Surgical anterior ventricular endocardial restoration (SAVER) in the dilated remodeled ventricle after anterior myocardial infarction. RESTORE group. Reconstructive Endoventricular Surgery, returning Torsion Original Radius Elliptical Shape to the LV

Concomitant valve surgery is associated with worse outcomes in surgical treatments of post-infarction ventricular aneurysm

Objective

To evaluate the impact of concomitant valve surgery on the prognosis of patients who experienced coronary artery bypass graft (CABG) with/without ventricular reconstruction for the ventricular aneurysm.

Methods

In our department, 354 patients underwent CABG with/without ventricular reconstruction for a ventricular aneurysm from July 23rd, 2000 to December 23rd, 2022. A total of 77 patients received concomitant valve surgery, 37 of whom underwent replacement, and 40 of whom underwent repair. The baseline characteristics, prognostic, and follow-up information were statically analyzed. Univariate and multivariate Cox regression analyses were applied to identify the risk factors of long-term outcomes.

Results

Compared with patients who did not undergo valvular surgery, patients who experienced concomitant valve surgical treatments had a significantly lower survival rate (p = 0.00022) and a longer total mechanical ventilation time. Subgroup analysis indicated that the options of repair or replacement exhibited no statistically significant difference in postoperative mortality (p = 0.44) and prognosis. The multivariate Cox regression analysis suggested that the pre-operative cholesterol level (HR = 1.68), postoperative IABP (HR = 6.29), NYHA level (HR = 2.84), and pre-operative triglyceride level (HR = 1.09) were independent and significant predictors for overall all-cause mortality after surgery.

Conclusion

Concomitant valve surgery was considerably related to a higher risk of postoperative mortality in patients with post-infarction ventricle aneurysms who underwent surgical treatments. No significant difference in the prognosis outcomes was observed between the operating methods of repair or replacement valve surgery.

Elucidating the mechanisms underlying left ventricular function recovery in patients with ischemic heart failure undergoing surgical remodeling: A 3-dimensional ultrasound analysis

OBJECTIVE

The study objective was to elucidate the mechanisms of left ventricle functional recovery in terms of endocardial contractility and synchronicity after surgical ventricular reconstruction.

METHODS

Real-time 3-dimensional transthoracic echocardiography was performed on 20 patients with anterior left ventricle remodeling and ischemic heart failure before surgical ventricular reconstruction and at 6-month follow-up, and on 15 healthy controls matched by age and body surface area. Real-time 3-dimensional transthoracic echocardiography datasets were analyzed through TomTec software (4D LV-Analysis; TomTec Imaging Systems GmbH, Unterschleissheim, Germany): Left ventricle volumes, ejection fraction, and global longitudinal strain were computed; the time-dependent endocardial surface yielded by 3-dimensional speckle-tracking echocardiography was postprocessed through in-house software to quantify local systolic minimum principal strain as a measure of fiber shortening and mechanical dispersion as a measure of fiber synchronicity.

RESULTS

Compared with controls, patients with heart failure before surgical ventricular reconstruction showed lower ejection fraction (P < .0001) and significantly impaired mechanical dispersion (P < .0001) and minimum principal strain (P < .0001); the latter worsened progressively from left ventricle base to apex. After surgical ventricular reconstruction, global longitudinal strain improved from -6.7% to -11.3% (P < .0001); mechanical dispersion decreased in every left ventricle region (P ≤ .017) and mostly in the basal region, where computed mechanical dispersion values were comparable to physiologic values (P ≥ .046); minimum principal strain improved mostly in the basal region, changing from -16.6% to -22.3% (P = .0027).

CONCLUSIONS

At 6-month follow-up, surgical ventricular reconstruction was associated with significant recovery in global left ventricle function, improved mechanical dispersion indicating a more synchronous left ventricle contraction, and improved left ventricle fiber shortening mostly in the basal region, suggesting the major role of the remote myocardium in enhancing left ventricle functional recovery.

Prognostic value of carbohydrate antigen 125 in patients undergoing surgical left ventricular reconstruction

BACKGROUND

Carbohydrate antigen 125 (CA125) is a biomarker often used in diagnosis of ovarian tumors. Studies also show that elevated CA125 implicates worse outcomes among patients with heart failure, while latter of which plays an important role in the pathophysiology of left ventricular aneurysm (LVA). However, the prognostic value of CA125 in LVA patients undergoing surgical left ventricular reconstruction (SLVR) remains unclear.

METHODS

In this single-centered cohort study, a total of 309 patients with LVA undergoing SLVR were retrospectively recruited. Univariable regression analysis was performed to identify the potential confounders for each outcome, followed by multivariable adjustment to confirm the association between CA125 and outcomes. The primary outcome was the overall mortality, and the secondary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE) and perioperative outcomes. A receiver operating characteristic (ROC) curve was use to find the optimal cut-off value of CA125.

RESULTS

The median follow-up time was 55 months. The cohort was predominantly male (86.4%), with an average age of 58.6 years. Log (CA125) was associated with overall mortality (hazard ratio [HR]: 2.15, 95% confidence interval [CI]: 1.06-4.36, P = 0.033), prolonged hospital-stay time (HR:1.07, 95%CI: 1.03-1.12, P = 0.001) and increased risk of postoperative ventricular support (HR: 2.81, 95%CI: 1.10-7.18, P = 0.031) after multivariate adjustment. The optimal cut-off value for the CA125 for all-cause mortality was 13.825 U/ml with the area under curve of 0.675.

CONCLUSION

Elevated-CA125 implicates poorer short- and long-term prognosis in LVA patients undergoing SLVR.

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.

Right ventricular remodelling after endo-exclusion during pulmonary valve replacement: evaluation by cardiac magnetic resonance

OBJECTIVES

Pulmonary valve replacement (PVR) performed for pulmonary valve regurgitation is the most common indication for reoperation during mid-to-long-term follow-up after tetralogy of Fallot repair. An aneurysmal dilation of the infundibulum is often associated secondary to the infundibulotomy performed in the first operation. The right ventricular outflow tract reconstruction with endo-exclusion aims to exclude the non-contractile segments of the dilated right ventricular. This study intends to assess the safety and efficiency of the endo-exclusion technique.

METHODS

Between January 2010 and December 2018, 86 patients underwent a PVR with (n = 46) or without (n = 40) endo-exclusion. The current study compares the outcomes in terms of survival, reintervention, structural valve deterioration, right ventricular function (volume and right ventricular ejection fraction) and pulmonary valve gradient. The median follow-up time was 4.45 years (1.9 months to 9.87 years).

RESULTS

There was no 30-day mortality. There was no difference in the freedom from reintervention at 7 years (without endo-exclusion, 97%, versus with endo-exclusion, 94%, log-rank = 0.68) or in the freedom from structural pulmonary valve deterioration at 7 years (without endo-exclusion, 94%, versus with endo-exclusion, 89%, log-rank = 0.94). No significant difference was observed in the indexed right ventricular end-diastolic volume (102.2 ± 34 ml/m2 in the PVR without endo-exclusion group and 93.3 ± 22 ml/m2 in the PVR with endo-exclusion group, P = 0.61). No significant difference was observed in the right ventricular function (right ventricular ejection fraction: 46 ± 11% in the PVR without endo-exclusion group and 46 ± 9% in the PVR with endo-exclusion group, P = 0.88).

CONCLUSIONS

PVR with or without endo-exclusion is a safe and effective procedure. PVR with endo-exclusion allows implantation without structural deformation of the valve and therefore excellent short- and medium-term results.

Anesthetic Considerations for a Novel Method of Surgical Ventricular Remodeling Using the BioVentrix Revivent TC System

Surgical ventricular remodeling (SVR) is an invasive method of treating patients with heart failure who also have ischemic cardiomyopathy and reduced ejection fraction (EF). Introduced in the mid-1980s, this technique was met with varying success and relatively high morbidity and mortality despite its theoretical benefits. The development of the BioVentrix Revivent TC System (BioVentrix, Inc., San Ramon, CA) as a less-invasive method of surgical ventricular remodeling has created a novel, multidisciplinary approach to heart failure management, which necessitates multiple subspecialties. Currently in the trial phase in the United States and widely used in Europe, the positive results to date appear promising for the rapid adoption of this procedure. For the cardiac anesthesiologist, a thorough understanding of the patient population, procedural goals, and intraoperative management is essential. This overview discusses the advancement in surgical ventricular remodeling, the pertinent surgical steps of the BioVentrix Revivent TC System placement, and specific anesthetic considerations for this novel procedure.

Long-Term Survival and Echocardiographic Findings After Surgical Ventricular Restoration

BACKGROUND

This study investigates the long-term survival and durability of mitral procedures on patients undergoing surgical ventricular restoration.

METHODS

From 1992 to 2017, 109 patients underwent surgical ventricular restoration. Survival was determined from hospital records and the National Death Index. Preoperative demographics, clinical characteristics and features, operative technique, and follow-up echocardiography findings were analyzed using Cox regression and log-rank to determine variables influencing survival.

RESULTS

The mean age was 61.57 ± 12.81 years. There were 101 (93%) true and 8 (7%) pseudo-aneurysms. Concomitant surgeries included mitral valve (MV) repair (n = 40, 37%), MV replacement (n = 5, 5%), tricuspid valve repair (n = 4, 4%), aortic valve replacement (n = 3, 3%), coronary bypass grafting (n = 76, 70%; 1.6 ± 1.3 grafts), and ventricular septal defect closure (n = 5, 5%). Redo-sternotomies were performed in 12 patients (11%). Median duration of echocardiographic follow up was 2.9 years (interquartile range, 9.0) and was obtained in 59 patients (54%). Left ventricular ejection fraction improved from 28% ± 13% to 33% ± 16% (p = 0.011). Median duration of echocardiographic follow-up of MV repair was 3.6 years (interquartile range, 9.5). MV repair led to sustained improvements in mitral regurgitation (MR; p = 0.001) where only 2 (5%) experienced recurrence of moderate to severe MR. For patients who did not undergo an MV procedure there was no difference in preoperative and follow-up MR severity (p = 0.586). Median patient follow-up was 7.1 years (interquartile range, 8.5). Overall 5-, 10-, and 15-year survival rates were 71.9%, 48.1%, and 26.2%, respectively.

CONCLUSIONS

Surgical ventricular restoration was associated with sustained improvement in left ventricular ejection fraction with almost half surviving to 10 years postoperatively. For patients undergoing concomitant MV repair, the improvement in mitral competence is durable.

Personalised computational cardiology: Patient-specific modelling in cardiac mechanics and biomaterial injection therapies for myocardial infarction

Predictive computational modelling in biomedical research offers the potential to integrate diverse data, uncover biological mechanisms that are not easily accessible through experimental methods and expose gaps in knowledge requiring further research. Recent developments in computing and diagnostic technologies have initiated the advancement of computational models in terms of complexity and specificity. Consequently, computational modelling can increasingly be utilised as enabling and complementing modality in the clinic—with medical decisions and interventions being personalised. Myocardial infarction and heart failure are amongst the leading causes of death globally despite optimal modern treatment. The development of novel MI therapies is challenging and may be greatly facilitated through predictive modelling. Here, we review the advances in patient-specific modelling of cardiac mechanics, distinguishing specificity in cardiac geometry, myofibre architecture and mechanical tissue properties. Thereafter, the focus narrows to the mechanics of the infarcted heart and treatment of myocardial infarction with particular attention on intramyocardial biomaterial delivery.

Heart Failure Interventions Targeting Impaired Left Ventricles in Structural Heart Disease

PURPOSE OF REVIEW

Interventional techniques have been developed for a wide spectrum of mechanisms of heart failure (HF), especially in valvular heart disease and cardiomyopathies (ischaemic cardiomyopathy and hypertrophic cardiomyopathy). In this article, we review recent reports on catheter interventions to treat patients with HF.

RECENT FINDINGS

Direct modification using the Parachute device and the REVIVENT-TC device for patients with impaired left ventricle with large infarct scars improves geometry and haemodynamic efficiency, resulting in a reduction of HF symptoms. Interatrial shunt therapy improves symptoms and quality of life in HF patients. Uniquely, left ventricular outflow tract obstruction has also been targeted in patients with transcatheter mitral valve implantation. For advanced stage HF patients with prohibitively high surgical risk, emerging transcatheter interventions make it possible to modify life-limiting symptoms. Further results on HF interventions are expected from ongoing clinical trials.

Treatment of Heart Failure with Abnormal Left Ventricular Systolic Function in Older Adults

Heart failure (HF) with abnormal left ventricular (LV) ejection fraction should be identified and treated. Treat hypertension with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Treat myocardial ischemia with nitrates and β-blockers. Treat volume overload and HF with diuretics. Treat HF with ACE inhibitors and β-blockers. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in chronic symptomatic HF and abnormal LV ejection fraction. Add isosorbide dinitrate/hydralazine in African Americans with class II to IV HF treated with diuretics, ACE inhibitors, and β-blockers. Exercise training is recommended. Indications for implantable cardioverter-defibrillator and cardiac resynchronization therapy are discussed.

Left Ventricular Aneurysmectomy: Tailored Scar Excision and Linear Closure

Coronary artery bypass surgery with or without aneurysmectomy is used to treat patients with left ventricular aneurysm. There is debate about patient selection and the appropriate surgical technique. We analyzed the results of 102 consecutive patients who underwent left ventricular aneurysmectomy and reconstruction using a modified linear closure technique between 1992 and 2003. The mean age was 62 years, 81% of the patients were male, and 47% had an ejection fraction < 35%. The locations of the left ventricular aneurysms were anteroapical (75%), apical (21%), and posteroinferior (4%); 23% contained thrombi. Additional procedures included aortic valve replacement in 4, mitral valve repair in 1, and coronary bypass grafting in 98 patients; 3 underwent isolated repair of left ventricular aneurysm. Hospital mortality was 7% and long-term survival was 76% at a mean follow-up of 39 months. Most patients improved symptomatically postoperatively. Left ventricular aneurysm repair with tailored scar excision and a modified closure technique is associated with acceptable mortality and long-term survival.

Transseptal and transmitral Parachute® implantation in conjunction with "MitraClipping"

AIMS

Parachute® implantation (PI) is an attractive treatment option for patients with left ventricular apical aneurysms (LVAA). So far, only the retrograde approach has been approved for PI. Unfortunately, severe functional mitral regurgitation (MR) restricts PI. Thus, we were intrigued to combine PI and MitraClip therapy (MCT) as a new transvenous hybrid concept.

METHODS AND RESULTS

PI was performed via a transseptally placed MitraClip guide in six consecutive patients (age 73.8±5.2; 66% male). Immediately after PI, MR was treated by MCT. Invasive right and left heart haemodynamics were taken before and after PI and MCT, respectively. Procedural success was 100%. PI induced a numerical increase in cardiac output (CO: +36.4; p=0.15) and stroke volume (SV: +30.1%; p=0.09), despite some evidence of MR aggravation. Subsequent MCT successfully reduced MR at least to mild in five patients and to moderate in one patient. SV and CO demonstrated a further increase (SV: +44.3%, p=0.03; CO: +44.5%; p=0.03).

CONCLUSIONS

The study documents for the first time the feasibility of transseptal and transmitral PI. Nevertheless, pre-procedural MR seems to counteract the beneficial effects of PI. Hence, the combined transseptal approach of PI and MCT seems to be the appropriate strategy in patients with significant MR and LVAA.

Impact of surgical ventricular reconstruction on sphericity index in patients with ischaemic cardiomyopathy: follow-up from the STICH trial

AIMS

We sought to evaluate associations between baseline sphericity index (SI) and clinical outcome, and changes in SI after coronary artery bypass graft (CABG) surgery with or without surgical ventricular reconstruction (SVR) in ischaemic cardiomyopathy patients enrolled in the SVR study (Hypothesis 2) of the Surgical Treatment for Ischemic Heart Failure (STICH) trial.

METHODS AND RESULTS

Among 1000 patients in the STICH SVR study, we evaluated 546 patients (255 randomized to CABG alone and 291 to CABG + SVR) whose baseline SI values were available. SI was not significantly different between treatment groups at baseline. After 4 months, SI had increased in the CABG + SVR group, but was unchanged in the CABG alone group (0.69 ± 0.10 to 0.77 ± 0.12 vs. 0.67 ± 0.07 to 0.66 ± 0.09, respectively; P < 0.001). SI did not significantly change from 4 months to 2 years in either group. Although LV end-systolic volume and EF improved significantly more in the CABG + SVR group compared with CABG alone, the severity of mitral regurgitation significantly improved only in the CABG alone group, and the estimated LV filling pressure (E/A ratio) increased only in the CABG + SVR group. Higher baseline SI was associated with worse survival after surgery (hazard ratio 1.21, 95% confidence interval 1.02 - 1.43; P = 0.026). Survival was not significantly different by treatment strategy.

CONCLUSION

Although SVR was designed to improve LV geometry, SI worsened after SVR despite improved LVEF and smaller LV volume. Survival was significantly better in patients with lower SI regardless of treatment strategy.

Restoration of optimal left ventricular apical geometry and rotation following surgical ventricular restoration using rectangular patch plasty technique: a pilot study using cardiac magnetic resonance

OBJECTIVES

Clinical outcomes of surgical ventricular restoration (SVR) have been confirmed by Registry data. Accurate assessment of left ventricular (LV) morphology and function can help optimize these outcomes.

METHODS

LV remodelling in 7 patients (NYHA class 3 ± 1.2) with post-myocardial infarction LV aneurysms was characterized by the regional LV volume (RLVV) computed by dividing the LV in cine steady-state free precession cardiac magnetic resonance imaging (CMR) at each slice level into six radial segments. Rotation of the LV apex and base was analysed using tagged CMR. The apical conicity ratio was used to characterize the restored apical geometry.

RESULTS

The mean end-diastolic volume (EDV) was 174.8 ± 100.3 ml and the mean ejection fraction (EF) was 18.8 ± 7.8%. Following SVR, all patients had significant clinical improvements (NYHA Class I), and significant increases in the left ventricular ejection fraction (LVEF) to 38.8 ± 4.4%. The LV volumes and regional volumes at the base and apex decreased with a trend towards significance. The mean preoperative apical conicity ratio (ACR) was 1.90 ± 0.43 and, following SVR by endoventricular linear patch plasty (EVLPP), was 1.35 ± 0.3 (P = 0.02). The percent decrease in the ACR following SVR from baseline was 28.68 ± 10.98%. The apical EF increased from 1.19 ± 13.9 to 15.8 ± 8.2% (P = 0.028). The basal rotations improved from 3.13 ± 2.1 to 4.69 ± 2.94° (P = 0.04). The apical rotations also improved significantly from 2.48 ± 1.23 to 3.93 ± 2.45° (P = 0.05) and reversed to the normal anticlockwise direction.

CONCLUSIONS

SVR by geometric repair using a rectangular intracavitary patch helps restoration of a physiological apex with normalization of apical rotation reflecting a near-physiological LV function.

Stroke volume paradox in heart failure: mathematical validation

BACKGROUND

In some patients with ischemic cardiomyopathy, despite large increases in ventricular size with decreased cardiac output, the paradox of preserved stroke volume has been observed. Following surgical ventricular restoration, despite marked improvements clinically and in ventricular volumes and ejection fraction, a decrease in stroke volume was observed.

METHODS

101 consecutive patients with postinfarction left ventricular aneurysms were studied by 2-dimensional echocardiography and contrast ventriculography at baseline, and 57 of these patients at 1.7 to 2.2 years (mean 1.95 ± 0.44 years) after surgical ventricular restoration.

RESULTS

Surgical ventricular restoration resulted in a decrease in end-diastolic volume index of 40.2 mL (95% confidence interval: 33.6-46.7) and stroke volume index of 10.0 mL (95% confidence interval: 6.6-13.5), and an increase in ejection fraction of 6.7% (95% confidence interval: 5.5-7.9). The stroke volume index had a significant linear relationship with the end-diastolic volume index at rest in patients with end-diastolic volume index < 150 mL (r = 0.64, p < 0.001). In patients with end-diastolic volume index >150 mL, this linear relationship was not seen. The change in end-diastolic volume index and stroke volume index had a significant linear relationship (r = 0.72, p < 0.001) that persisted at 1.95 years after surgery.

CONCLUSIONS

In ischemic cardiomyopathy, stroke volume increases linearly with increases in end-diastolic volume up to a certain magnitude of end-diastolic volume, beyond which it decreases. Hence, following surgical ventricular restoration, decreases in stroke volume are not a reflection of impaired cardiac function.

Surgical therapy for heart failure

Today's healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.

Multiscale Characterization of Impact of Infarct Size on Myocardial Remodeling in an Ovine Infarct Model

The surviving myocardium initially compensates the loss of injured myocardium after myocardial infarction (MI) and gradually becomes progressively dysfunctional. There have been limited studies on the effect of infarct size on temporal and spatial alterations in the myocardium during progressive myocardial remodeling. MI with three infarct sizes, i.e. 15, 25 and 35% of the left ventricular (LV) wall, was created in an ovine infarction model. The progressive LV remodeling over a 12-week period was studied. Echocardiography, sonomicrometry, and histological and molecular analyses were carried out to evaluate cardiac function, regional tissue contractile function, structural remodeling and cardiomyocyte hypertrophy, and calcium handling proteins. Twelve weeks after MI, the 15, 25 and 35% MI groups had normalized LV end diastole volumes of 1.4 ± 0.2, 1.7 ± 0.3 and 2.0 ± 0.4 ml/kg, normalized end systole volumes of 1.0 ± 0.1, 1.0 ± 0.2 and 1.3 ± 0.3 ml/kg and LV ejection fractions of 43 ± 3, 42 ± 6 and 34 ± 4%, respectively. They all differed from the sham group (p < 0.05). All the three MI groups exhibited larger wall areal expansion (remodeling strain), larger cardiomyocyte size and altered expression of calcium handing proteins in the adjacent myocardium compared to the remote counterpart from the infarct. A significant correlation was found between cardiomyocyte size and remodeling strain in the adjacent zone. A comparative analysis among the three MI groups showed that a larger infarct size (35 vs. 15% MI) was associated with larger remodeling strain, more serious impairment in the cellular structure and composition, and regional contractile function at regional tissue level and LV function at organ level.

Interrelation between myocardial oxidative metabolism and diastolic function in patients undergoing surgical ventricular reconstruction

PURPOSE

Diastolic function is impaired in patients with end-stage heart failure. Favorable structural changes by surgical ventricular reconstruction (SVR) are thought to improve diastolic function, however, previous studies reported the contradictory results. We hypothesized that cardiac oxidative metabolism and diastolic dysfunction might improve in parallel to the reduction of left ventricular chamber size after SVR.

METHODS

We studied 11 patients underwent SVR associated with mitral valve repair for end-stage heart failure due to dilated cardiomyopathy. Diastolic function was assessed by echocardiography and myocardial oxidative metabolism was measured by the monoexponential clearance (k-mono) of (11)C-acetate positron emission tomography at baseline and 1 month after SVR.

RESULTS

All patients had preoperative severe diastolic dysfunction [E/A 4.11 ± 1.18, deceleration time (DT) 134 ± 26 ms]. The study patients were divided into 2 groups according to the changes in diastolic function after SVR; unchanged or worsened diastolic function in 6 patients (55 %, Non-responder) and improved diastolic function in 5 (45 %, Responder). K-mono and wall stress decreased only in responder. The changes in k-mono before and after SVR correlated with those in deceleration time (r =  -0.63; p < 0.05) and wall stress (r = 0.75; p < 0.01).

CONCLUSIONS

Improvement of diastolic dysfunction in patients with end-stage heart failure by SVR was in parallel to that in oxidative metabolism. It suggests that SVR reduced excessive metabolism during the diastolic phase, in part, via the improvement in diastolic function and the reduction in LV wall stress.

Growth and remodeling of the left ventricle: A case study of myocardial infarction and surgical ventricular restoration

Cardiac growth and remodeling in the form of chamber dilation and wall thinning are typical hallmarks of infarct-induced heart failure. Over time, the infarct region stiffens, the remaining muscle takes over function, and the chamber weakens and dilates. Current therapies seek to attenuate these effects by removing the infarct region or by providing structural support to the ventricular wall. However, the underlying mechanisms of these therapies are unclear, and the results remain suboptimal. Here we show that myocardial infarction induces pronounced regional and transmural variations in cardiac form. We introduce a mechanistic growth model capable of predicting structural alterations in response to mechanical overload. Under a uniform loading, this model predicts non-uniform growth. Using this model, we simulate growth in a patient-specific left ventricle. We compare two cases, growth in an infarcted heart, pre-operative, and growth in the same heart, after the infarct was surgically excluded, post-operative. Our results suggest that removing the infarct and creating a left ventricle with homogeneous mechanical properties does not necessarily reduce the driving forces for growth and remodeling. These preliminary findings agree conceptually with clinical observations.

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.

Percutaneous left ventricular partitioning in patients with chronic heart failure and a prior anterior myocardial infarction: Results of the PercutAneous Ventricular RestorAtion in Chronic Heart failUre PaTiEnts Trial

OBJECTIVES

The aim of this study was to assess the feasibility, safety, and preliminary efficacy of a novel percutaneous left ventricular partitioning device (VPD) in patients with chronic heart failure (HF) and a prior anterior myocardial infarction.

BACKGROUND

Anterior myocardial infarction is frequently followed by left ventricular remodeling, HF, and increased long-term morbidity and mortality.

METHODS

Thirty-nine patients were enrolled in a multinational, nonrandomized, longitudinal investigation. The primary end point was an assessment of safety, defined as the successful delivery and deployment of the VPD and absence of device-related major adverse cardiac events over 6 months. Secondary (exploratory) efficacy end points included changes in hemodynamics and functional status and were assessed serially throughout the study.

RESULTS

Ventricular partitioning device placement was not attempted in 5 (13%) of 39 subjects. The device was safely and successfully implanted in 31 (91%) of the remaining 34 patients or 79% of all enrolled patients. The 6-month rate of device-related major adverse cardiac event occurred in 5 (13%) of 39 enrolled subjects and 5 (15%) of 34 treated subjects, with 1 additional event occurring between 6 and 12 months. For patients discharged with the device to 12 months (n = 28), New York Heart Association class (2.5 ± 0.6 to 1.3 ± 0.6, P < .001) and quality-of-life scores (38.6 ± 6.1 to 28.4 ± 4.4, P < .002) improved significantly; however, the 6-minute hall walk distance (358.5 ± 20.4 m to 374.7 ± 25.6 m, P nonsignificant) only trended toward improvement.

CONCLUSIONS

The left VPD appears to be relatively safe and potentially effective in the treatment for patients with HF and a prior anterior myocardial infarction. However, these limited results suggest the need for further evaluation in a larger randomized controlled trial.

Linkages between anxiety and outcomes in heart failure

OBJECTIVE

We investigated the relationship between anxiety and event-free survival (ie, composite endpoint of death, emergency department visits, or hospitalizations) for patients with heart failure (HF), and examined whether behavioral and physiologic mechanisms mediate any association between anxiety and outcomes.

METHODS

In this longitudinal study, patients with HF completed the anxiety subscale of the Brief Symptom Inventory, and heart-rate variability and plasma norepinephrine levels were measured. Dietary adherence and medication adherence were measured according to 24-hour urine sodium level and the Medication Event Monitoring System, respectively. Patients were followed at least 1 year for event-free survival.

RESULTS

In total, 147 patients were enrolled. Patients with high anxiety had a shorter (hazard ratio, 2.2; 95% confidence interval, 1.1-4.3; P = .03) period of event-free survival than patients with lower anxiety. Anxiety independently predicted adherence to medication (P = .008), which in turn predicted event-free survival (hazard ratio, 2.0; 95% confidence interval, 1.2-3.3; P = .008). The effect of anxiety (P = .17) on event-free survival was less significant when the regression model included both anxiety and adherence to medication than when the model only included anxiety (P = .03), indicating that adherence to medication mediated the relationship between anxiety and event-free survival.

CONCLUSION

This is the first study to show that nonadherence to medication links anxiety and event-free survival for patients with HF. Interventions that reduce anxiety and improve adherence may benefit outcomes.

Surgical Therapy of End-Stage Heart Failure: Understanding Cell-Mediated Mechanisms Interacting with Myocardial Damage

Worldwide, cardiovascular disease results in an estimated 14.3 million deaths per year, giving rise to an increased demand for alternative and advanced treatment. Current approaches include medical management, cardiac transplantation, device therapy, and, most recently, stem cell therapy. Research into cell-based therapies has shown this option to be a promising alternative to the conventional methods. In contrast to early trials, modern approaches now attempt to isolate specific stem cells, as well as increase their numbers by means of amplifying in a culture environment. The method of delivery has also been improved to minimize the risk of micro-infarcts and embolization, which were often observed after the use of coronary catheterization. The latest approach entails direct, surgical, transepicardial injection of the stem cell mixture, as well as the use of tissue-engineered meshes consisting of embedded progenitor cells.

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.

Myocardial reverse remodeling

Despite an extensive literature defining the mechanisms and significance of pathological myocardial remodeling, there has been no comprehensive review of the inverse process, often labeled reverse remodeling. Accordingly, the goal of this review is to overview the varied settings in which clinically significant reverse remodeling has been well documented. When available, we reviewed relevant randomized, controlled clinical trials, and meta-analyses with sufficient cardiac imaging data to permit conclusions about reverse remodeling. When these types of studies were not available, relevant case-control studies and case series that employed appropriate methodology were reviewed. Regression of pathological myocardial hypertrophy, chamber shape distortions, and dysfunction occurs in a wide variety of settings. Although reverse remodeling occurs spontaneously in some etiologies of myocardial dysfunction and failure, remodeling is more commonly observed in response to medical, device-based, or surgical therapies, including β-blockers, revascularization, cardiac resynchronization therapy, and valve surgery. Indeed, reverse remodeling following pathophysiologically targeted interventions helps validate that the targeted mechanisms are propelling and/or sustaining pathological remodeling. The diverse clinical settings in which reverse remodeling has been observed demonstrates that myocardial remodeling is bidirectional and occurs across the full spectrum of myocardial disease severity, duration, and etiology. Observations in several settings suggest that recovered hearts are not truly normal despite parallel improvements at organ, tissue, and cellular level. Nevertheless, the link between reverse remodeling and improved outcomes should inspire further research to better understand the mechanisms responsible for both reverse remodeling and persistent deviations from normalcy.

Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery

BACKGROUND

Although pulmonary valve replacement (PVR) is effective in reducing right ventricular (RV) volume overload in patients with chronic pulmonary regurgitation, persistent RV dysfunction and subsequent adverse clinical outcomes have been reported. This trial was conducted to investigate whether the addition of surgical RV remodeling with exclusion of scar tissue to PVR would result in improved RV function and laboratory and clinical parameters, as compared with PVR alone.

METHODS AND RESULTS

Between February 2004 and October 2008, 64 patients who underwent RV outflow tract procedures in early childhood had more than or equal to moderate pulmonary regurgitation, and fulfilled defined criteria for PVR were randomly assigned to undergo either PVR alone (n=34) or PVR with surgical RV remodeling (n=30). No significant difference was observed in the primary outcome (change in RV ejection fraction, -2±7% in the PVR alone group and -1±7% in the PVR with RV remodeling group; P=0.38) or in any of the secondary outcomes at 6-month postoperative follow-up. Multivariable analysis of the entire cohort identified preoperative RV end-systolic volume index <90 mL/m(2) and QRS duration <140 ms to be associated with optimal postoperative outcome (normal RV size and function), and RV ejection fraction <45% and QRS duration ≥160 ms to be associated with suboptimal postoperative outcome (RV dilatation and dysfunction).

CONCLUSIONS

The addition of surgical remodeling of the RV to PVR in patients with chronic pulmonary regurgitation did not result in a measurable early benefit. Referral to PVR based on QRS duration, RV end-systolic volume, or RV ejection fraction may be beneficial. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00112320.

Clinical characteristics of patients undergoing surgical ventricular reconstruction by choice and by randomization

OBJECTIVES

The aim of this study was to confirm the generalizability of the conclusions of the STICH (Surgical Treatment for Ischemic Heart Failure) trial.

BACKGROUND

Surgical ventricular reconstruction (SVR) added to coronary artery bypass grafting (CABG) did not decrease death or cardiac hospitalization in STICH patients randomized to CABG with (n = 501) or without (n = 499) SVR.

METHODS

Baseline clinical characteristics of 1,000 STICH SVR hypothesis patients and 1,036 STICH-eligible Society of Thoracic Surgeons (STS) National Cardiac Database patients undergoing CABG plus SVR were entered into a multivariate model equation to predict a mortality that placed these 2,036 patients in 1 of 32 risk at randomization (RAR) groups. The number of patients in each RAR group profiled the risk of STICH treatment arms and of STICH and STS STICH-eligible patients.

RESULTS

That 85% of the 1,000 STICH patients known to have no significant differences in baseline characteristics between the 2 treatment arms shared the same RAR group suggests that the RAR methodology has sufficient accuracy to compare RAR profiles of STICH and STS patients. RAR group was shared by 1,522 of 2,036 STICH and STS STICH-eligible patients (75%) who underwent CABG plus SVR. Differences in baseline characteristics responsible for more low-risk STICH patients and more high-risk STS patients were modest. Cox proportional hazard ratios of 1,000 STICH patients in 3 RAR groups suggested by STICH and STS RAR differences showed no differential treatment effect on survival across the low-, intermediate-, and high-risk groups.

CONCLUSIONS

The STICH conclusion of no benefit from adding SVR to CABG applies to a broad spectrum of CABG-eligible patients with ischemic cardiomyopathy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease; NCT00023595).

Review article: the new concept of interventional heart failure therapy--part 1: electrical therapy, treatment of CAD, fluid removal, and ventricular support

Congestive heart failure is a chronic and debilitating disease responsible for high cardiac morbidity and mortality in the world and is associated with more than 290 000 deaths in the United States each year. Recent advances in heart failure therapy target many of the mechanical and structural aspects of heart failure that are not addressed by drug-based therapies; these include abnormalities in electrical conduction, coronary artery or valvular architecture, and in ventricular size and shape. To target these abnormalities, newer therapies have largely been mechanical and device-based in nature and can be collectively described as interventional therapy. Interventional therapy includes the use of interventional medical therapy, electrical-based devices to augment ventricular function, catheterization-based devices for the treatment of underlying coronary artery disease and valvular disease, machines for the removal of excess fluid, mechanical pumps to assist the ventricles, surgical techniques aimed at reshaping the ventricles, the use of tissue therapies such as stem cell transplantation or complete heart transplant, palliative care, and self-care. This article is the first in a 2-part series that will review interventional heart failure therapy and present the most recent data supporting its use.

Left ventricular surgical restoration for anteroseptal scars: volume versus shape

OBJECTIVE

We report the long-term results of left ventricular surgical restoration in which 2 different strategies were used, which had restoration of ventricular volume or ventricular shape as their target.

METHODS

From 1988 to 2008, 308 patients with anterior scars underwent elective left ventricular surgical restoration. Before 2002, a Dor procedure was performed in 107 cases to reduce left ventricular volume (group V); from 1998 to 2001, a Guilmet procedure was performed in 32 patients to rebuild a left ventricular conical shape (group S). From 2002, 169 patients (group S) underwent left ventricular surgical restoration to reshape a conical left ventricle by means of the Dor procedure (n = 29, septoapical scars) or septal reshaping (n = 140, when the septum was more involved than the anterior wall). The 2 groups were similar for all features but age, mitral regurgitation grade, mitral valve surgery rate (higher in group S), and ejection fraction (higher in group V).

RESULTS

Early mortality was 7.8% (11.2% in group V vs 6.0% in group S, P = .102). Logistic regression showed that volume reduction was significantly related to higher early mortality. Five-year cardiac survival, cardiac event-free survival, and event-free survival were higher in group S. Cox analysis showed that the choice of volume reduction provided lower survival (hazard ratio, 2.1), cardiac survival (hazard ratio, 3.0), cardiac event-free survival (hazard ratio, 2.7), and event-free survival (hazard ratio, 2.2). When 30-day events were excluded, volume reduction was still a risk factor for cardiac event-free survival (hazard ratio, 2.2).

CONCLUSIONS

When the main target of left ventricular surgical restoration is left ventricular reshaping rather than left ventricular volume reduction, early and late outcomes seem to improve.

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.

Cardiac support devices

Heart failure is an increasingly common condition in the United States and is associated with high mortality and burden to health care. It is a chronic condition that is characterized by progressive left ventricular enlargement. While medical therapy can slow the progression of left ventricular remodeling, surgical approaches to treatment have been developed to improve the survival and quality of life of heart failure patients. This article reviews the surgical procedures for left ventricular dysfunction and focuses on cardiac support devices as a new therapy for heart failure patients. The nursing care of patients with cardiac support devices will be presented and a case study will highlight practical points to help guide patient care.

Calcified anterior myocardial infarction depicted by cardiac MRI

We present the case of a 68-year-old man with previous history of myocardial infarction and coronary artery bypass grafting. An initial chest X-ray showed a curvilinear calcification involving the left-sided profile of the mediastinal shadow. Cardiac MRI cine images demonstrated findings compatible with a calcified anterior myocardial infarction.

Increased myocyte content and mechanical function within a tissue-engineered myocardial patch following implantation

During the past few years, studies involving the implantation of stem cells, chemical factors, and scaffolds have demonstrated the ability to augment the mammalian heart's native regenerative capacity. Scaffolds comprised of extracellular matrix (ECM) have been used to repair myocardial defects. These scaffolds become populated with myocytes and provide regional contractile function, but quantification of the myocyte population has not yet been conducted. The purpose of this study was to quantitate the myocyte content within the ECM bioscaffold and to correlate this cell population with the regional mechanical function over time. Xenogenic ECM scaffolds derived from porcine urinary bladder were implanted into a full-thickness, surgically induced, right ventricular-free wall defect in a dog model. Zero, 2, and 8 weeks following implantation, regional function and myocyte content were determined in each patch region. Regional function did not significantly increase from 0 to 2 weeks. At 8 weeks, however, regional stroke work increased to 3.7 +/- 0.7% and systolic contraction increased to 4.4 +/- 1.2%. The myocyte content also significantly increased during that period generating a linear relationship between regional function and myocyte content. In conclusion, ECM used as a myocardial patch increases both the regional function and the myocyte content over time. The mechanical function generated in the patch region is correlated with the quantity of local tissue myocytes.