RU2766245C1 - Method for suturing right ventricular defect in intraventricular forms of myocardial bridges of coronary arteries - Google Patents

Abstract

FIELD: medicine; cardiovascular surgery.

SUBSTANCE: before performing a supracoronary myotomy, a series of preventive U-shaped sutures on the spacers are applied to the intraventricular segment of the artery, capturing all layers of the heart, and a longitudinal supracoronary myotomy of the muscle bridge tissues over the coronary artery is performed. Then the right ventricular defect is eliminated by tightening and fixing the imposed preventive U-shaped sutures.

EFFECT: method allows minimizing intraoperative blood loss and, consequently, the need for blood transfusion therapy; reducing the likelihood of emergency conversion to artificial circulation; performing a supracoronary myotomy with the removal of the artery to the epicardial position.

1 cl, 1 ex, 4 dwg

Description

The invention relates to medicine, to cardiovascular surgery, and can be used when performing supracoronary myotomy in intraventricular forms of myocardial bridges of the coronary arteries.

The most physiological and pathogenetically substantiated method of surgical treatment of myocardial bridges of the coronary arteries is currently supracoronary myotomy. A special type of myocardial bridges, requiring a specific surgical approach, is a variant of the intraventricular subendocardial location of the coronary artery. At the same time, the epicardially located artery perforates the entire thickness of the myocardium at an acute angle and enters the cavity of the right ventricle, lying subendocardially. Performing supracoronary myotomy in intraventricular forms of myocardial bridges of the coronary arteries in almost all cases is accompanied by the formation of a defect in the free wall of the right ventricle, which is the most life-threatening complication.

It is known that in cases of formation of a defect in the free wall of the right ventricle during supracoronary myotomy, if the operation was performed on a beating heart, an emergency conversion to artificial circulation due to uncontrolled bleeding is performed. The right ventricular defect is sutured under conditions of parallel circulation with recirculation of the lost blood volume. In most cases, myotomy is not fully performed, and the intramyocardial artery is bypassed distally (Sun X, Chen H, Xia L, Zhao D, Ding W, Wang C. Coronary artery bypass grafting for myocardial bridges of the left anterior descending artery J Card Surg. 2012 Jul; 27(4): 405-7. doi: 10.1111/j. 1540-8191.2012.01457.x. Epub 2012 May 20. PMID: 22607045).

However, bypass surgery in patients with dynamic stenosis of the coronary arteries - the absence of atherosclerotic hemodynamically significant stenosis, i.e. isolated myocardial bridges of the coronary arteries show unsatisfactory results due to the high incidence of shunt thrombosis, which is explained by the formation of competitive blood flow between the shunt and the coronary artery (Bockeria LA, Sukhanov SG, Orehova EN, Shatakhyan MP, Korotayev DA, Sternik L. Results of coronary artery bypass grafting in myocardial bridging of left anterior descending artery J Card Surg. 2013; 28:218-21 doi: 10.1111/jocs.12101).

The technical result of the claimed invention is to minimize the volume of intraoperative blood loss, avoid emergency conversion to artificial circulation due to uncontrolled bleeding in patients with intraventricular forms of myocardial bridges of the coronary arteries, and perform supracoronary myotomy with the removal of the artery to the epicardial position.

The claimed technical result is achieved in a method for suturing a right ventricular defect with intraventricular forms of myocardial bridges of the coronary arteries, according to which, before performing supracoronary myotomy, a number of preventive "P-shaped" sutures are applied to the intraventricular segment of the artery on gaskets, capturing all layers of the heart, and longitudinal supracoronary tissue myotomy is performed muscle bridge over the coronary artery, to eliminate the defect of the right ventricle, the applied preventive "U-shaped" sutures are tightened and fixed.

The imposition of a number of preventive "U-shaped" sutures on gaskets on the intraventricular segment of the artery before performing supracoronary myotomy allows, in the event of a defect in the right ventricle during supracoronary myotomy, to stop bleeding and eliminate the right ventricular defect by tightening and fixing the previously applied preventive "U-shaped "seams.

The figures schematically show the steps of the method:

- Fig. 1 - intramyocardial course of the coronary artery, the diagram shows the intraventricular segment of the artery;

- Fig. 2 - orientation of preventive sutures of the wall of the right ventricle;

- Fig. 3 - execution of supracoronary myotomy;

- Fig. 4 - fixation of preventive sutures.

The method is carried out, for example, as follows.

Based on the data obtained from the results of multispiral computed angiography of the coronary arteries, a revision of the anterior interventricular artery 2 involved in the myocardial bridge 1 and identification of the intraventricular segment 3 (Fig. 1) are performed.

The start of the operation, anesthesia and access to the heart are carried out as standard.

Throughout the intraventricular segment 3 of artery 2, preventive "U-shaped" sutures 4 are placed on pads 5 made of polytetrafluoroethylene, covering all layers of the heart (Fig. 2).

Perform a longitudinal myotomy 6 tissues of the muscle bridge over the coronary artery 2, which allows you to expose the artery (Figure 3).

In the case of the formation of a right ventricular defect, tightening and fixation of previously applied sutures 4 is performed (Fig. 4).

Signs of a formed right ventricular defect are abundant venous blood flow from the ventricular cavity at the site of dissection and a characteristic appearance of right ventricular trabecularity on the endocardial surface. After stopping the bleeding, myotomy is performed throughout the entire intramyocardial segment of the artery. Thus, after a full myotomy, the artery is brought to the epicardial position.

In cases where myotomy of intraventricular forms of myocardial bridges of the coronary arteries was performed without the formation of a defect in the right ventricle, the question of the need to remove or fix previously applied preventive sutures is at the discretion of the surgeon. At the same time, it should be noted that the remaining wall thickness of the right ventricle under the freed artery plays an important role in decision making.

The method is illustrated by a clinical example.

A 37-year-old patient was admitted to the cardiosurgical department in a planned manner with complaints of chest pain of a pressing nature, radiating to the left arm during physical exertion, relieving at rest, periodic occurrence of shortness of breath when walking fast. At the time of admission, the patient has III functional class of angina according to the classification of the Canadian Association of Cardiology (L. Campeau, 1976).

From the anamnesis of the disease, it is known that in July 2019 the patient suffered an acute Q-myocardial infarction in the territory of the anterior interventricular artery, which, according to the patient, was associated with prolonged and intense physical activity.

In January 2020, stress echocardiography was performed: the test was positive, exercise tolerance was moderate. In February 2020, the patient felt a pressing pain in the chest, for which he sought medical help at the district clinic. According to the results of functional studies, ischemic changes in the basin of the anterior interventricular artery were revealed. In order to stop an attack of angina pectoris, antianginal therapy was carried out - without a significant effect.

With the idea of unstable (progressive) angina, the patient was hospitalized.

Coronary angiography was performed: coronary arteries without signs of atherosclerotic lesions, myocardial bridge in the middle third of the anterior interventricular artery with 95% stenosis in systole. According to multispiral computed angiography of the coronary arteries, the myocardial bridge of the anterior interventricular artery (ALVA) was confirmed in the middle segment of the artery for 7 cm with an intraventricular course for 2.5 cm. In this case, the intraventricular segment of the artery began at a distance of 1.5 cm from the proximal diagonal artery, which served as an anatomical landmark.

An operation was performed - supracoronary myotomy of the LA on a beating heart. After identifying the intraventricular segment of the artery, the length of which was 2.5 cm, and applying 3 preventive "U-shaped" sutures, myotomy was performed in the projection of the middle third of the anterior interventricular artery for 7 cm using the technique of excision and processing of the edges of the muscle bridge. The segment of the artery passing intramyocardially was isolated from the thickness of the myocardium. Perforation of the right ventricle was eliminated after tightening and tying preventive sutures. The volume of blood loss was not more than 20 ml. The artery is brought to the epicardial position. After achieving hemostasis, the wound was sutured in layers. The patient was transferred to the intensive care unit.

The early postoperative period was uneventful. The patient was discharged in a satisfactory condition on the 7th day after the operation. There were no complaints of ischemic pain, exercise tolerance increased.

After 3 months, stress echocardiography was repeated at rest and during physical activity, according to the results of which no signs of ischemia were detected, stress-induced myocardial hypoperfusion was not established.

After 3 months, repeated coronary angiography and multislice computed angiography of the coronary arteries were performed. According to the results of the examination: coronary arteries without hemodynamically significant stenoses, no signs of extravasal compression of the LAD were detected.

During the follow-up period, angina pectoris did not recur. The patient is regularly observed by a cardiologist, complies with the prescribed drug therapy.

Since 2016, more than 50 supracoronary myotomies have been performed on a beating heart. In 6 cases, an intraventricular form of the myocardial bridge of the LAD was diagnosed. In order to minimize intraoperative blood loss in these cases, the technique of applying preventive sutures in the area of myotomy according to the claimed method was used. When verifying a right ventricular defect, the preventive sutures were immediately tightened and fixed. Thus, in all these cases, it was possible to avoid an emergency connection of the heart-lung machine, significantly reduce the volume of intraoperative blood loss, and perform a full-fledged myotomy with the removal of the artery to the epicardial position.

The claimed method allows minimizing intraoperative blood loss and, consequently, the need for blood transfusion therapy; reduce the likelihood of emergency conversion to cardiopulmonary bypass; perform a supracoronary myotomy with the removal of the artery in the epicardial position.

Claims (1)

A method for suturing a defect of the right ventricle in intraventricular forms of myocardial bridges of the coronary arteries, which consists in the fact that before performing supracoronary myotomy, a number of preventive U-shaped sutures are placed on the intraventricular segment of the artery, capturing all layers of the heart, and longitudinal supracoronary myotomy of the tissues of the muscle bridge over the coronary artery, to eliminate the defect of the right ventricle, the applied preventive U-shaped sutures are tightened and fixed.

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