Sol ventrikül destek cihazı uygulanmış hastalarda asendan ve desendan aorta outflow greft anastomozunun femoral ve karotis arter akımlarına etkisi
Küçük Resim Yok
Dosyalar
Tarih
2022
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
AMAÇ: Primer dekompanse kalp yetmezliğinin yanında iskemik kalp yetmezliği olarak da tanımlanabilecek ve özellikle daha önce geçirilmiş kalp cerrahisi öyküsü de olan hastalarda sol torakotomi ile outflow greftin desendan aorta implante edildiği yöntem, redo sternotomi ve redo kalp cerrahisine bağlı morbidite ve mortaliteyi azalttığından giderek daha fazla uygulanmaya başlamıştır. Literatüre bakıldığında, bu alternatif yöntemin daha kısa kardiyopulmoner bypass süresi, daha kısa mekanik ventilasyon süresi, daha az transfüzyon ihtiyacı, daha düşük inotropik ajan desteği, daha az sağ ventrikül disfonksiyonu insidansı ve daha kısa süre yoğun bakım ve hospitalizasyon süresi ile ilişkili olduğu, dolayısıyla çoğu yönden hastaya faydalı olduğu belirlenmiştir. Bu yöntemde outflow greftin desendan aortaya uygulaması, rutin asendan aorta uygulanmasından farklı olarak sürekli akımın öncelikle arkus aorta ve dallarına değil de desendan aort sonrası distal dolaşıma yönlendirilmesi nedeniyle, serebral akım ve buna bağlı perfüzyonu olumsuz yönde etkileyebileceğini düşündürmektedir. Çalışmamızda amacımız, torakotomi ile desendan aorta outflow greft anastomoz edilen olgular ile konvansiyonel median sternotomi ile outflow grefti asendan aorta anastomoz edilen hastaların orta serebral arter, bilateral karotis ve vertebral arter ve bilateral femoral arterlerindeki akımlar üzerindeki farklılıkların incelenmesi ve hastalarda serebrovasküler olayların bu cerrahi yöntemler arasındaki insidans farklılıklarının belirlenmesi olacaktır. Bunlar vesilesiyle tekrar sternal cerrahiye alternatif olarak sol torakotomi yaklaşımının güvenirliğini sorgulamak amaçlanmaktadır. GEREÇ VE YÖNTEM: İleri evre kalp yetersizliği tanısı ile kliniğimizde sol torakotomi ile sol ventrikül destek cihazı uygulanmış 12 adet hastaya ek olarak median sternotomi ile sol ventrikül destek cihazı implantasyonu uygulanmış en az 12 hasta olmak üzere toplam 20-30 hasta örneklem boyutunu oluşturacaktır. Sol torakotomi ile destek cihazı uygulanmış hastalar deney grubu, median sternotomi ile asendan aorta outflow greft anastomoz edilmiş hastalar kontrol grubunu oluşturacaktır. Deney grubunun tamamı erkek hastalardan ve bu hastaların tamamına Heartware implante edilen hastalar olduklarından, cinsiyet faktörünü ve cihazlar arası oluşabilecekleri farklılıkları kapsam dışı bırakmak için kontrol grubu da erkek hastalardan ve Heartware implantasyonu yapılmış hastalardan oluşacaktır. Bu hastaların klinik arşivinden ve e-nabızdan alınan laboratuvar sonuçları ve görüntülemeleri üzerinden postoperatif dönemlerinde gerçekleştirilmiş olan ultrasonografi değerlendirmelerine erişilecek, bu görüntüler üzerinden hastalardaki bilateral karotis arter, vertebral arter, femoral arter ve değerlendirilebildiği takdirde orta serebral arter pulsatilite indeks, rezistivite indeks ve akım hacmi değerleri hesaplanacaktır. Bu ölçümlerin asendan ve desendan aorta gruplarında kıyaslamalı şekilde analizi, bu analizlerin postoperatif serebrovasküler olay ve pompa trombozu görülmesi arasındaki ilişki açısından incelenmesi ve bunların karşılaştırmalı analizi yapılacaktır. BULGULAR: Çalışmaya 12 adet sol torakotomi ile Heartware HVAD cihazı implante edilen hasta dahil edildi. Kontrol grubu için 12 adet daha Heartware HVAD implante edilmiş konvansiyonel cerrahi geçirmiş hasta çalışmaya dahil edildi. Yaş ortalaması 54,5tu. Hasta grubu içerisinde her iki grupta da serebrovasküler olay ve pompa trombozu insidansı oranı aynıydı. Her iki grup arasındaki akım karakteristiklerinin karşılaştırmalı analizinde, femoral arter pulsatilite indeks, rezistivite indeks ve akım hacmi değerleri, çalışma öncesi öngörülen şekilde desendan aorta outflow greft anastomozu yapılmış olan hastalarda, asendan gruba göre daha fazla bulundu. Desendan aort grubundaki hastalarda sağ internal karotis arter akım hacmi değeri, asendan grubu hastalara göre istatistiksel açıdan anlamlı olacak şekilde daha yüksek bulundu. Ayrıca istatistiksel olarak anlamlı olmamakla birlikte sol internal karotis akım hacmi de desendan grupta daha yüksekti. Diğer arteriyel ölçümler arasında, desendan aort grubuar ile asendan aort grubu hastalar arasında istatistiksel olarak anlamlı fark görülmedi. Ölçüm değerlerinin serebrovasküler olay ve pompa trombozu insidansı açısından kıyaslamasında anlamlı fark tespit edilmedi. SONUÇ: Minimal invaziv girişimlerle sol ventrikül destek cihazı implantasyonu, daha ileri jenerasyon cihazların geliştirilmesi ile birlikte, özellikle redo cerrahiden kaçınılan olgularda giderek artan sıklıkta uygulanmaktadır. Sol torakotomi ile cerrahi uygulamasında outflow greft anastomoz sahası olarak desendan aortanın tercih edildiği olgularda, öngörülenin aksine karotis ve serebral dolaşıma giden kan miktarı anlamlı olarak değişmemekte, aksine sağ internal karotis arter akım hacmi anlamlı olarak yükselmektedir. Pompa trombozu ve serebrovasküler olay insidansları arasında arteriyel akım ölçüm değerleri açısından anlamlı bir fark yoktur. Dolayısıyla, sol torakotomi ile desendan aorta outflow greft anastomozu yöntemi, uzun dönem meydana gelebilecek advers etkilerin insidansında artışa neden olmadığının bilincinde olan cerrah için güvenilir bir seçenektir.
PURPOSE: In left ventricular assist device implantation to decompensated heart failure patients especially for the ones who were diagnosed with ischemic cardiomyopathy and who previously had a cardiac surgery, the method in which the outflow graft attached to the descending aorta by left thoracotomy is becoming more widely implemented due to the fact that it reduces the mortality and morbidity in contrast to the redo sternotomy and redo surgery. Based on the literature, this alternative method comes with shorter duration of mechanical ventilation, shorter duration of cardiopulmonary bypass, less need for transfusion, lower inotropic agent support, less incidence of right ventricular dysfunction and so, associated with shorter period of hospitalization and shorter intensive care stay length; therefore has been determined to be beneficial to health in many ways. With outflow graft attachment to the descending aorta, it is thought that, different from the routine ascending aorta method, because of the continuous flow primarily directed to descending aorta and then to the distal circulation, cerebral blood flow and due to this cerebral perfusion would be affected unfavorably. In our study, our purpose is to examine the middle cerebral artery, bilateral internal carotid artery, vertebral artery and femoral artery flow differences between the cases which underwent left thoracotomy surgery with outflow graft attached to the descending aorta and the ones that underwent conventional left ventricular assist device implantation surgery with outflow graft attached to the ascending aorta, in addition to that, also to determine the difference in incidence of cerebrovascular incidents between these surgical approaches. Bearing these in mind, the aim is to question the reliability of the left thoracotomy approach as an alternative to redo sternal surgery. MATERIALS and METHODS: The 12 patients diagnosed with severe decompensated heart failure which underwent left ventricular assist device implantation surgery by left thoracotomy in our clinic and at least 10-15 patients who underwent left ventricular assist device implantation surgery by median sternotomy will form together the sample size. Left thoracotomy left ventricular assist device patients will be the experimental group, median sternotomy left ventricular assist device patients will be the control group. Because of the experimental group patients are all males and implanted with the Heartware ventricular assist device, the control group will also be chosen from male and Heartware ventricular assist device implanted patients, in order to exclude the sex factor and the differences between different brands of devices. From the clinic archive, postoperative ultrasonographic scannings of these patients will be viewed, and on these the pulsatility index, resistivity index and the flow volume of the bilateral carotid arteries, vertebral arteries, femoral arteries, and middle cerebral arteries, if could be displayed, will be calculated. The comparative analysis of these calculations between the descending group and ascending group patients, the examinations of these calculations in comparison of postoperative cerebrovascular incident and pump thrombosis incidences and the comparative analysis of these will be done. RESULTS: 12 patients which implanted LVAD with left thoracotomy are added to the study. For the control group, 12 patients who underwent LVAD implantation surgery by conventional median sternotomy also added. Mean age was 54,5. In patient groups the number of cerebrovascular incidents and pump thrombosis incidents were equal. In comparative analysis of flow characteristics between these two groups, the femoral artery resistive index, pulsatility index and flow volume values found higher in descending aorta group patients whose outflow graft had attached to the descending aorta than the ascending group patients, anticipated as before the study. Right internal carotid artery flow volume values of the descending aorta group is found statistically significantly higher than the ascending aorta group. Also, albeit not significantly, left carotid artery flow volumes were higher in the descending aorta group. There were no statistically significant differences in other arterial measurements between the ascending and descending aorta groups. In the comparison of measurement values as cerebrovascular incident and pump thrombosis incidence, there were no significant differenceS. CONCLUSIONS: As more advanced devices are being developed, especially in cases which the redo surgery is intended to be avoided, left ventricular assist device implantations with minimally invasive approaches are being implemented increasingly. When left thoracotomy is used in which the outflow graft attachment site is chosen as descending aorta, the blood volume which sent to the carotid arteries and cerebral circulation, on the contrary to the foreseen thoughts, is not being changed meaningfully, rather the right internal carotid artery flow volume is significantly being increased. In pump thrombosis and cerebrovascular incidents, there is no significant difference in arterial flow measurements. So, for left ventricular assist device implantation, the method in which outflow graft is attached to the descending aorta by left thoracotomy, is a reliable choice for the surgeon knowing that this method does not produce an incremental effect in long term adverse effects.
PURPOSE: In left ventricular assist device implantation to decompensated heart failure patients especially for the ones who were diagnosed with ischemic cardiomyopathy and who previously had a cardiac surgery, the method in which the outflow graft attached to the descending aorta by left thoracotomy is becoming more widely implemented due to the fact that it reduces the mortality and morbidity in contrast to the redo sternotomy and redo surgery. Based on the literature, this alternative method comes with shorter duration of mechanical ventilation, shorter duration of cardiopulmonary bypass, less need for transfusion, lower inotropic agent support, less incidence of right ventricular dysfunction and so, associated with shorter period of hospitalization and shorter intensive care stay length; therefore has been determined to be beneficial to health in many ways. With outflow graft attachment to the descending aorta, it is thought that, different from the routine ascending aorta method, because of the continuous flow primarily directed to descending aorta and then to the distal circulation, cerebral blood flow and due to this cerebral perfusion would be affected unfavorably. In our study, our purpose is to examine the middle cerebral artery, bilateral internal carotid artery, vertebral artery and femoral artery flow differences between the cases which underwent left thoracotomy surgery with outflow graft attached to the descending aorta and the ones that underwent conventional left ventricular assist device implantation surgery with outflow graft attached to the ascending aorta, in addition to that, also to determine the difference in incidence of cerebrovascular incidents between these surgical approaches. Bearing these in mind, the aim is to question the reliability of the left thoracotomy approach as an alternative to redo sternal surgery. MATERIALS and METHODS: The 12 patients diagnosed with severe decompensated heart failure which underwent left ventricular assist device implantation surgery by left thoracotomy in our clinic and at least 10-15 patients who underwent left ventricular assist device implantation surgery by median sternotomy will form together the sample size. Left thoracotomy left ventricular assist device patients will be the experimental group, median sternotomy left ventricular assist device patients will be the control group. Because of the experimental group patients are all males and implanted with the Heartware ventricular assist device, the control group will also be chosen from male and Heartware ventricular assist device implanted patients, in order to exclude the sex factor and the differences between different brands of devices. From the clinic archive, postoperative ultrasonographic scannings of these patients will be viewed, and on these the pulsatility index, resistivity index and the flow volume of the bilateral carotid arteries, vertebral arteries, femoral arteries, and middle cerebral arteries, if could be displayed, will be calculated. The comparative analysis of these calculations between the descending group and ascending group patients, the examinations of these calculations in comparison of postoperative cerebrovascular incident and pump thrombosis incidences and the comparative analysis of these will be done. RESULTS: 12 patients which implanted LVAD with left thoracotomy are added to the study. For the control group, 12 patients who underwent LVAD implantation surgery by conventional median sternotomy also added. Mean age was 54,5. In patient groups the number of cerebrovascular incidents and pump thrombosis incidents were equal. In comparative analysis of flow characteristics between these two groups, the femoral artery resistive index, pulsatility index and flow volume values found higher in descending aorta group patients whose outflow graft had attached to the descending aorta than the ascending group patients, anticipated as before the study. Right internal carotid artery flow volume values of the descending aorta group is found statistically significantly higher than the ascending aorta group. Also, albeit not significantly, left carotid artery flow volumes were higher in the descending aorta group. There were no statistically significant differences in other arterial measurements between the ascending and descending aorta groups. In the comparison of measurement values as cerebrovascular incident and pump thrombosis incidence, there were no significant differenceS. CONCLUSIONS: As more advanced devices are being developed, especially in cases which the redo surgery is intended to be avoided, left ventricular assist device implantations with minimally invasive approaches are being implemented increasingly. When left thoracotomy is used in which the outflow graft attachment site is chosen as descending aorta, the blood volume which sent to the carotid arteries and cerebral circulation, on the contrary to the foreseen thoughts, is not being changed meaningfully, rather the right internal carotid artery flow volume is significantly being increased. In pump thrombosis and cerebrovascular incidents, there is no significant difference in arterial flow measurements. So, for left ventricular assist device implantation, the method in which outflow graft is attached to the descending aorta by left thoracotomy, is a reliable choice for the surgeon knowing that this method does not produce an incremental effect in long term adverse effects.
Açıklama
Anahtar Kelimeler
LVAD, Doppler, Ultrasonografi, Pulsatilite İndeksi, Rezistivite İndeksi, Akım Hacmi, LVAD, Doppler, Ultrasonography, Pulsatility Index, Resistive Index, Flow Volume
