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J Thorac Cardiovasc Surg 2004;127:302-303
© 2004 The American Association for Thoracic Surgery

Letter to the editor

Partial left ventriculectomy in patients with neoplasms and severe heart failure who are not candidates for cardiac transplantation

Stefan Christiansen, MD

Department of Cardiothoracic Surgery, University of Aachen, Aachen, Germany

To the Editor:

I read the article of Casarotto and colleagues1 with great interest. The article described a patient with Castleman disease who was treated with chemotherapy, leading to a dilated cardiomyopathy. Because of the neoplasm, cardiac transplantation was contraindicated. Because of a progredient severe heart failure, the patient had to be supported with a Novacor (World Heart Corporation, Ottawa, Ontario, Canada) left ventricular assist device (LVAD). After a total of 1512 days, the patient had no signs of a relapse of Castleman disease and underwent orthotopic heart transplantation.

The number of patients with severe heart failure after chemotherapy for neoplasms should not be underestimated: from 1990 to 1996, cardiac transplantation was performed in 89 selected patients in the United States for this indication.2 The number of patients in whom cardiac transplantation cannot be performed because there is no proof of cure of the neoplasm is probably much higher. Therefore these patients are not so rare as might be supposed, and alternative treatment concepts are necessary.

Recently, I introduced a canine model for research on partial left ventriculectomy (PLV).3,4 Heart failure was induced by intracoronary doxorubicin administration, leading to a dilated cardiomyopathy with histologic myocardial changes similar to those described by Casarotto and colleagues.1 PLV was performed by resecting the interpapillary segment of the left ventricle (group 2). Measurement of hemodynamic and echocardiographic parameters demonstrated an improvement of left ventricular function relative to a control group without PLV (group 1; Table 1).


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  		TABLE 1. Hemodynamic and echocardiographic parameters before and after doxorubicin chemotherapy with (group 2) or without (group 1) PLV

 
PLV thus may also work in chemotherapy-induced heart failure, and I propose it as an alternative treatment option. PLV has some advantages relative to LVAD implantation. Well-known drive line or device pocket infections, as well as mechanical failures (also described by Casarotto and colleagues1), are not possible with PLV. Anticoagulation treatment is avoided, reducing the risk of bleeding complications. Thromboembolic events caused by clot formation within the LVAD are also avoided. Furthermore, PLV is much less invasive than LVAD implantation, and quality of life is enhanced by avoiding a transcutaneous drive line and dependence on a mechanical device. Regarding the economic aspect, costs for PLV are much lower than for LVAD implantation, and PLV can be performed in many more hospitals than can LVAD implantation, which is restricted to specialized centers.

I congratulate Casarotto and colleagues1 on their successful management of this difficult case. However, I encourage cardiac surgeons to take alternative treatment options such as PLV into consideration in such challenging cases.


   References
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 References
 

  1. Casarotto D, Bottio T, Gambino A, Testolin L, Gerosa G. The last to die is hope: prolonged mechanical circulatory support with a Novacor left ventricular assist device as a bridge to transplantation. J Thorac Cardiovasc Surg. 2003;125:417–418[Free Full Text]
  2. Shah HR, Vaynblat M, Ramdev G, Cunningham JN, Chiavarelli M. Experimental cardiomyopathy as a model of chronic heart failure. J Invest Surg. 1997;10:387–396[Medline]
  3. Christiansen S, Redmann K, Scheld HH, Jahn UR, Stypmann J, Fobker M, et al. Adriamycin-induced cardiomyopathy in the canine—an appropriate model for research on partial left ventriculectomy? J Heart Lung Transplant. 2002;21:783–790[Medline]
  4. Christiansen S, Stypmann J, Jahn UR, Redmann K, Fobker M, Gruber AD, et al. Partial left ventriculectomy in the modified adriamycin-induced cardiomyopathy in the dog. J Heart Lung Transplant. 2003;22:301–308[Medline]



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S. Christiansen and R. Autschbach
Doxorubicin in experimental and clinical heart failure
Eur J Cardiothorac Surg, October 1, 2006; 30(4): 611 - 616.
[Abstract] [Full Text] [PDF]

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