- Email: [email protected]
Biventricular pacing for weaning from extracorporeal circulation in heart failure
960
CASE REPORT KLEINE ET AL BIVENTRICULAR PACING FOR ECC WEANING
References 1. Leier C, Dewan C, Anatasia L. Fatal hemorrhage as a complication of neurofibromatosis. Vasc Surg 1972;6:98 –101. 2. Brasfield R, Gupta T. Von Recklinghausen’s disease: a clinicopathological study. Ann Surg 1972;175:86 –104. 3. Knight J, Cancilla P. Neurofibroma involving the superior vena cava with formation of aneurysm. Arch Pathol 1968;86: 427–30. 4. Ahlgren J, Maggio W, Chen F, Kent A. Neurofibromatosis mRNA expression in blood vessels. Biochem Biophys Res Commun 1993;197:1019–24. 5. Fuyano G, Kobayashi R, Horio H, Kodera K, Moringa S. A case of Von Recklinghausen’s disease associated with a hemothorax due to a rapidly growing malignant schwannoma. Jpn J Thorac Dis 1995;33:682–5. 6. Muluk S, Kaufman J, Torchinan D, Gertler J, Cambria R. Diagnosis and treatment of thoracic aortic intramural hematoma. J Vasc Surg 1996;24:1022–9. 7. Harris K, Braverman A, Gutierrez F, Barzilai B, Davila-Roman V. Transesophageal echocardiographic and clinical features of aortic intramural hematoma. J Thorac Cardiovasc Surg 1997;114:619–26.
Biventricular Pacing for Weaning From Extracorporeal Circulation in Heart Failure Peter Kleine, MD, Mirko Doss, MD, Tayfun Aybek, MD, Gerhard Wimmer-Greinecker, MD, and Anton Moritz, MD Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
Resynchronization of the intra- and interventricular conduction by biventricular pacing has been suggested in patients with end-stage heart failure. We present a case in which extracorporeal circulation could only be weaned after placement of an additional left ventricular pacing wire. Biventricular stimulation led to normal motion of the anterior wall and a previously bulging interventricular septum; this improved the hemodynamic situation significantly. (Ann Thorac Surg 2002;73:960 –2) © 2002 by The Society of Thoracic Surgeons
P
atients suffering from severe impairment of left ventricular function and dilatation of either the right or left ventricle often demonstrate changes of their interand intraventricular conduction system. Asynchronous ventricular contractions and thus shortened diastolic filling times are the major hazards of this pathology. Widening of ventricular complexes on electrocardiogram (QRS complexes) to more than 150 ms has been defined
Accepted for publication July 12, 2001. Address reprint requests to Dr Kleine, Klinik fu¨ r Thorax-, Herz-, und Thorakale Gefa¨ sschirurgie, Johann Wolfgang Goethe-Universita¨ t, Theodor Stern Kai 7, 60590 Frankfurt, Germany; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;73:960 –2
to be one independent risk factor for cardiac mortality in patients with poor left ventricular function [1]. An underlying complete left bundle branch block especially leads to interventricular septal wall motion abnormalities [2]. In these patients, resynchronization of the interventricular conduction system by biventricular stimulation leads to immediate improvement of cardiac function and New York Heart Association class [3, 4]. The perioperative mortality of patients undergoing open heart surgery with impaired left ventricular function is increased. Weaning from extracorporeal circulation especially can be difficult in these high-risk patients. Conventional therapeutic strategies focus on maximizing cardiac output by administration of adrenergic drugs and, in severe cases, implantation of intraaortic balloon pumps. Several studies [5, 6] have demonstrated, that intra- and postoperative biventricular pacing as well as shortening of atrioventricular delay can improve cardiac output, although these studies did not only investigate patients with depressed ventricular function. A 72-year-old male patient was referred to our hospital for further evaluation of mitral and aortic valve disease. One year earlier, a first episode of left ventricular failure had been treated by digitalis and diuretics with prompt relief of symptoms. Prior to admission, the patient complained of severe angina and shortness of breath. The electrocardiogram showed atrial tachycardia and a complete left bundle branch block with QRS complex width of 170 ms. The echocardiographic examination revealed aortic stenosis III° and mitral insufficiency III°. The ascending aorta was aneurysmatic; the left ventricle was significantly enlarged with an end-diastolic diameter of 78 mm. The global contraction was depressed with an ejection fraction of approximately 40%. During left heart catherization, biventricular failure accompanied by pulmonary edema occurred; the patient was intubated and referred to the intensive care unit. Implantation of an intraaortic balloon pump failed due to kinking of iliac arteries. An emergency operation was performed after stabilization of hemodynamics. Intraoperatively, the left ventricle was enlarged with a global reduction of contractility. Aortic valve replacement by a stented bioprosthesis size 23 mm, mitral ring annuloplasty size 26 mm, and replacement of the supracoronary ascending aorta were performed with an Xclamp time of 95 minutes. During reperfusion, complete atrioventricular block with a junctional escape rhythm was present. Dual chamber pacing with a right atrial and a right ventricular wire was started. Even with a high dosage of inotropic support, weaning from extracorporeal circulation failed due to left and right ventricular failure. The echocardiographic examination showed competence of the mitral valve, but revealed anterior hypokinesia and bulging of the interventricular septal wall (Fig 1A). This led to an eccentric shape of the left ventricular cavity. The atrioventricular delay was reduced to 80 ms as recommended by previous studies [5], and an additional temporary ventricular pacing wire was 0003-4975/02/$22.00 PII S0003-4975(01)03113-6 25
Ann Thorac Surg 2002;73:960 –2
CASE REPORT KLEINE ET AL BIVENTRICULAR PACING FOR ECC WEANING
961
postoperative day with now-stable hemodynamics. The following postoperative course was uneventful; a control echocardiographic examination showed significant improvement of the left ventricular function.
Comment
Fig 1. Echocardiographic short axis view of the left ventricle demonstrating the changes due to biventricular pacing. During reperfusion (A), the anterior wall and the interventricular septum demonstrated severe hypokinesia. With biventricular pacing (B), anterior and septal wall motion normalized (arrow) leading to a symmetrical left ventricular chamber.
placed on the left posterolateral wall close to the left atrial appendage. Atrio-biventricular pacing was started leading to a reduction of QRS width from 170 ms to 110 ms. Immediately, a normal anterior wall and interventricular septum motion was observed with transesophageal echocardiography leading to a symmetric contour of the left ventricular chamber (Fig 1B). Now weaning from extracorporeal circulation was successful with medium inotropic support. Hemodynamic stability was maintained during the rest of the operation with continuous atrio-biventricular pacing. The sternotomy was left open because of persistent right ventricular dilatation. During the following hours, the hemodynamic situation further improved. The sternotomy was closed on the 1st, and weaning from artificial ventilation was successful on the 8th, postoperative days. During the whole period of intensive care treatment, biventricular stimulation was performed. This was stopped on the 9th
Resynchronization of the intra- and interventricular conduction system by biventricular stimulation has been suggested in patients with impaired left ventricular function and widened QRS complex [2, 3]. The acute hemodynamic improvement was also observed in the postoperative course in patients with coronary artery disease with or without depressed left ventricular contractility [4 – 6]. In our patient, we were able to demonstrate that this acute benefit can be used for weaning from extracorporeal circulation in acute left ventricular failure. Optimization of cardiac output is the standard approach in these patients. Compared with conventional methods like intraaortic balloon implantation or administration of high doses of inotropic support, biventricular pacing can be easily initiated, is less invasive, and is accompanied by almost no side effects. The positive effect on regional wall contractility can be monitored by M-mode transesophageal echocardiography. In our case, anterior wall and interventricular wall motion abnormality was demonstrated, a phenomenon which is very common in open heart surgery, not only in patients with reduced ventricular function and left bundle branch block. Biventricular pacing led to immediate normalization of the regional wall motion. Thus, in our opinion, biventricular pacing has to be considered in a larger patient population. It can avoid the hazards of interventricular septum bulging as asymmetrical contraction, dilatation of the left ventricle, and reduced diastolic filling time. Additionally, a short atrioventricular delay of 80 ms can further improve the left ventricular function by optimizing the diastolic filling of dilated ventricular chambers, which has been demonstrated before [5]. Postoperative patients in left heart failure will especially benefit from biventricular stimulation, because the improvement of ventricular function following correction of the underlying disease is often rapid and can usually be observed within the first 24 hours after the operation; long-term multisite pacing is not necessary in this patient group. In summary, we describe a case, in which weaning from extracorporeal circulation was impossible due to biventricular failure. Placement of an additional left ventricular pacing wire and optimized biventricular pacing with a short atrioventricular-delay led to immediate symmetry of the left ventricular chamber and thus successful weaning from extracorporeal circulation. Thus, biventricular pacing should always be considered in the high-risk patient group with reduced left ventricular contractility especially if regional contractility is abnormal. This therapeutic option should be considered before more invasive techniques like intraaortic balloon pumping are initiated.
962
CASE REPORT MICHLER AND CAMACHO PRETRANSPLANT EX-VIVO MITRAL VALVE REPAIR
References 1. Josephson RA, Chahine RA, Morganroth J, Anderson J, Waldo A, Hallstrom A. Prediction of cardiac death in patients with a very low ejection fraction after myocardial infarction: a Cardiac Arrhythmia Suppression Trial (CAST) study. Am Heart J 1995;130:685–91. 2. Ikeoka K, Tanimoto M, Nomoto Y, et al. Interventricular septal wall motion abnormality in left bundle branch block. J Cardiol 1987;17:887–94. 3. Cazeau S, Ritter P, Lazarus A, et al. Multisite pacing for end-stage heart failure: early experience. PACE 1996;19: 1748–57. 4. Mansourati J, Etienne Y, Gilard M, et al. Left ventricularbased pacing in patients with chronic heart failure: comparison of acute hemodynamic benefits according to underlying heart disease. Eur J Heart Fail 2000;2:195–9. 5. Liebold A, Rodig G, Merk J, Birnbaum DE. Short atrioventricular delay dual-chamber pacing early after coronary bypass grafting in patients with poor left ventricular function. J Cardiothorac Vasc Anesth 1998;12:284–7. 6. Saxon LA, Kerwin WF, Cahalan MK, et al. Acute effects of intraoperative multisite pacing on left ventricular function and activation/contraction sequence in patients with depressed ventricular function. J Cardiovasc Electrophys 1998;9: 13–21.
Ex-Vivo Mitral Valve Repair Prior to Orthotopic Cardiac Transplantation Robert E. Michler, MD, and Diego R. Camacho, MD Division of Cardiothoracic Surgery, The Ohio State University School of Medicine, Columbus, Ohio
Mitral valve annuloplasty was performed prior to orthotopic cardiac transplantation in two donor hearts which were diagnosed with moderate to severe mitral regurgitation. The technical aspects are reviewed of ex-vivo mitral valve repair with concomitant heart transplantation. The recipients were classified as United Network for Organ Sharing (UNOS) I and both patients have had an excellent postoperative recovery. Over 2-year follow-up demonstrates normal mitral valve function without regurgitation. (Ann Thorac Surg 2002;73:962–3) © 2002 by The Society of Thoracic Surgeons
T
he continuing shortage of donor hearts remains a major limitation to widespread application of cardiac transplantation. Each year, the number of patients placed on transplantation waiting lists exceeds the supply of donor organs [1]. One approach to increase the number of available donors is to expand donor criteria [2]. Conventional cardiac procedures performed on im-
Accepted for publication April 17, 2001. Address reprint requests to Dr Michler, Division of Cardiothoracic Surgery and Transplantation, Heart Hospital, The Ohio State University Medical Center, N820 Doan Hall, 410 West 10th Ave, Columbus, OH 43210; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;73:962–3
paired donor hearts can expand the donor pool by making these hearts suitable for orthotopic transplantation in critically ill patients [3, 4]. This report discusses 2 cases in which mitral valve repair was performed prior to orthotopic heart transplantation.
Case Reports Patient 1 A 58-year-old man, with end-stage congestive heart failure due to idiopathic cardiomyopathy, was placed on the cardiac transplant waiting list as United Network for Organ Sharing (UNOS) status I. A 21-year-old male donor without history of cardiac disease suffered brain death from a motor vehicle accident. Echocardiography obtained prior to organ procurement revealed moderate mitral regurgitation without evidence of leaflet or chordal disease. Regional and global myocardial contractility was unimpaired and the ejection fraction (EF) was 55%. At organ procurement, the mitral valve was carefully inspected and was without degenerative alterations. A secundum atrial septal defect was observed. The heart was transported to our institution and the mitral valve was tested with injection of cold saline in the left ventricle while holding up the edges of the left atrium. Central insufficiency was noted due to incomplete coaptation of the leaflets. This appeared to be secondary to annular dilation. Annuloplasty was performed ex-vivo with a #30 Baxter (Baxter, Deerfield, IL) ring. The valve was again tested and excellent coaptation of the leaflets was confirmed by the absence of regurgitation. The heart was then implanted using the biatrial parasepstal technique. An intraoperative transesophageal echocardiogram obtained after separation from cardiopulmonary bypass revealed no mitral regurgitation. Postoperatively, the patient had an uneventful recovery. The intensive care unit stay was 3 days, and he was discharged 9 days after surgery in excellent condition. Echocardiography 24 months after heart transplantation demonstrated normal mitral valve function without regurgitation and an EF of 55%.
Patient 2 A 54-year-old man with end-stage congestive heart failure secondary to ischemic cardiomyopathy was placed on the cardiac transplantation waiting list as a UNOS status I recipient. He had a history of multiple coronary artery bypass procedures in 1984 and in 1990, and he was not a candidate for a third revascularization procedure. A 24-year-old male donor without cardiac history suffered an intracranial bleed from a closed head injury. The echocardiogram demonstrated severe mitral regurgitation without evidence of primary valvular pathology. The annulus appeared dilated. Left ventricular contractility was normal with an ejection fraction of 55%. Following explant, the mitral valve was inspected and annular dilatation was observed without evidence of valve disease. A #30 Baxter annuloplasty ring was implanted. The heart was then transplanted using the biatrial parasepstal technique. Intraoperative trans0003-4975/02/$22.00 PII S0003-4975(01)02865-X34
CASE REPORT KLEINE ET AL BIVENTRICULAR PACING FOR ECC WEANING
References 1. Leier C, Dewan C, Anatasia L. Fatal hemorrhage as a complication of neurofibromatosis. Vasc Surg 1972;6:98 –101. 2. Brasfield R, Gupta T. Von Recklinghausen’s disease: a clinicopathological study. Ann Surg 1972;175:86 –104. 3. Knight J, Cancilla P. Neurofibroma involving the superior vena cava with formation of aneurysm. Arch Pathol 1968;86: 427–30. 4. Ahlgren J, Maggio W, Chen F, Kent A. Neurofibromatosis mRNA expression in blood vessels. Biochem Biophys Res Commun 1993;197:1019–24. 5. Fuyano G, Kobayashi R, Horio H, Kodera K, Moringa S. A case of Von Recklinghausen’s disease associated with a hemothorax due to a rapidly growing malignant schwannoma. Jpn J Thorac Dis 1995;33:682–5. 6. Muluk S, Kaufman J, Torchinan D, Gertler J, Cambria R. Diagnosis and treatment of thoracic aortic intramural hematoma. J Vasc Surg 1996;24:1022–9. 7. Harris K, Braverman A, Gutierrez F, Barzilai B, Davila-Roman V. Transesophageal echocardiographic and clinical features of aortic intramural hematoma. J Thorac Cardiovasc Surg 1997;114:619–26.
Biventricular Pacing for Weaning From Extracorporeal Circulation in Heart Failure Peter Kleine, MD, Mirko Doss, MD, Tayfun Aybek, MD, Gerhard Wimmer-Greinecker, MD, and Anton Moritz, MD Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
Resynchronization of the intra- and interventricular conduction by biventricular pacing has been suggested in patients with end-stage heart failure. We present a case in which extracorporeal circulation could only be weaned after placement of an additional left ventricular pacing wire. Biventricular stimulation led to normal motion of the anterior wall and a previously bulging interventricular septum; this improved the hemodynamic situation significantly. (Ann Thorac Surg 2002;73:960 –2) © 2002 by The Society of Thoracic Surgeons
P
atients suffering from severe impairment of left ventricular function and dilatation of either the right or left ventricle often demonstrate changes of their interand intraventricular conduction system. Asynchronous ventricular contractions and thus shortened diastolic filling times are the major hazards of this pathology. Widening of ventricular complexes on electrocardiogram (QRS complexes) to more than 150 ms has been defined
Accepted for publication July 12, 2001. Address reprint requests to Dr Kleine, Klinik fu¨ r Thorax-, Herz-, und Thorakale Gefa¨ sschirurgie, Johann Wolfgang Goethe-Universita¨ t, Theodor Stern Kai 7, 60590 Frankfurt, Germany; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;73:960 –2
to be one independent risk factor for cardiac mortality in patients with poor left ventricular function [1]. An underlying complete left bundle branch block especially leads to interventricular septal wall motion abnormalities [2]. In these patients, resynchronization of the interventricular conduction system by biventricular stimulation leads to immediate improvement of cardiac function and New York Heart Association class [3, 4]. The perioperative mortality of patients undergoing open heart surgery with impaired left ventricular function is increased. Weaning from extracorporeal circulation especially can be difficult in these high-risk patients. Conventional therapeutic strategies focus on maximizing cardiac output by administration of adrenergic drugs and, in severe cases, implantation of intraaortic balloon pumps. Several studies [5, 6] have demonstrated, that intra- and postoperative biventricular pacing as well as shortening of atrioventricular delay can improve cardiac output, although these studies did not only investigate patients with depressed ventricular function. A 72-year-old male patient was referred to our hospital for further evaluation of mitral and aortic valve disease. One year earlier, a first episode of left ventricular failure had been treated by digitalis and diuretics with prompt relief of symptoms. Prior to admission, the patient complained of severe angina and shortness of breath. The electrocardiogram showed atrial tachycardia and a complete left bundle branch block with QRS complex width of 170 ms. The echocardiographic examination revealed aortic stenosis III° and mitral insufficiency III°. The ascending aorta was aneurysmatic; the left ventricle was significantly enlarged with an end-diastolic diameter of 78 mm. The global contraction was depressed with an ejection fraction of approximately 40%. During left heart catherization, biventricular failure accompanied by pulmonary edema occurred; the patient was intubated and referred to the intensive care unit. Implantation of an intraaortic balloon pump failed due to kinking of iliac arteries. An emergency operation was performed after stabilization of hemodynamics. Intraoperatively, the left ventricle was enlarged with a global reduction of contractility. Aortic valve replacement by a stented bioprosthesis size 23 mm, mitral ring annuloplasty size 26 mm, and replacement of the supracoronary ascending aorta were performed with an Xclamp time of 95 minutes. During reperfusion, complete atrioventricular block with a junctional escape rhythm was present. Dual chamber pacing with a right atrial and a right ventricular wire was started. Even with a high dosage of inotropic support, weaning from extracorporeal circulation failed due to left and right ventricular failure. The echocardiographic examination showed competence of the mitral valve, but revealed anterior hypokinesia and bulging of the interventricular septal wall (Fig 1A). This led to an eccentric shape of the left ventricular cavity. The atrioventricular delay was reduced to 80 ms as recommended by previous studies [5], and an additional temporary ventricular pacing wire was 0003-4975/02/$22.00 PII S0003-4975(01)03113-6 25
Ann Thorac Surg 2002;73:960 –2
CASE REPORT KLEINE ET AL BIVENTRICULAR PACING FOR ECC WEANING
961
postoperative day with now-stable hemodynamics. The following postoperative course was uneventful; a control echocardiographic examination showed significant improvement of the left ventricular function.
Comment
Fig 1. Echocardiographic short axis view of the left ventricle demonstrating the changes due to biventricular pacing. During reperfusion (A), the anterior wall and the interventricular septum demonstrated severe hypokinesia. With biventricular pacing (B), anterior and septal wall motion normalized (arrow) leading to a symmetrical left ventricular chamber.
placed on the left posterolateral wall close to the left atrial appendage. Atrio-biventricular pacing was started leading to a reduction of QRS width from 170 ms to 110 ms. Immediately, a normal anterior wall and interventricular septum motion was observed with transesophageal echocardiography leading to a symmetric contour of the left ventricular chamber (Fig 1B). Now weaning from extracorporeal circulation was successful with medium inotropic support. Hemodynamic stability was maintained during the rest of the operation with continuous atrio-biventricular pacing. The sternotomy was left open because of persistent right ventricular dilatation. During the following hours, the hemodynamic situation further improved. The sternotomy was closed on the 1st, and weaning from artificial ventilation was successful on the 8th, postoperative days. During the whole period of intensive care treatment, biventricular stimulation was performed. This was stopped on the 9th
Resynchronization of the intra- and interventricular conduction system by biventricular stimulation has been suggested in patients with impaired left ventricular function and widened QRS complex [2, 3]. The acute hemodynamic improvement was also observed in the postoperative course in patients with coronary artery disease with or without depressed left ventricular contractility [4 – 6]. In our patient, we were able to demonstrate that this acute benefit can be used for weaning from extracorporeal circulation in acute left ventricular failure. Optimization of cardiac output is the standard approach in these patients. Compared with conventional methods like intraaortic balloon implantation or administration of high doses of inotropic support, biventricular pacing can be easily initiated, is less invasive, and is accompanied by almost no side effects. The positive effect on regional wall contractility can be monitored by M-mode transesophageal echocardiography. In our case, anterior wall and interventricular wall motion abnormality was demonstrated, a phenomenon which is very common in open heart surgery, not only in patients with reduced ventricular function and left bundle branch block. Biventricular pacing led to immediate normalization of the regional wall motion. Thus, in our opinion, biventricular pacing has to be considered in a larger patient population. It can avoid the hazards of interventricular septum bulging as asymmetrical contraction, dilatation of the left ventricle, and reduced diastolic filling time. Additionally, a short atrioventricular delay of 80 ms can further improve the left ventricular function by optimizing the diastolic filling of dilated ventricular chambers, which has been demonstrated before [5]. Postoperative patients in left heart failure will especially benefit from biventricular stimulation, because the improvement of ventricular function following correction of the underlying disease is often rapid and can usually be observed within the first 24 hours after the operation; long-term multisite pacing is not necessary in this patient group. In summary, we describe a case, in which weaning from extracorporeal circulation was impossible due to biventricular failure. Placement of an additional left ventricular pacing wire and optimized biventricular pacing with a short atrioventricular-delay led to immediate symmetry of the left ventricular chamber and thus successful weaning from extracorporeal circulation. Thus, biventricular pacing should always be considered in the high-risk patient group with reduced left ventricular contractility especially if regional contractility is abnormal. This therapeutic option should be considered before more invasive techniques like intraaortic balloon pumping are initiated.
962
CASE REPORT MICHLER AND CAMACHO PRETRANSPLANT EX-VIVO MITRAL VALVE REPAIR
References 1. Josephson RA, Chahine RA, Morganroth J, Anderson J, Waldo A, Hallstrom A. Prediction of cardiac death in patients with a very low ejection fraction after myocardial infarction: a Cardiac Arrhythmia Suppression Trial (CAST) study. Am Heart J 1995;130:685–91. 2. Ikeoka K, Tanimoto M, Nomoto Y, et al. Interventricular septal wall motion abnormality in left bundle branch block. J Cardiol 1987;17:887–94. 3. Cazeau S, Ritter P, Lazarus A, et al. Multisite pacing for end-stage heart failure: early experience. PACE 1996;19: 1748–57. 4. Mansourati J, Etienne Y, Gilard M, et al. Left ventricularbased pacing in patients with chronic heart failure: comparison of acute hemodynamic benefits according to underlying heart disease. Eur J Heart Fail 2000;2:195–9. 5. Liebold A, Rodig G, Merk J, Birnbaum DE. Short atrioventricular delay dual-chamber pacing early after coronary bypass grafting in patients with poor left ventricular function. J Cardiothorac Vasc Anesth 1998;12:284–7. 6. Saxon LA, Kerwin WF, Cahalan MK, et al. Acute effects of intraoperative multisite pacing on left ventricular function and activation/contraction sequence in patients with depressed ventricular function. J Cardiovasc Electrophys 1998;9: 13–21.
Ex-Vivo Mitral Valve Repair Prior to Orthotopic Cardiac Transplantation Robert E. Michler, MD, and Diego R. Camacho, MD Division of Cardiothoracic Surgery, The Ohio State University School of Medicine, Columbus, Ohio
Mitral valve annuloplasty was performed prior to orthotopic cardiac transplantation in two donor hearts which were diagnosed with moderate to severe mitral regurgitation. The technical aspects are reviewed of ex-vivo mitral valve repair with concomitant heart transplantation. The recipients were classified as United Network for Organ Sharing (UNOS) I and both patients have had an excellent postoperative recovery. Over 2-year follow-up demonstrates normal mitral valve function without regurgitation. (Ann Thorac Surg 2002;73:962–3) © 2002 by The Society of Thoracic Surgeons
T
he continuing shortage of donor hearts remains a major limitation to widespread application of cardiac transplantation. Each year, the number of patients placed on transplantation waiting lists exceeds the supply of donor organs [1]. One approach to increase the number of available donors is to expand donor criteria [2]. Conventional cardiac procedures performed on im-
Accepted for publication April 17, 2001. Address reprint requests to Dr Michler, Division of Cardiothoracic Surgery and Transplantation, Heart Hospital, The Ohio State University Medical Center, N820 Doan Hall, 410 West 10th Ave, Columbus, OH 43210; e-mail: [email protected].
© 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;73:962–3
paired donor hearts can expand the donor pool by making these hearts suitable for orthotopic transplantation in critically ill patients [3, 4]. This report discusses 2 cases in which mitral valve repair was performed prior to orthotopic heart transplantation.
Case Reports Patient 1 A 58-year-old man, with end-stage congestive heart failure due to idiopathic cardiomyopathy, was placed on the cardiac transplant waiting list as United Network for Organ Sharing (UNOS) status I. A 21-year-old male donor without history of cardiac disease suffered brain death from a motor vehicle accident. Echocardiography obtained prior to organ procurement revealed moderate mitral regurgitation without evidence of leaflet or chordal disease. Regional and global myocardial contractility was unimpaired and the ejection fraction (EF) was 55%. At organ procurement, the mitral valve was carefully inspected and was without degenerative alterations. A secundum atrial septal defect was observed. The heart was transported to our institution and the mitral valve was tested with injection of cold saline in the left ventricle while holding up the edges of the left atrium. Central insufficiency was noted due to incomplete coaptation of the leaflets. This appeared to be secondary to annular dilation. Annuloplasty was performed ex-vivo with a #30 Baxter (Baxter, Deerfield, IL) ring. The valve was again tested and excellent coaptation of the leaflets was confirmed by the absence of regurgitation. The heart was then implanted using the biatrial parasepstal technique. An intraoperative transesophageal echocardiogram obtained after separation from cardiopulmonary bypass revealed no mitral regurgitation. Postoperatively, the patient had an uneventful recovery. The intensive care unit stay was 3 days, and he was discharged 9 days after surgery in excellent condition. Echocardiography 24 months after heart transplantation demonstrated normal mitral valve function without regurgitation and an EF of 55%.
Patient 2 A 54-year-old man with end-stage congestive heart failure secondary to ischemic cardiomyopathy was placed on the cardiac transplantation waiting list as a UNOS status I recipient. He had a history of multiple coronary artery bypass procedures in 1984 and in 1990, and he was not a candidate for a third revascularization procedure. A 24-year-old male donor without cardiac history suffered an intracranial bleed from a closed head injury. The echocardiogram demonstrated severe mitral regurgitation without evidence of primary valvular pathology. The annulus appeared dilated. Left ventricular contractility was normal with an ejection fraction of 55%. Following explant, the mitral valve was inspected and annular dilatation was observed without evidence of valve disease. A #30 Baxter annuloplasty ring was implanted. The heart was then transplanted using the biatrial parasepstal technique. Intraoperative trans0003-4975/02/$22.00 PII S0003-4975(01)02865-X34