Indications and initial stage of surgical access
The main indication for this surgical procedure is the diagnosis of a large aneurysm located in the area of the left ventricle.
Surgical intervention begins with work in the pericardial cavity. At the first stage, the operating surgeon opens the pericardium. After that, it is extremely important to carefully separate the leaves of the pericardium directly from the bottom of the aneurysmal sac. This maneuver allows for the mobilization of the affected area and prepares the operative field for further intracardiac manipulations.
Intracardiac stage and preparation for excision
After adequate access to the pathological focus is ensured, the cavity of the aneurysm itself is widely opened. At this stage, the operating team faces a crucial task: the thorough and complete removal of all thrombi.
Having cleaned the cavity, the surgeon proceeds to assess the extent of the lesion. The key point here is that the precise determination of the boundaries of the upcoming resection is carried out exclusively from the inside — from the endocardium side. Only visual control of the inner lining of the heart makes it possible to adequately assess the transition from healthy functioning tissue to pathologically altered and thinned tissue.
Technique of resection and left ventricular wall suturing
Moving directly to excision, the surgeon removes the altered walls of the aneurysm. At the same time, a strict rule applies: tissue must be resected in such a way that a dense rim consisting of fibrous tissue remains along the edges of the formed surgical defect. The width of this rim must be exactly 1.5 centimeters. This fibrous edge serves as a reliable and durable support for subsequent wound closure.
The resulting left ventricular wall defect is sutured. To ensure maximum reliability, the technique of applying two rows of continuous sutures is used. This technique guarantees high mechanical strength of the reconstruction zone under constant intracardiac pressure.
Prevention of air embolism and completion of the main stage
Before completely closing the left ventricular cavity, it is necessary to perform a crucial maneuver — the prevention of air embolism. The essence of the method is that the last stitch of the applied double-row suture is not tightened immediately. Ventricular sealing is performed using a specific technique — "on the blood stream". The surgeons wait for the moment when the blood entering the cavity completely displaces the remaining air bubbles, and only then do they finally tighten the thread.
After successful sealing of the heart cavity and restoration of adequate hemodynamics, the patient is disconnected from the cardiopulmonary bypass (CPB) machine.
Petrovsky plasty and closure of the surgical wound
To additionally reinforce the left ventricular suture line and ensure absolute hemostasis, the Petrovsky plasty technique is used.
Main steps of the plasty:
- From the left dome of the diaphragm, the surgeon carves a full-fledged pedicle muscle flap.
- This blood-supplied flap is moved to the heart and securely fixed to the left ventricular wall.
- The formed suture line is completely covered with the flap.
At the final stage of the operation, the surgeons proceed to work with the pericardium. Suturing of the pericardium is performed by applying interrupted sutures.
Briefly: answers to topical questions
What methods of left ventricular aneurysm plasty exist, besides the Petrovsky method?
In addition to the Petrovsky method, endoventricular plasty is used for left ventricular reconstruction, and the left ventricular wall defect is sutured with two rows of continuous sutures.
- Endoventricular plasty — performed as part of surgical left ventricular reconstruction to normalize its shape and volume.
- Defect closure — the left ventricular wall defect is sutured with two rows of continuous sutures.
Which vessels are cannulated to connect the cardiopulmonary bypass machine during aneurysm resection?
To connect the cardiopulmonary bypass machine, the venae cavae are cannulated for blood collection and arteries for its return.
- Superior vena cava — the first catheter is inserted through the right atrial appendage.
- Inferior vena cava — the second catheter is inserted through the wall of the right atrium.
- Femoral artery or ascending aorta — used for arterial cannulation and returning blood to the body.
What main stages does the cardiac aneurysm resection operation include?
Cardiac aneurysm resection includes the following stages:
- Access — opening the pericardium and separating it from the bottom of the aneurysm, wide opening of the aneurysm.
- Removal of thrombi from the aneurysm cavity.
- Determination of resection boundaries from the endocardial side.
- Excision of the aneurysm walls, leaving a 1.5 cm fibrous tissue rim.
- Defect closure of the left ventricular wall with two rows of continuous sutures. Before finally tightening the last stitch, blood is allowed to displace the air, after which the ventricular cavity is sealed to prevent air embolism.
- Completion of the stage — disconnecting the cardiopulmonary bypass machine, performing the Petrovsky plasty, and suturing the pericardium with interrupted sutures.
Class and exam questions
For which pathologies is this surgery strictly indicated?
The surgical intervention is performed when large aneurysms are detected in the patient, localized exclusively in the left ventricular wall.
How do surgeons determine the boundaries for excising affected tissues?
Assessment of the resection boundaries is performed visually from the inside, from the endocardial side. During the excision itself, a supporting rim of fibrous tissue 1.5 centimeters wide is necessarily preserved.
What is the essence of the Petrovsky plasty?
This is a method of reinforcing the suture line and ensuring hemostasis, in which a pedicle muscle flap is carved from the left dome of the diaphragm and fixed over the sutured left ventricular wall.
How is the entry of air into the systemic circulation prevented?
The left ventricular cavity is sealed using the technique of tightening the last stitch "on the blood stream," allowing blood to completely displace the air before final defect closure.
What else to study on this topic
- Topographic anatomy and layers of the left ventricular wall
- Principles of cardiopulmonary bypass (CPB) operation in cardiac surgery
- Mechanisms of intracardiac thrombus formation in aneurysms
- Topography of the left dome of the diaphragm and blood supply to the muscle flap
- Histological structure of fibrous tissue in the post-infarction aneurysm zone
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