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J Thorac Cardiovasc Surg 1999;117:616-618
© 1999 Mosby, Inc.

BRIEF COMMUNICATIONS

PARTIAL LEFT VENTRICULECTOMY IN AN INFANT WITH DILATED CARDIOMYOPATHY

Shinpei Yoshii, MDa, Shigeru Hosaka, MDa, Wataru Takahashi, MDa, Hiroshi Amano, MDa, Samuel J. K. Abraham, MDa, Shigeaki Kaga, MDa, Yusuke Tada, MDa, Hisashi Sugiyama, MDb, Jun Yanai, MDb, Yamanashi, Japan

From the Departments of Surgerya and Pediatrics,b Yamanashi Medical University, Yamanashi, Japan.

Received for publication Oct 19, 1998. Accepted for publication Nov 2, 1998. Address for reprints: Shinpei Yoshii, MD, Yamanashi Medical University, Tamaho-Cho, Nakakoma-Gun, Yamanashi, 409-3898, Japan.

Partial left ventriculectomy for dilated cardiomyopathy (DCM) was first reported by Batista and associatesGo 1 in 1996. Several authors have reported their clinical experience with this operation in adults.Go Go 1-3 However, its use in infants has not been reported. We have performed partial left ventriculectomy in an infant with DCM.

Clinical summary

A 5-month-old girl was admitted on an emergency basis with symptoms of severe congestive heart failure. The cardiothoracic ratio (CTR) on chest radiography was 67%. Echocardiography revealed left ventricular dilatation and a thin myocardium. At the apex, sponge-like myocardiumGo 4 was detected. The diastolic dimension was 44.5 mm, the systolic dimension was 42.4 mm, and the ejection fraction was 13.5%. The patient was treated with dopamine, amrinone, and furosemide, and her condition stabilized. The CTR was reduced from 67% to 63%.

Laboratory investigation revealed no signs of acute myocarditis. Cardiac catheterization showed normal coronary arterial anatomy. Myocardial biopsy revealed no abnormalities. The diagnosis of DCM was made, and conventional treatment was started.

Echocardiography and chest cardiography 2 months later revealed an increase in the diameter of the left ventricle and a decrease in the ejection fraction. Her general condition was deteriorating. Growth hormone therapyGo 5 was started. Mitral regurgitation and left ventricular enlargement (diastolic dimension, 51.3 mm; systolic dimension, 49.5 mm; ejection fraction, 7.4%) were detected by echocardiography 2 weeks later, at which time she became seriously ill. The CTR increased to 67% (Fig. 1). Reduced urine volume, elevated hepatic transaminase concentrations, and metabolic acidosis also were detected. Emergency partial left ventriculectomy was carried out. The 8-month-old patient weighed 5.2 kg. Using cardiopulmonary bypass and cardioplegic arrest, a partial left ventriculectomy and mitral valvuloplasty with Alfieri repairGo 3 were performed. Transesophageal echocardiography and continuous monitoring of mixed venous oxygen saturation (SvO2) with a thermodilution cannula were used. The inner wall of the apex of the left ventricle contained sponge-like coarse trabeculations. The posterior left ventricular muscle between the two papillary muscles was resected as much as possible, especially at the apex. Weaning from cardiopulmonary bypass was smooth. No mitral regurgitation was detected by intraoperative transesophageal echocardiography.



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  		Fig. 1. Preoperative chest x-ray film and echocardiogram.

 
The initial SvO2 was 24% and a severe low-output syndrome was suspected. In the intensive care unit, the hemodynamics were maintained with dopamine, dobutamine, milrinone, and hydralazine. The SvO2 increased steadily. On the third postoperative day, the SvO2 was 60% to 70%. On the fourth postoperative day, the SvO2 was 70%. She was weaned from the respirator. Her general condition improved. After the first postoperative week, the diastolic dimension was 41.4 mm, the systolic dimension was 37.6 mm, the ejection fraction was 25%, and the CTR was 57% (Fig. 2). One month after the operation, ß-blocker therapy was started. Her condition improved clinically.



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  		Fig. 2. Postoperative chest x-ray film and echocardiogram.

 
Histopathologic examination revealed fibrous thickening of the endomyocardium, interstitial fibrosis, and perivascular fibrosis in the myocardium, consistent with DCM.

Comment

In Japan, heart transplantation in infants is not possible because of legal problems. Although Batista's operation is an option for severe DCM in adults, it is a palliative procedure that is in no way equal to heart transplantation. In our situation, partial left ventriculectomy has several advantages; the procedure can be performed on an elective basis, no donor is needed, and postoperative immunosuppressive therapy is not required.

Our patient was critically ill just before the operation. The following key points were considered before the procedure was attempted. Theoretically, this procedure results in improved left ventricular function in adults. We expected the same results. Clinically, many reports have been published concerning adults who have become well enough to be removed from the heart transplantation waiting list. Although resection of the left ventricle in an infant with DCM could be limited to the area between the two papillary muscles, it was determined that Alfieri's mitral repair could also be used to improve left ventricular function.

Our patient's condition improved clinically. Therefore partial left ventriculectomy should be considered for infants with DCM.

References

  1. Batista RJV, Santos JLV, Takeshita N, Bocchino L, Lima PN, Cunha MA. Partial left ventriculectomy to improve left ventricular function in end-stage heart disease. J Card Surg 1996;11:96-7. [Medline]
  2. Batista RJV, Verde J, Nery P, Bochino L, Takeshita N, Bhayana JN, et al. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg 1997;64:634-8. [Abstract/Free Full Text]
  3. McCarthy PM, Starling RC, Wong J, Scalia GM, Buda T, Vargo RL, et al. Early results with partial left ventriculectomy. J Thorac Cardiovasc Surg 1997;114:755-65. [Abstract/Free Full Text]
  4. Chin TK, Perloff JK, Williams RG, Jue K, Mohrmann R. Isolated noncompaction of left ventricular myocardium: a study of eight cases. Circulation 1990;82:507-13. [Abstract/Free Full Text]
  5. Fazio S, Sabatini D, Capaldo B, Vigorito C, Giordano A, Guida R, et al. A preliminary study of growth hormone in the treatment of dilated cardiomyopathy. N Engl J Med 1996;334:809-14. [Abstract/Free Full Text]



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