Denervation of Pulmonary Arteries in Patients with Mitral Valve Defects Complicated by Atrial Fibrillation and Pulmonary Hypertension

The aim of the study was to evaluate whether sympathetic denervation of the trunk and orifices of pulmonary arteries could reduce pulmonary hypertension and help in managing atrial fibrillation. In addition, we aimed to identify the main predictors of recurrent rhythm disturbances in patients with mitral valve dysfunction complicated by atrial fibrillation and high pulmonary pressure.

Materials and Methods. We analyzed the results of surgical treatment of 140 patients with mitral defects complicated by atrial fibrillation and high-grade pulmonary hypertension (more than 40 mm Hg). In the main group of patients (n=51), surgical intervention included the correction of mitral defect, the treatment for atrial fibrillation according to Maze IV, and the radiofrequency denervation of the trunk and orifices of the pulmonary artery in order to correct pulmonary hypertension. In the control group (n=89), patients with similar heart defects underwent the mitral dysfunction repair (Maze IV), but no denervation of the pulmonary trunk or orifices was performed.

Results. We found that the circular radiofrequency denervation of the trunk and orifices of the pulmonary arteries effectively reduced pulmonary hypertension in patients with mitral valve defects complicated by atrial fibrillation and high pulmonary pressure. The proposed procedure results in reverse remodeling of the heart cavities, especially the left atrium (p=0.01), a decrease in pulmonary hypertension, and permanent restoration of a sinus rhythm after the Maze IV procedure (p=0.008). The main predictors of recurrent atrial fibrillation in these patients after the combined surgical treatment are arrhythmias lasting over 5 years (p=0.04), initial pulmonary hypertension of more than 60 mm Hg (p=0.028), concomitant severe tricuspid insufficiency (p=0.006) and atherosclerotic lesions in the brachiocephalic and cerebral vessels.

1. Kim J.S., Lee S.A., Park J.B., Chee H.K., Chung J.W. Preoperative risk factor analysis of postoperative stroke after Cox-maze procedure with mitral valve repair. BMC Cardiovasc Disord 2014; 14(1): 166, https://doi.org/10.1186/1471-2261-14-116.
2. Bockeria L.A., Shengelia L.D. Treatment of atrial fibrillation. Part II. Current realities and future prospects. Annaly aritmologii 2014; 11(2): 76–86, https://doi.org/10.15275/annaritmol.2014.2.2.
3. Ter-Akopyan A.V., Likov V.F., Alekhin M.N., Abramov A.S., Tagaev N.B., Gogin G.E. Experience of endovascular implantation of the WATCHMAN device in patients with atrial fibrillation. Kardiologia 2015; 55(9): 22–24.
4. Sulimov V.A., Lishuta A.S. Prospects for the treatment of patients with atrial fibrillation. Ratsional’naya farmakoterapiya v kardiologii 2011; 7(3): 323–333.
5. Trofimov N.A., Medvedev A.P., Babokin V.E., Demarin O.I., Zhamlikhanov N.K., Dragunov A.G., Gartfelder M.V., Nikolaeva O.V., Dragunova M.V. Relapse prevention and improvement of results of complex arrhythmias surgical correction in cardiac patients. Al’manah kliniceskoj mediciny 2015; 38: 74–80.
6. Belozerov Yu.M., Osmanov I.M., Magomedova Sh.M. Prolaps mitral’nogo klapana u detey i podrostkov. Tom 1 [Mitral valve prolapse in children and adolescents. Vol. 1]. Moscow: Medpraktika-M; 2010; 132 p.
7. Bogachev-Prokofiev A.V., Sapegin A.V., Pivkin A.N., Sharifulin R.M., Afanasyev A.V., Ovcharov M.A., Karaskov A.M. Evaluation of the new onset atrial fibrillation in patients with mitral valve lesion and left atrial enlargement. Annaly aritmologii 2017; 14(2): 73–80, https://doi.org/10.15275/annaritmol.2017.2.2.
8. Babokin V.E., Shipulin V.M., Antonchenko I.V., Batalov R.E., Lukyanenok P.I., Aymanov R.V., Popov S.V. Radiofrequency labels in surgical treatment of left ventricle postinfarction aneurysms and ventricular tachycardias. Grudnaa i serdecno-sosudistaa hirurgia 2011; 5: 23–28.
9. Trofimov N.A., Medvedev A.P., Dragunov A.G., Babokin V.E., Nikol’skiy A.V., Mizurova T.N., Gartfelder M.V., Orlova A.V. Denervation of pulmonary trunk and pulmonary orifice in patients with surgically corrected mitral valve disease against high pulmonary hypertension. Al’manah kliniceskoj mediciny 2017; 45(3): 192–199, https://doi.org/10.18786/2072-0505-2017-45-3-192-199.
10. Trofimov N.A., Medvedev A.P., Babokin V.E., Zhamlikhanov N.Kh., Dragunov A.G., Gartfelder M.V., Nikolaeva O.V., Dragunova M.V. Efficiency of surgical treatment of mitral insufficiency with atrial fibrillation of nonishemic etiology. Medicinskij al’manah 2014; 5(35): 165–169, https://doi.org/10.18786/2072-0505-2017-45-3-192-199.
11. Shipulin V.M., Kozlov B.N., Krivoshchekov E.V., Kazakov V.A., Lezhnev A.A., Babokin V.E., Vatolina T.V. Morphofunctional characteristics of myocardium of patients with postinfarction remodeling as a possible cause of adverse results of surgical treatment. Grudnaya i serdechno-sosudistaya khirurgiya 2009; 5: 37–41.
12. Zheleznev S.I., Demidov D.P., Afanasiev A.V., Nazarov V.M., Demin I.I., Bogachev-Prokofiev A.V., Astapov D.A., Karaskov A.M. Radiofrequency denervation of pulmonary artery in surgery of dysplastic mitral valve defects with severe pulmonary hypertension. Rossijskij kardiologiceskij zurnal 2016, 11: 70–72, https://doi.org/10.15829/1560-4071-2016-11-70-72.
13. Mamchur S.E., Khomenko E.A., Chistyukhin O.M., Kurilin M.Yu., Ivanov A.Yu. Effectiveness and safety of radiofrequency ablation of slow atrio-ventricular pathways in irrigated regime using non-fluoroscopic navigational mapping. Vestnik aritmologii 2012; 69: 28–31.
14. Kirchhof P., Benussi S., Kotecha D., Ahlsson A., Atar D., Casadei B., Castella M., Diener H.C., Heidbuchel H., Hendriks J., Hindricks G., Manolis A.S., Oldgren J., Popescu B.A., Schotten U., Van Putte B., Vardas P., Agewall S., Camm J., Baron Esquivias G., Budts W., Carerj S., Casselman F., Coca A., De Caterina R., Deftereos S., Dobrev D., Ferro J.M., Filippatos G., Fitzsimons D., Gorenek B., Guenoun M., Hohnloser S.H., Kolh P., Lip G.Y., Manolis A., McMurray J., Ponikowski P., Rosenhek R., Ruschitzka F., Savelieva I., Sharma S., Suwalski P., Tamargo J.L., Taylor C.J., Van Gelder I.C., Voors A.A., Windecker S., Zamorano J.L., Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18(11): 1609–1678.
15. Vaskovskiy V.A., Serguladze S.Yu. Possibilities and prospects of surgical treatment of atrial fibrillation. Annaly aritmologii 2016; 13(2): 64–72, https://doi.org/10.15275/annaritmol.2016.2.1.
16. Gillinov A.M., Gelijns A.C., Parides M.K., DeRose J.J. Jr., Moskowitz A.J., Voisine P., Ailawadi G., Bouchard D., Smith P.K., Mack M.J., Acker M.A., Mullen J.C., Rose E.A., Chang H.L., Puskas J.D., Couderc J.P., Gardner T.J., Varghese R., Horvath K.A., Bolling S.F., Michler R.E., Geller N.L., Ascheim D.D., Miller M.A., Bagiella E., Moquete E.G., Williams P., Taddei-Peters W.C., O’Gara P.T., Blackstone E.H., Argenziano M.; CTSN Investigators. Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med 2015; 372(15): 1399–1409, https://doi.org/10.1056/nejmoa1500528.
17. Hurdman J., Condliffe R., Elliot C.A., Davies C., Hill C., Wild J.M., Capener D., Sephton P., Hamilton N., Armstrong I.J., Billings C., Lawrie A., Sabroe I., Akil M., O’Toole L., Kiely D.G. ASPIRE registry: assessing the spectrum of pulmonary hypertension identified at a REferral centre. Eur Respir J 2012; 39(4): 945–955, https://doi.org/10.1183/09031936.00078411.
18. Bogunetsky A.A., Ussov V.Yu., Babokin V.Ye. Cardiovascular magnetic resonance with contrast agent: prognostic role in determining arrhytmogenic focus. Bulleten’ sibirskoj mediciny 2014; 13(1): 98–102.
19. Simonneau G., Gatzoulis M.A., Adatia I., Celermajer D., Denton C., Ghofrani A., Gomez Sanchez M.A., Krishna Kumar R., Landzberg M., Machado R.F., Olschewski H., Robbins I.M., Souza R. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 2013; 62(25 Suppl): D34–D41.
20. Trofimov N.A., Medvedev A.P., Babokin V.E., Dragunov A.G., Efimova I.P., Gartfelder M.V., Nikolaeva O.V., Dragunova M.V., Sozykin A.V., Averin E.E., Shlykov A.V., Novikova N.T. 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. Meditsinskiy alfavit 2018; 4(37): 18–24.
21. Rubin L.J. Primary pulmonary hypertension. N Engl J Med 1997; 336(2): 111–117, https://doi.org/10.1056/nejm199701093360207.
22. Galiè N., Manes A., Negro L., Palazzini M., Bacchi-Reggiani M.L., Branzi A. A meta-analysis of randomized controlled trials in pulmonary arterial hypertension. Eur Heart J 2009; 30(4): 394–403, https://doi.org/10.1093/eurheartj/ehp022.
23. Hoeper M.M., Barberà J.A., Channick R.N., Hassoun P.M., Lang I.M., Manes A., Martinez F.J., Naeije R., Olschewski H., Pepke-Zaba J., Redfield M.M., Robbins I.M., Souza R., Torbicki A., McGoon M. Diagnosis, assessment, and treatment of non-pulmonary arterial hypertension pulmonary hypertension. J Am Coll Cardiol 2009; 54(1 Suppl): S85–S96, https://doi.org/10.1016/j.jacc.2009.04.008.
24. Guazzi M., Vitelli A., Labate V., Arena R. Treatment for pulmonary hypertension of left heart disease. Curr Treat Options Cardiovasc Med 2012; 14(4): 319–327, https://doi.org/10.1007/s11936-012-0185-6.
25. Osorio J., Russek M. Reflex changes on the pulmonary and systemic pressures elicited by stimulation of baroreceptors in the pulmonary artery. Circ Res 1962; 10(4): 664–667, https://doi.org/10.1161/01.res.10.4.664.
26. Baylen B.G., Emmanouilides G.C., Juratsch C.E., Yoshida Y., French W.J., Criley J.M. Main pulmonary artery distention: a potential mechanism for acute pulmonary hypertension in the human newborn infant. J Pediatr 1980; 96(3 Pt 2): 540–544, https://doi.org/10.1016/s0022-3476(80)80863-8.
27. Juratsch C.E., Jengo J.A., Castagna J., Laks M.M. Experimental pulmonary hypertension produced by surgical and chemical denervation of the pulmonary vasculature. Chest 1980; 77(4): 525–530, https://doi.org/10.1378/chest.77.4.525.
28. Chen S.L., Zhang F.F., Xu J., Xie D.J., Zhou L., Nguyen T., Stone G.W. Pulmonary artery denervation to treat pulmonary arterial hypertension: the single-center, prospective, first-in-man PADN-1 study (first-in-man pulmonary artery denervation for treatment of pulmonary artery hypertension). J Am Coll Cardiol 2013; 62(12): 1092–1100, https://doi.org/10.1016/j.jacc.2013.05.075.
29. Zhang H., Zhang J., Xie D.J., Jiang X., Zhang F.F., Chen S.L. Pulmonary artery denervation for treatment of a patient with pulmonary hypertension secondary to left heart disease. Pulm Circ 2016; 6(2): 240–243, https://doi.org/10.1086/685550.
30. Song X., Zhang C., Chen X., Chen Y., Shi Q., Niu Y., Xiao J., Mu X. An excellent result of surgical treatment in patients with severe pulmonary arterial hypertension following mitral valve disease. J Cardiothorac Surg 2015; 10(1): 70, https://doi.org/10.1186/s13019-015-0274-1.
31. Briongos Figuero S., Moya Mur J.L., García-Lledó A., Centella T., Salido L., Aceña Navarro Á., García Martín A., García-Andrade I., Oliva E., Zamorano J.L. Predictors of persistent pulmonary hypertension after mitral valve replacement. Heart Vessels 2016; 31(7): 1091–1099, https://doi.org/10.1007/s00380-015-0700-2.
32. Bogachev-Prokofev A.V., Zheleznev S.I., Afanas’ev A.V., Fomenko M.S., Demidov D.P., Sharifulin R.M., Pivkin A.N., Astapov D.A., Semenova E.I., Ivanov S.N., Karas’kov A.M. Denervation of pulmonary artery during mitral valve surgery in patients with high pulmonary hypertension. Patologiya krovoobrashcheniya i kardiokhirurgiya 2015; 19(4): 19–25.
33. Trofimov N.A., Medvedev A.P., Dragunov A.G., Nikolsky A.V., Mizurova T.N., Gartfelder M.V., Orlova S.A., Nikolayeva O.V., Dragunova M.V. Method of surgical treatment of secondary pulmonary hypertension in the case of patients having surgical correction of mitral valve pathology. Medicinskij al'manah 2017; 3(48): 33–37, https://doi.org/10.21145/2499-9954-2017-3-33-37.

Trofimov N.A., Medvedev A.P., Nikolsky A.V., Kichigin V.A., Zhamlikhanova S.S., Babokin V.E. Denervation of Pulmonary Arteries in Patients with Mitral Valve Defects Complicated by Atrial Fibrillation and Pulmonary Hypertension. Sovremennye tehnologii v medicine 2019; 11(4): 95, https://doi.org/10.17691/stm2019.11.4.11