Method for predicting end-diastolic and stroke volumes and choosing the method for plasty of left ventricle in case of postinfarction cardiac aneurysms

FIELD: medicine, cardiovascular surgery.

SUBSTANCE: one should carry out left-hand ventriculography, measure end-diastolic, end-systolic volumes, ejection fraction, ejection fraction of contracting segment. Additionally, one should measure basal-apical size of left ventricle without capturing aneurysm, the largest cross-sectional diameter of left ventricle without capturing aneurysm into ventricular systole and diastole. One should repeatedly conduct ventriculography in left-hand oblique caudal (45 degrees and 50 degrees) projection. One should chooses tactics for operations - myocardial revascularization and dissection of aneurysm without a patch or with patch plasty - by the values of necessary and predicted stroke and end-diastolic volumes. At the value of predicted end-diastolic volume being below the value of necessary end-diastolic one, or the value of predicted stroke volume being below the value of necessary stroke one should carry out myocardial revascularization and dissection of aneurysm at patch plasty. Application of the innovation enables to objectively detect the method of left-ventricular plasty before operation.

EFFECT: higher accuracy of prediction.

3 dwg, 2 ex

 

The present invention relates to medicine, namely, cardiovascular surgery, and can be used to select the method plastics left ventricle myocardial aneurysms of the heart.

The formation of aneurysms of the left ventricle significantly worsens the prognosis of coronary heart disease. Five-year survival rate of such patients is reduced to 25-52% when isolated conservative therapy. Generally poor prognosis of the disease is associated with depletion of compensatory mechanisms, the development of heart failure, low ejection fraction of the left ventricle. In addition, left ventricular aneurysm potentially thrombogenic and in 40% of cases patients have transient episodes of embolism arterial bed. On this basis, the role of surgical treatment of aneurysms of the heart to improve hemodynamics and thereby reducing heart failure, improve prognosis and quality of life of such patients. Known surgical excision of the aneurysm with the plastic of the left ventricle are not always stable results in the absence of a clear angiographic criteria for assessing possible excision of the aneurysm. Excessive excision of the scar leads to severe diastolic dysfunction of the left ventricle in the early postoperative period. To avoid this the apply various patches to compensate for the required end-diastolic volume. The need to use the patches selected by the surgeon, usually from their own experience.

There is a common way intraoperative selection of the necessary patches. On Salati you need to create the length of the longitudinal axis of the left ventricle more than 7 cm, and the diameter of the patch not less than 5 cm (Salati M, Di Biasti P., Page, A., et al. Severe diastolic dysfunction after endoventriculoplasty// J.Thorac. Cardiovasc. Surj. 1995. Vol.7. P.574-579).

The drawback of the proposed methods, based on calculations of echocardiography, is that they do not always reflect the true state of the geometry of the left ventricle. Way to adequately make the choice of plastic based on the data of x-ray contrast studies in the available literature.

Closest to the invention by a combination of traits is the way A. M. Cherniavsky, Krasikova A. M. (A. M. Cherniavsky, Karaskov A. M., Marchenko, A.V., Chapaev S.A. Reconstructive surgery post-infarction aneurysm of the left ventricle. - Novosibirsk: Publishing house of SB RAS, branch "geo", 2003). The authors developed a method for pre-operative simulation of the left ventricle. The essence of the method lies in the echocardiographic assessment of contractile function nenavistnicheskih of the left ventricle, determining the optimal end-diastolic volume of the left ventricle, the definition of the area off the I of left ventricular aneurysm. The method requires intraoperative measurement of the surface area of the scar area of the aneurysm and comparison with preoperative calculated allowable square off. On the basis of comparison is the choice of the method of sculpture.

The disadvantages of this method are:

- the need for intraoperative measurement of the area of the scar, and therefore tactics operations finally determined only after its commencement;

the subjectivity of the method of echocardiography;

- the need to dorisovyvanie path of future ventricular doctor, producing research based on their own experience, which is very subjective and determines the large error in the calculation of the volume of the proposed method.

The technical result of the invention is the preoperative determination of the tactics of surgical treatment, the simplification of the way, increasing its objectivity.

Total for the proposed object of the invention and the method Cherniavsky are: visualization of the left ventricle, the choice of plastics depending on the end-diastolic volume, the definition of the original surface area of the left ventricle and the projected surface area of the left ventricle after resection of the aneurysm.

The main differences of the proposed method:

1. Visualization of the left ventricle by using Bhaktivinoda method: left ventriculography.

2. Calculations of the area are less time-consuming method.

3. The surface area of the left ventricle is determined on the basis of data obtained by measuring the size of the aneurysm, there is no need for subjective determination of the contour plan of the left ventricle.

4. Based on these calculations produce the selection method plastics individually for each patient and with high precision.

This technical result is achieved by the fact that they left ventriculography to measure end-diastolic, end-systolic volumes, ejection fraction, ejection fraction shrinking segment, additionally measured of the basal-apical size of the left ventricle without capture of the aneurysm, the largest transverse diameter of the left ventricle without capture aneurysm in the systole and diastole of the ventricles, to estimate the area of the defect after excision of the aneurysm determine the size of the aneurysm along the basal-apical size of the left ventricle and the height of the defect, re-conduct ventriculography in the left oblique 45 degrees and 50 degrees caudal projection, measure the transverse size of the aneurysm, calculate the lengths of the semiaxes of the left ventricle and the base of the aneurysm, then the area of the defect after excision of the aneurysm, the surface area of the left ventricle, calculate the necessary udarn the second volume and the required end-diastolic volume, determine the projected end-diastolic volume and the predicted stroke volume; when the value of the predictable end-diastolic volume that is equal to or larger values are required in the end-diastolic volume, and the value predicted stroke volume equal to or greater required stroke volume, the tactics of the operation is reduced to revascularization and excision of the aneurysm without patch; with the value predicted end-diastolic volume, the smaller value of the required end-diastolic volume, or the value predicted stroke volume, smaller values are required stroke volume, perform myocardial revascularization and excision of the aneurysm with the plastic patch.

The proposed method is as follows: all patients with coronary heart disease before reconstructive operations performed coronary angiography and left ventriculography as the gold standard examination on the basis of which it is possible to determine the extent and localization of lesions of the coronary vessels, Hypo-, a-, dyskinesis of the left ventricular wall. Left ventriculography performed according to the following scheme: after processing the surgical field and local anesthesia designated puncture of the femoral artery (1 cm below Papatowai ligament) according to Seldinger set Introducer, h is the cut which probe the Pigtail is held in the left ventricle. Produce opacification of the left ventricle from angiographic automatic syringe contrast omnipak or Ultravist rate of 1 ml per kg of body weight of the patient, with the speed of 17-18 ml/s During contrasting write a series of radiographs in the right oblique projection 30 degrees at 0 degrees cranially. The recording speed of 25 frames per second. After contrasting the heart is placed radiopaque ball of known diameter, which is recorded on x-rays for calibration measurements. In addition to conventional measurements of end-diastolic (EDV0), end-systolic (ESV0) and stroke volume (SV0), ejection fraction (EF0), ejection fraction shrinking segment (EFwm) additionally measure the largest transverse dimension of the left ventricle without capture aneurysm in the systole (as2) 1, the largest transverse dimension of the left ventricle without capture aneurysm in diastole (ad2) 2, the largest longitudinal dimension of the left ventricle in systole (bs2) 3 and diastole (bd2) 4. To estimate the area of the defect after excision of the aneurysm determine the size of the aneurysm along the basal-apical size of the left ventricle (Aa2) 5 and the height of the defect (h) 6 (1, 2). To determine the transverse size of the aneurysm using advanced left oblique 45 degrees and 50 degrees caudal projection, in which is conducted the recording of a series of radiographs when you contrast enhancement of the left ventricle. Using radiopaque balloon produce a re-calibration due to changes in focal length x-ray tube. The selected projection allows you to visualize and the transverse size of the aneurysm (ba2) 7, and, when spuriousness right oblique projection, the height of the defect in excision of the aneurysm (h) 6 (3).

Based on these measurements, carried out the calculations:

1. Calculate the lengths of the semiaxes of the left ventricle and the base of the aneurysm

as=as2/2, bs=bs2/2, ad=ad2/2, bd=bd2/2, aa=aa2/2, ba=ba2/2,

where as is the semiminor axis of the left ventricle in systole, bs is the semimajor axis of the left ventricle in systole, ad is the semiminor axis of the left ventricle in diastole, bd is the semimajor axis of the left ventricle in diastole, AA - half of the longitudinal (basal-apical) the size of the aneurysm Foundation and ba - half the lateral dimension of the base of the aneurysm.

2. The area of the defect after excision of the aneurysm

Sd=π·AA·(ba+h).

3. The surface area of the left ventricle produce on the computer

for the area of the left ventricle in diastole (EDS0) a=ad2,;

for the area of the left ventricle in systole (ESS0) a=as2,

4. Projected end-diastolic volume when excision of the aneurysm

5. The predicted shock about what to eat when excision of the aneurysm

6. The calculation of the required end-diastolic and stroke volume of the left ventricle.

The calculation is based on the minimum cardiac index, CI=2, average heart rate 80 beats/min and the surface area of the patient's body.

Required stroke volume:

SVnc=BSA·SI/800

The required end-diastolic volume Cherniavsky

OEDV=SVnc/EFwm

7. After calculating evaluate the obtained results

If EDVp≥OEDV and SVp≥SVnc, the tactics of the operation is reduced to revascularization and excision of the aneurysm with the plastic without patches if EDVp<OEDV or SVp<SVnc spend myocardial revascularization and excision of the aneurysm with the plastic patch.

Figure 1 shows a diagram of measurements in the right oblique 30 deg projection ventriculogram in diastole, figure 2 - scheme of measurements in the right oblique 30 deg projection ventriculogram in systole, figure 3 - dimensions in the left oblique and caudal projection of ventriculography.

Example 1:

Patient L., aged 45, was admitted with a diagnosis of ischemic heart disease, myocardial (2003) krupnooptovyj infarction, chronic left ventricular aneurysm with thrombus, circulatory insufficiency 2A, a functional class 4 according to NYHA. Patient study of the proposed method. Obtained the following data: AA=2.3 cm, ba=1 cm, h=1.3 cm, ad=3.0 cm, bd=4.4 cm, as=2.5 cm, bs=4.2 cm, EDV0=170 cm3, ESV0=109 cm3, BSA=1.9, EFwm=0.69, SVnc=50 cm3. On the basis of the obtained values calculations. EDVp=142 cm3, SVp=56 cm3, OEDV=73 cm3. The necessary shock and end-diastolic volume is reached (SVp>SVnc and EDVp>OEDV) - tactics of the operation is reduced to revascularization and excision of the aneurysm with a linear plasticity without patches. The patient underwent surgical correction according to the obtained data. In the early postoperative period phenomena diastolic failure was not observed. The patient was discharged on the 14th day after surgery without signs of heart failure.

Example 2:

Patient H., 56 years old, was admitted with a diagnosis of ischemic heart disease, myocardial (2002) krupnooptovyj infarction, chronic aneurysm of the anterior wall of the left ventricle with blood clot, circulatory insufficiency 2A, a functional class 4 according to NYHA. The patient study. We obtained the following data: AA=3.6 cm, ba=2.8 cm, h=1.6 cm, ad=3.2 cm, bd=4.2 cm, as=2.7 cm, bs=4.0 cm, EDV0=184 cm3, ESV0=116 cm3, BSA=1.9. EFwm=0.47, SVnc=50 cm3. On the basis of the obtained values calculations. EDVp=103 cm3, SVp=50.5 cm3, OEDV=106 cm3. Required stroke volume is achieved, however, necessary (106 ml) end-diastolic volume is not reached (SVp>SVnc and EDVp<OEDV), along with made a decision to produce plastics with the use of patches. Underwent surgical correction according to the obtained data. In the early postoperative period phenomena diastolic failure was not observed. According to ECHOCARDIOGRAPHY end-diastolic volume at day 2 after surgery 132 ml the Patient was discharged on the 20th day after surgery without signs of heart failure.

Thus, implementation of the proposed method in practice allows cooperation objective to establish a method of plastics left ventricle resection postinfarction left ventricular aneurysm.

The selection method method plastics left ventricle myocardial aneurysms of the heart depending on the required end-diastolic volume, including visualization of the left ventricle, the measurement of end-diastolic and end-systolic volumes of the left ventricle prior to surgery, the definition of the original surface area of the left ventricle, determine the required stroke volume (SVnc) by the formula

SVnc=BSA·CI/800,

where BSA is body surface area of (m2);

CI - needed cardiac index equal to 2;

calculation of the required end-diastolic volume (OEDV) by the formula

OEDV=SVnc/EFwm,

where EFwm - ejection fraction shrinking segment,

characterized in that hold the left ventriculography and facilities is but the measure of basal-apical size of the left ventricle without capture aneurysm in the systole (bs2), basal-apical size of the left ventricle without capture aneurysm in diastole (bd2), the largest transverse diameter of the left ventricle without capture aneurysm in the systole (as2) and diastole of the ventricles (ad2), the size of the base of the aneurysm along the basal-apical size of the left ventricle (Aa2) and the height of the defect (h), re-conduct ventriculography in the left oblique 45 degrees and 50 degrees caudal projection, measure the transverse size of the aneurysm (ba2), then calculate the length of the minor axis of the left ventricle in systole (as)equal to as=as2/2, the length of the large axis of the left ventricle in systole (bs), equal bs=bs2/2, the length of the minor axis of the left ventricle in diastole (ad)equal to ad=ad2/2, the length of the semimajor axis of the left ventricle in diastole (bd), is equal to bd=bd2/2, half the size of the base of the aneurysm along the basal-apical size of the left ventricle (AA), equal aa=aa2/2, half the lateral dimension of the base of the aneurysm (ba), equal ba=ba2/2; then calculate the area of the defect after excision of the aneurysm (Sd the formula

then the surface area of the left ventricle by the formula

where the area of the left ventricle in diastole (EDS0) a=ad2,

for the area of the left ventricle in systole (ESS0) a=as2,

then determine the projected end-diastolic volume (EDVp) by the formula

where EDS0 - area of the left ventricle in diastole;

EDV0 - end-diastolic volume of the left ventricle before surgery

and the predicted stroke volume (SVp) by the formula

where ESS0 - area of the left ventricle in systole;

ESV0 - end-systolic volume of the left ventricle before surgery

when EDVp is equal to or larger values OEDV, and the value SVp of equal or greater value SVnc, tactics operations reduce to revascularization and excision of the aneurysm without the patch, and when the value of the EDVp, smaller values OEDV, or the value of the SVp, the smallest value of SVnc, conduct myocardial revascularization and excision of the aneurysm with the plastic patch.



 

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EFFECT: high accuracy and self-descriptiveness of the method.

FIELD: medicine, obstetrics.

SUBSTANCE: one should carry out clinical and ultrasound uterine testing, moreover, additionally, on the 3d and the 7th d of post-operational period it is necessary to detect conditional area of uterine sutures, systolo-diastolic ratio (SDR), percentage content of lymphocytes against total amount of cells in uterine aspirate to establish protein coefficient (PC) and leukocytic index of intoxication (LII) being necessary to state upon prognostic coefficients F1 and F2 by the following formulas: F1 = -6726.59 + 27.58 x K1 + 21.84 x K2 - 0.03 x K3 + 93.36 x K4 + 156.47 x K5 - 4.21 x K6 + 760.82 x K7 + 978.46 x K8 + 11.47 x K9 + 96.40 x K10 + 306.40 x K11 + 321.13 x K12 - 24.32 x K13 - 50.56 x K14; F2 = -57.81.76 + 35.89 x K1 + 26.50 x K2 + 0.00 x K3 + 96.81 x K4 + 146.78 x K5 - 3.89 x K6 + 500.76 x K7 + 651.60 x K8 + 4.83 x K9 + 34.83 x K10 + 276.16 x K11 + 535.35 x K12 - 14.26 x K13 - 17.28 x K14, where digital values - the constants of discriminant equation and discriminant coefficients, K1,2...14 - gradations and digital values of post-operational period flow: K1 - the length of uterine sutures on the 3d d, K2 - the width of uterine sutures on the 3d d, K3 - conditional area of sutures on the 3d d, K4 - the length of uterine sutures on the 7th d, K5 - the width of uterine sutures on the 7th d, K6 - conditional area of sutures on the 7th d, K7 - SDR right-hand on the 7th d, K8 - SDR left-hand on the 7th d, K9 - percentage content of lymphocytes against the total amount of cells in uterine aspirate on the 3d d, K10 - percentage content of lymphocytes against the total amount of cells in uterine aspirate on the 7th d, K11 - PC on the 3d d, K12 - PC on the 7th d, K13 - LII on the 3d d, K14 - LII on the 7th d, and at F1>F2 one should predict favorable nature in recovery of uterine wound and at F1<F2 - unfavorable nature.

EFFECT: higher accuracy and efficiency of evaluation.

2 ex

FIELD: veterinary science.

SUBSTANCE: during the first 1-3 h of life one should measure umbilical diameter and at its diameter being above 18 mm it is possible to diagnose earlier manifestation of omphalitis that, in its turn, enables to perform antibacterial therapy in due time and avoid mortality in animals.

EFFECT: higher accuracy of diagnostics.

1 ex, 1 tbl

FIELD: medicine, oncourology.

SUBSTANCE: one should choose the number of points for biopsy : 1 point of biopsy/5 cu. cm of an organ, then it is necessary to detect the portion of cancerous parenchyma in bioptates in percentage morphometrically due to analyzing of not less than 1000 points minimum in 5 sections of preparation, the volume of cancerous parenchyma in an organ should be detected by the following formula:

where X - average value for the portion of cancerous parenchyma in an organ, in %; ΣA - the portion of cancerous parenchyma in bioptate in %; N - the number of bioptates. The present innovation enables to detect cancerous parenchyma both in case of interrupted and diffused forms of prostatic cancer.

EFFECT: higher accuracy of detection.

1 dwg, 3 ex

FIELD: medicine, neurology.

SUBSTANCE: the method deals with detecting an interferon status followed by medicinal therapy. Moreover, additionally one should determine patient's body area, and at observed degree I of interferon system suppression it is necessary to prescribe "Antilympholin Kz" preparation as medicinal therapy intravenously by drops at course dosage being (0.5-0.6)g x S, where S - patient's body area, every other day, and thioctacide preparation at the dosage of 300-600 mg intravenously by drops daily at a 6-8-d-long course. In case of degrees II and III of interferon system suppression one should prescribe "Antilympholin Kz" at course dosage being 0.4-0.5 g/sq. m and 0.3 -.4 g/sq. m, as for thioctacide - it should be applied at the dosage of 600-900 mg and 900-1200 mg, correspondingly. The method enables to selectively affect the immune system efficiently due to combined prescription of an immunimodulator and a preparation that accelerates its introduction at suppressing the activity of proinflammatory cytokines that prolongs disease remission due to preventing the development of immunological disorders.

EFFECT: higher efficiency of therapy.

3 ex

FIELD: medicine, cardiology, endocrinology, gynecology.

SUBSTANCE: one should detect informational-valuable signs of patient's state, such as either the presence or absence of hypertonic disease and uterine extirpation together with adnexa, the value of body weight index, predominance of disorders according to modified menopausal index (MMI)such as autonomic, metabolic-endocrine or psycho-emotional ones, the type of metabolic structures of blood serum, moreover, it is necessary to echocardiographically detect stroke volume, cardiac index and systemic vascular resistance (SVR), at ultrasound testing one should detect maximal linear rate of circulation (LRC max) by medial cerebral artery and thyroid alterations, rheovasographically one should detect specific circulation (SC) of shins, at testing laser doppler flowmetry one should detect microcirculation index, biochemically it is necessary to detect the value of beta-adrenoreactivity, cholesterol level and that of B-lipoproteides, crystallographically - the presence of serotonin and dopamine crystals, due to immunoenzymatic assay on should detect the values by Table 1 and then after obtaining the values of diagnostic coefficients of every parameter it is necessary to summarize them and obtain diagnostic index (DI), at its value being below 10 one should state no alteration, at its value 10-10 - undetermined state, at its value being 21-30 - the 2nd severity degree of disorders, and at DI value being above 31 one should state the 3d severity degree of disorders available.

EFFECT: higher accuracy of evaluation.

5 ex, 2 tbl

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