Interact CardioVasc Thorac Surg 2008;7:272-274. doi:10.1510/icvts.2007.165571
© 2008 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Cardiac general |
Novel adjunct to surgery for end-stage cardiomyopathy receiving hemodialysis
Koichi Todaa,*,
Kazuhiro Taniguchia,
Hajime Matsueb and
Kiyoshi Yoshidaa
a Department of Cardiovascular Surgery, Japan Labor Health and Welfare Organization, Osaka Rosai Hospital, 1179-3, Nagasone-cho, Kita-ku, Sakai, Osaka, Japan
b Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan
Received 22 August 2007;
received in revised form 11 November 2007;
accepted 12 November 2007
*Corresponding author. Tel.: +81-72-252-3561; fax: +81-72-255-3349.
E-mail address: ktoda2002{at}yahoo.co.jp (K. Toda).
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Abstract
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Surgical management of heart failure patients receiving hemodialysis (HD) is a challenge to surgeons and reports are limited. Five patients receiving HD underwent a mitral annuloplasty with or without restoration of the left ventricle because of class III or IV heart failure due to mitral regurgitation and poor ventricular functions. Of those, three fully recovered to NYHA class I after the cardiac procedure, however, two patients remained symptomatic and required an adjunctive procedure. For that, we converted the arteriovenous dialysis shunt to an inter-arterial bypass by dividing the venous side of the shunt and anastomosing it to the proximal radial artery (RA), followed by ligation of the RA between the two anastomoses so that the RA was bypassed by the cephalic vein. Following this procedure, left ventricular end-diastolic pressure and volume were reduced, and heart failure symptoms diminished. This simple procedure was able to reduce the cardiac overload, while keeping the vascular access intact and may be a relevant adjunct to surgical reverse remodeling in end-stage heart failure patients receiving HD.
Key Words: Heart failure; Cardiomyopathy; Functional mitral regurgitation; Hemodialysis
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1. Introduction
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Cardiovascular disease is the major cause of mortality and morbidity in end-stage renal disease (ESRD) patients receiving hemodialysis (HD) and the overall prevalence of congestive heart failure (CHF) was reported to be 33% according to National incidence data on 107,922 new ESRD patients [1]. Surgical management of end-stage heart failure patients receiving chronic HD remains a challenge and there are limited number of reports [2]. We converted an arteriovenous dialysis shunt to an inter-arterial bypass in two end-stage ischemic cardiomyopathy (ICM) patients receiving HD, who demonstrated class II–III heart failure symptoms after restrictive mitral annuloplasty (RMA) and coronary artery bypass with or without restoration of the left ventricle (LV).
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2. Case 1
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A 64-year-old male ICM patient receiving HD developed class IV heart failure despite maximum medical treatment including Carvedilol which was reported to improve LV function and survival of patients with uremic dilated cardiomyopathy [3]. The left ventriculogram (LVG) showed poor LV function [ejection fraction (EF)=18%] with severe functional mitral regurgitation (MR). We performed an LV restoration, double vessel bypass using LITA to LAD and SVG to OM, RMA with a Carpentier–Edwards Physio ring #24 (Edwards Lifesciences, Irvine, CA), and tricuspid annuloplasty with a Cosgrove–Edwards Annuloplasty System #28 (Edwards Lifesciences, Irvine, CA). Three weeks after the surgery, he still complained of NYHA II–III heart failure symptoms despite there being no residual MR. We determined the dialysis shunt flow rate by measuring the shunt flow velocity and cross-sectional area of the shunt and found the shunt flow to be relatively high (1–1.5 l/min) as compared with the minimum required for a dialysis shunt (0.6 l/min) [4]. Therefore, we converted the arteriovenous shunt between the radial artery (RA) and cephalic vein to inter-arterial bypass by dividing the venous side of the shunt and anastomosing it to the proximal RA, followed by ligation of the RA between the two anastomoses so that the RA was bypassed by the cephalic vein (Fig. 1). Following the second procedure, LV end-diastolic pressure (LVEDP) was reduced and heart failure symptoms improved to NYHA class I (Table 1).
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Fig. 1. (a) Schematic drawing of arteriovenous shunt between radial artery (RA) and distal cephalic vein. (b) The arteriovenous shunt was converted to an inter-arterial bypass by dividing the venous side of the shunt and anastomosing it to the proximal RA, followed by ligation of the RA between the two anastomoses.
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Table 1 Change in CTR, cardiac volumes and functions, and BNP level before and after conversion of a dialysis shunt
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3. Case 2
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A 68-year-old female ICM patient with severe functional MR became intolerable to β-blocker therapy because of hypotension during HD. An angiogram showed triple-vessel disease with poor LV function (LVEF=25%) and severe functional MR. She underwent a triple-vessel bypass using LITA to LAD, SVG to OM and SVG to 4PD, RMA, and tricuspid annuloplasty as described in case 1. Three weeks after surgery, she still complained of NYHA II–III heart failure symptoms despite there being no residual MR. The dialysis shunt flow rate was evaluated and the shunt was converted to an inter-arterial bypass as described in case 1. Her heart failure symptoms improved and quantitative gated SPECT (QGS) revealed reductions in LV end-systolic volume (LVESV) and end-diastolic volume (LVEDV), and improvement of LVEF after conversion of the shunt (Table 1).
Both patients have been followed for more than 1.5 years, during which time they have been doing well without heart failure symptoms and converted vascular access have been functioning well in each without ischemic or embolic events in the hand.
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4. Discussion
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Surgical management of end-stage ICM generally consists of revascularization, LV restoration [5], and control of functional MR by RMA [6]. However, it is unknown whether those cardiac procedures alone are sufficient to reverse the cardiac remodeling that occurs in ICM patients with a dialysis shunt, because creation of a dialysis shunt increases cardiac output by 15% to accommodate shunt flow and chronic volume overload results in cardiac remodeling including enlargement and hypertrophy of LV [7]. Management of end-stage ICM patients receiving HD is a challenge to surgeons and there are limited reported experiences. Chang et al. successfully performed RMA in five heart failure patients receiving HD whose EF was 42±15% [2] and advocated the usefulness of RMA in surgical treatment of functional mitral regurgitation with uremic congestive cardiomyopathy. We treated five end-stage cardiomyopathy patients who were receiving HD and whose EF was lower than 35%. Three of those fully recovered to NYHA class I after RMA and LV restoration, whereas the two remaining patients presented herein remained symptomatic and required an adjunctive procedure.
In a prospective study of renal transplant recipients who underwent surgical closure of a dialysis shunt, significant reductions in LV dilatation and hypertrophy were shown, suggesting that LV remodeling caused by a dialysis shunt is reversible [8]. Therefore, we considered surgical closure of a dialysis shunt in conjunction with LV restoration, and RMA may reverse the remodeling process in ICM patients receiving HD. However, a dialysis shunt is the standard means of access for long-term HD [4] and there are problems with peritoneal dialysis (PD) or catheter based dialysis. Notably patients with CHF have a significantly poorer survival when treated with PD as compared to those with HD [1]. In order to diminish cardiac overload due to the dialysis shunt and also keep the vascular access intact, we converted the arteriovenous dialysis shunt to an inter-arterial bypass. Following that adjunctive procedure, patients' symptoms were improved along with decreases in LVEDV, LVESV, LVEDP and plasma brain natriuretic peptide (BNP) level. Because BNP is produced by ventricular myocytes in response to increases in ventricular pressure and stretch, the reduction of plasma BNP level might have been attributable to decreased ventricular pressure and stretch.
The artery itself has been utilized as a permanent vascular access in some cases, after using a subcutaneously fixed superficial femoral artery for HD [9]. However, this is a traumatic procedure that can be performed only in younger patients with an unchanged artery. Our procedure was easy to perform under local anesthesia and applicable for older patients with diseased arteries.
In conclusion, our preliminary observations suggest that conversion of arteriovenous dialysis shunt may be a relevant adjunct to surgical reverse remodeling in selected end-stage heart failure patients receiving HD, though the long-term follow-up is mandatory.
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References
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Abstract
1. Introduction