Multi-component reconstructive heart surgery as an alternative to transplantation in a patient with combined cardiac pathology and critically low left ventricular contractility

Multi-component reconstructive heart surgery as an alternative to transplantation in a patient with combined cardiac pathology and critically low left ventricular contractility V.V. Sokolov, A.V. Redkoborodyy, N.V. Rubtsov, L.G. Khutsishvili*, E.N. Ostroumov, E.V. Migunova, N.M. Bikbova N.V. Sklifosovsky Research Institute for Emergency Medicine, 3 Bolshaya Sukharevskaya Sq., Moscow 129090, Russia


Introduction
The treatment of chronic heart failure (CHF) is an urgent problem arising due to a continuously increasing number of cases with this pathology in the world [1]. The "traditional" treatment tactics is aimed at eliminating the causes of CHF and includes conservative, endovascular, and surgical methods and, if they turn ineffective or unfeasible, the question should be considered of either replacing the failed organ completely by means of transplantation, or creating more favorable conditions for organ function by the implantation of resynchronization devices or mechanical circulatory support systems [2,3].
Patients with severe CHF resulting from coronary pathology, previous myocardial infarction with the formation of the left ventricle (LV) aneurysm, and valvular defects are often considered candidates for heart transplantation (HT), given a high operational risk inherent in this cohort of patients in case of the "traditional" surgical treatment.
At the same time, HT is characterized by a number of specific features, among which the development of complications associated with immunosuppressive therapy (acute and chronic rejection, infection) comes first [4]. Therefore, in patients with a correctable morphological cause of CHF, even in the end-stage, the possibility of a "traditional" intervention should primarily be considered.
When deciding on the choice of a treatment technique for a patient with terminal CHF, it is extremely important to assess the degree of myocardial damage reversibility by using various methods (ultrasound, radiopaque, radioisotope) [5][6][7]. Of no less importance for the choice of treatment tactics is to take into consideration the premorbid status of the patient and the severity of damage to the target organs.
When choosing a reconstructive intervention, the main focus should be placed on reducing surgical risks. One of the options to reduce the extent of surgery is a combined approach including endovascular methods [8].
Impaired functions of visceral organs should be corrected as much as possible. The cardiotonic therapy courses with levosimendan are to be undertaken as a method of additional myocardial stimulation in the perioperative period [9]. This report demonstrates the clinical case of a successful multicomponent surgical treatment in a patient with severe CHF who was initially considered a candidate for HT. From the medical history, it was known that in September 2014, without a previous history of ischemic heart disease (IHD), the patient suffered a myocardial Q-infarction with ST segment elevation at anterior septal location. After 3 hours from the onset of anginal pains at the local hospital where percutaneous coronary intervention (PCI) was not available on technical reasons, the patient received an Actilyse thrombolytic therapy accoridng to a standard scheme. After 2 days, for early recurrent angina pectoris and an increasing heart failure of up to Killip Class III-IV with the development of pulmonary edema, the patient was transferred to a Moscow hospital where the coronary angiography was performed and a proximal occlusion of the anterior interventricular branch (AIVB) of the left coronary artery (LCA) was diagnosed that was treated by means of transluminal balloon angioplasty with stenting the LCA AIVB using a single stent coated with a Cypher SELECT drug (Fig. 1). The course of myocardial infarction was complicated by an acute LV aneurysm formation, the decrease in the LV ejection fraction (EF) to 35%, and ischemic mitral regurgitation. Then, the patient was newly diagnosed with an ascending aortic (AA) aneurysm of over 7 cm in diameter (Fig. 2).

Arrows indicate an ascending aortic aneurysm
Immediately after having suffered a myocardial infarction, the patient had a clinical presentation of CHF. The load tolerance decreased over time for which the patient was examined at Academician V.I.Shumakov National

Medical Research Center of Transplantology and Artificial Organs in
December 2014, where ischemic cardiomyopathy was diagnosed. However, given the AA aneurysm, the risk of HT was calculated as being extremely high. The patient was recommended a drug therapy for heart failure.
A significant heart failure deterioration was avoided over the following 3 years, by using progressively increasing doses of drugs. By 2017 the conservative treatment ceased to be effective, and the patient was hospitalized with subcompensated heart failure to N.V.Sklifosovsky Research Institute for Emergency Medicine to consider the feasibility of HT.
Objectively, the condition at admission was regarded as moderately severe due to the signs of subcompensated heart failure. The skin was pale, there was diffuse cyanosis, no peripheral edema was noted. There was coarse breathing in lungs, without wheezing; the respiratory rate was 18 per minute, SatO 2 was 96% when breathing with atmospheric air. Heart sounds were muffled, the rhythm was regular with a heart rate (HR) of 70 beats per minute, blood pressure was 100/70 mm Hg, blowing systolic murmur was auscultated over the entire surface of the heart. The liver extended 4 cm below the costal margin. Ascites was determined at percussion. Despite a diuretic therapy, diuresis was slightly reduced.
On examination: The 6-minute walk test: 100 meters that corresponds to heart failure functional class (FC) IV according to the New York Heart Association (NYHA) functional classification.
Electrocardiography: sinus rhythm, heart rate 64 per minute, the electrical axis of the heart is left axis deviated, first-degree AV block, signs of cardiosclerosis along the anterior wall.  AA angiography: ascending aorta is expanded to 8.0 cm, 3rd-degree regurgitation on AV (Fig. 4).  The duration of mechanical lung ventilation after surgery was 20 hours. The patient was transferred from the intensive care unit to the hospital ward on the 3rd day.
Due to persisting signs of myocardial insufficiency (LVEF 27-28%, an impossibility of reducing inotropic support), a repeated infusion of levosimendan was performed on day 5 after surgery.
On day 15 after surgery, the patient was discharged from the hospital.
Control examinations were made immediately before the patient's discharge, and later on at 1.5 years after surgical treatment. The changes in the results over time are presented in the  At postoperative examination of the patient before his discharge from hospital, marked decreases in LV volumetric parameters (EDV 175 mL, ESV 125 mL) were noted without their significant increases over time (after 1.5 years: EDV 210 mL, ESV 120 mL). An increase in LVEF was also seen confirmed by various instrumental methods (from 23% to 39% by EchoCG, from 20% to 35% by LVG, from 25 to 39% by myocardial perfusion scintigraphy). Moreover, according to the results of myocardial scintigraphy, a significant increase in the actively perfused volume of the myocardium ( Fig. 7) and an increase in LVEF from 20 to 40% were noted. Subjectively, the patient feels significantly better, does not express the clinical signs of heart failure, tolerates physical activity, which is confirmed by the results of the 6-minute walk test (after 1.5 years: a distance of more than 500 m, which corresponds to the heart failure of 0-1 NYHA FC. The patient's follow-up continues.

Discussion
The decrease in global myocardial contractility is a key independent factor affecting the outcome of "traditional" surgical treatment. Despite advances in therapeutic and surgical methods, the treatment of patients with moderate or severe LV dysfunction who have undergone heart surgery remains a challenge. Patients with low LVEF are known to have a higher risk of postoperative complications and mortality after heart surgery [10,11]. Thus, the identification of high risk patients of an unsatisfactory outcome of surgery plays a key role in the decision-making process regarding the choice of patient treatment tactics. Low LVEF per se is a major predictor of a poor outcome and is included in all currently available assessment systems [10,11].
In view of the above, patients with low LVEF are often considered candidates for HT, the implantation of circulation assist devices (VAD), or cardiac resynchronization therapy, even if there is a possibility of the surgical correction of the existing pathology (heart disease, coronary heart disease, LV aneurysm) [12].
Currently, the HT in the treatment of end-stage heart failure remains high and is recognized as the "gold standard", however, this method cannot The study of the literature showed that HT is associated with a significantly better quality of life and body functional capabilities in patients with low myocardial contractility than "open" cardiac surgery they undergo [13]. However, in patients with LVEF not exceeding 20%, "open" surgery, such as the coronary artery bypass grafting, can be performed with an acceptable hospital mortality rate of 4.6-7.1%, which is similar to that for HT [14].

Conclusion
Our clinical case report has confirmed the feasibility of the combined pathology correction with obtaining acceptable immediate and long-term (1.5 years after surgery) results in a patient with a low myocardial contractility. The positive effects of surgery include a significant increase in the total left ventricle ejection fraction from 23% to 39% (one should bear in mind that before the surgery, the effective left ventricle ejection fraction and cardiac index in the presence of total aortic and mitral valve regurgitation were at least 2 times lower), a significant improvement in the patient's quality of life due to diminishing chronic heart failure manifestations, avoidance of the need for immunosuppressive therapy and, accordingly, of its related complications. The patient selection criteria for the "traditional" surgery, as an alternative to heart transplantation, in patients with low LV contractility should include the sufficient myocardial reserves as estimated by scintigraphy, at least, and the technical feasibility of adequately correcting the existing pathology.