Semeniv P. Prevention of ischemic myocardial damage in the surgical treatment of two-valve heart defects in combination with coronary pathology

Thesis for the degree of Doctor of Philosophy in specialty 222 "Medicine" (22 - Health). – SI “Amosov National Institute of cardiovascular Surgery of the NAMS of Ukraine”, Kyiv, 2023. The purpose of this study is to improve the results of surgical treatment of patients with multi-valve lesions in combination with coronary pathology by developing a methodology for optimal intraoperative myocardial protection. The work is based on a comparative analysis of the results of a single-stage multi-valve correction in combination with coronary artery bypass surgery in 93 patients, which was performed in Amosov national institute of cardiovascular surgery for the period from 2014 to 2022. Depending on the tactical approaches and the sequence of surgical manipulations, patients were divided into three groups: Group I – patients who performed the first stage of correction of heart valves, and then coronary artery bypass surgery in cardioplegia conditions (n = 42); Group II - patients who first underwent coronary artery bypass grafting, then valve correction in cardioplegia (n = 36); Group III - patients who underwent coronary artery bypass grafting on a beating heart in the first stage, then heart valve correction (n = 15). In the study groups, all patients belonged to III-IV FC NYHA and had a stage of heart failure IIa-III (Tab 2.6). It was found that the groups had no statistically significant differences in the stage and degree of damage to the cardiovascular system, the nature of myocardial lesions and coronary vessels. To perform the tasks in the work, the study material included the results of diagnosis and treatment of three groups that were close in demographic and clinical characteristics. The patient’s initial condition was assessed as severe. The degree of severity was due to manifestations of heart failure and manifestations of stenosis of coronary vessels. All 93 patients had single-stage surgery: Correction of valve lesions and coronary artery bypass surgery. A single-stage replasment of the aortic and mitral valves was performed in 38 (40.8%) patients from the general group of the study (n=93). Only one patient (1.7%) from the entire sample was performed one-time prosthetics of three valves. In total, 135 prostheses of heart valves were sewn – 87 prostheses of aortic valve (93%) and 47 prostheses of mitral valve (50%). Bivalve prostheses of St. Jude Medical Regent, ATS, on-X. Support rings in the mitral position were implanted 34 (36%)(ATS, St. Jude). The seam plastic was rolled out to 12 patients: Semi-cytic plastic and Reed plastic, Alfieri. Anouloplication tricuspid valve Amosov-De Vega was carried out by 30 people (32%). Manipulations on the aortic valve, which did not require its further prosthetics were distributed as follows: The removal of the aortic valve vegetation is performed by one patient І group; Valvulotomy also for one patient of the ІІ group; Decalcification of aortic valve was carried out by two patients І group. Re -replasment of aortic valve was performed in 3 patients (one in the I group and two in the II group). Aortic root plastic was performed in 3 patients. The elimination of subaortic stenosis (myectomy) the Morrow operation was carried out by 2 patients of the ІІ group. The internal left atrium plastic is performed in 7 patients. Stitching and ligation of the left atrium is carried out by 47 patients of the entire sample, 2 patients were additionally removed from the left atrium blood clots. All patients were performed direct revascularization of the myocardium by coronary artery bypass surgery. In total, 214 distal anastomoses were performed. 196 of them were performed using autogenous transplants and 18 by the left internal thoracic artery (LITA). The index of myocardial revascularization in the entire study group was 2.3. Sequential anastomoses in the entire sample were performed 31. Most often, the shunted artery in the study is anterior descending artery of the left coronary artery. 62 shunts were performed, 9 of which by using LITA.