Cardiac Resynchronization Therapy for Drug Refractory New York Heart Association Class IV Congestive Heart Failure

In Brazil, in 1983, Dr. Randas Batista, disheartened by the shortage of donor hearts developed a procedure (later coined the Batista procedure) as an alternative to heart transplantation.^1-3 The Batista procedure attempted to reverse the effects of remodeling in cases of end-stage dilated cardiomyopathy by removing a small portion of the enlarged left ventricle of the heart, bringing the size of the ventricle back down towards normal. Initial survival following the Batista procedure at six-month follow-up was similar to heart transplantation. Twenty-five percent of patients receiving the Batista procedure improved following surgery; however, one-third of patients rapidly deteriorated, and therefore, the procedure was eventually abandoned.^4,5

Case Report 

This patient is a 69-year-old man with a history of a prior myocardial infarction, an ejection fraction of 15 percent, and ventricular tachycardia with a left-sided implantable cardioverter-defibrillator. In addition, the patient had a right-sided dual chamber permanent pacemaker for complete heart block, which was implanted in the right pectoral region. Several years ago, the patient underwent the Batista procedure for drug refractory congestive heart failure. The procedure failed to yield any improvement in congestive heart failure symptoms. The patient was referred to us for cardiac resynchronization, cardioverter-defibrillator, and had documented ventricular tachycardia, New York Heart Association Classification IV congestive heart failure on optimal medical therapy, and a QRS duration of 280 milliseconds. Due to the patient s distorted ventricular anatomy, a transesophageal echocardiogram was performed in order to determine the patency of the coronary sinus vein. Figure 1 shows the coronary sinus vein evident and widely patent for this procedure. Figures 2A-C show the right anterior, anterior-posterior and left anterior oblique fluoroscopic projections of catheter placement from a femoral venous procedure, in which intracardiac electrograms were recorded in order to map out the coronary sinus vein. Using a steerable 20-pole catheter, we were able to identify and map out the coronary sinus vein. Images were stored. We were then able to proceed with a biventricular implantable cardioverter-defibrillator implant. Please note from the images that the right ventricular pacing lead was positioned in the proximal component of the coronary sinus vein. Pacing from the pacemaker and that from the defibrillator showed only subtle differences in the QRS duration, as indicated in Figures 3A and 3B. We then proceeded with the implantation of an ICD. Using subclavian venous access, we first explanted the old implantable cardioverter-defibrillator. We then placed an additional right atrial and left ventricular lead. Using a steerable sheath (Attain, Medtronic, Inc., Minneapolis, Minnesota), we were able to place the left ventricular lead in a left ventricular lateral branch of the coronary sinus with excellent pacing, sensing and defibrillation threshold. Figures 4A-C show the right anterior oblique, anterior-posterior, and left anterior oblique fluoroscopic images of the leads in position. At 2-month follow-up, the patient reported significant improvement in congestive heart failure (at least one New York Heart Association Classification improvement).

Discussion

This report demonstrates the technical feasibility of implanting a left ventricular lead (via the coronary sinus vein) in a patient post the Batista procedure. Our initial concern was whether the changes in left ventricular anatomy would have prohibited left ventricular lead deployment through the coronary sinus vein. A careful non-invasive (transesophageal echo) and invasive (preimplantation electrophysiology study) demonstrated a patent coronary sinus orifice and vessel. During the implant, a coronary sinus venogram demonstrated a patent left ventricular branch. This type of careful analysis is necessary in order to diagnose a preexisting coronary sinus vein occlusion which may impede successful transvenous left ventricular lead placement. In summary, patients who have failed the Batista procedure with end-stage congestive heart failure may be candidates for biventricular pacing.