Surgical ventricular restoration: left ventricular shape influence on cardiac function, clinical status, and survival

Left ventricular diastolic function assessed by speckle tracking echocardiography in patients with left ventricular aneurysm

Speckle-tracking echocardiography (STE) parameters are an integral part of the assessment of left ventricular (LV) function. We aimed to evaluate established and novel STE parameters of LV diastolic function and their prognostic role in patients with LV anteroapical aneurysm undergoing surgical ventricular repair (SVR). We retrospectively examined the data of 137 patients with anteroapical LV aneurysm who underwent SVR. In 27 patients, the correlation of STE parameters with invasive hemodynamic parameters was evaluated. Preoperative echocardiographic parameters were assessed for their association with outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation. The late diastolic strain rate (GLSRa) showed a stronger correlation with mean pulmonary artery pressure (r =  - 0.75, p < 0.001) than all other parameters. GLSRa was also significantly correlated with mean pulmonary capillary wedge pressure and LV end-diastolic pressure. In the multivariate model, GLSRa and the ratio of early diastolic filling velocity to GLSRa demonstrated incremental prognostic value in addition to clinical and echocardiographic parameters. Patients with GLSRa < 0.59 s-1 had significantly shorter event-free survival than those with GLSRa > 0.59 s-1 (6.7 vs. 10.9 years, p < 0.001). Peak reservoir left atrial strain showed a weaker association with hemodynamic parameters and outcome compared to GLSRa. In patients with LV aneurysm, late diastolic strain rate and left atrial strain can be used for the assessment of LV diastolic function and have a predictive value for the outcome after surgical ventricular restoration.

Characteristics of Akinetic and Dyskinetic Left Ventricular Aneurysms in the Context of Echocardiographic Diagnosis and Treatment Selection

Background and Objectives. Distinct pressure curve differences exist between akinetic (A-LVA) and dyskinetic (D-LVA) aneurysms. In D-LVA, left ventricular (LV) ejection pressure decreases relative to the aneurysm size, whereas A-LVA does not impact pressure curves, indicating that the decrease in stroke volume (SV) and cardiac output is proportional to the size of dyskinesia. This study aimed to assess the frequency of A-LVA and D-LVA, determine aneurysm size parameters (volume and surface area), and evaluate predictive parameters using echocardiography in A-LVA and D-LVA. Furthermore, it aimed to compare individual echocardiographic parameters, according to ejection fraction (EF) and SV, with hemodynamic events shown in experimental models of A-LVA and D-LVA and their significance in everyday clinical practice. Materials and Methods. This clinical study included patients with post-infarction left ventricular aneurysm (LVA) admitted to the cardiovascular institute ''Dedinje", Serbia. Echocardiographic volume and surface area of LV and LVA were determined (by the area-length method) along with EF (by Simpson's method). Results. A-LVA was present in 62.9% of patients, while D-LVA was present in 37.1%. Patients with D-LVA had significantly higher systolic aneurysm volume (LVAVs) (94.07 ± 74.66 vs. 51.54 ± 53.09, p = 0.009), systolic aneurysm surface area (LVAAs) (23.22 ± 11.73 vs. 16.41 ± 8.58, p = 0.018), and end-systolic left ventricular surface areas (LVESA) (50.79 ± 13.33 vs. 42.76 ± 14.11, p = 0.045) compared to patients with A-LVA. The ratio of LVA volume to LV volume was higher in the D-LVA in systole (LVAVs/LVESV). The end-diastolic volume of LV (LVEDV) and end-systolic volume of LV (LVESV) did not significantly differ between D-LVA and A-LVA. EF (21.25 ± 11.92 vs. 28.18 ± 11.91, p = 0.044) was significantly lower among patients with D-LVA. Conclusions. Differentiating between A-LVA and D-LVA using echocardiography is crucial since D-LVA causes greater hemodynamic disturbances in LV function, and thus surgical resection of the aneurysm or LV reconstruction must have a positive effect regardless of myocardial revascularization surgery.

CT-Based Analysis of Left Ventricular Hemodynamics Using Statistical Shape Modeling and Computational Fluid Dynamics

Background

Cardiac computed tomography (CCT) based computational fluid dynamics (CFD) allows to assess intracardiac flow features, which are hypothesized as an early predictor for heart diseases and may support treatment decisions. However, the understanding of intracardiac flow is challenging due to high variability in heart shapes and contractility. Using statistical shape modeling (SSM) in combination with CFD facilitates an intracardiac flow analysis. The aim of this study is to prove the usability of a new approach to describe various cohorts.

Materials and Methods

CCT data of 125 patients (mean age: 60.6 ± 10.0 years, 16.8% woman) were used to generate SSMs representing aneurysmatic and non-aneurysmatic left ventricles (LVs). Using SSMs, seven group-averaged LV shapes and contraction fields were generated: four representing patients with and without aneurysms and with mild or severe mitral regurgitation (MR), and three distinguishing aneurysmatic patients with true, intermediate aneurysms, and globally hypokinetic LVs. End-diastolic LV volumes of the groups varied between 258 and 347 ml, whereas ejection fractions varied between 21 and 26%. MR degrees varied from 1.0 to 2.5. Prescribed motion CFD was used to simulate intracardiac flow, which was analyzed regarding large-scale flow features, kinetic energy, washout, and pressure gradients.

Results

SSMs of aneurysmatic and non-aneurysmatic LVs were generated. Differences in shapes and contractility were found in the first three shape modes. Ninety percent of the cumulative shape variance is described with approximately 30 modes. A comparison of hemodynamics between all groups found shape-, contractility- and MR-dependent differences. Disturbed blood washout in the apex region was found in the aneurysmatic cases. With increasing MR, the diastolic jet becomes less coherent, whereas energy dissipation increases by decreasing kinetic energy. The poorest blood washout was found for the globally hypokinetic group, whereas the weakest blood washout in the apex region was found for the true aneurysm group.

Conclusion

The proposed CCT-based analysis of hemodynamics combining CFD with SSM seems promising to facilitate the analysis of intracardiac flow, thus increasing the value of CCT for diagnostic and treatment decisions. With further enhancement of the computational approach, the methodology has the potential to be embedded in clinical routine workflows and support clinicians.

Predictive Value of Two-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Ventricular Restoration

Objectives

Parameters of left ventricular (LV) mechanics, obtained from speckle-tracking echocardiography (STE), were found to be of prognostic value in patients with heart failure and those who underwent cardiac surgery. This study aimed to assess the value of STE in patients scheduled to undergo surgical ventricular restoration (SVR).

Methods

A total of 158 consecutive patients with baseline STE who underwent SVR due to an LV anteroapical aneurysm were included in the analysis. Preoperative longitudinal STE parameters were evaluated for their association with an outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation. The echocardiographic follow-up to assess the change in the regional function of the segments remote from the aneurysm was performed in 43 patients at a median of 10 months [interquartile range (IQR): 6–12.7 months] after SVR.

Results

During a median follow-up of 5.1 years (IQR: 1.6–8.7 years), events occurred in 68 patients (48%). Less impaired mean basal end-systolic longitudinal strain (BLS) with a cutoff value ≤ −10.1 % demonstrated a strong association with event-free survival, also in patients with an LV shape corresponding to an intermediate shape between aneurysmal and globally akinetic. Initially hypo- or akinetic basal segments with preoperative end-systolic strain ≤ −7.8% showed a greater improvement in wall motion at the short-term follow up.

Conclusion

Patients with less impaired preoperative BLS exhibited a better event-free survival after SVR, also those with severe LV remodeling. The preserved preoperative segmental longitudinal strain was associated with a greater improvement in regional wall motion after SVR. BLS assessment may play a predictive role in patients with an LV anteroapical aneurysm who are scheduled to undergo SVR.

Clinical and hemodynamic outcomes of the Dor procedure in adults with ischemic cardiomyopathy

Ischemic cardiomyopathy continues to be a major contributor to congestive heart failure, which places a significant burden on our healthcare system. Improving medications and different coronary revascularization strategies are the mainstays in the management of ischemic cardiomyopathy. Although medications and mechanical circulatory support are playing an ever-increasing role, cardiac transplantation remains the gold standard for treating advanced heart failure. Given the small number of available and suitable donor hearts, transplantation is limited for the majority of patients. Surgical ventricular restoration has repeatedly been suggested as a viable alternative in managing heart failure in select patients, as it is believed that surgically returning the ventricle to its original dimensions is possible and associated with favorable outcomes. The purpose of this manuscript is to comprehensively review the current literature on various surgical strategies for ventricular restoration. We also contextualize the published data with respect to ventricular function, volume, structure, arrhythmias, mitral regurgitation, and clinical outcomes.

Restoring ventricular restoration: A call to re-evaluate a surgical therapy considered ineffective

The technique of surgical restoration of postischemically dilated left ventricles (SVR) has almost disappeared from operating theaters after the Surgical Treatment of IsChemic Heart failure (STICH) Trial demonstrated no treatment effect in patients with CAD and ejection fraction below 35%. Criticism on the trial was expressed stating that surgical expertise and patient selection (i.e., almost no aneurysm patients included) may have been inadequate to test the procedure s potential. Gaudino and colleagues now propose to conduct an analysis comparing the STICH patient population to a group of comparable SVR patients treated by a center with documented specific expertise for this technique. We here address the background of the trial and the following controversy and suggest a rationale why the suggested analysis has the potential to add valuable information to the field.

Results of reconstructive interventions in patients with ischemic cardiomyopathy

BACKGROUND

Effective treatment of patients with ischemic cardiomyopathy is one of the most difficult issues in contemporary cardiac surgery. The aim of this study was to evaluate the long-term effectiveness of reconstructive interventions on the left ventricle during chronic heart failure in patients with ischemic cardiomyopathy.

METHODS

Between March 2013 and December 2017, 178 patients underwent surgical treatment for ischemic cardiomyopathy. Isolated coronary artery bypass grafting was compared with coronary artery bypass grafting with left ventricular reconstruction, using propensity score matching analysis. The primary endpoints of the study were hospital mortality and long-term survival.

RESULTS

After propensity score matching, 29 pairs of patients were compared. The 30-day hospital mortality was comparable (6.8% versus 6.8%, p = 0.952), the average follow-up was 37.4 ± 12.6 months, with no statistically significant difference in mortality from all causes (p = 0.352). After coronary artery bypass in combination with left ventricular reconstruction, patients showed a statistically significant decrease in clinical and functional indicators of chronic heart failure compared to those who had coronary artery bypass grafting alone, in terms of peak oxygen consumption (15.3 versus 13.5 mL·kg^-1·min^-1, p = 0.043) and N-terminal pro-brain natriuretic peptide concentrations (298.6 versus 461.1 pg·mL^-1, p = 0.032).

CONCLUSIONS

Compared to isolated coronary artery bypass, coronary artery bypass in combination with left ventricular reconstruction for the treatment of ischemic cardiomyopathy leads to a significant decrease in the clinical and functional parameters of chronic heart failure in the long-term postoperative period.

[Surgical Treatment of Ischemic Cardiomyopathy: Current State of the Problem]

In this article we present discussion of the current state of the problem of surgical treatment of ischemic cardiomyopathy (ICM). The pathophysiological aspects of left ventricular remodeling in patients with ICM are also covered. A detailed characterization of methods for assessing the myocardial viability is given and their role in patients with ICM is shown. The problem of right ventricular dysfunction in ICM is discussed. Main attention is focused on the methods of surgical treatment of ICM. Limitations of the Surgical Treatment for Ischemic Heart Failure (STICH) study are analyzed. The article is intended for cardiologists, general practitioners and cardiac surgeons.

"Frozen Apex" Repair of a Dilated Cardiomyopathy

We try to make surgical ventricular restoration simpler and more adjustable to safely enhance ventricular function. In eight patients with DiDonato type III dilated cardiomyopathy, we applied a few short-axis purse-string sutures to the endocardial side of the left ventricular apex ("Frozen-Apex" restoration) to make a smaller, cone-shaped apex, based on the concept that the left ventricular apex is important in its existence, but not in its function. The procedure took less than 15 minutes in all the patients. There was no hospital or late death with the follow-up of 549 ± 389 days. Mid-late postoperatively, New York Heart Association functional class changed from 3.5 ± 0.8 (preoperative) to 1.6 ± 0.6 (P = 0.000 vs preoperative), left ventricular diastolic diameter from 64 ± 16 to 61 ± 15 mm, systolic diameter from 57 ± 15 to 50 ± 17mm (P = 0.070), ejection fraction from 27 ± 10 to 40 ± 16% (P = 0.014). Diastolic function as assessed by the ratio of the early to late ventricular filling velocities, the ratio of mitral annular early diastolic velocity to early mitral inflow velocity, and estimated right ventricular pressure remained at the similar level to preoperative one. The new ventricular restoration was associated with better systolic left ventricular function without deteriorating diastolic one. It may improve the outcome of the treatment of selected patients with dilated cardiomyopathy.

Effects of Surgical Ventricular Restoration on Left Ventricular Shape, Size, and Function for Left Ventricular Anterior Aneurysm

Background:

Surgical ventricular restoration (SVR) has been performed to treat left ventricular (LV) aneurysm. However, there is limited analysis of changes in LV shape. This study aimed to evaluate the changes in LV shape induced by SVR and the effects of SVR on LV size and function for LV aneurysm.

Methods:

Between April 2006 and March 2015, 18 patients with dyskinetic (dyskinetic group) and 12 patients with akinetic (akinetic group) postinfarction LV anterior aneurysm receiving SVR with the Dor procedure at Chinese People's Liberation Army General Hospital were enrolled in this study. A retrospective analysis was carried out using data from the echocardiography database. LV shape was analyzed by calculating the apical conicity index (ACI). LV end-diastolic volume index, end-systolic volume index, and ejection fraction (EF) were measured. One-way analysis of variance was used to compare means at different time points within each group.

Results:

Within one week after SVR, LV shape became more conical in the two groups (ACI decreased from 0.84 ± 0.13 to 0.69 ± 0.11 [t = 5.155, P = 0.000] in dyskinetic group and from 0.73 ± 0.07 to 0.60 ± 0.11 [t = 2.701, P = 0.026] in akinetic group; LV volumes were decreased significantly and became closer to normal values and EF was improved significantly in the two groups). On follow-up at least one year, LV shape remained unchanged in dyskinetic group (ACI increased from 0.69 ± 0.11 to 0.74 ± 0.12, t = −1.109, P = 0.294), but became more spherical in akinetic group (ACI significantly increased from 0.60 ± 0.11 to 0.75 ± 0.11, t = −1.880, P = 0.047); LV volumes remained unchanged in dyskinetic group, but increased significantly in akinetic group and EF remained unchanged in the two groups.

Conclusions:

SVR could reshape LV to a more conical shape and a more normal size and improve LV function significantly early after the procedure in patients with dyskinetic or akinetic postinfarction LV anterior aneurysm. However, LV tends to be more spherical and enlarged in the akinetic group on at least 1-year follow-up.

Regional left ventricular function does not predict survival in ischaemic cardiomyopathy after cardiac surgery

OBJECTIVES

To define the prognostic contribution of global and regional left ventricular (LV) function measurements in patients with ischaemic cardiomyopathy randomised to coronary artery bypass graft surgery (CABG) with (n=501) or without (n=499) surgical ventricular reconstruction (SVR).

METHODS

Novel multivariable methods to analyse global and regional LV systolic function were used to better formulate prediction models for long-term mortality following CABG with or without SVR in the entire cohort of 1000 randomised SVR hypothesis patients. Key clinical variables were included in the analysis. Regional function was classified according to the discreteness of anteroapical hypokinesia and akinesia into those most likely to benefit from SVR, those least likely and those felt to have intermediate likelihood of benefit from SVR.

RESULTS

The most prognostic clinical variables identified in multivariable models include creatinine, LV end-systolic volume index (ESVI), age and NYHA (New York Heart Association) class. Addition of LV ejection fraction, LV end-diastolic volume index and regional function assessment did not contribute additional power to the model. Subgroup analysis based on regional function did not identify a cohort in which SVR improved mortality.

CONCLUSIONS

ESVI is the single parameter of LV function most predictive of mortality in patients with LV systolic dysfunction following CABG with or without SVR in multivariable models that include all key clinical and LV systolic function parameters. Assessment of regional cardiac function does not enhance prediction of mortality nor identify a subgroup for which SVR improves mortality. These results do not support elective addition of LV reconstruction surgery in patients undergoing CABG.

TRIAL REGISTRATION NUMBER

NCT00023595.

Impact of left ventricular remodelling on outcomes after left ventriculoplasty for ischaemic cardiomyopathy: Japanese surgical ventricular reconstruction group experience

OBJECTIVES

Surgical ventricular reconstruction (SVR) for patients with severe left ventricular (LV) remodelling due to ischaemic cardiomyopathy is still controversial, because the Surgical Treatment for Ischaemic Heart Failure (STICH) trial demonstrated that SVR not only has no beneficial effect on survival compared with coronary artery bypass grafting (CABG) alone, but also is worse for those with a larger LV. Therefore, we assessed the impact of LV remodelling on the outcomes after SVR for ischaemic cardiomyopathy in Japan, using Di Donato's LV shape classification.

METHODS

From 2000 to 2010, 627 patients underwent SVR for ischaemic heart failure in 11 Japanese hospitals. To assess the patients with an LV ejection fraction (LVEF) of ≤ 35% like the STICH trial, considering the severity of LV remodelling, the patients with a preoperative LVEF of >35%, no preoperative LV volume assessment and no preoperative LV shape classification were excluded. Finally, 323 patients were selected as the study subjects. The LV shape was divided into three types according to Di Donato's classification. Types 1 and 3 indicate the aneurysmal and globally akinetic LV, respectively. Type 2 is the intermediate shape.

RESULTS

Type 1, 2 and 3 LV shapes were observed in 85 (26%), 104 (32%) and 134 (42%) of the patients, respectively. The preoperative LV volume and diameter increased if the LV became more akinetic (Type 3 > 2 > 1, P < 0.001). LVEF was lower in those with more akinetic LV (P = 0.002). The preoperative LV end-diastolic volume index and LVEF in Type 3 patients were 133 ± 47 ml/m(2) and 22 ± 7%, respectively. Mitral valve repair was more frequently performed for patients with the Type 3 LV shape (65%) than for the others (P < 0.001). The hospital mortality rates were 2.4, 2.9 and 7.4% for Type 1, 2 and 3 patients, respectively (P = 0.16). Kaplan-Meier analysis demonstrated no significant difference in mortality among the three groups (log-rank P = 0.37). The 5-year survival rates were 81, 70 and 73% for Type 1, 2 and 3 patients, respectively.

CONCLUSIONS

The severity of LV remodelling did not affect survival after SVR plus CABG. The results of SVR were acceptable even for those with globally akinetic LV due to ischaemic cardiomyopathy.

Surgical ventricular reconstruction with endocardectomy along radiofrequency ablation-induced markings

OBJECTIVE

The objective of this study was to evaluate the efficacy of a novel approach for endocardectomy during coronary artery bypass graft with surgical ventricular restoration in patients with postinfarction left ventricular aneurysm.

METHODS

One hundred sixty-eight patients underwent coronary artery bypass graft with surgical ventricular restoration from 2005 to 2011. Endocardectomy was performed as an integral part of surgical ventricular restoration for the prevention of ventricular tachycardia. The experimental group (surgical ventricular restoration-endocardectomy group; n = 74) underwent preoperative electrophysiologic study with electroanatomic left ventricular mapping. Radiofrequency ablation-induced markings were placed and were used later as guides for performing endocardectomy during coronary artery bypass graft with surgical ventricular restoration. The control group (surgical ventricular restoration group; n = 94) underwent surgical ventricular restoration without endocardectomy.

RESULTS

The 1-year mortality rates in the surgical ventricular restoration-endocardectomy and surgical ventricular restoration (control) groups were 5% and 13%, respectively. During the postoperative period, 3% of patients in the surgical ventricular restoration-endocardectomy group and 38% of patients in the surgical ventricular restoration group experienced ventricular tachycardia events (P < .05). Automatic implantable cardioverter-defibrillators were implanted in 11 patients in the surgical ventricular restoration group and in 1 patient of the surgical ventricular restoration-endocardectomy group for secondary prevention of sudden cardiac death.

CONCLUSIONS

When performed as an integral part of surgical ventricular restoration, endocardectomy was crucial in preventing postoperative ventricular tachycardia. Use of radiofrequency ablation-induced markings allowed clear visualization of the reentry zones for efficient endocardectomy during coronary artery bypass graft with surgical ventricular restoration, resulting in better patient outcomes.

Influence of baseline left ventricular function on the clinical outcome of surgical ventricular reconstruction in patients with ischaemic cardiomyopathy

AIMS

The Surgical Treatment for Ischemic Heart Failure (STICH) trial demonstrated no overall benefit when surgical ventricular reconstruction (SVR) was added to coronary artery bypass grafting (CABG) in patients with ischaemic cardiomyopathy. The present analysis was to determine whether, based on baseline left ventricular (LV) function parameters, any subgroups could be identified that benefited from SVR.

METHODS AND RESULTS

Among the 1000 patients enrolled, Core Lab measures of baseline LV function with adequate quality were obtained in 710 patients using echocardiography, in 352 using cardiovascular magnetic resonance, and in 344 using radionuclide imaging. The relationship between LV end-systolic volume index (ESVI), end-diastolic volume index, ejection fraction (EF), regional wall motion abnormalities, and outcome were first assessed only by echocardiographic measures, and then by 13 algorithms using a different hierarchy of imaging modalities and their quality. The median ESVI and EF were 78.0 (range: 22.8-283.8) mL/m2 and 28.0%, respectively. Hazard ratios comparing the randomized arms by subgroups of LVESVI and LVEF measured by echocardiography found that patients with smaller ventricles (LVESVI <60 mL/m2) and better LVEF (≥33%) may have benefitted by SVR, while those with larger ventricles (LVESVI >90 mL/m(2)) and lower LVEF (≤25%) did worse with SVR. Algorithms using all three imaging modalities found a weaker relationship between LV global function and the effects of SVR. The extent of regional wall motion abnormality did not influence the effects of SVR.

CONCLUSIONS

Subgroup analyses of the STICH trial suggest that patients with less dilated LV and better LVEF may benefit from SVR, while those with larger LV and poorer LVEF may do worse. Clinical Trial Registration #: NCT00023595.

Myocardial regeneration in heart failure: integrated development of biological therapeutic approaches

Heart failure currently constitutes one of the greatest health problems in the Western world. Its incidence, far from diminishing or even remaining stable, is actually still increasing in association with the aging of the population and its lifestyle. A better knowledge of physiopathological mechanisms has allowed for the development of new therapeutic focal points and lines of research. Nevertheless, its treatment is complex and encompasses a multidisciplinary approach. Patients in an advanced stage still have a very high mortality rate in spite of receiving optimum medical care. The development of new therapeutic techniques that afford a better prognosis has therefore been essential. Of these, and leaving aside surgical treatments, myocardial regeneration by means of cellular therapy, new concepts in tissue engineering and their results, and the applications of new advances in the field of immunomodulation have all recently experienced development. In this article, the aim is to bring the latest concepts in the physiopathology and humoral response of cardiac failure up to date as well as doing the same with the therapeutic approaches in this area.

A modified technique of left ventricular restoration: endoventricular spiral plication

We describe a modified technique of left ventricular restoration after anterior myocardial infarction, referred to as endoventricular spiral plication (ESP). This technique was designed for surgical ventricular restoration with a modified spiral stitch and no patch plasty. A continuous spiral stitch can reconstruct the left ventricular shape both at the short and long axis, and appropriate restoration can be achieved by adjusting the tension of the string and the degree of spiral rotation. 

Impact of surgical ventricular restoration on ventricular shape, wall stress, and function in heart failure patients

Surgical ventricular restoration (SVR) was designed to treat patients with aneurysms or large akinetic walls and dilated ventricles. Yet, crucial aspects essential to the efficacy of this procedure like optimal shape and size of the left ventricle (LV) are still debatable. The objective of this study is to quantify the efficacy of SVR based on LV regional shape in terms of curvedness, wall stress, and ventricular systolic function. A total of 40 patients underwent magnetic resonance imaging (MRI) before and after SVR. Both short-axis and long-axis MRI were used to reconstruct end-diastolic and end-systolic three-dimensional LV geometry. The regional shape in terms of surface curvedness, wall thickness, and wall stress indexes were determined for the entire LV. The infarct, border, and remote zones were defined in terms of end-diastolic wall thickness. The LV global systolic function in terms of global ejection fraction, the ratio between stroke work (SW) and end-diastolic volume (SW/EDV), the maximal rate of change of pressure-normalized stress (dσ*/dt(max)), and the regional function in terms of surface area change were examined. The LV end-diastolic and end-systolic volumes were significantly reduced, and global systolic function was improved in ejection fraction, SW/EDV, and dσ*/dt(max). In addition, the end-diastolic and end-systolic stresses in all zones were reduced. Although there was a slight increase in regional curvedness and surface area change in each zone, the change was not significant. Also, while SVR reduced LV wall stress with increased global LV systolic function, regional LV shape and function did not significantly improve.

Restrictive mitral annuloplasty for functional mitral regurgitation: acute hemodynamics and serial echocardiography

BACKGROUND

Long-term effects of restrictive mitral annuloplasty (RMA), especially on hemodynamics and left ventricular (LV) function in patients with functional mitral regurgitation (MR), have not been fully investigated.

METHODS AND RESULTS

From 1999 to 2008, 44 patients with refractory heart failure and functional MR underwent RMA with stringent downsizing of the mitral annulus. Serial echocardiography was performed to evaluate LV function (reverse remodeling), estimated systolic pulmonary artery pressure (PAP) and mitral valve geometry at baseline and at discharge, and annually thereafter. Cardiac catheterization was performed at baseline, and at discharge to evaluate acute hemodynamic change. There were 3 early deaths, and the 5-year survival rate was 78 ± 8%. In 41 survivors the clinical symptoms, stratified according to New York Heart Association class, significantly improved after surgery. Postoperative cardiac catheterization showed significant unloading for left ventricle, as well as improvement in LV systolic function. Serial echocardiography showed that improvements in LV function and systolic PAP were sustained in the majority of patients. Multivariate Cox regression analysis identified preoperative pulmonary hypertension (systolic PAP>60 mm Hg) as the significant predictor for postoperative adverse cardiac events.

CONCLUSIONS

RMA for functional MR resulted in sustained improvement of hemodynamics and LV function over time. Additional studies are needed to define the negative impact of preoperative pulmonary hypertension in patients with this condition.

Left ventricular aneurysm using the Dor technique: mid-term results

OBJECTIVE

We have retrospectively analyzed the early and the mid-term results of the operations for modified endoventricular circular patch plasty for left ventricular aneurysm (LVA) repair in our clinic.

PATIENTS AND METHODS

Sixty-seven cases with anterior LVA were included in the study. Mean age of the patients were 64.8 +/- 8.9 (ranged from 51 to 74) years. Fifty-three patients were male and 14 female (M:F = 3.8). Preoperative left ventricular ejection fraction (LVEF) was 30.8% +/- 4.5%, LV end-diastolic diameter (LVEDD) 6.0 +/- 1.9 cm, and end-systolic diameter (LVESD) was 4.6 +/- 0.8 cm in average. Coronary revascularization was performed in 61 patients and mitral ring annuloplasty in five patients.

RESULTS

Thirty-day mortality was 5.9%. The surviving 63 patients were followed up for 4.3 +/- 2.3 years on average (ranged from 0.2 to 8.5 years), adding up to 267.8 patient/years. In the immediate postoperative and long-term follow-up, there was a significant improvement in LVEF, LVESD, LVEDD, and mitral valvular function. Four patients died in the follow-up with only a single patient due to cardiac causes. The five years survival was 87.7% +/- 4.1% and the freedom from cardiac death was 98.2% +/- 1.7%.

CONCLUSION

LVA repair with Dor procedure can be performed with low mortality. With appropriate repair of LVA and coronary revascularization, patients may have benefit both for survival and also for clinical status.