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Ann Thorac Surg 2002;73:960-962
© 2002 The Society of Thoracic Surgeons

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Case report

Biventricular pacing for weaning from extracorporeal circulation in heart failure

^a Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany

Accepted for publication July 12, 2001.

* Address reprint requests to Dr Kleine, Klinik für Thorax-, Herz-, und Thorakale Gefässchirurgie, Johann Wolfgang Goethe-Universität, Theodor Stern Kai 7, 60590 Frankfurt, Germany
e-mail: p.kleine{at}em.uni-frankfurt.de

	Abstract

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Resynchronization of the intra- and interventricular conduction by biventricular pacing has been suggested in patients with end-stage heart failure. We present a case in which extracorporeal circulation could only be weaned after placement of an additional left ventricular pacing wire. Biventricular stimulation led to normal motion of the anterior wall and a previously bulging interventricular septum; this improved the hemodynamic situation significantly.

	Introduction

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Patients suffering from severe impairment of left ventricular function and dilatation of either the right or left ventricle often demonstrate changes of their inter- and intraventricular conduction system. Asynchronous ventricular contractions and thus shortened diastolic filling times are the major hazards of this pathology. Widening of ventricular complexes on electrocardiogram (QRS complexes) to more than 150 ms has been defined to be one independent risk factor for cardiac mortality in patients with poor left ventricular function [1]. An underlying complete left bundle branch block especially leads to interventricular septal wall motion abnormalities [2]. In these patients, resynchronization of the interventricular conduction system by biventricular stimulation leads to immediate improvement of cardiac function and New York Heart Association class [3, 4].

The perioperative mortality of patients undergoing open heart surgery with impaired left ventricular function is increased. Weaning from extracorporeal circulation especially can be difficult in these high-risk patients. Conventional therapeutic strategies focus on maximizing cardiac output by administration of adrenergic drugs and, in severe cases, implantation of intraaortic balloon pumps. Several studies [5, 6] have demonstrated, that intra- and postoperative biventricular pacing as well as shortening of atrioventricular delay can improve cardiac output, although these studies did not only investigate patients with depressed ventricular function.

A 72-year-old male patient was referred to our hospital for further evaluation of mitral and aortic valve disease. One year earlier, a first episode of left ventricular failure had been treated by digitalis and diuretics with prompt relief of symptoms. Prior to admission, the patient complained of severe angina and shortness of breath. The electrocardiogram showed atrial tachycardia and a complete left bundle branch block with QRS complex width of 170 ms. The echocardiographic examination revealed aortic stenosis III° and mitral insufficiency III°. The ascending aorta was aneurysmatic; the left ventricle was significantly enlarged with an end-diastolic diameter of 78 mm. The global contraction was depressed with an ejection fraction of approximately 40%. During left heart catherization, biventricular failure accompanied by pulmonary edema occurred; the patient was intubated and referred to the intensive care unit. Implantation of an intraaortic balloon pump failed due to kinking of iliac arteries. An emergency operation was performed after stabilization of hemodynamics.

Intraoperatively, the left ventricle was enlarged with a global reduction of contractility. Aortic valve replacement by a stented bioprosthesis size 23 mm, mitral ring annuloplasty size 26 mm, and replacement of the supracoronary ascending aorta were performed with an X-clamp time of 95 minutes. During reperfusion, complete atrioventricular block with a junctional escape rhythm was present. Dual chamber pacing with a right atrial and a right ventricular wire was started. Even with a high dosage of inotropic support, weaning from extracorporeal circulation failed due to left and right ventricular failure. The echocardiographic examination showed competence of the mitral valve, but revealed anterior hypokinesia and bulging of the interventricular septal wall (Fig 1A). This led to an eccentric shape of the left ventricular cavity. The atrioventricular delay was reduced to 80 ms as recommended by previous studies [5], and an additional temporary ventricular pacing wire was placed on the left posterolateral wall close to the left atrial appendage. Atrio-biventricular pacing was started leading to a reduction of QRS width from 170 ms to 110 ms. Immediately, a normal anterior wall and interventricular septum motion was observed with transesophageal echocardiography leading to a symmetric contour of the left ventricular chamber (Fig 1B). Now weaning from extracorporeal circulation was successful with medium inotropic support. Hemodynamic stability was maintained during the rest of the operation with continuous atrio-biventricular pacing. The sternotomy was left open because of persistent right ventricular dilatation. During the following hours, the hemodynamic situation further improved. The sternotomy was closed on the 1st, and weaning from artificial ventilation was successful on the 8th, postoperative days. During the whole period of intensive care treatment, biventricular stimulation was performed. This was stopped on the 9th postoperative day with now-stable hemodynamics. The following postoperative course was uneventful; a control echocardiographic examination showed significant improvement of the left ventricular function.

View larger version (94K): [in this window] [in a new window]   Fig 1. Echocardiographic short axis view of the left ventricle demonstrating the changes due to biventricular pacing. During reperfusion (A), the anterior wall and the interventricular septum demonstrated severe hypokinesia. With biventricular pacing (B), anterior and septal wall motion normalized (arrow) leading to a symmetrical left ventricular chamber.

	Comment

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Postoperative patients in left heart failure will especially benefit from biventricular stimulation, because the improvement of ventricular function following correction of the underlying disease is often rapid and can usually be observed within the first 24 hours after the operation; long-term multisite pacing is not necessary in this patient group. In summary, we describe a case, in which weaning from extracorporeal circulation was impossible due to biventricular failure. Placement of an additional left ventricular pacing wire and optimized biventricular pacing with a short atrioventricular-delay led to immediate symmetry of the left ventricular chamber and thus successful weaning from extracorporeal circulation. Thus, biventricular pacing should always be considered in the high-risk patient group with reduced left ventricular contractility especially if regional contractility is abnormal. This therapeutic option should be considered before more invasive techniques like intraaortic balloon pumping are initiated.

	References

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1. Josephson R.A., Chahine R.A., Morganroth J., Anderson J., Waldo A., Hallstrom A. Prediction of cardiac death in patients with a very low ejection fraction after myocardial infarction: a Cardiac Arrhythmia Suppression Trial (CAST) study. Am Heart J 1995;130:685-691.[Medline]
2. Ikeoka K., Tanimoto M., Nomoto Y., et al. Interventricular septal wall motion abnormality in left bundle branch block. J Cardiol 1987;17:887-894.[Medline]
3. Cazeau S., Ritter P., Lazarus A., et al. Multisite pacing for end-stage heart failure: early experience. PACE 1996;19:1748-1757.
4. Mansourati J., Etienne Y., Gilard M., et al. Left ventricular-based pacing in patients with chronic heart failure: comparison of acute hemodynamic benefits according to underlying heart disease. Eur J Heart Fail 2000;2:195-199.[Medline]
5. Liebold A., Rodig G., Merk J., Birnbaum D.E. Short atrioventricular delay dual-chamber pacing early after coronary bypass grafting in patients with poor left ventricular function. J Cardiothorac Vasc Anesth 1998;12:284-287.[Medline]
6. Saxon L.A., Kerwin W.F., Cahalan M.K., et al. Acute effects of intraoperative multisite pacing on left ventricular function and activation/contraction sequence in patients with depressed ventricular function. J Cardiovasc Electrophys 1998;9:13-21.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mirko Doss Tayfun Aybek Gerhard Wimmer-Greinecker Anton Moritz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kleine, P. Articles by Moritz, A. Search for Related Content PubMed PubMed Citation Articles by Kleine, P. Articles by Moritz, A.