80 yr. old myectomy patient

[Rene' Koenig]

Hi! Today I was speaking with a lady at work (she is the POA of my mothers roommate in the nursing home). I knew she was having heart problems and they had been doing some testing to find out what was wrong with her. She has had several heart caths. over the years and they told her that her heart muscle is "thick", but never actually diagnosed her with HCM. She is in her late 70's or early 80's. She and her dtr. were talking about her upcoming surgery at The Cleveland Clinic in Sept. Her dtr. said that she was recently diagnosed with Hypertrophic Cardiomyopathy and saw Dr. Lever. Small world! By the way she explained what they were going to do, I believe she is having her mitral valve replaced and a septal myectomy. However, she also said that they are replacing part of her heart muscle with a muscle from her leg...and that it is an 8 hour surgery. What??!!

Rene'

[Reenie]

Re: 80 yr. old myectomy patient

I don't know anything about replacing muscle, but it sure is a small world!

Reenie

[Lisa Salberg]

Re: 80 yr. old myectomy patient

Not sure what she is talking about ??

And YES it is a VERY small world

Lisa

[Linda]

Re: 80 yr. old myectomy patient

Hmmm, I wonder if the doctor told her he was replacing part of a heart vessel with a vessel from her leg? kind of like maybe a bypass? Just a thought Linda

[Lisa Salberg]

Re: 80 yr. old myectomy patient

I had the same thought ... Hey Linda - great minds...

Lisa

[Toogoofy317]

Re: 80 yr. old myectomy patient

Actually there is a procedure out there that takes if I'm not mistaken the thigh muscle and wraps it around the ventricals to assit.

It is a last resort for those who are in severe failure waiting for a heart transplant.

If anyone wants more specifics I can probably find the article again.

Mary S.

[Rene' Koenig]

Re: 80 yr. old myectomy patient

Hi! Thanks for the info. She DID say that she asked Dr. Lever what would happen if she didn't have the surgery...she said he told her she'd die if she didn't. So, obviously pretty serious. She and her daughter are both very intelligent ladies, they just both seemed so "unsure" of things. I'm sure this was all such a shock to the family (her husband is 88 yrs. old and he had a heart attack last year). I told her she would be in great hands at The Cleveland Clinic! Of the million cardiac surgeons at CCF , she has the same one that did my brothers surgery. Again, small, small world.

Rene'

[Stuart Schwartz]

Re: 80 yr. old myectomy patient

Mary,

I had the same thoughts as LISA & Linda when I read this.
This proceedure your talking about is very interesting.
So now we will look to you & lisa to find out more on this ( just for interest) and maybe we will see a tread in the future under procedures.
I will be in Dr Levers office on Wednesday - I'll ask about it.

Stuart

[Linda]

Re: 80 yr. old myectomy patient

Mary, I've read about that procedure too, but I'm not sure what the success has been. Also, when she said "replace", it didn't really sound like that procedure. I guess time will tell. Linda

[Toogoofy317]

Re: 80 yr. old myectomy patient

Hope this will shed more light on the subject!
Mary


CLINICAL EXPERIENCE
Indications and Contraindications
Dynamic cardiomyoplasty is a surgical procedure in which a skeletal muscle pedicle graft is wrapped around failing ventricles, electrically transformed into fatigue-resistant type I fibers, and then stimulated to contract in synchrony with cardiac systole to provide cardiac assist. This surgical procedure is proposed for selected patients who suffer from dilated cardiomyopathy and heart failure. [48 ] Patient age and etiology of the cardiomyopathy are not as important as in heart transplantation, since the procedure does not require a donor organ, is an autologous tissue, and does not require immunosuppression. In addition to common idiopathic and ischemic cardiomyopathies, patients who suffer from Chagas' disease can also be candidates for cardiomyoplasty. [49 ] .

Dynamic cardiomyoplasty should be considered one of several
therapeutic options for patients with heart failure. Patients should be selected for operation by comparing benefits and risks of cardiomyoplasty with alternate therapies, which include medical therapy and cardiac transplantation. [50 ] Currently, investigative restrictions exclude patients with comorbid cardiac disease such as left ventricular aneurysm, symptomatic coronary arterial disease, valvular disease, and sustained ventricular arrhythmias from cardiomyoplasty; however, the procedure does not exclude concomitant cardiac procedures. An ideal candidate is a New York Heart Association functional class III patient who is unsatisfied with symptom progression despite appropriate medical therapy and not eligible or unwilling to undergo heart transplantation.

There are a number of absolute and relative contraindications for cardiomyoplasty. Patients who do not have an intact latissimus dorsi muscle, such as those who have had previous posterolateral thoracotomy, require the contralateral latissimus dorsi or another muscle for the wrap. Patients who have had previous thoracic or cardiac surgery may require extensive lysis of adhesions, which may increase the technical difficulty and risk. Since the muscle flap occupies part of the pleural space, patients with poor pulmonary function may experience some reduction in respiratory reserve. Patients in terminal heart failure, such as those in New York Heart Association functional class IV, have a higher operative mortality because the procedure requires several weeks for muscle transformation. [51 ] Although absolute physiologic contraindications are still being determined, experience so far suggests that patients with maximal exercise oxygen consumptions (vo 2 ) of less than 10 mL/kg per min, patients with high pulmonary vascular resistance, and those with very low ejection fractions tend to have higher risks, even though some patients with ejection fractions as low as 10 percent have survived and benefited. [52 ]

Operative Techniques
Skeletal muscle grafts have been used to either replace or reinforce diseased myocardium. In the former operation, the muscle is used to replace a segment of ventricular wall after resection of a ventricular aneurysm or to enlarge a small ventricular cavity. For reinforcement, the skeletal muscle graft is wrapped over the heart and contracts in synchrony to augment contractile force. [26 ] So far, hemodynamic improvement after dynamic replacement cardiomyoplasty has not been well demonstrated, but clinical experience is small. Reinforcement dynamic cardiomyoplasty constitutes most of the clinical experience [53 ] , [54 ] (Fig. 52-7) .

General anesthesia is induced using a double-lumen endotracheal tube; the patient is placed in the right lateral position with the left arm elevated. The incision for raising the latissimus dorsi muscle flap is made at the lateral border of the muscle and extends from axilla to iliac crest. The muscle is detached from all surrounding tissues, except for the thoracodorsal neurovascular bundle. This bundle is easily seen from the costal (deep) surface of the muscle [23 ] (see Fig. 52-5) . Test stimulation of the nerve is done to ensure proper placement of the permanent electrodes. For such testing, muscle relaxants administered during anesthesia must be reversed. Approximately 6 cm of the second or third rib at the anterior axillary line is resected. After detaching the origin of the latissimus dorsi muscle from the humerus, the muscle and electrode leads are introduced into the left pleural cavity through the bed of the resected rib, taking care not to kink or overstretch the neurovascular bundle. The detached tendinous origin of the latissimus muscle is then sutured to the periosteum of the resected rib using pledgeted mattress sutures. The bed of the latissimus dorsi is drained using a closed draining system, the incision is closed, and dressings are applied.

The patient is then turned supine and reprepped and draped. A standard midline sternal incision is made. A reversed C-shaped pericardial incision is made to fashion a pericardial flap, which may be used to anchor or supplement the muscle wrap later. Epicardial sensing electrodes are placed, and sensing thresholds are measured as done for a demand cardiac pacemaker. The latissimus dorsi muscle flap and nerve electrodes are retrieved from the pleural cavity, and the muscle is wrapped around both ventricles. It does not appear to make any difference which surface of the muscle flap is applied to the epicardium, but it is important to avoid twisting the muscle flap. The entire muscle graft is inspected and palpated for evidence of twist. It is possible to wrap the muscle around both ventricles without placing sutures directly in the diseased and often friable myocardium. Two sutures in the posterior pericardium, one to the left of the pulmonary valve and the other at the medial junction of the inferior vena cava and right atrium, together define the location of the posterior atrioventricular groove. When these two pericardial sutures are sewn to corresponding points on the posterior border of the muscle flap, the muscle flap is secured behind the heart. The maneuver requires briefly lifting the cardiac apex, sliding the posterior border of the muscle flap beneath, and tying the two sutures. Arrhythmias associated with manipulation of the heart are controlled by intravenous xylocaine prior to the maneuver. [55 ] Following this, the rest of the muscle is folded over the right border and apex of the heart and pulled up snugly but not tightly to the lateral border of the muscle flap to complete the wrap. The pericardial flap fashioned earlier is used either to anchor the wrap cephalad or to cover the outflow tract of the right ventricle when the length of the muscle flap is not sufficient to cover both ventricles.

The sensing and stimulating electrodes are then connected to a cardiomyostimulator that is placed into a subcutaneous pocket, usually made in the left upper quadrant of the abdomen. The mediastinum is drained, the sternum is approximated, and all wounds are closed. Cardiopulmonary bypass is on standby throughout the operation; an intraaortic balloon pump may be inserted if necessary.

Postoperative Management
The patient is monitored and supported in the intensive care unit, and then allowed to recover for 1 week with the cardiomyostimulator turned off. This is the vascular delay period designed to avoid stimulating the ischemic distal portion of the muscle graft caused by division of some collaterals when the muscle graft is raised. [15 ] Following the delay, the patient undergoes a graded protocol of skeletal muscle transformation by incrementally increasing the frequency and strength of stimulation for the following 4 to 6 weeks prior to full-burst stimulation used for cardiac assist. [14 ]

Although the burst stimulation may be delivered during every systole, less frequent muscle stimulation such as a 1:2 ratio to heart rate may prevent skeletal muscle damage, particularly during high heart rates. Stimulation voltage is adjusted either by palpating the muscle contraction of the extrathoracic portion of the muscle graft in the left axilla or by observing contraction of the muscle under fluoroscopy or ultrasonography. The synchronizing delay is best determined using two-dimensional echocardiography. Many patients with dilated cardiomyopathy have mild to moderate mitral insufficiency, and premature initiation of the muscle wrap contraction can increase mitral regurgitation. Therefore, the onset of burst stimulation is synchronized with mitral valve closure, as determined by ultrasound. This is particularly important for patients with cardiac conduction abnormalities. In many patients, synchronization delay can be further optimized by measuring aortic flow of stimulated beats with Doppler echocardiography and selecting the delay period that maximizes observed aortic flow velocity. [47 ] Burst frequency is usually started at about 30 Hz, which has been shown experimentally to produce near-maximal recruitment of skeletal muscle motor units with minimal stimulator battery consumption. [24 ] Burst duration also must be programmed to avoid impairment of diastolic filling by the muscle wrap if it fails to relax in time. [56 ]

The patient is monitored long term in a manner similar to patients who have cardiac pacemakers and heart failure. Medical therapy is optimized according to the patient's condition, and arrhythmias are controlled carefully by medication and electrical conversion if necessary. The cardiomyo-stimulator is replaced as required; prophylactic replacement is predicted by the selected stimulation parameters chosen for each individual patient.

Results
Since the first clinical application of dynamic cardiomyoplasty a decade ago, more than 500 patients worldwide have undergone this operation. Results reported by various centers [22 ] , [36 ] , [37 ] are largely consistent with those obtained in the recently completed phase II clinical trial under a protocol approved by the Food and Drug Administration of the United States. [57 ] At present, a phase III prospective, randomized clinical trial to compare dynamic cardiomyoplasty with medical therapy is under way in North America. This study, in itself, pioneers rigorous scientific evaluation of new surgical procedures. [47 ]

In the phase II trial, a prospective study was carried out in approximately 50 patients who had dynamic cardiomyoplasty. Outcomes were compared with those of a reference group of medically treated patients with matched demographic, etiologic, clinical, and hemodynamic parameters. [58 ] Entry criteria and pre- and postoperative evaluations were clearly defined. Both in cardiomyoplasty and in the reference group, most patients were in New York Heart Association functional class III heart failure, suffered from either idiopathic or ischemic cardiomyopathies, and received well-supervised medical therapy. Operative mortality for cardiomyoplasty was about 10 percent, and 6 months after operation more than 80 percent of patients showed functional improvement that was significantly better than that of the reference group (Fig. 52-8) . These results were consistent with improved quality of life measurements observed in cardiomyoplasty patients (Fig. 52-9) . Hemodynamically, systolic functions such as left ventricular ejection fraction showed statistically significant but clinically modest improvement (Fig. 52-10) . There also was a trend toward less utilization of intensive care services by cardiomyoplasty patients. Actuarial survival data at 1 year were similar in the two groups (Fig. 52-11) . However, nearly 20 percent of patients in the reference group received heart transplants during this period; thus this survival comparison may not be valid because so many patients were not on medical therapy alone.

Dynamic cardiomyoplasty can be considered a bridge to transplantation in selected patients. Successful heart transplantation has been carried out in a number of patients after cardiomyoplasty. One of the important findings obtained so far is that few patients who survived the early postoperative period died from pump failure; more than 70 percent succumbed to sudden death, presumably due to arrhythmias. A new generation of cardiomyostimulators that also have the capacity to function as an implantable defibrillator is being developed. This may further improve the survival of patients following dynamic cardiomyoplasty.


http://www.ctsnet.org/edmunds/Chapter52section5.html

[Rene' Koenig]

Re: 80 yr. old myectomy patient

Mary,

I had never heard of such a thing! Boy, oh boy...modern medicine!

Thanks for the article.

Rene'

[Rene' Koenig]

Re: 80 yr. old myectomy patient

Hi everyone,

Thought I'd give you an update. She had surgery on 9/16 and had a few complications...was in the hospital for 10 or 11 days. Her husband stopped into work the other day and told me that they were getting ready to lifeflight her back to Cleveland. Apparently Cleveland Clinic was coming here to pick her up, rather than our hospital flying her there. He said she was running a fever. I haven't been at work since that day, so I'm not sure how she's doing now. Please keep her in your thoughts and prayers.

Rene'

[Reenie]

Re: 80 yr. old myectomy patient

I hope all goes well with her and that the CC can help her.

Reenie

[shirleymahoney]

Re: 80 yr. old myectomy patient

Rene

All my hopes and prayers will be with her

Shirley

[Rene' Koenig]

Re: 80 yr. old myectomy patient

Thanks for the positive thoughts.

I saw her daughter today and she said that she had developed pneumonia. She is now in the stepdown unit, and feeling much better. Her daughter said she even sounds like her old self, so that's good news!
They are very impressed with Dr. Lever and the Cleveland Clinic.

Rene'