Surgical Anterior Ventricular Restoration for Ischemic Cardiomyopathy

Abstract

Emergency angioplasty or thrombolytic therapy for acute anterior wall infin'ction revascularizes the infarct-related artery. The damaged region includes the anterolateral left ventricle and septum. Revascularization avoids transmural scarring and suhsequent aneurysm because it spares the elficardial muscle. Regional akinesia develops due to damage to the inner two-thirds of the left ventricular and/or apical and anteroseptal wall. The epicardium, spared of transmural necrosis, may remain pink. The underlying midventricular and endoventricular muscles contain seglnental nonfllctional muscle with trabecular scarring. This region cannot thicken during systole to contribute to cardiac OUtlmt. Tile elulocardiuln often remains completely trabecuiated, so that the transmural thinning characteristic of aneuryslns is allsent. Akinesia of a large segment of ventricle resuhs in rclnodeling of the remaining ventricle, with increased sphericity and loss of elliptical apical contour. Occurring within hours of infarction, this may result in depressed ventricular flmetion that worsens over time as the remote, normally perfllsed nmscle dilates. The administration of lleta-blockers and ACE inhibitors early postinfarction has a salutary effect on tile remodeling process, but nevertheless about one-half of patients receiving aggressive treatment still display signs and SynllltOlnS of congestive heart failure due to progressive dihltion and sphericity of the noninfarcted muscle. For many )'ears, endoventricular circular patchplasty has been applied to the thinned dyskinetic ventricular aneurysm, llecause transmural necrosis avoids the thickened appearance that characterizes reperfused muscle. The anatomic changes lwo,luced l,y this rebuihling technique improve ventricular fimction as COnllmred to excision and linear closure. 1 Aneurysm is now uncolnmOl~ due to acute revascularization of the infarct-related artery. A similar ol,erative technique using an endoventricular l,atch has been al,l,lic,l to postinfarction akinesia, l This surgical al,l,roach is not commonly used because of surgical rehlctance to incise tile normal-appearing anterior wall due to epicardial muscle salvage. Tile ventricle surface may appear pink and rotate during systole. Ilowever, the underlying myocardium does,not thicken before bypass or collapse by venting during extracorporeal circulation. The recently organized RESTORE group includes an intermttional group of cardiac surgeons and cardiologists from four continents. One of its lnwposes has been to confirm the efficacy of surgical anterior ventrieular restoration (SAVI{) of postinfarction akinesia. This procedure was initially aplllied to akinetic muscle that does not collapse by venting due to epicardial sah'age by rewlscularization. Inferences allout intraoperative protection to preserve postcardiotomy ventricular function were drawn fi'om Batista's Ollerative techni(lue for llartial ventriculotomy using tile l,eating ol,en (as ol)posed to the cardiol)legically arrested) heart. This report describes the operative technique used in our 52-patient subsegment of RESTORE centers with the lleating open heart technique of protection. It outlines the SAVR technique applied to anterior akinetic postinfarction ventricle eardiomyolmthy and congestive heart failure (ejection fraction 28%, left ventriculogram systolic vohnne index [LVESVI] 132 mL/m2).