How to make a failing heart pump better: the Batista procedure and its competitors.

More than a year after the Batista procedure jumped into national headlines, experts at the 71st Scientific Sessions of the American Heart Association meeting in Dallas, Tex, reported both good and bad news about the radically different surgery. Patrick McCarthy, MD, cardiovascular surgeon at the Cleveland Clinic in Cleveland, Ohio, said 72% of patients who had the procedure have survived $2 years. “The good news is that it works well in some patients,” he said. “How often it will work well and how it will last remain undetermined. “The troublesome news is that it sometimes doesn’t work,” said McCarthy. One reason is that although the procedure improves the way the heart contracts, it detracts from the muscle’s relaxation. In addition, fibrotic hearts will not respond as well with improved contractions. “Sometimes it is just too late for some patients,” McCarthy said. He predicted that the Batista procedure will become the Batista concept. Already, he said, one company is developing a device that will simulate the benefits of the operation without opening the chest or discarding heart tissue. Akira T. Kawaguchi, MD, a Japanese surgeon from Tokai University who learned the procedure from Brazilian surgeon Randas Batista, MD, said the operation is used in his country, where transplant is virtually impossible because of laws governing organ donation. “It is used for socioeconomic reasons in Brazil and social reasons in Japan,” said Kawaguchi. Batista, who himself appeared at an AHA press conference, agreed, saying that in the United States, surgery and transplants benefit 270 million people, but that many of the world’s 6 billion people have no access to such care. “In countries like mine [Brazil], where we don’t have the facilities or equipment to work with, this procedure is very simple and available,” Batista said. US hospitals like the Cleveland Clinic can perform studies to explain why smaller hearts work better, he said. “I congratulate the other institutions for putting it in a better perspective,” he said. “In Brazil, we have only dying patients.” A different method of achieving the same effect as the Batista procedure was described by Steven F. Bolling, MD, professor of cardiac surgery at the University of Michigan in Ann Arbor. He advises repairing the mitral valve in some patients with congestive heart failure. The mitral valve frequently weakens and is unable to close completely in patients with this type of heart failure. The inefficient mitral valve causes increased pressure on an already damaged heart. Pooling blood in the heart can clot and obstruct the blood vessels to the brain, causing a stroke, Bolling said. “Mitral valve reconstruction is a simple operation,” he said. “It is easily applied to these patients. It is the same old operation with a new twist because it is applied to a new group of patients.” He said that like surgeons performing the Batista procedure, he believes that a smaller heart performs better. But he achieves this goal by surgically reinforcing the leaflets of the mitral valve with a relatively small annuloplasty ring at the valve opening. Bolling has performed mitral valve reconstruction in nearly 100 patients at University of Michigan hospitals. After surgery, exercise tolerance improved for most of these patients, and the size of their hearts decreased, he said. On average, the ejection fraction increased from 16% before surgery to 26% after surgery. The average time of follow-up has been 3.5 years. Bolling pointed out that the muscle removed in the Batista procedure is very similar in appearance to that left in the heart. “Why throw away muscle that has the possibility to recover?” he asked. “These hearts will shrink themselves; they will perform an auto-Batista on themselves.” According to Bolling, the procedure does not cure patients, but they are able to leave the hospital. “Part of the benefit is that we have changed the geometry of the left ventricle, reduced it, and allowed the heart to recover over time.” The procedure unloads the extra pressure on the heart by abolishing regurgitation. “The myocytes have the ability to recover,” Bolling said. But the Batista and similar procedures were not the only ones to show benefit for patients with refractory heart disease. Although Keith B. Allen, MD, of St. Vincent Hospital and Health Care Center in Indianapolis, Ind, was at a loss to explain why transmyocardial revascularization (TMR) seems to alleviate angina in patients for whom bypass is difficult, he said a multicenter study at his and other hospitals demonstrated an advantage to adding TMR to CABG surgery. Patients in the study were scheduled for CABG surgery but had areas of the heart that were not suitable for bypass. In 106 of those patients, the areas not suitable for bypass received TMR; in the control group of 115, the areas unsuitable for bypass went without revascularization. Predicted early mortality in the doubly-treated group was 8.8%, whereas it was 8.4% in the group that received bypass alone. However, only 1 of the 106 patients who received both treatments died during the early period. By comparison, 8 of the 115 in the comparison group died. The mortality rate in the first group was slightly less than 1%, far below the expected mortality. In the second group, the 7% observed mortality rate was roughly equal to the expected mortality rate. Early results from 3-month follow-up that did not include all patients showed that there were significantly fewer adverse