RU2846398C1 - Method for infraannular implantation of a valve-containing prosthesis of the ascending aorta - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention relates to cardiac surgery and can be used as a method for infraannular implantation of a valve-containing prosthesis (conduit) of the ascending aorta. Cuff of the aortic valve prosthesis of the valve-containing conduit is underrun with U-sutures without pads in the bottom-up direction; the same sutures are used to suture a fibrous ring of the aortic valve from a left ventricular cavity. Valve-containing conduit is brought down into the left ventricular cavity so that the prosthetic aortic valve cuff is placed in the infraannular position in relation to the fibrous ring of the aortic valve. Valve-containing conduit is fixed to the left ventricular outflow tract by knotting the U-sutures.

EFFECT: method allows to completely wrap the conduit cuff with the own tissues of the aortic root, thereby reducing the risk of paraprosthetic bleeding; besides placing the cuff below the level of the semilunar line of the base of the native cusps of the aortic valve, which will provide even with the low location of the coronary artery mouths, their location opposite the free wall of the ascending aortic prosthesis, and not opposite the cuff of the aortic valve prosthesis of the valve-containing conduit, which will prevent intra- and postoperative complications.

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Description

The invention relates to cardiac surgery and can be used as a method for infraannular implantation of a valve-containing prosthesis (conduit) of the ascending aorta.

A method for replacing the ascending aorta with a valve-containing prosthesis is known, described in 1968 by H. Bentall and A. DeBono [1 Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23(4):338-339]. This method is accepted as an analogue.

To date, many modifications of the Bentall-DeBono operation have been proposed. The authors of all existing modifications aimed to attempt to solve the problems of paraprosthetic bleeding and reimplantation of the coronary artery orifices [2-7]. The total number of modifications, as well as the fact that they continue to appear to this day, is evidence of the absence of a radical solution to the problem.

A method for replacing the ascending aorta with a valve-containing prosthesis proposed by Nicholas T. Kouchoukos is known [8 Nicholas T. Kouchoukos, Marc Haynes, Joshua N. Baker. The Button Bentall Procedure. Operative Techniques in Thoracic and Cardiovascular Surgery, Volume 23, Issue 2, 50 - 61]. The technology for performing the operation proposed by Nicholas T. Kouchoukos was used as a prototype for the method of infraannular implantation of a valve-containing prosthesis of the ascending aorta.

The prototype operation includes the following stages of fixation of the valve-containing prosthesis: excision of the tissues of the ascending aorta; excision of the aortic valve cusps; cutting out the orifices of the coronary arteries while preserving a 5 mm wide rim of aortic root tissue; suturing the fibrous ring of the aortic valve with U-shaped sutures on gaskets with placement of the gaskets in the lumen of the left ventricle; suturing the cuff of the aortic valve prosthesis of the valve-containing conduit with threads of the same U-shaped sutures; placement of the valve-containing prosthesis in a supraannular position in relation to the fibrous ring of the aortic valve; fixation of the valve-containing prosthesis by tying knots of the U-shaped sutures. In this case, the knots of the U-shaped sutures are tied above the cuff of the aortic valve prosthesis of the valve-containing conduit.

The next stage of the prototype operation is cutting holes in the aortic prosthesis of the valved conduit, implanting the coronary artery orifices into the holes cut in the aortic prosthesis of the valved conduit, and forming an anastomosis between the distal end of the valved conduit and the proximal end of the aortic arch.

The disadvantages of the method of fixing the valve-containing conduit during the prototype operation are the risk of bleeding associated with blood leakage between the cuff of the aortic valve prosthesis and the native tissues of the aortic root, as well as the difficulty of implanting the coronary artery orifices into the aortic prosthesis of the valve-containing conduit when they are located low. Low location of the coronary artery orifices is a variant of the anatomical structure of the aortic root, when the coronary artery orifices are located directly near the semilunar line of the base of the aortic valve cusps. In this case, the difficulty of implanting low-positioned coronary artery orifices is primarily due to the fact that after fixing the valve-containing conduit, the orifices are located opposite the cuff of the aortic valve prosthesis, which necessitates their displacement, which is associated with the risk of myocardial infarction.

The described invention is intended to eliminate the shortcomings of the prototype method.

The aim is to improve the results of ascending aortic replacement with a valved conduit by reducing the risk of paraprosthetic bleeding.

The technical result consists in that the cuff of the aortic valve prosthesis of the valve-containing conduit is sutured with U-shaped sutures using threads without pads in the direction from bottom to top; the same threads are used to suture the fibrous ring of the aortic valve in the direction from the cavity of the left ventricle; the valve-containing conduit is lowered into the cavity of the left ventricle in such a way that the cuff of the aortic valve prosthesis is located in an infraannular position relative to the fibrous ring of the aortic valve; the valve-containing conduit is fixed to the outflow tract of the left ventricle by tying knots of the U-shaped sutures.

Fig. 1. Scheme of the process of fixation of the valve-containing conduit of the ascending aorta: 1 - the mouths of the coronary arteries,

2 - remaining aortic root tissue after resection,

3 - cuff of the aortic valve prosthesis of the valve-containing conduit,

4 - threads of U-shaped seams,

5 - fibrous ring of the aortic valve.

The method is carried out as follows.

In the ascending part of the thoracic aorta, the root containing the aortic valve and the tubular segment are distinguished.

Aortic aneurysm is a disease characterized by an increase in the diameter of any of its sections by 50% or more.

The incidence of patients with thoracic aortic aneurysm is 5-10 per 100,000 patients. Of these, at least 60% of patients have either the aortic root or the entire ascending aorta involved in the process.

A valve-containing prosthesis (conduit) is a device consisting of an aortic valve prosthesis and an ascending aortic prosthesis fixed to it.

The method of infraannular implantation of a valve-containing prosthesis (conduit) of the ascending aorta is carried out by excising the tissues of the ascending aorta; excising the aortic valve cusps, cutting out the orifices of the coronary arteries while preserving a 5 mm wide border of aortic root tissues. Then, the cuff of the aortic valve prosthesis of the valve-containing conduit is sutured with U-shaped sutures using threads without pads in the direction from bottom to top. Then, the same threads are used to suture the fibrous ring of the aortic valve in the direction from the left ventricular cavity. Then, the valve-containing conduit is lowered into the left ventricular cavity in such a way that the cuff of the aortic valve prosthesis is located in the infraannular position relative to the fibrous ring of the aortic valve. Next, the valve-containing conduit is fixed to the outflow tract of the left ventricle by tying U-shaped sutures.

The further course of the operation includes cutting holes in the aortic prosthesis of the valved conduit, implantation of the coronary artery orifices into the holes cut in the aortic prosthesis of the valved conduit, and formation of an anastomosis between the distal end of the valved conduit and the proximal end of the aortic arch.

The method is confirmed by the following examples.

Example 1. Patient A., 45 years old. Computed tomography in the angiography mode revealed an aneurysm of the root and tubular segment of the ascending aorta. The anatomical feature of the patient's aortic root was a low position of the orifice of the left coronary artery trunk: the distance from the base of the aortic valve leaflet to the lower edge of the orifice of the left coronary artery trunk was 3 mm. The maximum diameter of the ascending aorta was 60 mm. According to echocardiography, the patient has grade 3 bicuspid aortic valve insufficiency. According to coronary angiography, there is no pathology of the coronary arteries of the heart. Thus, the patient is indicated for surgical intervention in the volume - prosthetics of the root and ascending aorta using a valved conduit. During revision of the aortic root during the operation, the low position of the orifice of the left coronary artery trunk was confirmed. During the operation, the method of infraannular implantation of the valve-containing prosthesis (conduit) of the ascending aorta was used, due to which it was possible to avoid disposition of the left coronary artery trunk during its reimplantation into the valve-containing conduit. Otherwise, when performing prosthetics of the ascending aorta with a valve-containing conduit according to the Bentall-DeBono method modified by Nicholas T. Kouchoukos, the orifice of the left coronary artery trunk after fixation of the conduit would be immediately opposite the cuff of the aortic valve prosthesis. During the operation, the cuff of the aortic valve prosthesis of the valve-containing conduit is sutured with U-shaped sutures using threads without pads in the direction from bottom to top; the same threads are used to suture the fibrous ring of the aortic valve in the direction from the cavity of the left ventricle; the valve-containing conduit is lowered into the cavity of the left ventricle in such a way that the cuff of the aortic valve prosthesis is located in an infraannular position relative to the fibrous ring of the aortic valve; the valve-containing conduit is fixed to the outflow tract of the left ventricle by tying U-shaped sutures.

Intraoperative blood loss was 300 ml. The postoperative period was uneventful. The patient was discharged from the hospital on the sixth day after the operation. Before discharge and 6 months after the operation, the patient was followed up. During the follow-up examination, which included transthoracic echocardiography and computed tomography in the angiography mode, it was established that, being fixed in the infra-annular position, the aortic valve prosthesis does not compromise the anterior leaflet of the mitral valve, the configuration of the left ventricular outflow tract is unchanged, the lower edges of the coronary artery orifices are located more than 5 mm above the aortic valve prosthesis, the function of the aortic valve prosthesis is satisfactory (mean gradient = 12 mm Hg).

Example 2. Patient M., 49 years old. Based on computed tomography in the angiography mode, the patient was found to have an aneurysm of the root and tubular segment of the ascending aorta. The anatomical feature of the patient's aortic root was a low position of the orifice of the left coronary artery trunk: the distance from the base of the aortic valve leaflet to the lower edge of the orifice of the left coronary artery trunk was 2.5 mm. The maximum diameter of the ascending aorta was 62 mm. Based on echocardiography data, the diagnosis was: grade 3 bicuspid aortic valve insufficiency. There is no pathology of the coronary arteries according to coronary angiography data. The patient is indicated for surgical intervention in the amount of prosthetic replacement of the root and ascending aorta using a valved conduit. During the operation, during revision of the aortic root, the low position of the orifice of the left coronary artery trunk was confirmed. The operation was performed using the claimed method - the method of infraannular implantation of a valve-containing prosthesis (conduit) of the ascending aorta, due to which it was possible to avoid disposition of the left coronary artery trunk during its reimplantation into the valve-containing conduit. During the operation, the cuff of the aortic valve prosthesis of the valve-containing conduit is sutured with U-shaped sutures using threads without pads in the direction from bottom to top; the same threads are used to suture the fibrous ring of the aortic valve in the direction from the cavity of the left ventricle; the valve-containing conduit is lowered into the cavity of the left ventricle in such a way that the cuff of the aortic valve prosthesis is located in the infraannular position relative to the fibrous ring of the aortic valve. The valve-containing conduit is fixed to the outflow tract of the left ventricle by tying knots of the U-shaped sutures.

Intraoperative blood loss was 300 ml. The postoperative period was uneventful. The patient was discharged from the hospital on the seventh day after the operation. Before discharge and 6 months after the operation, the patient was examined again. When performing transthoracic echocardiography and computed tomography in the angiography mode, it was found that, being fixed in the infra-annular position, the aortic valve prosthesis does not compromise the anterior leaflet of the mitral valve, the configuration of the left ventricular outflow tract is not changed, the lower edges of the coronary artery orifices are located more than 4 mm above the aortic valve prosthesis, the function of the aortic valve prosthesis is satisfactory (the average gradient is 11 mm Hg).

The proposed method of infraannular implantation of a valve-containing prosthesis (conduit) of the ascending aorta provides the following advantages:

1) The cuff of the aortic valve prosthesis of the valve-containing conduit is completely wrapped in the aortic root's own tissues, thereby reducing the risk of paraprosthetic bleeding;

2) In case of blood leakage between the U-shaped sutures, the bleeding can be eliminated without re-clamping the aorta by suturing the remaining tissues of the fibrous ring of the aortic root directly to the prosthesis of the ascending aortic valve-containing conduit;

3) The cuff of the aortic valve prosthesis of the valve-containing conduit is located below the level of the semilunar line of the base of the native aortic valve cusps. Consequently, even with a low position, the orifices of the coronary arteries are located opposite the free wall of the ascending aorta prosthesis, and not opposite the cuff of the aortic valve prosthesis of the valve-containing conduit.

Surgical treatment according to the claimed method was performed on 85 patients. No bleeding was observed during the operation, which confirms the achievement of the purpose of the invention.

Claims (1)

A method for infraannular implantation of a valve-containing prosthesis of the ascending aorta, which includes excision of tissue of the ascending aorta and the aortic valve cusp; then cutting out the orifices of the coronary arteries while preserving a 5 mm wide border of aortic root tissue, characterized in that the cuff of the aortic valve prosthesis of the valve-containing conduit is stitched with U-shaped sutures using threads without pads in the direction from bottom to top; the same threads are used to stitch the fibrous ring of the aortic valve in the direction from the cavity of the left ventricle; the valve-containing conduit is lowered into the cavity of the left ventricle in such a way that the cuff of the aortic valve prosthesis is located in an infraannular position relative to the fibrous ring of the aortic valve; the valve-containing conduit is fixed to the outflow tract of the left ventricle by tying knots of the U-shaped sutures.