RU2840590C1 - Method for preventing and/or treating secondary mitral regurgitation in patients with chronic heart failure and left ventricular dilatation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely cardiosurgery, and may be used for preventing and/or treating secondary mitral regurgitation in the patients with chronic heart failure and left ventricular dilatation. That is followed by bringing the papillary muscles together with a U-suture of a non-absorbable braided polyfilament 2-0 suture on opposite pads made of polytetrafluoroethylene and a restrictive mitral annuloplasty with a support ring.

EFFECT: method allows to reduce the co-optation depth and increase the mitral valve co-option line by reducing the size of the left ventricle, reduce the size of the fibrous ring of the mitral valve, eliminate lateral displacement of papillary muscles due to their approximation, which reduces the probability of developing secondary mitral regurgitation in the postoperative period and, as a result, helps to restore the pumping function of the heart and reduce the degree of congestive heart failure.

1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to cardiac surgery, and can be used for the prevention and/or treatment of secondary mitral regurgitation in patients with chronic heart failure and left ventricular dilation.

Below, the applicant presents the terms and abbreviations used in the correspondence materials:

Myocardial infarction (MI) is myocardial necrosis due to prolonged acute ischemia.

Left ventricular aneurysm (LVA) is an increase in the size of the LV with the formation of paradoxical kinetic zones as a result of a previous MI with a subsequent set of structural and morphological changes. The changes affect not only the immediate necrosis zone, but also areas of the myocardium remote from it, involving cardiomyocytes, interstitial cells and coronary vessels. After the loss of part of the contracting myocardium as a result of necrosis, physiological mechanisms are launched in the heart aimed at restoring the stroke volume - the volume of blood that the LV ejects into the aorta during systole (contraction). According to the Frank-Starling law, an increase in the size of the LV cavity ensures that the stroke volume is maintained at the proper level, regardless of the consistent decrease in contractility. According to the Laplace law, compensatory dilation leads to an increase in diastolic and systolic wall tension, stimulating further expansion of the LV. Thus, the results of LV remodeling are a progressive decrease in systolic and diastolic myocardial function, the development of mitral regurgitation and LV spherification:

- secondary mitral regurgitation (MR) - mitral valve insufficiency resulting from ischemic remodeling of the LV,

- restrictive annuloplasty of the mitral valve (MV) - a method of surgical treatment of ischemic mitral regurgitation, which consists of reducing the size of the fibrous ring of the mitral valve,

- depth of mitral valve co-optation - the distance between the plane of the valve ring and the point of contact of its cusps,

- mitral valve co-optation lines - length of the contact line of the mitral valve leaflets,

- typical surgical approaches to the mitral valve: separate approach through the left atrium behind the interatrial groove; approach through the right atrium and interatrial septum without combining the incision lines; extended biatrial approach with a single incision line.

Myocardial infarction (MI) leads to complications that significantly worsen the prognosis and course of coronary heart disease. One of these complications is ischemic mitral regurgitation (MR), the incidence of which reaches 10-50% [1]. Restrictive annuloplasty of the mitral valve (MV) remains the method of choice among many other surgical procedures.

However, the development of secondary MR recurrence ranges from 5 to 58% [2-4].

There are a number of reasons underlying the development of secondary MR:

- imbalance between the locking capacity of the mitral valve and the tension forces acting on its cusps [5-7],

- enlargement of the left ventricle (LV),

- displacement of the papillary muscles in the apical and transverse directions increases the tension forces,

- dyssynchrony of the left ventricle and papillary muscles,

- a decrease in the contractile ability of the myocardium leads to a decrease in the valve's locking ability, and as a consequence, a violation of the co-optation of the valve cusps and the development of MR [8].

Thus, the treatment of mitral valve insufficiency requires a comprehensive approach that affects all links in the pathogenesis of secondary MR.

A method of plastic surgery of subvalvular structures of the mitral valve is known, such as relocation of papillary muscles, which consists of double suturing of the fibrous part of the papillary muscles with a polypropylene thread followed by a puncture in the area of the fibrous ring [9]. The essence of the known method is fixation of the distance between the plane of the mitral valve and the tips of the papillary muscles. However, this method of plastic surgery of subvalvular structures is associated with the appearance of stenosis of the mitral valve, and the procedure itself is not effective in the case of pronounced remodeling of the LV and a large sphericity index, since the papillary muscle itself is lengthened.

A method for suspending the papillary muscles of the MC is known, which consists of passing a polytetrafluoroethylene tube around the base of the papillary muscles and then tightening the loop until the muscles come into close contact [10]. The essence of the known method is the convergence of the papillary muscles, which will prevent lateral displacement of the walls of the left ventricle. However, the implementation of this procedure is limited by the anatomy of the papillary muscles, in particular, the papillary muscles can be too short, which makes it difficult to pass a polytetrafluoroethylene tube around the base of the papillary muscles. At the same time, excessive convergence can lead to ischemia of the papillary muscles and their rupture.

A method of plastic surgery of subvalvular structures of the mitral valve is known based on the principle of a ring loop, which consists of suturing the base of the anterolateral and posteromedial papillary muscle with a polytetrafluoroethylene thread, followed by puncturing the thread into the left atrium in the area of the fibrous ring of the posterior mitral valve leaflet [11]. The essence of the known method is fixing the distance between the bases of the papillary muscles and the mitral valve plane. However, this procedure is associated with the risk of damaging the posterior mitral valve leaflet, since the thickness of the fibrous ring of the mitral valve in patients with ischemic cardiomyopathy is less than 1 mm, and precise suturing of the fibrous ring with a needle whose diameter is comparable to the diameter of the fibrous ring of the mitral valve is very difficult. Suturing the base of the posterior leaflet leads to the formation of a fistula and the development of MR.

Of the known ones, the closest in technical essence is the method for treating mitral insufficiency type IIIb according to A. Carpentier in patients with left ventricular dilation (patent No. 2374994, published on 10.12.2009). The method consists in both bringing the papillary muscles closer together with opposing U-shaped sutures and moving the coaptation zone of the mitral valve leaflets towards the plane of the fibrous ring by bringing the papillary muscles closer together with the plane of the fibrous ring. The papillary muscles are brought closer to the fibrous ring by suturing the tops of the papillary muscles to the fibrous ring of the mitral valve by forming 4 neochords from polytetrafluoroethylene: 2 from the anterior papillary muscle - to the border of the posterior leaflet segments P1-P2; 2 from the posterior papillary muscle - to the border of the posterior leaflet segments P2-P3, while the pulling of the adjacent papillary muscles to the fibrous ring of the valve is dosed, calculating the length of the formed neochords using the formula:

Lнх=Lпфк+ln-hк,

where Lнx is the calculated length of the neochord;

Lпфк - the distance from the apex of the papillary muscle to the fibrous ring of the mitral valve (for the anterior papillary muscle - to the border of the posterior leaflet segments P1-P2; for the posterior papillary muscle - to the border of the posterior leaflet segments P2-P3);

ln - the distance from the top of the papillary muscle to the point of fixation of the beginning of the neochord;

hк - depth of coaptation of the mitral valve leaflets.

As the method of plastic surgery of subvalvular structures that we propose, it consists of bringing the papillary muscles together with a U-shaped suture.

However, this method does not eliminate the main cause of mitral regurgitation - mitral valve annuloectasia, in addition, this method requires precise measurements of the distance from the top of the papillary muscles to the fibrous ring of the mitral valve, the depth of co-optation of the mitral valve cusps, the distance from the top of the papillary muscle to the place of fixation of the neochord beginning, which is associated with technical difficulties, possible measurement errors, ineffectiveness of mitral regurgitation treatment. Also, fixation of neochords to the fibrous ring of the mitral valve can limit the opening of the mitral valve cusps, which will lead to the development of stenosis of the mitral valve, and as a consequence, the development of rhythm disturbances, the formation of blood clots in the left atrium, thromboembolism and the development of pulmonary hypertension.

The technical result of the claimed method is a decrease in the depth of co-optation and an increase in the line of co-optation of the mitral valve due to a decrease in the size of the left ventricle, a decrease in the size of the fibrous ring of the mitral valve, and the exclusion of lateral displacement of the papillary muscles due to their convergence reduces the likelihood of developing secondary mitral regurgitation in the postoperative period and, as a consequence, the restoration of the pumping function of the heart and a decrease in the degree of chronic heart failure.

A method for preventing secondary mitral regurgitation in patients with chronic heart failure and severe left ventricular dilation, consisting of plastic surgery of subvalvular structures, characterized in that papillary muscles are successively brought together with a U-shaped suture of non-absorbable braided polyfilament 2-0 thread on counter-spacers made of polytetrafluoroethylene and restrictive mitral annuloplasty with a support ring.

The claimed method is illustrated by the following materials:

Fig. 1 shows the sequence of execution of the claimed method of surgical intervention, namely:

1A - view of the mitral valve from a typical approach through the right atrium and interatrial septum,

1B - level of papillary muscle suturing,

1C - the final stage of convergence of the papillary muscles,

1D - restrictive mitral annuloplasty with MedInzh support ring No. 28, valve function is satisfactory.

Fig. 2 shows the sequence of execution of the claimed method for performing surgical intervention, namely:

2A - EchoCG 36 months after surgery (polytetrafluoroethylene spacers are visible, papillary muscles are brought together, valve function and contractility of the left ventricle are not impaired),

2B - results of MRI examination before surgery (LV in diastolic phase, distance between papillary muscles increased), End diastolic dimension of LV = 60 mm, Interpapillary distance = 32 mm in diastole,

2C - MRI results 12 months after surgery (LV in the diastolic phase, papillary muscles are brought together, during the specified observation period the LV decreased in size, which indicates the effectiveness of the technique), End-diastolic size of the LV = 42 mm, Interpapillary distance = 3 mm in diastole.

The essence of the claimed method consists in restoring the physiological size of the mitral valve by means of restrictive annuloplasty with a supporting ring and simultaneous convergence of the papillary muscles in patients with chronic heart failure and left ventricular dilation through a typical atriotomic approach.

This combination of new features will reduce the number of postoperative complications in the form of progression of chronic heart failure and development of secondary mitral regurgitation due to the effect on all links of pathogenesis, which include the elimination of lateral displacement of papillary muscles and simultaneous reduction of the left ventricle size, elimination of annuloectasia (expansion of the fibrous ring of the mitral valve). At the same time, the elimination of mitral regurgitation leads to a decrease in the preload of the left ventricle (stretching of the LV myocardium at the end of diastole), which leads to an increase in the contractility of the LV.

The applicant further provides an example of a specific implementation of the claimed method. The method is implemented as follows:

- a patient in the operating room,

- induction of anesthesia, tracheal intubation, catheterization of the central vein and radial artery,

- then, under conditions of neuroleptanalgesia, the surgical field is treated with an antiseptic solution, the surgical field is delimited,

- then a sternotomy is performed,

- then a pericardiotomy is performed,

- then systemic heparinization is carried out,

-then the artificial blood circulation machine is connected according to the scheme “superior vena cava + inferior vena cava - aorta”,

- then the aorta is clamped, a cardioplegic solution is administered, and cardiac activity is stopped,

- then surgical access to the mitral valve is performed, using a typical approach through the right atrium and interatrial septum. To do this, the wall of the right atrium is dissected with a wide incision, starting from the base of the auricle upwards to the atrioventricular groove,

- then the interatrial septum is dissected in the area of the oval fossa,

-then the incision is extended to the upper muscular limbus, without going beyond the interatrial septum,

- then the mitral valve is exposed using the Cooley cardiac hook, which is used for traction after placement in the left atrium,

- then visualization of the mitral valve is performed,

- then the surgeon should exclude pathology from the valves, papillary muscles and chords, make sure there are no visible defects of the valves, elongation and/or rupture of the chords, rupture of the papillary muscles,

- for this purpose, it is possible to conduct a preventive hydraulic test. For this, the middle part of the posterior leaflet is brought closer to the anterior leaflet with tweezers or a ligature and the LV cavity is filled with saline solution using a Janet syringe. Thus, the absence of regurgitation (the flow of saline solution through the mitral valve) indicates the advisability of mitral valve plastic surgery,

- then, to bring the papillary muscles closer together, non-absorbable braided polyfilament threads 2-0 and polytetrafluoroethylene pads (∅ = 10 mm) are used, while two pads are sufficient to perform this procedure, and one of the pads should initially be stitched with a U-shaped suture using the thread indicated above,

- then, under visual control, a surgical needle holder with a charged thread and a gasket is inserted into the cavity of the left ventricle through the mitral valve and the posteromedial papillary muscle is pierced (since it is located to the right in relation to the surgeon and at a greater distance) with a needle at the level of the middle part,

- then remove the needle and pull the thread to the middle,

- then the same needle is used to stitch the anterolateral papillary muscle. The same is done with the remaining end of the thread: the free needle is used to stitch the posteromedial papillary muscle (above the previous puncture),

- then the anterolateral papillary muscle is sutured,

- then the counter-pad is stitched and by tightening the knot the papillary muscles are brought closer to each other,

- when tightening the thread, the papillary muscles are brought together until they are completely closed, dosing the load so as to prevent the sutures from cutting through,

- in this case, for restrictive mitral annuloplasty, a semi-rigid support ring of a closed contour without deflection, 28 mm in size, is used (manufactured by MedInzh, https://medeng.ru/annuloplasty-ring),

- the fixation of the support ring is carried out with separate U-shaped sutures with non-absorbable braided polyfilament 2-0 threads with Teflon gaskets. U-shaped sutures are formed along the fibrous ring of the MV at an equal distance from each other, while the puncture is carried out from the side of the atrium at a distance of about 0.5 cm from the fibrous ring of the MV, the puncture is in the immediate vicinity of the fibrous ring of the MV,

- for the convenience of implantation of the support ring, the circumference of the MC can be conditionally divided into 3 sectors: the distance between the commissures behind the anterior leaflet, the distance between the posteromedial commissure to the middle of the posterior leaflet and the distance between the anterolateral commissure and the middle of the posterior leaflet. For successful implantation of the support ring, four U-shaped sutures are sufficient for each sector, which in total gives 12 U-shaped sutures,

- then, to assess the viability of the MC reconstruction, a hydraulic test is repeated, for which the LV cavity is filled with a saline solution using a Janet syringe,

- thus, in the absence of regurgitation (flow of saline solution through the mitral valve), a conclusion is made about the viability of mitral valve plastic surgery,

- then the surgical access is sutured,

- perform a stop of artificial circulation,

- postoperative drainage, hemostasis, and metal osteosynthesis of the sternum are performed sequentially,

- then the wound is sutured layer by layer,

- and apply an aseptic dressing.

Thus, the use of the proposed method in patients with chronic heart failure and left ventricular dilation allows preserving the native mitral valve, eliminating the main pathogenetic mechanisms of its insufficiency development: displacement of the papillary muscles in the lateral direction and an increase in the size of the fibrous ring of the mitral valve (annuloectasia).

An example of the implementation of an example of a specific implementation of the claimed method in the conditions of a surgical department in accordance with the actions described above

Patient N, 56 years old. IHD: angina pectoris 3 FC, post-infarction cardiosclerosis (2010, 2018). Mitral valve insufficiency st. 3. CHF IIA FC III according to NYHA. Coronary artery bypass grafting, mitral valve plastic surgery with a support ring and papillary muscle rapprochement were performed.

First, a preliminary stage was performed. Under combined endotracheal anesthesia, the surgical field was processed. A skin incision and sternotomy were performed, and conduits were collected for aortocoronary bypass. Under systemic heparinization, an artificial blood circulation machine was connected. The aorta was clamped with a transverse clamp. The heart was stopped with a crystalloid cardioplegic solution. The wall of the right atrium and the interatrial septum were dissected.

The following is a sequence of actions according to the claimed method (Fig. 1A-D).

In Fig. 1A, the mitral valve, anterolateral and posteromedial papillary muscles are visualized through a typical atriotomic approach. The fibrous ring of the mitral valve is dilated, the cusps are thin and unchanged, the distance between the papillary muscles is increased, which is a consequence of myocardial infarction and LV remodeling.

Fig. 1B shows the first stage of papillary muscle approximation - suturing of the papillary muscles with a U-shaped suture of non-absorbable braided polyfilament 2-0 thread on counter spacers made of polytetrafluoroethylene. Under visual control, a surgical needle holder with a loaded thread and a spacer is inserted into the cavity of the left ventricle through the mitral valve and the posteromedial papillary muscle is pierced (since it is located to the right in relation to the surgeon and at a more distant distance) with a needle at the level of the middle part. Then the needle is removed and the thread is pulled to the middle. The same needle is used to suture the anterolateral papillary muscle. The remaining end of the thread is treated similarly: the posteromedial papillary muscle (above the previous puncture) is suturing with a free needle, then the anterolateral papillary muscle is suturing.

Fig. 1C shows the result of bringing the papillary muscles together with a U-shaped suture of 2-0 non-absorbable braided polyfilament thread on opposing polytetrafluoroethylene pads. The muscles are brought together as much as possible, without cutting through the sutures or deforming the polytetrafluoroethylene pads.

Fig. 1D shows the result of restrictive mitral annuloplasty with a support ring after a hydraulic test - the LV cavity is filled with saline, valve function is restored, and there is no backflow of saline.

Next, the surgical access is sutured. In accordance with the coronary bed lesion, myocardial revascularization is performed - aortocoronary bypass. Then the clamp is removed from the aorta, artificial blood circulation is stopped. Hemostasis is performed, the postoperative wound is drained and sutured layer by layer. Aseptic dressing.

The postoperative period was uneventful. On the 11th day after the operation, the patient was discharged from the hospital in a satisfactory condition. According to the ultrasound examination at discharge, mitral regurgitation was absent.

Based on the above, it is possible to conclude that the claimed method provides the possibility of achieving the claimed technical results, namely:

- restoration of the physiological size of the mitral valve is ensured by restrictive annuloplasty with a supporting ring and simultaneous convergence of the papillary muscles in patients with chronic heart failure and left ventricular dilation through a typical atriotomic approach,

- the possibility of reducing the number of postoperative complications in the form of progression of chronic heart failure and development of secondary mitral regurgitation is ensured due to a combination of actions of the surgeon declared in an independent paragraph of the sequence of actions during the implementation of the declared method that is not obvious to the specialist.

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Claims (1)

A method for treating secondary mitral regurgitation in patients with chronic heart failure and left ventricular dilation, including plastic surgery of subvalvular structures, characterized in that surgical access to the mitral valve is achieved through the right atrium and interatrial septum, for which the wall of the right atrium is dissected with an incision that starts from the base of its auricle upwards to the atrioventricular groove, then the interatrial septum is dissected in the area of the oval fossa, the incision is extended to the upper muscular limbus, without going beyond the interatrial septum, the mitral valve is exposed using a Cooley cardiac hook, then pathologies from the cusps, papillary muscles and chords are excluded and there are no visible defects in the cusps, elongation or rupture of the chords, rupture of the papillary muscles, a preventive hydraulic test is performed, while the middle part of the posterior cusp is brought closer to the anterior cusp with tweezers or with a ligature and fill the cavity of the left ventricle with saline solution using a Janet syringe, in the absence of regurgitation - the flow of saline solution through the mitral valve, bring the papillary muscles closer together, using non-absorbable braided polyfilament sutures 2-0 and 2 polytetrafluoroethylene gaskets, while one of the gaskets is initially stitched with a U-shaped suture of non-absorbable braided polyfilament sutures 2-0, then under visual control, a surgical needle holder with a loaded thread and gasket is inserted into the cavity of the left ventricle through the mitral valve and the posteromedial papillary muscle is pierced with a needle at the level of the middle part, the needle is removed and the thread is pulled to the middle, then the anterolateral papillary muscle is stitched with the same needle, then with the remaining end of the thread and a free needle, the posteromedial papillary muscle above the previous puncture, then the anterolateral papillary muscle is sutured, the counter pad is sutured and the papillary muscles are brought closer to each other by tightening the knot, when tightening the thread, the papillary muscles are brought together, dosing the load, excluding the cutting of the sutures, then a restrictive mitral annuloplasty is performed using a semi-rigid support ring of a closed contour without deflection measuring 28 mm, while the fixation of the support ring is carried out with separate U-shaped sutures with non-absorbable braided polyfilament threads 2-0 with Teflon pads, U-shaped sutures are formed along the fibrous ring of the mitral valve at an equal distance from each other, while the puncture is made from the side of the atrium at a distance of 0.5 cm from the fibrous ring of the mitral valve, the puncture is made at the fibrous ring of the mitral valve, the circumference The mitral valve is conventionally divided into 3 sectors: the distance between the commissures behind the anterior leaflet, the distance between the posteromedial commissure to the middle of the posterior leaflet, and the distance between the anterolateral commissure and the middle of the posterior leaflet. Four U-shaped sutures are applied to each sector, then a hydraulic test is repeated, for which the cavity of the left ventricle is filled with a saline solution using a Janet syringe.