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II. ХИРУРГИЯ
МРНТИ 76.29.30
ABOUT THE ÄUTHORS
Kvashnin A.V. -
National Scientific Center of Surgery named after A.N. Syzganov, cardiac surgeon, candidate of medical sciences, Ph.D.
Sagatovl.Y. -
National Scientific Center of Surgery named after AN. Syzganov, Head of the management scientific department, Doctor of medical sciences
Dosmailov N.S. -
National Scientific Center of Surgery named after A.N. Syzganov, cardiac surgeon
Momynov B.M. -
National Scientific Center of Surgery named after A.N. Syzganov, resident.
Koshkinbaev Zh.B. -
National Scientific Center of Surgery named after A.N. Syzganov, pediatrician
Keywords
occluder, radiofrequency ablation, atrial septal defect, surgical treatment
АВТОРЛАР ТУРАЛЫ Квашнин А.В. -
А.Н. CbtfFaHOB атындаш Улттык FbrnbiMtt хирургия орталь^ы, кардиохирург, медицина Fылымдарыньщ кандидаты Сагатов I.E. -А.Н. Станов атындаш Улттык рылыми хирургия орталы^ы, -ГЗЖменеджмент бел/м/нц басшысы, медицина Fылымдарыньщ докторы Досмаилов Н.С. -А.Н. Сыызганов атындаш Улттык рылыми хирургия орталы^ы, кардиохирург Момынов Б.М. -А.Н. Сы^анов атындаш Улттык рылыми хирургия орталы^ы, резидент Кешкшбаев Ж.Б. -А.Н. Сы^анов атындаш Улттык шлыми хирургия орталы^ы, бала дэр1гер1
Тужн сездер
окклюдер, радиожи!лíktí абляция, журекше аралык капка акауы, оталык емдеу
REMOVAL OF THE OCCLUDER IN A PATIENT WITH ATRIAL SEPTAL DEFECT. CASE FROM PRACTICE
Kvashnin A.V., Sagatov I.Y., Dosmailov N.S., Momynov B.M., Koshkinbaev Zh.B.
JSC "National scientific center of surgery named after A.N. Syzganov", Almaty, Kazakhstan
Abstract
The article presents the case of installing the occluder into the atrial septal defect, after which becomes frequent the attacks of ventricular premature beats and paroxysmal tachycardia, which cannot be stopped by drug therapy and radiofrequency ablation. The problem was solved by surgical treatment - removal of the occluder and closure of the atrial septal defect with a patch from the autopericardium. The surgical method for certain locations of the atrial septal defect is fundamental in the treatment of this pathology. This clinical case demonstrates the ability to perform such operations with a good result.
Журекше аралык калка акауы бар наукастан окклюдерд1 алып тастау. Тэж1рибеден алынган окига
Квашнин А.В., Сагатов I.E., Досмаилов Н.С., Момынов Б.М., Кешкшбаев Ж.Б.
«А.Н. CbßfaHOB атындаш Улттык, ^шыми хирургия орталь™» АК, Алматы, Казахстан
Ащдатпа
Макалада журекше аралык акду¥а окклюдер орнатканнан кей!нг1 жа$дай карастырыжан: карыншалык экстрасистолалар устамасы жэне устамалы тахикардия жи!лен1п, дэрШк терапия жэне радиожиШкт! аблация аркылы токтату мумк!н емес. Бул мэселенщ шеш!м! оталык емдеу аркылы жузеге асты - окклюдердi алып тастау жэне аутоперикардпен жамау аркылы журекше аралык калка акауын жою. Журекше аралык калка акауыньщ белгШ бiр жерШ хирургиялык эдюпен емдеу - бул патологияны емдеудег непзп эдс. Осы клиникалык жа^дай мундай операцияларды сэттi журпзт, он нэтижелерге жету мумк!н екен!н керсетедi.
ОБ АВТОРАХ Квашнин А.В. -
Национальный научный центр хирургии им. А.Н. Сызганова, кардиохирург, кандидат медицинских наук Сагатов И.Е. -Национальный научный центр хирургии им. А.Н. Сызганова, руководитель отдела менеджмента НИР, доктор медицинских наук Досмаилов Н.С. -Национальный научный центр хирургии им. А.Н. Сызганова, кардиохирург Момынов Б.С. -Национальный научный центр хирургии им. А.Н. Сызганов, резидент Кошкинбаев Ж.Б. -Национальный научный центр хирургии им. А.Н. Сызганова, педиатр
Ключевые слова
окклюдер, радиочастотная аблация, дефект межпредсерд-ной перегородки, оперативное лечение
Удаление окклюдера у больной с дефектом межпредсердной перегородки. Случай из практики
Квашнин А.В., Сагатов И.Е., Досмаилов Н.С., Момынов Б.М., Кошкинбаев Ж.Б.
АО «Национальный научный центр хирургии им. А.Н. Сызганова», Алматы, Казахстан
Аннотация
В статье представлен случай установки окклюдера в дефект межпредсердной перегородки, после которого участились приступы желудочковой экстрасистолии и пароксизмальной тахикардии, не купирующиеся лекарственной терапией и радиочастотной аблацией. Решение проблемы помогло оперативное лечение - удаление окклюдера и закрытие дефекта межпредсердной перегородки заплатой из аутоперикарда. Хирургический метод при определенных расположениях дефекта межпредсердной перегородки является основным в лечении данной патологии. Данный клинический случай демонстрирует возможность выполнения подобных операций с хорошим результатом.
Background
Atrial septal defect is related to congenital heart disease and, according to different authors, is 10-15%. The last decades have been actively implemented endovascular closure of this pathology by occluders. In order to avoid complications, such as deformation of the heart valves, closure of the coronary sinus, occluder dislocation, this manipulation requires a specific location of the defect with the nearby structures of the heart, its size [1-8]. Deviation from these requirements may lead to a malfunction of the heart valves, to the development of heart rhythm disorders. Surgical closure of the atrial septal defect allows to avoid these complications.
Clinical case
Patient B, 33 years old, was admitted to the cardiac surgery department of our center on 12.04.2018.
Complaints at admission to shortness of breath during exercise, interruptions in the work of the heart, attacks of tachycardia, fatigue, general weakness.
Anamnesis morbi: Congenital heart disease, atrial septal defect 1.6 x 1.9 cm in size diagnosed in 2013. In the same year, an endocardial endovas-cular closure of the defect was performed with occlude Occlutech No.24 in the cardiac surgery center. In the postoperative period, the patient noted an increase in tachycardia attacks, in the flesh until he lost consciousness, increased shortness of breath, weakness. The patient is diagnosed: "Heart rhythm disorder. Ventricular extrasystole IV b graduation on the Luna". In the cardiac surgery center of April 28, 2014, September 12, 2014, and of October 6, 2017, an electrophysiological study and radiofrequency ablation were performed. Unfortunately, there was no improvement in the state of health of the patient.
External evidence: performance status of the patient at admission is estimated as moderate severity, due to the underlying disease. The skin and visible mucous membranes of normal color. Vesicular breathing in the lungs. RR 18 per minute. With auscultation of the heart tones are muffled, clear. The rhythm is correct with heart rate = 94bpm., ABP - 130/80 mm Hg. The liver at the edge of the costal arch, painless on palpation. Edema on the lower limbs no.
Conducted laboratory studies within normal range.
ECG 12.04.2018: The normal position of the electrical axis of the heart. Sinus rhythm. HR 94 bpm. Partial blockade of the right bundle of His. Dystrophic changes in the myocardium.
Echocardiography 12.04.2018: Tricuspid valve - regurgitation of I degree. Left ventricle: EDD 5.1 cm, ESD 3.3 cm, EDV 126 ml, ESV 46 ml, SV 80 ml,
EF 62%. Atrial septum: occluder is usually located, there is no reset. Right atrium: 4.8x4.1 cm. Right ventricle: RVSP 32-35 mm Hg. TAPSE 2.4 cm.
The patient is diagnosed with: "Congenital heart disease. X-ray endovascular closure of atrial septal defect with occluder (2013). Radio frequency ablation (04.2014, 09.2014, 10.2017). Supraventricular tachycardia. Extasystole. Relative tricuspid insufficiency. Pulmonary hypertension. II functional class by NYHA".
The severity of the patient is considered due to the inconsistency of the installed occluder (No. 24) and the size of the defect (1.6 x 1.9 cm).
20.04.2018 an operation was performed in conditions of cardiopulmonary bypass and pharmaco-cold cardioplegia - "Removal of the occluder of the atrial septal defect. Plastic atrial septal defect patch of autopericardium. Ligation of the left atrial appendage. Tricuspid valve annuloplasty by De Vega".
During the operation after opening the right atrium, it can be seen that the occluder partially overlaps the aperture of the coronary sinus (figure 1).
After removal of the occluder, a defect with a diameter of 1.6 x 1.9 cm was revealed with a lower membranous margin, which is excised (figure 2).
Figure 1.
The occluder partially overlaps the aperture of the coronary sinus
Figure 2.
ASD with a diameter of 1.6 x 1.9 cm was revealed with a lower membranous margin
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Figure 3.
ASD is closed by a patch from an autopericardium
The defect is closed by a patch from an autopericardium, ligation of the left atrium appendage, an annuloplasty of the tricuspid valve according to de Vega is performed (figure 3).
The postoperative period proceeded according to the severity of the operation.
At the time of discharge, the patient's condition is satisfactory. Conscious, adequate. The skin is a normal color. Vesicular breathing in the lungs, no wheezing. Heart sounds are clear, sonorous. ABP 120/70 mm Hg., HR - 80 bpm., the rhythm is
References
correct. The abdomen is soft, painless, there is no swelling in the lower limbs. Postoperative wound heals by primary intention.
ECG 24.04.2018: Sinus rhythm. HR 80 bpm. The normal position of the electrical axis of the heart. Partial blockade of the right bundle of His. Dystrophic changes in the myocardium.
Echocardiography 05.02.2018.: EDD-4,8 cm ESD-3,1cm, EDV -110 ml, ESV-37 ml, EF-65%. IAS patch sewn tightly, no reset. RVSP-23 mm Hg. TV no regurgitation. TAPSE-1.5 cm.
On the 10th day, the patient in satisfactory condition was discharged home.
Conclusion
Consequently, endovascular closure of sep-tal defects with occluders, without taking into account the anatomical features of the patient's heart, can lead to disruption of the heart valves, to the development of cardiac arrhythmias. Surgical closure of the atrial septal defect allows to avoid these complications, as well as to correct the associated pathology, such as tricuspid valve insufficiency.
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