Bypass surgery without opening the chest. Mitral valve replacement without opening the chest

In the Department of Cardiac Surgery of the Beilinson Hospital, operations on the heart valves (replacement of the aortic valve, reconstruction of the mitral and tricuspid valves) are performed without opening chest but through a small surgical incision. Operations are carried out according to their own exclusive method, which is called "minimal invasive".

This approach allows not to cut the sternum, as is done according to the traditional method, but to perform the operation through a small hole in the right side of the chest.

Dr. Ram Sharoni, a leading cardiac surgeon and minimal invasive surgeon who has trained for two years at New York University (NYU), explains how this method reduces the risk of surgical complications and shortens the recovery period after surgery: “The operation is performed through a small incision special long tools that are designed specifically for such cases and are able, literally, to crawl through the eye of a needle.

Connection to the heart-lung machine is made through the aorta and the right atrium, as is customary according to the traditional method, or through femoral artery in the groin We use a wide range of valve rebuild rings and synthetic materials in place of torn valve ligaments (chords). When valves need to be replaced, biological or mechanical valves are used.

Each operation is performed using ecocardiography, which allows you to see the quality of surgical work directly during the operation. Scientific studies prove the advantage of this method over the traditional one: the injury inflicted on the body is much less, so resuscitation and recovery are faster.

Used in the medical center. Rabin (Beilinson Hospital) method of minimal surgical intervention "minimal invasive" allows for the replacement of the aortic and reconstruction of the mitral and tricuspid valves without injury to the sternum. This gets rid of possible complications that occur when the sternum is damaged: infection and sepsis, in addition, it practically leaves no scars, only a small incision between the 3rd and 4th ribs when replacing the aortic valve and between 4-5 when replacing the mitral valve.

According to Dr. Ram Sharoni: "These surgeries require not only great experience, but also the teamwork of cardiologists, anesthesiologists, operating room nurses and the coordinated work of the entire center."

At the Medical Center Rabin performed operations on the mitral and aortic valves without opening the chest.

Branches: Cardiac and thoracic surgery.

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Reasons for this operation

The tricuspid is located between the right atrium and the right ventricle. The bicuspid is located between the right ventricles and the atria. This bicuspid valve is called the mitral valve.

As a result of certain reasons, physiological and functional changes in the mitral valve occur. This leads to the fact that its valves do not close completely and part of the blood returns.

Or the valves close too tightly, and the blood does not have the opportunity to fully pump into the atria.

All these processes lead to violations heart rate and subsequently to the development of heart failure.

If the disease is found in early stages its development, experts recommend patients a medical method of treatment. Otherwise, surgery on the mitral valve is indispensable.

Variety of operations

Operations on the mitral valve are divided into several types:

Plastic. In one case, the essence of the operation is to replace that part of the organ on which there is a pathology. In the second case, cutting the adhesions that formed on the walls of the MC. Plastic surgery is not aimed at replacing the old organ with a new one, but at preserving the old one.

Plastic has two subspecies:

valvuloplasty is the process of suturing the valve leaflets. This type of surgical intervention is resorted to if the distance between the valves is too large and part of the blood returns back to the atrium. To stabilize and strengthen the stable distance, a support ring is inserted between them;
commissurotomy - a procedure for dissecting adhesions that have formed between the valves. As a result, the distance between the halves of the MC on the heart becomes too small to pass the necessary volume of blood from the atrium to the ventricle. This type of operation can be performed without opening the patient's sternum (closed method) or with opening the chest (open method).
Prosthetics. The operation to replace the mitral valve is carried out if the old one can no longer be saved. It is much more difficult and dangerous than plastic. The diseased organ is removed and an artificial one is implanted in its place. In some cases, specialists resort to valve transplantation of another person.

In the event that experts believe that the old MC of a person with pathology is no longer subject to treatment, they stop at such a type of treatment as mitral valve replacement surgery.

Classification of prostheses

Valve replacement surgery involves removing the old valve and replacing it with an artificial prosthesis. All prostheses can be divided into several types:

Mechanical. Non-biological materials and mechanical working elements are used for its manufacture. Due to this, such an artificial prosthesis in very rare cases is rejected by the patient's body. This type of prosthesis has a long service life. But do not forget that the introduction of mechanical prostheses increases the risk of blood clots several times. Therefore, people with such prostheses have to take medications throughout the subsequent time after the operation that prevent the thrombosis process.

Biological. Distinctive feature Such a prosthesis is that it is made from human or animal tissue, such as pig or cow. The possibility of using some mechanical elements is not excluded. I have been working with biological prostheses for about 9–18 years. After this time, it becomes necessary to repeat the operation to replace the mitral valve. Patients with a biological valve installed do not need to take anticoagulant drugs.

Allograft. This type of prosthesis is used extremely rarely, but it is characterized by the maximum degree of engraftment. Its peculiarity lies in the fact that it is transplanted from one another person.

When choosing any one type of artificial valves, specialists take into account factors such as the age of the patient, his state of health, the presence of chronic or other diseases, etc.

Recovery period

In most cases, after the introduction of an artificial valve, patients may experience the following symptoms:

blurred vision;
fast fatiguability;
lack of appetite;
drowsiness;
irritability;
swelling of the lower extremities.

Do not despair and panic. These symptoms will last for 2-3 weeks.

After this period, the patient undergoes a period of rehabilitation. The essence of this process is to perform a course of physical exercises aimed at restoring all body functions.

A prerequisite for rehabilitation is diet and healthy lifestyle life.

After the operation was performed, the further condition of the patient depends entirely on himself, on his desire to return to active and healthy life. Be healthy!

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Indications and contraindications for prosthetic heart valves

Heart surgeries, no matter how they are performed, carry certain risks, are technically complex and require the participation of highly qualified cardiac surgeons working in a well-equipped operating room, so they are not performed just like that. With heart disease, for some time, the organ itself copes with the increased load, as its functional abilities are weakened, drug therapy is prescribed, and only if conservative measures are ineffective, the need for surgery arises. Indications for prosthetic heart valves are:

Thus, the reason for surgical correction is any irreversible structural change in the components of the valve, which makes the correct unidirectional blood flow impossible.

There are also contraindications for heart valve replacement surgery. Among them are the serious condition of the patient, the pathology of other internal organs that make the operation life-threatening for the patient, severe bleeding disorders. An obstacle to surgical treatment may be the patient's refusal to operate, as well as the neglect of the defect, when intervention is inappropriate.

The mitral and aortic valves are most often replaced, they are also usually affected by atherosclerosis, rheumatism, and a bacterial inflammatory process.

Depending on the composition, the heart valve prosthesis is mechanical and biological. Mechanical valves made entirely of synthetic materials, they are metal structures with semicircular doors moving in one direction.

The advantages of mechanical valves are their strength, durability and wear resistance, the disadvantages are the need for lifelong anticoagulant therapy and the possibility of implantation only with open access to the heart.

biological valves consist of animal tissues - elements of the pericardium of a bull, valves of pigs, which are fixed on a synthetic ring that is installed in the place where the heart valve is attached. Animal tissues in the manufacture of biological prostheses are treated with special compounds that prevent immune rejection after implantation.

The advantages of a biological artificial valve are the possibility of implantation during endovascular intervention, the limitation of the period of taking anticoagulants within three months. A significant disadvantage rapid wear is considered, especially if the mitral valve is replaced with such a prosthesis. On average, a biological valve works for about 12-15 years.

The aortic valve is easier to replace with any type of prosthesis than the mitral valve, therefore, when the mitral valve is damaged, different types of plasty (commissurotomy) are first resorted to, and only if they are ineffective or impossible, the possibility of a total valve replacement is decided.

Preparing for valve replacement surgery

Preparation for surgery begins with a thorough examination, including:

General and biochemical analyzes blood;
Urinalysis;
Determination of blood clotting;
electrocardiography;
Ultrasound examination of the heart;
Chest X-ray.

Depending on the accompanying changes, the list diagnostic procedures coronary angiography, vascular ultrasound, and others may be included. Mandatory consultations of narrow specialists, conclusions of a cardiologist and therapist.

On the eve of the operation, the patient talks with the surgeon, the anesthetist, takes a shower, dinner - no later than 8 hours before the start of the intervention. It is advisable to calm down and get enough sleep, many patients are helped by talking with the attending physician, clarifying all questions of interest, knowing the technique of the upcoming operation and getting to know the staff.

Technique for heart valve replacement surgery

Heart valve replacement can be performed through open access and in a minimally invasive way without incision of the sternum. Open operation held under general anesthesia. After immersing the patient in anesthesia, the surgeon treats the operating field - the anterior surface of the chest, dissects the sternum in the longitudinal direction, opens the pericardial cavity, followed by manipulations on the heart.

To disconnect the organ from the blood flow, a heart-lung machine is used, which allows implanting valves on a non-working heart. In order to prevent hypoxic damage to the myocardium, it is treated with cold saline throughout the operation.

To install the prosthesis, the necessary cavity of the heart is opened using a longitudinal incision, the altered structures of its own valve are removed, an artificial valve is installed in its place, after which the myocardium is sutured. The heart is “started” with an electrical impulse or with direct massage, artificial circulation is turned off.

After the artificial heart valve is installed and the heart is sutured, the surgeon examines the cavity of the pericardium and pleura, removes blood and sutures the surgical wound in layers. To connect the halves of the sternum, metal brackets, wire, screws can be used. Ordinary sutures or cosmetic intradermal sutures with self-absorbable threads are applied to the skin.

Open surgery is very traumatic, so the operational risk is high, and postoperative recovery takes a long time.

Endovascular technique valve replacement shows very good results, it does not require general anesthesia, so it is quite feasible for patients with severe comorbidities. The absence of a large incision allows you to minimize the stay in the hospital and subsequent rehabilitation. An important advantage of endovascular prosthetics is the possibility of performing surgery on a beating heart without the use of a heart-lung machine.

With endovascular prosthetics, a catheter with an implantable valve is inserted into the femoral vessels (artery or vein, depending on which cavity of the heart needs to be penetrated). After the destruction and removal of fragments of your own damaged valve, a prosthesis is installed in its place, which straightens itself thanks to a flexible stent-frame.

After installing the valve, stenting of the coronary vessels can also be performed. This possibility is very relevant for patients in whom both valves and vessels are affected by atherosclerosis, and in the process of one manipulation two problems can be solved at once.

The third option for prosthetics is from a mini-access. This method is also minimally invasive, but an incision of about 2-2.5 cm is made on the anterior chest wall in the projection of the apex of the heart, a catheter is inserted through it and the apex of the organ to the affected valve. Otherwise, the technique is similar to that for endovascular prosthetics.

Heart valve transplantation is in many cases an alternative to heart valve transplantation, which can significantly improve well-being and increase life expectancy. The choice of one of the listed methods of operation and the type of prosthesis depends both on the patient's condition and on the technical capabilities of the clinic.

Open surgery is the most dangerous, and endovascular technique is the most expensive, but, having significant advantages, it is the most preferable for both young and elderly patients. Even if there are no specialists and conditions for endovascular treatment in a particular city, but the patient has the financial opportunity to go to another clinic, then it should be used.

If aortic valve replacement is required, mini-access and endovascular surgery are preferred, while mitral valve replacement is more often performed by an open method due to its location inside the heart.

Postoperative period and rehabilitation

The operation to replace the heart valve is very painstaking and time-consuming, it lasts at least two hours. After its completion, the operated person is placed in the intensive care unit for further observation. After a day and with a favorable condition, the patient is transferred to a regular ward.

After open operation stitches are processed daily, they are removed for 7-10 days. All this period requires a stay in the hospital. With endovascular surgery, you can go home already for 3-4 days. Most patients note a rapid improvement in well-being, a surge of strength and energy, ease in performing ordinary household activities - eating, drinking, walking, showering, which previously provoked shortness of breath and severe fatigue.

If during prosthetics there was an incision in the sternum, then the pain can be felt for quite a long time - up to several weeks. With strong discomfort, you can take an analgesic, but if swelling, redness progresses in the area of \u200b\u200bthe seam, pathological discharge appears, then you should not hesitate to visit the doctor.

The rehabilitation period takes on average about six months, during which the patient regains strength, physical activity, gets used to taking certain medicines(anticoagulants) and regular monitoring of blood clotting. It is strictly forbidden to cancel, independently prescribe or change the dosage of drugs; this should be done by a cardiologist or therapist.

Drug therapy after valve replacement includes:

Anticoagulants with an implanted mechanical valve avoid thrombosis and embolism, which are provoked foreign body in the heart, but there is also a side effect of taking them - the risk of bleeding, stroke, therefore regular monitoring of INR (2.5-3.5) is an indispensable condition for life with a prosthesis.

Among the consequences of artificial heart valve transplantation, the most dangerous are thromboembolism, which is prevented by taking anticoagulants, as well as bacterial endocarditis - inflammation of the inner layer of the heart, when antibiotics are required.

At the rehabilitation stage, some disturbances in well-being are possible, which usually disappear after a few months - six months. These include depression and emotional lability, insomnia, temporary visual disturbances, discomfort in the chest and the area of the postoperative suture.

Life after the operation, subject to successful recovery, is no different from that of other people: the valve works well, the heart too, there are no signs of its insufficiency. However, the presence of a prosthesis in the heart will require changes in lifestyle, habits, regular visits to the cardiologist and control of hemostasis.

The first control examination by a cardiologist is carried out about a month after prosthetics. At the same time, blood and urine tests are taken, an ECG is taken. If the patient's condition is good, then in the future the doctor should be visited once a year, in other cases - more often, depending on the patient's condition. If you need to undergo other types of treatment or examinations, you should always warn in advance about the presence of a prosthetic valve.

Lifestyle after valve replacement requires avoiding bad habits . First of all, you should stop smoking, and it is better to do this even before the operation. The diet does not dictate significant restrictions, but it is better to reduce the amount of salt and liquid consumed so as not to increase the load on the heart. In addition, the proportion of foods containing calcium should be reduced, as well as the amount of animal fats, fried foods, smoked meats in favor of vegetables, lean meats and fish.

High-quality rehabilitation after heart valve prosthetics is impossible without adequate physical activity. Exercise helps to improve overall tone and train cardiovascular system. In the first weeks, do not be too zealous. It is better to start with feasible exercises that will serve as a prevention of complications without overloading the heart. Gradually, the volume of loads can be increased.

So that physical activity does not go to the detriment, experts recommend undergoing rehabilitation in sanatoriums, where exercise therapy instructors will help create an individual physical education program. If this is not possible, then all questions regarding sports activities will be clarified by a cardiologist at the place of residence.

The prognosis after transplantation of an artificial valve is favorable. Within a few weeks, the state of health is restored, and patients return to normal life and work. If a labor activity is associated with intense workloads, it may be necessary to transfer to lighter work. In some cases, the patient receives a disability group, but it is not associated with the operation itself, but with the functioning of the heart as a whole and the ability to perform one or another type of activity.

Patient reviews after heart valve replacement surgery are more often positive. The duration of recovery is different for everyone, but most notice a positive trend already in the first six months, and relatives are grateful to surgeons for the opportunity to extend the life of a loved one. Relatively young patients feel good, some, according to the words, even forget about the presence of a prosthetic valve. Older people have a harder time, but they also notice a significant improvement.

Heart valve transplantation can be done free of charge, at the expense of the state. In this case, the patient is put on a waiting list, and preference is given to those who need an operation urgently or urgently. Paid treatment is also possible, but, of course, it is not cheap. The valve itself, depending on the design, composition and manufacturer, can cost up to one and a half thousand dollars, the operation - starting from 20 thousand rubles. It is difficult to determine the upper threshold for the cost of the operation: some clinics charge 150-400 thousand, in others the price of the entire treatment reaches one and a half million rubles.

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Causes causing problems in the operation of the valve

This valve is located between the left ventricle and the aorta, which will carry oxygenated blood throughout the body. During the process of filling the heart muscle with blood, this valve must be in a closed state. When the ventricle contracts, it opens and allows blood to flow into the aorta.

Replacement of the aortic valve of the heart is necessary when it cannot function properly, resulting in impaired blood circulation. Sometimes deformation of the aortic valve is observed from birth - this is a congenital defect. But there are cases when it worked normally for many years, and then it begins to not fully open and close, then they talk about acquired pathology of the aortic valve. This can happen due to wear with age, as a result of the buildup of calcium salts on the valve, which disrupts its operation.

Some diseases can also lead to disruption of the valve, these include:

Complications after past illnesses, for example, streptococcal infection, may well have a negative impact on valve function.
Endocarditis, when the infection affects the heart and its valves.
Aortic aneurysm.
Hemorrhage into the wall of the aorta.
Aortic valve stenosis, in which the valve is so rigid that even pressurized blood cannot open it fully.
A condition in which the valve is unable to close completely after the ejection of blood, and some of it returns to the ventricle.

All of these diseases and pathologies can lead to the need for aortic valve replacement surgery.

Features of the valve replacement operation

This type of surgery is considered the most difficult. Perform an operation on open heart not every surgeon can. Such an intervention requires modern equipment and highly qualified doctors.

Currently, our country does not have a sufficient number of clinics equipped with the latest technology, so there is no way to provide assistance in a timely manner to all those in need of such operations. Replacement of the aortic valve of the heart is for many the only way to save a life, but, unfortunately, not everyone is waiting for their turn.

But there are also foreign cardiology centers that are ready to accept foreign patients and provide them with the necessary assistance, thereby saving lives.

Valve types

Even the possibilities of modern science and technology still do not allow creating an ideal valve. Those varieties that are used now have their pros and cons. For replacement, surgeons use several types of prostheses:

When an aortic valve replacement is required, the choice of variety depends on several factors:

Age group of patients.
General health.
Why does the valve need to be replaced?
The presence of other chronic diseases.
Does the patient have the opportunity to take anticoagulants for life.

Once the type of valve has been selected, complex operation for its replacement.

Types of surgery

Until recently, surgery to replace an aortic valve on the heart necessarily required stopping the heart muscle and opening the chest. These are the so-called open operations. During surgery, the life of the patient is supported by a heart-lung machine.

But at present, in some clinics, it is possible to replace the aortic valve without opening the chest. These are minimally invasive surgeries that do not require cardiac arrest, as well as large incisions.

Of course, it must be said that such surgical interventions require real skill from the surgeon. For example, clinics in Israel are famous for their cardiac surgeons, so many patients, if funds allow, are sent to this country for such an operation.

Preparing for the operation

Aortic valve replacement requires careful patient preparation. After contacting a doctor, the patient is prescribed a series of studies:

A few days before the operation, the patient must follow the following recommendations:

Stop taking anti-inflammatory drugs and aspirin.
Do not take anticoagulants.
The day before surgery, only light foods should be included in the diet.
On the day of the operation, you can not eat at all.
Clothing should be prepared so that it does not restrict movement.

Only after all the necessary preparations for the operation, the doctor appoints the time of the surgical intervention and the aortic valve will be replaced.

Operation

When the patient is on the operating table, he is given general anesthesia, and he falls asleep. If the operation is performed with an opening of the chest, then in the middle the surgeon makes an incision and pushes the chest apart so that you can get to the heart.

Cardiac arrest is required to allow replacement, so the patient is connected to a heart-lung machine. The doctor makes an incision in the aorta, removes the worn or damaged valve, and installs a new one in its place. After that, the aorta is sutured, the heart muscle is triggered, the chest is connected and sutured.

After aortic valve replacement surgery

Once the operation is completed, the patient is sent to the intensive care unit. Here he is taken out of anesthesia and is monitored for vital functions:

After an aortic valve replacement, the patient usually spends 5-7 days in the hospital if there are no complications.

Complications during the operation

Surgery on the heart is always a big risk. When an aortic valve replacement is planned, the following complications are possible:

Infection.
Possible bleeding during the operation.
The appearance of clots if there was a stroke or problems with the kidneys.
Complications of anesthesia.

There are other factors that increase the risk of complications during surgery:

Presence of heart disease.
Diseases of the lungs.
Hypertension.
Diabetes.
Obesity.
Smoking.
The presence of infections in the body.

Complications after surgery

For any surgeon, not only the process of the operation itself and its outcome are important, but also the recovery period, which can also be accompanied by serious complications:

Growth of scar tissue. There are cases when, after surgery, a patient has a rapidly growing fibrous scar tissue at the site of a valve replacement. This process does not even depend on the type of valve and can lead to thrombosis. But thanks to modern techniques of the operation, such a complication is quite rare.
Bleeding while taking anticoagulants. Moreover, it can occur not only in the valve area, but also in any organ, for example, in the stomach.
Thromboembolism. You can recognize it by the following manifestations:

The patient has shortness of breath.
Clouding of consciousness.
Loss of sight and hearing.
Numbness and weakness in the body.
Dizziness.

4. Infection of the delivered valve. Even the most sterile valve, once inside, can become infected. That is why, if the body temperature suddenly rises, respiratory problems appear, then it is urgent to inform the doctor in order to conduct tests and exclude infection of the valve.

5. Hemolytic anemia. It causes damage a large number erythrocytes during contact with valve material. There is a strong weakness, fatigue, which does not go away after rest.

As a rule, in the presence of a heart disease, the patient has one or another group of disabilities. All this is determined by a special commission of doctors. If an aortic valve has been replaced, disability can be removed if the council of doctors considers that you are healthy and you do not need special payments from the state. In some cases, group 3 is left.

Postoperative period

For several days after the valve replacement surgery, the patient is given injections of painkillers to reduce pain. But after a while they are cancelled. In addition, the patient may also face the following problems:

Edema of the extremities.
Pain in the incision area.
Inflammatory process in the place where the incision was made.
Nausea.
Accession of an infection.

If all these manifestations continue for too long, then you should tell your doctor. Aortic valve replacement surgeries (patients say this) bring noticeable improvements in a couple of weeks. Significant positive changes come in a few months.

It is best if the patient spends the recovery period not at home, but in a specialized institution, for example, in a sanatorium or in a cardiological rehabilitation center.

There, under the supervision of doctors, the body is being restored, each individual program is selected. Recovery can take varying amounts of time. It all depends on the general condition of the patient, the complexity of the operation and the recovery abilities of the body.

Without fail, the doctor prescribes medications to the patient after surgery. Their reception must be carried out strictly according to the scheme and cannot be canceled independently.

If various physiotherapeutic procedures, medical interventions are required, then it is necessary to inform that an artificial aortic valve is worth it.

If there are concomitant heart diseases, then valve replacement does not cure them, so it is necessary to visit a cardiologist and carry out appropriate therapy.

Rehabilitation therapy at home

If the patient does not have the opportunity to go to a sanatorium for recovery after surgery, then all recommendations of the doctor at home should be strictly followed.

If a mechanical valve is installed, then it is imperative to take anticoagulants, and this will have to be done all your life.
If you have a dental intervention or other surgical operations, then be sure to take before them antibacterial drugs to prevent inflammation in the valve area.
Be sure to control the balance of fluid in the body.
Do special exercises on the recommendation of a doctor that will help normalize respiratory function.
To carry out hardware prevention of pneumonia.

Lifestyle change

Any surgical intervention on the heart muscle requires a radical review of your lifestyle. Aortic valve replacement (reviews only confirm this) is no exception. Patients after surgery:

Eliminate all bad habits from your life, unless, of course, life is dear. Smoking, drinking alcohol and drinking large amounts of caffeine are not compatible with an artificial valve, and indeed with heart pathologies.
You will have to practically eliminate fatty foods from your diet.
Reduce salt intake to a minimum, no more than 6 grams per day.
Nutrition should be balanced and contain more fresh vegetables and fruits.
Drink enough clean water, but without gas.
Gradually introduce loads that will help strengthen the heart muscle.
Every day, in any weather, take walks in the fresh air.
Eliminate psycho-emotional overload, stress from your life.
Make a daily routine with your doctor and stick to it.
Take vitamin preparations to maintain mineral balance.

If you look at the reviews of patients who underwent valve replacement surgery, you can see that most of them were able to return to a normal lifestyle. Disappeared unpleasant symptoms that haunted, normalized heart function.

Aortic valve replacement (reviews confirm this) is not an obstacle to future pregnancy. Many women suffering from heart disease did not even hope to become mothers, and such an operation gives them such an opportunity.

In such a situation, the most important thing is to find a competent specialist, then you can be sure of a positive outcome of the operation. Modern science and medicine allow you not to put an end to your life even in the presence of serious pathologies in the heart, so you should not give up. We must always hope for the best, and a miracle will happen - your heart will work long and reliably. Take care of yourself and be healthy.

Radical treatment coronary disease hearts is considered coronary bypass surgery (CABG). The operation is associated with a large surgical trauma (anesthesia, opening the chest, artificial circulation, postoperative resuscitation) and a long period of rehabilitation.

Cardiology our clinic team can offer complete alternative to surgery- minimally invasive treatment - stenting- without anesthesia, without opening the chest, through small punctures on the hand. The patient walks the next day and is discharged home the next day.

An illustrative example of such an alternative operation was recently performed in our center.

The patient is 83 years old, she has a pronounced atherosclerosis of the arteries of the heart, and importantly, one of the main arteries of the heart was completely blocked. In such cases, they usually offer coronary artery bypass grafting (surgery to create shunts to bypass the occluded area). However, the patient's age and comorbidities greatly increased the risk of open surgery. Despite adequate drug treatment the patient had severe angina pectoris, attacks did not allow to perform the small range of movements that is necessary for self-care.

Our cardiac surgeons successfully performed a low-traumatic operation stenting, without any surgical trauma, anesthesia and resuscitation. Having previously opened the clogged area, they restored blood flow to the heart muscle using unique technologies and tools.

The state of the arteries of the heart before and after such a minimally invasive intervention is clearly shown in the figures. As a result, it turned out COMPLETE REPLACEMENT OF AORTO-CORONARY BYPASS. On the 3rd day after such treatment, the patient was safely discharged and went home, avoiding a major traumatic surgical operation!!!

This is what the arteries of the heart looked like after a diagnostic study. Note the blockage of the main artery of the heart right from the start (shown by the arrow). The course of this artery should be as shown by the dotted line, however, it is not visible, because due to blockage, blood does not flow there.

And this is an image of the same arteries, but their view is given from a different angle. Note how much of the artery (dashed line) is cut off from the bloodstream.

And here is what the arteries of the heart of a patient who was offered aorto-coronary bypass surgery look like. Instead of bypassing the blood flow, we covered the artery, the blood flow was restored in a natural way, i.e. as it was before the blockage. We did not insert a bypass shunt, but reconstructed our own damaged heart vessel. As we can see at the site of the stent (prosthesis) installation, the lumen of the artery looks great (arrows show) and the artery is already visible throughout, i.e. the blood flow is carried out in full, as well as before blockage.

Let's try to lift the veil of the mystery of their work and find out what types of heart surgeries exist and are carried out today. Is it also possible to perform heart surgery without opening the chest?

1 When the heart is in the palm of your hand or open surgery

Heart-lung machine (AIC)

Open heart surgery is called so because the heart surgeon "opens" the patient's chest, cuts through the sternum, and that's it. soft tissues performs an opening of the chest. Such interventions, as a rule, are performed with the connection of a heart-lung machine (hereinafter referred to as AIC), which is a temporary replacement for the heart and lungs of the operated person. This apparatus is a complex device of rather impressive dimensions, which continues to pump blood through the body when the patient's heart is artificially stopped.

Thanks to AIC, open-heart surgery can be extended for many hours if necessary. Open surgeries are used for valve replacement, coronary artery bypass grafting can also be performed in this way, many heart defects are eliminated by open interventions. It should be noted that AIC is not always used during their implementation.

Not always the body can tolerate the intervention of a foreign heart substitute: the use of AIC is fraught with such complications as kidney failure, violation of cerebral blood flow, inflammatory processes, violations of blood rheology. Therefore, some operations on the open heart are carried out in the conditions of his work, without the connection of the AIC.

Such interventions on a beating heart include coronary artery bypass grafting, during this operation on a beating heart, the area of \u200b\u200bthe heart that the surgeon needs is temporarily switched off from work, and the rest of the heart continues to work. Such manipulations require high qualifications and skills of the surgeon, and also have a much lower risk of complications, they are perfect for people over 75 years old, patients with a large arsenal of chronic diseases, patients with diabetes mellitus than operations on an organ that is turned off from the blood circulation.

But all the pros and cons, of course, are determined by the cardiac surgeon. Only the doctor decides to keep the heart working, or stop it for a while. Open surgeries are the most traumatic, having a higher percentage of complications; after surgery, a scar remains on the patient's chest. But sometimes only such an operation can save a person's life, improve his health, return him to a full, happy life.

2 Intact heart or closed surgeries

If, during the operation, the sternum, heart chambers and the heart muscle itself were not opened, then these are closed heart operations. During such operations, the surgical scalpel does not affect the heart, and the surgeon's work consists in the surgical treatment of large vessels, cardiac arteries and aorta, the chest is also not opened, only a small incision is made on the chest.

Thus, a pacemaker can be installed, heart valve correction, balloon angioplasty, shunting, vascular stenting can be performed. Closed operations are less traumatic, have a lower percentage of complications, unlike open ones. Closed vascular surgery can often be the first step before subsequent heart surgery.

Indications for their conduct is always determined by the doctor.

3 Achievements of modern cardiac surgery or minimally invasive operations

Endovascular heart surgery

Cardiac surgery is steadily moving forward, and an indicator of this is the increasing percentage of low-traumatic, high-tech manipulations that allow you to get rid of the pathology of the heart and blood vessels with minimal intervention and impact on the human body. What are minimally invasive interventions? These are surgical operations carried out by introducing instruments or special devices, through mini-access centimeter incisions, or without any incisions at all: during endoscopic operations incisions are replaced by punctures.

When performing minimally invasive manipulations, the path to the heart and blood vessels can lie through the femoral vessels, for example - these operations are called endovascular, they are performed under X-ray control. Elimination of congenital malformations, prosthetic heart valves, all operations on the vessels (from the removal of a blood clot to the expansion of the lumen) - all these interventions can be performed using minimally invasive technologies. Emphasis is placed on them in modern cardiac surgery, since a low risk of complications, minimal impact on the body are those huge advantages that patients can appreciate literally on the operating table.

Coronary angiography, a method for examining the vessels of the heart by introducing contrast and subsequent x-ray control

Anesthesia during endoscopic procedures is not required, it is enough just to anesthetize the puncture site. Recovery after heart surgery performed using a minimally invasive technique is ten times faster. Such methods are also indispensable in diagnostics - coronary angiography, a method for examining the vessels of the heart by introducing contrast and subsequent x-ray control. In parallel with the diagnosis according to indications, the cardiac surgeon can also perform therapeutic manipulations on the vessels - the installation of a stent, balloon dilatation in a narrowed vessel.

And diagnosis and treatment by puncture on the femoral artery? Isn't this a miracle? Such miracles for cardiac surgeons are becoming routine. The contribution of endovascular methods of treatment is also invaluable in cases where the threat to the life of the patient is especially acute and minutes count. These are situations of acute coronary syndrome, thromboembolism, aneurysm. In many cases, the availability of the necessary equipment and qualified personnel can save the lives of patients.

4 When is surgery indicated?

Indications for surgery

It is up to an experienced cardiac surgeon or a council of doctors to decide whether an operation is indicated, as well as to determine the type of surgical intervention on the heart and blood vessels. The doctor can make a conclusion after a thorough examination, familiarization with the history of the development of the disease, monitoring the patient. The doctor should know the ins and outs of the disease very well: how long the patient has been suffering from cardiac pathology, what medications he takes, what chronic diseases he has, when he felt worse ... After evaluating all the pros and cons, the doctor makes his verdict: whether to have surgery or not. If the situation develops according to the above scheme, then we are dealing with a planned cardiac surgery.

It is shown to the following people:

lack of effect from adequate drug therapy;
rapidly progressive deterioration of well-being against the background of ongoing treatment with pills and injections;
severe arrhythmias, angina pectoris, cardiomyopathy, congenital and acquired heart defects requiring correction.

But there are situations when there is no time for reflection, questioning and analysis of the medical history. We are talking about life-threatening conditions - a blood clot broke off, an aneurysm exfoliated, a heart attack occurred. When the time goes by for minutes, emergency cardiac surgery is performed. Stenting, coronary artery bypass grafting, thrombectomy can be performed urgently coronary arteries, radiofrequency ablation.

5 Consider the most common types of heart surgery

Radiofrequency ablation of the arrhythmogenic zone

CABG - coronary artery bypass grafting "on hearing" in many, probably because it is performed for coronary heart disease, which is extremely common among the population. CABG can be performed both open and closed, and combined techniques with endoscopic inclusions are also performed. The essence of the operation is to create bypass routes of blood flow through the vessels of the heart, restoring normal blood supply to the myocardium, which leads to a better supply of oxygen to the heart muscle.
RFA - radiofrequency ablation. This type of surgical intervention is used to eliminate persistent arrhythmias, when drug therapy is powerless in the fight against arrhythmias. This is a minimally invasive intervention that is performed under local anesthesia, through the femoral or subclavian vein a special conductor is introduced, supplying an electrode to the focus of pathological impulses in the heart, the current flowing through the electrode to the pathological focus destroys it. And the absence of a focus of pathological impulses means the absence of arrhythmia. 12 hours after the manipulation, the patient is already allowed to get up.

Heart valve replacement

Disability after heart surgery - bypass surgery, stenting

Rehabilitation after heart surgery - stages

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Are heart surgeries done without opening the chest?

To date, surgical interventions on the heart can be performed without opening the chest. With this approach, there is no need to cut the sternum, and the entire operation is performed through a small diameter hole in the chest.

Using this technique, it is possible to perform aortic replacement and reconstruction of the mitral and tricuspid valves of the heart without damaging the sternum. Also, the advantage of operations without opening the chest is the absence of large cosmetic defects in the form of scars and scars.

This technique of heart surgery significantly reduces the duration of rehabilitation of patients in the postoperative period.

Often patients wonder how long they live after heart bypass surgery? The prognosis of life after CABG is favorable, if all the recommendations of doctors are followed, and the surgery itself does not reduce the life expectancy of patients.

Question number 34 - How is the aortic valve replaced without opening the chest?

Asks Olga, 27 years old:

My brother is about to have an aortic valve replacement surgery. Doctors suggested using new methodology which does not involve opening the chest. How effective and safe is it?

Our expert answers:

Heart valve replacement is a very complex and dangerous operation that should be performed exclusively by an experienced surgeon with the necessary skills. If the surgical intervention is unsuccessful, there is a potential danger to the life of the patient. To reduce the risk of severe complications, minimally invasive techniques that are less traumatic for the patient have recently gained popularity.

How is the operation performed

Can an aortic valve be replaced without opening the chest, is it safe, and is it effective? Such surgery is actively used by doctors in many modern clinics and has many advantages over traditional methods:

a small incision is made between the ribs in the first part of the chest, which is used by the doctor for the necessary manipulations;
during the procedure, cardiac arrest is not performed;
in some cases, there is no need for general anesthesia;
the duration of surgery is significantly reduced;
echocardiography is used to control the actions of the surgeon;
the opening of the sternum is not performed, so the recovery period after the operation is reduced several times.

In minimally invasive surgery, special rings and synthetic devices are used to reconstruct the heart valves. If it is necessary to completely replace them, specially created biological or mechanical materials are used.

Risks during the operation

Despite the high efficiency of the operation without opening the chest, it may be accompanied by some complications:

infectious damage to the body;
difficulty in breathing;
development inflammatory process at the site of the incision;
disorders of the gastrointestinal tract;
the appearance of pain in the kidneys, difficulty urinating;
headache;
cough accompanied by chest pain;
the appearance of edema;
jumps in blood pressure.

If such symptoms appear, you should consult a doctor and undergo an additional study, which will prevent the development of dangerous postoperative complications. But usually, subject to all the recommendations of specialists and correct execution surgical intervention, the risk of undesirable consequences is almost zero.

Video: Open heart surgery will become closed

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Methods for performing a heart bypass and the course of the operation

The coronary arteries supply the human heart with blood. In this case, the body is provided with both oxygen and nutrients. If the blood supply occurs in insufficient quantities, then this causes serious heart problems, which sometimes end in a sad outcome. Therefore, with such a manifestation, serious medical intervention is required. In cases where therapy does not lead to the desired result, a special coronary bypass operation is performed. It provides a full supply of blood to the heart.

If the process of supplying the heart with blood is disrupted, the patient has serious health problems.

What is bypassing the heart and also blood vessels is explained quite simply. This is the process of creating an additional path that is "laid" around the area affected by the pathology. Bypass surgery is performed on both blood vessels and the digestive tract. Such an operation is performed on the ventricular system of the brain. Bypass surgery has become widespread in the heart due to the fact that blockages of the coronary vessels quite often occur.

Description of the procedure

A coronary artery bypass is used to create a bypass (anastomosis) around the section of the artery that is blocked. It can also be quite narrowed, in connection with which it prevents normal blood flow to the heart. What is coronary artery bypass surgery or CABG reduction needs to be considered in more detail.

Bypass surgery is a common operation that restores blood flow in the arteries.

The shunt in this case is a human vein, most often the one located in lower limb. AT human body it is the longest. In this regard, it is possible to remove a piece from it, and sew the ends, having previously pulled them together. In this case, one side of the vein prepared in advance is sewn to the artery, and the other side to the aorta, in which a hole was previously made. The thoracic artery can also be used. On the one hand, it is already connected to the aorta. It is only necessary to connect the second end to the coronary vessel. The execution of this sequence is CABG on the heart. The blood supply has been restored. There is a new way that functions correctly.

AT last years the bypass is more often the thoracic artery, which has unique features. She has a high resistance to atherosclerosis. In addition, it has another feature - it is durability. It is also possible to use the vein of the radial artery.

Surgeons often use a lower extremity vein as a shunt.

Previously, bypass surgery was done only with cardiac arrest when the patient was connected to a device that forced, bypassing the heart, supplying the body with blood. Currently, there are techniques that do not require a heart-lung machine. The operation is done on a normally beating heart. This significantly reduces the risk of complications, manifested in postoperative period. However, such an operation is much more complicated and requires certain practical skills of a cardiac surgeon.

Indications for surgery

There are main indications for coronary artery bypass grafting. There are also conditions in the identification of which it is recommended to carry out such an operation. The main indications for the appointment of coronary artery bypass grafting are the following manifestations:

the patency of the coronary artery on the left side of the heart is less than 50%;
all coronary vessels are narrowed by 70 percent or more;
the anterior interventricular artery is significantly narrowed, while this condition is combined with stenoses of two more coronary arteries.

With a significant reduction in the lumen of the coronary vessels, the patient is indicated for CABG

Such criteria are called prognostic indications. In these situations, non-surgical therapy cannot seriously change the situation.

There is the concept of "symptomatic indications", these include symptoms of angina pectoris. At the same time, drug treatment helps to eliminate such manifestations. Subsequently, however, especially in chronic angina, the likelihood of recurrence of attacks is much higher than in cases where cardiac bypass surgery is performed. The operation is also recommended in the detection of cardiomyopathy (changes in the heart muscle for unknown reasons) of the ischemic type.

Emergency surgery is often performed when a lesion is detected in an artery that is considered the main one (left coronary artery) or in cases where the lumens of several vessels are narrowed at once, and the therapy performed is ineffective. Surgery can prevent a massive heart attack.

Ischemic cardiomyopathy is one of the indications for bypass surgery.

Training

In order for the bypass of the heart vessels to be successful, careful preparation is required. To do this, the patient must undergo an almost complete examination. Must pass laboratory tests. An assessment of the general condition is also necessary. It is required to perform studies such as ultrasound and ECG, as well as coronography or angiography in another way. This procedure allows you to find out what condition the arteries that feed the heart muscle are in. This reveals the exact place where the plaque formed, as well as the degree of narrowing of this vessel. A radiopaque agent is used. It is introduced into the vessels, and control is performed using an X-ray machine.

Before the operation, the patient should undergo a comprehensive medical examination.

Some of the studies can be performed before the patient enters the hospital. Hospitalization is made a week before the operation. From this moment, the preparatory procedures begin. During this period, the patient receives the necessary or missing knowledge about what the process of heart bypass surgery is. In the process of preparation, special attention is paid to mastering the method of special breathing. The patient will need to use them immediately after the operation. At the end of the diagnostic procedures and in the absence of contraindications, bypass surgery of certain coronary vessels can be performed.

In the evening before the scheduled operation, patients should undergo hygiene measures, including an enema and shaving. Eating is canceled, and after midnight and drinking.

Before the operation, the patient is taught a special breathing technique, later it will help him recover from CABG

Operation progress

An operation such as coronary artery bypass grafting of certain vessels of the heart is performed in a certain sequence. After the patient enters the operating room, he is connected to the monitors. Anesthesia, that is, general anesthesia, is performed, and the patient falls asleep. Then antiseptic treatment is carried out, the installation of a probe and a catheter.

Next, cardiac arrest is performed with the help of a special fluid, and the patient is connected to a machine that performs cardiopulmonary bypass. It is sometimes referred to as a heart-lung machine. The surgeon then prepares access to the heart and blood vessels. At the same time, the second specialist removes the material for the shunt, for example, from the patient's leg.

The transplanted vessel has a diameter of no more than 3 mm, while the suture has a thickness comparable to that of a human hair. In this regard, microsurgical loupes are used during the operation.

The average duration of the operation is 4 hours

The use of an instrument such as an electric scalpel helps to stop bleeding when making an incision during bypass surgery.

Further, after starting the heart with electric shock and closing the sternum, the patient is transported to the ward for intensive care. In time, the operation can last up to six hours, and on average - about four.

The need to get an answer to the question of interest, what is heart bypass, especially after a heart attack, becomes urgent for people who have survived this deadly condition. In short, this is a parallel “suturing” of additional vessels, bypassing the arteries with impaired performance. After a heart attack, such an operation is performed after an interval of three to seven days. This time is considered the safest time to perform the operation.

Minimally invasive operations are performed without dissection of the sternum and allow the patient to recover faster

There is also a technique of X-ray endovascular surgery, which is a surgical intervention without the use of a scalpel. During this operation, coronary bypass surgery is performed without opening the chest. In this case, using a catheter, a special stent is inserted into the narrowed vessel, which restores impaired blood circulation. This is the least traumatic type of surgery. After its implementation, the patient is discharged on the second or third day.

Recovery period

Primary rehabilitation is carried out in the intensive care unit with intensive care and constant monitoring of the patient's condition. As the recovery from heart bypass surgery progresses, the breathing tube is removed first, followed by the tube, drains, and catheter. The patient is prescribed antibiotics and sedatives, as well as pain medications.

After the operation, the patient is transferred to the intensive care unit, where the staff continues to monitor his condition.

When taking material for a shunt from the lower limb, it is necessary to wear a special compression stocking. The postoperative period for coronary artery bypass grafting, carried out in a hospital, is usually up to two weeks. If there is no inflammation, then the stitches are removed after a week.

Further recovery is carried out at home. The patient must adhere to a special diet, stop smoking. At the same time, a number of medications, including cardioprotectors and anti-inflammatory nonsteroidal drugs. Taking medications such as Aspirin, as well as Clopidogrel, is necessary for nine postoperative months. Moderate exercise is recommended.

The patient will be able to start work approximately 45 days after the permission of the attending physician.

After being discharged home, the patient is prescribed special drug therapy.

Forecasts

How long patients live after bypass surgery is a question that is of interest not only to patients with heart problems. The findings of one of the studies, conducted over 30 years, say that after a period of 15 years after CABG, the mortality rate of patients undergoing surgery was no different from ordinary people. At the same time, out of more than 1 thousand patients studied, about 200 patients exceeded the age of 90 years.

Many patients are interested in whether they give disability after vascular bypass surgery, but the answer to this question depends entirely on medical commission. Disability must be established. At the same time, heart bypass is a possible reason for obtaining a referral to such a commission.

Approximately 20% of people who have CABG live to age 90

After performing CABG, according to statistics, disability was obtained in less than 7% of patients. It should be borne in mind that after a year, in most cases, confirmation of disability is necessary.

Possible Complications

Mortality statistics after coronary artery bypass grafting shows that, compared with long-term anti-ischemic therapy, mortality is almost two times lower. Absolute figures suggest that two to three percent of patients die after CABG. Concomitant diseases can lead to the fact that rehabilitation after coronary artery bypass surgery on the heart will take a significantly longer period of time.

It is worth noting that since the first CABG operation was performed, the technique of the procedure has improved significantly. The same applies to suture materials, equipment and instruments. However, in some cases there are complications after coronary bypass surgery. Among them are not only postoperative, but also remote, manifested after a certain period of time.

Duration rehabilitation period the patient depends on the general level of his health

Complications that arise include:

Bleeding. It can occur both immediately after the operation, and after a few days. Most often, this manifestation is due to some features inherent in the patient. This may be a decrease in blood clotting due to the action of drugs or an increase in pressure. Perhaps the manifestation of a change in the properties of blood under the influence of forced artificial circulation.
vascular thrombosis. Such a manifestation is possible due to the fact that a temporary violation of blood circulation may occur in the place where the material for the shunt was taken from. In this case, even the fact of surgical intervention causes injury to the vessel. Because of these factors, the development of thrombosis is possible. Swelling of the lower limb may appear three days after the operation. Active treatment is required.
Heart rate changes. When performing many hours of operation, strong pressure is exerted on the body. In this regard, both immediately after the operation and after a certain time, disturbances associated with heart rhythms are possible.
Stroke. It can be caused by the fact that the patient had low blood pressure during the operation, and therefore the blood supply to the brain was insufficient.

During the operation on the background reduced pressure the patient may have a stroke

Myocardial infarction. This formidable manifestation is possible in the first postoperative hours due to the fact that atherosclerosis in the human body affects not only those vessels on which bypass is performed. It also affects other paths of the coronary bed. Those changes that occur after the operation in the patient's body can provoke the growth of a blood clot in unforeseen places.
Shunt narrowing. Such a manifestation often occurs through the fault of the “relaxed” patient himself, who does not follow the medical prescription.

These are the most common complications, possibly manifestations of others, but they are much less common.

The video explains in detail how a coronary artery bypass is performed:

Mitral valve replacement without opening the chest

In the Department of Cardiac Surgery of the Beilinson Hospital, operations on the heart valves (aortic valve replacement, reconstruction of the mitral and tricuspid valves) are performed without opening the chest, but through a small surgical incision. Operations are carried out according to their own exclusive method, which is called "minimal invasive".

This approach allows not to cut the sternum, as is done according to the traditional method, but to perform the operation through a small hole in the right side of the chest.

Connection to the heart-lung machine is made through the aorta and right atrium, as is done by the traditional method, or through the femoral artery in the groin. We use a wide range of valve rebuild rings and synthetic materials in place of torn valve ligaments (chords). When valves need to be replaced, biological or mechanical valves are used.

Used in the medical center. Rabin (Beilinson Hospital) method of minimal surgical intervention "minimal invasive" allows for the replacement of the aortic and reconstruction of the mitral and tricuspid valves without injury to the sternum. This eliminates the possible complications that occur when the sternum is damaged: infection and sepsis, in addition, it practically leaves no scars, only a small incision between the 3rd and 4th ribs when replacing the aortic valve and between 4-5 when replacing the mitral valve.

At the Medical Center Rabin performed operations on the mitral and aortic valves without opening the chest.

Departments: Cardiology and thoracic surgery,.

Reasons for this operation

The tricuspid is located between the right atrium and the right ventricle. The bicuspid is located between the right ventricles and the atria. This bicuspid valve is called the mitral valve.

As a result of certain reasons, physiological and functional changes in the mitral valve occur. This leads to the fact that its valves do not close completely and part of the blood returns.

Or the valves close too tightly, and the blood does not have the opportunity to fully pump into the atria.

All these processes entail heart rhythm disturbances, and subsequently to the development of heart failure.

If the disease is detected in the early stages of its development, experts recommend medication to patients. Otherwise, surgery on the mitral valve is indispensable.

Variety of operations

Operations on the mitral valve are divided into several types:

Plastic. In one case, the essence of the operation is to replace that part of the organ on which there is a pathology. In the second case, cutting the adhesions that formed on the walls of the MC. Plastic surgery is not aimed at replacing the old organ with a new one, but at preserving the old one.

Plastic has two subspecies:

valvuloplasty is the process of suturing the valve leaflets. This type of surgical intervention is resorted to if the distance between the valves is too large and part of the blood returns back to the atrium. To stabilize and strengthen the stable distance, a support ring is inserted between them;
commissurotomy - a procedure for dissecting adhesions that have formed between the valves. As a result, the distance between the halves of the MC on the heart becomes too small to pass the necessary volume of blood from the atrium to the ventricle. This type of operation can be performed without opening the patient's sternum (closed method) or with opening the chest (open method).
Prosthetics. The operation to replace the mitral valve is carried out if the old one can no longer be saved. It is much more difficult and dangerous than plastic. The diseased organ is removed and an artificial one is implanted in its place. In some cases, specialists resort to valve transplantation of another person.

In the event that experts believe that the old MC of a person with pathology is no longer subject to treatment, they stop at such a type of treatment as mitral valve replacement surgery.

Classification of prostheses

Valve replacement surgery involves removing the old valve and replacing it with an artificial prosthesis. All prostheses can be divided into several types:

Biological. A distinctive feature of such a prosthesis is that it is made from human or animal tissue, such as pig or cow. The possibility of using some mechanical elements is not excluded. I have been working with biological prostheses for about 9–18 years. After this time, it becomes necessary to repeat the operation to replace the mitral valve. Patients with a biological valve installed do not need to take anticoagulant drugs.

When choosing any one type of artificial valves, specialists take into account factors such as the age of the patient, his state of health, the presence of chronic or other diseases, etc.

Recovery period

In most cases, after the introduction of an artificial valve, patients may experience the following symptoms:

Do not despair and panic. These symptoms will last for 2-3 weeks.

After this period, the patient undergoes a period of rehabilitation. The essence of this process is to perform a course of physical exercises aimed at restoring all body functions.

A prerequisite for rehabilitation is diet and a healthy lifestyle.

After the operation was performed, the further condition of the patient depends entirely on himself, on his desire to return to an active and healthy life. Be healthy!

Indications and contraindications for prosthetic heart valves

Severe stenosis (narrowing) of the valve opening, which cannot be eliminated by simple dissection of the valves;
Stenosis or insufficiency of the valve due to sclerosis, fibrosis, calcium salt deposits, ulceration, shortening of the valves, their wrinkling, limitation of mobility for the above reasons;
Sclerosis of the tendon chords, disrupting the movement of the valves.

Thus, the reason for surgical correction is any irreversible structural change in the components of the valve, which makes the correct unidirectional blood flow impossible.

There are also contraindications for heart valve replacement surgery. Among them are the serious condition of the patient, the pathology of other internal organs, making the operation dangerous for the life of the patient, severe blood clotting disorders. An obstacle to surgical treatment may be the patient's refusal to operate, as well as the neglect of the defect, when intervention is inappropriate.

The mitral and aortic valves are most often replaced, they are also usually affected by atherosclerosis, rheumatism, and a bacterial inflammatory process.

Depending on the composition, the heart valve prosthesis is mechanical and biological. Mechanical valves are made entirely of synthetic materials, they are metal structures with semicircular flaps moving in one direction.

Biological valves consist of animal tissues - elements of the pericardium of a bull, valves of pigs, which are fixed on a synthetic ring that is installed in the place where the heart valve is attached. Animal tissues in the manufacture of biological prostheses are treated with special compounds that prevent immune rejection after implantation.

The advantages of a biological artificial valve are the possibility of implantation during endovascular intervention, the limitation of the period of taking anticoagulants within three months. Rapid wear is considered a significant drawback, especially if the mitral valve is replaced with such a prosthesis. On average, a biological valve works for about a year.

The aortic valve is easier to replace with any type of prosthesis than the mitral valve, therefore, when the mitral valve is damaged, different types of plasty (commissurotomy) are first resorted to, and only if they are ineffective or impossible, the possibility of a total valve replacement is decided.

Preparing for valve replacement surgery

Preparation for surgery begins with a thorough examination, including:

General and biochemical blood tests;
Urinalysis;
Determination of blood clotting;
electrocardiography;
Ultrasound examination of the heart;
Chest X-ray.

Depending on the accompanying changes, the list of diagnostic procedures may include coronary angiography, vascular ultrasound, and others. Mandatory consultations of narrow specialists, conclusions of a cardiologist and therapist.

Technique for heart valve replacement surgery

Heart valve replacement can be performed through open access and in a minimally invasive way without incision of the sternum. Open surgery is performed under general anesthesia. After immersing the patient in anesthesia, the surgeon treats the operating field - the anterior surface of the chest, dissects the sternum in the longitudinal direction, opens the pericardial cavity, followed by manipulations on the heart.

Open surgery is very traumatic, so the operational risk is high, and postoperative recovery takes a long time.

The endovascular valve replacement technique shows very good results, it does not require general anesthesia, therefore it is quite feasible for patients with severe comorbidities. The absence of a large incision allows you to minimize the stay in the hospital and subsequent rehabilitation. An important advantage of endovascular prosthetics is the possibility of performing surgery on a beating heart without the use of a heart-lung machine.

The third option for prosthetics is from a mini-access. This method is also minimally invasive, but an incision of about 2-2.5 cm is made on the anterior chest wall in the projection of the apex of the heart, a catheter is inserted through it and the apex of the organ to the affected valve. Otherwise, the technique is similar to that for endovascular prosthetics.

Heart valve transplantation is in many cases an alternative to heart valve transplantation, which can significantly improve well-being and increase life expectancy. The choice of one of the listed methods of operation and the type of prosthesis depends both on the patient's condition and on the technical capabilities of the clinic.

Postoperative period and rehabilitation

After an open operation, the sutures are processed daily, they are removed on the 7-10th day. All this period requires a stay in the hospital. With endovascular surgery, you can go home already for 3-4 days. Most patients note a rapid improvement in well-being, a surge of strength and energy, ease in performing ordinary household activities - eating, drinking, walking, showering, which previously provoked shortness of breath and severe fatigue.

The rehabilitation period takes an average of about six months, during which the patient regains strength, physical activity, gets used to taking certain medications (anticoagulants) and regular monitoring of blood clotting. It is strictly forbidden to cancel, independently prescribe or change the dosage of drugs; this should be done by a cardiologist or therapist.

Drug therapy after valve replacement includes:

Anticoagulants (warfarin, clopidogrel) - for life with mechanical prostheses and up to three months with biological ones under constant coagulation monitoring (INR);
Antibiotics for rheumatic malformations and the risk of infectious complications;
Treatment of concomitant angina pectoris, arrhythmia, hypertension, etc. - beta-blockers, calcium antagonists, ACE inhibitors, diuretics (most of them are already well known to the patient, and he just continues to take them).

Anticoagulants with an implanted mechanical valve make it possible to avoid thrombosis and embolism, which are provoked by a foreign body in the heart, but there is also a side effect of taking them - the risk of bleeding, stroke, so regular monitoring of INR (2.5-3.5) is an indispensable condition for a lifetime with prosthesis.

Among the consequences of artificial heart valve transplantation, the most dangerous are thromboembolism, which is prevented by taking anticoagulants, as well as bacterial endocarditis - inflammation of the inner layer of the heart, when antibiotics are required.

The first control examination by a cardiologist is carried out about a month after prosthetics. At the same time, blood and urine tests are taken, an ECG is taken. If the patient's condition is good, then in the future the doctor should be visited once a year, in other cases - more often, depending on the patient's condition. If you need to undergo other types of treatment or examinations, you should always warn in advance about the presence of a prosthetic valve.

Lifestyle after valve replacement requires the abandonment of bad habits. First of all, you should stop smoking, and it is better to do this even before the operation. The diet does not dictate significant restrictions, but it is better to reduce the amount of salt and liquid consumed so as not to increase the load on the heart. In addition, the proportion of foods containing calcium should be reduced, as well as the amount of animal fats, fried foods, smoked meats in favor of vegetables, lean meats and fish.

High-quality rehabilitation after heart valve prosthetics is impossible without adequate physical activity. Exercise helps to increase overall tone and train the cardiovascular system. In the first weeks, do not be too zealous. It is better to start with feasible exercises that will serve as a prevention of complications without overloading the heart. Gradually, the volume of loads can be increased.

The prognosis after transplantation of an artificial valve is favorable. Within a few weeks, the state of health is restored, and patients return to normal life and work. If the work activity is associated with intensive loads, then a transfer to lighter work may be required. In some cases, the patient receives a disability group, but it is not associated with the operation itself, but with the functioning of the heart as a whole and the ability to perform one or another type of activity.

Similar operations have been carried out for 70 years.

Atherosclerosis is a human condition in which a fatty layer forms on the walls of the heart arteries due to a large amount of cholesterol, calcium and the remains of dead cells. It contributes to the thickening and narrowing of the arteries, which can eventually cause a heart attack, stroke, and a number of others. cardiovascular diseases. Coronary bypass surgery is an inevitable procedure after a severe heart attack. Its main goal is to create bypass routes (shunts) for the movement of blood through the arteries.

The principle of the operation and indications for its implementation

Shunting is a process in which additional paths are created to bypass a damaged area using a system of shunts.

The main indications for an operation of this purpose for the treatment of coronary heart disease (blockage of the coronary arteries) are:

damage to the left coronary artery, which delivers blood to the left side of the heart;
damage to all coronary vessels.

During this operation, the surgeon installs a shunt (a bypass vessel, which can be a large vein under the skin on the thigh, internal thoracic or radial artery) between the aorta and the coronary artery in the lumen where the atherosclerotic plaque has formed. When a shunt is applied, blood from the aorta to the coronary artery moves through a healthy vessel. As a result, cardiac blood flow returns to normal.

How less age patient, the more optimistic the prognosis after coronary artery bypass grafting. Before the start of the surgical intervention, patients are required to undergo a full range of examinations: make a cardiogram, coronography and undergo an ultrasound examination of the heart. Aortic bypass surgery is performed under general anesthesia and excludes eating 8 hours before the operation.

This type of surgery is performed in several ways: using the traditional method, using new technologies and modern technology. The classical method demonstrates the process by which the patient is connected to a heart-lung machine. The second way is using new technology which does not require connection to the machine. The latest method of minimally invasive shunting without the use of thoracotomy (opening the chest) is used only when bypassing the anterior inferior artery on the left. CABG methods are chosen based on the condition of the patient's heart and blood vessels.

Operation

After anesthesia, the patient is connected to the equipment with a monitor. Anesthetic drugs are administered throughout the operation. After the patient is immersed in drug-induced sleep, an endotracheal tube is inserted into the trachea, which communicates with the anesthesia machine. This stage ends the work of the anesthetist and begins the work of the surgeon.

The surgeon makes a longitudinal incision in the sternum and, by visual assessment, decides exactly where to place the shunt (or shunts).

For a blood vessel, a large saphenous vein of the thigh, internal thoracic or radial artery is selected. In order to prevent the formation of blood clots, the patient is given heparin. The surgeon stops the patient's heart, while the blood circulation of the entire operating process works with the help of an artificial device for 90 minutes. Cardiac arrest is performed by injecting a potassium-containing chilled solution into the heart.

The surgeon then sutures the shunt to the aorta and to the site of the coronary artery from the narrowing site. The heart starts again, all devices are removed. To neutralize heparin, protamine is administered. The sternum is sutured. This completes the operating process. Bypass surgery time is about 4 hours. The patient is transferred to the intensive care unit, where he stays for a day. On the fifth day after the operation, the operated patient is discharged.

Sometimes there may be a postoperative syndrome, when in the first 3 hours there is a violation of the heart rhythm. This is a temporary phenomenon that is eliminated with the help of therapeutic procedures.

What are the possible complications?

After heart bypass surgery, in some cases, a number of complications can be observed, among which the most common are bleeding and palpitations. There are cases of thrombus detachment, which occurs due to untimely closure of the shunt lumen or in the process of its damage, which can cause myocardial infarction. Poor healing of the sternum, infectious complications, stroke, cases of temporary amnesia and chronic pain at the site of surgery are not excluded.

All side effects are due to the poor condition of the patient before surgery or insufficient time for preparation. There are unlikely risks when a planned coronary artery bypass graft is performed. The risk is much higher in the presence of diseases such as diabetes, emphysema, kidney pathology. In order to exclude all kinds of risks before starting a coronary artery bypass surgery, it is necessary to analyze all the risks, consult a doctor and be sure to undergo complete diagnostics and survey.

Patients often complain about severe pain in the place where the operation was performed. Doctors recommend not to endure pain, to use painkillers, but only after consulting a cardio specialist.

For some patients, minimally invasive direct coronary artery bypass grafting may be appropriate. This applies to those patients who have several affected arteries.

Postoperative rehabilitation and prevention

Although small veins are used to replace the removed vein, there is a risk of swelling, so patients are advised to wear an elastic stocking for the first 1.5-2 months after surgery.

Since the sternum heals for a very long time, patients are not recommended to lift weights and engage in active work after coronary operations. This should be followed for at least 6 weeks. In addition, you need to increase the load gradually.

In no case should the problem that caused the operation be allowed to return. To do this, doctors recommend adhering to proper nutrition: reduce the consumption of sugar, salt, foods high in fat.

Foods rich in vitamins and minerals will bring much more benefit after such operations. You should include as much food as possible in the diet, which includes selenium, vitamins A, B, C and E. This will not only strengthen the heart muscles, keep blood circulation normal, normalize weight, but also increase the effectiveness of the protective properties of the body.

After a person has undergone coronary artery bypass surgery, his daily lifestyle must be corrected to the smallest detail. It is necessary to completely eliminate the use of alcoholic beverages and quit smoking. After heart surgery, rehabilitation and rehabilitation measures are very popular, which include patient education in techniques that promote proper nutrition, individual programs of physical activities.

After such operations on the heart, patients are recommended to undergo rehabilitation treatment in sanatoriums or dispensaries of this profile. Patients with atherosclerosis and other heart diseases should understand that the more such operations are performed by surgeons, the more often this leads to a weakening of the heart, which is responsible for the viability of the human body.

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Coronary artery bypass grafting: is it worth it?

Coronary artery bypass grafting has been used in cardiology for more than half a century. The operation consists in creating an artificial way for blood to enter the myocardium, bypassing the thrombosed vessel. At the same time, the heart lesion itself is not touched, but blood circulation is restored by connecting a new healthy anastomosis between the aorta and the coronary arteries.

Synthetic vessels can be used as a material for a coronary artery bypass graft, but the patient's own veins and arteries turned out to be the most suitable. The autovenous method reliably "solders" the new anastomosis, does not cause a rejection reaction to foreign tissue.

In contrast to balloon angioplasty with a stent, the non-functioning vessel is completely excluded from the blood circulation, and no attempts are made to open it. A specific decision on the use of the most effective method in the treatment is made after a detailed examination of the patient, taking into account the age, concomitant diseases, and the safety of the coronary circulation.

Who was the "pioneer" in the use of aortic bypass surgery?

The most famous cardiac surgeons from many countries worked on the problem of coronary artery bypass grafting (CABG). The first human operation was performed in 1960 in the USA by Dr. Robert Hans Goetz. An artificial shunt was used to select the left thoracic artery, which originates from the aorta. Its peripheral end was attached to the coronary vessels. Soviet surgeon V. Kolesov repeated a similar method in Leningrad in 1964.

Autovenous shunting was the first to be performed in the United States by a cardiac surgeon from Argentina, R. Favaloro. A significant contribution to the development of intervention techniques belongs to the American professor M. DeBakey.

Currently, such operations are performed in all major cardio centers. The latest medical equipment has made it possible to more accurately determine the indications for surgical intervention, to operate on a beating heart (without a heart-lung machine), and to shorten the postoperative period.

How are indications for surgery selected?

Coronary artery bypass grafting is performed when balloon angioplasty results are impossible or absent, conservative treatment. Before the operation, coronary angiography of the coronary vessels is mandatory and the possibilities of using a shunt are being studied.

The success of other methods is unlikely with:

severe stenosis of the left coronary artery in the area of its trunk;
multiple atherosclerotic lesions of the coronary vessels with calcification;
the occurrence of stenosis within the installed stent;
the impossibility of passing the catheter into a vessel that is too narrow.

The main indications for the use of the method of coronary artery bypass grafting are:

a confirmed degree of obstruction of the left coronary artery by 50% or more;
narrowing of the entire course of the coronary vessels by 70% or more;
a combination of these changes with stenosis of the interventricular anterior artery in the area of its branch from the main trunk.

Patients may need more than one shunt to achieve results.

There are 3 groups of clinical indications that doctors also use.

Group I includes patients who are resistant to drug therapy or have a significant ischemic zone of the myocardium:

with angina pectoris III-IV functional classes;
with unstable angina;
with acute ischemia after angioplasty, impaired hemodynamic parameters;
with developing myocardial infarction up to 6 hours from the onset of pain (later, if signs of ischemia persist);
if the stress test according to the ECG is sharply positive, and the patient needs elective abdominal surgery;
with pulmonary edema caused acute insufficiency heart with ischemic changes (accompanies angina pectoris in the elderly).

Group II includes patients who need a very likely prevention of acute infarction (the prognosis is unfavorable without surgery), but who are difficult to treat medicines. In addition to the main reasons already given above, it takes into account the degree of dysfunction of the heart's ejection function and the number of affected coronary vessels:

damage to three arteries with a decrease in function below 50%;
damage to three arteries with a function above 50%, but with severe ischemia;
damage to one or two vessels, but at a high risk of infarction due to the extensive area of ischemia.

To III group include patients for whom coronary artery bypass grafting is performed as a concomitant operation with a more significant intervention:

during operations on valves, to eliminate anomalies in the development of the coronary arteries;
if the consequences of a severe heart attack (aneurysm of the heart wall) are eliminated.

The International Association of Cardiology recommends Clinical signs and indications in the first place, and then take into account anatomical changes. It is estimated that the risk of death from a probable heart attack in a patient significantly exceeds mortality during the operation and after.

When is surgery contraindicated?

Cardiac surgeons consider any contraindication relative, since additional myocardial vascularization cannot harm a patient with any disease. However, the probable risk of death, which increases sharply, should be taken into account and the patient should be informed about it.

The classic general contraindications for any operations are considered to be available to the patient:

chronic lung diseases;
kidney disease with signs of kidney failure;
oncological diseases.

The risk of mortality increases dramatically with:

coverage of atherosclerotic lesions of all coronary arteries;
a decrease in the ejection function of the left ventricle to 30% or less due to massive cicatricial changes in the myocardium in the post-infarction period;
the presence of severe symptoms of decompensated heart failure with congestion.

What is the additional shunt vessel made of?

Depending on the vessel selected for the role of the shunt, bypass operations are divided into:

mammarocoronary - the internal thoracic artery serves as a bypass;
autoarterial - the patient has his own radial artery;
autovenous - a large saphenous vein is selected.

The saphenous vein of the leg perfectly replaces the coronary vessel

The radial artery and saphenous vein can be removed:

openly through skin incisions;
using endoscopic techniques.

The choice of technique affects the duration recovery period and residual cosmetic defect in the form of scars.

What is the preparation for the operation?

The upcoming CABG requires a thorough examination of the patient. Standard analyzes include:

clinical blood test;
coagulogram;
liver tests;
the content of glucose in the blood, creatinine, nitrogenous substances;
protein and its fractions;
Analysis of urine;
confirmation of the absence of HIV infection and hepatitis;
dopplerography of the heart and blood vessels;
fluorography.

Special studies are carried out in the preoperative period in the hospital. Be sure to do coronary angiography (X-ray image of the vascular pattern of the heart after the introduction of a contrast agent).

The patient must inform the surgeon about past illnesses, a tendency to allergic reactions to foods or medicines

Complete information will help to avoid complications during the operation and in the postoperative period.

To prevent thromboembolism from the veins of the legs, 2-3 days before the scheduled operation, a tight bandage is performed from the foot to the thigh.

It is forbidden to have dinner the night before, breakfast in the morning to exclude possible regurgitation of food from the esophagus and its entry into the trachea during the period of narcotic sleep. If there is hair on the skin of the anterior chest, they are shaved off.

An anesthesiologist's examination consists of an interview, pressure measurement, auscultation, and re-evaluation of past diseases.

Anesthesia method

Coronary artery bypass surgery requires complete relaxation of the patient, so general anesthesia is used. The patient will feel only a prick from the intravenous entry of the needle when the dropper is inserted.

Falling asleep occurs within a minute. A specific anesthetic drug is chosen by the anesthesiologist, taking into account the patient's state of health, age, functioning of the heart and blood vessels, and individual sensitivity.

It is possible to use different combinations of painkillers for induction and main anesthesia.

State full sleep and anesthesia is controlled by special indicators

Specialized centers use equipment for monitoring and control of:

pulse;
blood pressure;
breathing;
alkaline reserve of blood;
saturation with oxygen.

The question of the need for intubation and transfer of the patient to artificial respiration is decided at the request of the operating physician and is determined by the technique of the approach.

During the intervention, the anesthesiologist informs the chief surgeon about life support indicators. At the stage of suturing the incision, the administration of the anesthetic is stopped, and by the end of the operation, the patient gradually wakes up.

How is the operation carried out?

The choice of surgical technique depends on the capabilities of the clinic and the experience of the surgeon. Currently, coronary artery bypass grafting is performed:

through open access to the heart when cutting the sternum, connecting to a heart-lung machine;
on a beating heart without cardiopulmonary bypass;
with a minimal incision, access is used not through the sternum, but by mini-thoracotomy through an intercostal incision up to 6 cm long.

Shunting with a small incision is possible only for connection with the left anterior artery. Such localization is considered in advance when choosing the type of operation.

It is technically difficult to implement the beating heart approach if the patient has very narrow coronary arteries. In such cases, this method is not applicable.

The advantages of surgery without the support of an artificial blood pump include:

the practical absence of mechanical damage to the cellular elements of the blood;
reducing the duration of the intervention;
reduction of possible complications caused by the equipment;
faster postoperative recovery.

In the classical method, the chest is opened through the sternum (sternotomy). With special hooks it is bred to the sides, and the apparatus is attached to the heart. For the duration of the operation, it works like a pump and distills blood through the vessels.

Cardiac arrest is induced with a chilled potassium solution. When choosing a method of intervention on a beating heart, it continues to contract, and the surgeon enters the coronaries with the help of special devices (anticoagulators).

Usually there are at least two surgeons and nurses in the operating team

While the first is accessing the zone of the heart, the second ensures the release of autovessels to turn them into shunts, injects a solution with heparin into them to prevent the formation of blood clots.

A new network is then created to provide a circuitous route for blood delivery to the ischemic site. The stopped heart is started with a defibrillator, and artificial circulation is turned off.

For stitching the sternum, special tight staples are applied. A thin catheter is left in the wound to drain blood and control bleeding. The whole operation takes about four hours. The aorta remains clamped for up to 60 minutes, cardiopulmonary bypass is maintained for up to 1.5 hours.

How is the postoperative period?

From the operating room, the patient is taken to the intensive care unit on a gurney under a dropper. He usually stays here for the first day. Breathing is carried out independently. In the early postoperative period, continue monitoring the pulse and pressure, control over the release of blood from the installed tube.

The frequency of bleeding in the coming hours is no more than 5% of all operated patients. In such cases, re-intervention is possible.

Exercise therapy (physiotherapy exercises) is recommended to start from the second day: make movements imitating walking with your feet - pull socks towards you and back so that the work of the calf muscles is felt. Such a small load allows you to increase the "pushing" of venous blood from the periphery and prevent thrombosis.

On examination, the doctor pays attention to breathing exercises. Deep breaths straighten the lung tissue and protect it from congestion. Balloons are used for training.

A week later, the suture material is removed at the sites of saphenous vein sampling. Patients are advised to wear an elastic stocking for another 1.5 months.

It takes up to 6 weeks for the sternum to heal. Heavy lifting and physical work are prohibited.

A special bandage is put on the chest to support the ribs and sternum to heal the sutures on the skin and strengthen the sternum

Discharge from the hospital is carried out after a week.

In the early days, the doctor recommends a small unloading due to light nutrition: broth, liquid cereals, sour-milk products. Taking into account the existing blood loss, dishes with fruits, beef, and liver are offered. This helps restore hemoglobin levels in a month.

The motor mode is gradually expanded taking into account the cessation of angina attacks. Do not force the pace and chase sporting achievements.

The best way to continue rehabilitation is to transfer to a sanatorium directly from the hospital. Here, monitoring of the patient's condition will continue, and an individual regimen will be selected.

Small hematomas remain at the site of vein sampling, which disappear after 10 days

How likely are complications?

The study of the statistics of postoperative complications indicates a certain amount of risk for any type of surgical intervention. This should be clarified when deciding on consent to the operation.

The lethal outcome in planned coronary artery bypass grafting is now no more than 2.6%, in some clinics it is less. Experts point to the stabilization of this indicator in connection with the transition to trouble-free operations for the elderly.

It is impossible to predict in advance the duration and degree of improvement in the condition. Observation of patients shows that the indicators of coronary circulation after surgery in the first 5 years dramatically reduce the risk of myocardial infarction, and in the next 5 years do not differ from patients treated with conservative methods.

The "lifetime" of a bypass vessel is considered to be 10 to 15 years. Survival after surgery is within five years - 88%, ten - 75%, fifteen - 60%.

From 5 to 10% of cases among the causes of death are acute heart failure.

What complications are possible after the operation?

Most frequent complications coronary artery bypass grafting are considered:

Less frequent include:

myocardial infarction caused by a detached thrombus:
incomplete fusion of the sternal suture;
wound infection;
thrombosis and phlebitis of deep veins of the leg;
stroke;
kidney failure;
chronic pain in the area of operation;
the formation of keloid scars on the skin.

The risk of complications is associated with the severity of the patient's condition before surgery, concomitant diseases. Increases in case of emergency intervention without preparation and sufficient examination.

Feedback from patients who survived surgery makes you think about personal choices and values in life.

Galina Mikhailovna, 58 years old, music teacher: “I read the article and began to remember what inspired me to agree to the operation. She had just reached retirement when she had a heart attack. True, before that for 10 years there was constant hypertension. I was treated from time to time, there was no time to rest (like all musicians, I roam in two more places). Once in a hospital bed with constant seizures and fear, she agreed, without even thinking about the consequences. She was referred to the regional cardiological center for a consultation. 3 months waiting in line for coronary angiography. When the operation was proposed, I immediately agreed. Before and after I did everything according to the recommendations of the doctor. The chest pain lasted for 3 days, then practically disappeared. Now I continue to do what I love, I lead students, I earn extra money in the orchestra.

Sergey Nikolaevich, 60 years old, retired lieutenant colonel: “It is impossible to be constantly afraid and expect a heart attack, it is better to take a chance. After the operation, there are practically no seizures for 2 years. Once I increased the load at the dacha, I felt dizzy. It's gone after the rest. Maybe at least 5 or 10 years I can live without thinking about the heart. My peers are no longer able to physically work.”

My husband had a coronary bypass. A month has already passed, and the pain in the operation area does not go away. What to do?

Three years after the ternary bypass surgery, one shunt was thrombosed. What to do?

20 days after the operation, the sternum and the left side of the incision hurt. This is fine?

How is coronary artery bypass grafting performed?

Coronary artery bypass grafting is the most effective treatment for many heart conditions, including coronary artery disease.

With the help of this procedure, patients become capable again, the symptoms of diseases recede.

Coronary artery bypass grafting is performed in a hospital, after surgical treatment followed by a long recovery period.

What is an operation

Patients who have problems with the coronary or coronary artery are wondering if coronary bypass surgery is what it is, is the operation dangerous. Coronary artery bypass grafting - surgical method treatment of coronary heart disease. It allows you to restore the blood supply to the heart muscle in full.

This is the most effective method treatment of ischemia, which reduces the risk of a heart attack. Heart bypass after a heart attack is a necessary measure and the only way to save a person's life.

During surgery, a vessel taken from the thoracic artery or a leg vein is inserted into the patient. A new vessel is placed above the site where the narrowing occurred or at its level. The blood flow after treatment is restored.

As a result of narrowing of the coronary artery, ischemic heart disease develops. For this reason, the process of blood supply is disrupted, and the heart muscle begins to experience a lack of oxygen and other nutrients. With insufficient therapy, the disease is complicated by myocardial infarction.

Shunting allows you to completely solve the problem with blood supply. During the operation, an alternative blood flow is formed, which supplies the heart with all the necessary elements.

Coronary artery bypass grafting is indicated for the treatment of one or more vessels. Postoperative mortality statistics are a small percentage of 1 to 3% of all cases.

Mortality is affected by the age of the patient, the number of affected areas, and the characteristics of the shunt.

What is a shunt

During CABG, a graft is introduced into the artery - a shunt, one end of which is sutured into the aorta, and the other is slightly below the clogged area. Thus, the blood flow rushes along a new channel, bypassing the affected area.

A shunt is a vessel graft. The graft, in this case, is the thoracic or radial artery. In some cases, they resort to using the saphenous vein of the thigh as a bypass. The appearance of a shunt normalizes blood circulation, the symptoms of the disease disappear.

Before the operation, an additional examination of the removed vessel is carried out in order to exclude a complication that may entail the removal of the vein.

Types of bypass

Coronary artery bypass grafting is performed under general anesthesia The operation is performed on the open heart.

Surgery for coronary artery bypass grafting proceeds according to one of the following methods:

Surgery on a stopped heart, while using special equipment, which during the period of temporary cardiac arrest, performs artificial circulation.
Coronary artery bypass surgery can also be done on a beating heart. This method eliminates the long postoperative recovery of the patient. The procedure itself does not take long, but for its implementation it is necessary to contact a high-level specialist, since this type of operation is very complicated.
Application of endoscopic methods. To perform the operation, the surgeon makes small incisions, so that the wounds heal quickly, the patient recovers faster after treatment. The whole procedure takes about two hours. This method is very popular in European clinics.

Coronary artery bypass grafting can cause complications. The outcome of each surgical intervention depends on individual features organism and the severity of the disease.

Preparation for the procedure

In order for the coronary bypass surgery to be successful, the patient needs preliminary preparation. Before the surgical procedure, a complete examination is required. The patient is prescribed:

In addition to information about general condition the patient, during the diagnosis, the doctor determines the condition of the arteries, how narrow the lumen is in them, the specific place of the pathology. The specialist will explain to the patient what heart bypass surgery is, how to prepare for the operation.

Immediately before the bypass, the patient should observe the following measures:

dinner on the eve of the operation should not be plentiful, it is forbidden to eat at night;
men should shave the places on the chest where the operation will be performed;
on the night before the operation, you need to clean the intestines;
after dinner they take their last medicines.

If possible, the medication is canceled a week before the procedure.

Operation progress

Treatment is carried out in intensive care, where the patient is sent on a stretcher. The operation is performed under general anesthesia. How is the operation done:

the surgeon performs an opening of the chest;
if necessary, the patient's heart is stopped, surgery on a functioning heart is allowed;
artificial circulation is supported with the help of special equipment;
the sternum is dissected;
the chest is fully opened;
shunts are being introduced;
The doctor closes the incision.

The modern method of shunting, practiced in European clinics, is carried out with minimal invasive intervention. The procedure is carried out without opening the chest, but through the intercostal space. This type of operation is possible thanks to modern equipment. The minimally invasive method reduces the duration of the postoperative period and reduces the risk of postoperative complications.

Coronary artery bypass grafting will be done from 3 to 6 hours, depending on the complexity of the disease and the number of implanted shunts. After the procedure, the patient is sent to the intensive care unit, where he is kept for a day.

Postoperative and rehabilitation periods

After the operation, the patient will not immediately be able to return to a normal lifestyle. He will need a postoperative recovery period. How the rehabilitation proceeded also depends on whether the disease will recur in the future.

Postoperative recovery lasts about 10 days and proceeds with the involvement of several techniques:

drug treatment;
physical procedures;
psychological mood.

Drug treatment in each case is selected individually. The doctor selects complex therapy with the inclusion of the following drugs:

For the first few days, the patient is given painkillers and antibiotics. medicines. The patient is placed on bed rest. An immobile posture in the supine position is contraindicated, this can cause fluid to accumulate in the lungs, which in turn can cause pneumonia.

On the condition of good condition on the second day, it is allowed to sit down on the bed and get up for a short while. Required breathing exercises, a special diet.

Physical treatments are recommended from the second day after bypass surgery. The patient gradually restores physical activity day by day. An important point is walking. With its help, the patient's blood circulation is restored, the heart muscle is strengthened.

Particular attention should be paid to breathing exercises.

Psychological rehabilitation is equally important. Psychologists will help the patient cope with the psychological trauma that develops as a result of postoperative pain, cerebral hypoxia. Patients are irritable, anxious, they are disturbed by insomnia.

The patient will be discharged from the hospital two weeks after the operation, provided that the postoperative period was successful, there were no complications and exacerbation of concomitant diseases.

After discharge, the patient is registered with a specialist and visits a doctor every three months. Later, it will be enough to go to the doctor for a check-up once a year.

Are heart surgeries done without opening the chest?

This technique of heart surgery significantly reduces the duration of rehabilitation of patients in the postoperative period.

Review

Open heart surgery is a surgical procedure in which the chest is opened and the muscles, valves, or arteries of the heart are affected.

Coronary artery bypass surgery is the most common adult heart surgery, according to the US National Heart, Lung, and Hematology Institute (NHLBI). During this surgery, a healthy artery or vein is transplanted (attached) to a blocked coronary (heart) artery. As a result, the transplanted artery delivers blood to the heart bypassing the blocked artery (NHLBI).

Open heart surgery is sometimes referred to as conventional heart surgery. Today, many new procedures on the heart require only small incisions rather than large incisions. That is, the concept of open heart surgery can sometimes be misleading.

The reasons

Open heart surgery allows coronary artery bypass surgery. Coronary artery bypass surgery may be required for patients with coronary artery disease.

Coronary artery disease occurs when the vessels that carry blood and oxygen to the heart become narrow and inelastic. This disease is known as atherosclerosis.

Atherosclerosis occurs when fatty deposits build up on the walls of the coronary arteries. Plaque narrows the arteries, making it difficult for blood to pass through them. If blood is not supplied to the heart properly, a heart attack can occur.

Open heart surgery is also performed to:

restore or replace blood vessels, which will allow blood to pass through the heart; repair damaged or abnormal areas of the heart; install medical devices that will help the heart work properly; replace the damaged heart with a donor one (transplantation).

Operation

Coronary artery bypass surgery takes four to six hours, according to the National Institutes of Health. Consider what it is, step by step.

The patient receives general anesthesia. He falls asleep and feels no pain from the operation. After making a 20 to 25 centimeter incision in the chest, the surgeon cuts all or part of the breast bone to gain access to the heart. Once the heart opens, the patient is connected to a heart-lung machine. It diverts blood away from the heart so that the surgeon can operate. Some new technologies allow to refuse this device. The surgeon uses a healthy vein or artery to create a new path around the blocked artery. The chest is held together with wire, which remains inside the body. The initial incision is sutured. (NIH)

Occasionally, a chest plate is used in high-risk patients, especially in the elderly and those who have undergone repeated surgery. In this case, the breast bone after the operation is connected with small titanium plates.

Risks

Risks in coronary artery bypass surgery:

wound infection of the chest (most common in obesity, diabetes, repeated bypass surgery); heart attack or stroke; violation of the heart rhythm; damage to the lungs or kidneys; chest pain, subfebrile body temperature; memory loss or blurred memories; blood clots; blood loss; difficulty breathing.

According to the University medical center Chicago (UCM), the use of a heart-lung machine increases the risks. These risks include stroke and memory problems (UCM).

Training

Tell your doctor about all medicines you take, including over-the-counter drugs, vitamins, and herbs. Report any health problems, including herpes, infection, colds, flu, fever.

Two weeks before surgery, your doctor may ask you to refrain from smoking and stop taking vasoconstrictor drugs such as aspirin, ibuprofen or naproxen.

On the eve of the operation, you will be asked to wash yourself with a special soap. It destroys bacteria on the skin and reduces the chance of infection after surgery. You may be asked not to eat or drink anything after midnight.

You will receive further instructions when you arrive at the hospital for your operation.

Rehabilitation

When you wake up after surgery, you will have two or three tubes in your chest. They are needed to drain fluid from the area around the heart.

You may have intravenous tubes that will provide you with fluids.

You may have a catheter (thin tube) placed in bladder to remove urine.

You may also have machines connected to you to monitor your heart. Nurses will be nearby to help you if needed.

Most likely, you will spend the first night in the intensive care unit. After three to seven days, you will be transferred to a regular ward.

Long

You must be ready for a gradual recovery. Improvement will come in about six weeks, and in about six months you will feel the full benefits of the operation. So, the outlook is optimistic for many people, the shunt can work for years to come.

Nevertheless, the operation does not exclude re-occlusion of the vessels. The state of health will support the following measures:

proper nutrition; restriction of salty, fatty and sweet food; maintaining physical activity; to give up smoking; control of high blood pressure and cholesterol levels.

Heart surgeries are very common these days. Modern cardiac surgery and vascular surgery are very advanced. Surgical intervention is prescribed in the case when conservative drug treatment does not help, and, accordingly, the normalization of the patient's condition is impossible without surgery.

For example, heart disease can only be cured by surgery, this is necessary in the case when blood circulation is severely disturbed due to pathology.

And as a result, a person feels bad and severe complications begin to develop. These complications can lead not only to disability, but also to death.

Often prescribed surgical treatment of coronary heart disease. Since it can lead to myocardial infarction. Due to a heart attack, the walls of the cavities of the heart or aorta become thinner and protrusion appears. This pathology can also be cured only by surgery. Quite often, operations are performed due to disturbed heart rhythm (RFA).

They also perform heart transplantation, that is, a transplant. This is necessary when there is a complex of pathologies due to which the myocardium is not able to function. Today, such an operation prolongs the life of the patient by an average of 5 years. After such an operation, the patient is put on disability.

Operations can be carried out urgently, urgently, or a planned intervention is prescribed. It depends on the severity of the patient's condition. An emergency operation is performed immediately, immediately after the diagnosis is established. If such an intervention is not carried out, then the death of the patient may occur.

Such operations are often performed on newborns immediately after birth with congenital heart disease. In this case, even minutes are important.

Urgent operations do not require fast execution. In this case, the patient is prepared for some time. As a rule, it is several days.

A planned operation is prescribed if at this time there is no danger to life, but it must be carried out to prevent complications. Doctors prescribe surgery on the myocardium only if it is necessary.

Invasive Research

Invasive methods for examining the heart are to conduct catheterization. That is, the study is carried out through a catheter, which can be installed both in the cavity of the heart and in the vessel. With the help of these studies, you can determine some indicators of the work of the heart.

For example, blood pressure in any part of the myocardium, as well as to determine how much oxygen is in the blood, to evaluate cardiac output, vascular resistance.

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Invasive methods allow you to study the pathology of the valves, their size and degree of damage. This study takes place without opening the chest. Cardiac catheterization allows you to take an intracardiac electrocardiogram and phonocardiogram. This method is also used to monitor the effectiveness of drug therapy.

Such studies include:

Angiography. This is a method for which a contrast agent is used. It is injected into the cavity of the heart or vessel for accurate visualization and detection of pathologies. coronary angiography. This study allows you to assess the degree of damage to the coronary vessels, it helps doctors understand whether surgery is needed, and if not, what therapy is suitable for this patient. Ventriculography. This is a radiopaque study that will determine the condition of the ventricles, the presence of pathology. All ventricular parameters can be studied, such as cavity volume, cardiac output, cardiac relaxation and excitability measurements.

With selective coronary angiography, contrast is injected into one of the coronary arteries (right or left).

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Coronary angiography is often performed in patients with angina pectoris 3-4 functional class. In this case, it is resistant to drug therapy. Doctors need to decide what type of surgical treatment is needed. It is also important to carry out this procedure for unstable angina.

Also, invasive procedures include punctures and probing of the heart cavities. With the help of probing, it is possible to diagnose heart defects and pathologies in the LV, for example, it can be tumors, or thrombosis. To do this, use the femoral vein (right), a needle is inserted into it through which the conductor passes. The needle diameter becomes about 2 mm.

When performing invasive studies, local anesthesia is used. The incision is small, about 1-2 cm. This is necessary to expose the desired vein for the installation of the catheter.

These studies are carried out in different clinics and their cost is quite high.

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Surgery for heart disease

Heart defects include

stenosis of the heart valves; insufficiency of heart valves; septal defects (interventricular, interatrial).

valve stenosis

These pathologies lead to many disorders in the work of the heart, that is, the goals of operations for defects are to relieve the load from the heart muscle, restore the normal functioning of the ventricle, as well as restore contractile function and reduce pressure in the heart cavities.

To eliminate these defects, the following surgical interventions are performed:

Valve replacement (prosthetics)

This type of operation is done on the open heart, that is, after opening the chest. In this case, the patient is connected to a special apparatus for cardiopulmonary bypass. The operation consists in replacing the affected valve with an implant. They can be mechanical (in the form of a disk or ball in a grid, they are made of synthetic materials) and biological (made from animal biological material).

Valve implant placement

Plastic defects of partitions

It can be carried out in 2 options, for example, suturing a defect or its plastic. Suturing is carried out if the size of the hole is less than 3 cm. Plastic surgery is performed using synthetic tissue or autopericardium.

Valvuloplasty

With this type of operation, implants are not used, but simply expand the lumen of the affected valve. At the same time, a balloon is introduced into the lumen of the valve, which is inflated. It should be noted that such an operation is performed only on young people, as for the elderly, they are only entitled to open-heart intervention.

Balloon valvuloplasty

Often, after heart disease surgery, a person is given a disability.

Operations on the aorta

Open surgeries include:

Prosthetics of the ascending aorta. At the same time, a valve-containing conduit is installed; this prosthesis has a mechanical aortic valve. Prosthetics of the ascending aorta, while the aortic valve is not implanted. Prosthetics of the ascending artery and its arch. Surgery to implant a stent graft in the ascending aorta. This is an endovascular intervention.

Prosthetics of the ascending aorta is the replacement of this section of the artery. This is necessary in order to prevent serious consequences, for example, a break. To do this, prosthetics are used by opening the chest, and endovascular or intravascular interventions are also performed. In this case, a special stent is installed in the affected area.

Of course, open-heart surgery is more effective, since in addition to the main pathology - aortic aneurysm, it is possible to correct the accompanying one, for example, stenosis or valve insufficiency, etc. And the endovascular procedure gives a temporary effect.

Aortic dissection

When prosthetics of the aortic arch are used:

Open distal anastomosis. This is when the prosthesis is installed, so that it does not affect its branches; Arc semi-replacement. This operation consists in replacing the artery where the ascending aorta passes into the arch and, if required, replacing the concave surface of the arch; Subtotal prosthetics. This is when the replacement of branches (1 or 2) is required during prosthetics of the arterial arch; Complete prosthetics. In this case, the arch is prosthetized together with all supra-aortic vessels. This is a complex intervention that can cause neurological complications. After such an intervention, a person is given a disability.

Coronary artery bypass grafting (ACS)

CABG is open-heart surgery that uses a patient's vessel as a shunt. This heart operation is needed in order to create a bypass for the blood, which will not affect the occlusive section of the coronary artery.

That is, this shunt is installed on the aorta and brought to the area of the coronary artery not affected by atherosclerosis.

This method is quite effective in the treatment of coronary heart disease. Due to the installed shunt, the blood flow to the heart increases, which means that ischemia and angina pectoris do not appear.

CABG is prescribed if there is angina pectoris, in which even the smallest loads cause seizures. Also, indications for CABG are lesions of all coronary arteries, and if an aneurysm of the heart has formed.

Coronary artery bypass grafting

During CABG, the patient is put into general anesthesia, and then, after opening the chest, all manipulations are performed. This operation can be performed with or without cardiac arrest. And also, depending on the severity of the pathology, the doctor decides whether it is necessary to connect the patient to a heart-lung machine. The duration of CABG can be 3-6 hours, it all depends on the number of shunts, that is, on the number of anastomoses.

As a rule, the role of the shunt is performed by a vein from the lower limb, and sometimes a part of the internal thoracic vein, the radial artery, is also used.

Today, CABG is performed, which is performed with minimal access to the heart, while the heart continues to work. Such an intervention is considered not as traumatic as the others. In this case, the chest is not opened, the incision is made between the ribs and a special expander is also used so as not to affect the bones. This type of CABG lasts 1 to 2 hours.

The operation is performed by 2 surgeons, while one makes an incision and opens the sternum, the other operates on the limb to take a vein.

After carrying out all the necessary manipulations, the doctor installs drains and closes the chest.

CABG significantly reduces the likelihood of a heart attack. Angina pectoris does not appear after surgery, which means that the quality and duration of the patient's life increase.

Radiofrequency ablation (RFA)

RFA is a procedure that is performed under local anesthesia, since the basis is catheterization. Such a procedure is carried out in order to exfoliate the cells that cause arrhythmia, that is, the focus. This happens through a catheter-conductor, which conducts an electric current. As a result, tissue formations are removed by RFA.

RF catheter ablation

After conducting an electrophysical study, the doctor determines where the source is located, which causes a rapid heartbeat. These sources can be formed along the conducting paths, as a result of which an anomaly of the rhythm manifests itself. It is RFA that neutralizes this anomaly.

RFA is carried out in case of:

when drug therapy does not affect the arrhythmia, and also, if such therapy causes side effects. If the patient has Wolff-Parkinson-White syndrome. This pathology is perfectly neutralized by RFA. If a complication may occur, such as cardiac arrest.

It should be noted that RFA is well tolerated by patients, since there are no large incisions and opening of the sternum.

The catheter is inserted through a puncture in the thigh. Only the area through which the catheter is inserted is anesthetized.

The guide catheter reaches the myocardium, and then a contrast agent is injected. With the help of contrast, the affected areas become visible, and the doctor directs the electrode to them. After the electrode acted on the source, the tissues are scarred, which means that they will not be able to conduct the impulse. After RFA, a bandage is not needed.

Carotid surgery

Allocate these types of operations to carotid artery:

Prosthetics (used with a large lesion); Stenting is performed if stenosis is diagnosed. In this case, the lumen is increased by installing a stent; Eversion endarterectomy - at the same time, atherosclerotic plaques are removed along with the inner lining of the carotid artery; Carotid endarectomy.

These operations are performed under both general and local anesthesia. More often under general anesthesia, since the procedure is performed in the neck and there are discomfort.

The carotid artery is occluded, and in order to continue the blood supply, shunts are installed, which are bypass routes.

Classical endarterectomy is done if long plaque lesions are diagnosed. During this operation, the plaque is peeled off and removed. Next, the vessel is washed. Sometimes it is still necessary to fix the inner shell, this is done with special seams. At the end, the artery is sutured with a special synthetic medical material.

Endarterectomy of the carotid arteries

Eversion endartectomy is performed in such a way that the inner layer of the carotid artery at the site of the plaque is removed. And after that they fix, that is, sew. For this operation, the plaque should be no more than 2.5 cm.

Stenting is performed using a balloon catheter. This is a minimally invasive procedure. When the catheter is located at the site of stenosis, it inflates and thereby expands the lumen.

Rehabilitation

The period after heart surgery is no less important than the operation itself. At this time, the patient's condition is monitored by doctors, and in some cases, cardio training, therapeutic diets, etc. are prescribed.

Other recovery measures are also needed, such as wearing a bandage. The bandage at the same time fixes the seam after the operation, and of course the entire chest, which is very important. Such a bandage should be worn only if the operation is performed on the open heart. The cost of these items may vary.

The bandage that is worn after heart surgery looks like a T-shirt with tightness clamps. You can purchase male and female versions of this bandage. The bandage is important to prevent lung congestion by coughing regularly.

Such prevention of stagnation is quite dangerous because the seams can disperse, the bandage in this case will protect the seams and contribute to strong scarring.

Also, the bandage will help prevent swelling and bruising, promotes correct location organs after heart surgery. And the bandage helps to relieve the load from the organs.

After heart surgery, the patient needs rehabilitation. How long it will last depends on the severity of the lesion and the severity of the operation. For example, after CABG, immediately after heart surgery, you need to start rehabilitation, this is a simple exercise therapy and massage.

After all types of heart surgery, medical rehabilitation, that is, supportive therapy, is needed. In almost all situations, the use of antiplatelet agents is mandatory.

If there is high blood pressure, then ACE inhibitors and beta-blockers are prescribed, as well as drugs to lower blood cholesterol (statins). Sometimes the patient is prescribed physical procedures.

Disability

It should be noted that disability is given to people with diseases of the cardiovascular system even before surgery. There must be evidence for this. From medical practice, it can be noted that they necessarily give disability after coronary artery bypass grafting. Moreover, there may be a disability of both 1 and 3 groups. It all depends on the severity of the pathology.

People who have circulatory disorders, grade 3 coronary insufficiency, or have had a myocardial infarction are also entitled to disability.

Regardless of whether the operation was performed or not yet. Patients with grade 3 heart defects and combined defects can apply for disability if there are persistent circulatory disorders.

Clinics

Name of clinic Address and telephone Type of service Cost

NII SP im. N. V. Sklifosovsky	Moscow, Bolshaya Sukharevskaya sq., 3	CABG without IR CABG with valve replacement Angioplasty and coronary artery stenting RFA Aortic stenting Valve replacement Valve repair	64300 rub. 76625 rub. 27155 rub. 76625 rub. 57726 rub. 64300 rub. 76625 rub.
KB MGMU them. Sechenov	Moscow, st. B. Pirogovskaya, 6	CABG with valve replacement Angioplasty and stenting of coronary arteries RFA Aortic stenting Prosthetic valves Valve repair Aneurysm resection	132000 rub. 185500 rub. 160000-200000 rub. 14300 rub. 132200 rub. 132200 rub. 132000-198000 rub.
FSCC FMBA	Moscow, Orekhovy Boulevard, 28	CABG Angioplasty and stenting of the coronary arteries RFA Aortic stenting Prosthetic valves Valve repair	110000-140000 rub. 50000 rub. 137000 rub. 50000 rub. 140000 rub. 110000-130000 rub.
NII SP im. I.I. Janelidze	St. Petersburg, st. Budapestskaya, 3	CABG Angioplasty and stenting of the coronary arteries Aortic stenting Prosthetic valves Valve plasty Multivalve prosthetics Probing of the heart cavities	60000 rub. 134400 rub. 25000 rub. 60000 rub. 50000 rub. 75000 rub. 17000 rub.
SPGMU them. I.P. Pavlova	St. Petersburg, st. L. Tolstoy, 6/8	CABG Angioplasty and coronary artery stenting Prosthetic valve replacement Multivalve prosthetic RFA	187000-220000 rub. 33000 rub. 198000-220000 rub. 330000 rub. 33000 rub.
MC "Shiba"	Derech Sheba 2, Tel Hashomer, Ramat Gan	CABG Prosthetic valves	30000 USD 29600 USD
MedMira	Huttropstr. 60, 45138 Essen, Germany 49 1521 761 00 12	Angioplasty CABG Prosthetic valves Cardiac examination Coronary angiography with stenting	EUR 8000 EUR 29000 EUR 31600 EUR 800-2500 EUR 3500
Greekomed	Central Russian office: Moscow, 109240, st. Upper Radishchevskaya, house 9 A	AKSH valve replacement	20910 euros 18000 euros

Do you still think that getting rid of HEART DISEASES is impossible!?

Do you often experience discomfort in the area of the heart (pain, tingling, squeezing)? You may suddenly feel weak and tired... high blood pressure... There is nothing to say about shortness of breath after the slightest physical exertion ... And you have been taking a bunch of medications for a long time, dieting and watching your weight ...

Bondarenko Tatiana

DlyaSerdca.ru project expert