Interactive Cardiovascular and Thoracic Surgery 1:35-37(2002)
© 2002 European Association of Cardio-Thoracic Surgery
Biventricular assist device in extreme anorexia nervosa
Sven Beholza,*,
Holger Hotza,
Jochen Grosseb and
Wolfgang Konertza
a Department of Cardiovascular Surgery, Charité, Humboldt-University Berlin, Luisenstrasse 65, 10117 Berlin, Germany
b Department of Anaesthesiology and Intensive Care, Charité, Humboldt-University Berlin, Berlin, Germany
* Corresponding author. Tel.: +49-30-450-522196; fax: +49-30-450-522921
sven.beholz{at}charite.de
Received April 28, 2002;
received in revised form July 9, 2002;
accepted July 11, 2002
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Abstract
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Low body mass index is an independent risk factor in cardiac surgery. Cardiac function may be severely impaired in the case of extreme malnutrition and require cardiac assistance if cardiac surgery is necessary. We report a case of the successful use of a biventricular assist device in a patient with an extreme low body mass index (6.7) due to anorexia nervosa for recovery after mitral valve replacement due to endocarditis after infusion therapy for nutrition.
Key Words: Assist device; Endocarditis; Anorexia
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1. Introduction
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Anorexia nervosa frequently is accompanied by severe malnutrition; this may lead to severely impaired left ventricular function [1]. A body mass index (BMI) below 20 kg/m2 is known to be an independent risk factor for mortality after cardiac surgery [2]. In the case of urgent cardiac operation different strategies such as management of inotropics and the use of a ventricular assist device have to be considered critically when facing the increased risk of these procedures [3] in patients with low BMI.
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2. Case report
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A 31-year-old woman was admitted to our hospital due to increasing weakness after complete starving for 2 weeks. There was a history of anorexia nervosa with repeated psychotherapeutical interventions for more than 10 years. Body weight at the time of admission was 19 kg with a height of 168 cm (BMI 6.7 kg/m2). Nutritional status was reduced (Table 1). After 10 days of infusion therapy for nutrition the patient suffered from an acute mitral valve endocarditis with a 3 cm vegetation on the annulus and the posterior mitral leaflet leading to partial obstruction of the orifice. Echocardiographic assessment furthermore showed a severely impaired left and right ventricular function immediately prior to operation with an ejection fraction (EF) of 20% resulting from a diffuse hypocinesia of both ventricles in spite of high doses of inotropics (adrenaline 0.35 µg/kg per min). A mitral valve replacement with a 25 mm Hancock II Bioprosthesis (Medtronic, Minneapolis, MN) was performed during normothermic extracorporeal circulation (ECC) with a cross-clamping time of 39 min using intermittent antegrade warm blood cardioplegia. In spite of prolonged reperfusion weaning from ECC was not possible; due to the failure of both ventricles a biventricular assist device (BiVAD) using a 25 ml left and a 22.5 ml right ventricle (Medos, Medos AG, Stolberg, Germany) was implanted and weaning from ECC was possible after a total bypass time of 172 min. The patient was reexplored on postoperative days (POD) 1, 3 and 5 due to increased chest tube loss without finding any surgical bleeding. Activated clotting time was held in a range of 160–200 s using continuous infusion of heparin (500–750 units/h). Hemodynamics as well as serum lactate improved in the following days (Fig. 1). After 6 days of uneventful assistance weaning from BiVAD was possible and the device was explanted with only little increase in inotropics and primary chest closure. After temporary renal failure and continuous hemofiltration renal function recovered and hemofiltration was stopped on POD 87; after tracheotomy on POD 17 and recovery from different pneumonias decanulation was possible on POD 88. Echocardiographic assessment showed significant improvement of the left ventricular function (EF 45%) on POD 77 with regular function of the prosthesis. The patient was transmitted to a psychosomatic care unit on POD 95 and left hospital 2 months later on POD 150. Body weight increased during hospital stay to 33.5 kg (BMI 11.9 kg/m2).
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3. Comment
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In our young anorectic patient with an extreme low BMI of 6.7 kg/m2 mitral valve endocarditis occurred after infusion therapy for nutrition, a complication reported earlier [4]. Due to the size of the vegetation with partial obstruction of the orifice conservative antibiotic treatment was not possible in this particular patient. Malnutrition [1] as well as septic endocarditis [5] are well known reasons for myocardial insufficiency resulting in an increased risk of death, renal failure, pneumonia or reexploration for bleeding after cardiac surgery [2] as observed in our patient. Single use of a left ventricular device in patients with low BMI [3,6] with chronic heart failure or a right ventricular assist device combined with an intraaortic balloon pump in the case of postoperative biventricular failure [7] are described in the literature although the risk of death is increased in these subsets of patients. The use of a paracorporeal pulsatile biventricular assist device as used in our patient for temporary assistance may increase survival in patients with extreme low BMI and reduced ventricular function undergoing high risk urgent cardiac surgery.
PII: S1569929302000105
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References
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Abstract
1. Introduction