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Optimization of the surgical treatment in congenital heart malformations with intracardiac shunting and prognosis of complications


Author: Anatol Ciubotaru
Degree:doctor habilitat of medicine
Speciality: 14.00.44 - Cardiovascular Surgery
Year:2006
Scientific consultant: Eva Gudumac
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Institution:
Scientific council:

Status

The thesis was presented on the 21 March, 2006
Approved by NCAA on the 29 June, 2006

Abstract

Adobe PDF document0.95 Mb / in romanian

Thesis

CZU 616.12-007-053.1-089.168.1-06-037

Adobe PDF document 16.00 Mb / in romanian
256 pages


Summary

The goal of this research is the study of the clinico-evolutive particularities and surgical management in congenital heart malformations with intracardiac shunting, as well as the assessment of new prognosis criteria for the post-operative complications; identification of the indications for using synthetic and biological materials in correction of congenital heart defects according to their localization; and creation of new biological materials and their implementation in the clinic.

The given study was fulfilled within the Scientific and Practical Centre of Cardiovascular Surgery, from the Republican Clinical Hospital, in the period since 1989 until 2005, as well as in the Clinic of Thoracic and Cardiovascular Surgery from Hanover, Germany, based on a collaboration agreement signed in 2001. The study was based on the results of clinical, laboratory, echocardiography, and radiological assessment of 479 patients having congenital heart malformation with intracardiac shunting, who were subject to the surgical treatment, and constituted 51.1% of all the patients with congenital heart malformations operated under the circumstances of extracorporeal circulation.

It was shown that the clinical diagnosis, determination of the surgical management and the post-operative assessment, are established in almost 95% with the help of Colour Doppler Echocardiography. The presented study confirmed that the late diagnosis and late surgical treatment largely do not resolve the patient’s problems, displaying a mortality rate directly proportionate to the patient’s age – the older is the patient, the worse is the outcome. Both from medical and psycho-emotional reasons, the patients should be subject to surgery at the age of the pre-scholar.

It was demonstrated that in the correction of inter-atrial defects, the material of choice is the autologus pericardium, while in the interventricular defects the synthetic materials are preferable. In some cases, the bovine xenopericardium treated with glutaraldehyde may be applied, yet in very few cases, due to the postoperative complications such as recanalization, degeneration and calcification of the material.

There was proposed a new method of plasty of pulmonary artery valve for the radical correction of Fallot’s tetralogy – „cuspo-pexy”. This procedure reduces the pulmonary artery insufficiency and offers a possibility to enlarge the ejection tract out of the right ventricle, while applying a trans-valvular graft.

There were performed a number of experimental studies on animals and human cadaver tissues (homo-grafts), allowing to develop a new method of de decellularization keeping the basal membrane. It was also developed a new method of re-planting the decellularized grafts with endothelial cells of the recipient „in vitro”, which being later implanted reduce the chances for infecting and thrombosis of these grafts. These newly developed methods were applied for prosthesis of the pulmonary artery valve and trunk in case of atresia either insufficiency, especially for the radical correction of tetralogy of Fallot. Yet, the main benefit of this study is the fact that it proved the property of the decellularized homografts and recellularized with autologous endothelia cells, to grow concomitantly with the child, the need for re-interventions because of the child’s growth being removed. This fact was not described ever before by anyone, and represents a perspective both for cardiovascular surgery and for other surgical disciplines, which impose the use of biological grafts, and particularly for paediatric surgery.