RU2773613C1 - Method for planning surgical intervention - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and can be used to predict surgical operations on the thoracic aorta from a J-shaped mini-sternotomy. In the preoperative period, a physical examination and CT of the chest with intravenous contrast are performed. The following indicators are identified in the patient and scored in points: age, excess body weight over 30 kg/m², presence of interventions on the Hemiarch aortic arch, planning of 7.5 cm or less skin incision, the diameter of the aorta at the level of the ascending section larger than 45 mm, the diameter of the aorta at the level of the brachiocephalic trunk larger than 37 mm, the diameter of the aorta at the level of the left common carotid artery larger than 29 mm, the skin – mouth of the left coronary artery distance in the axial plane greater than 9.53 cm, the sagittal plane drawn through the centre of the sternum – mouth of the left coronary artery distance in the axial projection greater than 22.1 cm, the jugular notch – fibrous ring of the aortic valve distance in the sagittal projection greater than 14.5 cm. The scores are then summed. The prognosis of the operation is evaluated as favourable if the value of the sum is below 12 points; moderately favourable from 12 to 44 points; unfavourable from 44 to 77 points.

EFFECT: method allows for objective prediction of operations on the thoracic aorta from a J-shaped mini-sternotomy by evaluation of a set of most significant indicators.

1 cl, 5 dwg

Description

Technical field

The invention relates to the field of cardiovascular surgery and X-ray diagnostics, in particular to a method for planning cardiac surgical interventions on the root, ascending aorta and proximal aortic arch, performed from a J-shaped upper median ministernotomy based on the patient's anthropometric parameters and computed tomography (CT) measurement data . It can be used in specialized departments of cardiovascular surgery to assess the possibility of performing, as well as determine the prognosis of a minimally invasive operation.

State of the art

Currently, full longitudinal sternotomy remains the “gold standard” for interventions on the thoracic aorta; over the past decade, a minimally invasive approach in surgery has become very popular. With the advent of randomized clinical trials proving the benefits of mini-access surgery, the popularity and prevalence of a minimally invasive approach is constantly growing, and therefore the risk of compromising the technique increases in cases where operations are performed on technically complex patients by a surgeon with initial experience. The most common complications in patients with high technical complexity of the intervention are conversion to full sternotomy, a change in the intervention tactics to a less radical one, the need to use additional tools and equipment, and an increase in the likelihood of hard-to-reach life-threatening bleeding. Such complications can not only compromise the minimally invasive technique and expose the patient to unjustified risk, but also force novice surgeons to permanently refuse to perform such operations from the mini-access.

Currently, the problem of preoperative planning and forecasting the possibility and performance of the operation is extremely relevant. Currently, there are no objective methods in the literature for planning and predicting operations on the thoracic aorta from a J-shaped ministernotomy. In most cases, the authors indicate subjective data based on empirical experience [1, 2] without indicating specific numerical values and scales. The disadvantage of the available methods is the lack of clear quantitative criteria for planning and

predicting intervention, which does not allow adequate mass use of them in practice. Thus, the previously described methods of forecasting do not provide a clear guide to planning a surgical intervention: in which case and to what extent it is possible to perform each minimally invasive operation. The task of our proposed method for preoperative planning of performing reconstructive operations on the thoracic aorta from ministernotomy is to determine and use clear quantitative criteria that increase the likelihood of a favorable prognosis for each minimally invasive operation.

Disclosure of the essence of the invention

The problem is solved by the method of preoperative planning and forecasting the performance of reconstructive operations from ministernotomy, which consists in creating a special scale for predicting a favorable prognosis when performing each minimally invasive operation.

Brief description of the drawings.

On FIG. 1 shows a favorable prognosis scale in the form of a table consisting of three main criteria: “favorable prognosis” - up to 12 points, “medium-favorable prognosis” - up to 44 points, “unfavorable prognosis” - up to 77 points.

The assessment was based on significant parameters (anthropometric, anatomical and stereometric CT data and type of intervention) identified by creating a correlation matrix with surgical assessments of technical complexity. Significant predictors of a technically difficult case were obtained: the length of the skin incision, "Depth of the wound" (distance in the axial plane "skin - the mouth of the left coronary artery"), "Distance" (distance in the sagittal projection "jugular notch - fibrous ring of the aortic valve"), "Deviation" (distance in the axial projection "the sagittal plane drawn through the center of the sternum - the mouth of the left coronary artery", the diameters of the aorta at the level of the ascending section, the brachiocephalic trunk, the left common carotid artery, the intervention on the aortic arch and the patient's age. Criteria for making a prognosis calculated based on the total score of Fig. 2.

On FIG. 2 risk assessment scale for the technical complexity of surgery on the thoracic aorta from a mini-access.

Based on the ROC analysis, the limiting numerical values of the technical characteristics of each variable were identified and converted into scores of the technically complex case risk assessment scale, which is based on the logarithmic regression equation. With the proposed method for planning and predicting the technical complexity of operations on the root, ascending section and proximal part of the aortic arch from ministernotomy in the preoperative period, a physical examination of patients, a CT scan of the chest with intravenous contrast is performed and the volume of intervention and the size of the skin incision are determined. The definition of technical complexity is determined by the measurement data of 10 parameters (Fig. 2). After that, the scores are summed up and, based on the logarithmic regression equation, a numerical estimate (%) of the probability of a technically complex operation from 0 to 100% is estimated (Fig. 3).

On FIG. 3. Logarithmic regression of the dependence of the convenience group on the patient's total score.

The proposed method for preoperative prediction of the technical convenience of performing operations on the ascending aorta and its arch from ministernotomy allows, based on the approbation given below, with a total accuracy of 75.5% (73.1% sensitivity, 78.3% specificity) to assess the probability of a favorable prognosis when performing an intervention. The obtained quantitative data of the sum of the scale points are decisive in choosing the tactics of surgical treatment of patients with pathology of the thoracic aorta.

Implementation of the invention

Below is a clinical approbation of the use of the proposed risk assessment scale, which clearly demonstrates the advantages of the proposed method for planning operations on the root, ascending aorta and proximal aortic arch from ministernotomy.

Based on the clinical results of the proposed method, a binary logarithmic analysis was carried out between the independent variable obtained after the operation and the preoperative predictor "sum of scores" on clinical material in a sample size of 49 patients. The overall accuracy of the test was 75.5%, sensitivity 73.1%, specificity 78.3%, OR 14.29 (95% CI: 3.053-66.89) (Fig. 4). An equation for the probability of the risk of an inconvenient event was also obtained: p=1/(1+e-z), according to which it was possible to calculate the probability in percent (%) - Fig. 5.

On FIG. 4 approbation on own clinical experience of the developed method.

On FIG. 5 Online calculator for determining the favorable prognosis when performing minimally invasive interventions on the thoracic aorta.

Sources of information

1. Shrestha M, Krueger H, Umminger J, Koigeldiyev N, Beckmann E, Haveric h A, et al. Minimally invasive valve sparing aortic root replacement (David procedure) is safe. Ann Cardiothorac Surg 2015; 4:148-53.

2 Harky A, et al. Minimally Invasive Versus Conventional Aortic Root Replacement: A Systematic Review and Meta-Analysis. Heart, Lung and Circulation (2018), https://doi.org/10.1016/j.hlc.2018.10.023

Claims (1)

A method for predicting operations on the thoracic aorta from a J-shaped ministernotomy, including a physical examination in the preoperative period, CT of the chest with intravenous contrast, while identifying the patient's indicators and scoring them: age over 61 years is estimated as 11 points, the presence of excess body weight over 30 kg/m ² is assessed as 5 points, the presence of interventions on the aortic arch Hemiarch is assessed as 7 points, the planning of a skin incision of 7.5 cm or less is assessed as 6 points, the aortic diameter at the level of the ascending section of more than 45 mm is assessed as 1 a point, the diameter of the aorta at the level of the brachiocephalic trunk more than 37 mm is evaluated as 27 points, the diameter of the aorta at the level of the left common carotid artery is more than 29 mm is evaluated as 4 points, the distance in the axial plane of the skin - the orifice of the left coronary artery of more than 9.53 cm is evaluated as 6 points, distance in axial projection the sagittal plane drawn through the center of the sternum - the mouth of the left coronary artery and more than 22.1 cm is evaluated as 41 points, the distance in the sagittal projection of the jugular notch - fibrous ring of the aortic valve more than 14.5 cm is evaluated as 1 point, then the scores are summed up and the prognosis of the operation is assessed as favorable with a sum of points up to 12; moderately favorable prognosis - from 12 to 44 points; the prognosis is unfavorable - from 44 to 77 points.

Images