Circular Sympathetic Pulmonary Artery Denervation in Cardiac Surgery Patients With Mitral Valve Defect, Atrial Fibrillation and High Pulmonary Hypertension

Objective Investigate the influence of the sympathetic denervation of the pulmonary trunk and the orifices of the pulmonary arteries on the degree of pulmonary hypertension (PH) and outcomes of the surgical treatment of atrial fibrillation (AF) in patients with mitral valve defects, complicated AF, and high PH.
Material and methods We analyzed the surgical treatment of 140 patients with mitral valve defect, concomitant AF, and high PH – pulmonary artery systolic pressure (PASP) gradient more than 40 mm Hg. The group of interest included 51 patients (46 patients with severe mitral stenosis and five patients with grade 4 mitral valve regurgitation). All patients underwent mitral valve correction (47 valve replacement surgeries and 4 valve-sparing interventions), biatrial Maze IV procedure, and additionally, denervation of the pulmonary trunk and the orifices of the pulmonary arteries. The control group included 89 patients diagnosed with mitral valve defect, AF, and PH with PASP > 40 mm Hg. However, unlike in patients of interest, denervation of the pulmonary arteries was not performed.
Results Circular radiofrequency denervation of the pulmonary trunk and the orifices of the pulmonary arteries using a clamp-destructor is an effective and safe method, significantly reduces secondary PH (p=0.018), promotes reverse remodeling of the heart chambers, left atrium in particular (p=0.01), and improves outcomes of the Maze IV procedure (p=0.022) by restoring sinus rhythm in patients with mitral valve defects, complicated AF, and high PH.
Conclusion This technique must be studied further involving a more significant number of patients, analyzing long-term results, and using this technique in patients with non-valvular causes of secondary PH.

1. Sulimov V.A., Lishuta A.S. Prospects of treatment of patients with atrial fibrillation. Rational Pharmacotherapy in Cardiology. 2011;7(3):323–33. [Russian]

2. Trofimov N.A., Medvedev A.P., Babokin V.Е., Demarin O.I., Zhamlihanov N.H., Dragunov A.G. et al. Improvement of the results of surgical correction of complex rhythm disturbances and prevention of their recurrence in cardiac surgery patients. Almanac of Clinical Medicine. 2015;38:74–80. [Russian]

3. Kim JS, Lee SA, Park JB, Chee HK, Chung JW. Preoperative risk factor analysis of postoperative stroke after Cox-maze procedure with mitral valve repair. BMC Cardiovascular Disorders. 2014;14(1):116. DOI: 10.1186/1471-2261-14-116

4. Bokeria L.A., Shengelia L.D. Treatment of atrial fibrillation. Part II. Current realities and future prospects. Annals of Arrhythmology. 2014;11(2):76–86. [Russian] DOI: 10.15275/annaritmol.2014.2.2

5. Babokin V, Trofimov N. Prevention of Atrial Fibrillation Recurrence after the Maze IV Procedure. The Annals of Thoracic Surgery. 2019;pii:S000349751931478X. [Epub ahead of print]. DOI: 10.1016/j.athoracsur.2019.08.087

6. Bogachev-Prokofiev A.V., Sapegin A.V., Pivkin A.N., Sharifulin R.M., Afanasyev A.V., Ovcharov M.A. et al. Evaluation of the new onset atrial fibrillation in patients with mitral valve lesion and left atrial enlargement. Annals of Arrhythmology. 2017;14(2):73–80. [Russian] DOI: 10.15275/annaritmol.2017.2.2

7. Babokin V.E., Shipulin V.M., Antonchenko I.V., Batalov R.E., Lukyanenok P.I., Aymanov R.V. et al. Radiofrequency labels in surgical treatment of left ventricle postinfarction aneurysms and ventricular tachycardias. Russian Journal of Thoracic and Cardiovascular Surgery. 2011;5:23–8. [Russian]

8. Mamchur S.Е., Homenko Е.A., Chistyukhin O.M., Kurilin M.Yu., Ivanov A.Yu. Efficiency and safety of radiofrequency ablation of slow pathways of atrioventricular conduction in irrigated mode using non-fluoroscopic navigation mapping. Journal of arrhythmology. 2012;69:28–31. [Russian]

9. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18(11):1609–78. DOI: 10.1093/europace/euw295

10. Vaskovskiy V.A., Serguladze S.Yu. Possibilities and prospects of surgical treatment of atrial fibrillation. Annals of Arrhythmology. 2016;13(2):64–72. [Russian] DOI: 10.15275/annaritmol.2016.2.1

11. Gillinov AM, Gelijns AC, Parides MK, DeRose JJ, Moskowitz AJ, Voisine P et al. Surgical Ablation of Atrial Fibrillation during Mitral-Valve Surgery. New England Journal of Medicine. 2015;372(15):1399–409. DOI: 10.1056/NEJMoa1500528

12. Belozerov Yu.M., Osmanov I.M., Sh.M. Magomedov. Mitral valve prolapse in children and adolescents. Vol. 1. -M.: Medpraktika-M;2009. 132 p. [Russian] ISBN 978-5-98803-200-7

13. Trofimov N.A., Medvedev A.P., Dragunov A.G., Babokin V.Е., Nikol’skiy A.V., Mizurova T.N. et al. Denervation of pulmonary trunk and pulmonary orifice in patients with surgically corrected mitral valve disease against high pulmonary hypertension. Almanac of Clinical Medicine. 2017;45(3):192–9. [Russian] DOI: 10.18786/2072-0505-2017-45-3-192-199

14. Trofimov N.A., Medvedev A.P., Babokin V.E., Zhamlikhanov N.Kh., Dragunov A.G., Gartfelder M.V. et al. Efficiency of surgical treatment of mitral insufficiency with atrial fibrillation of nonishemic etiology. Medical Almanac. 2014;5(35):165–9. [Russian]

15. Shipulin V.M., Kozlov B.N., Krivoschekov E.V., Kazakov V.A., Lezhnev A.A., Babokin V.E. et al. Morphofunctional characteristics of the myocardium of patients with post-infarction remodeling as a possible cause of adverse results of surgical treatment. Thoracic and cardiovascular surgery. 2009;5:37–41. [Russian]

16. Zheleznev S.I., Demidov D.P., Afanasiev A.V., Nazarov V.M., Demin I.I., Bogachev-Prokofiev A.V. et al. Radiofrequency denervation of the pulmonary artery in surgical correction of dysplastic mitral valve defects with high pulmonary hypertension. Russian Journal of Cardiology. 2016;21(11):70–2. [Russian] DOI: 10.15829/1560-4071-2016-11-70-72

17. Hurdman J, Condliffe R, Elliot CA, Davies C, Hill C, Wild JM et al. ASPIRE registry: Assessing the Spectrum of Pulmonary hypertension Identified at a REferral centre. European Respiratory Journal. 2012;39(4):945–55. DOI: 10.1183/09031936.00078411

18. Bogunetsky A.A., Usov V.Yu., Babokin V.E. Magnetic resonance imaging of the heart with contrast enhancement: prognostic role in determining arrhythmogenic focus. Bulletin of Siberian Medicine. 2014;13(1):98–102. [Russian]

19. Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A et al. Updated Clinical Classification of Pulmonary Hypertension. Journal of the American College of Cardiology. 2013;62(25):D34–41. DOI: 10.1016/j.jacc.2013.10.029

20. Trofimov N.A., Medvedev A.P., Babokin V.E., Dragunov A.G., Efimova I.P., Gartfelder M.V. et al. Effectiveness of PADN-procedure in patients with high pulmonary hypertension against background of mitral valve dysfunction complicated by atrial fibrillation and effect on preservation of sinus rhythm in postoperative period. Medical Alphabet. 2018;4(37):18–24. [Russian]

21. Rubin LJ. Primary Pulmonary Hypertension. New England Journal of Medicine. 1997;336(2):111–7. DOI: 10.1056/NEJM199701093360207

22. Galie N, Manes A, Negro L, Palazzini M, Bacchi-Reggiani ML, Branzi A. A meta-analysis of randomized controlled trials in pulmonary arterial hypertension. European Heart Journal. 2008;30(4):394–403. DOI: 10.1093/eurheartj/ehp022

23. Hoeper MM, Barberà JA, Channick RN, Hassoun PM, Lang IM, Manes A et al. Diagnosis, Assessment, and Treatment of Non-Pulmonary Arterial Hypertension Pulmonary Hypertension. Journal of the American College of Cardiology. 2009;54(1):S85–96. DOI: 10.1016/j.jacc.2009.04.008

24. Osorio J, Russek M. Reflex Changes on the Pulmonary and Systemic Pressures Elicited by Stimulation of Baroreceptors in the Pulmonary Artery. Circulation Research. 1962;10(4):664–7. DOI: 10.1161/01.RES.10.4.664

25. Baylen BG, Emmanouilides GC, Juratsch CE, Yoshida Y, French WJ, Criley JM. Main pulmonary artery distention: A potential mechanism for acute pulmonary hypertension in the human newborn infant. The Journal of Pediatrics. 1980;96(3):540–4. DOI: 10.1016/S0022-3476(80)80863-8

26. Juratsch CE, Jengo JA, Castagna J, Laks MM. Experimental Pulmonary Hypertension Produced by Surgical and Chemical Denervation of the Pulmonary Vasculature. Chest. 1980;77(4):525–30. DOI: 10.1378/chest.77.4.525

27. Guazzi M, Vitelli A, Labate V, Arena R. Treatment for Pulmonary Hypertension of Left Heart Disease. Current Treatment Options in Cardiovascular Medicine. 2012;14(4):319–27. DOI: 10.1007/s11936-012-0185-6

28. Chen S-L, Zhang F-F, Xu J, Xie D-J, Zhou L, Nguyen T et al. Pulmonary Artery Denervation to Treat Pulmonary Arterial Hypertension. Journal of the American College of Cardiology. 2013;62(12):1092– 100. DOI: 10.1016/j.jacc.2013.05.075

29. Briongos Figuero S, Moya Mur JL, García-Lledó A, Centella T, Salido L, Aceña Navarro Á et al. Predictors of persistent pulmonary hypertension after mitral valve replacement. Heart and Vessels. 2016;31(7):1091–9. DOI: 10.1007/s00380-015-0700-2

30. Bogachev-Prokofev A.V., Zheleznev S.I., Afanas’ev A.V., Fomenko M.S., Demidov D.P., Sharifulin R.M. et al. Denervation of pulmonary artery during mitral valve surgery in patients with high pulmonary hypertension. Circulatory pathology and cardiac surgery. 2015;19(4):19–25. [Russian]

31. Trofimov N.A., Medvedev A.P., Dragunov A.G., Nikol’skiy A.V., Mizurova T.N., Gartfel’der M.V. et al. Method of surgical treatment of secondary pulmonary hypertension in the case of patients having surgical correction of mitral valve pathology. Medical Almanac. 2017;3(48):33–7. [Russian]