Method for intraoperative assessment of coronary bypass leak

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to cardiosurgery. The bypass blood flow is assessed with assisting artificial circulation and clamped aorta. After a distal anastomosis is created, the bypass is connected to a heart and lung apparatus by means of an intravenous infusion system. Each anastomosis is assessed successively.

EFFECT: method enables the intraoperative assessment of the blood flow in the bypasses and the inspection of the dysfunctional anastomosis before unclamping the aorta and applying cardioplegic solution additionally.

3 dwg

 

The invention relates to medicine, namely to cardiosurgery, and can be used for intraoperative diagnosis of insolvency coronary bypass grafts.

According to many authors occlusion of shunts may occur during an operation in 4-12% of patients [1, 2, 3]. At the time of discharge from the hospital, this figure reaches 5-20% and increases to 30% in the first year [4]. Impaired function of the shunts in turn leads to early postoperative complications such as recurrence of angina, myocardial infarction, malignant arrhythmia [5]. In many cases the failure of shunts is a consequence of errors in surgical technique, respectively, these figures could be reduced by improving the quality of coronary bypass surgery.

Known methods of intraoperative assessment of the function of the shunt, such as echocardiography and coronary angiography. Intraoperative transesophageal echocardiography is used to identify areas of violation of local contractility of the myocardium, which indirectly indicate the insolvency of the shunt. The disadvantage of this method is its low information if you have the original cardiosclerosis in the area of responsibility of the shunt or if you use this method at the stage of reperfusion before stopping artificial circulation. Coronary angiog�afia is the "gold standard" for assessment of coronary grafts [6, 7]. This method provides visualization of blood flow within the shunt allows blood flow to be assessed in line shunted arteries, thus reflects the quality of the formed anastomosis. However, the intraoperative use of angiography is limited due to the need of the organization equipped with a hybrid lab. In addition, the development of complications associated with invasive techniques and the use of nephrotoxic contrast agents [8, 9].

Known the closest in technical essence is a method of intraoperative studies of the coronary shunts (patent No. 2481059, published on 10.05.2013. As proposed by us method of intraoperative studies of the coronary shunts is ultrasound scanning transplants. However, this method is only applicable after the completion of the main phase of the operation, the termination of cardiopulmonary bypass, in conditions of stable hemodynamics and preobladanie strict rules of measurement (the location of the sensor at an angle of 45° to the axis of the shunt at a distance of 10-15 mm, limiting the mobility of the shunt, the presence of fluid in the pericardial cavity).

The technical result of the proposed method is the possibility to exclude the impairment of blood flow in coronary shunts during the main phase of the operation before removal of the aortic clamp�.

The essence of the proposed method lies in the fact that ultrasound assessment of coronary grafts, according to the invention, is carried out in conditions of artificial blood circulation and parizatoi the aorta, while in the case of a sequential bypass grafting are making consistent assessment of each anastomosis, arteriovenous shunting of measurements carried out after the connection of the arteriovenous shunt to the circuit extracorporeal circulation system for intravenous infusion.

This combination of new signs will reduce the number of early postoperative complications such as recurrent myocardial infarction, recurrent angina, and arrhythmias.

The method is as follows.

The measurement is carried out using a flowmeter VeryQ MediStim®(Oslo, Norway) after the formation of each anastomosis sensors 1.5-3 mm (frequency of 3.7 MHz). In the case of a sequential bypass conduit was closed distal anastomosis clamp debate. When the arteriovenous shunting of the measurement is performed after the formation of the distal anastomosis and the connection of the arteriovenous shunt to the circuit of the heart-lung machine. For these purposes a system for intravenous infusion needle and debate. Needle debaki injected into the lumen of the autologous vein and fixed with a ligature. From system nutrion�th infusion separate air filter, keep a part of the tubing with a cannula. Free from the cannula end of the tube is connected to a three-way cock of the arterial cannula. Prevention of air embolism connect the tube with the needle debate, carry out short-term start of blood flow through the shunt. During start-up of the blood flow perform measurements of hemodynamic parameters in autovenous the conduit.

A control measurement is carried out after the end of IR and inactivation of anticoagulants, when the systolic pressure is 100-110 mm Hg.PT.

To describe the parameters of blood flow using the following indicators:

1) average volumetric flow rate (Qmean) - average value of all the average values over one cardiac cycle in a certain period of time (on the spectrum, the program displays these values in the form of transverse lines of red color);

2) the index pulsation (PI) - reflects the state of the peripheral segments of the coronary arteries, peripheral vascular resistance to flow;

3) DF ("predominantly diastolic flow") is the fraction diastolic volume of blood flow in the total volumetric flow during one cardiac cycle, expressed as a percentage.

An example of the method

Patient N., aged 56. Produced a revision of anastomosis "end-to-side between LUGA and the PNA. Revealed bundles of the vascular wall in the distal part of LUGA. The problem is resolved by excision of the distal fragment of LUGA � re-formation of the anastomosis "end to side".

Fig.1, 2 and 3 shows graphs flowmetrics curves for the shunt.

Fig.1 shows the decrease of the volumetric flow rate (Qmean=4 ml min-1), increased peripheral resistance indices (PI=4) and the appearance of a diastolic phase of blood filling of the conduit (DF=70%).

During the revision of the anastomosis revealed a dissection of the distal part of LUGA. After the removal of the broken fragment of the artery and re-formation of the anastomosis obtained satisfactory blood flow parameters. Fig.2 shows programme shunt LUGA - PNA after revision of anastomosis: Qmean=84 ml min-1; PI=0,2; diastolic phase of the blood supply is absent.

Fig.3 shows Pogramme shunt LUGA - PNA after stopping artificial circulation: Qmean=83 ml min-1; PI=1,6; DF=75%.

Sources of information

1. Alderman, E. L. Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial / E. L. Alderman, J. H. Levy, J. B. Rich // The Journal of Thoracic and Cardiovascular Surgery - 1998. - No. 116. - P. 716-730.

2. Goldman, S. Department of Veterans Affairs Cooperative Study Group. Starting aspirin therapy after operation. Effects on early graft patency / S. Goldman, J. Copeland, Moritz T // Circulation 1991. - No. 84. - P. 520-526.

3. Poirier, N. C. Quantitative angiographic assessment of coronary anastomoses performed without cardiopulmonary bypass // N. C. Poirier, M. Carrier, J. Lesperance // The Journal of Thoracic and Cardiovascular Surgery - 1999. - No. 117. - P. 292-297.

4. Alexander, J. H. Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass grft surgery: PREVENT IV: a randomized controlled trial / J. H. Alexander, G. Hafley, R. A. Harrington, et al. // Journal of the American Medical Association - 2005. - No. 294. - P. 2446-2454.

5. Taggart, D. P. Biochemical assessment of myocardial injury after cardiac surgery: effects of a platelet activating factor antagonist, bilateral internal thoracic artery grafts, and coronary endarterectomy / D. P. Taggart // The Journal of Thoracic and Cardiovascular Surgery - 2000. - No. 120. - P. 651-659.

6. Leacche, M. grafts Intraoperative assessment / M. Leacche, J. M. Balaguer, J. G. Byrne // Seminars in Thoracic and Cardiovascular Surgery - 2009. - No. 21. - P. 207-212.

7. Mack, M. J. Intraoperative coronary graft assessment / M. J. Mack // Current Opinion in Cardiology - 2008. - No. 23. - P. 568-572.

8. Zhao, D. X. Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room / D. X. Zhao, M. Leacche, J. M. Balaguer, Boudoulas, K. D., et al. // Journal of the American Collage of Cardiology - 2009. no.53. - P. 232-241.

9. Hol, P. K. Intraoperative angiography leads to graft revision in coronary artery bypass surgery / P. K. Hol, Lingaas PS, R. Lundblad, et al. // The Annals of Thoracic Surgery - 2004. no.78. - P. 502-505.

Method of intraoperative assessment of insolvency, coronary shunts, consisting of ultrasound grafts, characterized in that the evaluation of blood flow in the shunt is carried out in conditions of artificial blood circulation and parizatoi the aorta, which after the formation of the distal anastomosis to connect the shunt to the circuit extracorporeal circulation system for intravenous infusion, if necessary, conduct a sequential evaluation of each anastomosis.



 

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