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J Thorac Cardiovasc Surg 1995;109:189-190
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

Dynamic cardiomyoplasty at 5 years: Russian clinical experience

Milwaukee Heart Project
Sinai Samaritan Medical Center
945 North 12th St.
Milwaukee, WI 53201-0342

To the Editor:

In the July 1993 issue of the JOURNAL (1993;106:42-54), Carpentier and colleagues presented their data on dynamic cardiomyoplasty performed on 52 patients with end-stage heart disease. Cardiomyoplasty with stimulated skeletal muscle was first performed by Carpentier at Hôpital Broussais in Paris in 1985. Hôpital Broussais has done the largest number of these operations in the world. In this article the authors mentioned that an additional 130 cardiomyoplasties have been performed worldwide. In Moscow, Russia, my colleagues and I began to perform dynamic cardiomyoplasty in 1988. Until March 1993, 35 such operations had been performed. Unfortunately, we published our complete results only in Russian journals and this information was not made readily available to centers where there are programs for clinic cardiomyoplasty.

The general program for skeletal muscle assistance was evaluated at Bakulev Institute for Cardiovascular Surgery in Moscow, Russia (director academician Vladimir Bourakovsky; 4000 operations on the heart, aorta, and its branches every year, including 2000 cardiopulmonary bypass procedures) in 1985. The first patient was operated on in October of 1988. We also taught this operation at the Siberian Scientific Investigation Institute of Cardiology, Tomsk, Russia (1990), Escort Heart Institute, New Delhi, India (1990), and Cumballa Hill Institute, Bombay, India (1991). In this letter I will discuss only 25 patients who were operated on before April 1992 and on whom were performed carefully comparative preoperative and postoperative studies.

Twenty-one patients had ischemic cardiomyopathy and four had dilated cardiomyopathy Four patients were in New York Heart Association class III and 21 in class IV. Exercise thresholds ranged from 25 to 50 watts, with an average of 30.5 watts. End-diastolic volume of the left ventricle was from 264 to 420 ml with a mean of 310.2 ± 4.6 ml. Left ventricular ejection fraction varied from 18% to 38% with a mean of 30.2 ± 2.6%. The range for left ventricular end-diastolic pressure was from 16 to 32 mm Hg with a mean of 22.8 ± 1.2 mm Hg. A median sternotomy, in four patients, was used as the operative approach in 1988 and 1989. Since 1990 the exposure of choice has been left anterolateral thoracotomy through the fourth intercostal space. Thirteen patients received the first-generation Russian myocardiostimulators (Stiminak 805, Moscow, Russia). Since 1991 the second-generation device (EKS 445, Moscow, Russia) has been used. The advantage of these stimulators is the ability to change stimulation ratios from 1:1 to 1:8. Four patients died during the early postoperative period, within 7 days after the operation (coronary artery thromboembolism in 1; progressive heart failure in 2; acute myocardial infarction in 1). One patient died in the postoperative period at 25 days; cause of death was cerebrovascular stroke. In the late postoperative period (8 and 12 months after operation) two patients have died of myocardial infarction. The follow-up period ranged from 6 months to 4.5 years. Fourteen patients were studied. Tolerance to physical exercise increased by two times up to 83.7 watts. The left ventricular end-diastolic volume decreased by an average of 15% to 265.1 ± 3.8 ml. The left ventricular ejection fraction increased by an average of 10% up to 41.2 ± 1.6%. Ten patients were examined and selected to determine the optimal regimen of myostimulation. Mean value of the cardiac index without stimulation was 3.9 ± 1.2 L/min per square meter, and with stimulation it was 5.1 ± 1.2 L/min per square meter. Stroke index changed from 38.5 ± 3.2 ml/m² without stimulation to 51.0 ± 4.2 ml/m² with stimulation. The maximal increase of cardiac index and stroke index was seen at a low synchronization ratio (1:4 or 1:6).

Because of our findings, I believe that cardiomyoplasty leads to clinical improvement in patients who have been followed up for 5 years. Cardiomyoplasty has a positive effect on central hemodynamics. The myostimulation regimens of 1:4 and 1:6 are the most advantageous for graft stimulation, and skeletal muscle rest is an important factor in overall outcome.

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