Nontransplant cardiac surgery for end-stage cardiomyopathy

Outcomes after surgical ventricular restoration for ischemic cardiomyopathy

OBJECTIVE

The study objective was to evaluate the short- and long-term outcomes of patients with ischemic cardiomyopathy after surgical ventricular restoration and to identify risk factors related to poor results.

METHODS

Between August 2002 and April 2016, 62 patients affected by ischemic cardiomyopathy underwent surgical left ventricular restoration at our unit. Patients' mean age at operation was 63 years (39-79 years). Mean ejection fraction was 29.6%. The Surgical Treatment for Ischemic Heart Failure trial criteria have been used as indications for surgery. Fifty-seven patients (91%) received surgical myocardial revascularization. Mitral valve repair was performed in 39 patients (63%). The surgical technique consisted of the classic Dor operation or a different approach reducing the equatorial diameter of the left ventricle and avoiding the use of a patch. The data were analyzed retrospectively for perioperative results and short- and long-term clinical outcomes.

RESULTS

One patient died of noncardiac causes within 30 days (1.6%). All-cause death occurred in 36 patients (58%) during follow-up (0.6-14.7 years; median follow-up time, 7.02 years), of whom 15 died of cardiac causes. Age, need for preoperative intra-aortic balloon pump, reduction less than 35% of postoperative left ventricular end-diastolic and end-systolic volumes, type of surgical technique, and ejection fraction less than 25% were identified as risk factors for late cardiac mortality. Perioperative levosimendan administration and presence of preoperative moderate to severe mitral regurgitation influenced early and intermediate-term outcomes, but no statistical relevance on long-term results was demonstrated.

CONCLUSIONS

Patients with ischemic dilative cardiomyopathy have favorable short- and long-term outcomes after ventricular restoration. Age, preoperative ejection fraction less than 25%, inadequate left ventricular surgical reverse remodeling, and type of surgical technique negatively affect long-term survival.

Basic fibroblast growth factor attenuates left-ventricular remodeling following surgical ventricular restoration in a rat ischemic cardiomyopathy model

OBJECTIVE

Although surgical ventricular restoration for ischemic cardiomyopathy is expected as an alternative or bridge to heart transplantation, post-operative remodeling of left ventricle (LV) needs to be addressed. This study aimed to examine the effect of basic fibroblast growth factor (bFGF), which induces angiogenesis and tissue regeneration in ischemic myocardium, to prevent remodeling after surgical ventricular restoration (SVR) using a rat ischemic cardiomyopathy model.

METHODS

Four weeks after coronary artery ligation, rats were divided into two groups: rats treated with SVR alone (SVR; n = 21), and rats treated with SVR and local sustained release of bFGF using gelatin hydrogel sheet (SVR + bFGF; n = 22). Cardiac function was assessed by serial echocardiography and cardiac catheterization. Cardiac tissue sections were histologically examined for vascular density and fibrosis.

RESULTS

Higher systolic function and lower LV end-diastolic pressure (LVEDP) were observed in rats treated with SVR + bFGF (SVR vs SVR + bFGF; Ees: 0.22 ± 0.11 vs 0.33 ± 0.22 mmHg/μL, p = 0.0328; LVEDP: 12.7 ± 7.0 vs 8.5 ± 4.3 mmHg, p = 0.0230). LV area tended to be lower in rats treated with SVR + bFGF compared to rats treated with SVR alone (left-ventricular end-diastolic area: 0.66 ± 0.07 vs 0.62 ± 0.07 cm², p = 0.071). Vascular density tended to be higher in rats treated with SVR + bFGF than those without bFGF (23.3 ± 8.1 vs 28.8 ± 9.5/mm², p = 0.0509).

CONCLUSIONS

BFGF induced angiogenesis and attenuated remodeling after SVR which secured the efficacy of SVR in a rat ischemic cardiomyopathy model.

The top 100 manuscripts in emergency cardiac surgery. Potential role in cardiothoracic training. A bibliometric analysis

Background

Emergency Cardiac Surgery (ECS) is a component of cardiothoracic training. Citations are considered to represent a papers influence. Bibliometric analyses allow us to identify the most influential work, and future research. We aim to highlight the key research themes within ECS and determine their potential impact on cardiothoracic training.

Methods

Thomas Reuters Web of Science was searched using terms [Emergency AND Card* AND Surg*]. Results were ranked by citation and reviewed by a panel of cardiac surgeons to identify the top 100 cited papers relevant to ECS. Papers were analysed by topic, journal and impact. Regression analysis was used to determine a link between impact factor and scientific impact.

Results

3823 papers were identified. Median citations for the top 100 was 88. The paper with the highest impact was by Nashef et al. focusing on the use of EuroSCORE (2043 citations). The Annals of Thoracic Surgery published most papers (n = 18:1778 citations). The European Journal of Cardiothoracic Surgery coveted the most citations (n = 2649). The USA published most papers (n = 55).The most ubiquitous topics were; risk stratification, circulatory support and aortic surgery. A positive relationship between journal impact fact and the scientific impact of manuscripts in ECS (P = 0.043) was deduced.

Conclusion

This study is the first of its kind and identified the papers which are likely to the contribute most to training and understanding of ECS. A papers influence is partially determined by journal impact factor. Bibliometric analysis is a potent tool to identify surgical training needs.

Posterior ventricular restoration treatment for heart failure: a review, past, present and future aspects

Congestive heart failure (CHF) is one of the major causes of death and occurs in more than 15,000,000 patients worldwide. The incidence is expected to increase in parallel with the aging population. Most current therapies for CHF are medications, and biventricular pacing implantation as appropriated by cardiologists, or surgical interventions. The heart transplantation for indicated patients is still gold standard surgery although the 10-year survival rate is approximately 60% based on the worldwide data. However, the cardiac transplantation remains epidemiologically insignificant because of donor pool limitations. New strategies for treating CHF are needed. In addition to conventional cardiac surgery, surgical ventricular restoration was reported as a promising surgical therapy in 1990s. After the first report of partial left ventriculectomy in which posterior wall was widely resected for dilated heart, many controversial clinical and animal research studies have been reported. In this review, the principles of posterior cardiac restoration therapy will be discussed. An overview of posterior cardiac restoration, structure, and torsion are presented. By understanding the structure of cardiac muscle, shape, and torsion of left ventricle for surgical restoration, the procedure can be performed based on appropriate indication and this knowledge can be used to optimize and improve its efficacy. The use of mechanical support devices has recently become commonplace in many centers, and the use of implantable ventricular assist devices as destination therapy will increase. Surgeons will be able to select several options of the treatment for CHF by understanding the advantages and disadvantages of those surgical treatments.

Posterior restoration procedures and the long-term results in indicated patients with dilated cardiomyopathy †

OBJECTIVES

Non-transplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. We performed posterior restoration for dilated akinetic or dyskinetic lesions in patients with DCM and obtained favourable outcomes. The early and long-term results of the procedures are discussed.

METHODS

Between 2005 and 2013, posterior restoration procedures (PRPs) for DCM were electively performed in 58 patients (17 with ischaemic and 41 with non-ischaemic DCM). There were 45 men and 13 women with a mean age of 56 ± 12 years old. The mean preoperative ejection fraction was 24% and the preoperative New York Heart Association functional class was Class III in 24 and Class IV in 34 patients with intravenous inotrope support. Indications for PRPs were determined by using speckle-tracking echocardiography of the posterior region of the left ventricle before surgery (GE ultrasound machine, Vivid 7 or Vivid E9). After cardioplegic arrest, mitral surgery or coronary artery bypass grafting (CABG) was performed and the posterior left ventricular (LV) muscle between bilateral papillary muscles was incised or resected. The LV apex was preserved and cryoablation was applied between the cut edge and the posterior mitral annulus. All patients were followed up by transthoracic echocardiography.

RESULTS

In addition to PRP, mitral surgery was performed in 56 (plasty 51, replacement 5), tricuspid annuloplasty in 21, CABG in 17, cardiac resynchronization therapy in 6 and LV lead implantation in 27 patients. Perioperative intra-aortic balloon pumping was used in 9 patients and there was no hospital mortality. After the operation, 35 patients (60%) improved their functional class to Class I or II. In the late follow-up, there were 14 cardiac deaths (congestive heart failure 10, ventricular arrhythmia 4). The 3- and 8-year survival rates were 77 or 66%, respectively.

CONCLUSIONS

DCM with posterior akinesis or dyskinesis indicated by speckle-tracking echocardiography can be surgically treated with PRP. Our results demonstrated that 60% of the selected patients could avoid heart transplantation with relief of their symptoms.

Papillary muscle sandwich plasty for the treatment of functional mitral valve regurgitation

We evaluated the availability of original "sandwich plasty" for the treatment of functional mitral regurgitation (FMR) associated with ischemic heart disease (IHD) and aortic valve disease (AVD). Forty-three patients were reviewed, including 27 IHD patients and 16 AVD patients. Preoperatively severe FMR was detected in 14 patients, moderate FMR in 26, and mild FMR in 3. The papillary muscle heads of anterior leaflets and posterior leaflets were approximated using Teflon-pledgeted 3-0 Ticron sutures at anterolateral and posteromedial commissural portions. After surgery, residual moderate FMR was observed in 1 patient and mild FMR in 3 patients. Tenting height of the mitral valve significantly decreased. FMR free rates 2 years after surgery were 93% among IHD patients and 83% in AVD patients. "Sandwich plasty" was simple and effective for the treatment of functional FMR caused by tethering effects due to left ventricular dilatation.

Surgical ventricular restoration improves the left ventricle basal wall function using quantitative gated SPECT

OBJECTIVE

It is not clear whether surgical ventricular restoration (SVR) or procedures approaching mitral complex for controlling functional mitral regurgitation (MR) affect the regional left ventricular wall function. The purpose of the present study was to evaluate the regional LV function after SVR using overlapping left ventriculoplasty (OLVP) using quantitative gated myocardial perfusion SPECT (QGS).

PATIENTS AND METHOD

Forty-one heart failure patients, including those with ischemic cardiomyopathy (ICM) (n = 25) and non-ICM (NICM) (n = 16), underwent SVR and/or papillary muscle approximation (PMA). The rest myocardial perfusion SPECT were performed before and early after operation (mean 25.8 ± 10.6 days). These patients were divided into 4 groups based on the surgical procedures (SVR and/or PMA) and etiology of patients (ICM or NICM) as follows: SVR (with or without PMA) of ICM, SVR of NICM, PMA of ICM and PMA of NICM groups. The regional wall thickening was compared before and after the operation between the four groups.

RESULTS

NYHA functional classes were improved after the operation in all four groups. MR grade was also improved in three groups other than SVR of the ICM group. The left ventricular basal wall thickening was improved postoperatively in following three groups (SVR of ICM: 12.7 ± 3.8% to 16.5 ± 4.6% p <0.05, PMA of ICM: 11.1 ± 4.3% to 14.9 ± 4.8% p <0.05, SVR of NICM: 5.8 ± 6.6% to 12.3 ± 6.4% p <0.05), whereas PMA of the NICM group did not show an improvement. Wall thickening in the middle and distal levels was not improved in all groups.

CONCLUSION

OLVP improved NYHA functional classes, and also improved the regional wall function at the basal level of the left ventricle. In contrast, lone PMA did not improve or impair the regional wall function at any of the levels.

Perioperative management of pediatric patients on mechanical cardiac support

The population of children with end-stage heart failure requiring mechanical circulatory support is growing. These children present for diagnostic imaging studies, various interventions and noncardiac surgical procedures that require anesthetic care. This article is a review of the population demographics of children on mechanical cardiac support, the alternative devices available, and the important concepts for safe perioperative management of these patients. The discussion will be limited to devices for short- and long-term cardiac support, excluding extracorporeal membrane oxygenation (ECMO) for respiratory support.

Surgical Ventricular Restoration: An Operation to Reverse Remodeling - Clinical Application (Part II)

The first part of the article dealt with the basic science behind the evolution of ventricular restoration procedures and the rationale for the use of novel surgical techniques. The second part describes the preoperative workup of patients in advanced heart failure, the core information required to determine the surgical approach and the essential principles and techniques of ventricular restoration. It then examines the effects of ventricular restorative procedures on pump function and clinical outcomes, the results of the worldwide experience with ventricular restoration and concludes with more recent advances in this field.

A long-term follow-up of a girl with dilated cardiomyopathy after mitral valve replacement and septal anterior ventricular exclusion

We treated a 10 year 11 month old girl with severe mitral valve regurgitation, stenosis and dilated cardiomyopathy, presented with New York Heart Association (NYHA) functional classification IV. She acutely developed cardiogenic shock with a dyskinetic anterior-septal left ventricle and entered a shock state during our consultation about heart transplantation. Septal-anterior ventricular exclusion and mitral valve replacement were performed emergently. She successfully recovered from cardiogenic shock. Left ventricular end-diastolic diameter and fractional shortening improved from 71.5 mm (188.0% of normal) to 62.5 mm (144.2% of normal) and 7.6% to 18.3% respectively. Furthermore, her serum BNP decreased from 2217.5 pg/ml to 112.0 pg/ml. Her cardiac function has remained stable for 7 years since the procedures were performed.

Partial left ventriculectomy

Batista introduced the partial left ventriculectomy (PLV), which is based on physics alone. With experience, it has been found that the extent of myocardial disease and viability of retained muscle is an important determinant of early and late survival. Although the PLV has been almost abandoned in many countries following the negative message from the Cleveland Clinic, it is still alive in Japan with a refined concept, surgical technique and patient selection. In a series of 63 patients undergoing PLV for idiopathic dilated cardiomyopathy since 1996, operative mortality was 9.5%, and 1-, 3- and 5-year survival rates were 71.1%, 56.2% and 45.9%, respectively. Improved survival has obtained by using appropriate patient selection and concomitant restrictive mitral annuloplasty (1-, 3- and 5-year survival rate =86.5%, 78.6% and 59.4%, respectively, in the most recent 33 patients). Because of insufficient availability of donors for heart transplantation, nontransplant cardiac surgery for medically refractory heart failure is important. Ventricular restoration procedures, including PLV, should be seriously considered as an important option for endstage heart failure.

Original papillary muscle sandwich plasty for ischemic mitral regurgitation

BACKGROUND

Mitral valve plasty for functional ischemic mitral regurgitation (MR) is still a controversial procedure.

METHODS AND RESULTS

The present study was a review of 23 patients who underwent an original technique known as "papillary muscle sandwich plasty" in which the mitral valve is approached via either the left atrium or left ventricle. The heads of the papillary muscles of the anterior leaflet and leaflets are plicated using Teflon-pledgeted 3-0 Ticron sutures in both the anterolateral and posteromedial commissural portions. Postoperative residual mild MR occurred in 1 patient (4%), but moderate or severe MR was not observed. In the follow-up study, prominent MR occurred in 1 patients and the MR-free rate at 2 years after surgery was 93%. Late cardiac death was significantly (P<0.05) fewer in patients without prominent MR than that in patients with MR.

CONCLUSIONS

"Sandwich plasty" is an effective technique for patients requiring left ventricular plasty and may improve the prognosis of ischemic heart failure.

Surgical ventricular reconstruction in mice: elucidating potential targets for combined molecular/surgical intervention

OBJECTIVES

We hypothesize that persistent alterations in molecular signaling may drive recurrent pathologic remodeling even after the reduction of mechanical stress achieved via surgical ventricular reconstruction. We developed a murine model of surgical ventricular reconstruction that would facilitate molecular analysis of the postreconstruction myocardium and allow future exploitation of genetic models.

METHODS

C57/B6 mice underwent coronary artery ligation. For surgical ventricular reconstruction at 4 weeks after myocardial infarction, a purse-string suture (7-0 polypropylene) achieved at least partial exclusion of the apical aneurysm. Serial echocardiography was correlated to measurements of apoptosis and to Western blot analysis of key signaling cascades.

RESULTS

An immediate 21.7% +/- 2.6% improvement in fractional shortening was seen in the remaining myocardium after surgical ventricular reconstruction. Reduction in left ventricular volume and improved function persisted at 1 week, but recurrent dilatation at 4 weeks (left ventricular end-diastolic volume of 63.5 +/- 2.5 vs 42.1 +/- 5.4 microL immediately after reconstruction; P < .05) was associated with a loss of functional improvement (fractional shortening 41.2% +/- 2% vs 46% +/- 0.9%; P < .01). At 1 week after surgical ventricular reconstruction, there was a transient reduction in myocardial apoptosis. A steady reduction in cardioprotective myocardial Akt activation, however, was not affected by ventricular reconstruction.

CONCLUSION

This murine model recapitulates both the immediate benefits of surgical ventricular reconstruction and the longer-term recurrence of dilated cardiomyopathy seen previously in some animal models and human studies. Early analysis has begun to implicate persistent signaling changes in the postinfarction myocardium that may be responsible for recurrent dilatation after surgical ventricular reconstruction and that may become targets for combined surgical and molecular interventions.

Combined surgery for ischemic cardiomyopathy: report of a case

A 65-year-old female with catecholamine-dependent ischemic cardiomyopathy was admitted to our hospital. Preoperative examination revealed severe triple vessel coronary artery disease, severe mitral valve regurgitation and left ventricular (LV) dilatation associated with low ejection fraction. Coronary artery bypass grafting with four distal anastomoses, mitral valve plasty using original papillary muscle application method, LV volume reduction using overlapping method and biventricular pacing were performed. Postoperative course was uneventful and quality of life at 2 years after surgery was good. Active combined surgery has the possibility of improving the outcome of patients with severe ischemic cardiomyopathy.

Echocardiography in Heart Failure

Echocardiography is well qualified to meet the growing need for noninvasive imaging in the expanding heart failure (HF) population. The recently-released American College of Cardiology/American Heart Association guidelines for the diagnosis and management of HF labeled echocardiography "the single most useful diagnostic test in the evaluation of patients with HF...," because of its ability to accurately and noninvasively provide measures of ventricular function and assess causes of structural heart disease. It can also detect and define the hemodynamic and morphologic changes in HF over time and might be equivalent to invasive measures in guiding therapy. In this article we will discuss: 1) the clinical uses of echocardiography in HF and their prognostic value; 2) the use of echocardiography to guide treatment in HF patients; and 3) promising future techniques for echocardiographic-based imaging in HF. In addition, we will highlight some of the limitations of echocardiography.

Development of an Artificial Myocardium using a Covalent Shape-memory Alloy Fiber and its Cardiovascular Diagnostic Response

The authors have been developing a newly-designed totally-implantable artificial myocardium using a covalent shape-memory alloy fibre (Biometal&#174;, Toki Corporation), which is attached onto the ventricular wall and is also capable of supporting the natural ventricular contraction. This mechanical system consists of a contraction assistive device, which is made of Ti-Ni alloy. And the phenomenon of the martensitic transformation of the alloy was employed to achieve the physiologic motion of the device. The diameter of the alloy wire could be selected from 45 to 250&#956;m. In this study, the basic characteristics of the fiber of 150&#956;m was examined to design the sophisticated mechano-electric myocardium. The stress generated by the fiber was 400gf under the pulsatile driving condition (0.4W, 1Hz). Therefore it was indicated that the effective assistance might be achieved by using the Biometal shape-memory alloy fiber.

Septal anterior ventricular exclusion procedure for idiopathic dilated cardiomyopathy

BACKGROUND

Eight-year experience with the septal anterior ventricular exclusion procedure for congestive heart failure due to idiopathic dilated cardiomyopathy was evaluated.

METHODS

In 36 patients (27 men and 9 women with a mean age of 60 years) with heart failure; New York Heart Association class III/IV (21/15); and mitral regurgitation 2+ or greater, the procedure was indicated when the diastolic dimension was 75 mm or greater, and the septum was akinetic. A long, narrow oval patch was sutured to form a downsized elliptical left ventricle by excluding the septum and anterior wall. Mitral reconstruction was combined for all patients (26 repairs with undersized ring and 10 replacements with bioprosthesis) and tricuspid repair was added for 16 patients (44%).

RESULTS

Hospital mortality was 13.8% (5 of 36), with 6.5% (2 of 31) in elective and 60% (3 of 5) in emergency operations. Ejection fraction increased from 20.9% +/- 6.4% to 27.5% +/- 8.8%, left ventricular diastolic dimension decreased from 81.9 +/- 9.2 mm to 70.1 +/- 10.0 mm, and left ventricular endodiastolic and endosystolic volume indices decreased from 236.5 +/- 65.0 mL/m2 to 183 +/- 60.5 mL/m2 and from 181.3 +/- 55.4 mL/m2 to 133.5 +/- 54.1 mL/m2, respectively. Left ventricular endodiastolic pressure decreased from 24.3 +/- 9.7 mm Hg to 19.4 +/- 7.6 mm Hg. Brain natriuretic peptide decreased from 975 +/- 866 pg/mL to 404 +/- 366 pg/mL at 1 to 6 postoperative months. Eleven late deaths were noted and were due to heart failure (6), sudden death (4) and stroke (1). The mean New York Heart Association class was 1.7 among the survivors. One- and 3-year survival rates were 67.5% and 60.7%, respectively.

CONCLUSIONS

The septal anterior ventricular exclusion procedure with mitral reconstruction is a useful option for the treatment of advanced idiopathic dilated cardiomyopathy in extremely dilated left ventricle with akinetic septum.

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.

Flexible Versus Nonflexible Mitral Valve Rings for Congestive Heart Failure: Differential Durability of Repair

BACKGROUND

Surgical intervention is playing an increasingly important therapeutic role in congestive heart failure (CHF) patients with ischemia and dilated cardiomyopathy. Their mitral regurgitation (MR) is a result of left ventricular (LV) geometrical distortion. The optimal type of ring for CHF patients with geometric ventricular-based MR is unknown. This study reviewed the results of flexible versus nonflexible complete mitral valve rings in CHF patients with geometric mitral regurgitation.

METHODS AND RESULTS

Using a prospectively maintained database, patients undergoing mitral valve reconstruction (MVR) with either a flexible or nonflexible complete ring were identified on the basis of preoperative ejection fraction (EF) < or = 30% and no primary mitral pathology. These 2 groups of CHF patients with severe geometric MR were then compared in terms of recurrent MR requiring reoperation. Between 1992 and 2004, 289 patients with EF < or = 30%, received an undersized complete mitral annuloplasty ring as their MVR procedure. Of these, 170 patients had a flexible complete ring. In follow-up, 16 "flexible" patients (9.4%) required a repeat procedure for significant recurrent geometric MR and CHF (10 replacements, 3 re-repairs, 3 transplants). The average time to reoperation was 2.4 years. In contrast, 119 patients with an EF < or = 30% received a MVR using an undersized nonflexible complete ring. Only 3 "non-flexible" patients required a repeat operation, MVR (1), and 2 patients required a transplant. The time to reoperation was 4.0 years. A significant difference in reoperation rates, for recurrent MR, between the 2 groups (P=0.012). There were no differences between groups, in terms of age, ring size used, preoperative EF, LV size, MR grade, or New York Heart Association class.

CONCLUSIONS

Patients with CHF having a flexible ring have a higher likelihood of developing recurrent MR requiring reoperation. The use of a nonflexible ring appears to significantly reduce the need for repeat surgical procedures. Further refinement and development of nonflexible ring systems, aimed at LV restoration, deserve ongoing investigation.

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

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

A surgical approach to severe congestive heart failure--overlapping ventriculoplasty

BACKGROUND

Previously we developed a new procedure of overlapping cardiac volume reduction (OLCVR) surgery for patients with dilated cardiomyopathy refractory to medical treatment. Papillary muscle plication (PMP) when combined with OLCVR may achieve a better clinical outcome.

PURPOSE

To investigate the early and intermediate results of OLCVR with or without PMP.

METHODS

Twenty-five patients (21 males, 4 females, aged 60 +/- 13 years) with either ischemic (n = 7) or nonischemic (n = 18) dilated cardiomyopathy underwent either isolated OLCVR (n = 11; Original Group) or PMP combined with OLCVR (n = 14; Integrated Group).

RESULTS

Early deaths occurred in two (8%) from a noncardiac cause and late deaths in six, two from a cardiac and four from a noncardiac cause. Postoperative data in survivors were significantly improved in terms of NYHA functional class (from 3.6 +/- 1.9 to 1.6 +/- 1.1), ejection fraction (from 18 +/- 6% to 31 +/- 8%), left ventricular diastolic dimension (from 73 +/- 9 to 65 +/- 6 mm), and left ventricular end-diastolic volume index (from 194 +/- 81 to 128 +/- 43 mL/m2) (p < 0.05) in selected comparative cases. One-year crude and cause-specific survivals were 70.9% and 83.1%, respectively, at a mean follow-up of 12.8 months. One-year crude survival of the Integrated and Original Group was 85.7% and 55.6%, respectively (p = 0.24).

CONCLUSIONS

Although limitations exist in evaluating operative results, we consider OLCVR to be a relatively safe and effective procedure for selected patients with dilated cardiomyopathy. The addition of PMP to OLCVR may enhance the elliptic formation of left ventricle shape and improve mitral valve tethering, but further study is mandatory.

Early and Mid-Term Results of Left Ventricular Volume Reduction Surgery for Dilated Cardiomyopathy

OBJECTIVE

To evaluate structure-oriented left ventricular volume reduction surgery (LVVRS). The purpose of this study was to report the early and mid-term results of left volume reduction surgery for dilated cardiomyopathy (DCM).

METHODS

We performed LVVRS on 29 patients with DCM. The age of the patient ranged from 8 to 73 years (mean 58 +/- 18 years). There were 19 male patients (63%). Twenty-three patients were ischemic, 5 were non-ischemic, and 1 had salcoidosis. Twenty-three patients were in New York Heart Association class III or IV. Fourteen patients underwent the Dor operation, 11 underwent a septal anterior ventricular exclusion operation, and 6 underwent a modified Batista operation. Fifteen patients underwent mitral annuloplasty and 2 patients had mitral valve replacement. All patients were divided into two groups, a Dor group (n = 14) and non-Dor group (n = 15). Postoperative early results and mid-term survival rate were compared between the two groups.

RESULTS

Hospital mortality was 13.8% (4/29). The causes of death were low-output syndrome (n = 3) and septic shock (n = 1). Survival rate was 80% at 1 year and 72% at 3 years. Two-year survival rate of Dor and non-Dor groups were 69.8% and 93.8%, respectively (p = 0.099).

CONCLUSIONS

Early and mid-term results of LVVRS were satisfied, and the non-Dor operation tended to be superior in mid-term survival to the Dor operation. Long-term follow-up is warranted.

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.

Ventricular reconstruction surgery for congestive heart failure

The significant increase in the prevalence of heart failure in the United States has made this disease a major health problem. The continued shortage of donor organs has prevented heart transplantation from becoming an effective solution for the treatment of end-stage heart failure, and as a result, surgical treatments for heart failure have been reexamined. Surgical therapies represent the evolution of conventional operations, such as coronary artery bypass surgery, and the application of the more novel left ventricular (LV) reconstruction operations which address the geometry of the LV, the important component in the failing heart.

Left ventricular reconstruction: Early and late results

OBJECTIVES

In patients with coronary disease and poor left ventricular function, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. This study reports results achieved with ventricular reconstruction in 285 patients who had akinesia or dyskinesia associated with relative wall thinning.

METHODS

Data were prospectively collected. Reconstruction on the beating heart was accomplished by a modified linear closure plus septoplasty, when indicated, (dyskinetic septum). Preoperatively, 237 (83%) were in symptom class III or IV with congestive heart failure (n =174; 61%), angina (n = 157; 55%), or ventricular tachycardia (n = 107; 38%). Average ejection fraction was 24% +/- 11%, and 144 (51%) had preoperative grade 2+ mitral regurgitation. Operative procedures included coronary artery bypass grafting in 262 (92%), septoplasty in 64 (22%), ablation of ventricular tachycardia in 118 (41%), and a mitral valve procedure in 6 (2%).

RESULTS

Operating room mortality was 2.8%. Perioperative support included intra-aortic balloon pumping in 49 (17%) and inotropic drugs in 154 (54%). During a mean follow-up of 63 +/- 48 months, 8 patients required transplantation (interval of 49 +/- 41 months), 2 needed mitral valve replacement, and 9 required use of an implantable cardioverter-defibrillator for ventricular tachycardia. At 1, 5, and 10 years actuarial survivals were 92%, 82%, and 62%. Freedom from sudden death was 99%, 97%, and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), mean improvement 1.3 +/- 1.1 functional class per patient. Average increase in ejection fraction postoperatively was 10% +/- 9%.

CONCLUSIONS

Using wall thinning as a criterion for patient selection, left ventricular reconstruction can be performed with low operative mortality, provides good control of symptoms, excellent long-term survival, and freedom from sudden death. This approach should be considered in all patients with coronary disease, poor left ventricular function, and relative wall thinning.

Quantitative gated myocardial perfusion single photon emission computed tomography improves the prediction of regional functional recovery in akinetic areas after coronary bypass surgery: useful tool for evaluation of myocardial viability

OBJECTIVE

Assessment of myocardial viability in akinetic areas is essential in surgery for ischemic heart disease, including coronary artery bypass grafting and left ventriculoplasty. The aim of this study is to evaluate the utility of quantitative indices of perfusion uptake, wall motion, and wall thickening of each region calculated by quantitative electrocardiogram-gated single photon emission computed tomography (SPECT) for prediction of functional recovery after coronary artery bypass grafting.

METHODS

Forty patients scheduled for coronary artery bypass grafting were prospectively included. Electrocardiogram-gated SPECT was performed before and 1 week and 3 months after operation, and coronary angiography was performed before and after operation. The myocardium was divided into 9 segments and myocardial viability, assessed by improvement of the wall motion score using a cine mode display, and evaluated by radionuclide criteria (perfusion uptake, wall motion, wall thickening). Twenty-four segments with moderate hypokinesis and 14 segments with akinesis with patent grafts were assessed.

RESULTS

All segments with moderate hypokinesis except 1 (96%) had improved wall motion scores postoperatively, whereas of 14 segments with akinesis only 7 segments (50%) had improved wall motion scores. The preoperative perfusion uptake in the improved segments was significantly higher than in the nonimproved segments (62.7% +/- 15.6% vs 46.4% +/- 24.5%, P =.01). There was a significant difference in wall motion between the improved and nonimproved segments (3.8 +/- 2.2 mm vs 1.4 +/- 1.4 mm, P =.001), and the preoperative wall thickening of the improved segments was significantly higher than in the nonimproved segments (27.2% +/- 14.1% vs 8.2% +/- 10.3%, P <.0001). The optimal cutoff level of perfusion uptake was 50%, with the highest accuracy of 72%, and the optimal cutoff levels of wall thickening and wall motion were 10% and 1.5 mm, with the highest accuracies of 76% and 85%, respectively.

CONCLUSION

The regional functional index calculated by electrocardiogram-gated SPECT indicated that wall thickening was well correlated with functional recovery compared with wall motion or perfusion uptake. This suggests that the wall thickening calculated by electrocardiogram-gated SPECT may be more useful to predict functional recovery than regional myocardial perfusion. Or, it could suggest that in addition to perfusion uptake, wall thickening could enhance the objective assessment of myocardial viability.

Ventricular volume reduction procedures

Although partial left ventriculectomy (PLV) has been abandoned in many institutions, a few hospitals continue to perform it with a relatively favorable outcome. Other volume reduction procedures have become popular with renewed interest in ventricular reshaping to improve function. Although recent refined selection criteria have improved survival with PLV, earlier unpredictable results prompted less invasive procedures based on the same physiologic concept of reducing radius or wall tension by wrapping, piercing, or clasping. These new techniques are not only less invasive but also reversible and adjustable and appear safer for less symptomatic patients at risk of progressive heart failure. Nonetheless, mechanisms of action and degrees of volume reduction and/or restriction need to be delineated before widespread clinical application.

Efficacy of modified endoventricular circular patch plasty in ischemic cardiomyopathy--innovative delimitation technique using integrated myocardial management

BACKGROUND

Optimal delimitation is one of the most important factors for successful endoventricular circular patch plasty (EVCPP). The aim of this study was to determine whether our modification as an application of integrated myocardial management enables reproducible delimitation and feasible myocardial protection, resulting in better clinical outcomes for ischemic cardiomyopathy (ICM) patients.

METHODS

Between September 1998 and November 2001, 22 ICM patients underwent EVCPP with coronary artery bypass grafting (CABG) [group I, n = 14] or CABG only [group II, n = 8]. The majority had congestive cardiac failure, and NYHA in groups I and II were 2.9 +/- 0.5 and 2.7 +/- 0.8, respectively. After complete revascularization, delimitation was determined by palpation of the empty beating heart during antegrade warm blood perfusion without unclamping the aorta. The heart was then re-arrested for secure cryotherapy and suturing under single aortic clamping.

RESULTS

There were no in-hospital deaths and no need for mechanical support. Preoperative angiograms in group I showed a lower EF (21.2 +/- 4.0 vs 26.8 +/- 2.6%, P < 0.01) and a more dilated ventricle (LVESVI: 115 +/- 39 vs 73 +/- 15 ml/m2,P < 0.01). In contrast, early postoperative results were comparable between the groups as far as EF (39 +/- 12 vs 43 +/- 9%) and LVESVI (55 +/- 26 vs 54 +/- 11 ml/m2). During follow-up (15 +/- 10 months), freedom from cardiac death was 100%, and 95% of patients were NYHA I or II.

CONCLUSIONS

ICM patients with LV dilation could safely be treated by CABG and EVCPP with modified delimitation technique to regain reduced LV volume and function as good as patients without LV dilation undergoing CABG alone.

Surgical therapy in advanced heart failure

Congestive heart failure (CHF) affects about 1% of adults in the United States and is a contributing factor in >250,000 deaths per year. In an increasingly elderly population, the surgical treatment of CHF made great progress during the past 3 decades, consuming enormous health care resources. Heart transplantation is still the most effective therapy for end-stage heart disease, with the 10-year survival rate after transplantation approaching 50%. Efforts to increase the supply of donor organs have failed to improve the shortage, underscoring the crucial need for alternatives to cardiac allotransplantation. Alternative surgical options to end-stage heart transplantation are rapidly evolving. Left ventricular assist devices have been used as a bridge to heart transplantation for patients who otherwise might die awaiting a new heart. There is also continued interest in the use of these devices either to bridge patients to full recovery or to destination therapy, without the need for heart replacement. Left ventricular reconstruction, including the Batista and Dor procedures, along with mitral valve repair, cardiomyoplasty, and extreme coronary artery bypass graft surgery, are now being increasingly performed as alternative options. The history, status, and personal experience of surgical treatment of end-stage heart disease are discussed.

Left ventricular restoration for ischemic cardiomyopathy--comparison of presence and absence of mitral valve procedure

OBJECTIVE

Association of mitral regurgitation (MR) with ischemic cardiomyopathy (ICM) increases the degree of heart failure and its surgical management remains controversial. The aim of this study was to report the surgical results in patients with or without MR in association with ICM.

PATIENTS AND METHODS

Ninety-two patients with ischemic cardiomyopathy (left ventricular [LV] ejection fraction less than 30% with global akinesis) underwent LV restoration. Pre-operative New York Heart Association (NYHA) functional class was either in class-3 or -4 in all patients. MR was moderate to severe in 38 patients (MR-group) and none or mild in 54 patients (noMR-group). Moderate to severe MR was repaired in addition to the complete coronary artery bypass (CABG) and LV restoration. All patients were followed up and echocardiogram was repeated every 6 months after the surgery.

RESULTS

The procedure of LV restoration was selected pre- and intra-operative examination and endoventricular circular patch plasty was performed in 76, partial left ventricle resection in three, and septal anterior exclusion in 13. CABG was performed in 85 patients with mean 2.4+/-1.1 grafts in MR-group and 3.2+/-0.4 grafts in noMR-group (P<0.0001). In MR-group mitral valve plasty was performed in 24 and replacement in 14. Undersized (26 or 28 mm) circumferential mitral ring was used in 16 patients for mitral plasty. Emergent operation required in 15 patients (13 in MR-group and two in noMR group) and the hospital mortality was 18.4% in MR-group and 3.7% in no MR-group. Mitral regurgitation recurred in two patients with posterior ring annuloplasty and they underwent valve replacement. The post-operative NYHA functional class improved to class-1 or -2 in 65 patients and cumulative survival in 5 years including emergent and hospital deaths was 60.9% in MR-group and 70.1% in noMR-group.

CONCLUSION

In association of MR to ICM, emergent operation required more often and perioperative mortality rate was high. However, the aggressive combined mitral operation in addition to CABG and LV restoration showed the improvement of clinical symptom and quality of life after the surgery.

Congenitally corrected transposition of the great arteries treated by partial systemic ventriculectomy

Congenitally corrected transposition of the great arteries (CCTGA) is a rare congenital heart disease characterized by atrioventricular (AV) and ventriculo-arterial discordance;(1) that is, the left ventricle supports the pulmonary circulation and the right ventricle supports the systemic circulation. The most common cardiac anomalies in CCTGA include ventricular septal defect, pulmonary outflow tract obstruction and abnormalities of the systemic AV valve. (1) The dysfunction of the systemic ventricle occurs with increasing frequency in older patients with CCTGA, independent of their commonly associated structural defects.(2-4) We report a patient with CCTGA undergone the partial ventriculectomy for his systemic ventricular dysfunction.

Importance of preserving the apex and plication of the base in left ventricular volume reduction surgery

OBJECTIVE

Volume reduction surgery for dilated cardiomyopathy has not yielded predictable outcomes. The purpose of this study was to clarify the efficacy of modified volume reduction surgery in preserving the left ventricular apex and reducing the left ventricular diameter at the base to maintain fiber continuity.

METHODS

Heart failure was induced with propranolol in 12 dogs, and the animals were randomized into 2 groups. In one group the left ventricular wall was plicated between the 2 papillary muscles from the middle to the apex (apex-sacrificing volume reduction surgery, group A, n = 6), and in the other group plication was done from the base to the middle (apex-sparing volume reduction surgery, group B, n = 6). Left ventricular function was then compared between the groups by using echocardiography and sonomicrometry crystals.

RESULTS

After volume reduction surgery, the fractional area change at the base in group B was greater than that in group A (40% +/- 3% vs 27% +/- 4%, P =.003). Cardiac output in group B was better than that in group A (2.5 +/- 0.2 vs 1.8 +/- 0.2 L/min, P =.023). Left ventricular end-diastolic pressure in group A was higher than that in group B (16 +/- 2 vs 8 +/- 1 mm Hg, P =.001). Fractional shortening in the long axis, as assessed by means of sonomicrometry, was better in group B than in group A.

CONCLUSIONS

Apex-sparing volume reduction surgery capable of maintaining left ventricular fiber continuity provided better left ventricular function in both the systolic and diastolic phases than apex-sacrificing volume reduction surgery in the acute heart failure model. This modification might improve the results of left ventricular volume reduction surgery.

Surgery for cardiomyopathy with mitral regurgitation and dyssynchrony

We present a case of dilated cardiomyopathy with medically intractable congestive heart failure, which was improved by surgical intervention including mitral valve repair and biventricular pacing. This strategy is effective against dilated cardiomyopathy with interventricular dyssynchrony and mitral regurgitation.

Left ventriculoplasty for nonischemic dilated cardiomyopathy

From December 1996 to May 2001, we have performed 82 cases of left ventriculoplasty (LVP) for nonischemic dilated cardiomyopathy (DCM). Surgical procedure was partial left ventriculectomy in 70 patients and septal anterior ventricular exclusion in 12 patients with evaluation by utilizing intraoperative echocardiography. There were 70 men and 12 women with a mean age of 49, varying from 14 to 76. All patients had medically refractory heart failure with New York Heart Association (NYHA) Functional Class III in 33 patients and NYHA IV in 49; 34 patients were supported by inotropic infusion prior to the operation. Intra-aortic balloon pump (IABP) and left ventricle assist device (LVAD) were used in 12 and 2 patients at perioperative period, respectively. Hospital mortality was 8.2% in elective operation (5/61), 57.1% in emergency operation (12/21), and 20.7% overall. One- and four-year survival rates were 75.5% and 69.3% in elective cases, 37.9% and 0 in emergency cases, and 64.7% and 3.6% overall, respectively. Left ventricular (LV) ejection fraction increased from 22.3% to 29.0% at the time of surgery and has maintained around 33% up to two years. LV diastolic dimension and LV end diastolic pressure decreased from 83.8 mm to 65.0 mm; from 31.7 mmHg to 22.0 mmHg have maintained around 70 mm and 22.1 mmHg up to two years, respectively. Over one year most of the survivors were medically controlled within NYHA Class I-II. In conclusion, careful choice of surgical procedure by utilizing intraoperative echocardiography enables left ventriculoplasty to effectively treat severe heart failure with nonischemic cardiomyopathy.

Non-transplant cardiac surgery for end-stage dilated cardiomyopathy in small children

Between October 1997 and December 2000, a total of 7 pediatric patients with end-stage dilated cardiomyopathy (DCM) were referred to our service for heart transplantation; non-transplant cardiac surgery was offered as a biologic bridge. Two patients died before surgery and the in-hospital surgical mortality rate was 50%: 75% in 4 patients who received emergency surgery and 0% in 2 patients who received urgent surgery. Non-transplant cardiac surgery improved clinical outcome and acted as a biologic bridge, instead of a mechanical bridge, to heart transplantation in small children with DCM and severe heart failure.

Surgical treatment of congestive heart failure

Cardiac transplantation is the definitive surgical treatment for patients with severe left ventricular dysfunction and congestive heart failure. Unfortunately, however, the supply of donor hearts remains severely limited, so transplantation is an option for only a minority of these patients. Even after being approved for a heart transplant, patients often have a long wait until a suitable donor heart can be found. This waiting period entails a significant mortality rate. Because the supply of donor hearts is not expected to increase, surgeons have introduced several alternatives to heart transplantation, including partial left ventriculectomy, mitral valve repair, myocardial revascularization, and endoventricular circular patch plasty. For maximal benefit, surgeons must refine the selection criteria for determining which patients are the best candidates for each of these procedures.