RU2801967C1 - Method of rehabilitation of children in the long period after surgical treatment of abnormal discharge of the left coronary artery from the pulmonary artery - Google Patents

Abstract

FIELD: medicine; cardiology; pediatrics; physiotherapy; exercise therapy.

SUBSTANCE: invention can be used at the stage of rehabilitation of children who have undergone surgical treatment of abnormal discharge of the left coronary artery from the pulmonary artery. A complex of rehabilitation methods is implemented in a given sequence: laser therapy with a power of 4–5 W, exposure for 1–3 minutes at 3 points, exercise therapy, halotherapy, if necessary, psycho-corrective classes with a psychologist. In addition, each subsequent method of rehabilitation is carried out 30 minutes after the previous one. The rehabilitation course consists of 12 sessions with a break of 2 days after each 5 sessions, and the full rehabilitation course is repeated after 6 months.

EFFECT: method provides improvement of the functional state of the cardiovascular system and prevention of bronchopulmonary complications due to improvement of ventilatory parameters in case of their decrease.

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Description

The invention relates to the field of medicine, namely to cardiology, pediatrics, physiotherapy, exercise therapy, and can be used at the stage of rehabilitation of children who have undergone surgical treatment of an abnormal origin of the left coronary artery (LCA) from the pulmonary artery (LA).

Abnormal separation of the LCA from the LA is a rare but dangerous congenital coronary disease associated with early childhood mortality and a high risk of sudden cardiac death in adults. The first description of this defect belongs to J. Brooks, who in 1886 at autopsy in 2 adults who had not previously suffered from heart pathology, revealed an abnormal discharge of the LCA. A.I. Abrikosov in 1911 described in detail the anatomical features of the coronary arteries in this pathology. Later, in 1933, American cardiologists E. Bland, P. White and J. Garland described the specific clinical picture and electrocardiographic signs of this anomaly in an infant, subsequently the syndrome was named after them (BWG-syndrome - Bland-White syndrome - Garland, SBUG). In 1973, F. Gerbode and D. Radeliff first demonstrated this defect during angiography.

Among all congenital heart diseases (CHDs), according to the literature, abnormal LCA separation from LA is 0.25-0.5% and occurs in 1 case per 300,000 live births, mortality in case of late diagnosis is 90% of cases.

After birth, the prognosis and manifestation of the disease are determined by the degree of development of intercoronary anastomoses and the severity of left ventricular (LV) myocardial ischemia, that is, the clinical type of defect. Depending on the development of collateral circulation, two types of anomalies are distinguished: children's (infantile) and adult. With the infantile type, which is more often observed in children of the first year of life, the collaterals are poorly developed. In the adult type, the network of collaterals is well developed. In this regard, the clinical picture associated with myocardial hypoperfusion will be different. More than 2/3 of the filling of the coronary bed occurs in LV diastole, the rest of the blood volume overcomes resistance during LV systole. The resistance to flow is less in the subepicardial layers and, increasing towards the subendocardial layer, it contributes to a decrease in perfusion during early systole to almost zero, which increases the likelihood of ischemia, making the subendocardial layer the most vulnerable. At the same time, fibrotic changes, destruction of myofibrils, glycogen accumulation, and an increase in the number of mitochondria are determined microscopically in the myocardium, which is typical for hibernated myocardium.

The causes of sudden death in these patients are: myocardial infarction, ischemic cardiomyopathy, critical heart failure, mitral insufficiency, hemodynamically significant arrhythmias. The non-alternative method of treatment of congenital LCA anomaly is surgical treatment.

For the first time in 1960, an operation to ligate an abnormally outgoing artery was performed by D. Sabiston. In our country, this operation was first performed by V.I. Burakovsky in 1974. Subsequently, techniques were developed, the purpose of which was to restore an adequate two-coronary blood supply to the myocardium, that is, translocation of the LCA mouth into the aorta. The first operation to transfer the orifice of an abnormal artery to the aorta was performed by R. Grace et al. in 1977. One of the methods, in addition to translocation, is coronary artery bypass grafting (CABG) using an autovein, an internal mammary artery, or a prosthesis. This technique was used by D. Cooley in 1966, and in our country by V.I. Burakovsky in 1974. Another approach is the formation of an intrapulmonary tunnel proposed by J. Takeuchi et al. in 1974. When choosing the tactics of surgical treatment, it is necessary to take into account the anatomical features of the LCA. The volume of surgical intervention depends on the depth of ischemic damage to the LV myocardium, the reversibility of its violations.

According to the literature, early diagnosis of the disease and immediate surgical treatment lead to good results in normalizing the size of the left ventricle and its functional characteristics, and reducing mitral regurgitation. At the same time, many researchers note the occurrence of arrhythmias in the postoperative period, exacerbation of heart failure, the persistence of severe mitral regurgitation, the appearance of coronary artery stenosis, requiring repeated surgical treatment or even heart transplantation.

The persistence of myocardial ischemia and fibrosis, mitral valve insufficiency, the appearance of residual stenosis and occlusion of the coronary arteries worsen the clinical course of the disease in patients after corrective surgery. Therefore, lifelong monitoring of this category of patients is extremely important for timely diagnosis, treatment of complications and timely rehabilitation of patients aimed at preventing these complications.

It is known that patients with anomalies of the coronary arteries have reduced physical performance, a decrease in peak oxygen consumption was noted during cardiorespiratory exercise testing in such children compared with healthy ones (Giardini A. et al. Natural history of exercise capacity after the Fontan operation: a longitudinal study Ann. Thorac. Surg. 2008; 85: 818-21; Amedro P. et al. Cardiopulmonary fitness in children with congenital heart diseases versus healthy children. Heart. 2017; 0: 1-11), which certainly affects their quality. life and requires correction during rehabilitation. For the physical and mental well-being of children and adolescents after CHD correction, regular physical activity is necessary. However, patients with rare CHD are often unable to exercise due to overprotective parents or prescriptions from their doctors who fear complications.

These aspects were taken into account when developing a method for the rehabilitation of children in the long-term period after surgical correction of the abnormal separation of the LCA from the LA.

Currently known methods of rehabilitation of children after surgical treatment of other congenital heart diseases. For example, the method of postoperative rehabilitation of children with CHD is known (Khairetdinova T.B., Baidalin A.V., Khabibullina A.R., Farshatova D.G., Ramentyeva M.I. Prospects for the rehabilitation of children with congenital heart defects in the republic Bashkortostan, Orenburg Medical Bulletin, 2017, T. V, 2 (18): 29-31), which includes a complex effect: climatotherapy, diet therapy, drug treatment, apparatus physiotherapy, massage, psychotherapy. This technique was used in the rehabilitation of children operated on for septal heart defects, and was mainly aimed at increasing the functional reserves of the body, increasing efficiency, increasing immunity, and restoring the physical and emotional state after surgery.

To date, a comprehensive rehabilitation program for children with complex congenital heart disease who underwent surgery to correct abnormal LCA protrusion with residual cardiofibrosis has not been developed.

The causes of persistent circulatory failure in this category of patients is the persistence of dystrophic, cardiosclerotic changes in the myocardium. The technique proposed by us for the rehabilitation of children after surgery to restore the two-coronary system of myocardial blood supply is mainly aimed at increasing the myocardial reserve.

Previously, we developed a comprehensive rehabilitation program for patients with CHD in the late postoperative period (patent RU 2676656 C1, 2019). The technique consisted in the use of rehabilitation methods: physiotherapy exercises (exercise therapy), transcranial electrical stimulation (TES), whirlpool baths, enteral oxygen therapy, psycho-corrective sessions in the sensory room with changes in emotional status in the form of increased anxiety and reduced self-esteem. Exercise therapy, TES, whirlpool baths, enteral oxygen therapy are carried out in this sequence daily for 10 days in the morning. On the days of the procedures, after they have been completed, psycho-corrective classes are carried out in the sensory room in the form of a consistent exposure to relaxation methods, controlled imagination and art therapy. Only 5 psycho-correctional sessions are carried out, every other day. This method allows to achieve an increase in the effectiveness of rehabilitation of children with an unfavorable emotional status in the long-term period after CHD correction, provided that the duration of rehabilitation measures is reduced, which is expressed in a stable improvement in the functional state of the cardiovascular system and the mentioned emotional indicators. We use this technique in the long-term period after radical surgery in children with mainly emotional status problems in the form of increased anxiety and low self-esteem.

In the case of rehabilitation of children after correction of abnormal LCA deviation from LA, the use of a combination of methods that have a positive effect not only on physical performance and emotional sphere, but mainly on improving the condition of the LV myocardium and reducing signs of heart failure is of decisive importance.

The technical problem is to increase the effectiveness of the rehabilitation of children in the long term after the surgical correction of this defect.

The technical result is to improve the functional state of the cardiovascular system, prevent bronchopulmonary complications by improving ventilatory performance when they decrease.

The achievement of the specified technical result is due to the use of a comprehensive rehabilitation program with the following set of essential features:

- within one session, the following set of rehabilitation methods is performed, implemented in a given sequence, namely: laser therapy, exercise therapy or aqua gymnastics, halotherapy;

- the rehabilitation course includes 12 sessions, with a break of 2 days after each 5 procedures;

- the complex is carried out mainly in the first half of the day, in order to achieve the maximum adaptive effect;

- each subsequent method of rehabilitation from the complex is carried out 30 minutes after the completion of the previous one;

- The course of rehabilitation is repeated every 6 months.

The developed rehabilitation program (a course of non-drug rehabilitation) began with the procedure of spot irradiation of the myocardium with low-intensity infrared laser radiation (LILI). The physiological effect of this factor is based on the absorption of radiation by photoacceptor molecules, which leads to a change in their physicochemical state (Khan M.A., Razumov A.N., Korchazhkina N.B., Pogonchenkova I.V. Physical and rehabilitation medicine in Pediatrics, Moscow: GEOTAR-Media, 2018: 118-9). In particular, physical and chemical changes in membranes occur, which creates the preconditions for a change in their ionic permeability, as well as an increase in the activity of the adenylate cyclase and ATPase systems, which, in turn, enhances bioenergetic and biosynthetic processes. Such changes contribute to the development of recovery reactions in tissues and increase their functionality. In addition, the effect of laser radiation on tissues stimulates the activity of the enzyme link of the body's antioxidant system (catalase, superoxide dismutase). Thus, trophostimulating, regenerating and antioxidant effects of LILI are achieved. Since this physical factor is inherently a non-specific biostimulant, the purpose of its appointment is to activate the mechanisms of cellular respiration, prepare the myocardium for the upcoming aerobic physical activity, and also improve myocardial blood supply.

Assigned to 12 procedures per course. Emitters were installed in the second intercostal space to the right and left of the sternum, as well as in the projection of the apex of the heart. We used a frequency of 80 Hz, a power of 4-5 W, an exposure of 1-3 minutes per point, a total of 3 points. After the LILI procedure, the patient was allowed to rest for 30 minutes.

Then the patient was sent to exercise therapy, which was carried out in a specially equipped room or, in the case of aqua gymnastics, in a specially equipped pool.

The appointment of exercise therapy gave, first of all, an increase in exercise tolerance, an increase in the efficiency of the act of breathing, an increase in physical performance and an improvement in the contractile function of the myocardium. Under the influence of regular physical exercises in the myocardium, the number of mitochondria increases, the capacity of the coronary bed increases, the activity of enzymes increases (Epifanov V.A. et al. Therapeutic physical culture: Textbook. M .: GEOTAR-Media; 2009: 143-5), which positively affects the efficiency of cardiovascular activity. In addition, each set of exercises included a block of breathing exercises, which contributed to the improvement of the ventilation function of the lungs. We used respiratory, active, general developmental, dynamic exercises for large muscle groups. The pace of the exercises is low (20-39 movements per minute) or medium (40-60 movements per minute), which depended on the general condition of the child, his level of fitness and tolerance to physical activity.

When conducting classes in the exercise therapy room, the following set of exercises was used:

Starting position (ip) standing. Squeezing / unclenching the hands for 30 s. Inhale/exhale. 3 repetitions.

I.p. standing. Rotation in the wrist joints 30 s. Inhale/exhale. 3 repetitions.

I.p. standing. Spread your arms to the sides - inhale. Hug yourself - exhale. 5 repetitions.

I.p. standing. Put the hands on the shoulders, rotate the arms in the shoulder joint for 30 s, 4-5 repetitions.

I.p. standing. Elastic tape (load up to 5 kg) is fixed to the wall. Stand facing the wall, the ends of the tape in your hands. Alternately pull the tape towards you with your hands. The pace is individual. Run 1-3 min. Then 1 minute walk at a low pace. Repeat 1 time.

I.p. standing. Elastic tape (load up to 5 kg) is fixed to the wall. Stand with your back to the wall, the ends of the tape in your hands. Alternately pull the tape with your hands. The pace is individual. Run 1-3 min. Then 1 minute walk at a low pace. Repeat 1 time.

I.p. standing. Hands on the belt. Rise on toes, linger for 3-5 seconds, return to the starting position for 1-2 minutes. The pace is individual. Then 1 minute walk at a low pace. Repeat 1 time.

I.p. standing. Perform 5-10 squats. The pace is individual. Repeat 2-3 times. Then 1 minute walk at a low pace.

I.p. standing. Climbing a step 20 cm high (individual pace, but no more than 20-30 climbs per minute). Perform no longer than 40-60 s. 1-2 repetitions. Then 1 minute walk at a low pace.

I.p. in free movement. Walking "sitting down", with a wide step. The pace is individual. 1-1.5 min. Repeat 1 time. Then 1 minute walk at a low pace.

I.p. in free movement. Walking with arms out in front of you. 1.5-2 min. The pace is individual. Repeat 1-2 times. Then 1 minute walk at a low pace.

I.p. in free movement. Walking on toes 1.5-2 minutes. The pace is individual. Repeat 1 time. Then 1 minute walk at a low pace.

I.p. standing. Spread your arms to the sides - inhale. Hug yourself - exhale. 5 repetitions.

In the case of training in water, the water temperature for preschool children is 32-33°C, for schoolchildren - 30°C. Air humidity up to 55%. The maximum depth of the pool for preschoolers is 600 mm, for schoolchildren - 1300 mm. The length of the pool for preschoolers is 7 m, the width is 3.5 m. For schoolchildren, the length is 9.2 m, the width is 3.5 m.

We used the following set of exercises in water:

I.p. standing at the edge. The water level is chest deep. Inhale through the nose - spread the arms to the sides, exhale through the mouth - hug yourself. It is performed 4-6 times, the pace is individual.

I.p. standing at the edge. Hands on the board. The water level is chest deep. Deep breath in through the nose, long exhalation into the water. 1.5-3 min. The pace is individual.

I.p. standing at the edge. Hands on the board. The water level is chest deep. Deep breath in through the nose, quick, powerful exhalation into the water. 2-3 min. The pace is individual.

I.p. standing at the edge. Hands on the board. The water level is chest deep. Take a deep breath through the nose, perform a squat in the water, submerging with your head. Hands remain on the side. Exhale in the water at the bottom of the movement. Straighten up. 3-4 min. The pace is individual.

I.p. lying on the water on his stomach. Hands on the board. Take a deep breath, perform crawl-style leg movements with an exhalation into the water. The pace is individual. 4-5 min.

I.p. standing. The water level is chest deep. Take a deep breath, perform a squat in the water with an exhalation at the bottom point, push off from the bottom of the pool, carefully jump out of the water. 2-3 min. The pace is individual.

I.p. in free movement. At the bottom are a few small items. Collect items from the bottom of the pool. 5 minutes. The pace is individual.

I.p. in free movement. Freestyle swimming at your own pace.

I.p. standing at the edge. The water level is chest deep. Inhale through the nose - spread the arms to the sides, exhale through the mouth - hug yourself. Perform 4-6 times, the pace is individual. After the session, the patient was allowed to rest for 30 minutes.

Exercise therapy sessions should be continued on an outpatient basis according to the recommendations when the patient is discharged.

Before, during and after training, heart rate (HR) and oxygen saturation were measured using a pulse oximeter, and blood pressure (BP) was measured after each training session. Chest excursion was measured at the beginning and at the end of the course.

The lesson consisted of a warm-up, the main part and the final part. The course of treatment was carried out with a gradual increase in load from low (at the beginning of the course) to medium (at the end of the course).

After rest, the patient was sent to the halotherapy procedure. The purpose of this procedure made it possible to improve the functioning of the respiratory system by improving the rheological properties of bronchial contents, which contributes to the normalization of mucociliary clearance. Dry sodium chloride aerosol has a significant volumetric negative particle charge. Negatively charged particles, moving in the lumen of the respiratory tract, actively settle on the surface of the airways, which have a weakly positive electrical charge. Dry aerosol does not cause swelling of the mucous membrane of the respiratory tract and bronchospasm. In addition, halotherapy reduces the inflammatory response of the mucosa of the upper and lower respiratory tract, has a positive effect on the state of humoral and cellular immunity (Ushakov A.A. Practical Physiotherapy: A Guide for Physicians. 3rd ed., Revised and added. M .: Publishing house "Medical Information Agency"; 2013: 246-7). Additional health-improving factors are the stay of children in conditions of hypoallergenic and hypobacterial air environment, isolation from noise, and a comfortable psychological environment.

Children from 3 to 13 years of age received halotherapy as group procedures in a specially equipped halochamber for 10–20 minutes; children over 13 years of age received individual haloinhalations.

The advantage of individual halotherapy is the possibility of an individual procedure. An aerodisperse medium containing predominantly (more than 90%) the respirable fraction (particles of 1-5 μm) is created in the inhaler chamber and supplied to the patient's respiratory organs through a tube connected to the mask. Individual procedures of halotherapy can be carried out, for example, on the apparatus "GISA-01" (Galoneb), on the 2nd mode of operation ("P 2") (corresponding to a performance of 0.-1.2 mg/min).

Group halotherapy is carried out in a halochamber, for example, using the apparatus "Halogenerator AGG-03". A halochamber is a special room, the walls and floor of which are covered with a layer of salt (halite). With the help of a halogenerator, a stream of dry purified air saturated with highly dispersed particles of dry sodium chloride aerosol, which creates an aerodisperse medium in the given parameters of an artificial microclimate, is supplied to the room. In order to maintain the specified treatment regimens, a sensor for continuous monitoring of the aerosol mass concentration is installed in the treatment room. The air environment has a stable humidity (40-60%) and a constant temperature (18-24°C), which are the most favorable and comfortable for the respiratory organs and the stability of the aerodisperse medium. In the treatment room, a hypoallergenic and hypobacterial environment is constantly maintained. In the room where the halotherapy procedure is carried out, during the session there are 5-6 people at the same time, they are located in comfortable chairs for the duration of the procedure.

If necessary, depending on the presence of concomitant pathology, the complex of rehabilitation measures can be expanded by other methods. Thus, children with concomitant psycho-emotional problems are given psycho-corrective classes with a psychologist aimed at increasing the level of direct memory, normalizing their emotional state, as well as classes in the sensory room in the form of sequential exposure to relaxation methods, controlled imagination and art therapy.

All procedures are performed in the sequence described above.

The conducted studies made it possible to establish that in a group of pediatric patients in the long-term period after surgical correction of abnormal LCA separation from the LA, the indicated sequence of techniques (exactly in the specified sequence) with the mode of their implementation in the first half of the day allows achieving such a technical result when implementing this method as effective and fast (in 14 days) rehabilitation with an improvement in the functional state of the cardiopulmonary system, a decrease in the level of brain natriuretic peptide (BNP), and an increase in physical performance in pediatric patients. To improve physical performance, and, accordingly, the quality of life of such children, it is proposed to carry out this set of measures.

To consolidate the effect, it is recommended to carry out this rehabilitation complex every 6 months.

Such a set of procedures, with good tolerability and the absence of contraindications to each specific method, can be prescribed to all patients after correction of the anomalous deviation of the LCA from the LA.

As the study showed, it is the implementation of a full course of rehabilitation, the described procedure for conducting exercise therapy and physiotherapy procedures that provide the maximum positive effect.

Example 1

Patient G., 12 years 10 months.

Clinical diagnosis: CHD. SBUG. Condition after LCA reimplantation into the ascending aorta with LA trunk plasty with an autopericardial patch (October 14, 2016). LCA trunk occlusion, stenosis of the anterior interventricular branch up to 50%. Mitral valve insufficiency (grade 1.5). Tricuspid valve insufficiency (grade 1.5). Hypokinesis of the LV apex. Moderate decrease in LV myocardial contractility. Circulatory failure - 2. Functional class - 2.

Complaints: shortness of breath with moderate physical exertion, periodic palpitations, increased fatigue, reduced resistance to physical exertion, periodic pain in the region of the heart of a stabbing character.

Anamnesis of the disease: a child at the age of 1 month had pneumonia, from the age of 6 months he began to gain weight poorly. At the age of 1 year 3 months, against the background of an increase in temperature, cough, wheezing in the lungs, shortness of breath, and peripheral edema appeared. He was hospitalized with suspected pneumonia. At the same time, according to the X-ray of the chest organs, an increase in the size of the heart was revealed, when performing echocardiography (EchoCG), mitral valve insufficiency up to 4 degrees was revealed, a decrease in ejection fraction up to 45%. Diagnosed with dilated cardiomyopathy. Conducted a course of treatment with glucocorticosteroids, cardiac glycosides, diuretics without effect. From 2009 to 2016, he was repeatedly hospitalized in the cardiology department at the place of residence due to the presence of signs of heart failure. In 2016, according to EchoCG data, there was a suspicion of an anomaly of the coronary vessels and the presence of coronary-right ventricular fistulas (zones of myocardial hypokinesis were detected), on the electrocardiogram (ECG) - increased ST segment depression, prolongation of the QT interval. Hospitalization. Aortocoronary angiography (ACG) revealed an abnormal separation of the LCA from the LA. On October 14, 2016, an operation was performed to reimplant the VA in the ascending aorta with plastic surgery of the LA trunk with an autopericardial patch. The postoperative period was uneventful, he was discharged under the supervision of a cardiologist at the place of residence. After the operation, he repeatedly suffered from bronchitis. Periodically worried about pain in the heart. In December 2018, he was hospitalized in a cardiological hospital at the place of residence, CT angiography with contrast was performed, occlusion of the LCA trunk, stenosis of at least 50% of the anterior interventricular branch in the middle section was detected. Re-examined in 2019. According to ACG data, occlusion of the LCA trunk was confirmed; place of residence. He took courses of diuretic, cardiotrophic therapy.

Objective examination: general condition is satisfactory. Height 143 cm. Body weight 40 kg. Body surface area: BSA=1.27. Body mass index: BMI=334.5. The development of subcutaneous tissue is moderate. There are no edema. The color of the skin is pale pink, the skin is clean. Saturation of capillary blood with oxygen 99%. Mucous membranes pale pink are not changed, clean. Zev is not hyperemic. Nasal breathing is preserved. Skeletal system: violation of posture, the right leg is shorter by 3-5 cm than the left one. Lungs, percussion data: clear pulmonary sound. Respiratory rate 21 per minute. Respiration is vesicular. There are no wheezes. Apex push in 5 m / r. Rhythmic heart sounds, I tone is normal, II tone is normal, heart rate (HR) is 61 beats/min. Pulse rate 61, satisfactory filling and tension. Blood pressure on the left arm 90/58 mm Hg. The liver is located on the right, not enlarged. Physiological functions are normal. Nervous system without focal symptoms. Mental development corresponds to age.

Examination before the start of the course of rehabilitation treatment

ECG: sinus rhythm. Heart rate per minute 85. The position of the electrical axis of the heart: normal. The length of the PQ interval is 0.18 s. QRS 0.08 s. QRST 0.36 s. ST segment elevation up to 2 mm with negative T in V ₂ , up to 1 mm in V ₁ .

EchoCG: left atrium 29 mm. Left ventricle according to Teicholz: end systolic size (ESD) 3.2 cm, end diastolic size (EDD) 4.6 cm, end systolic volume (ESV) 41.0 ml, end diastolic volume (EDV) 97.3 ml, stroke volume (VV) 56.4 ml, ejection fraction (EF) 57.9%, shortening fraction (FU) 30.4% Slight LV apex hypokinesis. Mitral valve: leaflets are thin, movable, anterior is elongated, prolapses into the left atrium, induration of subvalvular structures, regurgitation of 1.5 degree. Aorta: the arch and isthmus are not changed. Aortic valve: tricuspid, leaflets thin, movable. The blood flow is not changed. The right atrium is not dilated. Right ventricle (RV) (inflow department): calculated pressure 37 mm Hg, not dilated. Pulmonary valve: pressure gradient 13 mm Hg, regurgitation 1 degree. Tricuspid valve: leaflets thin, mobile, regurgitation 1.5 degrees.

Conclusion: abnormal separation of the LCA from the LA, state of p/o reimplantation of the LCA trunk into the aorta, occlusion of the orifice of the LCA trunk, a moderate decrease in the LV pumping function, mainly in the apex, mitral insufficiency grade 1.5+.

Holter ECG monitoring: no hemodynamically significant rhythm and conduction disturbances were recorded, no ischemic dynamics were detected.

Bicycle ergometry: load duration 7:18 min. Recovery period 4 min. Maximum performed load 8.6 METS (75 W - 46%). Maximum heart rate 160 beats / min. Maximum blood pressure 125/69 mm Hg. (3 step). Exercise tolerance is low (1.9 W/kg). Normotonic type of reaction to the load. Rhythm disturbances are not induced.

In the 6-minute walk test, the distance covered was 420 m, dyspnea on the Borg scale was 3 points. Before the test, HR 78 beats/min, BP 114/70 mm Hg, SpO ₂ 97%, after HR 93 beats/min, BP 116/74 mm Hg, SpO ₂ 99%.

Examination of the ventilation function of the lungs - spirometry: minimal obstructive disorders of the external ventilation function of the lungs (deformation of the flow-volume curve). Parameters FEV1, FVC, VC, FEV1/FVC are normal. The maximum ventilation capacity of the lungs is normal (MVV 166% predicted).

The cardiorespiratory test was performed according to the RAMP 20 WATT protocol. The patient exerted maximum effort (RER >1.10). The study was terminated due to the patient's complaints of shortness of breath (RR 46/min), accompanied by horizontal depression of the ST segment (>1 mm) in leads II, aVF, V ₅ , V ₆ . Achieved heart rate 140 beats/min (67%). Physical performance (51% of predicted values) is reduced. The anaerobic threshold of 17.4 ml/kg/min (reduced), indicates a reduced physical activity of the patient. Peak oxygen consumption 21.5 ml/kg/min (51% of predicted values). VE/VCO ₂ (AT) ratio - 34 (II fan class). Load duration 05:07 min. Recovery period 03:06 min. Performed load 6.1 METS (58 W (45% of predicted values). Maximum blood pressure 156/82 mm Hg. Oxygen pulse 7 ml / beats (80%) of predicted parameters). Heart rate reserve is high (>15%). Considering the data of the performed load in W -% of the predicted values (45%), the patient has low tolerance to physical activity.

Biochemical blood test: BNP 60 pg/ml.

According to magnetic resonance imaging (MRI): subendocardial accumulation of a contrast agent along the anterior wall and anterior septal walls of the left ventricle at the level of the lower third (the volume of fibrous-modified myocardium is 5%) - changes in ischemic genesis in the basin of the anterior interventricular branch of the LCA. LV ejection fraction 58%. On the anterior wall of the left ventricle at the level of the middle third, there is an area of pronounced hypokinesis/akinesis with thinning of the LV myocardium up to 3 mm.

Psychologist's consultation: mental development according to the age norm. In the emotional-personal sphere, anxiety is increased.

Medical rehabilitation was carried out according to the program described above (12 sessions), including laser therapy, exercise therapy (aqua gymnastics), halotherapy.

After the rehabilitation course, the condition improved: shortness of breath decreased, fatigue decreased, pain in the heart area was not noted. The child was then discharged with recommendations for physical activity.

At the control examination after 3 months, there is a positive trend:

1. According to echocardiography - an increase in LV EF from 57.9% to 61.0%.

2. BNP level decreased from 60 pg/ml to 34.4 pg/ml.

3. According to bicycle ergometry, the tolerance of the study itself improved and the duration of the load increased from 7 min 18 s to 9 min.

4. In the 6-minute walk test, the distance covered was 540 m (gain - 120 m).

5. In cardiorespiratory testing, there was an increase in exercise tolerance (from 6.1 METS 58 W 45% of predicted to 6.9 METS 73 W 52% of predicted), a decrease in maximum blood pressure at peak exercise from 156/82 mm Hg. ., up to 147/74 mm Hg, increase in anaerobic threshold from 17.4 ml / kg / min (reduced) to 20.9 ml / kg / min (satisfactory), increase in peak oxygen consumption from 21.5 ml / kg / min (51% of the predicted values) to 24.3 ml / kg / min (56% of the predicted values), as well as the normalization of the ratio VE / VCO ₂ (AT) - from 34 (II ventilation class) to 29 (norm ).

6. After a series of remedial and developmental sessions with a psychologist, aimed at increasing the level of direct memory and normalizing the emotional state, there is a minimal positive trend.

Example 2

Patient T., 13 years 1 month

Clinical diagnosis: CHD. SBUG. Condition after LCA reimplantation in the ascending aorta with LA trunk plasty and xenopericardial patch, ligation of the patent ductus arteriosus in 2011. Stenosis of the LCA trunk mouth up to 50%. Mitral valve insufficiency 1.5 degrees. Fibromuscular aneurysm of the anterior-lateral wall of the left ventricle.

Complaints: shortness of breath with moderate physical exertion, increased fatigue; decrease in resistance to physical activity.

History of the disease: a heart murmur was detected at the age of 2 months, the diagnosis was made: congenital carditis, fibroelastosis (?). In September 2008, according to the control echocardiography revealed an increase in the left chambers of the heart, fibroelastosis, FI 43%. It was observed at the place of residence, in the dynamics there was an increase in the size of the heart, an increase in LV dilatation, a decrease in FI to 38%. Conducted therapy with glucocorticosteroids, diuretic, cardiotropic drugs. In February 2011, CHD was diagnosed for the first time: an anomaly of LCA separation from the LA. On March 30, 2011, LCA was reimplanted into the ascending aorta with LA trunk plasty with a xenopericardial patch; ligation of the open ductus arteriosus under IR. The early postoperative period was characterized by symptoms of decompensation of heart failure, cardiac arrhythmias. There was also a failure of the sutures of the sternum, in connection with which, on April 13, 2011, osteosynthesis of the sternum and secondary sutures were performed. In 2020, coronary angiography, scintigraphy, MRI of the heart with contrast were performed - a narrowing of the LCA mouth to 50%, postischemic cardiofibrosis was revealed. Considering the stable state against the background of balanced hemodynamics, hemodynamically insignificant stenosis of the LCA orifice, surgical treatment was not indicated, and dynamic monitoring by a cardiologist at the place of residence was recommended.

Objective examination: the general condition of the patient is satisfactory. Height 160 cm. Body weight 39 kg. Body surface area: BSA=1.33. Body mass index: BMI=308.32. The development of subcutaneous tissue is satisfactory. There are no edema. The skin color is pale pink, the skin is not changed, clean. Saturation of capillary blood with oxygen: 99%. Mucous membranes pale pink are not changed, clean. The chest is dysplastic, p/o scar median sternotomy without features. RR 19 per min. Breathing is vesicular, no wheezing. Heart rate 95 bpm. Pulsation in upper and lower limbs: distinct. Blood pressure on the left arm 97/68 mm Hg. The liver is located on the right, not enlarged. The chair is regular, urination is not disturbed. Nervous system without focal and meningeal symptoms. Mental development corresponds to age.

Examination before the start of the course of rehabilitation treatment

ECG: sinus rhythm, heart rate 89 bpm, electrical axis of the heart deviated to the left, PQ interval length 0.12 s, QRS 0.08 s, QRST 0.36 s.

EchoCG: left atrium 29 mm, not enlarged. Left ventricle according to Simpson: ESV 47.0 ml, ESV 96.0 ml, SV 49.0 ml, EF 51.0%, according to Teicholz: ESV 3.4 cm, ESV 4.7 cm, ESV 47.4 ml, EDV 102.4 ml, SV 54.9 ml, EF 53.7%, FU 27.7%. Mitral valve: leaflets are thin, mobile; compaction of subvalvular structures, fibrous ring 25 mm, regurgitation 1+. Aorta: the arch and isthmus are not changed. Aortic valve: tricuspid, leaflets thin, mobile, annulus fibrosus 20 mm, regurgitation is minimal. Right atrium: not dilated, pancreas (inlet section): Outflow section of the pancreas 24 mm, not dilated. Pulmonary artery: trunk 21 mm, not dilated. Pulmonary valve: pressure gradient 6 mm Hg, regurgitation is minimal, leaflets are thin, mobile. Tricuspid valve: leaflets thin, movable, annulus fibrosus 29 mm, regurgitation 1+. Interventricular septum (IVS): no reset; slight hypokinesis in the basal and middle segments. Interatrial septum: intact. Hypokinesis of the inferior LV wall in the basal and middle segments.

Conclusion: condition after LCA reimplantation into the ascending aorta with LA trunk plasty with a xenopericardial patch; ligation of the open ductus arteriosus; LV EF 50-53%. Mitral valve insufficiency 1 degree.

Holter ECG monitoring: no hemodynamically significant rhythm and conduction disturbances were recorded, no ischemic dynamics were detected, there was a tendency to moderate sinus tachycardia (average daily heart rate 93 beats/min).

In the 6-minute walk test: the distance traveled was 410 m, shortness of breath on the Borg scale - 4 points. Before the test, HR 89 bpm, BP 112/77 mm Hg, SpO ₂ 98%, after HR 110 bpm, BP 127/81 mm Hg, SpO ₂ 99%.

The cardiorespiratory test was performed according to the RAMP 20W protocol. The anaerobic threshold of 19.8 ml/kg/min indicates a satisfactory physical activity of the patient. Peak oxygen consumption 27.6 ml/kg/min (62% of predicted values). VE/VCO ratio ₂ 26 (norm). RR _ref 23/min, RR _max 40/min. The study was terminated due to the achievement of the anaerobic threshold and submaximal heart rate of 162 beats/min (78%). Completed load 81 W (60% of expected). Physical performance is reduced (62% of the predicted value); RER >1.10 WR _max . The patient made every effort to complete the study. Oxygen pulse 7 ml/beat is normal. Heart rate reserve is high (>15%). The test is negative. Ischemic significant changes in the ST segment, cardiac arrhythmias were not detected. The maximum increase in blood pressure is 136/86 mm Hg.

Biochemical blood test: BNP 33.5 pg/ml.

Psychologist's consultation: mental development corresponds to the age norm.

Medical rehabilitation was carried out according to the program described above (12 sessions), including laser therapy, exercise therapy (aqua gymnastics), halotherapy.

After the course of rehabilitation, the condition improved: shortness of breath decreased, fatigue decreased, physical activity increased. Then the child was discharged with recommendations for physical activity (a complex of exercise therapy for daily exercises was issued).

At the control examination after 3 months, there is a positive trend:

1. According to EchoCG, there is an increase in LV EF from 53.7 to 61.2%, a decrease in the size of the left chambers of the heart.

2. BNP level decreased from 35.5 pg/ml to 14.1 pg/ml.

3. According to HM ECG data, normalization of heart rate was noted.

4. In the 6-minute walk test, the distance covered was 494 m (an increase of 84 m), the severity of dyspnea on the Borg scale decreased from 4 to 2 points.

5. Cardiorespiratory testing showed an increase in exercise tolerance (from 81 to 88 W), an increase in anaerobic threshold from 19.8 to 23.7 ml/kg/min.

Example 3

Patient D., 9 years old.

Clinical diagnosis: CHD. Condition after radical correction of CHD: reimplantation of the LCA into the aorta under the conditions of EC from September 23, 2013. Fibrosis of the endocardium of the lateral, anterior wall with the involvement of papillary muscles. Hypokinesis of the anterior and anterior septal walls in the middle segment, IVS dyskinesia. Moderate LV dilatation.

Complaints: shortness of breath during physical exertion, running, increased fatigue, a slight decrease in resistance to physical exertion, increased sweating, frequent colds.

Anamnesis of the disease: according to the mother, from birth, increased sweating was noted, from 2 months of life, poor weight gain, shortness of breath, periodic dry cough, from 3 months, periodic refusal to eat, shortness of breath during feeding. On 07/09/2013, the condition worsened, dyspnea increased at rest, complete refusal to eat, increased anxiety. Was hospitalized. According to echocardiography, LV dilatation, EF 15%. Given the severity of clinical manifestations, cardiopulmonary insufficiency, the child was transferred to mechanical ventilation, infusion therapy with cardiotonic, diuretic drugs was started. By 14.07.2013, the condition stabilized, the diagnosis was made: dilated cardiomyopathy, circulatory failure grade 2B-3. Pulmonary hypertension (?). On July 21, 2013, she was transferred to a cardiac surgery center, diagnosed with abnormal LCA separation from the LA, IVS hypertrophy, narrowing of the RV outflow section, and a decrease in LV myocardial contractility. Received therapy aimed at compensating for heart failure. On September 23, 2013, a radical correction of the CHD was performed - reimplantation of the LCA into the aorta under EC conditions. Prolonged open sternotomy, postoperative period uncomplicated. In the future, she was regularly observed by a cardiologist, her condition remained stable.

Objective examination: the general condition of the patient is satisfactory. Height 128 cm. Body weight 21.6 kg. Body surface area: BSA 0.88. Body mass index: BMI 190.92. The development of subcutaneous tissue is satisfactory. There are no edema. The color of the skin is pale pink, the skin is clean, not changed. Saturation of capillary blood with oxygen 99%. Mucous membranes are pale pink clean. Lymph nodes available for palpation are not enlarged. Thorax - heart hump, p / o scar (median sternotomy) without features. RR 20 per min. Breathing is vesicular, no wheezing. Heart sounds are rhythmic, tone I is normal, tone II is normal, heart rate is 84 beats/min. Pulse rate 84, satisfactory filling and tension. The pulsation on the upper and lower extremities is symmetrical. Blood pressure on the right arm 112/60 mm Hg. The liver is located on the right, the borders are not expanded. The chair is regular, urination is not disturbed. Nervous system - without focal and meningeal symptoms. Mental development corresponds to age.

Examination before the start of the course of rehabilitation treatment

ECG: sinus arrhythmia rhythm, heart rate 69-78 beats/min, normal EOS, violation of ventricular repolarization. PQ interval length 0.12 s, QRS 0.08 s, QRST 0.4 s.

Echocardiography: left atrium 29 mm, LV according to Teicholz: ESR 2.7 cm, EDR 4.2 cm, ESR 27.0 ml, EDV 78.6 ml, SV 51.6 ml, EF 65.6%, FU 35, 7%. Mitral valve: leaflets are thin, mobile, induration of subvalvular structures, regurgitation of the 1st degree. Aorta: ascending 22 mm, features: the arch and isthmus are not changed. Aortic valve: tricuspid, the leaflets are thin, mobile, the blood flow is not changed.

The right atrium is not dilated. Right ventricle (inflow department): design pressure 30 mm Hg, not dilated. Pulmonary valve: 10 mmHg pressure gradient, grade 1 regurgitation. Tricuspid valve: leaflets are thin, mobile, regurgitation of 1 degree. Interventricular septum: no shunt, LV lateral wall dyskinesia. Interatrial septum: open oval window 4 mm.

Conclusion: condition after the operation to correct the abnormal origin of the coronary artery.

Holter ECG monitoring: no hemodynamically significant rhythm and conduction disturbances were recorded, no ischemic dynamics were detected.

In the 6-minute walk test: the distance traveled was 545 m, shortness of breath on the Borg scale 1 point, SpO ₂ up to 97%, after 99%, heart rate up to 77 bpm, after 89 bpm, blood pressure up to 104/59 mm Hg .st., after 104/62 mm Hg.

Cardiorespiratory test: performed according to the RAMP 10WATT protocol. The anaerobic threshold of 31.8 ml/kg/min indicates a satisfactory physical activity of the patient. Peak oxygen consumption 37.1 ml/kg/min (74%). Ratio VE/VCO ₂ - 31 (II fan class). The study was terminated due to complaints of leg fatigue. Anaerobic threshold reached, heart rate 143 beats/min (67%). Executed load 55 W (68% of expected). Functional ability is reduced (74% of the expected). The patient was able to apply only submaximal effort. RER< _1.10WRmax . Oxygen pulse 6 ml/beats (normal). Against the background of the achieved heart rate, ischemic significant changes in the ST segment, no cardiac arrhythmias were registered. The maximum increase in blood pressure is 158/72 mm Hg. Moderate threshold for exercise tolerance.

Bicycle ergometry: load duration 5:26 min. Recovery period 6 min. Maximum performed load 11.7 METS (50 W - 63%). Maximum heart rate 171 beats / min. Maximum blood pressure 140/78 mm Hg. (2 step). No diagnostically significant dynamics of the ST segment was registered. The patient complained of fatigue and dyspnea, with a maximum Borg score of 7/10 at the peak of exercise. Restoration of breathing at the 5th minute of the recovery period. Tolerance to physical activity is average (2.3 W / kg). Normotonic type of reaction to the load. Rhythm disturbances are not induced.

Biochemical blood test: BNP 67.6 pg/ml.

Psychologist's consultation: mental development according to the age norm. In the emotional sphere, anxiety is increased.

Medical rehabilitation was carried out according to the program described above (12 sessions), including laser therapy, exercise therapy (classes in the hall), halotherapy, as well as psycho-corrective classes with a psychologist aimed at normalizing the emotional state, classes in the sensory room in the form of sequential exposure to controlled relaxation methods. imagination and art therapy.

After the rehabilitation course, the condition improved: fatigue decreased, physical activity increased, the emotional background improved, mood returned to normal, and anxiety symptoms decreased. Then the child was discharged with recommendations for physical activity (a complex of exercise therapy for daily exercises was issued).

At the control examination after 3 months, there is a positive trend:

1. According to EchoCG - reduction in the size of the left chambers of the heart.

2. BNP level decreased from 67.6 pg/ml to 11.2 pg/ml.

3. ECG showed normalization of rhythm and heart rate.

4. In cardiorespiratory testing, there was an increase in exercise tolerance (from 55 W to 62 W), a decrease in maximum blood pressure at the peak of exercise from 158/72 mm Hg. to 141/90 mm Hg, increase in peak oxygen consumption from 37.1 ml/kg/min (74% of predicted values) to 39.8 ml/kg/min (77% of predicted values), and normalization ratio VE/VCO ₂ (AT) - from 31 (II ventilation class) to 30 (I ventilation class).

5. According to the bicycle ergometry, the tolerance of the study itself improved, the duration of the load increased from 5 min 26 s to 7 min, an increase in the maximum performed load was noted from 11.7 METS (50 W - 63% - average exercise tolerance) to 14.9 METS (62.5 W - 90% - high exercise tolerance).

6. There were significant improvements in the emotional background, normalization of mood, and a decrease in anxiety symptoms.

Due to the application of the proposed method, the functional state of the cardiopulmonary system improves, a positive effect on immunity, bronchopulmonary function and emotional and personal sphere is noted.

Patients showed an improvement in general well-being, there were no discomfort during the procedures, and there were no complications. All patients and their parents were given detailed recommendations on their future lifestyle, allowed physical activity, and were given a set of exercises to continue rehabilitation on an outpatient basis.

Thus, this method increases the effectiveness of the rehabilitation of children after surgical correction of the abnormal separation of the LCA from the LA. Against the background of improving physical condition, increasing immunity, there are also positive changes in the biochemical blood test (decrease in BNP levels), stabilization of hemodynamic parameters and emotional state. The method is well tolerated by patients and does not cause side effects, it is recommended in the conditions of rehabilitation departments of hospitals, rehabilitation centers and cardiological sanatoriums.

Claims (23)

A method for the rehabilitation of children in the long-term period after surgical treatment of an abnormal origin of the left coronary artery from the pulmonary artery, including the implementation of rehabilitation methods within one session, implemented in a given sequence: laser therapy with a power of 4-5 W, exposure for 1-3 minutes at 3 points: in second intercostal space to the right and left of the sternum, as well as in the projection of the apex of the heart; physiotherapy exercises carried out in the exercise therapy room or in the water, while the set of exercises in the gym includes: starting position (ip) - standing: squeezing / unclenching the hands for 30 s, inhaling / exhaling, 3 repetitions; i.p. - standing, perform rotation in the wrist joints for 30 s inhale / exhale, 3 repetitions; i.p. - standing, spread your arms to the sides inhale, hug yourself exhale, 5 repetitions; i.p. - standing, put the hands on the shoulders, rotate the arms in the shoulder joint for 30 s, 4-5 repetitions; i.p. - they stand facing the wall, hold the ends of the elastic tape fixed to the wall in their hands, alternately pull the tape towards themselves with their hands, perform 1-3 minutes, then 1 minute of walking, repeat 1 time; i.p. - standing, hands on the belt, rise on toes, linger for 3-5 seconds, return to the starting position, 1-2 minutes; then 1 minute walk, repeat 1 time; i.p. - standing, perform 5-10 squats, repeat 2-3 times, then walk for 1 minute; i.p. - standing, climb a step 20 cm high, no more than 20-30 climbs per minute, perform no longer than 40-60 s, repeat 1-2 times, then walk for 1 minute; i.p. - in free movement, they walk "sitting down" for 1-1.5 minutes, repeat 1 time, then 1 minute of walking; i.p. - in free movement, they walk with lunges with their hands in front of them, 1.5-2 minutes, repeat 1-2 times, then 1 minute of walking; i.p. - in free movement, walk on toes for 1.5-2 minutes, repeat 1 time, then 1 minute of walking; i.p. - standing, spread your arms to the sides inhale, hug yourself exhale, 5 repetitions; a set of exercises in the water includes: i.p. - standing at the side, the water level is up to the chest, inhale through the nose - spread the arms to the sides, exhale through the mouth - hug yourself, perform 4-6 times; i.p. - standing at the side, hands on the side, water level up to the chest, deep breath through the nose, long exhalation into the water, 1.5-3 minutes; i.p. - standing at the side, hands on the side, water level up to the chest, deep breath through the nose, quick exhalation into the water, 2-3 minutes; i.p. - standing at the side, hands on the side, water level to the chest, deep breath through the nose, perform squats in the water, immersed with the head, hands remain on the side, exhale in the water, straighten up, perform 3-4 minutes; i.p. - lying on the water on the stomach, hands on the side, take a deep breath, perform crawl-style leg movements with exhalation into the water, perform 4-5 minutes; i.p. - standing, chest-deep water level, take a deep breath, perform a squat in the water with an exhalation, push off from the bottom of the pool and jump out of the water, perform 2-3 minutes; i.p. - in free movement, collect objects from the bottom of the pool, perform 5 minutes; i.p. - in free movement, swim in a free style and pace; i.p. - standing at the side, the water level is up to the chest, inhale through the nose, spread to the sides, exhale through the mouth - hug yourself, perform 4-6 times; then halotherapy is carried out on a haloinhaler or in a group in a halochamber, the walls and floor are covered with halite salt using a halogenerator, then psychocorrective sessions with a psychologist, with each subsequent rehabilitation method being carried out 30 minutes after the previous one, and the rehabilitation course includes 12 sessions with a break in 2 days after every 5 sessions, and the full course of rehabilitation is repeated after 6 months.