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I. SURGERY
COMPARATIVE ASSESSMENT OF THE TIME OF PATIENTS' STAY IN THE INTENSIVE CARE UNIT AFTER MITRAL VALVE REPLACEMENT WITH PRESERVATION OF THE POSTERIOR LEAFLET AND COMPLETE REMOVAL OF SUBVALVULAR STRUCTURES
Zhumabaev S.A., Raiapov N.O., Asanaliev M.I., Bkhad Zh.A., Urmanbetov K.S., Tursunbekova G.T.
Research Institute of Cardiovascular Surgery and Organ Transplantation of the Ministry of Health of the Kyrgyz Republic, Bishkek, Kyrgyz Republic
Abstract
The aim is to evaluate the effectiveness of time spent in the intensive care unit and the use of inotropic drugs after mitral valve replacement surgery with preservation of the posterior leaflet with comparison of complete removal of subvalvular structures.
Material and methods. The study included 60 patients, including 28 patients after surgery with preservation of the posterior mitral valve leaflet and 32 patients after surgery with complete removal of subvalvular structures. The average age of the patients was 45.9±12.0 years. Inclusion criteria were the time spent in the intensive care unit after surgery, the use of inotropic drugs, and the duration of use of the ventilator.
Results. In comparison, the control group in the intensive care unit received more inotropic drugs. In the main group of renal doses - 21 (75%) patients received dopamine - 2.38±0.21 micrograms per kilogram minute, adrenaline - 0.021±0.003 micrograms per kilogram minute. Cardiotonics were not received at therapeutic doses. Above therapeutic doses - 2 (7.14%) patients received (dopamine) - 8±0.01 micrograms per kilogram minute. In the second group of renal doses - 23 (71.87%) patients received dopamine 2.24±0.54 micrograms per kilogram minute, adrenaline - 0.021±0.001 micrograms per kilogram minute. Therapeutic doses of 5 (15.6%) patients dopamine - 5.2±0.4 micrograms per kilogram minute, adrenaline - 0.04±0.001 micrograms per kilogram minute. Above therapeutic doses of 2 (6.25%) patients, dopamine is 8.2±0.02 micrograms per kilogram minute, adrenaline is 0.07±0.003 micrograms per kilogram minute.
Арткы жарманы сактай отырып, митральды какпакшаны протездеуден жэне клапан асты курылымдарын толык алып тастаганнан кейш наукастардыц каркынды терапия бeлiмшесiнде болу уакытын салыстырмалы багалау
https://doi.org/10.35805/BSK2021IV005
Zhumabaev S.A.
orcid.org/ 0000-0002-0673-1045
Raiapov N.O.
orcid.org/ 0000-0003-0818-3684 Asanaliev M.I.
orcid.org/ 0000-0001-9726-1888 Bkhad Zh.A.
orcid.org/ 0000-0003-1724-2092
Urmanbetov K.S.
orcid.org/0000-0002-8785-1398
Tursunbekova G.T.
orcid.org/ 0000-0001-7427-3122
Corresponding author: Zhumabaev S.A. - Junior researcher, Research Institute of Cardiovascular Surgery and Organ Transplantation, Bishkek, Kyrgyz Republic.
E-mail: Sultanmurat-89@mail.ru
Conflict of interest
The authors declare that they have no conflicts of interest
Keywords
mitral valve replacement, subvalvular structure, posterior cusp, cardiotonic drugs
Жумабаев С.А., Раяпов Н.О., Асаналиев М.И., Бхад Ж.А., Урманбетов К.С., Турсынбекова Г.Т.
Кы^ыз Республикасы Денсаулык, сак,тау министрлИнщ ЖYрек-к,ан тамырлары хирургиясы жэне агеаларды трансплантациялау ?ылыми-зертгеу институты, Бшкек к., Кь^ыз Республикасы
Ацдатпа
Жумыстьщ мацсаты - митральды какпакшаны ауыстыру отасынан кейiн арткы жарманы сактай отырып, клапан асты курылымдарыныщ толык жойылуын салыстыра отырып, каркынды терапия бвлiмiнде еткЫлген уакыттыц жэне инотропты препараттарды колданудыщ тиiмдiлiгiн баталау.
Материал жэне адстер. Зерттеуге 60 наукас катысты, олардыщ 28-i митральдi какпакшаныщ арткыжармасын сактай отырып жасалеан отадан кейiнгi наукастар жэне 32-а клапан асты курылымдарын толь^ымен алып таста€ан отадан кейнп наукастар. Наукастардыщ орташа жасы 45,9± 12,0 жасты курады. Косу критерийлерi отадан кейн жан сактау бвлiмiнде болтан уакыт, инотропты препараттарды колдану жэне вкпенщ жасанды вентиляция курыл€ысын пайдалану узактыты болды.
Нэтижелер. Салыстырмалы турде, жан сактау бвлiмiндегi бакылау тобы инотропты препараттарды квб'рек крбылдатан. Непзп топ емдк дозаларда кардиотониктердi кабылдамады. Екiншi топта ем^к дозаларда 5 наукас (15,6%), дофамин - килограмм минутына 5,2±0,4 микрограмм, адреналин - килограмм минутына 0,04±0,001 микрограмм кабылдады. Емдк дозадан жотары 2 наукас (6,25%), дофамин - килограмм минутына 8,2±0,02 микрограмм, адреналин - килограмм минутына 0,07±0,003 микрограмм кабылдады.
Хат алысатын автор: Жумабаев С.А. - Журек-кан тамырлары хирургиясы жене агзаларды трансплантациялау гылыми-зерттеу институтынын, к^ш^ рылыми Kbi3Mernepi, Бiшкекк., Кыргыз Республикасы. E-mail: Sultanmurat-89@mail.ru
Мудделер кактыгысы
Авторлар мудделер кактыгысынын, жокгыгын мeлiмдeйдi
Туйш сездер
митральды какпакшаны протездеу, клапан асты курылым, арткы тут/к, кардиотоникалык препараттар
Сравнительная оценка время пребывания больных в отделение интенсивной терапии после протезирования митрального клапана с сохранением задней створки и полного удаление подклапанных структур
Автор для корреспонденции: Жумабаев С.А. - младший научный сотрудник, НИИ сердечно-сосудистой хирургии и трансплантации органов, г. Бишкек, Кыргызская Республика. E-mail: Sultanmurat-89@mail.ru.
Конфликт интересов
Авторы заявляют об отсутствии конфликта интересов
Ключевые слова
протезирование митрального клапана, подклапанная структура, задний ствол, кардиотони-ческие препараты
Жумабаев С.А., Раяпов Н.О., Асаналиев М.И., Бхад Ж. А., Урманбетов К.С., Турсунбекова Г.Т.
Научно-исследовательский институт сердечно-сосудистой хирургии и трансплантации органов Министерства Здравоохранения Кыргызской Республики, г. Бишкек, Кыргызская Республика
Аннотация
Цель работы - оценить эффективность пребывание времени в отделении интенсивной терапии и использование инотропных препаратов после операции протезирования митрального клапана с сохранением задней створки со сравнением полным удалением подклапанных структур.
Материал и методы. В исследование включены 60 больных из них 28 пациентов после операции с сохранением задней створки митрального клапана и 32 пациентов после операции с полным удалением подклапанных структур. Средний возраст больных составил 45,9±12,0 лет. Критериями включения были время пребывание в отделение интенсивной терапии после операции, использование инотропных препаратов и длительность использование аппарата ИВЛ.
Результаты. По сравнению контрольная группа в отделении интенсивной терапии получали инотропные препараты больше. В основной группе терапевтических дозах не получали кардиотоники. Во второй группе терапевтических дозах 5 (15,6%) пациентов дофамин - 5,2±0,4 микрограмм на килограмм минуту, адреналин -0,04±0,001 микрограмм на килограмм минуту. Выше терапевтических дозах 2 (6,25%) пациентов дофамин -8,2±0,02 микрограмм на килограмм минуту, адреналин - 0,07±0,003 микрограмм на килограмм минуту.
Relevance
In many ways, in the studies, a parallel was drawn between the dependence of the functioning of the left ventricle and the safety of the mitral valve. However, there were no quantitative criteria by which it would be possible to compare the functional capabilities of the heart during reconstruction and pros-thetics of the mitral valve, to assess the compensatory and reserve capabilities of the left ventricular myocardium after these two types of operations. In 1990, N.A. Chigogidze, I.I. Skopin, P.A. Borsh in their studies determined the effect of reconstructive operations on the mitral valve and its prosthetics on the regional and general function of the left ventricle [1]. Using left ventriculography, it was proved that a decrease in the integral function of the left ventricle in patients after mitral valve replacement is mainly associated with impaired contractility of the posterior-basal and diaphragmatic segments directly related to the surgical intervention zone. This, according to the authors, was due to the removal of the chord-papillary apparatus and rigid fixation of the annulus fibrosus to the prosthesis. In addition, the change in the geometric shape and redistribution within the ventricular volume, along with the hyperfunction of the intact myocardium, served as a compensatory mechanism for maintaining the function of the left ventricle during mitral valve replacement. According to the calculations of the intragastric volume by segments, it was determined that the geometric shape of the left ventricle in patients after mitral valve replacement approached the spherical shape,
the most unfavorable from the point of view of the energy expenditure of the myocardium. In these conditions, hyperfunctional compensation mechanisms cannot be fully realized. During reconstructive operations on the mitral valve, regional disorders were also observed in the form of a decrease in the segmental ejection fraction. However, both in number and in severity, these segmental disorders were significantly less in comparison with patients who underwent mitral valve replacement. It is also important to note that after reconstructive operations on the mitral valve, the most favorable ellipsoid shape of the left ventricle was preserved. Thus, based on the analysis of the segmental and general function of the left ventricular myocardium in patients after reconstruction of the mitral valve and its prosthetics, it was determined that the mitral valve apparatus is actively involved in the reorganization of the left ventricular cavity, contributing to the most rational distribution of vectorial forces of contraction in the process of translational-rotational movement performed by the heart muscle [1, 2].
The analysis of indicators of invasive monitoring of central hemodynamics made it possible to establish that in the case of complete preservation of the subvalvular structures, there was a more significant decrease in pressure in the pulmonary circulation and the greatest increase in SI and SV, with the possibility of preserving only the posterior valve of the MV observed changes were less distinct, while in the group of people operated on with a routine method, the worst immediate re-
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 4-2021
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sults of prosthetics were demonstrated. Thus, the need for maximum preservation of the native mitral complex is quite obvious. The result of the implementation of the presented surgical approach, in addition to restoring the closure function of the MV, is the provision of the isovolumic contraction phase, which, according to the results of a number of studies, leads to an improvement or complete normalization of regional and general LV contractility [3,4]. Leaving subvalvular structures will further improve the immediate and long-term results [5]. An uncomplicated early postoperative period was observed in 69 (66.3%) patients. After being transferred to the intensive care unit, they had stable hemodynamics supported by therapeutic doses of cardiotonics, as well as an average mechanical ventilation time of 16 ± 3.8 hours, on the second day they were transferred to the unit [6]. The results on the preservation of the geometry and functional state of the LV are in the group with complete preservation of the subvalvular structures and the anterior and posterior cusps. The time and need for receiving cardiotonic drugs in the postoperative period in the intensive care unit clearly correlates with the preservation or excision of subvalvular structures [7].
The preservation of subvalvular structures is not a new concept, however, some surgical techniques for the treatment of left atrioventricular defect, depending on the nature of the lesion of the leaflets and subvalvular structures, must be adopted to achieve the best immediate and immediate clinical results, are not definitively defined, and are controversial. Therefore, the need for complete removal or preservation of the valves, subvalvular structures of the MV, their role in changing the functional state of the left ventricular myocardium is still being discussed [8].
The aim of the study is to show the feasibility of preserving the posterior leaflet with CPA in patients with mitral valve replacement (MVR).
Complete preservation of the subvalvular structure prevailed of all the types of operations with the preservation of the posterior leaflet in 89 (94.7%) cases, Due to the sharp thickening and shortening of the chords in 5 (5.3%) cases, we had to remove the first-order chords. The amount of chord removal depended on the degree of thickening and shortening of the chordal-papillary apparatus. Of these, in 1 case two were deleted and in 4 - one first-order chord. Nevertheless, being of the opinion that the preserved chordal-papillary apparatus of MV leads to an improvement in myocardial function, it is necessary to completely save the leaflet with subvalvular apparatus [8-9].
As far back as the 1960-70s, it was shown that the preservation of the chord-papillary apparatus
of mitral valve (MV) and annulopapillary continuity plays a crucial role in the functioning of the LV. Many surgeons believe that the preserved chord-papillary apparatus of MV allows to leave the sequence of physiological contraction of the left ventricular wall unchanged, improves contractility of the LV myocardium in the near and long-term postoperative period, especially in patients with increased LV and mitral insufficiency [10].
Material and methods
At the Research Institute of Heart Surgery and Organ Transplantation, retrospective analyzes after mitral valve surgery with and without preservation of the posterior cusp of the chordal-papillary apparatus (CPA) of the mitral valve in patients with a defect were selected.
The analysis includes the following parameters: total duration of treatment, intraoperative duration during cardiopulmonary bypass, duration of treatment in the intensive care unit and intensive care, drugs received (inotropic drugs: dopamine, adrenaline).
Divided into 2 groups for comparison. The average age of the patients was 47.4 ± 10.2 years. Of the total number of patients, 40 (66.6%) were female and 20 (33.3%) were male. All patients had heart failure of varying severity, namely, in functional class 2 (FC) there were 2 (3.33%), in 3 FC - 53 (88.3%) and in 4 FC - 5 (8.33%) patients. In 32 (53.33%) cases, there was atrial fibrillation before surgery.
In the overwhelming majority, rheumatism was the cause of MV defect (59 (98.3%) patients), 1 (1.66%) had infective endocarditis. Mitral stenosis or its predominance was diagnosed in 44 (73.33%) patients, insufficiency or its predominance was noted in 11 (18.33%) (Table 1).
Results
When analyzing the study group by the type of mitral defect in patients with insufficiency, the technique of preserving the posterior leaflet and CPA was more often used. Thickened chords together with papillary muscles can obstruct blood flow to the left atrium and create a large gradient between the left atrium and ventricle during diastole; therefore, in patients with severe stenosis, the MV in some cases had to remove completely subvalvular structures (Table 2).
Of all types of operations with preservation of the posterior valve, in 28 (46.66%) cases, complete preservation of GL prevailed. Due to the sharp thickening and shortening of the chords in 5 (5.3%) cases, we had to remove the chords of the first order. The amount of chord removal depended on the degree of thickening and shortening of the CPA. Of these, in 1 case, two were removed and in 4 - one
Table 1.
Clinical characteristics of patients
Table 2.
Preservation of subvalve structures
Indicators Absol. Number %
Average age, years 47,4 ±10,2
Floor:
men 2G 33,3
women 4О 66,6
Functional class:
II 2 3,33
III 53 88,3
IV б 8,33
The reason for the defect:
rheumatism 59 98,3
congenital defect О О
infective endocarditis 1 1,66
Heart rhythm:
sinus rhythm 28 46,6
fibrillation 32 53,33
The nature of the mitral valve defect:
stenosis 44 73,33
failure 11 18,33
№ Preservation of subvalve structures Abs.number %
1 Preservation of the back leaf and chordo-papillary apparatus 28 46,66
2 Complete removal of the leaflet and chordal-papillary apparatus 32 53,33
first order chord. Nevertheless, holding the opinion that preserved CPA MK leads to an improvement in the work of the myocardium [1,2,3]. In the second group, 32 patients were removed under the MV valve structure.
The duration of cardiopulmonary bypass in the main group averaged 85.89±29 minutes, the time of aortic clamping was 59±26 minutes, the control group averaged 88.15±36.6 minutes, the time of aortic clamping was 63.81±31.08 minutes Cold hy-perpotassium blood cardioplegia was used to protect the myocardium.
According to the restoration of cardiac activity in the main group, independent recovery of 17 patients (60.71%), as well as in the second group 26 (81.25%). Through fibrillation 11 (39.28%) in the first group, 6 (18.7%) in the second group (Table 3).
In the postoperative period, out of 60 patients, 10 (16.66%) patients had various types of complications (Table 4).
In 10 cases, non-fatal postoperative complications were noted. In patients with heart failure, car-diotonics have been used in therapeutic doses. In 4 cases, higher therapeutic doses and prolonged artificial ventilation were used. One patient developed sternal diastasis after surgery. Conducted osteosynthesis of the sternum, discharged on the 12th day after osteosynthesis (table 4). In the main group of renal doses, 21 (75%) patients received dopamine - 2.38±0.21 ^g / kg / min, adrenaline -0.021 ± 0.003 ^g / kg / min. Cardiotonics have not been received at therapeutic doses. Above therapeutic doses - 2 (7.14%) patients received (dopamine) - 8 ± 0.01 ^g / kg / min.
Table 3.
Operating indicators
Operating indicators 1st group 2nd group
Average time of extracorporeal circulation, min 85,89±29 88,15±36,6
Average time of aortic clamping, min 59±26 63,81±31,08
Recovery of cardiac activity: %
Independent 17 60,71% 26 81,25%
Through fibrillation 11 39,28% б 18,7%
Table 4.
Postoperative complications
Types of complications 1st group 2nd group
Absolute % Absolute %
Non-fatal complications: 28 46,66 32 53,33
a) heart failure 1 3,57 7 21,87
b) respiratory failure О О 1 3,12
c) diastasis of the sternum О О 1 3,12
Fatal complications О О
в
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 4-2021
Cardiotonics (inotropic drugs): (dopamine, adrenaline) 1st group (n-26) / kg / min) № п % 2nd group (11-32) / kg / min) № n % P
No inotropic support 4 14,28 2 6,25 <005
Renal fl-2,38±0,21 a-0,021±0,003 21 75 fl -2,24±0,54 a-0,021±0,001 23 71,875 <005
Therapeutic 0 0 fl-5,2±0,4 a-0,04±0,001 5 15,6 <005
Higher therapeutic fl-8±0,01 a- 0 2 7,14 fl-8,2±0,02 a-0,07±0,003 2 6,25 <005
Table 5.
Use of inotropic drugs
Stay before and after surgery 1 group No. 28 2 group No. 32
1) general, day 22,07±7,41 20,1±7,6
2) before surgery, day 9,85±5,11 8,18±4,44
3) after surgery, day 12,2±4,5 12 ±6,3
Hours spent in the intensive care unit, hours 42±22 48,75±41,11
Table 6.
Hospital stay
In the control group with renal doses, 23 (71.87%) patients received dopamine 2.24 ± 0.54 ^g / kg / min, adrenaline - 0.021 ± 0.001 ^g / kg / min. Therapeutic doses of 5 (15.6%) patients dopamine - 5.2 ± 0.4 ^g / kg / min, adrenaline - 0.04 ± 0.001 ^g / kg / min. Above therapeutic doses in 2 (6.25%) patients, dopamine - 8.2 ± 0.02 ^g / kg / min, adrenaline -0.07 ± 0.003 ^g / kg / min (Table 5).
The table shows that in the postoperative period the indicators changed significantly. However, there was a decrease in the use of cardiotonics in the first group, mainly at renal doses.
Hospital stay in the first group spent days 22.07 ± 7.41, before surgery 9.85 ± 5.11 days, after surgery 12.2 ± 4.5 days and in the second group 20.1 ± 7.6 days, before surgery 9 , 85 ± 5.11 days, after surgery 12.2 ± 4.5 days (Table 6).
Extubation after surgery in the 1st group on the first day, 25 (89.28%) patients were extubat-ed. There were 26 (84.37%) patients in the control group (table 7).
Сonclusions
Thus, according to the data obtained as a result of the analysis of the immediate postoperative results of MVR with the preservation of GL compared to the complete removal of CPA, the use of inotropic drugs decreases, the time spent in the A&R department decreases. And also immediately after the operating room heart failure is significantly reduced (Table 4). The operative technique of preserving the posterior cusp with its subvalvular structure is easy to perform surgically and does not lengthen the time of artificial circulation (Table 3).
Day 1 group No. 28 2 group No. 32
the first 89,28% 84,37%
second 10,71% 12,5%
third 0 0
fourth 0 3,25%
Table 7.
Extubation after surgery
References
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