Cor Vasa 2011, 53(3):158-162 | DOI: 10.33678/cor.2011.036

Bridge to heart transplantation by a combination of levosimendan and biventricular pacing in a patient with end-stage refractory heart failure

Dan Marek^*, Alan Bulava, Jan Lukl

I. interní klinika, Fakultní nemocnice Olomouc a Lékařská fakulta Univerzity Palackého, Olomouc, Česká republika

A 48-year-old man with dilated and ischemic cardiomyopathy was admitted for recurrent heart failure decompensation after all pre-vious drug therapy regimens had failed. A year before, he had biventricular pacemaker/defibrillator implantation; however, after early dislodgement of the left ventricular electrode, revision was completed with bifocal pacing (apex + right ventricular outflow tract). Orthotopic transplantation was contraindicated because of a body weight of 124 kg (limit of 100 kg). In addition to symptoms of bilateral decompensation, the patient had hypotension with blood pressure levels of 90/60 mmHg on admission, ventricular tachycardia with a rate of 140/min, and was oliguric. Following cardioversion, the ejection fraction was 19%. Intravenous furosemide had but a transient effect and the low cardiac output was progressively resulting in anuria. Despite the grim prognosis (end-stage heart failure) and contraindications (renal failure, hypotension, and ventricular tachycardia), the patient received levosimendan (a calcium senzitizer and potassium channel opener improving contractility and vasodilation). Echocardiography showed an increase in cardiac output and diuresis was restored. Due to that promising progress, a new attempt (successful) at repositioning the left ventricular electrode into the coronary sinus was made after five days, as the biventricular pacing is hemodynamically more advantageous than bifocal pacing. Echocardiography demonstrated resolved contractile synchrony and further improvement of hemodynamic parameters (rise in cardiac output, reduced size of left ventricle and atrium, reduced mitral regurgitation). The patient was discharged with compensated heart failure, and a body weight of 94 kg to have successful transplantation 12 months later. He has now been in stable condition for five years. The paper (together with detailed scans including tissue Doppler scans) documents not only the use of relatively new techniques of heart failure management capable of reversing an unfavorable course in what were formerly fatal cases but, most importantly, the fact that, in emergencies, one can go even against standard recommendations after a critical pathophysiological analysis and consideration of all the pros and cons.

Keywords: Refractory heart failure; Bridge-to-transplantation; Levosimendan; Ventricular tachycardia; Renal failure; Biventricular pacing; Bifocal pacing; Echocardiography

Published: March 1, 2011  Show citation