RU2571058C1 - Method for cardioplegic arrest (versions) - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: what is used is a mixture containing 50 ml of a cardioplegic solution (CPS) containing, wt %: 25% aqueous solution of magnesium sulphate - 32, 4% aqueous solution of potassium chloride - 40, 0.9% aqueous solution of sodium chloride - 28, and 50 ml of aortic blood taken from an aortic root before clamping (version 1), or a mixture containing 50 ml of the cardioplegic solution containing, wt %: magnesium sulphate 8.0; potassium chloride - 1.6; sodium chloride - 0.252; water for injections - up to 100, and 50 ml of aortic blood taken from the aortic root before clamping (version 2). After an ascending aorta is clamped, the mixture is administered once into an ascending aortic root.

EFFECT: method provides the cardiac arrest within 4 seconds, accelerated cardiac resuscitation after release of the aortic clamp, including the cases where a cardiac resuscitation path may pass through ventricular fibrillation, reduces the length of artificial circulation, as well as the number of rhythm disturbances.

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Description

The present invention relates to medicine, namely to cardiosurgery and cardioanesthesiology, and can be used when performing heart operations in a cardiopulmonary bypass using cardioplegia.

A known method of cardioplegia, used during heart surgery in a cardiopulmonary bypass against chemical cardioplegia (the introduction of pharmacological agents: potassium, acetylcholine, etc. into the coronary arteries of the heart). This method of cardiac arrest provides a sufficient level of myocardial protection from ischemic damage for a long time. The first chemical cardioplegia was carried out by introducing a 10% (1300 mmol / L) potassium citrate solution, once a bolus into the aortic root during compression and cardiopulmonary bypass. In this case, the cardioplegic solution (CRC) entered the natural way, that is, antegrade, through the coronary arteries into the myocardium [Melrose DG, Dreyer B, Bentall HH, et al: Elective cardiac arrest. Lance 1955; 2:21.]. This is a simple and effective method of cardioplegia, but the method has disadvantages associated with the damaging effect of high (more than 26 mmol / l) potassium concentrations on the myocardium and the development of focal necrosis, as well as the development of a small ejection syndrome in the early postoperative period in 25-30% of patients [ Colapinto ND, Silver MD: Prosthetic heart valve replacement: Causes of early postoperative death. J Thorac Cardiovasc Surg 1971; 61: 938].

For pharmacological cold crystalloid cardioplegia from extracellular solutions, the most commonly used are solutions of St. Thomas Hospital, a solution of the Institute of Cardiovascular Surgery AMS (ISSC AMS), a solution of "Consol" and others [Ostrovsky Yu.P. Heart surgery. M .: Honey. lit., 2007. - 576 p.]. CPR traditionally used in cardiac surgery does not completely prevent the metabolic and structural changes that develop in the myocardium during ischemia and subsequent reperfusion. The consequence of this is a reduced recovery of the pumping function of the heart during the resumption of blood circulation, which is complicated by the occurrence of reperfusion arrhythmias and the development of heart failure.

A known method of ischemic cardioplegia, in which stop coronary blood flow [Antunes M.J., Bernardo J.E., Oliveira J.M. et al. Coronary artery bypass surgery with intermittent aortic cross-clamping // Eur. J. Cardiothorac. Surg. - 1992. - Vol. 6, No. 4. - P. 189-193; discussion - P. 193-194].

A known method of cold cardioplegia, which is carried out in addition to ischemic cardioplegia, characterized in that the heart is irrigated with chilled saline to reduce the damaging effect of hypoxia [Shumway N., Lower L., Stofer R. Selective hypothermia of the heart in anoxic cardiac arrest // Surg. Gynec. Obstet - 1959. - Vol. 1096, No. 10. - P.750-754]. Methods of ischemic cardioplegia and cold cardioplegia do not provide sufficient myocardial protection during prolonged operations [A. Malashenkov Comparative evaluation of myocardial protection methods in operations with cardiopulmonary bypass: Abstract. dis. Doct. - M., 1982].

A known method of cardioplegia in operations with cardiopulmonary bypass, including perfusion of the heart with a cooled electrolyte solution, followed by the supply of perfusate to the cardiopulmonary bypass system, with the aim of reducing postoperative complications by reducing blood loss accompanying cardioplegia and preventing excessive hemodilution with perfusion duration of more than 60 minutes, the solution is prepared on the plasma of the operated patient, the solution is oxygenated and perfusion is carried out at a volume rate with a capacity of 300 ml / min [Copyright certificate SU 1732994, 1992].

A known method for the implementation of cardioplegia, which consists in the fact that the patient’s blood was used as a plegic medium, which was mixed with a potassium solution in a certain proportion and was supplied using a roller pump antegrade - naturally or retrogradely, that is, through the coronary sinus using a special cannula [Khudonogova S.V., Rubinchik V.E., Naimushin A.V. et al. Results of the use of blood cardioplegia in patients with coronary heart disease with reduced myocardial contractility. // Materials of the 3rd All-Russian Congress on Extra-Corporate Technologies. - Suzdal. - 2001. - S. 19]. The first session (induction) of cardioplegia lasting 2-2.5 minutes was carried out after clamping the aorta and decompression of the heart (removing blood from its cavities) at the rate of 10 ml / kg of patient weight. The introduction of a 10% potassium solution into the blood for cardioplegia was carried out with a syringe infusion pump at a constant speed for the given session in the line after the roller pump. Then, every 15 minutes, plegia sessions were repeated. The volume of repeated cardioplegia was 750 ml, duration 2.5 min. The speed of the syringe infusomat with potassium solution was reduced by the perfusionist from session to session from 300 to 100 ml / h [Barner N.V., Jelliner M. Blood cardioplegia: an introduction // A textbook of clinical cardioplegia - NY, 1982. - P. 227 -235].

A known method of cardioplegia is a crystalloid cardioplegic solution containing sodium chloride, potassium chloride, calcium chloride, magnesium sulfate, glucose, dihydroorthophosphate anion, bicarbonate anion, sulfate anion and water in the following ratio of ingredients, mmol / l: sodium 143; potassium 25; magnesium 16; calcium 0.3; bicarbonate anion 25; dihydroorthophosphate anion 1,2; glucose 11; chlorine anion 142.1; sulfate anion 16; distilled water 1 l. The specified solution is intended to protect the heart from global ischemia during cardiac surgery and has improved cardioprotective properties [Patent RU 2423135, 2011].

A known method for the implementation of cardioplegia, which is as follows. Extracorporeal circulation is performed using a Shtokert S3 cardiopulmonary bypass machine (AIC) using Quadrox disposable membrane oxygenators (Medtronics). The patient is connected to the AIK according to the standard scheme: the patient's blood is drained through the venous cannula or cannula into the cardiotomy reservoir. From the cardiotomic reservoir, the venous blood is pumped into the oxygenator with a roller pump, where gas is exchanged, the blood becomes arterial and enters the aorta through the aortic cannula. The aortic root is cannulated by a cannula with a tap (Jostra Root Cannula 9Fr), the coronary sinus is cannulated by a retrograde cannula (Jostra Cardioplegia Cannula retrograde 14 Fr). Through them, antegrade and retrograde plegia are conducted, respectively. At the exit of the oxygenator there is a port through which arterial blood is drawn through the roller pump at a certain speed for cardioplegia. After the cardioplegic pump, lines for monitoring pressure and feeding a potassium solution are included in the line. The concentration of potassium in the arterial blood of the patient was determined on an ion analyzer (Radiometer ABL800 FLEX). For analysis, samples of arterial blood were taken and, at the stages of the development of the method, paired samples of transmyocardial blood to control the level of potassium supplied to the coronary bed. Based on the plasma concentration of potassium, a syringe infusion pump Perfusor compact S (B. Braun Melsungen) (10) into the cardioplegic line at a rate calculated by the formula: SKIK (((Kplegii-Kpatsient) / 10) · (SKKP / 100)) / ( 0.134 · K%)) · 60, where SKI is the rate of infusion with a solution of potassium in ml / h; Kplegii - the necessary concentration of potassium in the solution of plegia, mmol / l; Kpatsient - plasma concentration of potassium of the patient, mmol / l; SKKP - cardioplegia rate in ml / min; K% - the concentration of potassium used in%; 0.134 - conversion factor mg per mole, a solution consisting of 45 ml of 10% potassium chloride and 5 ml of 25% magnesium sulfate is supplied. The blood mixed with this solution enters through the cardioplegic cannula into the coronary bed of the heart. Plegia is supplied in an intermittent manner, that is, 2-3 minutes every 15 minutes [patent RU 2434589, 2011].

Known methods of cardioplegia have the disadvantage that the number of postoperative complications remains quite high, since it is impossible to control the concentration of potassium in the solution of plegia. An insufficient concentration of potassium in the supplied solution will not cause cardiac arrest, which will entail a decrease in the quality of protection and uncomfortable working conditions for surgeons. Excessive potassium concentration causes spasm of the coronary vessels, uneven reperfusion, direct toxic damage due to overload of cardiomyocytes with calcium. An increased (excess) potassium content in cardioplegia causes a rise in plasma potassium above physiological values, which causes a delayed restoration of cardiac activity, impaired rhythm and conduction, and decreased contractility in the early recovery period. In some cases, iatrogenic hyperkalemia developed, which reduced the quality of myocardial protection, and was expressed in the necessity of administering inotropic support in 58% of patients for 6 or more hours, increased the time spent on mechanical ventilation (ALV), and the patient’s stay in the intensive care unit was extended, which amounted to an average of 37 hours.

There is a method of restoring contractile function of the heart after cardioplegia with calcium antagonists in the experiment, which consists in increasing the concentration of sodium ions during reperfusion to 185-240 mm to stimulate contractile function of the heart, which does not lead to myocardial damage [Patent RU 2133612, 1999 .].

The closest analogue of the first embodiment of the invention is a method of protecting the myocardium during heart surgery, which consists in injecting a cooled cardioplegic solution based on autoblood into the coronary vessels with a 4: 1 ratio of autoblood and crystalloid component, cooling the solution to 10-12 ° C, and the solution is led in stages: 1 stage 200 ml, 2 stage 100 ml, 3 and then 75 ml stages, each subsequent stage begins after application of the distal coronary anastomosis, and / or when the myocardial temperature rises above 15 ° C, and / or resumption of ektromehanicheskoy infarction activity, and before removing the clamp from the aorta carried thermal Blutwurst reperfusion myocardial preparations phosphocreatine, cardioplegia conducted under normothermic perfusion [Patent RU 2335290, 2008 g.]. The disadvantages of the prototype are: the need for cooling the solution, the frequency of administration.

The objective of the invention is to develop a method of cardioplegia, which increases the efficiency and reduces the risk of cardiac surgery.

The technical result is a simplification and reduction of the duration of the method due to the exclusion of cooling before the introduction of the cardioplegic solution and the additional introduction of CRC, cardiac arrest in 4 seconds (cardioplegia at the time of injection - "at the tip of the needle"), accelerated recovery of the heart rhythm after removing the clamp from the aorta, including, when the path to recovery of cardiac activity can occur through fibrillation of the ventricles of the heart, reducing the duration of cardiopulmonary bypass, as well as the amount of rhythm after restoration of cardiac activity.

The specified technical result is achieved by the fact that in the method of cardioplegia, comprising introducing a mixture of autoblood and cardioplegic solution into the root of the ascending aorta after squeezing the ascending aorta, according to the first embodiment of the invention, a mixture of 50 ml of CRC and 50 ml of aortic blood collected from the aortic root before applying the clamp is administered once while CRC contains the following ratio of components, wt. %:

Aqueous solution of magnesium sulfate 25% 32 Aqueous solution of potassium chloride 4% 40 Aqueous solution of sodium chloride 0.9% 28

The proposed method for cardioplegia (option 1) is as follows: during surgery for coronary artery bypass grafting after clamping the ascending aorta, 50 ml of cardioplegic solution containing, by weight. %: aqueous solution of magnesium sulfate 25% - 32, aqueous solution of potassium chloride 4% - 40, aqueous solution of sodium chloride 0.9% - 28, and 50 ml of aortic blood drawn directly from the aortic root before applying the clamp, only 100 ml of the mixture administered once directly into the root of the ascending aorta. The conservation of myocardial energy resources is achieved due to a quick cardiac arrest in 4 seconds, a pronounced stable action for up to 40 minutes.

Used cardioplegic solution is prepared as follows. Directly in the operating room, the required amount of injection solutions of magnesium sulfate, potassium chloride, sodium chloride is mixed in a sterile 50 ml bottle. The finished cardioplegic solution is a colorless, transparent sterile liquid, pH = 6.0, in the form of an injection solution intended for use in open heart surgery, namely, to stop it and local perfusion when compressing the proximal aorta when introduced into the aortic root in a small volume up to 50 ml. Then the CRC is mixed with 50 ml of autologous blood for better distribution in the coronary bed, reducing the damaging effect of the components on the cardiomyocyte.

The closest analogue of the second embodiment of the invention is a method of protecting the myocardium during heart surgery, which consists in injecting a cooled cardioplegic solution based on autologous blood into the coronary vessels at a ratio of autologous blood and crystalloid component of 4: 1, cooling the solution to 10-12 ° C, and the solution is led in stages: 1 stage 200 ml, 2 stage 100 ml, 3 and then 75 ml stages, each subsequent stage begins after application of the distal coronary anastomosis, and / or when the myocardial temperature rises above 15 ° C, and / or resumption of electromechanical activity of the myocardium, and before removing the clamp from the aorta, thermal blood reperfusion of the myocardium with phosphocreatine preparations is carried out, cardioplegia is performed under normothermic perfusion [Patent RU 2335290, 2008]. The disadvantages of the prototype are: the need for cooling the solution, the frequency of administration.

The objective of the invention is to develop a method of cardioplegia, which increases the efficiency and reduces the risk of cardiac surgery.

The technical result is a simplification and reduction of the duration of the method due to the exclusion of cooling before the introduction of the cardioplegic solution and the additional introduction of CRC, cardiac arrest in 4 seconds (cardioplegia at the time of injection - "at the tip of the needle"), accelerated recovery of the heart rhythm after removing the clamp from the aorta, including, when the path to recovery of cardiac activity can occur through fibrillation of the ventricles of the heart, reducing the duration of cardiopulmonary bypass, as well as the amount of rhythm after restoration of cardiac activity.

The specified technical result is achieved by the fact that in the method of cardioplegia, which includes introducing a mixture of autoblood and cardioplegic solution into the root of the ascending aorta after compressing the ascending aorta, according to the second embodiment of the invention, a mixture of 50 ml of CRC and 50 ml of aortic blood collected from the aortic root before applying the clamp is administered once while CRC contains the following ratio of components, wt. %:

Magnesium sulfate 8.0 Potassium chloride 1,6 Sodium chloride 0.252 Water for injections up to 100

The proposed method for cardioplegia (option 2) is as follows: during surgery for coronary artery bypass grafting after clamping the ascending aorta, 50 ml of cardioplegic solution containing, by weight. %: magnesium sulfate 8.0; potassium chloride - 1.6; sodium chloride - 0.252; water for injection - up to 100, and 50 ml of aortic blood drawn directly from the aortic root before applying the clamp, only 100 ml of the mixture is injected once directly into the root of the ascending aorta. The conservation of myocardial energy resources is achieved due to a quick cardiac arrest in 4 seconds, a pronounced stable action for up to 40 minutes.

Used cardioplegic solution is prepared as follows. The calculated amount of injection-friendly magnesium sulfate, potassium chloride, sodium chloride is dissolved at a temperature of 30-35 ° C in sterile water for injection, previously boiled to remove carbon dioxide. The pH of the solution is 6.0. The resulting solution was filtered through 0.22 μm Millipore membrane plates, poured into sterile 50 ml vials for run-in and steam sterilized at 100 ° C for 30 minutes. The finished cardioplegic solution is a colorless, transparent sterile liquid, pH = 6.0, in the form of an injection solution intended for use in open heart surgery, namely, to stop it and local perfusion when compressing the proximal aorta when introduced into the aortic root in a small volume up to 50 ml. Then CRC is mixed with 50 ml of autologous blood.

The proposed method (options 1 and 2) does not require cooling before the introduction of a cardioplegic solution and additional administration of CRC, provides cardioplegia at the time of administration (“at the tip of the needle”), restoration of the heart rhythm after removing the clamp from the aorta, including when the cardiac recovery path activity can occur through fibrillation of the ventricles of the heart and, as a result, a shorter duration of cardiopulmonary bypass, a reduction in the number of rhythm disturbances after restoration of cardiac activity.

Example 1. Patient N., 66 years old. He entered the Republican Cardiology Dispensary with complaints of pressing pain behind the sternum with little physical exertion, accompanied by weakness and shortness of breath, stopped by taking nitrates and stopping exercise.

During the operation, isolated coronary bypass grafting, not aggravated by the peripheral form of lesion, under anesthesia, the patient underwent sternotomy with cannulation of the aorta and right atrium with the inferior vena cava, after clamping the ascending aorta, cardioplegic drug 50 ml and 50 ml of aortic blood collected directly from the aortic root before by clamping, 100 ml of the mixture was injected directly into the root of the ascending aorta. Asystole for 3 s directly on the administration of the drug, cardiac arrest without fibrillation. Full coronary artery bypass grafting - two venous grafts into the basin of the envelope artery on the branch of obtuse margin 1 and 2. One venous graft into the basin of the right coronary artery - to the posterior interventricular artery. The internal thoracic artery to the anterior interventricular artery. Aortic occlusion was 32 minutes. Cardiac activity recovered spontaneously after removal of occlusion after 12 seconds, without atrial fibrillation. Cardiopulmonary bypass - 43 min.

The postoperative period without features. The patient is observed for 3 months, data for angina pectoris and heart failure have not been obtained.

Example 2. Patient N., 44 years old, was admitted to the Republican Cardiology Dispensary with complaints of pressing pain behind the sternum during exercise, stopped by taking nitrates and stopping exercise. On coronarography - a multivascular lesion of the coronary arteries.

Access to the heart was via median steronotomy. The left inner thoracic artery is highlighted. Cannula of the aorta and right atrium with the inferior vena cava was performed; after compression of the ascending aorta, cardioplegic means of 50 ml and 50 ml of aortic blood collected directly from the aortic root before clamping were applied; 100 ml of the mixture was injected directly into the root of the ascending aorta. Asystole for 3 s directly on the administration of the drug, cardiac arrest without fibrillation. Fully coronary bypass surgery - two venous grafts into the pool of the right coronary artery on the posterior interventricular artery and left ventricular branch. One venous graft in the basin of the envelope of the artery - to the branches of the blunt edge. The internal thoracic artery to the anterior interventricular artery. Aortic occlusion was 29 minutes. Cardiac activity recovered spontaneously after removal of occlusion after 10 seconds, without atrial fibrillation. Cardiopulmonary bypass - 40 min.

The postoperative period without features. The patient is observed for 3 months, data for angina pectoris and heart failure have not been obtained.

Example 3. Patient N., 77 years old, was admitted to the Republican Cardiology Dispensary with complaints of pressing pain behind the sternum with little physical exertion, stopped by taking nitrates and stopping exercise. On coronarography - a multivascular lesion of the coronary arteries.

Access to the heart was via median steronotomy. The left inner thoracic artery is highlighted. Cannula of the aorta and right atrium with the inferior vena cava was performed; after compression of the ascending aorta, cardioplegic means of 50 ml and 50 ml of aortic blood collected directly from the aortic root before clamping were applied; 100 ml of the mixture was injected directly into the root of the ascending aorta. Asystole for 3 s directly on the administration of the drug, cardiac arrest without fibrillation. Full coronary bypass surgery - one venous graft into the pool of the right coronary artery on the posterior interventricular artery. One venous graft in the basin of the envelope of the artery - to the branches of the blunt edge. The internal thoracic artery to the anterior interventricular artery. Aortic occlusion was 25 minutes. Cardiac activity recovered spontaneously, after removal of occlusion after 12 seconds, without atrial fibrillation. Cardiopulmonary bypass - 41 min.

The postoperative period without features. The patient was observed for 3 months, data for angina pectoris and heart failure were not obtained.

Thus, the claimed method of cardioplegia (option 1 and 2) is an effective method of protecting the myocardium with total ischemia.

Claims (2)

1. The method of cardioplegia, including the introduction of a mixture of autoblood and cardioplegic solution (CRC) into the root of the ascending aorta after compressing the ascending aorta, characterized in that a mixture of 50 ml of CRC and 50 ml of aortic blood collected from the aortic root before applying the clamp is administered once this CRC contains the following ratio of components, wt.%:
Aqueous solution of magnesium sulfate 25% 32 Aqueous solution of potassium chloride 4% 40 Aqueous solution of sodium chloride 0.9% 28 2. A method of conducting cardioplegia, including introducing a mixture of autoblood and cardioplegic solution (CRC) into the root of the ascending aorta after compressing the ascending aorta, characterized in that a mixture of 50 ml of CRC and 50 ml of aortic blood collected from the aortic root before applying the clamp is administered once this CRC contains the following ratio of components, wt.%:
Magnesium sulfate 8.0 Potassium chloride 1,6 Sodium chloride 0.252 Water for injections up to 100