RU2811764C1 - Method of infracoronary extraannular implantation of aortic valve prosthesis - Google Patents

Abstract

FIELD: medicine; cardiovascular surgery.

SUBSTANCE: access to the native aortic valve is created by completely transecting the aorta along the line of the sinotubular ridge. Then the leaflets of the native aortic valve are excised. Then the outer wall of the aortic root - the area located under the coronary arteries is isolated from the surrounding tissues. Then, a pre-cut strip of Dacron 5 mm wide and 140 mm long is placed around the circumference of the aortic root along the line located under the coronary arteries. Excess Dacron strips are cut off and a continuous contour of Dacron strips is formed around the aortic root without creating any duplication at its ends. The cuff of the aortic valve prosthesis, the wall of the aortic root and the Dacron strip are stitched with 15 U-shaped sutures, while needles with a synthetic braided thread for implanting heart valves are inserted into the cuff of the aortic valve prosthesis in the “top-down” direction, the aortic wall is stitched “from inside to outside”, the needle is poked through a strip of Dacron. When forming U-shaped sutures, 5 U-shaped sutures are placed on each 1/3 of the circumference of the aortic valve prosthesis, and 5 U-shaped sutures are placed on each 1/3 of the circumference of the aortic root, while maintaining the same distance between adjacent injections. The aortic valve prosthesis is placed in the aortic root so that its cuff is at the level of the threads injected into the aortic wall and corresponds to the Dacron strip located outside the aortic root. The aortic valve prosthesis is fixed to the aortic root by tying U-shaped sutures.

EFFECT: without increasing the volume of the operation, the method of infracoronary extraannular implantation of an aortic valve prosthesis allows to implant an aortic valve prosthesis 1–2 seat sizes larger than what the basal ring of the aortic root can accommodate, thereby reducing the risk of developing the syndrome of “prosthetic valve mismatch with the patient”.

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Description

The aortic valve prosthesis should be placed exclusively in the space between the left ventricular cavity and the ostia of the coronary arteries (infracoronary position). Otherwise, a disruption of the physiology of the blood supply to the myocardium, incompatible with life, occurs [1, 2].

Traditionally, the aortic valve prosthesis is fixed to the fibrous annulus of the native aortic valve. In this case, the fibrous “ring” of the aortic valve is the set of semilunar lines of attachment of the leaflets of the native aortic valve to the aortic root. Depending on the location of the fixing sutures, the aortic valve prosthesis is placed either itraannularly (U-shaped suture on the side of the aortic root) or supraannularly (U-shaped suture on the side of the left ventricle) [3].

As a result of using the traditional method, the patient is implanted with an aortic valve prosthesis having an outer diameter (fitting size) corresponding to the diameter of the aortic root at the level of the basal ring (the circle passing through the lower points of the semilunar lines of the aortic root).

It is important to understand that the effective area of a normally formed and normally functioning aortic valve is also equal to the area of the aortic root at the level of the basal annulus.

A feature of all framed aortic valve prostheses is that the effective area of such a device is limited by the internal diameter of the frame holding the leaflets. Consequently, the effective area of the aortic valve prosthesis is always less than its seat diameter (the outer diameter of the frame holding the leaflets) equal to the diameter of the basal ring of the aortic root. Consequently, the effective area of a framed aortic valve prosthesis is always less than the effective area of a normally formed and normally functioning valve in this particular patient.

In this regard, after implantation of an aortic valve prosthesis, there is a risk of developing the syndrome of “mismatch of the valve prosthesis to the patient,” the essence of which is that the effective area of the orifice of the implanted prosthesis is less than what is necessary for the given patient. In this situation, the characteristics of the transprosthetic blood flow correspond to those with stenosis of the native aortic valve. As a result, the patient continues to progress in left ventricular remodeling, and chronic heart failure develops and progresses.

If, as a result of an aortic valve replacement operation, the development of a pronounced discrepancy between the prosthesis and the patient is predicted, then in order to implant an aortic valve prosthesis of adequate diameter, the scope of surgical intervention is supplemented with annulodilator plasty of the aortic root. Increasing the volume of surgery entails the risk of developing specific, including life-threatening, complications.

The developed method of infracoronary extraannular implantation of an aortic valve prosthesis allows, without increasing the volume of the operation, to implant an aortic valve prosthesis 1-2 seat sizes larger than what the basal ring of the aortic root can accommodate, thereby reducing the risk of developing the syndrome of “prosthetic valve mismatch with the patient.”

As a prototype, we used the existing generally accepted method of aortic valve replacement, which includes creating access to the native aortic valve by completely transecting the aortic root along the line of the sinotubular ridge, excision of the native aortic valve cusps, stitching with U-shaped sutures using synthetic braided threads for implantation of fibrous heart valves “rings” of the aortic valve, stitching the cuff of the aortic valve prosthesis with threads of the same sutures, fixing the aortic valve prosthesis by tying U-shaped sutures with threads, restoring the integrity of the aortic wall.

The method of infracoronary extraannular implantation of an aortic valve prosthesis, similar to the prototype method, involves creating access to the native aortic valve by completely transecting the aorta along the line of the sinotubular ridge, after which the leaflets of the native aortic valve are excised. The difference between the developed method of infracoronary extraannular implantation of an aortic valve prosthesis is that the outer wall of the aortic root, the area located under the coronary arteries, is isolated from the surrounding tissues. A pre-cut strip of Dacron, 5 mm wide and 140 mm long, is then placed around the circumference of the aortic root along the line underneath the coronary arteries. Next, the excess Dacron strip is cut off and a continuous contour of the Dacron strip is formed around the aortic root, without forming a duplication at its ends. Then the cuff of the aortic valve prosthesis, the wall of the aortic root and the Dacron strip are stitched with 15 U-shaped sutures, while needles with a synthetic braided thread for implanting heart valves are inserted into the cuff of the aortic valve prosthesis in the “top-down” direction, the aortic wall is stitched “ from inside to outside,” the needle is poked through a strip of Dacron. In this case, when forming U-shaped sutures, 5 U-shaped sutures are placed on each 1/3 of the circumference of the aortic valve prosthesis, and 5 U-shaped sutures are placed on each 1/3 of the circumference of the aortic root, while maintaining the same distance between adjacent injections . The aortic valve prosthesis is placed in the aortic root so that its cuff is at the level of the threads injected into the aortic wall and corresponds to the Dacron strip located outside the aortic root. The aortic valve prosthesis is fixed to the aortic root by tying U-shaped sutures.

Clinical example

Patient L., born in 1967 Height 158 cm, weight 88 kg, body mass index 35.3, body surface area 1.97. According to echocardiography, moderate aortic valve stenosis was diagnosed due to calcification of the aortic valve leaflets. The diameter of the aortic root at the level of the basal ring is 20-21 mm. The average gradient across the aortic valve was 34 mm Hg, and the transvalvular flow velocity was 3.3 m/s. To reduce the risk of developing the “valve prosthesis mismatch” syndrome, the patient must be implanted with an aortic valve prosthesis with a prosthetic orifice diameter of at least 18 mm, which corresponds to a mechanical prosthesis with an outer diameter of at least 23 mm. However, the size of the aortic root at the level of the basal ring is such that without expanding the scope of the operation, the patient can be implanted with a prosthesis whose outer diameter does not exceed 21 mm. In this regard, a decision was made to use the method of infracoronary extraannular implantation of an aortic valve prosthesis. As a result of the operation performed in full accordance with the method described in the invention, a mechanical prosthetic aortic valve was implanted with an outer diameter of 23 mm, a diameter of the valve opening of 18.31 mm, and an area of the effective opening of the valve prosthesis of 2.63 cm ² . According to an echocardiographic study performed in the postoperative period, the blood flow velocity on the aortic valve prosthesis was 2.7 m/s, the average transprosthetic gradient was 12 mm Hg.

Bibliography

1. Michel, M. Supra-coronary Aortic Valve in a Pig Model with Severe Aortic Insufficiency / M. Michel, J. W. Pratt. — Text: direct // Chest. - 2004. - No. 126 (4), suppl. 856S.

2. Aortic Valve Translocation for Severe Prosthetic Valve Endocarditis: Early Results and Long-Term Follow-Up / R. Nottin, N. Al-Attar, R. Ramadan [et al.]. — Text: direct // The Annals of Thoracic Surgery. - 2005. - No. 79(5). - pp. 1486-1490.

3. Aortic valve replacement / Yu. V. Belov, G. I. Salagaev, A. V. Lysenko, P. V. Lednev. — Text: direct // Surgery. - 2017. - No. 11. - P. 56-59.

Claims (1)

A method of infracoronary extraannular implantation of an aortic valve prosthesis, including the formation of access to the native aortic valve by completely transecting the aorta along the line of the sinotubular ridge, after which the cusps of the native aortic valve are excised, characterized in that the outer wall of the aortic root is isolated from the surrounding tissues - the area located under the coronary arteries; along the circumference of the aortic root along the line located under the coronary arteries, a pre-cut strip of Dacron 5 mm wide and 140 mm long is placed; cut off the excess Dacron strip and form a continuous contour from the Dacron strip around the aortic root, without forming a duplication at its ends, after which the cuff of the aortic valve prosthesis, the wall of the aortic root and the Dacron strip are stitched with 15 U-shaped sutures, while the needles are a synthetic braided thread for implanting heart valves is injected into the cuff of the aortic valve prosthesis in the “top-to-bottom” direction, the aortic wall is sutured “inside-out”, the needle is poked out through a strip of Dacron; in this case, when forming U-shaped sutures, 5 U-shaped sutures are placed on each 1/3 of the circumference of the aortic valve prosthesis, and 5 U-shaped sutures are placed on each 1/3 of the circumference of the aortic root, while maintaining the same distance between adjacent injections ; the aortic valve prosthesis is placed in the aortic root so that its cuff is at the level of the threads injected into the aortic wall and corresponds to the Dacron strip located outside the aortic root; The aortic valve prosthesis is fixed to the aortic root by tying U-shaped sutures.