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Ann Thorac Surg 2000;70:958-960
© 2000 The Society of Thoracic Surgeons
a Department of Surgery, Texas Heart Institute, Houston, Texas, USA
Address reprint requests to Dr Frazier, Texas Heart Institute, M. C. 3-147, PO Box 20345, Houston, TX 77225-0345
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Abstract |
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Introduction |
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In 1995, a 48-year-old male Jehovah’s Witness with a 6-year history of progressive idiopathic dilated cardiomyopathy (New York Heart Association functional class IV) presented to our hospital as a potential heart transplant candidate. Cardiac catheterization showed patent coronary arteries, and echocardiography showed global left ventricular hypokinesia, a left ventricular ejection fraction (LVEF) of less than 20%, and mild mitral regurgitation.
Ten months later, a suitable donor organ had not become available, and he was evaluated for LVRS. During the week before the operation, he received erythropoietin (10,000 U by subcutaneous injection) three times. He had uneventful LVRS, with a mitral valvuloplasty. After cardiopulmonary bypass was initiated and the ascending aorta was cross-clamped, a 3.5 x 2.0 x 2.3-cm segment was resected from the left ventricular free wall, with preservation of the papillary muscle. A bow-tie mitral valve repair [3] was done by approximating the free margin of the mitral leaflets with a single polypropylene suture. The ventriculotomy was repaired with polypropylene sutures and Teflon felt pledgets. Three million units of aprotinin were administered intraoperatively, and cell salvage with inline autotransfusion was done. Intraoperative transesophageal echocardiography confirmed that the mitral valve was competent and ventricular wall motion was satisfactory. Blood loss amounted to 1000 mL.
Immediately postoperatively, transesophageal echocardiography showed an estimated LVEF of 25% to 29% and no mitral regurgitation. The patient’s postoperative course was uncomplicated, and he was discharged from the hospital on postoperative day 11. His lowest hematocrit was 11.1%, and his hematocrit at hospital discharge was 11.3%. Postoperatively, erythropoietin therapy was continued for 1 week. Maintenance medications included amiodarone, warfarin sodium, digoxin, and enalapril.
Two months postoperatively, echocardiography showed mild to moderate mitral insufficiency, a left ventricular end-diastolic diameter of 6 cm, and a calculated LVEF of 20% to 24%. With respect to functional status, the patient was in New York Heart Association class I.
Four months later, the patient presented with exertional dyspnea of acute onset and occasional resting dyspnea. His New York Heart Association status had regressed to class III/IV. Two-dimensional transesophageal echocardiography showed a dilated left atrium, left ventricular enlargement, and moderate to severe mitral regurgitation, with a possible rupture of mitral chordae tendineae. Right-sided heart catheterization showed patent coronary arteries. Echocardiography showed a calculated LVEF of 20% and a left ventricular end-diastolic diameter of 6.5 cm.
The patient was admitted to the hospital and was given a continuous infusion of milrinone (0.4 µg/kg per minute). He also received 10,000 U of subcutaneous erythropoietin three times a week for 2 weeks. At the end of that period, his hematocrit was 14.7%, and he underwent revision of the LVRS and mitral valve replacement. A 11.0 x 3.0 x 2.5-cm segment of the left ventricular free wall was resected, incorporating the previous ventriculotomy site. Examination of the mitral valve revealed that the valvuloplasty suture had torn through the anterior leaflet. The mitral valve was excised and replaced with an inverted 27-mm CarboMedics aortic valve (Sulzer CarboMedics, Austin, TX). The same blood-saving techniques were used as in the first operation, and the estimated blood loss was 750 mL.
Postoperative echocardiography confirmed that the mitral prosthesis was functioning normally. The left ventricular end-diastolic diameter was 6.6 cm, and the calculated LVEF was 27%. Although the patient was initially pacemaker-dependent because of a symptomatic third-degree atrioventricular block, his heart was converted to sinus rhythm by postoperative day 11. His hematocrit was 10.4% on postoperative day 15, when he was discharged from the hospital. At that time, he had a first-degree atrioventricular block, his heart was in sinus rhythm, and his New York Heart Association functional status was class I.
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In our case, additional blood-conservation techniques included the use of preoperative erythropoietin and intraoperative aprotinin, as well as cell salvage with autologous transfusion by means of an inline circuit. Erythropoietin previously has been used preoperatively to stimulate erythropoiesis and increase the hematocrit in patients who have cardiovascular operations [4]. Although our patient’s hematocrit was within the normal range at the time of both operations, preoperative erythropoietin was given to optimize postoperative erythropoiesis. Aprotinin’s beneficial effect on bleeding after primary and repeat cardiac operations has been reported by others [5, 6]. After using aggressive blood conservation techniques in 542 Jehovah’s Witnesses, Ott and Cooley [7] encountered only three deaths directly related to blood loss.
Single-suture valvuloplasty is a novel approach for correcting mitral insufficiency [3] associated with dilated cardiomyopathy. Technical simplicity and easy access through a left ventriculotomy make this procedure practical during LVRS. In the present case, mitral insufficiency recurred postoperatively because the suture pulled through the valve’s edge. (Since this case, we have routinely used Teflon felt pledgets for LVRS valvuloplasties and have had no subsequent repair failures.) This unfortunate complication worsened the problem by necessitating reoperation on a Jehovah’s Witness. During the reoperation, mitral valve replacement permitted additional resection of the left ventricular free wall, resulting in an improved LVEF. In a recent report of the first large series of patients who had LVRS, Batista and coauthors [2] indicated that mitral valve replacement improves the beneficial effects of the procedure by allowing more extensive resection of the ventricular free wall and by better restoring a normal ventricular-wall-thickness–to–volume ratio.
The overall utility of LVRS in the treatment of end-stage heart failure is still under investigation, but this procedure has resulted in morphologic and functional improvement in several patients [8]. Additional studies are needed to determine which specific patients and disease states will benefit most from LVRS. Although selected Jehovah’s Witnesses may be candidates for LVRS, this procedure might complicate transplantation in these patients should cardiac replacement become necessary.
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Related Article
Ann. Thorac. Surg. 2000 70: 960-961.
This article has been cited by other articles:
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  E. O'Flynn, S. Purkayastha, T. Athanasiou, and R. Casula Repair of a Giant Left Ventricular Pseudoaneurysm in a Jehovah's Witness. Asian Cardiovasc Thorac Ann, August 1, 2006; 14(4): 328 - 330. [Abstract] [Full Text] [PDF]
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