Ann Thorac Surg 2005;80:e5-e7
© 2005 The Society of Thoracic Surgeons
Case report
Successful Treatment of Tachycardia-Induced Cardiomyopathy With LVAD in a 12-Year-Old Boy
Hideki Tatewaki, MD
a
,
Munetaka Masuda, MD
a
,
*
,
Takahiro Nishida, MD
a
,
Yoshikazu Kaji, MD
b
,
Hiroya Ushinohama, MD
c
,
Shigeki Morita, MD
a
,
Hisataka Yasui, MD
a
a Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan
b Department of Medicine and Biosystemic Science, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
c Department of Pediatric Cardiology, Fukuoka Children’s Hospital, Fukuoka, Japan
Accepted for publication April 6, 2005.
* Address reprint requests to Dr Masuda, Department of Cardiovascular Surgery, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan (Email: masudam{at}heart.med.kyushu-u.ac.jp).
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Abstract
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Tachycardia-induced cardiomyopathy is an unusual cardiac disease that is life-threatening if tachycardia is not controlled. We report a 12-year-old boy who suffered from ectopic left atrial tachyarrhythmia that was refractory to medications and caused tachycardia-induced cardiomyopathy with severe heart failure. The patient required a left ventricular assist device (ABIOMED BVS5000 [ABIOMED Inc, Danvers, MA]) as a bridge to recovery. Tachycardia was finally controlled with flecainide while the patient was on left ventricular assist device support. The device was successfully explanted after 28 days of support. The temporary use of a left ventricular assist device was necessary to maintain a good hemodynamic status during the treatment of pharmacological refractory tachycardia, and it allowed a successful bridge to recovery.
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Introduction
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Tachycardia-induced cardiomyopathy is a reversible form of cardiomyopathy. Numerous reports have described the improvement of tachycardia-induced cardiomyopathy after control of supraventricular or ventricular tachycardia with medication or ablation, or both [1–2]. However, pharmacological treatment of tachyarrhythmia becomes quite difficult when severe left ventricular (LV) dysfunction develops, as most of the anti-arrhythmic drugs have a negative inotropic effect. In this article, we report a 12-year-old boy with profound LV failure secondary to tachycardia-induced cardiomyopathy, who required a left ventricular assist device (LVAD). We believe this is the first report to describe the use of the mechanical assist device [ABIOMED BVS 5000 (Abiomed, Inc, Danvers, MA)] as a bridge to recovery in a child suffering from severe tachycardia-induced cardiomyopathy.
A previously healthy 12-year-old boy with a body weight of 50 kg presented with tachycardia and exertional dyspnea. He was admitted to our affiliate children’s hospital. Echocardiography showed poor LV function and an electrocardiogram showed ectopic atrial tachycardia at a rate of 170 beats per minute. The ectopic atrial tachycardia was refractory to procainamide, bepridil, adenosine triphosphate, digitalis, ß-blocker, and direct current cardioversion. Four weeks after the onset of tachycardia, the patient experienced severe heart failure requiring high dose inotropes. Further pharmacological treatment with anti-arrhythmic drugs was withheld due to concern over severe LV dysfunction. He was transferred to our hospital as a potential candidate for heart transplantation. Upon his arrival, he was hypotensive with a heart rate of 170 beats per minute. His echocardiogram showed LV dilatation with an end-diastolic diameter of 58 mm. There was marked impairment of LV systolic function (ejection fraction, 5%) despite high-dose inotropes. Plasma levels of natriuretic peptide type A and B were 420 and 1,140 pg/mL, respectively. Due to his poor hemodynamic status he was taken to the operating room to be placed on a temporary LVAD.
Cardiopulmonary bypass was initiated with ascending aorta and bi-caval venous cannulation in the operating room. Interatrial groove was dissected and two pursestring sutures with pledgets were placed in the left atrial wall posterior to the interatrial groove. A 32-French angled venous cannula was placed directly into the left atrial through this area. This venous cannula and the aortic cannula were connected to the ABIOMED BVS 5000 (Abiomed, Inc). The patient was weaned from cardiopulmonary bypass and supported by the LVAD. Flow was maintained around 4.0 L/min (3.0 L/min/m2) throughout the support period. Anticoagulation was maintained with a continuous infusion of heparin to keep activated clotting time 200 to 250 seconds and to keep partial thromboplastin time at approximately 70 seconds. Two days after LVAD implantation, the hemodynamic state improved enough to allow weaning off the inotropes. However, ectopic atrial tachycardia persisted despite trying ß-blockers, digitalis, pilsicainide, bepridil, and diltiazem. A viral myocarditis was ruled out by negative antibody titers to common viruses. In addition, the boy had been afebrile during the hospitalization. After 3 weeks of LVAD support, flecainide was successfully used to restore sinus rhythm. Subsequently, the LV function improved (Fig 1). After 4 weeks of support, the patient was successfully weaned off the LVAD. An electrophysiological study showed that the ectopic rhythm originated from the left atrial, and flecainide effectively suppressed this ectopic rhythm (Fig 2). Echocardiography performed 2 weeks after the removal of the LVAD revealed further improvement of LV function with an ejection fraction of 63% and an end-diastolic diameter of 46 mm. Plasma natriuretic peptide type A and B concentrations decreased to 28 and 32.2 pg/mL, respectively. The boy was discharged home 4 weeks after removal of the LVAD. Follow-up cardiac echocardiography showed normal cardiac function 2 years after discharge, and he is currently active without limitation.
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Fig 2. Electrophysiological study after weaning off the left ventricular assist device (LVAD) revealed early excitation at the distal site of coronary sinus, which represents the lateral wall of the left atrium. After infusion of flecainide, left atrial rhythm returned to sinus rhythm. Non-filled, white arrows = p wave on electrocardiogram; solid, black arrows = the fastest electrical excitation site in the atrium; ovals = p wave on electrocardiogram. (aVL = the augmented unipolar lead of left arm of electrocardiogram; CS = coronary sinus; HRA = high right atrium; LA = left atrium; RVa = apex of the right ventricle; V1 = the bipolar lead I of electrocardiogram.)
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Comment
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The ABIOMED BVS 5000 (Abiomed, Inc) has an automatic console and a gravity-filled, pneumatically driven system with pulsatility, offering stable hemodynamics without cumbersome management. There are many reports that describe the usefulness of this assist device for short-term circulatory support as a bridge to recovery or transplantation [3–6]. This device is also applicable to pediatric patients except for small children [7, 8]. However, because the inner lining of the circuit is not coated with heparin or other anti-clotting agents, anticoagulation with high doses of heparin is mandatory. In our patient, despite continuous infusion of heparin, we had to change the system three times due to thrombus formation within the circuit. Initially, activated clotting time was kept between 180 and 200 seconds. After the first episode of thrombosis, heparin was increased to maintain activated clotting time approximately 250 seconds. However, subsequent to a bleeding episode, heparin was decreased to maintain activated clotting time to approximately 200 seconds. Subsequently there were two other episodes of LVAD thrombus formation. A perfect anticoagulation regimen remains to be determined, and further improvement in the field of biocompatibility is required for this device.
In our case, we decided to use this assist device on a short-term basis because this patient’s candidacy for heart transplantation was questionable. Left atrial cannulation through the interatrial groove was chosen for its ease of access. Because the function of the right ventricle was fairly well preserved, we felt that only LV support was required to maintain adequate cardiac output in this patient.
Tachycardia-induced cardiomyopathy is reversible when tachycardia can be treated with medication or ablation. However, neither could be used in our patient because of severe LV dysfunction leading to hemodynamic instability. We did not attempt surgical ablation or catheter ablation due to technical limitation at our Electrophysiological lab. The LVAD allowed us to treat the boy without deterioration of organ function for 4 weeks. After trials of various anti-arrhythmic drugs failed, we discovered that flecainide successfully suppressed tachycardia. It took 1 week for the LV to recover after restoration of sinus rhythm.
In conclusion, the 12-year-old boy suffering from tachycardia-induced cardiomyopathy was successfully treated with the ABIOMED BVS 5000 (Abiomed, Inc) for 4 weeks as a bridge to recovery.
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Acknowledgments
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We are indebted to Dr Muhammad A. Mumtaz for his help with this article.
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References
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- Shinbane JS, Wood MA, Jensen DN, Ellenbogen KA, Fitzpatrick AP, Scheinman MM. Tachycardia-induced cardiomyopathya review of animal model and clinical studies. J Am Coll Cardiol 1997;29:709-715.[Abstract]
- Nerheim P, Birger-Botkin S, Piracha L, Olshansky B. Heart failure and sudden death in patients with tachycardia-induced cardiomyopathy and recurrent tachycardia Circulation 2004;110:247-252.[Abstract/Free Full Text]
- Champsaur G, Ninet J, Vigneron M, Cochet P, Neidecker J, Boissonna P. Use of the Abiomed BVS system 5000 as a bridge to cardiac transplantation J Thorac Cardiovasc Surg 1990;100:122-128.[Abstract]
- Couper GS, Dekkers RJ, Adams DH. The logistics and cost-effectiveness of circulatory supportadvantages of the ABIOMED BVS 5000. Ann Thorac Surg 1999;68:646-649.[Abstract/Free Full Text]
- Samuels LE, Holmes EC, Thomas MP, et al. Management of acute cardiac failure with mechanical assist. Experience with the ABIOMED BVS 5000 Ann Thorac Surg 2001;71:S67-S72.[Abstract/Free Full Text]
- Acker MA. Mechanical circulatory support for patients with acute-fulminant myocarditis Ann Thorac Surg 2001;71(Suppl III):S73-S76.[Abstract/Free Full Text]
- Ashton Jr RC, Oz MC, Michler RE, et al. Left ventricular assist device options in pediatric patients ASAIO J 1995;41:M277-M280.[Medline]
- Throckmorton AL, Allaire PE, Gutgesell HP, et al. Pediatric circulatory support system ASAIO J 2002;48:216-221.[Medline]
Top
Abstract
Introduction
= EF; 
= LVDd; 
= LVDs. (LVAD = left ventricular assist device; LVDd = left ventricle end-diastolic dimension, LVDs = left ventricle end-systolic dimension.)