Asian Cardiovasc Thorac Ann 2000;8:305-310
© 2000 Asia Publishing EXchange Pte Ltd
Results of Batista Procedure in Ischemic Dilated Cardiomyopathy
Michael Zytowski, MD,
Gert Baumann, MD, PhD,1,
Holger Hotz, MD,
Simon Dushe, MD,
Christian Enzweiler, MD,2,
Adrian Borges, MD,1,
Viola Borak, MD,3,
Klaus Redmann, MD,4,
Peter Paul Lunkenheimer, MD, PhD,4,
Wolfgang Konertz, MD, PhD
Department of Cardiovascular Surgery
1 Department of Cardiology, Angiology, and Pulmonology
2 Department of Radiology
3 Department of Anesthesiology
Charité Humboldt University Berlin
Berlin, Germany
4 Department of Thoracic and Cardiovascular Surgery
University of Münster
Münster, Germany
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For reprint information contact: Michael Zytowski, MD Tel: 49 30 2802 5158 Fax: 49 30 2802 4529 email: michael.zytowski{at}rz.hu-berlin.de Department of Cardiovascular Surgery, Charité Humboldt University Berlin, Schumannstraße 20/21, Berlin 10098, Germany.
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Abstract
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From March 1995 to April 1998, 24 men and 5 women (mean age, 62.2 ± 10 years) underwent the Batista procedure for end-stage cardiac dysfunction due to ischemic dilated cardiomyopathy. Preoperatively, mean cardiac index was 1.9 ± 0.3 L•min–1•m–2, stroke index was 25 ± 5 mL•beat–1•m–2, ejection fraction was 20% ± 6%, and 22 (79%) patients were in New York Heart Association functional class IV. Associated procedures were coronary bypass (25), mitral valvuloplasty (15), aortic or mitral valve replacement (5), dynamic cardiomyoplasty (2), and aneurysmectomy (1). One patient (3.4%) died early and 3 (10.3%) died later. The 1- and 2-year actuarial survival was 87%. A left ventricular assist device was required in 2 patients during the follow-up period. Postoperatively, cardiac index was 2.9 ± 0.3 L•min–1•m–2, stroke index was 36 ± 5 mL•beat–1•m–2, and ejection fraction was 38% ± 10%. Left ventricular end-diastolic diameter decreased from 71 ± 8 mm to 55 ± 8 mm. Currently, 88% of survivors are in functional class I or II. It was concluded that the Batista procedure significantly improved objective and subjective parameters of cardiac performance during early and intermediate follow-up.
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Introduction
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Death due to cardiac failure is increasing and most patients are unsuitable for cardiac transplantation by current inclusion criteria.1 Partial left ventriculectomy, mainly used for idiopathic dilated cardiomyopathy, may also be applicable to ischemic dilated cardiomyopathy.2,3
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Patients and Methods
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From March 1995 to April 1998, 29 patients with ischemic dilated cardiomyopathy and profound cardiac failure (mean left ventricular end-diastolic diameter, 71 ± 8 mm; mean ejection fraction, 20% ± 6%) underwent the Batista procedure at Charité Humboldt University Berlin.2 The patients' ages ranged from 30 to 85 years with a median age of 64 years (mean, 62.2 ± 10 years). There were 24 men and 5 women. Ten patients (34%) fulfilled the criteria for cardiac transplantation: age under 70 years; absence of fixed pulmonary hypertension, diabetes, chronic obstructive lung disease, renal or hepatic failure, and cerebral or peripheral vascular disease; and psychosocial stability. Preoperative evaluation included left and right heart catheterization, coronary angiography, electron-beam computed tomography, and transthoracic or transeso-phageal echocardiography. Table 1
shows the specific cardiac and noncardiac comorbidity of these patients.
Ischemic dilated cardiomyopathy was defined according to the recent World Health Organization's definition as dilated myopathy that cannot be explained by the extent of the coronary lesions alone.4 Figures 1 and 2 are illustrative examples. Figure 1 shows ventriculography in systole and diastole of a patient with a large anterior aneurysm with extensive regional akinesia. This case was not considered to be suitable for the Batista procedure as the patient could be treated successfully by revascular-ization and aneurysmectomy according to the Dor technique.5 During the period of this study, 138 such patients, mostly with anterior aneurysms, were treated at our institution and they must be clearly distinguished from ischemic patients considered for the Batista pro-cedure. Figure 2 shows left ventriculography in a patient eligible for the Batista procedure. This patient had undergone mitral valve repair and coronary bypass grafting at another institution 3 years earlier. Excision of a large lateral wedge of myocardium and repeat revascularization of the left anterior descending coronary artery and the first diagonal branch were performed, which considerably improved the patient's condition. Thus, if the pathologic process was regional, no matter how large the region may be (Figure 1), we used the Dor technique of aneurysmec-tomy. If the pathology was diffuse and global (Figure 2), the Batista procedure was applied.
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Figure 1. Left ventriculography in systole and diastole in a patient with aneurysmal enlargement of the ventricle who was not considered as a candidate for the Batista procedure.
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Figure 2. Left ventriculography in systole and diastole in a patient with ischemic dilated cardiomyopathy who was suitable for the Batista procedure.
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The operation was performed under slightly hypothermic (34°C) cardiopulmonary bypass and cardioplegic arrest with antegrade delivery of 1 L of Bretschneider's crys-talloid cardioplegia. The distal anastomoses were per-formed first, using the left internal mammary artery to revascularize the left anterior descending coronary artery. In the last 10 patients, a Cosgrove ring (Baxter Healthcare Corp., Deerfield, IL, USA) was implanted from an atrial approach to shorten the posterior circumference of the mitral valve, thus increasing the area of coaptation. Sub-sequently, a ventriculectomy was performed in the apical area and the ventricle was inspected for scarring and thinned myocardium. The incision was extended and a wedge of myocardium large enough to reduce the ventricle to near normal size, was removed. In addition, Alfieri plasty of the mitral valve was performed to prevent it from prolapsing into the left atrium.6 Often in such large hearts, the chordae are also elongated. The ventricle was closed with the heart either beating or arrested, depending on the total aortic crossclamp time. In some patients, direct measurement of the left ventricular wall tension before and after ventriculectomy was carried out as described elsewhere.7 In addition to the Batista procedure, extensive reparative surgery was performed, as listed in Table 2. In 17 of the 29 patients, concomitant mitral valve surgery was performed; 11 had Alfieri plasty, 3 had a Cosgrove ring, and 1 had both. The other 2 patients underwent valve replacement.
Postoperative care followed standard institutional pro-tocols with special emphasis on strict afterload control for 24 to 48 hours. As part of an ongoing prospective trial, all patients treated after May 1998 received an automatic implantable cardioverter-defibrillator before discharge.
Data are presented as mean values ± standard deviation, or median and range to estimate the central tendency in abnormally distributed data. To check for significant differences, the Mann-Whitney U test was used. Actuarial survival was calculated by the Cutler-Ederer/Kaplan-Meier method.8
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Results
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Early (within 30 days) morality was 3.4% (1 patient) and there were 3 (10.3%) late deaths. The 1- and 2-year actuarial survival was 87% (Figure 3). Aortic crossclamp time ranged from 15 to 78 minutes with a median of 58 minutes. Weaning from cardiopulmonary bypass was performed very gradually; 2 patients required intraaortic balloon pump insertion but none needed a left ventricular assist device for weaning from cardiopulmonary bypass. Figure 4 shows the distribution of the sites of resection: anterior, posterior, lateral, or anteroposterior.
Hemodynamic improvement occurred in all patients. Intraoperatively measured wall tension decreased by up to 80% (Figure 5). Ejection fraction, cardiac index, and stroke index were significantly increased postoperatively (Table 3). Left ventricular end-diastolic diameter was reduced from 71 ± 8 mm preoperatively to 55 ± 8 mm postoperatively. Figures 6 and 7 illustrate the preoperative and postoperative electron-beam computed tomography findings in a 74-year-old patient who underwent triple coronary bypass grafting, mitral valve repair, and the Batista procedure with anterior resection. In this patient, the ejection fraction increased from 20% preoperatively to 45% postoperatively. The decreased left ventricular diameter and concurrent increase in systolic thickening of the left ventricle can be seen (Figure 7). The improve-ment in New York Heart Association functional class postoperatively is shown in Table 4. During follow-up, 1 patient deteriorated and required a left ventricular assist device. Two patients were readmitted due to cardiac failure. Functional improvement was maintained during follow-up in the other patients.
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Figure 5. Mean decrease in wall tension as measured intraoperatively with needle force probes in 2 patients. The measuring sites were in the anterolateral wall of the left ventricle at the apex, mid portion, and the base.
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Figure 6. Electron-beam computed tomography before the Batista procedure (A) at end-diastole and (B) at end-systole.
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Figure 7. Electron-beam computed tomography after the Batista procedure (A) at end-diastole and (B) at end-systole.
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Discussion
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Cardiac failure is increasing and it is the only common cardiovascular disease in which the mortality rate is rising.1 This is partly related to aging of the population. Better management after acute myocardial infarction, prevention of sudden death, previous interventional or surgical procedures, and better individual treatment in general has also led to an increased number of patients suffering from cardiac failure. However, most are unsuitable for cardiac transplantation because of their age or prohibitive comorbidity, as well as the shortage of donor hearts that precludes cardiac transplantation for all but a highly selected cohort of young patients. Permanent implantation of a left ventricular assist device is still in the early stages of development and it is an expensive treatment modality.9,10 The Batista procedure offers a less expensive and generally available treatment for dilated forms of end-stage myocardial failure. The extension of this procedure to ischemic hearts may benefit the large population of patients who present in advanced age with specific cardiac or noncardiac comorbidity and often with a history of previous open heart operations or multiple catheter interventions. Such patients may also have received an automatic implantable cardioverter-defibrillator after surviving cardiac arrest and although on effective treatment for arrhythmias, they may drift into heart failure. This is the type of patient population in Europe that might be considered for reverse remodeling of the dilated heart.
Patient selection criteria in this study included one or more of the following parameters: left ventricular end-diastolic diameter > 70 mm; left ventricular ejection fraction < 20%; and most importantly, left ventricular end-systolic volume index > 100 mL•m–2. The latter has been shown to be of prognostic value in ischemic patients.11 In a retrospective trial of coronary revascular-ization at our institution, operative mortality was 0% and 1- and 2-year survival was 100% when the left ventricular end-diastolic volume index was < 100 mL•m–2, regardless of preoperative ejection fraction (15% to 50%) or preoperative left ventricular end-diastolic pressure (10 to 40 mm Hg). Left ventricular end-diastolic volume index > 100 mL•m–2 was the only independent predictor of operative mortality and death in the intermediate follow-up period. Operative and 1- and 2-year survival after the Batista procedure was better than after revascularization alone in our patients with ischemic dilated cardio-myopathy. These data support the use of surgical reverse remodeling of ischemic hearts and in our experience, patients with ischemic dilated cardiomyopathy do better than patients with idiopathic dilated cardiomyopathy.12
Hemodynamic improvement after the Batista procedure and extensive revascularization in ischemic dilated cardio-myopathy is impressive. However, the optimal post-operative treatment for patients undergoing this procedure has to be found. Beta-blockers, angiotensin-converting enzyme inhibitors, calcium agonists, angiotensin-II receptor blockers, and spironolactone may become important tools to preserve and maintain the results obtained by surgery.
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References
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TOP
Abstract
Introduction
