Histopathology of resected myocardium and outcome of partial left ventriculectomy

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.

Factors affecting ventricular function and survival after partial left ventriculectomy

BACKGROUND

Partial left ventriculectomy (PLV) helps some patients but is deleterious in others. Selection of patients who will benefit from PLV, and exclusion of those who will not is necessary for safe and effective application of the procedure.

METHODS

Sixty-nine consecutive patients who underwent PLV were monitored with pressure-volume relationship analyses, Doppler echocardiography, and histopathologic studies of excised myocardium. These parameters were correlated with postoperative stroke volume (SV, ml), cardiac output (CO, L/min), ventricular function (improved, no change, or deteriorated), and postoperative course (duration of survival and/or hospital discharge).

RESULTS

Positive responders (n = 36) with increased SV at reduced end diastolic pressure had significantly larger preoperative end-systolic dimension, smaller SV, and less stroke work with milder fibrosis than non- or negative responders (n = 33). In multivariate analyses, poor preoperative hemodynamics were associated with increased SV and CO, but these improvements did not lead to improved survival. Postoperative survival was negatively affected by larger preoperative left ventricular end-diastolic volume and larger excised-muscle-weight. Milder fibrosis and thicker excised wall were consistently related to improved ventricular function and survival.

CONCLUSION

Although effects of PLV are related to preoperative status, factors affecting postoperative ventricular function and survival were often discordant. While poor preoperative ventricular function was associated with functional improvement without survival benefit, milder fibrosis, thicker excised wall and less myocardial resection were positive contributors to improved ventricular function, discharge, and survival. Preoperative evaluation with more cases and variables are needed to identify patients more likely to benefit from PLV.