THE BATISTA OPERATION

The newly developed Batista operation (named after Brazilian surgeon Dr. Randas Batista, who introduced the procedure in 1995) is a left ventricular remodeling operation for patients with end-stage heart failure. In this innovative operation which is technically called partial left ventriculectomy, or reduction left ventriculoplasty, a portion of heart muscle is removed and the geometry of the heart remodeled, thus improving the heart's ability to pump blood.

When the heart starts to fail, it increases in volume, occasionally to twice its original size. As a result, it loses its ability to pump blood effectively. Why this happens is not known. Typically, the only cure for patients with end-stage heart failure is a heart transplant. In the United States, these patients have about a one in ten chance of receiving a donor heart.

Now the Batista operation may provide these patients with relief of heart failure, and prolong their lives until a heart transplant can be performed. The early experience with this new operation is encouraging. Not all patients with end-stage heart failure can be candidates for it, but there are certain patients who might particularly benefit from it, especially those with very dilated (enlarged) hearts.

As of September 1998, Dr. Irvin B. Krukenkamp, professor of surgery and chief of cardiothoracic surgery, has successfully performed six Batista operations. With no mortalities, his results compare favorably to what has been achieved at other heart centers nationwide.

The Procedure Itself

The Batista operation is an open-heart operation performed with the aid of a heart-lung machine to maintain circulation while the heart is stopped. The essence of the procedure is to remove a wedge of left ventricle muscle (weighing about 40 to as much as 250 grams, or 1.5 to 9 ounces) and stitch together the two edges of the ventricle. In this manner the size of the left ventricle is reduced, and the ventricle is remodelled as well.

In addition, sometimes the mitral valve (which lies between the left ventricle and left atrium, and often leaks in end-stage heart failure) may need to be either repaired or removed and replaced with an artificial valve. In two of Dr. Krukenkamp's patients, mitral valve repair was done, rendering the valves completely competent.

In patients who have heart rhythm disturbances as well, an artificial implantable defibrillator device may be implanted. If the coronary arteries are diseased, they may be grafted, too (CABG operation).

In left ventricular failure, the muscle cells in the wall of the left ventricle have been stretched beyond physiologic limits. The Batista operation, by removing a wedge of the ventricular wall, reduces the circumference of the ventricle, and the size of the ventricle cavity. It changes the relationships of pressure and stress on the wall.

Consequently, the individual muscle fibers are restored to their normal length, and now come within the normal physiologic limit. They thus function more effectively in pumping blood, and in this way, heart failure is relieved.

In such a paradoxical manner, removal of heart muscle tissue actually helps the heart pump more effectively. The operation, as described above, is a radical departure from conventional thinking. Removal of too much muscle can weaken the heart and hasten death. It perhaps has the most potential benefit for patients with terminal heart failure caused by a disease of heart muscle (cardiomyopathy) and with a dilated left ventricle, who are not adequately helped by medication and are awaiting a heart transplant.

Bridge to Transplantation

The Batista operation is not an alternative to heart transplantation. It certainly helps most patients for some time. In a potential heart transplant candidate, the Batista operation buys some time to allow a more suitable and better matched donor heart to be found. Thus, it may serve as a useful bridge to transplantation.

Today, the only other alternative bridges to transplantation are the use of a ventricular assist device (VAD) and another new operation called dynamic cardiomyoplasty, in which muscle taken from the patient's back is wrapped around the heart and synchronized with a special pacemaker (cardiomyostimulator) to make it function like heart muscle.

VAD implantation is an extremely expensive option, and has a lot of complications and morbidity. Dynamic cardiomyoplasty is currently being studied in clinical trials, and its efficacy has not yet been established; possible side effects of this operation include body rejection phenomena/local tissue reaction, muscle and nerve stimulation, infection, erosion of the cardiomyostimulator/leads through the skin, transvenous lead- related thrombosis, embolism, and cardiac tamponade.

The Batista operation may therefore be a good option for treating end-stage heart failure. Ultimate heart transplantation, however, still remains an eventuality to be faced.

The future role of the Batista operation is not yet known. Scientific analysis of data from patients who have undergone this procedure is still in a very early stage. Without long-term follow-up and extensive analyses of different factors, the ultimate place of the Batista procedure in the management of heart failure cannot be determined. But with the extensive use of this new option for different stages and types of heart failure, such data will soon be available.

source: http://www.uhmc.sunysb.edu/surgery/batista1a.html