Internal Left Ventricular Reconstruction

Abstract

Surgical treatment of nonischemic dilated cardiomyopathy is a new field in cardiac surgery. Although current pharmacologic therapy has produced improved survival, many patients still need heart transplantation. Batista and colleagues1Batista RJV Verde J Nery P et al.Partial left ventriculectomy to treat end-stage heart disease.Ann Thorac Surg. 1997; 61: 634-638Abstract Full Text Full Text PDF Scopus (324) Google Scholar introduced partial left ventriculectomy to improve left ventricular function by reducing left ventricular wall tension. This is achieved by decreasing left ventricular diameter with wide excision of the left ventricular free wall (generally the posterolateral wall between the anterior and posterior papillary muscles). Because we found a higher incidence of interstitial fibrosis in the septum than in the lateral wall in a number of patients with nonischemic dilated cardiomyopathy,2Suma II Isomura T Howii T et al.Nontransplant cardiac surgery for end-stage cardiomyopathy.J Thorac Cardiovasc Surg. 2000; 119: 1211-1233Google Scholar we introduced the septal anterior ventricular exclusion (SAVE), or “pacopexy,” procedure. The weakest area of the left ventricle is detected by intraoperative echocardiography. Changes in left ventricular wall motion and thickness can be detected by echocardiography when the left ventricle is decompressed during cardiopulmonary bypass. By decompressing the left ventricle, the akinetic portion of the ventricle becomes thick and kinetic when it is viable, but remains akinetic when nonviable (Fig I). We decide to perform either a partial left ventriculectomy or a septal exclusion, depending on the site of akinesis. In 85 patients with nonischemic cardiomyopathy treated with left ventriculoplasty at Shonan Kamakura General Hospital and Hayama Heart Center between December 1996 and September 2001, 12 patients received the SAVE procedure. The 10 men and 2 women ranged in age from 35 to 76 years, with a mean age of 60. Seven patients were New York Heart Association (NYHA) class III and five patients were class IV, including three patients with inotropic support before operation. Mitral valve replacement was performed concomitantly in five patients and four patients had mitral annuloplasty with a ring. The remaining three patients had previous mitral valve replacement. Five patients also had tricuspid annuloplasty performed concomitantly. One patient who had previous aortic and mitral valve replacement died of heart failure on the seventh postoperative day after the operation. Another patient died of recurrent heart failure 3 months after discharge. The other 10 patients were discharged in NYHA class I or II (9 patients) or class III (1 patient). Postoperative ventricular variables are shown in Table 1.Table 1SAVE for Dilated CardiomyopathyPreoperativePostoperativeEF (%)21.5 ± 6.829.8 ± 5.6LVDd (mm)80.2 ± 11.068.0 ± 13.0LVEDVI (mL/m2)192.2 ± 42.9130.0 ± 40.0LVESVI (mL/m2)144.9 ± 35.191.6 ± 35.2PCWP (mm/Hg)26.2 ± 8.716.0 ± 4.2NYHA class3.4 ± 0.51.9 ± 0.4 Open table in a new tab Although more experience and longer follow-up are needed, we believe that the SAVE procedure is an excellent procedure for ventriculoplasty in nonischemic dilated cardiomyopathy with anteroseptal akinesis.