According to the Times, Dr. Batista has performed over 300 such operations since 1994 at a small, rural hospital in southern Brazil. Although mortality was 20% during the first month and another 20% during the remainder of the first year, many patients seem to have had significant clinical improvement. These statistics are hard to evaluate, however, since the conditions under which Dr. Batista operates are sub-optimal, while long-term follow up is incomplete for many patients.
A number of centers in the U.S. are investigating this technique. Looking for more information on the operation, I did a MEDLINE search, which turned up nothing. Dr. Sergio Kaiser, a cardiologist from Rio de Janeiro who knows and has worked with Dr. Batista, was kind enough to translate/summarize one of the very few articles about this operation that have been published so far. The only English-language reference that I was able to locate was a case report by Dr. Batista in the Journal of Cardiac Surgery of March, 1996.
Orthotopic cardiac transplantation presently seems to be the best therapeutic approach for patients suffering from this condition, but its applicability is limited due to lack of donors, high costs involved and logistic difficulties in implementing a complex, widespread transplantation program in Brazil. Recently, Batista et al (1) demonstrated that the removal of a portion of the left ventricle could improve the heart's pumping function during the early postoperative period. However, there are no data concerning the clinical and laboratory evolution of these patients after hospital discharge. The aim of this study was to describe the short-term evolution of patients with CHF who underwent partial ventriculectomy.
Patients and Methods
From February to June 1995, ten patients with end-stage heart failure admitted at the Ribeirão Preto Heart Institute underwent partial left ventriculectomy after giving informed consent. The cardiomyopathy was ischemic in one patient, hypertensive in 2 and idiopathic in 4. Three additional patients had rheumatic heart disease but were excluded from the analysis because valve surgery was also performed, leaving 7 patients that form the basis of this report.
Mean duration of symptoms was 36±20 months and 3/7 (42%) were receiving I.V. inotropic agents in order to achieve hemodynamic stability. All were receiving digitalis and furosemide (mean 148 mg/day), 5 were taking captopril (mean dose 87 mg/d) and one took enalapril, 5 mg/d. Radionuclide ejection fraction was determined in 5 pts, ranging from 0.10 to 0.20. Echocardiographic LV diastolic dimensions ranged from 60-90 mm and LA dimensions from 38-47 mm.
The surgical procedure followed the original description by Batista et al, consisting of installation of cardiopulmonary bypass without aortic clamping and removal of a portion of the lateral wall of the left ventricle, beginning at the cardiac apex and ending at the mitral ring level, between the papillary muscles.
After hospital discharge, patients were seen on the 30th and 60th postoperative day. A follow-up echocardiogram and Radio Nuclide Angiogram were obtained 30 days after surgery. Continuous variables obtained before and after surgery were compared with Wilcoxon's test and categorical variables with Fisher's test when necessary. Statistically significant differences were accepted at p<0.05.
There were no deaths during the study period. Mean hospital stay was 17±14 days and all patients were in NYHA class IV before operation. By the 60th postoperative day, there were 2 pts in class II and 5 in class I. Mean NYHA functional class was 1.71±0.48 (p=0.009). Mean furosemide and captopril doses were respectively reduced to 60±33mg (p<0.05) and 37.5±34 mg (p<0.05).
Postoperative echocardiographic evaluation was performed in six patients. Left ventricular diastolic diameter decreased significantly from 75.67±11.98 mm to 64.67±11.82 mm (p<0.02). Conversely, mean LVEF increased from 0.15±0.05 to 0.22±0.04 (p=0.02).
According to the authors, this study shows that partial left ventriculectomy can be safely performed in patients with end-stage cardiomyopathy with acceptable levels of morbidity and mortality. The reason why patients improve with this technique is not well understood. By reducing LV dimensions, and consequently afterload, according to Laplace's law one should also expect a reduction of wall stress, thereby favouring a more vigorous contraction and a higher forward output. Similar results were recently described for patients treated with prolonged mechanical LV unloading (2).
1. Batista RJV, Santos JLV, Cunha MA et al. Ventriculectomia parcial: Um novo conceito no tratamento cirurgico de cardiopatias em fase final. Anais do XXII Congresso Nacional de Cirurgia Cardíaca. Sociedade Brasileira de Cirurgia Cardíaca 1995;150-1
2. Levin HR, Oz MC, Chen JM et al. Reversal of chronic ventricular dilation in patients with end-stage cardiomyopathy by prolonged mechanical unloading. Circulation 1995;90:2717-20
Considering the "afterload mismatch" phenomenon, which has been used to explain the reversible pump dysfunction in aortic regurgitation, it is possible to speculate that such a mechanism might also play a role in aggravating left ventricular failure in dilated cardiomyopathy. If the patient still has some contractile reserve, although blunted due to very high chamber stresses (afterload), then the mechanical reduction of LV diameter by ventriculectomy might allow the full mobilization of this contractile reserve. Also, the partially restored eliptical shape would allow a reduction in mitral regurgitation, that worsens, in many instances, the clinical manifestations of heart failure in these patients.
However, if this is in fact the case, I wonder whether the optimization of medical therapy would have exerted the same benefits. We have to keep in mind that many patients waiting for a heart transplant are undertreated, and some papers have already been published addressing this problem. I believe that some of Dr. Batista's cases might belong to this category.
Sergio E. Kaiser, MD
Rio de Janeiro, Brazil
We should not place any emphasis on the p-values and comparisons that are noted in the article. Not only is this not a randomized study, but we don't even know how the ten patients were selected for inclusion. This article is really a collection of case reports, rather than an actual study. It is interesting that the New York Times quotes a 40% one-year mortality rate, whereas no deaths were reported here. Case selection presumably plays a major role.
Dr. Kaiser's point about medical therapy is key, since very vigorous afterload reduction might indeed produce some of the results noted here. Ultimately, only a randomized trial will tell.
The material in this summary is more experimental and tentative than other summaries presented here. I chose to include it because congestive heart failure is such a common clinical problem, and Dr. Batista's work was presented in the NY Times and also on ABC television's "20-20" news show, probably leading to many questions from patients.
Michael Jacobson, MD
A brief "News & Views" piece about this operation was just published in the August, 1996 issue of Nature Medicine 8:859-60. It is by Patrick McCarthy, MD, from the Cleveland Clinic and describes the surgery and their experience with it so far. Not peer-reviewed, not referenced and not a trial, but worth mentioning since so little has been published so far. -- mj
Date: Wed, 05 Feb 1997
From: gradinac <gradinac@EUnet.yu>
In Belgrade, Yugoslavia, we have performed 11 partial left ventriculectomies since october 1996. All NYHA IV preoperatively, improved to at least NYHA II, except one patient that has died due to cerebrovascular insult. At 3 months control (5 pts.) all have maintained improved EF. In one, regurgitation has deteriorated after initial success of reconstruction, and this patient is going to be reoperated for mitral and tricuspid insuficiency (with EF of 55%!). We hope that this operation will become a treatment of choice for idiopathic, and valvular dilated CMP's in the future.
Date: Mon, 21 Apr 1997
I am not a physician but have been searching for information on the "Batista Procedure." I am a lawyer who represents hospitals, and have been reviewing the information available from a "standard of care" perspective, albeit for an experimental procedure.
From first-hand experience, the interest is enormous. There is a March 5, 1997 article in the Milwaukee Journal Sentinel that a local physician (Alfred Tector, MD) performed this procedure on a patient after viewing a videotape and discussing it with others who had actually performed it. ["Radical Surgery Removes a Piece of Man's Heart to Save it"]. Information about physicians performing the procedure seem best found in the news databases.
I agree that the medical literature is sparse. After accessing physician names through the news databases, my best sources have been the websites for institutions where the procedure has been performed. These include the Cleveland Clinic, the medicalboard homepage of Bryn Mawr Hosital, and Texas Heart Institute at St. Luke's Episcopal Hospital -- where they provide patient information and preliminary discussion of their results.
The best information is right here, in word searches of the Internet.
The fact that searching the Internet turns up links to websites where the procedure is being performed is indicative of the new way medical news is being disseminated. This poses a significant challenge to the biomedical literature as traditional purveyors of medical news (see Biomedical journals and the Internet).
Date: Mon, 28 Apr 1997
We have to learn much more about the surgical procedure described by Batista. Altough many centers in Brazil and other countries described improvement in left ventricular functional parameters and NYHA class, they also described a very high index of mortality due to ventricular arrythmias, probably generated by the huge ventricular scar. Some centers use amiodarone empirically after ventriculectomy and they can show imorovement in survival rates, altough their number of patients is limited.
I've known that an investigational trial performing electrophysiologic study before and after ventriculectomy is going on at INCOR. I think that we have to encourage these investigational trials before we assume that Batista's surgery is clinically useful
Nilson Araujo M.D.
Date: Tue, 29 Apr 1997
From: email@example.com (Sergio Emanuel Kaiser)
According to some preliminary, not yet published observations from the Cleveland Clinic, most of the patients operated with this technique have returned to their previous hemodynamic status after 4-5 months postoperatively. Despite this undesirable outcome, there have been no deaths so far, and they have been feeling well. Does this reflect the potential strength of a placebo effect?
I insist on the fact that this is a personal communication from a colleague who just came from there, not yet confirmed by any presentation or publication.
Date: Fri, 02 May 1997
From: Jamil Mattar Valente <firstname.lastname@example.org>
Following is the abstract of a paper published in December 1996 in the journal Arquivos Brasileiros de Cardiologia by a group of INCOR (Sao Paulo - Brazil) about their experience with partial ventriculectomy in dilated cardiomyopathy.
Jamil Mattar Valente, MD, MSc
Universidade Federal de Santa Catarina
Instituto de Cardiologia de Santa Catarina
Florianopolis SC - Brazil
Effects of Partial Ventriculectomy on Cardiac Mechanics, Contractility, Shape and Geometry of the Left Ventricle.
Giovanni Bellotli, Alvaro Moraes, Edimar Bocchi, Antonio Esteves F,
Noedir Stolf, Fernando Bacal, Caio Medeiros, Pedro Graziosi, Giovanni
Cerri, Adib Jatene, Fulvio Pileggi
Sao Paulo SP
Purpose - To investigate the short-term effects of partial ventriculectomy (resection of lateral wall associated with mitral annuloplasty) on cardiac mechanics, contractility, shape and geometry of the left ventricle (LV).
Methods - Eleven male patients with severe congestive heart failure due to dilated cardiomyopathy were studied. The mean age was 51 ± 7 years and the functional class was III (five patients) or IV (six patients) before surgery. Patients were evaluated before and at 17 ± 4 days after surgery by simultaneous LV pressure and echocardiographic data. End-diastolic pressure (EDP - mmHg), wall stress (EDS - g/cm2) and diameter (EDD - cm); end-systolic wall stress (ESS) and diameter (ESD), fractional shortening (FS - %) and maximal elastance (Emax - mmHg/cm/s); the diastolic slope of the pressure-diameter (Kp mmHg/cm) and stress-strain (Km - g/cm2) loops; shape (L/EDD, adimensional, where L is the LV long axis) and geometry (Th/EDD, adimensional, where TH is the LV diastolic thickness) were obtained.
2) All patients were discharged from hospital (15-29 days) in class I (eight cases), II (two), and III (one).
3) There was observed a decrease in EDP (24.3 ± 7.7 to 17.5 ± 3.2, p=0.016); in EDD (8.0 ± 0.7 to 7.2 ± 0.8, p=0.002); in EDS (57.9 ± 26.8 to 37.4 ± 19.2, p=0.005); in ESS (199 ± 46.9 to 102.8 ± 33.1, p=0.004); in ESD (7.1 ± 0.7 to 5.7 ± 0.8, p<0.001); in Kp (22.3 ± 15.9 to 11.5 ± 6.9, p=0.014); and in Km (467.4 ± 212 to 214.6 ± 87.4, p=0.01).
4) There was noted an increase in FS (11.5 ± 1.8 to 19.8 ± 3.9, p<0.001); in Emax (13.8 ± 2.2 to 18.6 ± 3.2, p<0.001); and in L/EDD(1.32 ± 0.1 to 1.47 ± 0.13, p<0.007) and Th/Dd (0.11± 0.04 to 0.17 ± 0.08, p<0.038).
Conclusion - Partial ventriculectomy showed multiple significant beneficial effects in these dilated myopathic hearts.
(Arq Bras Cardiol, volume 67 (n. 6), 395-400, 1966)
These are interesting and encouraging results. It must be emphasized that short-term hemodynamic improvement doesn't necessarily correlate with long term improvement (see the previous reader comment); that hemodynamics don't always correlate with symptoms; and that hemodynamics or symptoms don't necessarily correlate with survival. Long-term studies should help clarify these issues. -- mj
Date:Fri, 6 Jun 1997
I was talking to a friend of mine yesterday who is a Medicare reimbursement lawyer from Baltimore.
He told me that Medicare does not pay for left ventricular remodeling. He says that many physicians are unware of this. He told me that some MDs use the CPT code of excision of a cardiac aneurysm when billing Medicare and that this is incorrect.
Coding the procedure as an aneurysmectomy is obviously incorrect, unless Medicare somehow agreed to allow this CPT code to be temporarily used for the procedure, which seems very unlikely.
Date: Tue, 24 Jun 1997
My husband is being evaluated for this procedure -- and we agree, the only place we've been able to get information is through the net. Thanks to all for their comments. We are currently investigating insurance coverage- but as you probably know, without published studies, that is difficult. Anyone with any ideas on how to work with the insurance cos, please feel free to respond. We are also looking for compiled statistics from institutions other than Cleveland Clinic. Is there anything out there? Thank you for this interesting information in this web site.
Date: Mon, 07 Jul 1997
From: Sinisa Gradinac <gradinac@EUnet.yu>
Since last October, 25 partial left ventriculectomies have been performed at Belgrade University Clinic. Only patients with severe pulmonary hypertension are refused. Many patients (40%) were not eligible for heart transplantation. The operative mortality at this time is 3/25, or 12%. Two more patients have died, 3 and 2 1/2 months postoperatively. All the deaths have ocurred in the first three months, and all of them had unresolved afib, and 3 pulmonary hypertension (TPG 16-22). The follow up period is up to 9 months, mean 6 months. It seems that patient are stabilised after 3 months, and there have been no hospital admissions after this initial period. We are open for professional cooperation and patients assistance. Feel free to write.
Sini Gradinac, MD
August 21, 1997
In the August 16, 1997 Lancet there is a brief report from Bristol, England about 14 patients undergoing the Batista procedure with relatively good results.
In the same issue is a commentary by the French surgeon Alain Carpentier summarizing the Cleveland Clinic experience with the procedure, comparing it to the Bristol report and giving his own perspective. Very worthwhile reading for those interested in this topic.
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