closed mitral commissure dissection

According to the five-level classification of cardiac function, the indications for closed mitral junction separation are as follows: Level 0 patients do not have to consider surgery. First-grade patients generally do not require surgery. However, x-ray examination showed more obvious pulmonary congestion and heart enlargement, or obvious right ventricular hypertrophy in ECG. For mitral balloon dilatation failure, surgery should be considered. Both the second and third grade patients have obvious symptoms of mitral stenosis. If the balloon fails to expand and there are no surgical contraindications, it is suitable for surgical treatment. The fourth-grade patient has obvious congestive heart failure and completely loses labor. Such patients are in urgent need of surgery; however, they must undergo medical treatment before surgery to control heart failure before surgery. Treatment of diseases: mitral stenosis Indication 1. According to the five-level classification of cardiac function, the indications for closed mitral junction separation are as follows: Level 0 patients do not have to consider surgery. First-grade patients generally do not require surgery. However, x-ray examination showed more obvious pulmonary congestion and heart enlargement, or obvious right ventricular hypertrophy in ECG. For mitral balloon dilatation failure, surgery should be considered. Both the second and third grade patients have obvious symptoms of mitral stenosis. If the balloon fails to expand and there are no surgical contraindications, it is suitable for surgical treatment. The fourth-grade patient has obvious congestive heart failure and completely loses labor. Such patients are in urgent need of surgery; however, they must undergo medical treatment before surgery to control heart failure before surgery. 2. Mitral stenosis with mild mitral regurgitation and mild aortic stenosis or regurgitation may be considered for this surgical treatment; if these combined multivalvular lesions have caused left ventricular hypertrophy, The operation is contraindicated. 3. Simple mitral stenosis, acute pulmonary edema or massive hemoptysis, when the medical treatment can not be effectively controlled, the metal is severely stenotic, should be treated early or even emergency surgery. Age should not be too restrictive, mainly due to the development of the disease. 4. Mitral stenosis combined with pregnancy is not a contraindication to surgery, but must be treated with caution. If it is decided to develop the disease. Patients who are significantly aggravated or who are able to maintain a grade 1 or 2 in a clinical grade may be considered for surgery after delivery. For example, during pregnancy, the symptoms are obviously aggravated, and the active medical treatment can not be controlled. Regardless of the pregnancy, surgery should be considered. 5. Mitral stenosis is suitable for surgical treatment, but those with clinical or laboratory tests of rheumatic activity should first control rheumatism and wait until it is controlled for 3 months before surgery. Except for cases requiring emergency surgery. 6. Patients with mitral stenosis and subacute bacterial endocarditis should actively treat endocarditis before surgery. However, if endocarditis is still uncontrollable after long-term treatment, and mitral valve disease can not wait after surgery, it has to be barely operated, but sensitive antibiotics must be guaranteed. 7. Simple mitral stenosis with atrial fibrillation, a history of embolism, echocardiography found in the left atrium with thrombosis, should be under the extracorporeal circulation for direct mitral valve junction separation. However, if the patient refuses to undergo extracorporeal circulation, he or she can also carefully perform closed separation, taking care to avoid thrombosis during surgery. Preoperative preparation 1. Do a good job in thinking, relieve the patient's concerns, and actively cooperate with treatment and care. 2. Control heart failure, improve heart function, strive for surgery during the compensation period, if necessary, digitalis can be used, but should be stopped 2 days before surgery, in order to compare the exact calculation body during the operation and postoperative need to use digitalis Stock. 3. Eliminate the infections that exist throughout the body, and start treatment with penicillin 1 day before surgery. 4. Actively correct possible electrolyte disturbances. Those who enter a low-salt diet should return to a normal diet 3 to 5 days before surgery. Surgical procedure 1. Position: The patient is slightly on the right side, the left chest and the left shoulder are 30° high, the left upper limb is extended, and the suspension is fixed on the head frame. 2. Incision: A left anterolateral thoracic incision was made along the fifth intercostal space (female patient along the lower edge of the breast). Cut the fifth costal cartilage (the fourth costal cartilage can be cut again if necessary). Be careful not to damage the blood vessels inside the thorax. 3. Cut the happy bag: The pericardial incision can make a longitudinal incision parallel to the nerve 1cm in front of the sacral nerve according to the position of the auricle. The upper end starts from the pulmonary artery and the diaphragm is released. Even if the heart is fully exposed, it is convenient for the left apex. Department of operation. The bleeding point on the pericardial incision must be occluded by hemostasis, and the anterior edge of the pericardial incision is sutured and fixed in the subcutaneous tissue of the incision inside the chest wall. Then sew a piece of gauze cloth on the back cutting edge and spread it back, which can not only pull the pericardium, but also block the left lung, so as not to squeeze out the chest cavity and affect the operation. 4. Extracardiac examination: first check the extracardiac, pay attention to the pulmonary trunk enlargement or right ventricular hypertrophy caused by pulmonary hypertension, and sequentially touch the left ventricle, right ventricle, left atrium and aortic root with finger to check whether there is Systolic or diastolic tremor to further clarify the diagnosis of mitral stenosis and to identify the condition of each valve. At the same time, the size, shape and hardness of the left atrial appendage should also be checked, and the difficulty of the finger entering, the accident that may occur during the operation, etc., should be fully estimated, so that the corresponding preventive measures can be made in advance. 5. Place the ear pliers for purse-string suture: Clamp the heart of the heart with a non-invasive heart-nose pliers (be careful not to clip the left coronary artery circumflex in the ditch of the housing), then slide it over the top of the heart-nose pliers with liquid paraffin The No. 7 silk thread was stitched with a purse. The suture should start from the inner surface of the auricle and the thread should be placed above the auricle. If the suture is too shallow, it will be easily torn off. If it is too deep, it may sew the opposite side of the ear. The needle spacing should not be too dense, about 1cm, 0.5 to 0.6cm between the needle and the needle. Then, use the hooked steel wire to put the ends of the purse string into a length of 8±cm long thin tube (12th catheter can be used), and use the hemostat to clamp the thread end of the other end of the hose to cut the ears and insert After the finger is indicated, tighten the purse string and control the bleeding. 6. Left ventricle for suture: In the avascular region of the left ventricular apex, a 4th silk thread is used for a sacral suture to tighten the wall and insert the dilator to tighten the bleeding control. The stitch length and spacing of the two needles should be appropriate, and all should be 1cm. A hose is placed at both ends of the suture to tighten the suture. 7. Cut happy ears, check the atrium: Before the happy ear, the operator should check the small round knife expander, needle, suture and other utensils, if necessary, re-adjust the operating table, so that the position is most conducive to the display of the auricle Intracardiac operation during expansion. After completing all the above steps, the heart tip is cut off with scissors, and the auricle incision is enlarged according to the thickness of the operator's finger, and the trabeculae that straddles the inner wall of the auricle are cut one by one, so that the finger enters the exploration. The clots in the auricle are washed with saline. The operator replaces the right hand glove that cuts the finger; before the replacement, the right hand indicator should be disinfected with iodine first, then rinsed with alcohol for deiodination and saline. After preparation, the operator puts the happy ear pliers on his left hand and extends the right hand finger into the atrium. If the incision leaks blood, the second assistant can gently tighten the purse string to control the bleeding. After the finger enters the atrium, the size of the mitral valve orifice, the valve activity, the presence or absence of fibrous nodules or calcification at the edge, and the presence or absence of back spray and its degree are examined to determine the presence or absence of mitral regurgitation and its severity. Finally, determine if it is suitable for expansion separation and determine the size of the dilator. If thrombosis is found in the atria, special care should be taken. Carefully rotate the finger from the space between the thrombus and the atrial wall and probe into the atrial cavity. Be careful not to break the thrombus to avoid falling off the pieces and accompanying the blood flow. Into the aorta, causing embolism of the brain or other parts of the artery, life-threatening or affecting the blood supply and function of the embolization site. 8. Cut the happy room and separate the mitral valve junction: the first assistant's right hand lifts the apical suture line for traction, and the right hand uses a small round knife to make a small incision in the sputum suture. The length of the incision should be commensurate with the diameter of the dilator when it is closed, about 0.6 cm; the depth is half the degree of incision of the myocardium, and it is not necessary to cut through. With the help of the first assistant, the surgeon gently inserts the incision with the left hand-held dilator, penetrates the myocardium into the ventricle, follows the direction of the inflow, and guides the dilator directly into the mitral valve under the guidance of the right hand in the left atrium. Inside the hole. The depth of insertion is preferably such that the central portion of the flank of the dilator is adapted to the position of the mitral orifice. Immediately thereafter, the left hand immediately squeezed the dilator handle to open the dilator's blade and expand the adhesion of the mitral valve junction. When the mitral valve junction is dilated and separated, the surgeon's left hand can feel the resistance suddenly disappear. Immediately after the expansion, the dilator blades should be closed and returned to the left ventricle. The right hand indicator checks the expansion effect and understands the degree of separation and the presence or absence of blood flow back. A blade and return to the left heart this inside. The right hand indicator checks the expansion effect and understands the degree of separation and the presence or absence of blood flow back. Generally, the mitral valve boundary separation can be completed with one expansion; if the separation is unsatisfactory, the expansion can be repeated; or the indication can be separated in the atrium to achieve better results. If the closure is incomplete after expansion, it should not be expanded to avoid aggravation. Once the expansion is complete, the dilator should be withdrawn early and the ventricular suture should be tightened to control bleeding. The ventricular incision was sutured with 2 to 3 needles with a 1st wire, and the tightened suture was sutured. The margin of the ventricular suture is suitably 0.5 cm from the edge of the incision. The depth does not have to penetrate the ventricular wall, but it should not be sutured too shallow to prevent tear bleeding or to form a pseudoventricular uterus in the future. 9. Exit the finger, ligation, suture the auricle incision: Before exiting the index finger, the index finger should be extended through the enlarged mitral valve hole to the valve to check the chordae and papillary muscles. If there is adhesion under the flap, it can be separated by fingertips. After placing the heart ear pliers with the left hand below the auricle incision, gradually withdraw the finger and clamp the heart ear pliers to the auricle; the second assistant gently tightens the purse string at the same time, and then ligatures the auricle with the 10th wire under the forceps. When ligating the auricle and purse suture, the force should be appropriate. If it is too tight, the heart may be broken or torn. If it is too loose, it may fall off. The auricle stump was sutured with a 4th wire and interrupted with 8 to 2 needles. 10. Suture the pericardium and chest wall incision: Before the pericardial suture, the blood and clot accumulated in the pericardium should be flushed and exhausted. The apex of the pericardium (usually behind the phrenic nerve) is 2~3cm long. The pericardial drainage is small incision; then, the suture and gauze that fix the pericardial margin are removed, and the pericardium is sutured. The thoracic drainage tube was placed in the posterior intercostal space of the seventh intercostal space, and the effusion in the thoracic cavity was exhausted. After the hemostasis was completely stopped, the chest wall was sutured layer by layer.