Volume reduction surgery for end-stage heart failure: experience in Korea

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.

Idiopathic cardiomyopathies in Korean children. - 9-Year Korean Multicenter Study-

BACKGROUND

Idiopathic cardiomyopathies (CMPs) are an important heterogeneous group of diseases. With the advance of therapeutic strategies, epidemiologic data on CMP have become very important, but only a few have been reported in Asian children. We conducted a retrospective epidemiologic study of primary CMP in Korean children.

METHODS AND RESULTS

Using a multicenter survey, we studied primary CMP among Korean children from January 1998 to December 2006 based on classification (2006) of CMP by the American Heart Association. A total of 277 primary CMP patients were reported from 17 cardiovascular centers. The average annual occurrence of new cases of primary CMP was 0.28 per 100,000 Korean children younger than 15 years of age (95% confidence interval (CI) 0.24-0.31). Dilated CMP (DCMP) was 66.43%, hypertrophic CMP (HCMP) 23.47%, restrictive CMP (RCMP) 6.50% and others 3.61%. The point prevalence of primary CMP at the end of the study was estimated as 2.11/100,000 (95%CI 1.83-2.43), DCMP 1.39/100,000, HCMP 0.51/100,000, RCMP 0.16/100,000 and others 0.04/100,000. Survival rates over 9 years were 69.8% in DCMP, 90.3% in HCMP, and 47.2% in RCMP.

CONCLUSIONS

Recent point prevalence of childhood primary CMP in Korea was estimated as 2.11/100,000. Further epidemiologic study with a nationwide survey is necessary.

Left ventricular volume reduction surgery: The 4th International Registry Report 2004

BACKGROUND AND METHODS

An international registry of left ventricular volume reduction (LVVR) procedures, including partial left ventriculectomy, has been expanded, updated, and refined to include 568 cases voluntarily reported from 52 hospitals in 12 countries.

RESULTS

Gender, age, ventricular dimension, ethnology, myocardial mass, presence or absence of mitral regurgitation, as well as transplant indication, had little effect on event-free survival, which was defined as either absence of death or ventricular failure requiring mechanical assist or transplantation. Poor preoperative patient condition such as New York Heart Association classification IV, depressed contractility and decompensation requiring an emergency procedure were associated with reduced event-free survival. Other risk factors included an early surgery date, lack of experience, dilated cardiomyopathy as the underlying pathology and extended myocardial resection. Performance of LVVR reached a peak by 1998, but was largely abandoned by 2001, except in Asia, where experienced institutes continue to perform it in patients in better condition with preserved myocardial contractility.

CONCLUSION

Avoidance of risk factors appears to have contributed to the recent survival improvement and may help stratify patients for LVVR. While performance has been decreasing, the concept has been extended to other LVVR and less invasive procedures, which are now under clinical trials.

Partial left ventriculectomy--The Third International Registry Report 2002

BACKGROUND

An international registry of partial left ventriculectomy (PLV) has been expanded, updated, and refined to include 440 cases voluntarily reported from 51 hospitals in 11 countries.

RESULTS

Gender, age, ventricular dimension, etiology, ethnology, myocardial mass, operative variation or presence or absence of mitral regurgitation as well as transplant indication had no effects on event-free survival, which was defined as either absence of death or ventricular failure requiring ventricular assist device or listing for transplantation. Preoperative patient condition such as NYHA functional class IV, depressed contractility, and decompensation requiring an emergency procedure were associated with reduced event-free survival. Other risk factors included early date of surgery, lack of experience, and extended myocardial resection. Performance of PLV reached a peak by 1998 and was largely abandoned by 2000 except in Asia, where experienced institutes continue to perform PLV in patients in better condition with preserved myocardial contractility.

CONCLUSION

Avoidance of delineated risk factors appears to improve recent survival and may help stratify high- or low-risk patients for PLV. An integrated approach with mechanical and biological circulatory assist may improve prognosis for patients with dilated failing hearts. While frequency of PLV has decreased, the concept of ventricular volume reduction has been extended to other volume reduction procedures and less invasive procedures now under clinical trial.

New surgical therapies for heart failure

A growing number of patients present with heart failure. Some of them may qualify for surgical correction of their cardiac condition. Since heart transplantation will always be available to only a small number of patients, several new surgical techniques have been developed for approval in heart failure patients. Classic interventions such as revascularization, valve repair, or valve replacement have been improved and modified to meet the need of heart failure patients. Several of these techniques are currently under investigation in large clinical trials. These trials will definitely have an impact on the development of surgical treatment of patients with heart failure.

Partial left ventriculectomy: the 2nd International Registry Report 2000

BACKGROUND

Partial left ventriculectomy (PLV) has been performed without standardized inclusion or exclusion criteria.

METHODS

An international registry of PLV was expanded, updated, and refined to include 287 nonischemic cases voluntarily reported from 48 hospitals in 11 countries.

RESULTS

Gender, age, ventricular dimension, etiology, ethnology, myocardial mass, operative variation, presence or absence of mitral regurgitation, and transplant indication had no effects on event-free survival, which was defined as absence of death or ventricular failure that required a ventricular assist device or listing for transplantation. Preoperative patient conditions, such as duration of symptoms (> 9 vs < 3 years; p = 0.001), New York Heart Association (NYHA) class (Class IV vs < Class IV; p = 0.002), depressed contractility (fractional shortening [FS] < 5% vs > 12%; p = 0.001), and refractory decompensation that required emergency procedure (p < 0.001) were associated with reduced event-free survival. Five or more cases in each hospital led to significantly better outcomes than the initial four cases. Rescue procedures for 14 patients nonsignificantly improved patient survival (2-year survival 52%) over event-free survival (2-year survival 48%; p = 0.49), with improved NYHA class among survivors (3.6 to 1.8; p < 0.001). Outcome was better in 1999 than in all series before 1999 (p = 0.02) most likely due to patient selection, which was refined to avoid known risk factors such as reduced proportion of patients in NYHA Class IV, FS < 5%, and hospitals with experience in 10 or less cases. A combination of these risk factors could have stratified 17 high-risk patients with 0% 1-year survival and 26 low-risk patients with 75% 2-year event-free survival.

CONCLUSION

Avoidance of risk factors appears to improve survival and might help stratify high- or low-risk patients. Although less symptomatic patients with preserved contractility had better results after PLV, change of indication requires prospective randomized comparison with medical therapies or other approaches.

Partial left ventriculectomy: history, current status, and future role

Whereas discouraging clinical results and lack of scientific evidence decreased the initial interest in partial left ventriculectomy (PLV), factors contributing to success and failure have now been identified by clinical observations, theoretical analyses, and data from an international registry, which are herein reviewed to outline the current status and future role of this procedure as a treatment of heart failure.