First Case of a Combined Baroreflex Activation Therapy and Carotid Endarterectomy for the Treatment of Heart Failure with a Reduced Ejection Fraction

M. Oberhoffer; E. Rafflenbeul; E. Tallone; J. Müller-Ehmsen; B. Bein; M. Schmoeckel; C. Heintz

doi:10.1055/s-0036-1571778

The Thoracic and Cardiovascular Surgeon, Table of Contents

First Case of a Combined Baroreflex Activation Therapy and Carotid Endarterectomy for the Treatment of Heart Failure with a Reduced Ejection Fraction

M. Oberhoffer ¹, E. Rafflenbeul ², E. Tallone ², J. Müller-Ehmsen ², B. Bein ³, M. Schmoeckel ¹, C. Heintz ⁴

¹Asklepios Klinik St. Georg, Herzchirurgie, Hamburg, Germany
²Asklepios Klinik Altona, Kardiologie, Hamburg, Germany
³Asklepios Klinik St. Georg, Anästhesie, Hamburg, Germany
⁴Asklepios Klinik St. Georg, Vascular Surgery, Hamburg, Germany

Abstract

Introduction: Increased sympathetic and decreased parasympathetic activity contribute to heart failure symptoms and disease progression. Recent data suggest that Baroreflex Activation Therapy (BAT) improves clinical status and outcomes in patients with heart failure and a reduced ejection fraction (HFrEF). Carotid endarterectomy (CEA)removes atherosclerotic plaques from the carotid arteries which contain baroreceptors. The procedure can cause collateral damage to the afferent pathway of the baroreflex; thus the responsiveness to BAT is unclear. We present the first patient who successfully underwent a combined BAT and CEA for the treatment of HFrEF.

Background: A 76-year-old man was admitted with recurrent decompensation of HFrEF. His past medical history consisted of coronary three-vessel disease with numerous percutaneous interventions, mitral valve repair, VVI-ICD-Implantation and a high-grade right-sided carotid stenosis. We performed at first CEA of the right carotid artery and after testing for responsiveness implanted a BAT-device (Fig. 1). The procedure was uncomplicated and the patient recovered uneventful. Baseline and 6-months follow-up clinical data, including New York Heart Association Functional Class Rank (NYHA), Minnesota Living with Heart Failure Quality of Life Score (MLWHFQ), Six-Minute Hall Walk Distance (6MHWD) and left Ventricular Ejection Fraction (LVEF) were evaluated (Table 1).

Discussion: The combined BAT and CEA procedure was performed safely. Follow-up data are promising and the procedure might offer an option for patients with HFrEF and carotid stenosis who were not considered to be BAT- candidates to the present .Knowing that CEA by itself impairs blood pressure homeostasis and leads to reduced baroreflex reserve through surgical destruction, care should be taken intraoperatively to preserve tissue around the carotid artery. Testing of the BAT device during the procedure is mandatory.

Fig. 1 Procedure.

Table 1
	Before BAT/CEA	6-month follow-up	Difference
NYHA (class)	III	II	I
MLWHFQ (score)	55	36	- 19
6MHWD (m)	360	408	+ 48
LVEF (%)	25	34	+9