Aneurysm excision and suture

The effect of ventricular aneurysm on left ventricular systolic function: 10% of the left ventricular wall may cause a decrease in ejection fraction; 15% may cause left ventricular end-diastolic pressure and volume increase; 25% may be affected, and a congestive left heart may occur Failure; 40% involved, can lead to cardiogenic shock. Excision of an anomalously moving ventricular aneurysm can improve cardiac work. Surgical treatment of ventricular aneurysms began as early as 1944, until the Cooley side underwent direct resection in the systemic cycle in 1958, including maximal removal of fibrous scar tissue and linear suture of the left ventricular incision. It took a long time, and by the late 1980s, Dor and Jatene began to propose surgical methods that were more consistent with left ventricular morphology and preserve left ventricular function. Treatment of diseases: myocardial infarction Indication 1, angina is the most common indication for the removal of ventricular aneurysm. After the aneurysm is removed, the volume of the heart chamber is reduced, so the wall tension and oxygen need to be reduced, and the angina is relieved. 2, congestive heart failure resection without contraction and abnormal pulsation of ventricular aneurysm can reduce the heart chamber volume and end-diastolic pressure, improve the residual myocardial contraction effect, thereby improving the heart work. 3. Repeated episodes of ventricular arrhythmia are an important option for surgery in this type of case. Especially after the clinical application of electrophysiological mapping technology, the number of surgical treatment cases is increasing. 4, systemic embolism Although 50% of cases of ventricular aneurysm have thrombosis, systemic embolization rate is not high, but it is still an indication for surgical treatment, if the wall thrombus occurs infective endocarditis, remove this surgery The source of infection with sepsis should be more positive. 5, pseudo ventricular aneurysm, a large chance of rupture, must consider early surgical resection. Contraindications 1. The ventricular aneurysm occupies more than 50% of the free wall of the left ventricle. There is too little myocardial remaining with contractile force after resection. 2, chronic ventricular aneurysm with extensive myocardial lesions, the heart is clearly spherical expansion. 3, functional ventricular aneurysm, whether dyskinetic aneurysm (dyskinetic aneurysm) or loss of functional atrial aneurysm (akinetic aneurysm) are generally not suitable for surgical resection. Such functional ventricular aneurysm or wall motion disorder is sometimes difficult to determine from left ventricular angiography alone. Mangschau proposed the use of radionuclides for left ventricular myocardial imaging for differentiation. Preoperative preparation 1. Carefully read coronary angiography, identify the location, extent and extent of the obstruction, estimate the number of grafts and determine the surgical plan. 2, correctly estimate the cardiopulmonary function, if the left ventricular ejection fraction <30%, left ventricular end-diastolic pressure > 20mmHg or left ventricular end-diastolic volume > 103ml / m2, suggesting that the left heart function is significantly impaired, for such patients before surgery Drug therapy should be done first to improve myocardial blood supply and increase cardiac function reserve. In addition, positron emission tomography should be performed before ischemic cardiomyopathy to understand the survival of myocardium in the ischemic area, which has guiding significance for the diagnosis of surgery, postoperative treatment and prognosis. 3, pay attention to check the carotid artery for stenosis. For patients with carotid stenosis, simultaneous or staging surgery should be considered to prevent cerebrovascular complications. 4, for patients with hyperlipidemia, should be given a low-fat diet and anti-hyperlipidemic drugs. People with high blood pressure need to apply drugs to lower blood pressure to the normal range. People with diabetes can be operated with drugs before surgery. 5, adequate analgesia, sedation before surgery, to prevent emotional tension induced angina, to expand coronary artery to prevent coronary artery spasm. Beta blockers can reduce myocardial oxygen consumption and reduce angina pectoris, and can be applied to patients with unstable angina pectoris. Surgical procedure 1, routine establishment of extracorporeal circulation, surgery in the coronary artery perfusion of cold cardiac arrest and in the local deep cryopreservation. In many cases, the left ventricular wall and pericardium may have adhesions. Do not separate before stopping the ascending aorta and cardiac arrest to prevent the thrombus from falling into the ascending aorta. After cardiac arrest, try to separate the pericardium from the ventricular aneurysm. If the adhesion is dense, do not have to be forced to separate, and the open tumor wall can be cut straight. Occasionally, a pseudo-ventricular aneurysm may be encountered, and the local pericardium constitutes a wall of the ventricular wall. In this case, the pericardium and ventricular aneurysm may also be considered for resection. 2, ventricular aneurysm resection and removal of the wall thrombus (1) Firstly, it is necessary to correctly determine the extent of ventricular aneurysm: it is easy to identify a large and thin ventricular aneurysm with abnormal pulsation during surgery. It is advisable for the suspicious person to further explore after the start of extracorporeal circulation. After the blood in the cavity is empty, the part of the left ventricular wall that collapses under normal circumstances is the part of the ventricular aneurysm that needs surgical resection. When it is difficult to determine the boundary of the tumor wall, a longitudinal incision can be made on the tumor wall 3 to 4 cm from the anterior descending artery after the pericardium is released. The incision margin is retracted, and the boundary of the aneurysm is determined from the inside and outside of the cardiac chamber. The extent of ventricular aneurysms. There are two signs that can be used as a reference for the extent of ventricular aneurysm. The wall of a true anatomical ventricular aneurysm is a thin scar tissue. There is no trabecular bone exploration from the heart chamber. Another sign is the open aortic obstruction forceps. Vibrant myocardium has a blood supply and should be preserved. However, experienced doctors generally determine the extent of ventricular aneurysm resection from the point of view and percussion. If there is a small ventricular aneurysm, there is no wall thrombus. It is not necessary to open the ventricular aneurysm, and the 2-0 non-invasive suture can be used to make the double-layered suture-seal suture closure neck. The outer part of the suture is reinforced with polyester strips, and the tumor is not removed, also called folding suture ( Iplication). It is rarely used in clinical practice because it is difficult to rule out wall thrombus. (2) Clearing the wall thrombus: If the wall of the tumor is incision, if there is a wall thrombus in the left ventricle, a piece of yarn should be placed at the bottom of the left ventricle during the free thrombus, blocking the aortic valve and the mitral valve. Oral, from the endocardial surface of the ventricular aneurysm and the trabecular bone, mechanical or non-mechanized thrombus, to prevent thrombosis or tissue debris from falling into the aorta or left atrium. Immediately after the free thrombus is removed, the gauze is removed and the heart chamber is flushed and the thrombus fragments are removed (Figures 6, 47, 2, 1-1). (3) Trim the ventricular aneurysm on both sides of the incision, and the margin of the ventricular aneurysm should leave about 1 cm of scar tissue for suturing. The intraventricular membrane surrounding the ventricular aneurysm should be removed and frozen at the same time to help eliminate ventricular arrhythmias. (4) If the ventricular aneurysm and pericardial adhesion are not separated, the aneurysm can be made 1 cm away from the left ventricular wall after the cardiac arrest, enter the left ventricular cavity, and then along the edge of the ventricular wall tumor Adhesive pericardial tissue is removed together. (5) If the ventricular aneurysm is located at the base of the anterior papillary muscle, the cut or displaced papillary muscle can be reset and fixed on the left ventricular wall with a spacer suture before the left ventricle is closed after the ventricular aneurysm is removed. 3, ventricular aneurysm defect suture method is often used in the linear suture method, that is, after the ventricular aneurysm resection, the wall wall incision is directly sutured. This method was first proposed by Cooley in 1958 and has been used as a "classic" method for more than 30 years. At present, direct suture is only used for small diameter ventricular aneurysms (<2cm). The biggest problem with this method is that it is easy to cause left ventricular cavity deformation and functional decline. There are 2 ways to choose linear stitching: (1) After the ventricular aneurysm is removed, the cutting edge is fibrous tissue, and it is tough. It can be reinforced with two long shims and intermittent sutures to align the margins on both sides of the ventricular aneurysm. (2) There are more muscle tissues at the edge of the incision, or the incision is larger. The first layer can be sutured with intermittent sutures. The sutures on both sides of the incision are passed through the long strips, and the incision of the chamber wall is closed longitudinally, and then The second layer is sutured continuously to achieve hemostasis. Because the left ventricular pressure is high, the application of the strip spacer reinforcement method can better prevent the tear and bleeding of the incision. The disadvantage is that the linear suture method often causes the left ventricular cavity to shrink and deform significantly, which seriously affects the ventricular filling and myocardial contraction effect. In addition, the incision suture has a large tension, and there are still suture slits and The cause of bleeding is currently limited to the use of small ventricular aneurysms.