UDC 616.126 -001 307-03-097
FRAGMENTAIOM OPERATION IN LEFT ATRIUM FOR CORRECTION OF ISOLATED MITRAL VALVE DISEASE
Popov V.V., Roy V.V., Pukas K.V., Klymenko S.G., Spysarenko S.P.,
Malysheva T.A.
Aim of investigation is to research possibilities of intraoperative renewal of sinus rhythm by proposed method during correction of mitral valve diseaese. 
In analyzed group are included 161 patients with isolated mitral valve disease in IV stage  who were operated in Institute. Plastic LA performed in 119 (78.9%) patients in order to reduce it and to prevent propagation wave of  re-entry. Fragmentation in the LA was held in low radiofrequency mode (25-35 watts) for option transactions left Maze-3,4. Of the 161 patients operated on at the hospital stage 3 patients died (hospital mortality 1.9%). Mitral valve replacement combined with maze low radiofrequency mode allows you successfully restore proper  rhythm in 80.2% of cases during hospital stay and stabilize it for six months after surgery.
Key words: mitral valve disease, arrhythmia, surgical rhythm's renewal, cardio-pulmonary bypass.

Material and methods.  Analyzed group consisted of 161 patients with isolated mitral valve disease  IV were on the surgical treatment in the Department of Surgery of acquired heart of the National Institute of Cardiovascular Surgery Academy of Medical Sciences of Ukraine since January 1, 2009 to January 1, 2014. The men were 59 (36,6%),  women - 102 (63,4%).  The age of patients ranged from 39 to 70 years (mean 57,3 ± 6,2 years).  
 39 (24.2%) patients  were belong in a class III classification NYHA, 122 (75.8%) patients  class IV. The leading etiology was rheumatic defects. Calcification of the mitral valve was observed in 49 (30.4%) patients. The average duration of the existence of atrial fibrillation was 3,0 ± 0,4 years.
Fragmenting procedure in the LA in all patients was carried out by low radiofrequency (25-35 watts in the coagulation mode) ablation of the left atrium of the embodiment operations left the Labyrinth (Maze-3,4). Fragmentation is a prerequisite ligation and resection of the outsid auriculum of  LA.  All operations were performed by a single surgeon  as unique methodology - the developer of methodologies (V.V Popov). When dilatation was performed additionally LA its reduction in 119 (72.4%) patients. Reduction techniques presented LA  paraannuly plication back wall of  LA (62 patients)  the triangular plastic  of  LA (patient 47) and arch plasty (n=10) to reduce the size of LA at least 5.0 cm and to prevent propagation re-entry due to creation of scar zones LA. The indication for the reduction of  LA  in combination with the fragmenting procedure was the size of the LA 5.0 cm or more. The original size of the LA was - 61,5 ± 1,5 mm.
All patients were performed MVR: 1) saving the posterior leaflet of MV (114 patients), 2) saving the posterior leaflet of  MV + translocation of  the papillary muscles of the front flap cut in the fibrous ring of the left atrioventricular ring (39 patients), 3) with complete retention of both mitral valve (2 patients).
All operations were performed under cardiopulmonary bypass and moderate hypothermia (33-34 °C). Myocardial protection was carried out under conditions of retrograde cardioplegia solution custodiol in combination with external cooling. Access to mitral valve was through the LA position and parallel to the diatrial groove. Used for implantation  in the mitral position of the bicuispid  valve prostheses Saint Jude. Fixation of prostheses to hold separate P-shaped sutures with teflon liners in the amount of 14-19 in an intermediate position. 
In order to keep the proper rhythm medication during surgery following criteria are met: 1) the level of plasmatic potassium maintained in post perfusion period of 4.5 mmol / L or greater 2) for the period of operation was introduced 20-30 ml of 25% magnesium sulfate at the rate of 0.25 ml / kg 3) in the postoperative period excludes the use of diuretics, potassium excretory  4) the value of hematocrit at the end of perfusion was 0.3 and above, to exclude significant hemodynamic failure, and fluid balance by not more than + 500,0-700,0 ml 5) administering cordarone during operation period within 300 mg on subsequent days - daily dose in the range 300-600 mg, 6) panangine application within a period of 20-30 ml per operation.
Aortic cross-clamping time was 75,2 ± 8,1 min. Hemorrhage noted within 400.0 mL, allowing in 101 (62,7%)  cases eliminate the use of blood and its components throughout the hospital stay. Complications during hospital stay associated with the procedure of the operation were observed.
Results and discussion. Of the 161 patients operated on at the hospital stage 3 deaths (1.9% hospital mortality). The causes of deaths: pneumonia and multi-organ failure. Inotropic support (dobutamine) was within 3-4 mkrg / kg / min. during the first 56 hours. Time on mechanical ventilation was 8,2 ± 1,5 hours and in the intensive care unit - 57,4 ± 3,5 hours. Dynamics of echocardiography parameters during the treatment were: left ventricular ejection fraction - 0,56 ± 0,03 (before surgery) and 0,58 ± 0,02 (after surgery), the diameter of the LP (mm) - 61,5 ± 1,5 ( before surgery) and 49,1 ± 1,7 (after surgery).
Sinus rhythm was restored immediately after the removal of the clamp from the aorta in 132 (81.7%) patients, and discharge ECG was observed in 130 (80.2%).  At 11,1 ± 1,2 days  after the operation in the department in 27 (17.4%) cases had to restore  rhythm  by defibrillation with successful results in 21 (77.7%) cases.
At discharge sinus rhythm in patients with plastic LA was higher than in the alternative group: 85,7% (n = 103/119), and 64,5% (n = 27/42) (p <0.05).

Conclusions. The presence of arrhythmias in patients with mitral defect reduces the performance of the heart by 38-39% [3-8]. This is especially important in patients with artificial heart valves as the presence of arrhythmias lead not only to progressive heart failure  and also creates conditions for thrombosis, embolism that leads to impaired graft function [1-6, 8]. In this regard, it is important to restore the proper rhythm is already in the early postoperative period. That's why do not stop looking for new surgical techniques to restore sinus rhythm, and optimization of intraoperative methods of restoring normal rhythm of the heart, particularly in prosthetic mitral valve (MVP).
Mitral valve surgery combined with maze in our modification can successfully restore proper rhythm in 80.6% of cases at the hospital stage. Applied drug support adequately consolidated efforts together with the original methodology implemented low radiofrequence ablation (scheme Maze-3) to restore sinus rhythm. The proposed method of fragmentation  inexpensive. Element of  LA reduction is important for the restoration of sinus rhythm. The data obtained nearest distant period allow us to evaluate the capacity of the proposed optimistic technique.

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