Ventricular volume and myocardial viability, evaluated using cardiac magnetic resonance imaging, affect long-term results after surgical ventricular reconstruction

Effect of left ventricular hyperenhancement in magnetic resonance imaging on reverse remodeling after mitral valve repair for moderate ischemic mitral regurgitation

We aimed to investigate cardiac magnetic resonance imaging (MRI)-derived predictors of a lack of left ventricular (LV) reverse remodeling after undersized mitral annuloplasty (uMAP) for moderate ischemic mitral regurgitation (IMR). We retrospectively reviewed 31 patients who underwent uMAP for moderate IMR and cardiac MRI evaluation between 2004 and 2017. Cardiac MRI evaluation included cine MRI LV and right ventricular volumetric measurements and gadolinium-enhanced MRI assessment of myocardial scarring. LV dimensions were assessed preoperatively, postoperatively, and at follow-up using serial transthoracic echocardiography, and the mid-term (median, 49 months) predictors of a lack of LV reverse remodeling were analyzed. At the mid-term follow-up (mean follow-up period: 85 ± 40 months), 15 patients exhibited reverse LV remodeling. The relative reduction in LV dimension at follow-up was negatively correlated with the preoperative number of LV segments with myocardial infarction (MI) (defined as an LV segment with >25% enhancement). The optimal cut-off for predicting a lack of reverse LV remodeling at follow-up was >5 LV segments with MI, with a sensitivity and specificity of 92% and 92%, respectively. This cut-off value also predicted all-cause mortality at follow-up, with a sensitivity and specificity of 88% and 67%, respectively. The presence of >5 LV segments with MI on gadolinium-enhanced MRI might be a useful predictor of lack of reverse LV remodeling and all-cause mortality outcomes after undersized mitral annuloplasty for moderate IMR.

Left ventricle restoration. Keep the door open

Surgical left ventricle restoration (SVR) was first by Cooley in 1958 with the "linear suture technique," and three decades later, Dor used a circular patch to reconstruct the left ventricle excluding the scarred parts of the septum and ventricular wall. It gained popularity and eventually almost abandoned after the contrasting literature evidence. Hassanabad et al. presented a comprehensive review of current literature on SVR techniques and clinical outcomes, trying to understand if SVR has still a substantial role in the modern medicine.

Raman Spectroscopic Assessment of Myocardial Viability in Langendorff-Perfused Ischemic Rat Hearts

Spontaneous Raman spectroscopy, which senses changes in cellular contents of reduced cytochrome c, could be a powerful tool for label-free evaluation of ischemic hearts. However, undetermined is whether it is applicable to evaluation of myocardial viability in ischemic hearts. To address this issue, we investigated sequential changes in Raman spectra of the subepicardial myocardium in the Langendorff-perfused rat heart before and during ligation of the left coronary artery and its subsequent release and re-ligation. Under 532-nm wavelength excitation, the Raman peak intensity of reduced cytochrome c at 747 cm^-1 increased quickly after the coronary ligation, and reached a quasi-steady state within 30 min. Subsequent reperfusion of the heart after a short-term (30-min) ligation that simulates reversible conditions resulted in quick recovery of the peak intensity to the baseline. Further re-ligation resulted in resurgence of the peak intensity to nearly the identical value to the first ischemia value. In contrast, reperfusion after prolonged (120-min) ligation that assumes irreversible states resulted in incomplete recovery of the peak intensity, and re-ligation resulted in inadequate resurgence. Electron microscopic observations confirmed the spectral findings. Together, the Raman spectroscopic measurement for cytochrome c could be applicable to evaluation of viability of the ischemic myocardium without labeling.

A single center's experience with total arterial revascularization and spiral aneurysmorrhaphy for ischemic cardiac disease

The restoration of left ventricular (LV) geometry in combination with coronary artery bypass grafting for the treatment of ischemic cardiac disease remains controversial. We hereby present the experience of our center with total arterial myocardial revascularization (TAMR) and spiral aneurysmorrhaphy for ischemic heart disease. A retrospective analysis of 101 patients with advanced cardiovascular disease who underwent TAMR and spiral aneurysmorrhaphy was performed. Spiral aneurysmorrhaphy is a modification of the linear aneurysmorrhaphy and was applied to patients who had a LV aneurysm with a diameter of less than 5 cm. Peri-operative and in-hospital data were retrieved. The majority of the patients were male (87.13%) with a mean age of 63.1 years. Mean pre-operative ejection fraction (EF) was 35.7% ranging between 20 and 65%. An average of 3.23 grafts was required per patient. Early mortality was 6.93% (one intra-operative and six in-hospital deaths). Addition of concomitant valve surgery was associated with prolonged total operative, cardiopulmonary bypass and cross-clamp time (p < 0.001), increased need for blood (p = 0.012) and plasma (p = 0.038), longer intensive care unit (ICU) stay (p = 0.045) and higher rate of post-operative cerebrovascular accident (p = 0.011). Furthermore, patients with a pre-operative EF between 30 and 50% had a shorter ICU stay (p = 0.045) and LoS (p = 0.029) compared with patients with EF <30%. Early mortality and post-operative complication rates following this combined procedure are in consistency with the relevant available data suggesting its feasibility regardless of the EF or addition of concomitant surgeries. Data from the follow-up of these patients are required to examine the long-term efficacy of this surgical modality.

Left ventricular reconstruction surgery in ischemic heart disease: a systematic review of the past two decades

INTRODUCTION

The aim of this paper is to systematically review the existing literature reporting on patients recruited during the past twenty years regarding the role of left ventricular (LV) reconstruction in ischemic cardiomyopathy in terms of efficacy and mortality and provide an updated overview of the current evidence.

EVIDENCE ACQUISITION

The PubMed and Cochrane bibliographical databases were thoroughly searched for the following MeSH terms: "ventricular reconstruction" OR ventriculoplasty OR "ventricular aneurysm" OR "ventricular restoration." Original studies -recruiting patients during the past twenty years- on LV reconstruction surgery in more than five cases and reporting on the associated peri- or postoperative mortality were deemed eligible.

EVIDENCE SYNTHESIS

Twenty-seven studies were included and provided data for 3220 patients with a mean age of 61 years. Angina was present in 66.6% (510/766) of the patients, while nine out of ten (635/699) had a history of myocardial infarction. Average preoperative ejection fraction was 29.9% and end-systolic volume index was 93.6 mL/m2. With respect to complications, low cardiac output syndrome and the need for intra-aortic balloon pump were prevalent in 9.3% (79/850) and 18.8% (334/1773), respectively. Thirty-day mortality was 7.1% (230/3220) and late-mortality (mean follow-up of 36.9 months) was 19.6% (548/2791), while the rate of MACCE was 40.1% (367/915). Five-year mortality was 29% (340/1171).

CONCLUSIONS

Our findings provide a current perspective of the role of LV reconstruction in the treatment of ischemic cardiomyopathy suggesting its benefit in survival. Taking into consideration the existing debate, further studies are required so that a solid conclusion to be made.

Ten-year experience of endocardial linear infarct exclusion technique for ischaemic cardiomyopathy

OBJECTIVES

To report the mid-term results of our surgical ventricular restoration procedure, called the endocardial linear infarct exclusion technique (ELIET), for ischaemic cardiomyopathy.

METHODS

From 2006 to 2015, 43 consecutive patients who underwent surgical ventricular restoration with ELIET for ischaemic cardiomyopathy were retrospectively analysed.

RESULTS

The mean age of patients at surgery was 65.3 ± 9.2 years and EuroSCORE II was 13.7 ± 12.0% (median 9.3%). The mean number of distal anastomoses of coronary artery bypass was 2.8 ± 1.5. A concomitant mitral procedure was performed in 58.1% of patients. The hospital mortality rate was 11.6% (5 patients). The ejection fraction was improved from 24.1 ± 9.2% to 31.7 ± 8.2% in 2 weeks after surgery. The end-systolic left ventricular volume index was effectively reduced, irrespective of performing a concomitant mitral procedure (reduction rate, ELIET: 35.6% vs ELIET + mitral: 39.2%). After ELIET, the sphericity index of the left ventricle did not worsen, and the conicity index was significantly improved. The 5-year estimated rates of survival and freedom from cardiac events were 71.3 ± 7.9 and 61.1 ± 8.3%, respectively. A concomitant mitral procedure was significantly associated with cardiac events based on univariate Cox hazard analysis.

CONCLUSIONS

This study showed that ELIET can effectively reduce the ventricular volume and create an ellipsoidal left ventricle.