Left ventriculoplasty for nonischemic dilated cardiomyopathy

Partial Left Ventriculectomy: Have Well-Succeeded Cases and Innovations in the Procedure Been Observed in the Last 12 Years?

OBJECTIVE

In 1996, the Brazilian cardiovascular surgeon, Dr. Randas Batista, introduced a surgical technique called partial left ventriculectomy, where he admitted the possibility of reducing the diameter of the left ventricle through the sectioning of one section of its wall. After the publication of this study, thousands of case reports and procedure analysis have been published, and due to several disappointing results, many doctors and institutions failed to execute it. As the main objective of this study, stands out the search for success cases of ventriculectomy in the last 12 years and if during this period it was achieved some significant development in this procedure that allows obtaining lower mortality rate postoperatively.

METHODS

Systematic review of indexed scientific literature over the past 12 years and the term "Partial Left Ventriculectomy".

RESULTS

There has been a considerable number of reported successful cases and highly significant findings in regard to determining the most suitable region for the section, proper selection of the patients indicated to the procedure, including the influence of the coronary artery anatomy in the nomination procedure and the need for preservation of ventricular geometry to ensure better quality of ventricular contractions after the sectioning.

CONCLUSION

This surgical procedure has been successfully performed, mainly in Japan, improvements in its efficiency were found and the need for a mathematical modeling of the slice to be severed is a prominent factor in many studies.

Cardiac sarcoidosis underlies idiopathic dilated cardiomyopathy: importance of mediastinal lymphadenopathy in differential diagnosis

BACKGROUND

Cardiac sarcoidosis is frequently overlooked or misdiagnosed as idiopathic dilated cardiomyopathy (DCM), primarily because of difficulties in its diagnosis. This is a crucial issue because appropriate therapy with immunosuppressive agents can be initiated if early diagnosis is achieved.

METHODS AND RESULTS

Thoracic computed tomography (CT) was retrospectively analyzed in detail with special reference to lymph node swelling (LNS) in the mediastinum of 8 patients diagnosed with idiopathic DCM who underwent left ventriculoplasty (LVP), and were later proven to have active cardiac sarcoidosis by histological evaluation of the resected myocardium. Twenty age-matched patients with idiopathic DCM who also underwent LVP served as controls. On conventional chest radiographs, none of the cardiac sarcoidosis patients exhibited lymph node involvement, including bilateral hilar lymphadenopathy. However, CT demonstrated significant mediastinal LNS in 7 (88%) of them and in only 1 (5%) of the 20 controls. There was a significant difference in the incidence of LNS in the 2 groups (p=0.00005).

CONCLUSION

Evaluation of mediastinal lymphadenopathy by CT is an easy and valuable initial screening method for distinguishing cardiac sarcoidosis from idiopathic DCM.

Surgical ventricular restoration in patients with ischemic dilated cardiomyopathy: evaluation of systolic and diastolic ventricular function, wall stress, dyssynchrony, and mechanical efficiency by pressure-volume loops

OBJECTIVES

Surgical ventricular restoration aims at improving cardiac function by normalization of left ventricular shape and size. Recent studies indicate that surgical ventricular restoration is highly effective with an excellent 5-year outcome in patients with ischemic dilated cardiomyopathy. We used pressure-volume analysis to investigate acute changes in systolic and diastolic left ventricular function, mechanical dyssynchrony and efficiency, and wall stress.

METHODS

In 3 patient groups (total, n = 33), pressure-volume loops were measured by conductance catheter before and after surgery. The main study group consisted of 10 patients with ischemic dilated cardiomyopathy (New York Heart Association class III/IV, left ventricular ejection fraction <30%) who had surgical ventricular restoration and coronary artery bypass grafting. In this group, 7 patients had additional restrictive mitral annuloplasty. To assess potential confounding effects of restrictive mitral annuloplasty and cardiopulmonary bypass, we included a group of 10 patients (New York Heart Association class III/IV, left ventricular ejection fraction <30%) who had isolated restrictive mitral annuloplasty and a group of 13 patients with preserved left ventricular function who had isolated coronary artery bypass grafting.

RESULTS

After surgical ventricular restoration, end-diastolic and end-systolic volumes were reduced from 211 +/- 54 to 169 +/- 34 mL (P = .03) and from 147 +/- 41 to 110 +/- 59 mL (P = .04), respectively. Left ventricular ejection fraction (from 27% +/- 7% to 37% +/- 13%, P = .04) and end-systolic elastance (from 1.12 +/- 0.71 to 1.57 +/- 0.63 mm Hg/mL, P = .03) improved. Peak wall stress (from 358 +/- 108 to 244 +/- 79 mm Hg, P < .01) and mechanical dyssynchrony (from 26% +/- 4% to 19% +/- 6%, P < .01) were reduced, whereas mechanical efficiency improved (from 0.34 +/- 13 to 0.49 +/- 0.14, P = .03). End-diastolic pressure increased (from 13 +/- 6 to 20 +/- 5 mm Hg, P < .01), whereas the diastolic chamber stiffness constant tended to be increased (from 0.021 +/- 0.009 to 0.037 +/- 0.021 mL(-1), NS).

CONCLUSIONS

Surgical ventricular restoration achieves normalization of left ventricular volumes and improves systolic function and mechanical efficiency by reducing left ventricular wall stress and mechanical dyssynchrony.

Left Ventricle Volume Affects the Result of Mitral Valve Surgery for Idiopathic Dilated Cardiomyopathy to Treat Congestive Heart Failure

BACKGROUND

Mitral valve surgery is a recommended treatment for congestive heart failure; however, its effect for idiopathic dilated cardiomyopathy (DCM) with an extremely enlarged left ventricle (LV) is not well documented. We examined our long-term results of mitral valve surgery for idiopathic dilated cardiomyopathy.

METHODS

Fifty-five patients of idiopathic dilated cardiomyopathy have undergone mitral valve surgery to treat intractable congestive heart failure since 1998. Forty-two patients were male with an average age of 55. Preoperative New York Heart Association functional class was III in 25, IV in 30, and 19 were dependent on inotropic infusion. The mitral valve was repaired in 37 patients and replaced in 18. The tricuspid valve was repaired in 35 patients and replaced in 3. We divided 46 elective cases into two groups by LV end-systolic volume index.

RESULTS

Postoperatively, an intraaortic balloon pump was required in 2 patients and a left ventricular assist device in 1; both were emergent cases. Hospital mortality was noted 4.3% in elective cases (2 of 46) and 14.5% in overall cases (8 of 55). One-year, 3-year, and 5-year survival rate of elective cases was 73.3%, 58.2%, and 51.7%, respectively. Left ventricle size has decreased and LV contractility has increased in a small LV group year by year, but those in a large LV volume group have not changed subsequently after surgery. There was a significant difference noted in the survival rate of the two groups divided by LV end-systolic volume index.

CONCLUSIONS

Mitral valve surgery for idiopathic dilated cardiomyopathy to treat end-stage heart failure is relatively safe and effective in elective status. However, isolated mitral reconstruction without any other type of surgery may not suffice for an extremely enlarged LV.

Volume Reduction Surgery for Dilated Left Ventricle-Is It Time for Another Progress Report?

(J Card Surg 2005;20:S3-S4).

Ventricular Structure and Surgical History

The Reviews report will establish guidelines that underlie why the "restoration concept" may develop a paradigm shift in thinking, by addressing the geometric underpinnings of heart failure and their evolution. This presentation will (a) show that the underlying structure of the failing dilated heart involves a cardiac architectural change from the normal elliptical shape toward a dilated spherical form, (b) define the anatomic framework of this shape change, (c) convey the functional characteristics of heart function that result from this architectural underpinning, (d) describe the pattern of CHF development, (e) indicate imaging measurement guidelines to follow as heart form adversely changes from ellipse to sphere, (f) identify how such architectural changes alter prognosis, and (g) develop a historical evolution of surgical approaches to alter form to improve function to create the background for subsequent RESTORE team reports of current restoration to treat CHF and its complications.