Ann Thorac Surg 2006;81:2302-2304
© 2006 The Society of Thoracic Surgeons
Case report
Biventricular Pacing 18 Months After Batista Operation
Kenji Iino, MD
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,
Hirokazu Ohashi, MD,
Yasushi Tsutsumi, MD,
Takahiro Kawai, MD,
Hiromichi Fujii, MD,
Masateru Ohnaka, MD
Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Fukui, Japan
Accepted for publication July 27, 2005.
* Address correspondence to Dr Iino, Department of Cardiovascular Surgery, Fukui Cardiovascular Center, 2-228 Shimbo, Fukui, 910-0833 Japan (Email: k-iino{at}m8.dion.ne.jp).
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Abstract
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We conducted biventricular pacing in a patient with dilated cardiomyopathy and complete left bundle branch block who had recurrent heart failure and mitral valve regurgitation 18 months after partial left ventriculectomy and mitral valve repair. An epicardial lead was fixed on the left ventricular free wall surgically through a thoracotomy, and the other two leads were implanted transvenously. Biventricular pacing restored contractile synchrony and led to more efficient left ventricular contraction and reductions in mitral regurgitation. Biventricular pacing may produce beneficial effects for patients with the recurrent intractable heart failure associated with cardiomyopathy and complete left bundle branch block after partial left ventriculectomy.
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Introduction
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Although cardiac transplantation is the golden standard for definitive surgical treatment of end-stage heart failure, the use of the procedure is often precluded by the limited availability of donor hearts and strict selection criteria. Alternatively, partial left ventriculectomy (PLV) and mitral valve repair may also provide benefit for patients with end-stage dilated cardiomyopathy [1], but the long-term outcomes of the alternative therapy have not yet been established, and several investigators have reported that patients undergoing these procedures may experience progressive heart failure.
Biventricular pacing (BVP) is another strategy to improve systolic function in patients with dilated cardiomyopathy and to reverse intraventricular conduction delay by re-synchronizing contraction. The present study describes the favorable results after the use of BVP in a patient with dilated cardiomyopathy and complete left bundle branch block who had recurrent heart failure and mitral valve regurgitation 18 months after PLV and mitral valve repair.
A 55-year-old man was in his usual state of good health until December 1997 when he had sensations of chest tightness. He was subsequently diagnosed with dilated cardiomyopathy in February 1998, and was started on medical treatment with beta-blocker medication. Despite this therapy, the patient had a left ventricular (LV) end-diastolic diameter of greater than 70 mm in September 1999. In December 2002, the patient had abrupt worsening of his dyspnea and was hospitalized for further examination and treatment. On admission the patient's blood pressure was 100/70 mm Hg, and his pulse was 88/min and regular. A grade 3/6 pansystolic murmur was appreciated at the apex, and a chest roentgenogram showed an enlarged heart (cardiothoracic ratio, 61.4%) with signs of mild congestive heart failure. Echocardiogram demonstrated grade IV mitral regurgitation, a LV diastolic dimension of 79 mm, a LV systolic dimension of 69 mm, a LV ejection fraction of 20%, and an interpapillary muscle distance of 8 cm. Coronary angiography showed normal coronary vasculature without signs of significant stenosis. Left ventriculography revealed an LV end-diastolic volume index of 151 mL/m2, an LV end-systolic volume of 111 mL/m2, and an ejection fraction of 27%. Based on these findings, a Batista operation with mitral valve reconstruction was selected.
Surgery was performed through a median sternotomy. Incision and retraction of the pericardium revealed a very dilated and enlarged heart. Cardiopulmonary bypass was instituted between the ascending aorta and both vena cavae. The ascending aorta was clamped and cold cardioplegic solution was infused. The mitral valve was exposed directly through the left atrium, showing severe mitral annular dilation without rupture of the chordae tendinae. Ring annuloplasty was performed under hypothermic, blood cardioplegic arrest using a 26-mm Carpentier-Edwards Physio ring (Edwards Lifesciences LLC, Irvine, CA). After the closure of the left atrium, the aorta was unclamped, and an incision was made at the apex of the left ventricle in the beating heart and was extended toward the base. The postlateral wall of the left ventricule between the anterior and posterior papillary muscles was resected (resected myocardium = 9.0 cm in length and 2.5 cm in width). Finally, the mitral valve was repaired by suturing the central portion of the medial segments of the anterior and posterior leaflets through the ventricle with a running 4-0 polypropylene mattress suture. The patient was weaned from bypass with the assist of an intraaortic balloon pump. The total cardiopulmonary bypass time was 179 minutes, and the aortic cross-clamp time was 56 minutes.
The patient's recovery was uneventful without any episodes of ventricular tachycardia and ventricular fibrillation. Postoperative chest roentgenogram and echocardiography revealed improvement in the cardiothoracic ratio (52.6%) and the severity of mitral regurgitation (trivial), respectively. However, the patient was readmitted for dyspnea in May 2003 (ie, 18 months after the Batista operation). Echocardiography revealed stable LV dimension but worsening mitral regurgitation (moderately severe), and electrocardiography revealed complete left bundle branch block with a ventricular complex on electrocardiogram interval of 160 ms. Furthermore, LV contraction seemed to be asynchronous secondary to complete left bundle branch block by echocardiography.
Based on these findings, BVP was selected. A permanent screw-in type epicardial lead (5071-55 [Medtronic, Minneapolis, MN]) was fixed on the LV free wall through a thoracotomy at the fifth intercostal space, and the other two leads (5071-35 and 4951M-53 [Medtronic]) were implanted transvenously. The atrial lead was placed high in the right atrium, and the right ventricular lead was placed at the right ventricular apex. A permanent pacemaker (KDR731 [Medtronic]) was implanted in the left subclavian space, and three leads were connected to the pacemaker with a Y-adapter (5866-38M [Medtronic]). The pacemaker was set to dual-chamber pacing, dual-chamber sensing, and dual mode of response pacing with an atrioventricular delay of 120 ms. The threshold of the LV lead was 1.6 V at a pulse width of 0.6 ms.
The effect of BVP on LV measurements was tested using electrocardiography, echocardiography, and Swan-Ganz catheter measurements while the patient was in the intensive care unit postoperatively. Activation of BVP reduced the ventricular complex on electrocardiogram interval from 160 ms to 120 ms, reduced the severity of mitral regurgitation from moderately severe to mild, and reduced the LV volume (ie, LV diastolic dimension from 78 mm to 72 mm and LV systolic dimension from 69 mm to 65 mm). Furthermore, BVP decreased the pulmonary capillary wedge pressure from 20 mm Hg to 13 mm Hg and increased the cardiac index from 2.3 L/min/m2 to 3.3 L/min/m2. These effects resulted in improvement in clinical condition from the New York Heart Association functional class III to I. Twenty months after surgery the patient remained well without limitations in his activities of daily living.
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Comment
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Although medical treatment can delay progression of heart failure, cardiac transplantation remains the only definitive option for those with progressive or severe heart failure, making limitations in the supply of the donor heart particularly problematic. Partial left ventriculectomy obviates the need for donor organs and may lead to short-term and long-term improvements in the New York Heart Association functional class of surviving patients, but often it does not produce appropriate or sustained improvements in echocardiographic and hemodynamic measurements. Furthermore, the operation is associated with a substantial mortality (between 18 and 66% within the first postoperative year) [1, 2]; studies from the Cleveland clinic report that event-free survival at 3 years after PLV was only 26% [3]. In the present study, the patient underwent mitral valve reconstruction along with PLV to prevent recurrence of mitral regurgitation and subsequent re-dilatation of the left ventricle. However, Starling and colleagues [4] reported that there was no correlation between preoperative mitral regurgitation and clinical outcome. Bolling and colleagues [5] reported that 1-year and 2-year actuarial survival was 80% and 70%, respectively, after mitral valve reconstruction with an undersized flexible annuloplasty ring in patients with end-stage cardiomyopathy and refractory mitral valve regurgitation. Furthermore, Bolling and colleagues [5] reported that the New York Heart Association functional class and LV ejection fraction of surviving patients improved and that end-diastolic LV volumes decreased. They have demonstrated that mitral valve annuloplasty alone can result in improvements in LV geometry. Thus, in the present study, valve repair using a small annuloplasty ring and Alfieri repair were elected to prevent chronic volume overload, which may otherwise lead to late re-dilatation and failure. Regardless of these measures, the present patient experienced recurrence of mitral regurgitation after the procedure, leading to late failure.
Until now, several studies have reported that larger myocyte diameter, hemodynamic instability, increased pulmonary artery pressure, and extensive myocardial fibrosis were all predictors of late failure and poor survival [2–4]. Presumably, PLV in patients without these predictors may increase the number of patients who were well in late follow-up.
Biventricular pacing has been shown to improve cardiac contractility and clinical symptoms in patients with severe chronic heart failure and interventricular conduction delay, particularly in patients with complete left bundle branch block [6]. Cardiac inefficiency in the context of complete left bundle branch block is primarily the result of dyssynchronous LV contraction. Biventricular pacing restores systolic contractile synchrony (resynchronization), thereby leading to more efficient LV contraction and reductions in mitral regurgitation. In addition, BVP also shortens the atrioventricular delay, leading to better ventricular filling and decreased pre-systolic mitral regurgitation. The present article is the first report of BVP therapy after PLV and mitral repair. Data from the present study suggest that cardiac resynchronization therapy with BVP may produce beneficial effects in LV function in patients with recurrent mitral regurgitation and late re-dilatation after PLV and mitral repair. Thus, BVP should be considered for patients with the recurrent intractable heart failure associated with cardiomyopathy and complete left bundle branch block after PLV.
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References
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- Batista RJV, Verde J, Nery P, et al. Partial left ventriculectomy to treat end-stage heart disease Ann Thorac Surg 1997;64:634-638.[Abstract/Free Full Text]
- Gardinac S, Miric M, Popovic Z, et al. Partial left ventriculectomy for idiopathic dilated cardiomyopathyearly results and six-months follow up. Ann Thorac Surg 1998;66:1963-1968.[Abstract/Free Full Text]
- Franco-Cereceda A, McCarthy PM, Blackstone EH, et al. Partial left ventriculectomy for dilated cardiomyopathyis this an alternative for transplantation?. J Thorac Cardiovas Surg 2001;121:879-893.[Abstract/Free Full Text]
- Starling RC, McCarthy PM, Buda T, et al. Results of partial left ventriculectomy for dilated cardiomyopathy J Am Coll Cardiol 2000;36:2098-2107.[Abstract/Free Full Text]
- Bolling SF, Smolens IA, Pagani FD. Surgical alternatives for heart failure J Heart Lung Transplant 2001;20:729-733.[Medline]
- Reuter S, Garrigue S, Bordachar P, et al. Intermediate-term results of biventricular pacing in heart failurecorrelation between clinical and hemodynamic date. Pacing Clin Electrophysiol 2000;23:1713-1717.[Medline]
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Abstract
Introduction
