Ann Thorac Surg 2003;76:1289-1291
© 2003 The Society of Thoracic Surgeons
Case report
Orthotopic cardiac transplantation 30 months after successful dynamic cardiomyoplasty
George V. Letsou, MD*a,
Jane E. Carter, MDa,
Saleh Shenaq, MDb,
Igor D. Gregoric, MDc,
Reynolds Delgado, MDd,
O. H. Frazier, MDc
a Department of Cardiothoracic and Vascular Surgery, The University of Texas–Houston Medical School, Houston, Texas, USA
b Department of Plastic Surgery, Baylor College of Medicine, Houston, Texas, USA
c Cardiopulmonary Transplantation Service, Houston, Texas, USA
d Heart Failure Clinic, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas, USA
Accepted for publication February 21, 2003.
* Address reprint requests to Dr Letsou, Department of Cardiothoracic and Vascular Surgery, The University of Texas–Houston Medical School, 6410 Fannin, Suite 450, Houston, TX, USA 77030
e-mail: george.v.letsou{at}uth.tmc.edu
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Abstract
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Reports of cardiac transplantation after successful cardiomyoplasty are rare. We report the case of a 63-year-old man with intractable heart failure who underwent successful orthotopic cardiac transplantation 30 months after dynamic cardiomyoplasty.
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Introduction
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Dynamic cardiomyoplasty has been proposed as a treatment for congestive heart failure [1]. Its effects on subsequent cardiac transplantation are unclear. Reports of cardiac transplantation after successful cardiomyoplasty are rare. We report here the case of a 63-year-old human with intractable heart failure who underwent successful orthotopic cardiac transplantation 30 months after dynamic cardiomyoplasty.
In 1997, a 63-year-old man presented with intractable heart failure, a maximal exercise oxygen consumption (MVO2) of 12.6 mL/kg/min, and a New York Heart Association functional class III. Renal function was normal, and there were no abnormalities of other organ systems.
Although an acceptable candidate for cardiac transplantation, the patient chose to enroll in a multicenter clinical trial of dynamic cardiomyoplasty at our institution. He was randomized to the surgical arm of the trial and underwent an uneventful dynamic cardiomyoplasty in August 1998. The surgery included harvesting of the latissimus dorsi through a lateral incision over the latissimus, transposition of the latissimus dorsi into the chest, electrical stimulation of the muscle, and wrapping of the latissimus dorsi about the heart in a clockwise fashion, posterior to anterior. Intraaortic balloon counterpulsation was instituted preoperatively and continued prophylactically for 2 days, postoperatively.
The patient was discharged from the hospital 10 days postoperatively. Two weeks postoperatively, the latissimus stimulation protocol (31-Hz stimuli interspersed with 16-ms delays) was begun. Thereafter, the patient was followed every 3 months. Cardiac performance (ie, ejection fraction) was assessed by echocardiography. During echocardiography, the timing of the latissimus stimulation was altered to synchronize muscle contraction with mitral valve closure. Functional status was also assessed. Ejection fraction improved marginally, and functional status improved to New York Heart Association functional class I. The patient had no heart failure-related hospitalizations for 18 months.
After 27 months, signs and symptoms of heart failure recurred. Clinical and laboratory evaluation revealed an MVO2 of 13.9 mL/kg/min, normal renal function, and normal function of all other extracardiac organs. The patient was accepted for transplantation and was placed on the cardiac transplantation waiting list. After a 3-month wait, an uneventful orthotopic cardiac transplantation was performed by median sternotomy. Intraoperatively, the latissimus was found to be viable, firmly adherent to the pericardium, and much less firmly adherent to the heart (Fig 1).
Histologic analysis confirmed the presence of viable muscle (Fig 2).
The left lung and latissimus dorsi were densely adherent. No attempt was made to free the latissimus within the pleural cavity. Only latissimus muscle adherent to the heart was resected. After excision of the native heart and adherent latissimus, the donor heart was implanted and anastomosed at the mid-atrial level. Function of the cardiac graft was excellent.
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Fig 1. Intraoperative photograph of native heart and cardiomyoplastic wrap. The latissimus wrap can be seen around the ventricular chambers extending in from the left chest to the mediastinum. The muscle was viable, contracting with electrical stimulation, and well perfused with no gross evidence of fibrosis.
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Fig 2. Photomicrograph of histologic specimen from excised native heart, showing the presence of normal-appearing skeletal muscle tissue (musculus latissimus dorsi). (Hematoxylin & eosin, x208.)
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The patient’s postoperative recovery was unremarkable. He is alive and well on immunosuppressive therapy 1 year after transplantation.
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Comment
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Carpentier and Chaques [2] reported the first successful cardiomyoplasty in 1985. Cardiomyoplasty involves wrapping the cardiac ventricular chambers with the latissimus dorsi. The muscle is harvested from the chest wall on its thoracodorsal neurovascular pedicle through an incision along the muscle’s anterior border and is translocated into the chest cavity through a small thoracotomy. A pacing electrode is woven through the proximal aspect of the muscle and connected to a pacemaker that can stimulate muscle contraction in synchrony with the cardiac cycle. The muscle is wrapped around the heart from the posterior to the anterior aspect and is anchored to the ventricular chambers with sutures. Muscle stimulation is not initiated until 2 weeks after surgery to allow adhesion of the heart and latissimus dorsi. After 2 weeks, latissimus electrical stimulation is initiated and progresses for more than 12 weeks to higher frequencies, resulting in a relatively fatigue-resistant muscle.
Clinical data from organized clinical trials support several conclusions about cardiomyoplasty. New York Heart Association functional class status and quality of life seem to improve consistently [3]. Modest improvements in left ventricular ejection fraction occur. Survival does not appear to be affected. Recurrent cardiac failure can develop [4, 5]. The magnitude of clinical improvement appears to exceed the degree of demonstrable improvement in left ventricular function [6].
The pathophysiology of improvements in cardiac performance after cardiomyoplasty is unclear. The expected mechanism of augmentation of left ventricular function by latissimus dorsi simultaneously contracting with the heart has been difficult to document. An alternate explanation is that cardiomyoplasty prevents left ventricular dilation, thus stabilizing cardiac function [7].
The present case report adds to the relatively scarce literature on cardiac transplantation after successful cardiomyoplasty. In doing so, it exemplifies the usual clinical course of patients undergoing cardiomyoplasty. As documented by the randomized multicenter dynamic cardiomyoplasty trial, which was prematurely terminated because of difficulty in recruiting patients, cardiomyoplasty results in markedly improved clinical performance, no objective improvement in ejection fraction, and good clinical recovery for prolonged periods (27 months) [8]. In our patient, the latissimus muscle remained viable and contractile 30 months after surgery. Moreover, cardiomyoplasty did not dramatically increase perioperative risks of transplantation; adhesions were easily dissected, the aorta and pulmonary arteries remained free of extensive adhesions, excision of the native heart at the mid-atrial level was uneventful, and muscle adherent to the pericardium was easily resected after removal of the native heart.
This patient illustrates that dynamic cardiomyoplasty does not unduly increase the risk of subsequent orthotopic cardiac transplantation.
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Acknowledgments
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We sincerely thank Jacki Abrams, MD, and Tomas Klima, MD, for their assistance in obtaining and analyzing the histologic specimen.
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References
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- Chacques J.C., Marino J.P., Lajos P., et al. Dynamic cardiomyoplasty: clinical follow-up at 12 years. Eur J Cardiothorac Surg 1997;12:560-567.[Abstract]
- Carpentier A., Chaques J.C. Myocardial substitution with a stimulated skeletal muscle: first successful clinical case. Lancet 1985;8440:1267.
- Jessup M. Dynamic cardiomyoplasty: expectations and results. J Heart Lung Transplant 2000;19:S68-72.[Medline]
- Letsou G.V., Austin L., Grandjean P.A., Braxton J.H., Elefteriades J.A. Dynamic cardiomyoplasty. Cardiol Clin 1995;13:121-124.[Medline]
- Lorusso R., Milan E., Volterrani M., et al. Cardiomyoplasty as an isolated procedure to treat refractory heart failure. Eur J Cardiothorac Surg 1997;11:363-372.[Abstract]
- Sevick M.A., Magovern J., Kamlet M.S., Rawson I., McCall M., Locke C. Health-related physical function and quality of well-being prior to and following cardiomyoplasty: a preliminary report. Panminerva Med 1998;40:8-12.[Medline]
- Schreuder J.J., van der Veen F.H., van der Velde E.T., et al. Left ventricular pressure-volume relationships before and after cardiomyoplasty in patients with heart failure. Circulation 1997;96:2978-2986.[Abstract/Free Full Text]
- Acker M.A. Dynamic cardiomyoplasty: at the crossroads. Ann Thorac Surg 1999;68:750.[Abstract/Free Full Text]
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