EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Cardiac transplants are limited because of a deficiency of donor organs. Most recipients with severe chronic heart failure are on a waiting list. Therefore, palliative surgical treatment of chronic heart failure is widely used. We report a case of successful application of palliative surgical approach for a patient with decompensated heart failure.

Key words : Bridge therapy, Chronic heart failure, End-stage cardiomyopathy, Mitral valve surgery

The main factor constraining the further development of heart transplant procedures is a deficiency of donor organs. Patients with chronic heart failure join a waiting list that strictly accords with the recipient’s selection criteria. Potential recipients are patients with severe chronic heart failure in whom all known methods of treatment (conservative and surgical) were unsuccessful. The average life expectancy of patients with chronic heart failure on transplant waiting lists is 1 year. Clearly, this period is often not long enough to selecting a donor heart.

Owing to the constraints mentioned above, in clinical practice, palliative medical approaches are taken to improve temporarily the decompensated state of these patients. These approaches fall into the general category of a “bridge to transplant” and comprise “mechanical,” “surgical,” and “medicamentous” bridge therapies. In the case presented, a “surgical bridge” was successfully applied to a patient with chronic heart failure.

Functional mitral regurgitation is a significant complication of end-stage cardiomyopathy; this complication can manifest in most heart failure patients as a preterminal or terminal event because it develops secondarily to a change in the annular-ventricular apparatus and altered ventricular geometry, resulting in incomplete leaflet coaptation.^1-4 Unfortunately, in patients with advanced dilated cardiomyopathy, mitral valve surgery for mitral regurgitation is generally associated with high operative risk and poor prognosis. Therefore, some authors believe that only heart transplant is an effective surgical treatment.^5-9However, despite severely decreased left ventricular function in these patients, mitral valve surgery can improve survival and reduce the need for allografts.^10-14

A 58-year-old patient arrived to the hospital by plane with complaints of shortness of breath during insignificant physical activity, a sensation of heartbeat, irregular heartbeat, easy fatiguability, and general weakness.

The patient had been ill since 2007, when heart rhythm interruptions started to become disturbing. The patient did not seek out medical care. In 2012, the patient began experiencing shortness of breath upon physical activity. That year, the patient’s state deteriorated owing to shortness of breath and edema in the lower extremities. The patient called emergency medical services. He was hospitalized in the Kostanay region hospital, where he was diagnosed with valvular heart disease with atrial fibrillation. He was discharged with recommendations for treatment. In 2014, he was rehospitalized in a planned way in our department.

Echocardiographic preoperative data were obtained on March 11, 2014. The findings were as follows: end-diastolic size of the left ventricle, 71 mm; end-systolic size, 56 mm; interventricular septum, 10 mm; posterior wall of the left ventricle, 11 mm; end-diastolic volume, 215 mL; end-systolic volume, 160 mL; ejection fraction, 22%; right ventricular size, 37 mm; base of the aorta, 29 mm; sinus of Valsalva, 39 mm; and ascending aorta, 35 mm. Diffuse hypokinesis of the ventricular walls was observed. The aortic valve is tricuspid, cusps were condensed at the edges and mobile. The mitral valve cusps were thickened and mobile. Aortic valve insufficiency was rated (+), and mitral valve insufficiency was rated (+ + +). The annulus of the mitral valve was 5.4 cm. The tricuspid valve cusps were condensed and mobile. Tricuspid regurgitation was rated (+ +). The annulus of the tricuspid valve was 5.2 cm.

Coronarographic data from January 14, 2014, showed left anterior descending artery stenosis of 20% to 30%. Other vessels appeared without lesions.

A surgical procedure was performed on the patient with cardiopulmonary bypass on March 20, 2014. The procedure involved mitral valve annuloplasty with a saddle-shaped ring (No. 30), tricuspid valve repair with a Tailor ring (No. 35), and implantation of left ventricular epicardial electrodes. Constant left ventricular epicardial electrodes were implanted in the side wall of the left ventricle owing to the patient’s initially low ejection fraction (22%), forthcoming repair of mitral valve insufficiency, expected decrease in ejection fraction after correction, and high probability of technical difficulties when implanting the endocardial electrodes in the left ventricle. However, considering the postoperative increase in ejection fraction of up to 45%, implantation of a cardiac resynchronization therapy device was refused. Instead, a follow-up survey of the patient’s condition, including control echocardiography 6 months later, was recommended.

Control echocardiographic images taken on April 2, 2014, showed mitral valve repair and no regurgitation. Tricuspid valve repair also was seen with no regurgitation. The pericardium was without lesions, and the left ventricular ejection fraction was 45%. Ultrasonography of the pleural cavities showed both the left and right sides to be without features. The patient was discharged in a satisfactory condition and given rehabilitation and recovery treatment.

In this case, surgical repair of the mitral and tricuspid valves improved the patient’s heart pumping function. Ejection fraction in the early postoperative period increased from 22% to 45% and was positively reflected in the patient’s subjectively improved condition. Previously, Gatti and associates⁵ reported on 24 consecutive patients with mitral regurgitation (> 2+) and advanced dilated cardiomyopathy who showed durable functional improvement after mitral surgery. Bolling1 reported on 140 patients with end-stage cardiomyopathy and refractory mitral regurgitation who achieved good outcomes after mitral valve repair with an undersized flexible annuplasty ring. Rukosujew and associates¹⁵ compared 1-, 2-, and 3-year survival rates in a group of 40 patients with ischemic or dilated cardiomyopathy who underwent mitral valve repair, with a group of patients who underwent heart transplant. These authors discovered that each group of patients had a similar survival rate. Thus, most investigators have concluded that mitral valve repair in patients with dilated or ischemic cardiomyopathy significantly improves clinical status. Thus, valve repair in these patients effectively extends the waiting time for a donor heart, and in some cases, can be alternative to transplant.

Volume: 13 Issue: 3 November 2015 - Supplement - 3

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