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The Batista Operation

There has been so much media-hype about the innovative heart operation first performed by Dr.Randas Batista, that I thought an article on this procedure wouldn't be out of place on a site dealing with heart disease. So here goes.....

The Batista operation is a daring, innovative application of one of the basic physiologic tenets of cardiovascular medicine to the treatment of the difficult problem of end-stage heart failure. To understand the thinking and logic behind the operation, we first need to review cardiac physiology briefly.

Physiologic Basis of the Batista Operation.

The heart, as we have seen earlier, is a muscular pump that circulates blood within the blood vessels all over the body. The ventricles are the major pumping chambers, and the left ventricle is the more powerful one that maintains circulation to all organs except the lungs. When the left ventricle weakens and is unable to maintain its pumping action, a condition called heart failure sets in.

The heart action occurs in cycles. There is a phase of relaxation, during which the pressure inside the ventricle is lowered, and blood rushes into it from the atrium and fills it. This is followed by a phase of contraction, in which the blood collected inside the ventricle is pumped forcefully into the arterial tree.

By a series of physiologic experiments on animal heart muscle, two scientists - Frank and Starling - were able to show that the more the heart filled up during relaxation, the more forcefully it pumped blood during a subsequent contraction. This finding which is equally applicable to the human heart, is called the LAW OF THE HEART. They however qualified their statement by saying that this was true only WITHIN PHYSIOLOGIC LIMITS. In other words, upto a limit, filling up the heart increased force of contraction, but beyond this limit the force of contraction actually decreased.

Let us now consider the anatomic basis for this law. The heart wall is made up numerous small muscle cells, attached to each other and working together to pump blood out of the heart. Each muscle cell is bound by Starling's law. When the heart fills up, each individual muscle is stretched out. It then recoils with a greater force, somewhat like an elastic rubber band that snaps harder when it is stretched longer. But when the muscle cell is stretched beyond physiologic limits, it becomes damaged, and is no longer able to contract forcefully. This is true for all the muscle fibers, and as a result the entire ventricle becomes weak in its action. The heart fails !

The Batista Operation - What is it ?

The Batista Operation is technically called a REDUCTION LEFT VENTRICULOPLASTY. It is an open-heart operation performed with the aid of a heart lung machine to maintain circulation while the heart is stopped. The essence of the procedure is to remove a wedge of left ventricle muscle (weighing about 40 to as much as 250 grams) and stitch together the two edges of the ventricle. In this manner the size of the left ventricle is reduced, and the ventricle is remodelled as well.

In addition, sometimes, the mitral valve (which lies between the left ventricle and left atrium) may need to be removed and replaced with an artificial valve. In patients who have heart rhythm disturbances as well, an artificial implantable defibrillator device may be implanted. If the coronary arteries are diseased, they may be grafted too (CABG operation).

Theoretic basis of Batista Operation

In left ventricular failure, the muscle cells in the wall of the left ventricle have been stretched beyond physiologic limits, and Starling's law is no longer applicable. The Batista operation, by removing a wedge of the ventricular wall, reduces the circumference of the ventricle, and the size of the ventricle cavity. The individual muscle fibers are thus restored to their normal length, and now come within the physiologic limit. They thus function more effectively in pumping out blood. And in this way, heart failure is relieved !

In such a paradoxic manner, thus, removal of heart muscle tissue actually HELPS the heart pump more effectively. A radical concept indeed, the application of which Dr.Batista is to be commended for.

Who will benefit from the Batista Operation ?

The operation as described above is a radical departure from conventional thinking. Removal of too much muscle can weaken the heart and hasten death. It perhaps has the most potential benefit for patients with terminal heart failure caused by a disease of heart muscle (cardiomyopathy) and with a dilated left ventricle, who are not adequately palliated by medication and are awaiting a heart transplant.

Is the Batista Operation then the alternative to heart transplantation that it is much touted to be ?

Certainly not. While the media hype has projected the operation to be an alternative to heart transplantation, the results so far are NOT supportive of such a conclusion. Of Dr.Batista's original series, over 60% of patients were dead within two years of the operation. Dr.Batista himself is very conservative in his forecast for the role of the procedure. It certainly helps most patients for some time. In a potential heart transplant candidate, the Batista Operation buys some time, to allow a more suitable and better matched donor heart to be found. It thus may be a useful "bridge to transplantation".

Today, the only other alternative "bridge to transplant" is the use of a ventricular assist device (VAD). This is an extremely expensive option, and has a lot of complications and morbidity. The Batista operation may be an alternative to a VAD in such a setting. Ultimate heart transplantation however still remains an eventuality to be faced.

What is the role of the Batista Operation in the future ?

The answer is not yet known. Scientific analysis of data from patients who have undergone this procedure is still in a very premature stage. Without longer term follow up and extensive analyses of different factors, the ultimate place of the Batista procedure in the management of heart failure cannot be determined. But with the extensive use of this option for different stages and types of heart failure, such data will soon be available. Dr.Batista's unique innovation, flying in the face of conventional thinking, has set the world of cardiac surgery on fire, and forced a re-thinking of basic physiologic tenets. And perhaps this turmoil will turn up more exciting and useful information as well.

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