Question Title: Batista Opportunity, philosophy

Name: Jean Durand
E-Mail: jdurand@efma.com
Subject: Batista : Opportunity, philosophy
Body of Message:

25 April 1998

Hi !

I address to you to ask a question you concerning Batista. (Would you
excuse my very bad english, please, I am French)

I am a man of 55 years, 179 cm, 78 Kg. In March 1997, I have
made a serious pulmonary oedema. In reanimation, one discovers while I
had a dilated cardiomyopathy severe (mass index=278/m2) with a fraction
of ejection (FE) < 15 %. Right cavities are normal. NYHA class 2+ or 3.

Unknown origin but very derogatory prognosis from my doctors that
recommend
an urgent transplant.

Processing : AEC, beta-bloker, diuretic, potassium, many anti-arythmics
to cause of my officials extra-systols. Problems of low tension and
fibrillation.

Examinations of meadow-transplant to the hospital : left ventricle in
very bad state, FE = 19 %, excellent arteries including coronarys,
technically possible transplant.

Two month later, improvements, less of breathlessness, progressive
disappearance of extra - systols, fraction of ejection = 33 %, Peak VO2
(ml/min/kg) = 21. Excellent processing !

I am put on a waiting list but one no longer speaks urgent transplant.
One waits that my state degrades to intervene. Obviously since, I have
informed on success and failure statistics of the transplants as well as
on continuations. Furthermore, I am come across the numerous articles
that figure on Internet concerning Batista.

To priori, I would be very favorable to this intervention : less heavy,
choice of the day and the surgeon and especially no problem of reject.
But I know also that one lacks recession, that a lot consider that one
is again to an experimental stage and that this is not again an
alternative to a transplant.

I know that it is very difficult for you to give me an advice without
to know my file. Nevertheless, could have you to give me your opinion on
next points :

- It seems that more one is young and in good condition, best are the
odds of success., Statistics (contradictory) concerning Batista show
all, for example, that stages III have best results that stages IV.

-Personne not believing to a real improvement of my heart, why to wait
a gradation that will decrease my chance of success ? Today, I am to a
stage between I and II. Think you what it is preferable to wait ?

-What are risks of mortality to the hospital after a Batista for a
population as mine ?

-Do you know a competent European team on Batista ? Or well do you think
that it is preferable to be made operate in the United States ?

Whole this puts elsewhere a philosophical problem. It seems that one
waits always that the state of a patient degrades to recommend an
intervention. The cardiologists tell that it does not is necessary to
intervene when odds of survivings are superior those after operation.
This appears me erroneous for the next reasons :

The majority of the serious cardiopathies never improve but degrade with
the time. Since an intervention will be a safe necessary day die
preliminary, why to wait that the state degrades to intervene, when odds
of success will be less good ?
It is paradoxical, especially for Batista that provokes no phenomenon of
reject !

I think that a lot cardiac pose the same question that me. Your
reputation is very important and your competence is recognized
universally. Would have you the amiability to reply me or to indicate
me an address internet or a book who speaks these problems ?

In advance, thank you very much. And please to excuse my very
approximate English.

Jdurand@efma.com

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M. Durand,
Je comprends le français, mais c'est discutable si je pourrais répondre aux vos questions en français! Donc, je continue en anglais...
You raise an important question regarding the indication, or necessity, of heart transplant (or Batista operation). Before one commits to either procedure, it is critical to be certain that the procedure will provide greater benefit than no procedure, that is, continuation of current medical therapy. You describe a recent episode of pulmonary edema and heart failure, with severely reduced ejection fraction (EF) <15%. However, in the following months, your heart seems to have recovered significantly, and you note that symptoms have improved, with most recent EF = 33%. Also, you describe a peak VO2 of 21 ml/kg/min.
Given these facts, it is very unlikely that you need a heart transplant at this time. In fact, it may be reasonable to remove you from the transplant list altogether. This is because, simply, your prognosis with medical therapy is significantly better than the prognosis with heart transplant. I mention transplant, and not Batista, because most centers that perform the Batista procedure (left ventricular reduction surgery) only do so in patients who are candidates for heart transplant. The results of the Batista have been mixed. It appears that a subgroup of patients with non-ischemic cardiomyopathy (no coronary artery disease) seem to benefit, but some patients stay the same, while others deteriorate. For this reason, Batista is best reserved for patients who could go on to transplant if the Batista fails, or in patients who have no other options, possibly requiring a Batista procedure as a last effort to improve their quality of life.
You ask many good questions, including the philosophy of transplantation. While it is unwise to wait until a patient is so ill that the risk of transplantation is increased, on the other hand it is inappropriate to transplant patients, such as yourself, who are too healthy for this procedure. As you are aware, a transplant surgery results in the substitution of the old disease (heart failure) with a new disease (transplant management). The transplanted heart is at risk for rejection as well as an advanced form of coronary artery disease that seems to be unique to transplanted hearts. Also, patients who have undergone transplant surgery require immunosuppressive medications (to suppress the immune system) for the rest of their lives. These medications have multiple side effects, a significant one being increased risk of infection.
Since you have improved a great deal over the past several months, it is reasonable to assume that you will continue to improve, or stay unchanged in the future. In fact, you may have suffered a limited episode of myocarditis that temporarily stunned the heart muscle. I recommend that you continue therapy with ACE inhibitors, diuretics, and discuss the beta blocker "Carvedilol" with your physicians. Also, if arrhythmia is a serious problem, one could consider implanting a permanent defibrillator, in order to resuscitate the heart should it experience a life-threatening arrhythmia. If your heart function continues to improve, I suspect that the arrhythmias will decrease in frequency.
Thus, I do not believe, given the information you have provided, that you are in need of either a transplant or a Batista procedure. Should these become necessary in the future (VO2 <10 ml/kg/min, recurrent arrythmias unresponsive to medical therapy, severe Class III-IV symptoms despite maximal medical therapy) then you may wish to be evaluated at a large transplant center, either in the U.S. or in Europe. Certainly, neither a heart transplant nor the Batista procedure should be attempted in hospitals that don't have a large experience with these procedures.
Bon chance. J'espère que j'ai répondu convenablement aux vos questions.

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