Syntopy of the human heart. Location of the heart in human anatomy. Left atrium, atrium sinistrum

Syndrome sudden death a baby is something that horrifies many new parents. The resulting panic awakens the desire to constantly be on duty near the baby's crib, which leads to lack of sleep, nervousness and constant fatigue.

Can a child die in a dream, or how to secure a child's sleep?

First of all, it is worth remembering that the removable sides of the crib are convenient only for parents. And this convenience must be sacrificed, because we are talking about the life of a baby. Also, the attention of parents should be drawn to the quality of fixing the parts of the crib and the distance between the slats, which should be a maximum of 6 cm.

You should forget about piling up a crib with soft toys, pillows and decor elements. Remember: even fabric protection in the arena can become a dangerous element, because a child, having learned to walk, may try to climb out of it!

Mobiles and other toys should be installed so that the baby could not grab onto them and throw them over, getting bruises and abrasions. And when the child sits down, they need to be removed altogether.

Can a child die in a dream? Such cases happen. To be more calm, mom and dad can watch the baby with a video and baby monitor, and even monitor their breathing with a special monitor that will let you know if something goes wrong. Despite all this, they must be handled very carefully, because the equipment malfunctions and can itself be a danger to the child.

... The kid suddenly "wakes up" and screams terrible words in a dream "Don't touch me, get away!" His eyes are open, his forehead is covered with sweat, the child is not himself. This horror can last from several minutes to half an hour. Here is an example of parasomnia, called "night tantrum" (night terror). Anyone who has ever experienced night hysteria will never forget it.

Parasomnia - what is it?

Human sleep is not just the absence of wakefulness, it is a whole world, a system organized in a special way. This system is controlled by the brain and subjugates the entire body during sleep. Even in an adult, sleep and wakefulness may not completely pass into each other. In a child, especially in the first months of his life, when the sleep phases are not yet fully formed, they sometimes appear at the “wrong time” or even overlap one another. At the moments of such a “superposition of phases”, the body behaves not quite normally - a person can walk, talk, move his arms and legs, or even sob bitterly, while continuing to sleep soundly. Such phenomena of activity during deep sleep are called parasomnia (from para - disturbance and somnus - sleep).

Parasomnia is not a pathology, but simply a consequence of the general immaturity of the brain. Over time, this "imposition of phases" occurs less and less, and by the transitional age it usually disappears altogether.

Well, except perhaps leaving the ability to talk in a dream about yourself “as a keepsake”.

Parasomnias in themselves do not pose a health hazard, however, they can add anxiety and excitement to parents. It is best to terrify parents with such manifestations of parasomnia as night tantrums and sleepwalking. Here we will dwell on them in more detail.

Night tantrums. Why does a child cry in his sleep?

Let's immediately distinguish between terms so as not to get confused further. There is about children's sleep, but the terminology is used everywhere differently. So, there are terrible unpleasant dreams. We all see them sometimes at night, but they have nothing to do with what we would call night tantrums, or nightmares / fears. The nature of night tantrums is very different from the nature of ordinary dreams, below we will consider and analyze the main differences.

Most often, night tantrums occur in children from one to five years. Night tantrums (in English-language sources "night terror") are called bouts of intense fear, usually accompanied by crying or screaming, which occurs when one phase of sleep overlaps with another.

Anyone who has ever experienced this phenomenon knows that it is really very scary. The child desperately screams, talks, his eyes are wide open, but he does not seem to see you, his forehead is covered with perspiration. You can feel how fast his heart is beating and how hard he is breathing. It is almost impossible to calm the baby, he does not respond to persuasion, does not allow himself to be hugged or pulled out of the crib.

And really, you shouldn't try to do that.

Although the child may appear to be awake, he is actually in a deep sleep stage. An attack of night hysteria can continue from several minutes to half an hour.

What is the main difference between night tantrums and bad dreams?

Frightening dreams, like any other dreams, occur during the rapid eye movement phase. During this phase, the body is asleep, but the brain works in much the same way as in waking mode. Sleep at this time is sensitive, a child who had a nightmare can wake up quickly, he remembers what scared him, and your gentle hands, hugs, motion sickness will help him calm down.

This is not at all the case in the case of an episode of nocturnal hysteria. Night tantrums usually occur at the beginning of the night, when the phases of deep sleep, in which a person sleeps without dreams, prevail. The child suddenly experiences a strong feeling of fear, his brain tries to wake up, but at the same time continues to sleep soundly. As a result, the baby screams and cries, but it will not work to correct the situation with persuasion or caress - even though the baby’s eyes are open, he sleeps and does not see you.

A kid who survived a night tantrum will not remember anything after waking up. Therefore, if you want to talk to him about what happened, your questions should be built only in the form of open-ended questions that do not offer a choice of two or three options and cannot be answered with "yes" or "no".

Let's clarify why you can't "guess". Imagine: the baby still woke up from a night of hysteria, does not remember anything, except that he slept sweetly in his bed. And then a frightened crowd stands in front of him: a neighbor with valerian, elder sister, and mom in tears asks: “Darling, did you dream that a shark was chasing you, or how mom left and didn’t return?”. Put yourself in the place of a child. Here you confess to anything, if only everyone would leave and stop asking strange questions. But doubts that everything is fine, the baby will definitely appear.

It's best to ask questions like "What do you remember?" or “What did you dream about?”, so as not to impose your vision of what happened on the child. And then, such questions can be asked once to make sure that it really was an episode of parasomnia, “night terror”. The more calmly and less intrusively you ask the baby about what happened, the less likely it will be to frighten him.

So what to do with night tantrums?

First of all, it is necessary to exclude the possibility of neurological causes of what is happening. Consult your doctor. If the doctor says that your baby is healthy and does not need treatment, then you need to behave with night tantrums as follows:

As already mentioned, do not try to wake the child - you will only disturb him more.
Dim the lights, sit next to him, but do not try to take the baby out of the crib or cuddle him. Make sure that the child does not injure himself if he jerks his arms or legs sharply. You can sing softly or say something soothing to him.
The most important thing to do is to prevent nighttime tantrums in the future - monitor the child's regimen, avoid "overwalking" or lack of sleep, avoid stress and overexcitation.
Be sure to keep a diary, where you write down what time your baby went to bed on the day the night tantrum arose, and what time the episode began. On the following nights, half an hour before the expected time of the start of the tantrum, you can wake the baby for a second with a gentle hug and kiss, this will bring down his rhythms and “reboot” sleep. Often this method helps to avoid night tantrums. Such work must be done within two weeks and try after that to see if it was possible to restart the system as a whole. Of course, all this time it is important to put the baby on night sleep early, offer daytime sleep, avoid noisy events and unusual trips.
Pay attention to the crib: it should be as safe as possible. Take special care to make the sleeping area safe so that the baby cannot harm himself when he swings his arms and legs in his sleep.

Night tantrums usually go away with adulthood, but in some cases they may return during adolescence. Be prepared for this and warn your child that this can happen.

It is also worth paying your attention to whether your relatives had parasomnias in childhood. Often this suggests that this can happen to your baby too - the causes of parasomnia have genetic roots. Moreover, if one of the relatives had one type of parasomnia, his child may have another. For example, a grandmother had night tantrums, and her grandson may have sleepwalking.

Sleepwalking

Studies have shown that 5% of children aged 6 to 16 experience sleepwalking up to 12 times a year. And another 10% had sleepwalking episodes every 3-4 months. modern science believes that sleepwalking is not associated with emotional stress or behavioral problems, and its causes lie in hereditary predisposition. Sleepwalking episodes usually occur 2-3 hours after falling asleep, and last up to half an hour. If at this time you look at the sleepwalker, it seems that he does not quite understand where he is. His gait is devoid of smoothness, and his movements seem to be aimless. During episodes of sleepwalking, the child can not only walk, but also dress, open doors and windows, and even eat! The problem does not require treatment, however, certain security measures should be taken care of. Make sure that your baby (or husband) will not be able to open the front door or window in a dream: put the door lock or chain so high that the child cannot reach it, put special handles with a lock on the windows. It is also worth removing toys and furniture with hard corners from the path of a sleeping child.

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Topographic anatomy hearts

2.1 Topography of the heart. Heart. Syntopy of the heart. Topographic anatomy of the heart

The heart has a base and an apex. The base of the heart, basis cordis, faces up, back and to the right. Behind it is formed by the atria, and in front by the aorta and pulmonary trunk. The rounded apex of the heart, apex cordis, faces down, forward and to the left, reaching the fifth intercostal space at a distance of 8-9 cm to the left of the midline; the apex of the heart is formed entirely by the left ventricle. The edges of the heart are of unequal configuration: the right edge of the heart is sharper; the left one is more obtuse, rounded due to the greater thickness of the wall of the left ventricle.

Both edges of the heart and part of its posterior-inferior surface are adjacent to the mediastinal pleura and lungs. It is believed that the size of the heart corresponds to the size of a human fist. The average size of the heart: length - 12--13 cm, largest diameter - 9--10.5 cm, anteroposterior size - 6--7 cm. In the heart, as in the pericardium, there are five surfaces: sternocostal (anterior), facies sternocostalis (anterior), diaphragmatic (lower), facies diaphragmatica (inferior), two pulmonary (lateral), facies pulmonales (laterales) dextra et sinistra, and back, facies vertebralis (posterior).

2.2 Anterior surface of the heart. Coronal sulcus of the heart. Anterior interventricular sulcus of the heart

The anterior surface of the heart, facies sternocostalis, is formed above and to the right by the anterior wall of the right atrium and the right ear. To the left and above is the left atrial appendage. Both ears cover the large vessels between them: the superior vena cava, the aorta and the pulmonary trunk. Below, most of the anterior wall is the anterior wall of the right ventricle; only a small part of it on the left is represented by the left ventricle. The boundary between the atria and the ventricles of the heart is the coronary sulcus, sulcus coronarius, and between the ventricles is the anterior interventricular sulcus, sulcus interventricularis anterior. The coronal sulcus of the heart is located on the border between the right atrium and the right ventricle. In it, in the subepicardial tissue, the right coronary artery is located, a. coronaria dextra.

The anterior interventricular sulcus of the heart projection corresponds to the anterior edge of the interventricular septum and divides the anterior surface of the heart into two sections: the larger one is the right one, formed by the anterior wall of the right ventricle, and the much smaller one is the left one, formed by the wall of the left ventricle. In the anterior interventricular sulcus in the subepicardial tissue are r. interventricularis anterior a. coronariae sinistrae and great vein of the heart, v. cordis magna. Most of the anterior surface of the heart (right atrium, right and left ventricles) is separated from the anterior chest wall (in addition to the pericardium) by the costomediastinal sinuses of the pleura and the anterior edges of the lungs. Only in the region of the lower interpleural triangle, a small part of the anterior surface of the heart (the right heart auricle and the right ventricle) is adjacent to the sternum and cartilages of the III-V ribs (here, cardiac dullness is determined during percussion). At this site, the pericardium can be opened without damaging the pleura.

2.3 Inferior surface of the heart. Left lateral surface of the heart. Right lateral surface of the heart. Posterior surface of the heart

The lower surface of the heart, facies diaphragmatica, lies on the middle segment of the tendon center of the diaphragm. The formation of this surface involves the ventricles (mainly the left and a small part of the right) and the lower part of the posterior wall of the right atrium. The boundary between the atria and ventricles is the back of the coronal sulcus; here it is most pronounced. In the coronary sulcus of the heart are the right coronary artery, a. coronaria dextra, circumflex branch of the left coronary artery, circumflexus a. coronariae sinistrae, coronary sinus, sinus coronarius, and small vein of the heart, v. cordis parva. Along the posterior interventricular sulcus of the heart, projectively corresponding to the posterior edge of the interventricular septum, the posterior interventricular branch of the right coronary artery, r. interventricularis posterior, and the middle vein of the heart, v. cordis media. The anterior and posterior interventricular sulci of the heart merge with each other with their lower ends and form on the right edge of the heart, immediately to the right of the apex of the heart, a cardiac notch, incisura apicis cordis.

The left lateral surface of the heart, facies pulmonalis sinistra, is formed by the upper third of the blunt edge of the left ventricle and a small area of the left atrium with an eye. The right lateral surface of the heart, facies pulmonalis dextra, is formed by the right atrium and the lateral surface of the right ear.

The posterior surface of the heart, facies vertebralis, is formed by the posterior and superior surfaces of the left and right atria. The atria are separated by an atrial sulcus that runs between the caval and right pulmonary veins. To the posterior wall of the left atrium of the heart are adjacent the left main bronchus, esophagus, aorta and vagus nerve. Part of the posterior wall of the right atrium of the heart is located anterior and inferior to the right main bronchus.

2.4 Chambers of the heart. Right atrium. The structure of the right atrium. Thebesian veins of the heart

Into the right atrium from behind pour in at the top v. cava superior and below v. cava inferior, anteriorly, the atrium continues into a hollow process - the right ear of the atrium, auricula atrii dextra. The septum between the atria, septum interatrial, is located obliquely. From the anterior wall, it goes back and to the right, so that the right atrium is located on the right and in front, and the left - on the left and behind. On the interatrial septum there is an oval-shaped recess - fossa ovalis. This recess is the remainder of the hole - foramen ovale, through which the atria communicate with each other in the period of intrauterine development.

Non-closure of the foramen ovale (atrial septal defect) is one of the most common birth defects hearts. In the lower anterior part of the atrium there is a wide right atrioventricular opening, ostium atrioventriculare dextrum, which leads into the cavity of the right ventricle. Between holes v. cavae inferior and ostium atrioventriculare dextrum, the opening of the coronary sinus, ostium sinus coronarii, which collects blood from the veins of the heart, opens into the right atrium; here are the openings of the small, or Tebeziev, veins of the heart. The inferior vena cava is separated from them by a low flap, varvula venae cavae inferioris.

2.5 Left heart. Right ventricle. Topography of the right ventricle. The structure of the right ventricle

The left atrium lies behind the descending aorta and esophagus. On each side, two pulmonary veins flow into it. The left ear, auricula atrii sinistra, protrudes anteriorly, bending around the left side of the ascending aorta and pulmonary trunk. In the lower anterior section, the left atrioventricular opening, ostium atrioventriculare sinistrum, leads into the cavity of the left ventricle.

2.6 Right ventricle. Topography of the right ventricle. The structure of the right ventricle

The right ventricle has the shape of a triangular pyramid, the top of which is directed downwards. The base at the top borders the right atrium, with the exception of the upper left corner, where the pulmonary trunk, taincus pulmonalis, emerges from the right ventricle. The part of the right ventricle closest to the pulmonary trunk is called the conus arteriosus. Ostium atrioventriculare dextrum, leading from the cavity of the right atrium to the cavity of the right ventricle, is equipped with a tricuspid valve, valva atrioventricularis dextra (valva tricuspidalis). The valve prevents blood from returning to the atrium during ventricular systole. From the right ventricle, blood enters the pulmonary trunk through an opening, ostium trunci pulmonalis, equipped with a valve, valva trunci pulmonalis, which prevents blood from returning from the pulmonary trunk back to the right ventricle during diastole. The valve consists of the right, left and anterior semilunar flaps (valvulae semilunares).

2.7 Left ventricle. aortic valve. Sinuses of Valsalva. Heart valves

The left ventricle has the shape of a cone, the walls of which are 2-3 times thicker than the walls of the right ventricle (10-15 mm versus 5-8 mm). The ostium atrioventriculare sinistrum leads from the cavity of the left atrium to the left ventricle. It is blocked by a bicuspid left atrioventricular valve, valva atrioventricularis sinistra (valva mitralis). The anterior and posterior leaflets of the valve face the cavity of the ventricle with their free edges. The opening of the aorta is called the ostium aortae, and the department of the ventricle closest to it is the conus arteriosus. The aortic valve, valva aortae, has the same structure as the pulmonary valve. It consists of the right, left and posterior semilunar flaps. The spaces between the semilunar valves and the wall of the aorta are called the sinuses of Valsalva. During systole, the valve flaps adhere to the vessel wall and the sinuses disappear.

During ventricular diastole, backflow of blood closes the valve and fills the sinuses. The septum between the ventricles, septum interventriculare, is represented mainly by muscle tissue, pars muscularis, with the exception of the uppermost section, where there is only fibrous tissue covered on both sides by the endocardium, pars membranacea. The inner surface of the cavities of the heart is lined by the endocardium, endocardium. All heart valves are folds (duplications) of the endocardium.

2.8 Intrapericardial regions of vessels. Ascending aorta in the pericardium. Arteries of the heart. coronary arteries. coronary arteries

The ascending aorta lies entirely within the pericardial cavity. The length of the ascending aorta is 5-6 cm. The beginning of the aorta is called the aortic bulb, bulbus aortae. It is covered in front and on the left by the pulmonary trunk, in front and on the right - by the right ear. From the aortic bulb at the level of the aortic valve, its first branches depart: the coronary (coronary) arteries. Behind the ascending aorta lies the right pulmonary artery, only partially covered by the pericardium.

Arteries of the heart. coronary arteries. Coronary arteries Coronary (coronary) arteries, right and left, aa. coronariae dextra et sinistra, start from the bulbus aortae in the region of the sinuses of Valsalva below the upper edges of the semilunar valves. In this regard, during systole, the entrance to the coronary arteries is covered by valves, and the arteries themselves are compressed by the contracted muscle of the heart. During systole, the blood supply to the heart decreases; blood enters the coronary arteries during diastole, when the inlets of these arteries, located at the mouth of the aorta, are not closed by the semilunar valves.

2.9 Right coronary artery. Right coronary artery. Left coronary artery. Left coronary artery

Right coronary artery, a. coronaria dextra, exits the aorta, respectively, to the right semilunar valve of the aortic valve from the right sinus of Valsalva and lies between the aorta and the auricle of the right atrium. Outside of the ear, it goes around the right edge of the heart along the coronary sulcus and passes to its posterior surface. Here it continues into the interventricular branch of the right coronary artery, ramus interventricularis posterior, which descends along the posterior interventricular groove to the apex of the heart, where it anastomoses with the branch of the left coronary artery. The branches of the right coronary artery vascularize the right atrium, part of the anterior and entire posterior wall of the right ventricle, a small portion of the posterior wall of the left ventricle, the interatrial septum, the posterior third of the interventricular septum, and the papillary muscles of the ventricles.

Left coronary artery, a. coronaria sinistra, leaving the aorta at the left semilunar valve of its valve, also lies in the coronary sulcus anterior to the left atrium. Between the pulmonary trunk and the left ear, it gives two branches: thinner - anterior interventricular, ramus interventricularis anterior, and larger - envelope, ramus circumflexus. The first descends along the anterior interventricular sulcus to the apex of the heart, where it anastomoses with the interventricular branch of the right coronary artery. The circumflex branch, continuing the main trunk of the left coronary artery, goes around the heart on the left side along the coronary sulcus and connects with the right coronary artery. As a result, an arterial ring is formed along the entire coronal sulcus, located in a horizontal plane, from which branches perpendicularly depart to the heart. The ring is a functional device for collateral circulation hearts. The branches of the left coronary artery supply the left atrium, the entire anterior and most of the posterior wall of the left ventricle, part of the anterior wall of the right ventricle, and the anterior 2/3 of the interventricular septum. Various options for the development of the coronary arteries are possible, as a result of which there are various ratios of blood supply pools. From this point of view, there are three forms of blood supply to the heart: uniform, with the same development of both coronary arteries, left vein and right vein.

2.10 Veins of the heart. Coronal sinus. Large vein of the heart. Middle vein of the heart. Vienna Thebesia

The veins of the heart do not open into the vena cava, but directly into the cavity of the heart. They begin in the form of networks located in various layers of its wall. The venous bed significantly predominates over the arterial. Venous outflow goes in three ways: into the coronary sinus, sinus coronarius; into the anterior veins of the heart; into the small veins of Thebesia, flowing directly into the right side of the heart. The coronary sinus, sinus coronarius, lies behind, in the coronary sulcus, and opens into the right atrium slightly below the trunk of the inferior vena cava.

The large vein of the heart, v. cordis magna, which collects blood from the anterior surface of both ventricles. First, it is located in the anterior interventricular sulcus, next to the ramus interventricularis anterior of the left coronary artery, then it goes under the left ear and passes to the posterior surface, where it flows (continues) into the coronary sinus. Middle vein of the heart, v. cordis media, from the posterior interventricular sulcus passes into the coronary sulcus and flows into the coronary sinus on the right. In addition to these large veins, a small vein of the heart flows into the coronary sinus, v. cordis parva, posterior vein of the left ventricle, v. posterior ventriculi sinistri, and oblique vein of the left atrium, v. obliqua atrii sinistra. Anterior veins of the heart, vv. cordis anteriores, carry blood from the upper part of the anterior wall of the right ventricle and flow into the right atrium. Small veins, vv. cordis minimae, collect blood in the depths of the walls of the heart and through many holes flow directly into the right atrium.

2.11 Pulmonary trunk. Botallov duct. Pulmonary arteries. Pulmonary veins. Vena cava

The pulmonary trunk, truncus pulmonalis, being a continuation of the arterial cone of the right ventricle, goes up backwards and somewhat to the left, crossing the ascending aorta in front, and then lying to the left of it. The length of the trunk varies from 2.5 to 5.1 cm, diameter - from 2 to 3.8 cm. The pulmonary trunk is covered with pericardium on all sides, except for the place where it is adjacent to the ascending aorta. Under the aortic arch, the pulmonary trunk divides into the right and left pulmonary arteries at level II of the left costal cartilage. To the wall of the pulmonary trunk at the site of its division and the beginning of the left pulmonary artery the arterial ligament is attached, lig. arteriosum (closed ductus arteriosus), coming from the aorta. Botallov duct. Pulmonary arteries. A. pulmonalis dextra is directed laterally to the hilum of the right lung, located behind the ascending aorta and superior vena cava and below the terminal section of the unpaired vein. Having entered the gates of the lung, the pulmonary artery divides first into lobar branches (branches of the 2nd order), and then into segmental (branches of the 3rd order). A. pulmonalis sinistra has a shorter trunk than the right artery and its diameter. From the place of origin, the artery goes back, up and to the left anterior to the left main bronchus. In front, the initial section of the artery is covered by the pericardium. In the pulmonary gates, it is divided in the same way as the right one.

Vienna Thebesia. Pulmonary veins Four pulmonary veins, vv. pulmonales dextrae et sinistra, two from each lung, approach the heart from the roots of the lungs in a transverse direction. Their terminal sections enter the pericardial cavity, where they empty into the left atrium. Hollow veins. V. cava superior enters the pericardial cavity from above. In the upper part of the pericardium, it lies on the right, next to the ascending aorta. Through the gap between them, you can enter the transverse sinus of the pericardium. Near the right ear, the superior vena cava empties into the right atrium. V. cava inferior flows into the right atrium from below, from the side of the diaphragmatic surface of the heart. Its intrapericardial section is much shorter than that of the superior vena cava.

3. Surgical treatment of acquired heart defects

3.1 Transventricular access technique

The position of the patient on the back with a roller under the left side. With simultaneous aortic and mitral commissurotomy, sometimes, especially when the heart rotates to the left, it is necessary to put the patient on the right side.

The chest cavity is opened with an anterior-lateral incision from the sternum to the posterior axillary line in the 5th intercostal space. Sometimes it is necessary to cross the cartilage of the VI rib. With mitral and aortic commissurotomy, the incision is made in the IV intercostal space with the intersection of the cartilage of the V rib. The pericardium is opened with a wide longitudinal incision from the pulmonary artery to the apex of the heart in front of the phrenic nerve. On the basis of the aorta, when palpating, a more or less pronounced trembling of its wall is always determined. Sometimes it is limited to a small area. In this case, there is a sharp stenosis with an eccentrically located hole. Trembling of the aortic wall is the most true diagnostic method, detected, however, already during the operation itself. heart aortic valve disease

On the surface of the left ventricle, 2-2.5 cm from the apex and at the same distance posterior to the descending branch coronary artery a small vascular area is selected and a purse-string suture of three stitches is applied to it. The ends of the suture are fixed in a tourniquet, and in the future, its slight tightening prevents bleeding. In the center of the area bounded by a purse-string suture, the ventricular wall is punctured with a narrow scalpel, and a dilator is immediately introduced into the wound. It is easily passed along the interventricular septum towards the aorta and passes into the aorta. The passage of the instrument head into the initial part of the aorta is determined by the fingers of the left hand, which are used to feel this part of the aorta. As soon as half of the head of the instrument is passed into the aorta, its branches are moved apart by a width of 2-2.5 cm by pressing the handle; at the same time there is a commissurotomy. The direction of the branches is oriented along the line of the location of the commissures. At the moment of expansion of the jaws of the instrument, one feels varying degrees resistance and sometimes a slight crackle or crunch is heard. The branches are opened again, once or twice, after which the folded instrument is removed from the heart. Tightening the purse-string suture prevents bleeding. The wound of the ventricle is sutured with two silk sutures. At the time of commissurotomy, the anesthetic agent presses the carotid arteries to prevent cerebral embolism.

In the case of a combination of aortic stenosis with mitral stenosis, mitral commissurotomy is subsequently performed in the usual way.

3.2 Transortal access technique

Commissurotomy with this access can be performed with a finger, which is passed to the aortic valve through an artificial aortic pocket. With very dense callous commissures, as well as with severe calcification, a commissurotomy can be additionally introduced into the lumen of the aorta along the finger and a commissurotomy is performed under the control of the finger. Transortal access aortic commissurotomy can also be performed using a dilator. In this case, the dilator is inserted into the aorta through an artificial pocket without a finger. His presence in aortic orifice determined by palpation through the wall of the aorta.

Comparing transventricular and transaortal approaches during aortic commissurotomy, preference should be given to the first one. Transventricular access is technically simpler, less traumatic and makes it possible to perform precisely dosed commissurotomy). With transortal access, which is technically more complex, there is also a greater risk of bleeding; Harken emphasizes at the same time the possibility of formation in the postoperative period of an aortic aneurysm. In addition, the digital commissurotomy practiced with transortal access is more traumatic and can rarely be dosed. Comparison of operative and postoperative mortality data also speaks to the benefits of transventricular access. Mortality during the operation of aortic commissurotomy, according to a number of authors, is 12--16%. Long-term results of the operation are generally assessed as positive. According to 9 foreign authors, for 120 operations with isolated aortic stenosis, excellent and good results were obtained in 73.3%, and with aortic-mitral stenosis in 83.2% of those operated on.

3.3 Surgery aortic valve insufficiency

Surgical treatment of aortic insufficiency has not yet received due development. A large number of surgical methods for the elimination of aortic valve insufficiency have been proposed. However, they, as well as with mitral valve insufficiency, cannot be considered satisfactory. Methods of surgery for aortic insufficiency proceed from the same principles that formed the basis for the surgical treatment of mitral insufficiency. They include proposals either aimed at reducing or completely covering the defect between the aortic valves using various types of prostheses, or pursuing the task of reducing the valvular defect by narrowing the fibrous valvular annulus. Along with this, the possibility of performing an operation on the aorta without opening the cavity of the heart gave rise to proposals to use artificial valves that can be inserted into the initial part or into subsequent parts of the aorta.

The first series of proposals includes operations designed to use various prostheses made of pericardium, cartilage and other tissues, as well as valvular prostheses made of nylon and other plastics in the form of rackets, balls, etc.

The second series of proposals includes operations to narrow the aortic fibrous ring by tightening it with a strip of nylon or other plastic material (Bailey, Taylor, Black, Harken, etc.) or suturing the wall of the initial part of the aorta. All these methods are technically rather complicated, cause high operative and postoperative mortality, and functionally cannot be considered satisfactory. The best results have been achieved using the methyl methacrylate artificial valve proposed by Hufnagel. The valve consists of a cylinder with cutouts along the walls and a ball moving inside the cylinder; the device of the valve allows blood to flow freely in one direction from the center to the periphery and makes it impossible to return blood flow. The valve is inserted into the initial part of the descending aorta by crossing it and fixed to the walls of the aorta using nylon rings with teeth. As the experience of the author, as well as a number of other researchers (Ellis, Bland, Kerklin and others), has shown, the use of the Hufnagel prosthesis gives good functional results even in late stage diseases; lethality does not exceed 20%. At the same time, a number of shortcomings of the Hufnagel valve have been identified, the main of which are the inability to improve blood circulation in the upper half of the body (above the prosthesis), as well as the risk of thrombosis and embolism.

3.4 Surgical treatment of tricuspid valve stenosis

An isolated lesion of the tricuspid valve is rare, it is usually accompanied by a lesion of the bicuspid valve, and sometimes with a particularly persistent, prolonged recurrent course of the rheumatic process and aortic valves. If normally the area of the venous opening approaches 6 cm 2 , then with stenosis it can decrease to 1 cm 2 , however, already reducing it by half causes hemodynamic disturbances [Reel and Goldberg]. Patients with identified stenosis of the right venous orifice should be operated on. A contraindication can only be the extremely serious condition of the patient (irreversible dystrophic stage of the disease), as well as the presence of acute diseases.

With a combination of stenosis of the right atrioventricular orifice with defects in other valves, it is advisable to first eliminate mitral stenosis and aortic (if any), and then tricuspid. The reverse sequence of surgery can lead to sudden overflow of blood from a relatively weak right ventricle and its acute insufficiency. Most surgeons with a combination of stenosis of the right venous opening with defects in other valves operate simultaneously. Various approaches have been proposed for the simultaneous elimination of mitral and tricuspid stenoses. Harken and Black (1955) perform commissurotomy on both valves using left-sided access. After a conventional mitral commissurotomy, the pericardium is sutured. Then a new longitudinal incision is made in the pericardium in front of the phrenic nerve. The heart is rotated to the left, while the right ear is shown. Commissurotomy is performed with the right index finger after dissection of the apex of the ear. Dogliotti, Actis-Dato and Angelino (1954) operate on both valves using an anterior wide transverse thoracotomy. Bailey uses right-sided access. This access is the most expedient: it is less traumatic, does not present great technical difficulties and allows you to simultaneously eliminate the stenosis of both holes. The position of the patient on the back with a small roller under the right side. Anterolateral thoracotomy in the IV intercostal space on the right. The pericardium is opened in front of the phrenic nerve with a longitudinal incision, turning at the bottom L-shaped to the left. Inspection and palpation of the heart usually reveal, in addition to signs mitral stenosis, a significant expansion of the right atrium, expansion and tension of the superior vena cava and diastolic trembling of the wall of the right ventricle. First, a mitral commissurotomy is performed. Access to the left atrioventricular orifice is carried out through the interatrial septum. At the end of the mitral commissurotomy and the restoration of the integrity of the interatrial septum, a commissurotomy is performed on the right. To do this, a fixing clip is applied to the top of the right ear, and then an elastic clip is applied to the base of the ear. The ear can be opened by cutting off the top or by a horizontal incision along the outer wall. Holders are placed on the edges of the incision. Then, the left index finger is inserted into the hole, which, after passing it into the atrium, examines the hole of the tricuspid valve and performs a commissurotomy (Fig. 1).

Rice. 1 Commissurotomy for stenosis of the orifice of the tricuspid valve

It is enough to separate only two commissures: anteroposterior and medial-posterior. After commissurotomy, the finger is removed from the atrium, while applying an elastic clamp to the ear. The hole in the ear is closed with two circular ligatures (one with stitching) or in another way. The wound of the chest wall is sutured tightly, leaving a drain in the chest cavity for continuous suction during the first two days.

3.5 Surgical treatment of tricuspid valve insufficiency

Surgical treatment of tricuspid valve insufficiency has not yet been developed. In this disease, all methods of valve correction can be applied, which are described above in relation to mitral valve insufficiency, however, even here a radical solution to the problem will become possible after the development of methods for surgical treatment of this defect on the open heart using artificial circulation devices.

3.6 Open heart surgery

New and very favorable opportunities in the surgical treatment of heart defects opened up with the development of methods for surgical intervention on the open heart, that is, after opening its cavities. Vision-guided operations are getting really drastic; they can be produced with much greater precision, without the risk of damaging the valvular structures and causing valve dysfunction. With such operations, it is possible wide application methods plastic surgery up to the complete replacement of the valve with an artificial prosthesis. In a crust, time of operation on an open heart can be made both with application of a hypothermia, and at artificial blood circulation.

The first method is less complicated, but it allows you to turn off the heart from the circulation for up to 8 minutes. Therefore, in the surgery of acquired heart defects, this method can be used only for aortic stenosis, and even then only in the simplest cases. Operations with cardiopulmonary bypass can be performed with devices of any systems, the performance of which is sufficient for adult patients. The use of these devices in adult patients is associated with a number of features, depending on both the nature of the heart disease and the degree of myocardial damage.

The opening of the chest cavity can be performed either by the usual (described above) unilateral incision on the right or left, or by a median incision with a longitudinal incision of the sternum. Right-sided access can be used for operations on bicuspid and tricuspid valves, left-hand access for operations on a bicuspid valve, and median access for operations on the aorta. The device is connected to the patient in the usual way. The hose, through which oxygenated blood enters the patient's arterial system, is inserted into the patient's femoral artery by means of a cannula. Venous catheters The channels that carry blood to the oxygenator, usually inserted into the superior and inferior vena cava, are in most cases replaced by a single, thicker catheter that is inserted into the right atrial cavity. This simplifies the device connection technique and makes it possible to drain not only the vena cava, but also the coronary sinus. In tricuspid valve surgery, catheters must of course be inserted into the vena cava. During operations for acquired heart defects, the left heart is also drained using a catheter inserted into the left atrial appendage. The dosed suction of blood through this catheter with its return to the device facilitates the work of the left heart, thereby protecting it from overload during the recovery period of the heart at the end of the operation. The aorta is taken on a ribbon, so that, if necessary, it can be periodically clamped. The operation can be performed both on a beating heart and on a stopped one. Hypothermia may also be used in combination with cardiopulmonary bypass.

3.7 Mitral valve surgery technique

Both right-handed and left-handed access can be applied. The first is associated with a lower risk of air embolism, but it is technically difficult due to the depth of the mitral valve. Left-side access creates Better conditions for valve surgery, but requires additional measures to prevent air embolism. With right-sided access, after opening the chest cavity and pericardium, the left atrium is opened with a longitudinal incision behind the interatrial sulcus and in front of the confluence of the pulmonary veins. The edges of the incision are stretched with a special expander. With left-sided access, the cavity of the left atrium is opened with a transverse incision extending from the top of the left atrial appendage posteriorly towards the inferior pulmonary vein. The edges of the incision are stretched with the help of holders and hooks. Mitral valve surgery is preferably performed on a beating heart in order to be able to control valve function.

Surgery for mitral stenosis. After examining the mitral valve and the subvalvular apparatus, a commissurotomy is performed under visual control. In this case, the dissection of the commissures is possible either in an acute way or with the use of a dilator. Necessary condition is the separation of the valve leaflets exactly along the commissures. Particular care must be taken to avoid damage to the chordae or papillary muscles. In subvalvular stenosis caused by agglutination of the chordae or papillary muscles, they must also be separated under visual control. If calcium deposits are found, they must be removed with a thin dissection or with a sharp spoon, otherwise the operation cannot be considered radical. If mitral stenosis is combined with valve insufficiency or if this insufficiency occurs during the intervention itself, it must be eliminated by one of the methods described below. At the end of the operation, the atrial wound is sutured with a continuous suture; until complete restoration of cardiac activity, a catheter connected to suction is left in the atrial cavity. Operations for mitral insufficiency. These operations must be strictly individualized depending on the nature of the pathological changes. There are the following types of changes:

a) a sharp stretching of the fibrous ring with preserved leaflets;

b) localization of changes that cause valve insufficiency in the area of one of the commissures;

c) localization of changes in the middle part of the valve;

d) rupture of one or another leaf of the valve after the previous operation of commissurotomy;

e) detachment of chords from the valve leaflets;

f) sharp wrinkling and sclerosis of both valve leaflets.

From the operational receptions which are most widely applied in a crust, time, it is necessary to specify the following options.

1. Annuloplasty - reduction of the circumference of the fibrous ring by corrugating it with strong silk sutures. With a general expansion of the ring, it can be narrowed by suturing along the poles (in the region of the commissures) and along the circumference. Valve insufficiency with changes in the area of one of the commissures can be eliminated by stitching the edges of the ring only in this area.

2. Applying a patch in the area of the valve defect.

3. In case of insufficiency arising from the loss of the leaflet tissue itself (usually the posterior one), Lillihey proposed to hem an aivalon cylinder under this leaflet in the middle part of the valve, which covers the defect and is in contact with the preserved leaflet.

4. If the sash is mechanically damaged, it can be sewn together directly or with a patch made of synthetic fabric.

5. When the chords are torn off, the sash is sutured to the ends of the chords or to the papillary muscles. All these methods, when used correctly, give quite satisfactory results. However, the problem of surgical correction of the mitral valve cannot be considered solved yet. With gross destructive changes in the valve, when its function is completely impaired, the elimination of insufficiency is possible only by completely replacing the valve. However, all the attempts made in this direction have not yet yielded sufficiently satisfactory results.

Bibliography

· Bakulev AN Surgical treatment of mitral stenosis. M.: Medgiz, 1958. Big encyclopedia: in 62 volumes. T.38. M.: TERRA, 2006. 592 p.

Byakin S.P. Surgical treatment of acquired heart defects, a course of lectures: textbook. allowance for medical universities. M.: Nauka, 2006. 131 p.

· ShimkevichV. M., Dogel A. S., Tarkhanov, Ostrovsky V. M., Serdtse // encyclopedic Dictionary Brockhaus and Efron: In 86 volumes (82 volumes and 4 additional). SPb., 1890--1907.

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