RU2361529C2 - Method of surgical treatment of heart diseases of ischemic genesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardiosurgery. Patient is subjected to preliminary multiple laser myocardium revascularisation with further introduction into myocardium of autologic cell culture. As cell culture used is suspension of cardiomyoblasts in isotonic physiological solution, containing 2×10⁸ cells, in presence of heparin, multiplied during 35-40 days "in vitro" from mesenchymal autologic stem cells of bone marrow, extracted from the patient said time before carrying out treatment. Suspension is introduced by means of multiple injections around zone of ischemic but viable myocardium, avoiding laser channels, total amount of introduced suspension constituting 8-10 ml. Method ensures high efficiency of treatment of heart diseases of ischemic genesis.

EFFECT: ensuring high efficiency of treatment of heart diseases of ischemic genesis.

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Description

The invention relates to medicine, in particular to cardiac surgery, and can be widely used in the surgical treatment of heart diseases of ischemic origin, in particular post-infarction cardiosclerosis, ischemic cardiomyopathy, chronic heart failure, etc.

A known method of surgical treatment of coronary heart disease, which consists in the formation of transmural channels in the myocardium of the left ventricle using laser radiation with a diameter of 0.5-1.0 mm The channels are formed using CO ₂ laser radiation with a wavelength of 10.6 μm, an output power of 250-1000 W at an exposure of 0.03-0.1 s (see patent RU No. 2200042, IPC-7: АВВ 17/00, publ. 03/10/2003).

According to the authors, the known method allows to increase the functioning of the newly formed vessels.

Despite the fact that laser revascularization surgery allows the formation of a new vascular bed in the ischemic myocardium that compensates for circulatory failure, this is not enough to restore the contractile function of the heart, since the structure of the damaged myocardium is not restored.

A known method of treating coronary heart disease by using cell transplantation is the introduction of autologous atrial cardiomyocytes into the necrosis zone (see application RU No. 20011131388, IPC-7: A61K 35/34, publ. 10.08.2003).

According to the authors of this method, this technique allows you to restore the structure and function of the disabled myocardium.

However, it is the use of autologous atrial cardiomyocytes that are not able to divide that makes the introduced structure less capable of engraftment in cardiac tissue.

And their introduction into the necrosis zone further reduces the ability to engraft.

However, the vascular bed is not restored sufficiently.

There is a known method of stem cell implantation in the myocardium in the experiment, chosen as the closest analogue, which consists in preliminary creating blind channels in the myocardial areas with a post-infarction scar using a laser beam and introducing stem cells into this channel with subsequent stitching of the hole with a previously applied purse string suture (see patent RU No. 2237440, IPC-7: АВВ 17/00, publ. 10.10.2004).

According to the authors, the known method allows to increase the accuracy of localization of implanted autologous stem cells and to achieve their minimum trauma.

In the known method, stem cells are isolated in a separate biological protection box from the bone marrow of the ribs of an experimental animal with experimental myocardial ischemia removed from the animal as a result of its subperiosteal resection.

As you can see, the known method is quite traumatic and not acceptable to humans.

In addition, the introduction of a stem cell suspension directly into the channels made by the laser cannot ensure the proper treatment of coronary heart disease, since the channel made using laser radiation with the parameters specified in the method is surrounded by a tissue necrosis zone, which reduces the survival of stem cells introduced into it, since they are deprived of a normal microenvironment and nutrient medium.

Moreover, the use of precisely stem cells for introducing into the ischemic myocardial region cannot guarantee the development of stem cells precisely in newly formed cardiomyocytes, as the authors of the known method indicate, since the ability of stem cells to differentiate not only to cardiomyocytes, but also their differentiation to tumor tissues, is known including at a distance from the place of their introduction, as well as the development of coarse scar tissue at the injection site as a result of their differentiation to fibroblasts. In other words, when using stem cells for cell transplantation, there is no certainty in obtaining the desired result.

In addition, the introduction of stem cells into the myocardial zone with a post-infarction scar does not provide sufficient treatment efficiency, since this zone is a connective tissue that cannot provide the necessary microenvironment conditions for differentiating stem cell cultures to cardiomyocytes and incorporating them into a single structure of a contracting myocardium.

Thus, the technical result, the solution of which the claimed invention is directed, is to increase the effectiveness of the treatment of heart diseases of ischemic origin.

The specified technical result is achieved by the fact that in the known method of surgical treatment of heart diseases of ischemic origin, including preliminary multiple laser myocardial revascularization followed by the introduction of an autologous cell culture into the myocardium, according to the invention, a suspension of cardiomyoblasts in an isotonic saline solution containing 2 × 10 is used as a cell culture ⁸ cells in the presence of heparin, propagated for 35-40 days “in vitro” from mesenchymal autologous stem bone marrow cells extracted from the patient at the same time before treatment, the suspension is administered by multiple chipping of the ischemic but viable myocardium zone, bypassing the laser channels, while the total amount of the suspension is 8-10 ml.

The use of a suspension of cardiomyoblasts as a cell culture contributes to a significant increase in the effectiveness of the treatment of ischemic heart diseases.

This is due to the fact that it is the cardiomyoblasts introduced by multiple chipping into the zone of the ischemic, but viable myocardium, bypassing the laser channels, that guarantee their differentiation into cardiomyocytes, since it is the cardiomyoblasts introduced into the claimed zone that fall into the corresponding microenvironment that it has are able to transform only into cardiomyocytes. Due to this, their own weakened or defective cardiomyocytes of viable ischemic zones or zones adjacent to necrosis are supplemented by full-fledged cardiomyocytes differentiated from cardiomyoblasts and in sufficient quantities. Multiple chipping of the claimed zone contributes to the guaranteed delivery of the drug throughout the volume of the ischemic, but viable myocardial zone, due to which multiple foci with the restored structure and function of the myocardium are ensured.

The authors experimentally established that it is the use of a suspension in isotonic saline solution containing 2 × 10 ⁸ cells in the presence of heparin that helps to achieve the best effect in the treatment of ischemic heart diseases.

The cultivation of in vitro cardiomyoblasts cells from the patient’s bone marrow mesenchymal stem cells, obtained from the patient’s autologous bone marrow cells 35–40 days before the suspension is administered, also improves the treatment efficiency.

The authors experimentally established that it is from the culture of mesenchymal stem cells that stem cells can be transferred to differentiation in the direction of cardiomyocytes, preventing the differentiation of most populations beyond the stage of cardiomyoblasts, in which the cells retain the ability to further proliferate and differentiate to cardiomyocytes after transplantation back into the human body. The authors experimentally established that the number of cells needed for transplantation of the order of 2 × 10 can be increased precisely for the specified period of time.

It has been experimentally established that the best result of the proposed method of treatment is achieved with a total amount of the administered suspension equal to 8-10 ml.

The inventive method is as follows.

In a patient with a confirmed diagnosis of heart disease of ischemic origin, 35-40 days before the expected day of surgery according to the claimed method, bone marrow is collected from punctured spongy bones.

From the obtained bone marrow punctate, a culture of mesenchymal stem cells is isolated and, according to the method developed by the specialists of the Medical Radiological Research Center of the Russian Academy of Medical Sciences, Obninsk, approximately 30% of stem-type cells are transferred to differentiation in the direction of cardiomyocytes, moreover, when the cell culture is increased for 35-40 days do not allow differentiation of most populations beyond the stage of cardiomyoblasts, in which cells retain the ability to further proliferate and differentiate after transplant tation back into the human body.

Upon admission to a hospital with the help of coronarography, the localization and distribution of the atherosclerotic process is established.

The operation is performed on an open heart under endotracheal anesthesia.

Perform left thoracotomy. Dissect the pericardium anterior to the phrenic nerve. The end of the monofilament fiber is mounted on the epicardium, after which a laser effect on the myocardium is produced. As a source of laser exposure, it is possible to use various types of laser radiation sources.

As a result of this effect, channels with a diameter of 0.5-1.0 mm are made on an ischemic, but viable area of the heart muscle. The number of channels depends on the area of the ischemic myocardium. The distance between the performed channels is 1.5-2.0 cm. The channels can be both through - to the cavity of the ventricles of the heart, and not through - to the endocardium. The formed channels are filled with blood or exudate. In the zone of localization of these channels, a new vascular bed is formed, and collateral blood supply is stimulated and vascular anastomoses are formed.

At the final stage of the operation, after performing laser channels, the patient undergoes multiple chipping of the ischemic, but viable myocardium zone with a suspension of autocardiomyoblasts in isotonic saline solution containing 2 × 10 ⁸ cells in the presence of 10 units / ml heparin. The total volume of injected suspension with multiple chipping is 8-10 ml. For injection use an insulin syringe. For one injection, approximately 1 / 5-1 / 4 of the contents of one syringe containing 1 ml of suspension is injected. The introduction is carried out in areas located at a distance of 0.5-1.0 cm from the completed channels

Window on the pericardium. Drainage on the posterior surface of the left pleural cavity. Palespasny seams on the intercostal space. The wound is sutured in layers. An aseptic dressing is applied.

The inventive method is illustrated by examples of specific performance.

Example No. 1. Patient G., 53 g. Diagnosis: CHD.

Postinfarction cardiosclerosis (MI 2001). Angina of exertion and rest IV FC CCS. Aneurysm of the left ventricle.

Echocardiography results: CSOL 128 ml / m ² BWW LV 190 ml / m ² FV LV 34%

Hypokinesis of the posterior lower LV segment with a transition to akinesis.

The next day, the patient was taken 1.0 ml of bone marrow punctate from the ilium.

Punctate was sent to the laboratory for extraction of mesenchial stem cells from it and the subsequent preparation of a suspension of cardiomyoblasts.

35-40 days after taking the punctate and receiving from the laboratory a finished suspension of cardiomyoblasts, the patient underwent surgery according to the claimed method.

With the help of coronarography, the localization and distribution of the atherosclerotic process was established: stenotic atherosclerosis of the coronary arteries (LCA; UCI; DV; OB; PCA) - 65-60%.

The operation was performed on an open heart.

Under intubation anesthesia, the patient underwent left-side thoracotomy. Dissected pericardium anterior to the phrenic nerve. The end of the monofilament fiber is mounted on the epicardium, after which a laser effect is made on the ischemic, but viable myocardium, as a result of which 53 laser channels are made in it, most of which (37) are through, made to the cavity of the left ventricle. The rest (16) are not end-to-end, performed to the endocardium. Through channels are filled with blood, but not through - with exudate. The diameter of the channels is 0.5 mm. The distance between the channels is 1.5-2.0 cm.

Modes of laser radiation when performing channels: YAG - Ne laser, wavelength 1.064 μm, radiation power 20 W, exposure 0.5 s.

After performing laser channels at the final stage of the operation, the patient underwent multiple chipping of the ischemic but viable myocardium zone with a suspension of autocardiomyoblasts in isotonic saline solution containing 2 × 10 ⁸ cells in the presence of 10 units / ml heparin. The volume of the introduced suspension material was 8 ml. An insulin syringe was used for injection. The introduction was carried out in areas located at a distance of 0.5-1.0 cm from the completed channels.

Window on the pericardium. Drainage on the posterior surface of the left pleural cavity. Palespasny seams on the intercostal space. The wound is sutured in layers. Aseptic dressing.

2 months after the operation, subjectively: improvement, transition of angina pectoris to a more favorable class (from IV to III according to CCS), increased exercise tolerance, and improved quality of life.

ECHOKG: CSR LV 102 ml / m ² BWW LV 172 ml / m ² FV LV 48%

Example No. 2. Patient S., 34 g. Diagnosis of ischemic heart disease.

Postinfarction cardiosclerosis (MI 2002). Angina pectoris IV FC according to CCS. Chronic heart failure 2 FC 2A stage.

EHLKG indicators: CSR LV 130 ml / m ² BWW LV 186 ml / m ² FV LV 32%

According to coronary angiography: diffuse stenosing atherosclerosis (65-70%) of the coronary arteries (LCA, PCJ, DV, OB).

On the second day after admission, the patient collected bone marrow punctate from the sternum. The amount of collected punctate 1.0 ml. The collected punctate was sent to the laboratory for the preparation of a suspension of cardiomilblasts.

37 days after the collection of punctate and receipt from the laboratory of the finished suspension of cardiomyoblasts, the patient underwent surgery by the claimed method. The operation was performed by analogy with example No. 1, with the exception of

- a diode laser with a wavelength of 0.97 μm, a radiation power of 10 W, an exposure of 1 s was used;

- hole diameter 1.0 mm;

- the distance between the channels is 1.5-2.0 cm;

- the number of completed channels 60;

- the amount of the drug administered is 10 ml;

- the drug is introduced into the area adjacent to necrosis (scar);

- the number of through channels 39, not through - 21.

3 months after the operation, subjectively: improvement in general condition, transition of angina pectoris from IV to FC II, symptoms of heart failure disappeared.

Echocardiography after surgery: CSR LV 110 ml / m ² BWW LV 170 ml / m ² FV LV 42%

Claims (1)

A method for surgical treatment of heart diseases of ischemic origin, including preliminary multiple laser myocardial revascularization followed by the introduction of an autologous cell culture into the myocardium, characterized in that the cell culture is a suspension of cardiomyoblasts in isotonic saline containing 2 · 10 ⁸ cells in the presence of heparin multiplied within 35-40 days "in vitro" from autologous bone marrow mesenchymal stem cells extracted from a patient at the same time before discharge During treatment, the introduction of the suspension is carried out by multiple chipping of the area of the ischemic, but viable myocardium, bypassing the laser channels, while the total amount of the suspension is 8-10 ml.