in the area of the aneurysm. Revision of the LV cavity with the determination of the prevalence of the cicatricial process and the presence of blood clots. Then, thrombectomy is performed (if necessary) and geometric reconstruction of the left ventricle according to the Dor method by implanting a synthetic patch, located taking into account the need to form the left ventricle as close as possible to the physiological shape.

In order to eliminate the residual cavity between the patch and the suture of the vetriculotomy incision, a sealing suture is applied in stages:

- 5 mm above the patch, the opposite walls of the left ventricle are stitched from the inside with a continuous internal Z-shaped suture along its entire length, after which the thread is brought out and tightened;

- the same end of the thread in the opposite direction to half the length of the ventriculotomy incision is applied with a continuous twisting external suture, capturing the entire thickness of the scar tissue;

- with the second free end of the thread, a continuous external external suture is applied to the second half of the length of the ventriculotomy incision, tightened and tied into a knot with the first end.

Perform the prevention of air embolism, filling the heart cavities with blood.

Hemodynamics is stabilizing. To enable temporary external pacing, electrodes are sutured to the epicardium of the right ventricle.

Parallel perfusion is stopped. Remove the cannula from the right atrium. Perform partial neutralization of the injected heparin with protamine, revision of the ventriculotomy access and anastomoses for the presence of sources of bleeding. Remove the cannula from the aorta. Perform hemostasis of the surgical wound.

Next, intraoperative shuntography and transesophageal echocardiography (EchoCG) are performed to evaluate the effectiveness of surgical treatment.

Install drains in the pericardium, anterior mediastinum, if necessary - in the pleural cavity. Next - osteosynthesis of the sternum and layer-by-layer suturing of the chest wound.

Example.

Patient Ch., 66 years old. Diagnosis: ischemic heart disease. Postinfarction cardiosclerosis. Postinfarction LV aneurysm. Angina pectoris III functional class (FC). Condition after transluminal balloon angioplasty with stenting of the anterior interventricular branch (AIV) and a. intermedia from 2017 Hypertension II-III stage, risk of CVC 4.

Complications: circulatory failure PA. Chronic heart failure III stage. Chronic bronchitis, remission. Condition after a new coronavirus infection (March 2021).

Minimally invasive myocardial revascularization was performed: mammary coronary artery bypass grafting of the LAD of the left coronary artery, coronary autocoronary artery bypass grafting of the diagonal branch, intermediate branch, right coronary artery, branch of the sharp edge with geometric reconstruction of the left ventricle according to Dor under conditions of parallel perfusion and normothermia.

The operation was as follows: a catheter was installed in the left radial artery by puncture. Combined anesthesia (ETN + IV). The operating field was treated with clindesin+alcohol three times. A median sternotomy was performed. At the same time, an open sampling of the great saphenous veins (GSV) of both n/c was performed at the rate of 3 shunts. The left internal mammary artery (LIMA) is skeletonized, isolated and mobilized from the subclavian vein to the bifurcation. Introduced 5000 IU of heparin. The distal end of the LVHA is clipped and cut off. The artery was dilated with papaverine solution. A channel was formed for conducting LVHA into the pericardial cavity. The pericardium was opened in a T-shape. A revision of the heart was made.

The anterior apex LV aneurysm is determined with dimensions of 3 × 4 cm.

Exposure of the right coronary artery in c/3. A distal end-to-side anastomosis of the autovein with the coronary artery was formed using Premilene 8/0 thread.

The ascending aorta is parietal pressed. A proximal anastomosis of the autovein with the aorta with a Premilene 6/0 thread was formed. Started blood flow through the shunt.

Exposure of the diagonal branch in c/3. A distal end-to-side anastomosis of the autovein with the coronary artery was formed using Premilene 8/0 thread.

The ascending aorta is parietal pressed. A proximal anastomosis of the autovein with the aorta with a Premilene 6/0 thread was formed. Started blood flow through the shunt.

Exposure a. intermedia in c/3. A distal end-to-side anastomosis of the autovein with the coronary artery was formed using Premilene 8/0 thread.

LAD exhibit at c/3. Arteriotomy. A distal end-to-side anastomosis of the LVHA with the coronary artery was formed using a Premilene 8/0 thread. Started blood flow through the shunt.

The ascending aorta is parietal pressed. A proximal anastomosis of the autovein with the aorta with a Premilene 6/0 thread was formed. Started blood flow through shunts.

Introduced the estimated dose of heparin.

According to the standard technique, the aorta and the right atrium were cannulated with a two-level cannula type. Parallel perfusion started.

On a beating heart under conditions of parallel perfusion and normothermia, LV ventriculotomy was performed in the region of the apex with a transition to the anterior wall of the LV.

Revision of the LV cavity with the determination of the prevalence of the cicatricial process and the presence of blood clots. Next, a geometric reconstruction of the left ventricle was performed according to the Dor method by implanting a synthetic patch, located taking into account the need to form the left ventricle as close as possible to the physiological shape.

To eliminate the residual cavity between the patch and the suture of the vetriculotomy incision, a sealing suture was applied in stages:

- 5 mm above the patch, the opposite walls of the left ventricle are stitched from the inside with a continuous internal Z-shaped suture along its entire length, after which the thread is brought out and tightened;

- the same end of the thread in the opposite direction to half the length of the ventriculotomy incision is superimposed by a continuous external suture, covering the entire thickness of the scar tissue;

- with the second free end of the thread, a continuous twisting external suture is applied to the second half of the length of the ventriculotomy incision, tightened and tied into a knot with the first end.

Prevention of air embolism, filling the cavities of the heart.

Stabilization of hemodynamics. Epicardial electrodes were sutured to the right ventricle. Parallel perfusion was stopped, the total time of cardiopulmonary bypass was 28 minutes. The cannula was removed from the right atrium. Neutralization of heparin with protamine. The cannula was removed from the aorta. Revision of ventriculotomy access and anastomoses - no bleeding. Hemostasis.

Intraoperative shuntography was performed: shunts are fully functional, anastomoses are consistent.

Drainages were installed in the pericardium, anterior mediastinum, left and right pleural cavities. Sewing of the sternum with wire sutures No. 7-9. Layered suturing of the chest wound. Aseptic sticker.

The main clinical method that determines the effectiveness of both the entire LV geometric reconstruction operation as a whole and the application of a sealing suture is echocardiography.

Preoperative echocardiography data

Left ventricle:

- according to Simpson: end systolic volume (ESV) 90.0 ml, end diastolic volume (EDV) 164.0 ml, stroke volume (SV) 74.0 ml, ejection fraction (EF) 45.1%;

- according to Teicholz: end systolic size (CSR) 3.3 cm, end diastolic size (CDR) 5.4 cm.

Features: akinesis-dyskinesis of the LV apex (wall thickness 4 mm) with a transition to the apical segments of the anterior and posterior walls of the LV; IVS akinesis at the apical and partially middle levels. BWW index 82 ml/m ² .

Conclusion: postinfarction aneurysm of the septal-apical region of the left ventricle. Moderate dilatation of the left chambers of the heart. The right cavities of the heart are not dilated. The overall contractility of the LV myocardium is reduced.

Data of intraoperative echocardiography

Left ventricle:

- according to Simpson: ESV 56.7 ml, EDV 109.0 ml, SV 52.3 ml, EF 48.0%;

- features - cardiac index (SI) LV 1.8 l/min/m ² . Mitral valve: the movement of the valves is multidirectional, regurgitation 1 (+) tbsp.

Right atrium: features - not expanded. Pericardial effusion: no fluid in the pericardial cavity.

Conclusion: the global systolic function of the LV myocardium is moderately reduced. There is no residual LV cavity. No pericardial effusion was detected.

Postoperative Echocardiography Data

Left ventricle:

- according to Simpson: ESV 55.0 ml, EDV 106.0 ml, SV 51.0 ml, EF 48.1%;

- features - SI LV 2.3 l / min / m ² .

Mitral valve: the movement of the valves is multidirectional, regurgitation 1 (+) tbsp.

Conclusion: global LV myocardial function is moderately reduced (LV EF 48%). Minimal pericardial effusion.

The patient was discharged on the 7th day after the operation in a satisfactory condition under the supervision of a cardiologist and a surgeon on an outpatient basis.

Thus, EchoCG parameters in the perioperative period (a slight increase in LV EF, a decrease in EDV, ESV, the absence of a residual LV cavity) confirm the achievement of the technical result.

Claims (1)

A method for eliminating an additional cavity of the left ventricle (LV) during its reconstruction, including opening the LV cavity with a longitudinal incision in the area of a scar-modified, dyskinetic myocardial area, determining the boundaries for sewing a patch, implanting a patch into the LV cavity with a continuous twist suture and sealing the residual cavity by suturing , characterized in that 5 mm above the patch, the opposite walls of the left ventricle are sutured from the inside with a continuous internal Z-shaped suture along its entire length, after which the thread is brought out and tightened, with the same end of the thread in the opposite direction, a continuous twist is applied to half the length of the ventriculotomy incision the outer suture, capturing the entire thickness of the scar tissues, with the second free end of the thread, a continuous twisting outer suture is applied to the second half of the length of the ventriculotomy incision, tightened and tied into a knot with the first end.