RU2748638C1 - Method for aortic valve prosthetics - Google Patents

Abstract

FIELD: medicine; cardiac surgery.

SUBSTANCE: longitudinal sternotomy is performed. The pericardial flap is separated and resected. The altered aortic valve leaves are excised. At the same time, a CT examination of the aortic root with ECG synchronization is performed beforehand. The inter-commissural distances are measured on the CT image of the phase of the cardiac cycle corresponding to the ventricular diastole. The height of each leaf is determined as a segment extending from the upper point of the demilune of the base through the middle of the corresponding inter-commissural distance to the point of intersection of the leaves with the valve closed in the CT image. According to the obtained values, the size of the leaf template with a height of 3-6 mm greater than the value on the CT image is determined, and the leaves are cut out of the patient's autopericardium immediately after its resection.

EFFECT: method makes it possible to increase the effectiveness of treatment, reduce the likelihood of complications by ensuring adequate coaptation, lack of regurgitation on the aortic valve, low transaortic pressure gradient, and improve the quality and duration of their life.

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Description

The invention relates to medicine, in particular to cardiac surgery, and can be used to treat pathology of the aortic valve of the heart.

The traditional treatment for aortic valve defects is valve replacement. There are two main types of prostheses: mechanical and biological. A significant drawback of mechanical aortic valve prostheses is the need for lifelong intake of anticoagulant drugs, which can be complicated by hemorrhagic complications in case of drug overdose or thrombotic complications at insufficient dose. This problem is leveled in biological prostheses, but they are not without drawbacks. Thus, a significant disadvantage of a biological prosthesis made from bovine or porcine pericardium or porcine aortic valve cusps is rather rapid degeneration and calcification, which requires valve reprosthetics. For biological and, to a lesser extent, mechanical prostheses, a significant problem is the presence of a prosthesis-patient mismatch, the meaning of which is the insufficient area of the effective opening of a small-diameter prosthesis for a patient with a large body surface area. This is manifested by a high pressure gradient across the aortic valve prosthesis.

A known method of prosthetics of the aortic valve leaflets from xenopericardium or synthetic material after measuring the length of the half moon - the place of attachment of the leaflet - using a special meter (patent RU 2314041, IPC А61В 17/00, А61В 2/24, publ. 2008). Valve prosthetics begin between the lowest point of the valve prosthesis and the lowest point of the fibrous crescent, continuing to fix the valve prosthesis from the bottom up without reaching 5 mm to the upper point of the crescent and to the protruding part of the flaps, after which three new commissures of the aortic valve are formed by stitching adjacent flaps and commissures aortic valve.

The disadvantage of this method is the high likelihood of insufficiency of co-optation of non-flaps, which can lead to aortic insufficiency. In addition, the use of the proposed materials often leads to calcification and degradation of the leaflets in the postoperative period.

The closest is the method of aortic valve prosthetics using cusps cut from the patient's autopericardium treated with glutaraldehyde. In this case, excision of the altered aortic valve cusps is performed. Then the intercommissural distance is measured using meters made of stainless steel. Carry out cutting out of semilunar valves according to templates, fixing the valves to the aortic ring. In this case, the length of co-optation of the aortic valve leaflets is increased by using a template with a height increased by 5 mm (RF Patent 2664183, IPC А61В 17/00, publ. 2018).

The disadvantages of this method are the long time of cardiopulmonary bypass and operations in connection with the measurement of intercommissural distances and the cutting of semilunar valves after the start of cardiopulmonary bypass, which reduces the effectiveness of the treatment.

The objective of the invention is to eliminate these disadvantages, increase the effectiveness of treatment, reduce the likelihood of complications, due to the provision of adequate coaptation, the absence of regurgitation on the aortic valve, a low transaortic pressure gradient. In addition, treatment should eliminate lifelong use of anticoagulant drugs.

To solve the problem in the prosthetics of the aortic valve using leaflets cut out from the patient's autopericardium treated with glutaraldehyde, including performing a longitudinal sternotomy, separating and resecting the pericardial flap, excision of the changed aortic valve leaflets, measuring intercommisural distances by increasing the length of the semilunar leaflets co-optation of the aortic valve leaflets by using a template with an increased height, it is proposed to preliminarily conduct a CT examination of the aortic root with ECG synchronization. In this case, the intercommissural distances are measured on the CT image of the phase of the cardiac cycle, corresponding to the diastole of the ventricles. Additionally, the height of each flap is determined as a segment passing from the upper point of the base half moon through the middle of the corresponding intercommission distance to the point of intersection of the folds with the valve closed on the CT image. According to the obtained values, the size of the valve template with a height of 3-6 mm greater than the value on the CT image is determined, and the cutting of the valves from the patient's autopericardium is carried out immediately after its resection.

The fact that the size of the valves is determined before the operation makes it possible to reduce the duration of the operation, the time of cardiopulmonary bypass, the time of myocardial ischemia, decrease in cerebral ischemia, and reduce the likelihood of late complications.

The method is carried out as follows.

A preliminary CT scan of the aortic root with ECG synchronization is performed to measure the size of the leaflets. An image is selected with the valve closed, the phase of the cardiac cycle corresponding to the diastole of the ventricles. Determine the height of each leaflet as a segment passing from the upper point of the base half moon through the middle of the corresponding intercommissural distance to the point of intersection of the leaflets with the valve closed on the CT image. A template is selected according to the obtained dimensions, while the height is taken with an increase of 3-6 mm of the value obtained on the CT image.

The operation is performed under endotracheal anesthesia. A longitudinal sternotomy is performed, a flap of the parietal layer of the pericardium is separated and resected, and it is treated with glutaraldehyde.

Each leaflet is cut out from glutaraldehyde-treated atutopericardium according to the selected template in accordance with the obtained values.

The IC apparatus is connected according to the "right atrium - ascending aorta" scheme, and LV drainage is established through the right superior pulmonary vein. Non-selective pharmaco-cold cardioplegia is performed. Aortotomy for 2/3 of the circumference. The leaves are excised.

The non-flaps are fixed to the aortic ring with a continuous twisting suture with a monofilament suture, with the suture starting from the middle of the flap. Neo-commissures are created by imposing U-shaped seams on the spacers (5 mm higher than the native commissures).

After fixation of all three leaflets, the aorta is sutured. Standard completion of the operation: switching off the infrared device, closing the wound.

Example 1.

Patient D., 51 years old, was admitted to the Department of Cardiac Surgery with complaints of dyspnea at rest, the diagnosis was made: combined degenerative aortic valve disease with a predominance of stenosis. According to echocardiography, the linear velocity of blood flow through the aortic opening is 599 cm / s, the average pressure gradient is 79 mm Hg. Art., the diameter of the aortic ring is 2.4-2.5 cm, the area of the effective opening is 0.9 cm2, regurgitation of the I degree. The valve leaves are thickened, calcified, inactive.

A preliminary CT examination of the aortic root with ECG synchronization was carried out, with the measurement of intercommissural distances, to determine the center of the line. Determine the height of each flap. The results were obtained: the distance between the right and left commissures was 25 mm, the distance between the left and non-coronary commissures was 26 mm, and the distance between the non-coronary and right commissures was 26 mm.

The following dimensions of the valve heights were obtained: non-coronary valve - 29 mm, right coronary valve - 31 mm, left coronary valve - 29 mm.

A longitudinal sternotomy was performed, a 10 × 15 cm parietal flap of the pericardium was separated and resected, and treated with glutaraldehyde.

Each leaflet is cut from glutaraldehyde-treated atutopericardium according to the selected dimensions with a height increased by 3 mm.

The operation is performed as described above.

Intraoperative transesophageal echocardiography data: no aortic regurgitation, average gradient 10 mm Hg. Art. Smooth postoperative course.

Echocardiographic data on the 8th day after surgery: the aortic valve cusps look like native, without limitation of their mobility, peak velocity - 240 cm / s, average pressure gradient - 8 mm Hg. Art., no regurgitation was detected.

Example 2

Patient K., 29 years old, was admitted to the department of cardiac surgery with complaints of dyspnea at rest, the diagnosis was made: insufficiency of the aortic valve.

A preliminary CT examination of the aortic root with ECG synchronization was carried out, with the measurement of intercommissural distances, to determine the center of the line. Determined the height of each flap. The results were obtained: the distance between the right and left commissures was 26 mm, the distance between the left and non-coronary commissures was 28 mm, the distance between the non-coronary and right commissures was 26 mm. The values from the middle of each intercommissural distance to the area of closure of the cusps of the base crescent were determined; the following dimensions were obtained: the height of the non-coronary cusp is 27 mm, the height of the right coronary cusp is 27 mm, and the height of the left coronary cusp is 29 mm.

A longitudinal sternotomy was performed, a 10 × 15 cm parietal flap of the pericardium was separated and resected, and treated with glutaraldehyde.

Each valve was cut out of the autopericardium treated with glutaraldehyde according to the obtained values of the valve heights with an increase of 6 mm.

The above operation was performed.

After fixation of all three leaflets and conducting a hydraulic test, the aorta is sutured, the standard completion of the operation.

The proposed method of treatment was applied in 9 patients. Control examinations after 6 months, 1 year did not reveal complications, the condition of all patients was satisfactory.

The proposed method makes it possible to increase the effectiveness of treatment of this category of patients, to improve the quality and duration of their life.

Claims (1)

A method of aortic valve prosthetics using leaflets cut out of a patient's autopericardium treated with glutaraldehyde, including performing a longitudinal sternotomy, separating and resecting the pericardial flap, excision of the changed aortic valve leaflets, measuring intercommissural distances, cutting out the semilunar leaflets of the aortic valve by increasing the length of the aortic valve along the cooptation using a template with an increased height, characterized in that a CT scan of the aortic root with ECG synchronization is preliminarily carried out, and the measurement of intercommissural distances is carried out on the CT image of the phase of the cardiac cycle corresponding to the diastole of the ventricles, the value of the height of each leaflet is determined as a segment passing from the base half moon through the middle of the intercommission distance to the point of intersection of the leaflets with a closed valve on the CT image, according to the obtained values, the size of the leaflet template with a height of 3-6 mm greater than the obtained value is determined values on the CT image, while cutting out the valves from the patient's autopericardium is carried out immediately after its resection.