The results of preserving the mitral subvalvular apparatus in mechanical mitral valve replacement at Hue Center Hospital

Nội dung text: The results of preserving the mitral subvalvular apparatus in mechanical mitral valve replacement at Hue Center Hospital

1. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 THE RESULTS OF PRESERVING THE MITRAL SUBVALVULAR APPARATUS IN MECHANICAL MITRAL VALVE REPLACEMENT AT HUE CENTER HOSPITAL Tran Thanh Binh1, Bui Duc Phu2, Dang Ngoc Hung1 SUMMARY Objectives: To evaluate the results of preserving the mitral subvalvular apparatus in mechanical mitral valve replacement (MVR) at Hue Center Hospital. Subjects and methods: The prospective study of patients with mitral valve disease (MVD) who underwent mechanical MVR with preservation of the mitral subvalvular apparatus, with or without tricuspid at Hue Center Hospital between March 2015 and September 2016. Results: Of 87 patients, the mean age was 46.9 ± 9.4 years old, and the majority was female. 43.7% of patients were NYHA II, 52.9% were NYHA III. Intraoperatively, pericardial adhesions accounted for 5.7%. Regarding the technique of preserving the mitral subvalvular apparatus: 36.8% papillary muscles resection; 88.5% U pledgeted suture; 3.4% posterior leaflet splitting. The average CPB time was 82.3 ± 20.8 minutes, aortic cross clamp time was 56.3 ± 15.9 minutes. Complications: 2 cases of in- hospital death; 2 cases of wound infection, 1 case of reoperation due to bleeding. Conclusions: Mechanical MVR surgery with preservation of the mitral subvalvular apparatus in patients with MVD at Hue Center Hospital was safe with good outcomes and a low rate of complications. * Keywords: Mitral valve; Mitral valve replacement; Preservation of the subvalvular apparatus. INTRODUCTION from 37% to 13% due to the technique of Mitral valve disease (MVD) is a common preserving both papillary muscles [5]. On heart valve disease. MVR surgery has the other hand, preserving the mitral become routine at cardiovascular centers subvalvular apparatus also reduces the in the whole country. Particularly, the rate of left ventricular rupture and improves function of the heart depends heavily on the left ventricular systolic function after the preservation of the mitral subvalvular surgery. Therefore, we carried out this apparatus after MVR surgery [4]. The study: To evaluate the results of mechanical study of Lillehei et al. (1964) showed that MVR with preservation of the subvalvular the mortality after classical MVR decreased apparatus in the treatment of MVD. 1Military Hospital 103, Vietnam Military Medical University 2Hue Centre Hospital Corresponding author: Tran Thanh Binh (thanhbinh7713@gmail.com) Date received: 09/7/2021 Date accepted: 12/7/2021 227
2. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 SUBJECTS AND METHODS - Patients underwent MVR combined 1. Subjects with other interventions (except for tricuspid valve repair); 87 patients with MVD underwent - Insufficient medical records. mechanical MVR with preserving the mitral subvalvular apparatus at Cardiovascular 2. Methods Center, Hue Central Hospital, from 3/2015 This is a prospective, non-controlled to 9/2016. study on patients with MVD associated * Selection criteria: with or without tricuspid regurgitation. The diagnosis of MVD on echography were - Patients with MVD were candidates for surgery; based on the 2017 European Society of Cardiology criteria [6]. Indications for mitral - The patient underwent mechanical valve surgery was based on the 2014 MVR surgery with preserving the subvalvular ACC/AHA guidelines [7]. The characteristics apparatus; included: Age, gender, NYHA class of heart - The patient agreed to participate in failure, electrocardiogram, echocardiogram, the study; lesions of the mitral valve, mechanical - Sufficient medical records. valve. Postoperative treatment at ICU, * Exclusion criteria: postoperative therapy and complications - Patients underwent MVR combined were monitored and evaluated. with aortic valve replacement and/or * Data processing: Using SPSS 20.0 CABG; software. RESULTS 1. Preoperative characteristics Of 87 selected patients in the study, their mean age was 46.9 ± 9.4 years old, female accounted for 72%. Table 1: General preoperative characteristics. Factors Figures Female, n (%) 63 (72.4) History of mitral valve interventions PMBC, n (%) 5 (5.7) Mitral valve repair, n (%) 2 (2.3) BSA (m2), ( X ± SD) 1.5 ± 0.1 NYHA I, n (%) 2 (2.3) II, n (%) 38 (43.7) III, n (%) 46 (52.9) IV, n (%) 1 (1.1) 228
3. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 Factors Figures ECG Sinus rhythm, n (%) 49 (56.3) AF, n (%) 38 (43.7) CT ratio < 50%, n (%) 13 (14.9) 50 - 60%, n (%) 44 (50.6) > 60%, n (%) 30 (34.5) Preoperative echo LA thrombus, n (%) 10 (11.5) MR ≥ ¾, n (%) 6 (6.8) LA diameter (mm), ( X ± SD) 50.9 ± 8.0 LVEDd (mm), ( X ± SD) 47.8 ± 7.8 LVESd (mm), ( X ± SD) 34.7 ± 7.4 LVEF (%),( ± SD) X 52.8 ± 8.3 ± PAPs (mmHg), ( X SD) 52.0 ± 16.7 TAPSE (mm), ( X ± SD) 20.0 ± 4.5 * BMI: Body mass index; BSA: Body surface area; NYHA: New York Heart Association 2. Intraoperative characteristics Of 87 patients who underwent mechanical MV replacement, 14 patients (16.1%) had simple MS, 11 patients (12.6%) had simple MR, and 62 patients (71.3%) had MS combined with MR. Table 2: Intraoperative characteristics. Factors Figures Pericardial adhesion, n (%) 5 (5.7) Sizes of prosthetic valve 25 mm, n (%) 17 (19.5) 27 mm, n (%) 44 (50.6) 29 mm, n (%) 24 (27.6) 31 mm, n (%) 2 (2.3) Techniques of posterior leaflet preservation Decalcification, n (%) 32 (36.8) Posterior leaflet splitting, n (%) 3 (3.4) U - pledgeted suture , n (%) 77 (88.5) Other, n (%) 9 (10.3) 229
4. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 Factors Figures Techniques of tricuspid valve repair, n (%) 34 (39.1) De Vega, n (%) 7 (20.6) Pericardial band, n (%) 15 (44.1) Dacron band, n (%) 12 (35.3) CBP time (min) X± SD (min - max) 82.3 ± 20.8 (45 - 141) Aortic cross clamp time (min) X ± SD (min - max) 56.3 ± 15.9 (28 - 108) 3. Postoperative characteristics Table 3: Postoperative characteristics. Factors Figures ± Ventilation (hour), X ± SD (min - max) 23.3 51.1 (3 - 432) ± Time at ICU (day), X ± SD (min - max) 5.0 2.7 (1 - 18) Early complications Bleeding, n (%) 1 (1.1) Wound infection, n (%) 2 (2.3) Early death, n (%) 2 (2.3) Table 4: Postoperative monitoring. Preoperative Third month Sixth month Twelfth month Factors p (n = 87) (n = 85) (n = 85) (n = 85) NYHA I 2 14 28 29 P21 < 0.05 II 38 69 57 56 P31 < 0.05 III 46 1 0 0 P41 < 0.05 IV 1 1 0 0 ECG Sinus rhythm 49 68 63 57 AF 38 17 22 28 Correct prosthetic MV, n (%) 85 (100) 85 (100) 85 (100) P21 < 0.05 LA (mm) 50.9 ± 8.0 42.4 ± 5.2 40.9 ± 4.5 40.4 ± 3.9 31 P < 0.05 ± (40.0 - 78.0) (32.0 - 54.0) (33.0 - 52.0) (32.0 - 51.0) 41 X SD (min - max) P < 0.05 230
5. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 Preoperative Third month Sixth month Twelfth month Factors p (n = 87) (n = 85) (n = 85) (n = 85) P21 < 0.05 LVEDd (mm) 47.8 ± 7.8 45.1 ± 5.4 44.7 ± 4.9 44.5 ± 4.6 31 P < 0.05 ± SD (min - max) (34.0 - 68.0) (36.0 - 57.0) (36.0 - 56.0) (37.0 - 64.0) 41 X P < 0.05 P21 < 0.05 LVESd (mm) 34.7 ± 7.4 31.1 ± 2.9 30.9 ± 3.3 30.9 ± 2.8 31 P < 0.05 ± (23.0 - 54.0) (24.0 - 42.0) (23.0 - 47.0) (24.0 - 44.0) 41 X SD (min - max) P < 0.05 21 LVEF (%) 52.8 ± 8.3 56.2 ± 6.4 57.8 ± 6.7 58.4 ± 7.5 P < 0.05 31 P < 0.05 ± 41 X SD (min - max) (32.0 - 67.0) (40.0 - 67.0) (44.0 - 70.0) (39.0 - 70.0) P < 0.05 P21 < 0.05 PAPs (mmHg) 52.0 ± 16.7 26.6 ± 2.7 26.4 ± 2.8 26.6 ± 2.4 31 P < 0.05 ± SD (min - max) (25.0 - 120.0) (25.0 - 35.0) (25.0 - 35.0) (25.0 - 35.0) 41 X P < 0.05 PG max (mmHg) 22.5 ± 8.7 9.5 ± 3.2 10.0 ± 3.1 10.3 ± 2.9 P21 < 0.05 X ± SD (min - max) (4.0 - 41.0) (4.0 - 20.0) (8.0 - 12.0) (8.0 - 12.0) P31 < 0.05 PG mean (mmHg) 11.9 ± 5.3 4.0 ± 1.3 4.6 ± 1.6 4.7 ± 1.4 41 P < 0.05 X ± SD (min - max) (2.0 - 22.0) (2.0 - 8.0) (4.0 - 5.7) (4.0 - 5.7) Note: P21: 3 months after surgery compared to before surgery. P31: 6 months after surgery compared to before surgery. P41: 12 months after surgery compared to before surgery. DISCUSSION episode of rheumatic fever [1]. If patients 1. Preoperative characteristics are not treated to prevent Streptococci reinfection after the first episode, cardiac Of 87 patients who underwent mechanical tissue will be damaged continuously due MVR surgery with preserving the mitral to recurrent rheumatic fever. That is why subvalvular apparatus, their mean age post rheumatic heart disease accounts for was 46.9 ± 9.4 years old, female a high rate at working ages. The severity accounted for 72%. This is the age of the of heart failure showed 43.7% NYHA II, major labors in the community. The 52.9% NYHA III, only 1.1% at the stage of results were consistent with other studies NYHA IV and 2.3% at NYHA I. According in our country or developing countries. In to the European authors, the survival the study of Dang Hanh Son, the average rates were 62% after 5 years and 38% surgical age was 43.58 ± 10.01 years old after 10 years at the stage of NYHA III, [1]. Rheumatic MVD is acquired during respectively [8]. In our study, the CT ratio the period of adolescence, commonly > 50% accounted for 85.1%, the CT ratio from 5 to 15 years of age. The manifestations 50 - 60% accounted for 50.6% and > 60% present at least 2 years after the first accounted for 34.5%. These results were 231
6. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 also consistent with the results of Dang annular was thinned to widen the valve Hanh Son with 90% of patients with the hole; the calcified lumps in the annular CT ratio > 50% [1]. Atrial fibrillation is the were also removed as much as possible. most common arrhythmia in MVD. In case of severe calcification at the Increasing left atrial pressure, especially in MS, caused remodeling in the atrial posterior leaflet, cutting calcifications can substrate and early onset of atrial be required. After that, the posterior fibrillation [9, 10]. We recorded 43.7% of leaflet was sutured and folded with patients with MVD with atrial fibrillation U-shaped stitches. Le Quang Thu and before surgery. This result is equivalent to Nguyen Hong Hạnh also performed these the study of domestic and foreign authors procedures in their research [2]. The [1, 8, 9]. mean aortic clamp time was 56.3 ± 15.9 2. Intraoperative characteristics minutes and the average CEC time was Of 87 patients (100%) who underwent 82.3 ± 20.8 minutes. This was equivalent mechanical MV replacement surgery, 14 to the study of Dang Hanh Son [1]. patients (16.1%) had simple MS, 11 3. Postoperative outcomes patients (12.6%) had simple MR, and the Our study recorded 5 patients with other 62 patients (71.3%) had MS complications (5.7%), including 2 cases of combined with MR. Intraoperatively, the early deaths (within 30 days after surgery); mechanical valves in size of 27 mm and 2 cases of wound infection and 1 case of 29 mm were most commonly used: 27 mm-size valves accounted for 50.6%, 29 reoperation due to bleeding. In the study mm-size valves accounted for 27.6%. Our of Doan Quoc Hung, of 45 samples of results were similar to the results of culture, 28.5% was positive, Gram (-) was Nguyen Hong Hanh [2]. Some authors major, especially only 70.8% of those suggested that preserving the apparatus were consistent with the antibiograme. may obstruct of the left ventricular outflow 9.8% of patients with acute heart failure tract [12]. In addition, the large-size valve had abnormal ECG, proBNP (> 125 pg/mL) can cause severe pressure on the heart or BNP (≥ 35 pg/mL) and echocardiography tissue [11]. However, a prosthetic valve is [3]. 2 cases died due to prolonged aortic appropriate when the effective orifice area clamp and postoperatively worsened heart (EOA) is suitable for patients with normal failure. The patients relied on mechanical transvalvular pressure gradient and mild ventilation. The family asked to go home obstruction of blood flow. In terms of on the 12th and 18th days after surgery. preservation techniques, removing the With MVR surgery, ventricular rupture is anterior leaflet with the anterior leaflet one of the fatal complications [15]. We did ligaments and preserving the posterior not record any case of ventricular rupture leaflet with posterior marginal ligaments after surgery. In the studies of other were applied in all patients. The thickened authors, preserving the subvalvular apparatus 232
7. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 minimized the rate of postoperative gradient was 10.65 ± 3.40 mmHg at the ventricular rupture [12]. Long-term follow-up re-examination time and there was no showed significant sinus rhythm recovery difference compared to the perioperative and heart failure improvement (mainly measurements (10.43 ± 3.38 mmHg) [3]. NYHA II, III preoperatively and mainly CONCLUSION NYHA I, II postoperatively) (p < 0.05%) at the time of 3 months, 6 months and The complication rate was significantly 12 months follow-up compared to low of 87 patients with MVD who underwent preoperative period. Recovering of sinus mechanical valve replacement surgery rhythm depends on several factors, such with preserving the mitral subvalvular as the duration of atrial fibrillation, the apparatus at Hue Center Hospital. These preoperative left atrial diameter, the outcomes showed that this procedure was postoperative antiarrhythmic therapy, etc. safe, effective, and helped to improve left [9]. MVR with preserving the apparatus ventricular function postoperatively. improves myocardial contractility, reduces REFERENCES abnormal regional movement, and improves left ventricular systolic function postoperatively. 1. Đặng Hanh Sơn. Nghiên cứu đánh giá Our results are equivalent to those of kết quả phẫu thuật thay van hai lá bằng van other domestic and foreign authors. cơ học Sorin tại Bệnh viện tim Hà Nội. Luận án Tiến sĩ Y học, Học viện Quân y 2009. At the end of follow-up period, all 2. Nguyễn Hồng Hạnh. Nghiên cứu biến survivals had correct prosthetic valves. đổi lâm sàng, huyết động trước và sau phẫu The diameters of the left heart chambers thuật thay van hai lá bằng van cơ học loại and the pulmonary artery pressure Saint Jude Master. Luận án Tiến sĩ Y h ọc, decreased significantly (p < 0.05) Viện nghiên cứu Y - D ược Lâm sàng 108. postoperatively. These results were 2012. completely consistent with other studies 3. Đoàn Quốc Hưng và CS. Đặc điểm lâm of domestic and foreign authors. The sàng, cận lâm sàng và kết quả phẫu thuật maximal transvalvular pressure gradients thay van hai lá bằng van cơ học tại Bệnh viện Hữu nghị Việt Đức. Tạp chí Nghiên cứu Y học were varied from 9.0 to 9.6 mmHg, the 2012; 3:58-66. mean ones ranged from 4.0 to 4.3 mmHg; 4. Vincens, J.J., et al. Long-term outcome There were no cases of pressure of cardiac surgery in patients with mitral gradients more than 10 mmHg. These stenosis and severe pulmonary hypertension. results showed that the prosthetic mitral Circulation, 1995; 92(9 Suppl):II137-42. valves helped to stabilize the structure of 5. Lillehei C.W., M.J. Levy, R.C. Bonnabeau. the heart and left ventricular diastolic MVR with preservation of papilary muscles function. In the study of Doan Quoc Hung, and chordae tendineae. J Thorac Cardiovasc the maximal transvalvular pressure Surg 1964; 47:532-543. 233
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