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Brief Communications View metadata, citation and similar papers at core.ac.uk brought to you byCORE provided by Elsevier - Publisher Connector BRIEF COMMUNICATIONS CARDIOMYOPLASTY COMBINED WITH IMPLANTATION OF A CARDIOVERTER DEFIBRILLATOR Valeri S. Chekanov, MD, PhD, Sanjay Deshpande, MD, and Donald H. Schmidt, MD, Milwaukee, Wis. In the United States alone, approximately 2 to 3 million 58/25 mm Hg and mean 36 mm Hg), elevated pulmonary patients generally are affected by heart failure, and this capillary wedge pressure (an atrial wave of 28 mm Hg, number is likely to increase. 1 Survival of patients with ventricular wave of 42 mm Hg, and mean of 32 mm Hg), advanced ventricular dysfunction is limited not only by and reduced cardiac index (2.12 L/min/m2). Coronary progressive pump dysfunction but also by the risk of angiography showed severe three-vessel coronary artery sudden cardiac death. The 1-year mortality risk exceeds disease. The left ventricle was severely hypocontractile, 50% for patients with class IV symptoms. 2 Dynamic with an ejection fraction of 10%. cardiomyoplasty is emerging as a promising form of Latissimus dorsi cardiomyoplasty was chosen instead of surgical therapy for patients with advanced ventricular heart transplantation because the patient did not have dysfunction, but sudden cardiac death remains a major end-stage heart failure. Cardiomyoplasty was performed factor in decreased long-term survival among patients who through a medial sternotomy and a posterior wrap was have undergone cardiomyoplasty.3 Among the various performed. A Medtronic cardiostimulator (Medtronic, available therapeutic strategies for patients at high risk for Inc., Minneapolis, Minn.) was implanted with the myocar- sudden cardiac death, the implantable cardioverter defi- dial and skeletal electrodes placed in the conventional brillator (ICD) has been shown to be effective. Adjunctive manner. The operation was completed without complica- use of the ICD may therefore provide an optimal outcome tions. for patients undergoing cardiomyoplasty.4 After satisfactory postoperative recovery, the electro- The following clinical summary describes the course of physiologic study was repeated to evaluate the efficacy of a patient who underwent cardiomyoplasty with concomi- drug therapy. Monomorphic VT of two hemodynamically tant ICD implantation. We believe that this combined compromising morphologies remained persistently induc- procedure may improve survival among cardiomyoplasty ible. Because of the patient's history of advanced ventric- candidates who are deemed to be at high risk for sudden ular dysfunction and cardiac arrest and the electrophysi- cardiac death. ologic indications of suppressive drug therapy failure, we Clinical summary. A 65-year-old retired physician with elected to proceed with the implantation of a cardioverter advanced ventricular dysfunction related to coronary ar- defibrillator for prophylactic management of VT and tery disease was evaluated for latissimus dorsi cardiomy- sudden cardiac death. Implantation of an ICD with a oplasty. In the months before evaluation, the patient had transvenous lead system was performed 2 weeks after two episodes of unexplained syncope. He had an out-of- cardiomyoplasty. Defibrillation testing was performed hospital cardiac arrest, from which he was successfully with step-down energy levels. The lead system used was a resuscitated; monomorphic ventricular tachycardia (VT) Medtronic Transvene right ventricular transvenous defi- was documented as the initial rhythm. brillation- and rate-sensing electrode with a second defi- The baseline 12-lead electrocardiogram showed sinus brillation electrode in the superior vena cava-innominate bradycardia with a first degree atrioventricular block, left vein junction and a subcutaneous patch placed along the bundle-branch block, and a rightward axis. During the left chest wall. A Medtronic pulse generator (model electrophysiology study, sustained monomorphic VT of at 7219D) was used in conjunction with this lead system, and least three morphologies and rates were easily inducible a defibrillation threshold of 24 J with a biphasic waveform and pace terminable. The patient was started on a regi- was obtained with this configuration. During defibrillation men of oral amiodarone loading for suppression of VT. testing, the cardiomyoplasty stimulator was temporarily Cardiac hemodynamic evaluation revealed evidence of programmed to deliver six pulses at the maximum ampli- pulmonary hypertension (right pulmonary artery pressure tude to evaluate any potential interaction between the cardiomyoplasty device and the ICD. No interaction was From the University of Wisconsin--Milwaukee Clinical Campus noted during testing, and all ventricular fibrillation epi- Milwaukee Heart Institute of Sinai Samaritan Medical Cen- sodes were appropriately detected by the ICD. The pa- ter, Milwaukee, Wis. tient had an excellent postoperative recovery after this Received for publication July 25, 1996; accepted for publication procedure. Dec. 11, 1996. A follow-up electrophysiologic evaluation of the ICD Address for reprints: Valeri S. Chekanov, MD, PhD, 945 N. and lead system was performed 3 days later. The cardio- Twelfth St., W419, P.O. Box 342, Milwaukee, WI 53201-0342. myoplasty generator was programmed to deliver six pulses at maximum amplitude and pulse width during this test- J Thorac Cardiovasc Surg 1997;114:489-91 ing, and the ICD was programmed at the maximum Copyright © 1997 by Mosby-Year Book, Inc. sensitivity to determine whether the ICD sensed any 0022-5223/97 $5.00 + 0 12/S4/79781 signals from the cardiomyoplasty generator. Inappropri- 489 The Journal of Thoracic and 490 Brief communications Cardiovascular Surgery September 1997 ate sensing was not observed despite these maneuvers, plasty remain at high risk for sudden cardiac death. and satisfactory defibrillation was obtained at 24 J in a Improvement in hemodynamic state and functional class biphasic waveform. The cardiomyoplasty generator was does not appear to eliminate this risk. Both primary and reprogrammed to its original settings after this procedure, secondary prevention of sudden cardiac death in this and the ICD also remained active. population must be addressed. The standard Medtronic cardiomyoplasty electrical In contrast with empirical or electrophysiologically stimulation protocol was started 2 weeks after cardio- guided antiarrhythmic therapy, the ICD appears to be myoplasty, and the final phase of training was reached associated with the best reduction in sudden cardiac death 70 days after the initial cardiomyoplasty operation. risk in this population. 4 Sudden cardiac death rates at During the follow-up period, the patient had two 5-year follow-up with the ICD have been reported to be episodes of VT. Both were detected by the ICD, and impressively low (4.5%). 9 The ICD thus appears to be the appropriate therapy was delivered with consequent optimal form of therapy for patients undergoing dynamic conversion to sinus rhythm. Interrogation and analysis cardiomyoplasty. of the stored electrograms revealed no interaction The timing of ICD implantation with respect to between the cardiomyoplasty generator and the ICD dynamic cardiomyoplasty needs to individually deter- during these clinical events. VT was appropriately mined. Cardiomyoplasty may be performed in patients detected by the ICD without oversensing of the cardio- who have already undergone ICD implantation. Alter- myoplasty generator during both events. natively, ICD implantation may be performed concom- The patient has continued to report subjective improve- itantly with or soon after the cardiomyoplasty proce- ment in functional class. He has had steady progress dure. In some patients, VT and cardiac arrest have not during 1 year of follow-up, although hypothyroidism re- recurred after cardiomyoplasty, perhaps as a result of sulting from amiodarone therapy has complicated his improvement in hemodynamics, ventricular stretch, or clinical course. Amiodarone therapy was initiated to re- autonomic imbalance. Implantation of a defibrillator duce the frequency of VT, and consequently the number should not be deferred in these cases, however, because of ICD shocks. The patient has had seven ICD shocks for the antiarrhythmic effect of cardiomyoplasty cannot be monomorphic VT since the initial ICD implantation, with accurately predicted. five of these shocks occurring before and two after At present, little is known about the potential interac- initiation of amiodarone therapy. tions between the ICD and cardiomyoplasty systems. It is Discussion. Survival of patients with advanced ven- necessary to perform careful intraoperative and postoper- tricular dysfunction is limited both by progressive pump ative testing to ensure that the cardiomyoplasty generator dysfunction and by the risk of sudden cardiac death. and the ICD do not interfere with one another. As long as The principal mechanism of sudden cardiac death in care is taken during implantation to ensure that such this population remains arrhythmia, with VT that de- interaction does not occur, long-term follow-up results generates into ventricular fibrillation being the most should parallel the results of concomitant ICD and pace- common. The development of VT, usually as a result of maker implantation. In our case, episodes of VT treated reentry, may be modulated by a variety of triggers, such by the ICD without compromising the operation of the as by alteration in myocardial wall stress from changing cardiomyoplasty
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