Biomedical subjects

RESTORE Group

Publications and source records attributed to RESTORE Group.

At least 19 recordsLinked to original sources

PubMed2006

The ventricular septum: the lion of right ventricular function, and its impact on right ventricular restoration.

OBJECTIVE: To evaluate the structure-function relationships of the right ventricle (RV) and septum and determine if the helical ventricular band model would define fiber orientation for maximal force response. Implications were made for right ventricular function. METHODS: The right ventricular free wall and biventricular septum were studied by inserting sonomicrometer crystals at different angulations to determine the maximum response of fiber shortening. These reactions were compared to the lateral left ventricular (LV) wall and further tested by use of positive and negative inotropic drug infusions. RESULTS: The maximum contraction of the free wall was achieved by placing crystals in the transverse orientation angulations, whereas oblique orientation allowed the maximal septal response. Fiber orientation angulation was the same for the LV free wall and septum. These angulations correlate with the MRI-related twisting actions of septal motion needed for ejection and suction for rapid filling. These findings have important impact, because they imply that the septum is 'lion of right ventricular function,' since septal twisting is essential when pulmonary vascular resistance is increased. The incidence of postoperative right heart failure due to septal dyssyncrony, with loss of septal twisting action from inadequate myocardial protection, is explored relative to RV free wall and septum function. Furthermore, early studies of right ventricular restoration in patients with RV dysplasia and RV failure after chronic pulmonary insufficiency following repair of Tetralogy of Fallot are described, with predominant attention directed toward rebuilding normal septal architecture and function. CONCLUSIONS: This experimental and clinical overview indicates that the septum is 'the lion of right ventricular function,' and implies that the use of this knowledge can become an important guideline for planning novel surgical geometric interventions after RV failure.

Heart Septum↗

PubMed2006

Left ventricular geometry reconstruction in ischemic cardiomyopathy patients with predominantly hypokinetic left ventricle.

OBJECTIVE: The effectiveness of the left ventricle (LV) geometry reconstruction (Dor procedure) as the method of surgical treatment of LV post-infarction aneurysm and large dilated myocardial scars is well established. The efficacy of LV restoration in cases of globally dilated hypofunctional LV, containing the same spherical architecture as scarred, remains questionable. METHODS: The results of LV geometry reconstruction in small population of patients with ischemic dilated cardiomyopathy (IDCMP) and predominantly hypokinetic LV are described in 14 patients of that underwent LV rebuilding into a conical architecture. Surgical procedures included LV geometry reconstruction with the synthetic patch, narrowing of widened dimensions between papillary muscles, coronary artery bypass grafting (CABG) and, in several cases, mitral and tricuspid valves annuloplasty. RESULTS: Initial mean end-diastolic and end-systolic volumes indexes were 177 and 112 ml/m2, respectively, mean LV ejection fraction (EF) of 32.9%. The analysis of immediate and mid-term (1 and 4 years) results proved that LV reconstruction markedly decreased LV volumes and increased LVEF an average of +12% above resting values with significant improvement in clinical status. CONCLUSIONS: A rebuilding procedure for the scarred heart is now introduced to be used in ischemic patients with dilated ischemic cardiomyopathy without significant scar. Preliminary structural and physiological results imply that creating an elliptical form has potential importance during LV reconstruction of very sick patients with IDCMP without discrete scar.

Adult↗

PubMed2006

A new concept of ventricular restoration for nonischemic dilated cardiomyopathy.

OBJECTIVE: Left ventricular restoration is used to treat patients with chronic progressive heart failure caused by nonischemic dilated cardiomyopathy. This study addresses the use of site selection to determine either lateral wall or septal exclusion. METHODS: Evolution of intraoperative echocardiography to define the site of poorest contraction and use of multiple biopsies to show the nonhomogeneous nature of damage are reviewed. To address the heterogeneity of extent of fibrosis in nonischemic cardiomyopathy, target selection was used to determine the mode of left ventriculoplasty. Either the lateral wall was excluded by partial left ventriculectomy (PLV) or septal anterior ventricular exclusion (SAVE or Pacopexy) was employed if the septum was primarily diseased. Surgical results in 107 high-risk (43% NYHA (New York Heart Association) class III and 57% class IV) patients with idiopathic dilated cardiomyopathy over the past 9 years are reviewed. RESULTS: Overall hospital mortality was 7.1% in 84 elective operations and 60.9% in 23 emergency operations, and fell from 42.8% (6 of 14) to 15.0% (14 of 93), when site selection for the area of left ventricular excision or exclusion was determined by the intraoperative echocardiography test. The SAVE/Pacopexy procedure was performed in 36 patients with 62.2% 5-year survival rate. For the entire cohort of PLV and SAVE/Pacopexy population, overall ejection fraction increased from 20 to 31%, and NYHA class improved from 3.6 to 1.8. The 1-, 5-, and 7-year survival rates were 66.9, 46.0, and 36.2%, respectively. In patients having the operation before inotropic dependent, the survival rate was 78.1, 58.0, and 50.2%, respectively. CONCLUSIONS: Left ventriculoplasty is effective for patients with idiopathic dilated cardiomyopathy with heart failure by proper patient selection, appropriate timing of the operation, and choice of the surgical procedure (exclusion site selection).

Adolescent↗

PubMed2006

Myocardial protection during surgical ventricular restoration.

OBJECTIVE: Ventricular restoration is a novel procedure for treating congestive heart failure (CHF). The two important features include a technically correct procedure and adequate myocardial protection. The two protective techniques include conventional cardioplegia and the beating heart. METHODS: This report reviews a RESTORE clinical registry and summarizes background experimental work related to myocardial protection in failing dilated hearts. RESULTS: The RESTORE registry is reported, where protection is 55% with cardioplegia and 45% with beating heart. The beating method was used more frequently in patients with ejection fraction <30%, end systolic volume 80 ml/m2, NYHA class >III/IV. Overall survival results favored cardioplegia except for the first 30 days, but after matching patients on age, ejection fraction (EF) and NYHA the beating results and cardioplegic results were comparable. Experimental work evaluated the safety of the beating method in failing dilated ventricles under acute conditions. Supplemental coronary perfusion studies in chronically dilated hearts after tachycardia induced cardiomyopathy were analyzed to show that (a) there was vascular remodeling (less flow at the same pressure in failing hearts with cardioplegic, but not beating delivery; (b) in the open state (used during restoration) subendocardial flow increased in the beating heart, and fell after cardioplegia. These studies were done without ischemia. CONCLUSIONS: Cardioplegic delivery for protection is 'time dependent' (needing ischemic intervals) while beating nourishment is 'procedure dependent,' as continuous perfusion is provided throughout the procedure is suggested. The importance of maintaining high perfusion pressure is emphasized.

Heart Arrest, Induced↗

PubMed2006

Septal anterior ventricular exclusion operation (Pacopexy) for ischemic dilated cardiomyopathy: treat form not disease.

OBJECTIVE: Restoration of left ventricle size and shape is an effective surgical procedure in patients with dilated cardiomyopathy. This report defines early and intermediate results following the reshaping of the left ventricle from spherical to ellipsoid configuration in patients with ischemic cardiomyopathy, employing a technique for LV restoration (LVR) that uses form rather than disease as the endpoint for oblique patch placement. METHODS: Between 1998 and 2004, a cohort of 83 patients with dilated ischemic cardiomyopathy underwent an operation to reshape the left ventricle. In 54 patients the Dor procedure was done, and 29 underwent the septal anterior ventricular exclusion (SAVE) procedure to emphasize the elliptical shape, whereby patch placement followed an oblique trajectory between the LV apex and septum below the aortic valve. Ventricular form, rather than the disease scar marked the suture placement site endpoint to create an ellipse. The mean age was 58+/-27, but SAVE patients had larger end systolic volume index (135+/-38 vs 95+/-25). Overall preoperative NYHA functional class III was in 69% and IV in 31 patients, but more SAVE patients were in class IV (38% vs 28%). The procedures were elective in 72 and emergent in 11, with similar entry criteria for each procedure. RESULTS: In combination with LVR operation, mitral surgery was performed in 49/83 and tricuspid annuloplasty in 23/83 patients, but these procedures were more common after SAVE (59% vs 44% and 45% vs 19%, respectively), because of larger LV volumes in SAVE patients; 2.8+/-1.3 coronary artery bypass grafts were used. Perioperative use of IABP or LVAD was 15 and 1, respectively in 83 patients. Hospital death was in 1/11 or 9% after emergent operations and 3/72 or 4% in elective procedures, with no difference between groups. After discharge from the hospital, NYHA class improved to class I or II in 57 patients, class III/IV in 14 patients, with 10 late deaths. The 5-year survival rate after the elective operation was 80.3% in SAVE and with elective operation and 77.4% in the Dor procedure. CONCLUSION: The SAVE or Pacopexy technique is easy to reshape the dilated left ventricle from spherical to ellipsoid form after the LVR, and the resultant improved configuration may contribute to the overall results for patients with ischemic dilated cardiomyopathy.

Adult↗

PubMed2006

Cell biology, MRI and geometry: insight into a microscopic/macroscopic marriage.

OBJECTIVE: The concept of cell therapy as an adjunctive therapy to myocardial surgical revascularization for patients with severe coronary artery disease is illustrated by two case reports of ischemic cardiac disease that were unsuitable for revascularization by coronary grafting. The potential interaction of cell therapy, magnetic resonance imaging (MRI) of viability, and left ventricle (LV) restoration is described. METHODS: Each patient had an ejection fraction below 30%, a relatively conical heart, and MRI gadolinium scan showing predominantly viable muscle. RESULTS: Intramyocardial injections of autologous bone marrow-derived cells (BMC) were performed along with either incomplete coronary artery bypass grafting (CABG) (to mother regions) or with transmyocardial laser revascularization (TMLR). An improvement in contractile function was seen at 6-12-month intervals after the procedure. CONCLUSIONS: The implications of possible underlying mechanisms of improvement in both myocardial perfusion and contractility suggest the striking importance of both micro- and macroenvironment for any cell-based therapeutic strategy. These observations imply that the interaction of cell biology, viability by MRI and geometry may be important in the future, as geometry can be restored surgically, and the new architectural form may develop enhanced function if it contains viable tissue and cell-based treatment can be delivered.

Aged↗

PubMed2006

Form versus disease: optimizing geometry during ventricular restoration.

OBJECTIVE: Dilated cardiomyopathy from many causes results in a change in ventricular geometry, whereby the elliptical chamber becomes more spherical. This may be the unifying geometric concept of heart failure, with similar alteration of spatial configuration in non-ischemic diffuse myocyte disease, ischemic cardiomyopathy with and without scar, and in valvular heart disease. METHODS: This change in architecture alters fiber direction and diminishes function, and has been related to alteration of the apical loop of the helical ventricular myocardial band model of cardiac shape. The underlying concept of rebuilding the ventricle by ventricular restoration is suggested to be reconstruction of form, rather than focusing on only the underlying disease. RESULTS: Examples are shown where the Surgical Anterior Ventricular Exclusion (SAVE) or Pacopexy procedure has been successfully applied to each of the above-mentioned diseases, and is suggested for dilated valvular cardiomyopathy. The interaction between rebuilding form and how this procedure restores more normal fiber orientation is discussed, and the possibility of a macroscopic/microscopic marriage between surgically altering the cardiac scaffold by restoration (macro) and cell biology to improve function in a new helical shape is suggested. CONCLUSIONS: The implication of these observations is that the surgical objective should become rebuilding ventricular form, rather than restricting restoration procedures to only addressing the disease.

Cardiomyopathy, Dilated↗

PubMed2006

Left ventricular geometry in normal and post-anterior myocardial infarction patients: sphericity index and 'new' conicity index comparisons.

BACKGROUND: Anterior myocardial infarction leads a sequence of structural changes that alter the size and the shape of the left ventricle. Efforts to assess shape have been made by global left ventricular (LV) chamber analysis (sphericity index, SI) but this analysis does not detect regional shape abnormalities like those at the apical level, which precede global ventricular dilatation. OBJECTIVE: The present study will introduce a new analysis of regional apical changes in 52 normal subjects and in 92 patients with previous anterior myocardial infarction. METHODS: All patients had transthoracic echocardiogram and multiple views were obtained (long axis, 4CH, 2CH and short axis view). From the 4CH view the long and the short axes were measured and their ratio was calculated (sphericity index). In the same view, the apical axis length was also measured and the ratio between apical and short axis length was calculated (apical conicity index, ACI). RESULTS: Patients had all the measured parameters significantly worse than normal, except the sphericity index which remained unchanged. Ventricular length and width increased following anterior MI but the ratio between the two measurements did not change. Conversely, apical conicity index is significantly different following anterior MI, thereby indicating anterior infarction produces a less conical shape. SI and ACI differed when correlations were made in the relationship of mitral valve function; SI correlates with the degree of mitral regurgitation (MR) and with the distance of papillary muscles, conversely ACI shows an inverse correlation with the determinants of mitral regurgitation. These observations reflect differences between apical versus global dilatation in ischemic cardiomyopathy, so that mitral function is better (lower tenting area and lower coaptation height) when the apex is markedly dilated in respect to the short axis (high conicity index). In contrast, mitral function is impaired (bigger distance between papillary muscles and higher degree of mitral regurgitation), when sphericity index is high. CONCLUSIONS: Sphericity index fails to detect regional apical shape abnormalities. To address this focal change, we introduce a simple new measure termed apical conicity index, which is abnormal in patients with myocardial infarction, and can be useful to evaluate changes induced by the subsequent surgical approach of ventricular re-shaping.

Adult↗

PubMed2006

Use of cardiac magnetic resonance imaging in surgical ventricular restoration.

OBJECTIVE: Surgical ventricular restoration (SVR) is a promising modality for treatment of heart failure due to left ventricular systolic dysfunction, particularly that due to ischemic heart disease. The role of MRI in improving diagnosis, operative planning, and follow-up is reviewed to analyze how one examination may define a spectrum of important considerations. METHODS: Proper patient selection and optimal surgical planning relies on accurate assessment of measures of ventricular volume, function, and viability, and of the mechanics of the mitral valve apparatus. A complete preoperative imaging evaluation includes assessment of the left ventricular volume (both systolic and diastolic), regional and global systolic function, viability of the target area for surgical exclusion and of the remote myocardium, determination of the adequacy of the remote myocardium remaining after proposed SVR to support circulatory function, and of the mitral annular dilatation and inter papillary muscle spacing, factors which contribute to functional mitral regurgitation. RESULTS: Cardiac magnetic resonance imaging (MRI) allows a complete evaluation of these quantities: the ventricular systolic and diastolic volumes (and hence ejection fraction) are easily assessed reproducibly and accurately; the regional wall motion of the asynergic area and the remote myocardium can be measured by several quantitative means, including with myocardial tagging, and the presence or absence of nonviable, irreversible scar can be detected with gadolinium-based interstitial contrast agents. Furthermore, an accurate measurement of the mitral annular dimensions and the papillary muscle spacing can be easily performed using cardiac MRI, allowing planning of effective therapy for mitral regurgitation. CONCLUSIONS: The entire imaging study can be performed in less than 1h, making cardiac MRI a truly useful and comprehensive tool in planning SVR, and for subsequently evaluating results.

Heart Failure↗

PubMed2006

End-stage cardiomyopathy and secondary mitral insufficiency surgical alternative with prosthesis implant and left ventricular restoration.

BACKGROUND: Secondary mitral insufficiency is a strong risk factor for death in end-stage cardiomyopathy. The possible correction of mitral regurgitation has now been accepted as an alternative to cardiac transplantation in a special subset of patients. We propose a new surgical approach that consists of implantation of a mitral prosthesis that is smaller than the annulus, and preservation and traction of the papillary muscles to reduce sphericity of the left ventricle. METHODS: Between December 1995 and September 2005, 116 patients with dilated cardiomyopathy underwent this procedure, with the following etiologic factors: ischemic (68), idiopathic (43), Chagas disease (3), viral (1), and postpartum (1). The patients were analyzed according to clinical criteria, echocardiographic findings, and morphology of left ventricle. RESULTS: All patients were in an end-stage phase, requiring >2 hospital admissions over the past 3 months, despite receiving full medication. Furthermore, seven were in intensive care unit receiving intravenous drugs or intra-aortic balloon counterpulsation, and one was in cardiogenic shock. Hospital mortality was 16.3% (19/116), yet midterm follow-up showed a relatively flat late survival curve, with evidence of improved clinical status, better echocardiographic parameters, and reduction in ventricular sphericity. CONCLUSIONS: The high early mortality rate related to other clinical conditions at the time of surgery. However, the resultant flat survival after this early interval offers a promising long-term therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy that is associated with moderate or severe secondary mitral regurgitation.

Adult↗

PubMed2004

Surgical ventricular restoration improves mechanical intraventricular dyssynchrony in ischemic cardiomyopathy.

BACKGROUND: In ischemic cardiomyopathy, dyssynchrony of left ventricular (LV) mechanical contraction produces adverse hemodynamic consequences. This study tests the capacity of geometric rebuilding by surgical ventricular restoration (SVR) to restore a more synchronous contractile pattern after a mechanical, rather than electrical, intervention. METHODS AND RESULTS: A prospective study of the global and regional components of dyssynchrony was conducted in 30 patients (58+/-8 years of age) undergoing SVR at the Cardiothoracic Center of Monaco. The protocol used simultaneous measurements of ventricular volumes and pressure to construct pressure/volume (P/V) and pressure/length (P/L) loops. Angiograms were done before and after SVR to study a 600-ms cycle during atrial pacing at 100 bpm. Mean QRS duration was similar, at 100+/-17 ms preoperatively and 114+/-28 ms postoperatively (NS). Preoperative LV contraction was highly asynchronous, because P/V loops showed abnormal isometric phases with a right shifting. Endocardial time motion was either early or delayed at the end-systolic phase so that P/L loops were markedly abnormal in size, shape, and orientation. Postoperatively, SVR resulted in leftward shifting of P/V loops and increased area; endocardial time motion and P/L loops almost normalized to allow a better contribution of single regions to global ejection. The hemodynamic consequences of SVR were improved ejection fraction (30+/-13% to 45+/-12%; P=0.001); reduced end-diastolic and end-systolic volume index (202+/-76 to 122+/-48 and 144+/-69 to 69+/-40 mL/m(2); P=0.001); more rapid peak filling rate (1.75+/-0.7 to 2.32+/-0.7 EDV/s; P=0.0001); peak ejection rate (1.7+/-0.7 to 2.6+/-0.9 Sv/s; P=0.0002), and mechanical efficiency (0.56+/-0.15 to 0.65+/-0.18; P=0.04). CONCLUSIONS: SVR produces a mechanical intraventricular resynchronization that improves LV performance.

Aged↗

PubMed2004

Heart failure following anterior myocardial infarction: an indication for ventricular restoration, a surgical method to reverse post-infarction remodeling.

Anterior myocardial infarction produces abrupt left ventricular (LV) dysynergy and global systolic dysfunction. Rapid intense neurohumoral activation, infarct expansion, and early ventricular chamber dilatation all contribute to restoring a normal stroke volume despite a persistently depressed ejection fraction. Continued neurohumoral activation provokes late remodeling of the remote non-infarcted myocardium, characterized by an abnormal progressively increasing LV volume/mass ratio that leads to further LV remodeling. Heart failure is a progressive disorder of LV remodeling. Heart failure from post-infarction remodeling is unique because of the persistent non-functioning scar that self- perpetuates abnormal loading conditions and neurohumoral activation. Medical therapy attenuates remodeling and improves survival but does not change the size of the scar. Surgical ventricular restoration to exclude the non-functioning infarct from the ventricular cavity decreases ventricular volumes, increases global ejection fraction, attenuates neurohumoral activation and yields an excellent 5-year survival. Combined medical and surgical therapy is recommended in this patient population.

Endocardium↗

PubMed2004

Surgical ventricular restoration: the RESTORE Group experience.

Congestive heart failure may be caused by late left ventricular (LV) dilation following anterior infarction. Early reperfusion prevents transmural necrosis, and makes the infarcted segment akinetic rather than dyskinetic. Surgical ventricular restoration (SVR) reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. The international RESTORE group applied SVR in a registry of 1198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined and risk factors identified.Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair, p < .001) Perioperative mechanical support was uncommon (< 9%). Global systolic function improved postoperatively, as ejection fraction increased from 29.6 +/- 11.0% to 39.5 +/- 12.3% (p < .001) and left ventricular end systolic volume index decreased from 80.4 +/- 51.4 ml/m(2) to 56.6 +/- 34.3 ml/m(2) (p < .001). Overall 5-year survival was 68.6 +/- 2.8%, Logistic regression analysis identified EF < or = 30%, LVESVI > o = 80 ml/m(2), advanced NYHA functional class, and age > or =75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were class III or IV, and postoperatively 85% were class I or II.SVR improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent 5-year outcome.

Aged↗

PubMed2004

Ventricular arrhythmias after LV remodelling: surgical ventricular restoration or ICD?

UNLABELLED: Ventricular arrhythmias cause ~50% of deaths in remodeled ventricles after myocardial infarction, and the Multicenter Automatic Defibrillator Implantation Trial (MADIT II) showed that the Implantable Cardioverter Defibrillator (ICD) saved lives in high risk coronary patients with advanced left ventricular dysfunction. We studied 382 patients with remodeled hearts by preoperative Ventricular stimulation (PVS) to evaluate surgical ventricular restoration (SVR) that excludes scar and lower ventricular volume alters the early and late arrhythmia process without ICD utilization. METHODS: Clinical and hemodynamic results before and after SVR in post-infarction patients, are compared to contrast spontaneous and/or inducible ventricular tachycardia to patients without arrhythmias. Study arrhythmia groups included: Spontaneous in 87 patients with clinical documented ventricular arrhythmias and inducible or not inducible ventricular tachycardia: Inducible in 105 patients without clinical ventricular arrhythmias but PVS inducible ventricular tachycardia; and No arrhythmias in 190 patients without spontaneous or PVS inducible ventricular tachycardia. RESULTS: Preoperative LV end systolic volume index helped define preoperative arrythmia potential: Spontaneous > 120/m(2), inducible > 100 ml/m(2), and none < 100ml/m(2). Overall operative mortality rate was 7.6% (29/382). Sudden cardiac death rate was 2.5% causing 18.7% of all deaths. Surgical management reduced inducible ventricular tachycardia, from 41% preoperatively (144/352) to 8% (26/307) at early study, and 8% (14/177) one year later. Cardiac mortality was low at 5-years and not different between groups, despite use of only one late ICD device. CONCLUSIONS: Favorable electrical success rate and low mortality always included volume reduction to interrupt functional re-entry circuits, but also added endocardiectomy, cryoablation, CABG and mitral repair when needed. Overall SVR findings show volume and shape alteration limits ventricular arrhythmias that impair prognosis, and suggests ICD devices are not needed.

Cardiac Surgical Procedures↗

PubMed2004

Mechanical synchrony: role of surgical ventricular restoration in correcting LV dyssynchrony during chamber rebuilding.

Cardiac failure is frequently complicated by intra and or interventricular conduction delay that results in dyssynchronized cardiac contraction and relaxation. In contrast to an electrical intervention by biventricular pacing, this study tests the capacity of geometric rebuilding by surgical ventricular restoration (SVR) to restore a more synchronous contractile pattern through mechanical reconstruction without exogenous pacing input. Thirty patients (58 +/- 8 years) undergoing SVR at the Cardiothoracic Center of Monaco were prospectively evaluated with a protocol which uses simultaneous measurements of ventricular volumes and pressure to construct pressure/volume (P/V) and pressure/length (P/L) loops. Mean QRS duration was within normal limits (100 +/- 17 ms) preoperatively. Preoperative LV contraction was highly asynchronous. Endocardial time motion was either early or delayed at the end-systolic phase, yielding P/L loops with abnormal in size, shape, and orientation. Postoperatively, SVR resulted in leftward shifting of P/V loops and increased area; endocardial time motion and P/L loops almost normalized. The hemodynamic consequences of SVR included improved ejection fraction; reduced end-diastolic and end-systolic volume index; more rapid peak filling rate; peak ejection rate and mechanical efficiency resulting in mechanical intraventricular resynchronization that improves LV performance.

Cardiac Catheterization↗

PubMed2004

Role of site selection for left ventriculoplasty to treat idiopathic dilated cardiomyopathy.

Ventriculoplasty was introduced to treat patients with chronic progressive heart failure from end-stage non ischemic dilated cardiomyopathy, which was presumed to be a homogeneous disease. However ventriculoplasty is not commonly used today, because variable results follow using only lateral ventriculoplasty as the treatment tool. This report traces our evolution in surgical management, defines that the homogeneous disease concept is not correct, and centers upon the importance of site selection, appropriate timing, and methods of patient selection. Left ventriculoplasty by either partial left ventriculoplasty (PLV) or septal anterior ventricular exclusion (SAVE or Pacopexy) was performed in 96 high risk (44% NYHA Class III, and 56% Class IV) patients with idiopathic dilated cardiomyopathy over the past 8 years. Overall hospital mortality was 8% in elective operations and 57% in emergency operations. Hemodynamic and functional improvement was evident from ejection fraction rising from 20% to 31%, and improved NYHA Class 3.6 to 1.8. The global series showed 1, 5 and 7 year survival rate was 66.4, 44.7 and 41.3%, respectively. However surgical results improved as experience allowed development of a strategy for timing, and defining proper exclusion site selection. Non homogeneous ventricular disease was identified, and 69% 4 year survival resulted from our intraoperative definition of the most diseased segment (septum or lateral wall), and then exclusion of this site. This evolving experience indicates that left ventriculoplasty is effective treatment for patients with end-stage cardiomyopathy, provided proper patient selection, appropriate timing of the operation, and choice of procedure are used as keys to a successful outcome.

Adolescent↗

PubMed2002

Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration.

OBJECTIVES: Functional mitral regurgitation in ischemic cardiomyopathy carries a poor prognosis, and its surgical management remains problematic and controversial. The aim of this study was to report the results of our surgical approach to patients who have had myocardial infarctions and have ventricular dilatation, mitral regurgitation, reduced pump function, pulmonary hypertension and coronary artery disease. This surgical approach consists of endoventricular mitral repair without prosthetic ring, ventricular reconstruction with or without patch, and coronary artery bypass grafting. PATIENTS: Forty-six patients (aged 64 +/- 10 years) with previous anterior transmural myocardial infarction and mitral regurgitation comprised the study group. Indication for surgery was heart failure in 93% of cases; 25 patients were in New York Heart Association functional class IV and 17 were in class III. Mitral regurgitation was moderate to severe in 32 cases (69%). RESULTS: All patients underwent coronary artery bypass grafting, with a mean of 3.2 +/- 1.3 grafts. Associated aortic valve replacement was performed in 4 cases. Global operative mortality rate was 15.2%. End-diastolic and end-systolic volumes significantly decreased after surgery (from 140 +/- 40 to 98 +/- 36 mL/m(2) and from 98 +/- 32 to 63 +/- 22 mL/m(2), respectively, P =.001). Systolic pulmonary pressure decreased significantly (from 55 +/- 13 to 43 +/- 16 mm Hg, P =.001). Ejection fraction did not change significantly. Postoperative mitral regurgitation was absent or minimal in 84% of cases; 1 patient had severe mitral regurgitation necessitating valve replacement. New York Heart Association functional class significantly improved. The mean preoperative functional class was 3.4 +/- 0.6 (median 3, range 2-4); after the operation, this decreased to 1.9 +/- 0.7 (median 2, range 1-3, P <.001). Cumulative survival at a 30-month follow-up was 63%. CONCLUSIONS: Our aggressive, combined surgical approach is aimed at correcting the three components of ischemic cardiomyopathy: relieving ischemia, reducing left ventricular wall tension by decreasing left ventricular volumes, and reducing volume overload and pulmonary hypertension by repairing the mitral valve. Despite a relatively high perioperative mortality rate, surviving patients benefitted from the operation, with improved clinical functional class and thus quality of life.

Adult↗

PubMed2001

Seeing congestive heart failure with the eyes of the mind: a surgical view.

Our normal approach is to recognize pathology and deal with what we see. This article shows that surgical actions in patients with congestive heart failure (CHF) are based on secondary changes in apparently normal looking structures that must be altered to restore normal function. These interventions follow the process of opening the normal pericardium to deal with the abnormal heart. Recognition of conceptual changes in structures without obvious pathology will lead to our incising the normal epicardium to deal with the scarred underlying muscle, narrowing the normal annulus to alter tethering of the lengthened papillary muscle chord connections, imbricating dilated normal myocardium between papillary muscle heads to narrow secondary widening, and rebuilding the dilated spheric ventricle to restore a normal elliptic contour. The overall objective is make our mental concepts guide surgical activities, and thus go beyond evident pathology in our corrective efforts. Our intent is to escape the boundary of the visible disease, and aim restoration toward the boundary of normality.

Cardiac Surgical Procedures↗