Journal Of Cardio-thoracic Surgery Research Articles

Rupture of a Kommerel's diverticle in a right aortic arch in aortic dissection Stanford type B

A 55-year-old male suffered acute thoracic pain, vertigo and hypertension. Due to emergent symptoms, emergency surgical repair was performed as distal aortic arch replacement under hypothermic circulatory arrest and antegrade cerebral perfusion, proximal descendens aortic replacement, and subsequent bilateral subclavian artery bypass in a single procedure (Figs. 1 and 2). European Journal of Cardio-thoracic Surgery 27 (2005) 347 www.elsevier.com/locate/ejcts

Coronary flow in sinus grafts?

I read with interest the article of De Paulis et al. “Coronary flow characteristics after a Bentall procedure with or without sinuses of Valsalva” in the July 2004 issue of the European Journal of Cardiothoracic Surgery [1], which examines the effects of the pseudosinuses of a ‘new conduit’ with pseudosinuses (Gelweave Valsalvae, Terumo Vascutek, Renfrewshire, Scotland, UK) upon coronary blood flow. While our observations on the subject of how the bulb geometry may modify coronary flow are comparable with those of the authors, i.e. the effect is minimal, if

Myxoma of the anterior leaflet of the mitral valve presenting with stroke in a young male

A healthy 29-year-old male presented with hemiplegia. The evaluation for this stroke was inconclusive, until an echocardiogram revealed a structure on the mitral valve (Fig. 1). This mass was resected and the leaflet was repaired (Fig. 2). The postoperative course was uncomplicated and his neurologic deficits improved over the next few months. European Journal of Cardio-thoracic Surgery 26 (2004) 1040 www.elsevier.com/locate/ejcts

Unusual chronic rheumatoid empyema, presenting as a chest wall mass

*Corresponding author. Address: Division of General Thoracic Surgery, Department of Surgery, Jichi Medical School, Minamikawachi-machi, Kawachi-gun, Tochigi 329-0498, Japan. Tel.: C81-285-587368; fax: C81-285-44-6271. E-mail address: tcvshun@jichi.ac.jp (S. Endo). 48 mm/h. A cystectomy was performed. Pathological study indicated a necrobiotic cyst containing rheumatoid nodules (Fig. 2). Neither fungus nor bacteria were identified. European Journal of Cardio-thoracic Surgery 26 (2004) 1042 www.elsevier.com/locate/ejcts

Aneurysmal bone cyst of the first rib

* Corresponding author. Address: Kardelen mahallesi Mobilyacilar sitesi, 482/19 Batikent, Ankara, Turkey. Tel.: C90-312-3801031; fax: C90-3122568136. E-mail address: mehmetsirmali@yahoo.com (M. Sirmali). the thorax depicted the mass lesion 5!6!7.5 cm in dimensions, including multiple septal formations in the location of left first rib (Fig. 1B). The left first rib was resected en bloc with the adjacent soft tissues via left posterior thoracotomy. Postoperative pathological evaluation was consistent with aneurysmal bone cyst (Fig. 2). European Journal of Cardio-thoracic Surgery 26 (2004) 826–827 www.elsevier.com/locate/ejcts

Lung cancer presenting as a giant tumor of the thoracic wall

A 70-year-old man presented with a giant painless, leftsided, thoracic mass (Fig. 1). Diagnostic imaging showed a large tumor with infiltration of the chest wall and erosion of adjacent ribs (Fig. 2a). Histology revealed a moderately differentiated adenocarcinoma of the lung (Fig. 2b). The patient refused any treatment and died at home 10 days later. European Journal of Cardio-thoracic Surgery 25 (2004) 1122–1123 www.elsevier.com/locate/ejcts

Thoracic surgery: is the future optimistic?

It is a moving experience to have met again after 18 years in Vienna where the First Meeting of the EACTS took place. Following a long period of turbulence we again stand here united in a joint meeting, which promises abundantly for the future. Within these 18 years, a lot of discussions took place and many conflicts arose. However, our essential effort and concern has never been the fulfillment of personal vanity or ambition but the promotion of practicing levels of our specialization. Huge steps have already been taken in this direction but there is a lot more to be done. After all, the last decade has given rise to pressing needs and the number of issues we have to handle has increased dramatically. The societies constitute the major channels for the communication of our ideas and the realisation of our hopes and pursuits in our professional and scientific future. At present the major demand is the standardisation of both training and practicing conditions across borders in Europe as concerns our area of interest. In the globalisation era we need an equalisation of working terms between Western and Eastern Europe as well as between the North and South. In order to formulate a unified scientific language on behalf of Europe the participation of all scientific teams and all countries is required. At the moment the conditions under which our specialty is practised are not equal across Europe. This is due to funding, educational and/or training, infrastructure and organisational, institutional and even cultural differences. EACTS and ESTS could play an important role in the elimination of these differences through interaction and communication of their members. Naturally, we cannot have much impact on economic or financial differences as they depend on official governmental policies. Yet, we can create a framework for the education and life-long training of doctors in surgical centers of reference, new surgical techniques, new technologies and new modality treatments. There are several ways in which the societies have initiated or developed changes towards the improvement of quality standards and the development of our field in general. † As refers to the institutional mission of the societies there can be an important contribution through the definition of objectives and content for our specialty in their constitution. It is well known that in several countries a large number of thoracic surgical procedures are performed by general surgeons and that in some cases thoracic surgery is considered a sub-specialty of general surgery. The societies’ instituted principles for membership are required to become part of national legislations. Thoracic surgery includes the totality of the field of cardio-thoracic surgery and the specialty can only develop within this framework. Collaboration and co-operation should ensure that the definition of a thoracic surgeon is drafted up by us and not by irrelevant pressure groups. † The European Thoracic Surgery Database Project is another step taken as it fulfills the requirements of a survey and it will facilitate founding high quality medical centers across Europe. Also, the establishment of European Boards allows the standardisation of qualifications for thoracic surgeons and helps towards the full recognition we are due. † Continuous life-long training is an imperative demand of our times and it is essential that all generations of thoracic surgeons partake of the advantages it offers. TechnoCollege offered within the work of the annual conference provides technology-oriented information and the opportunity of practicing technically demanding methods. The European School for Cardio-Thoracic Surgery in Bergamo, Italy also offers postgraduate courses of high standard quality. † Another important issue is the official organ of both societies, the European Journal of Cardio-thoracic Surgery. Its columns showcase the partnership between thoracic and cardiac surgeons and the well-educated and well-trained experts are encouraged and assisted in their development. The journal’s overall quality, as well as its acceptance within Europe and elsewhere, has been greatly enhanced. However, the vision should be for the journal to become a central reference point for the international scientific community.

Value of D-Dimer Testing in Acute Aortic Dissection

To the Editor: We read with great interest the recent review on etiology, diagnosis and management in aortic dissection.1 In their discussion on diagnostic strategies, the authors state that useful biomarkers for aortic dissection are currently absent. We recently reported on 24 patients with acute aortic dissection in whom D-dimer, a degradation product of cross-linked fibrin, was tested as a part of the initial diagnostic strategy.2 We found that, actually, all patients with acute aortic dissection …

Left ventricular assist devices: bridges to transplantation, recovery, and destination for whom?

Application of mechanical cardiac support now requires consideration of a wider range of goals beyond bridging to transplantation to include destination therapy and perhaps bridging to recovery.1,2 Responsible dissemination of the technology requires identification of patient populations from which to select candidates most likely to benefit. At this early stage, benefit is most apparent against a high background mortality from end-stage heart failure. Heart failure affects an estimated 5 million patients in the United States. Of those, ≈60% have heart failure with left ventricular dilation and reduced ejection fraction. Trials demonstrating benefit of therapies for heart failure have focused primarily on mild–moderate heart failure with reduced ejection fraction, generally with annual mortality in the range of 8% to 18%.3 Advanced heart failure has been defined as symptoms limiting daily activity (New York Heart Association class III and IV) despite attempted therapy with angiotensin-converting enzyme inhibitors, β-blockers, digoxin, and diuretics,4 a description that applies to ≈300 000 to 800 000 patients in the United States. Although often labeled as “refractory,” many patients enjoy improved quality of life and decreased hospitalizations after referral to experienced heart failure centers, where aggressive medical strategies focus on relief of congestion. Surgical approaches include complex revascularization, valvular repair/replacement, or ventricular reconstruction. When technically successful, biventricular pacing can improve functional status for many of the 25% to 40% of patients with marked ventricular asynchrony.5 If early stabilization allows institution of β-adrenergic–blocking agents, prognosis is further improved.6 Dedicated heart failure management programs that facilitate patient education, compliance, and fluid balance have been integral to benefits observed with these therapies. The highest-risk heart failure populations are best identified after optimization of current therapies. Low left ventricular ejection fraction is not sufficient description of either function or prognosis once heart failure has become advanced. Neither …

European Association for Cardio-Thoracic Surgery: carrying the torch

I would like to thank you for the honour of electing me as your President. As many of you might suspect and some of you know, in a well organised society like ours, with the Secretariat ably run by Torkel Aberg and Maud Zingmark, and the Organisational Secretariat efficiently managed by Kathy McGree, the duties of the President are not onerous. But still, a major task rests heavily on the shoulders of every President – the task of delivering the presidential address. After looking through the efforts of my predecessors, I decided on the topic, which captivated me for many years, but has received little attention in the past. I will talk about our society, the European Association for Cardio-thoracic Surgery (EACTS), which I had the honour to serve as Secretary, Editor, and now as President. I will try to give you my personal view of the origins of this association; I will share with you some observations why this association was started; how it developed and where it stands now; and I will offer some thoughts about actions, which we should take in the future. The EACTS traces its origin to a group of skiing cardiac surgeons, who enjoyed lively scientific exchange and sports, first in the shadows of Matterhorn in Cervinia, and continued to meet for a number of years on the slopes of Courchevel in France. The person who really started this association, to whom the association owns its existence, and who must be given full credit for its success, is Francis Fontan (Fig. 1). He has not only realised the necessity for an advanced European scientific forum for cardio-thoracic surgery, but also had the intellectual authority and tenacity to start this association. In 1986 he invited a small group of European cardio-thoracic surgeons to a meeting to be held at the airport in Amsterdam. He made a careful preparation of the topics to be discussed, centred on the formation of a new scientific organisation of cardio-thoracic surgery. As a thoracic counterpart in the formative years of the EACTS, the honour goes to Keyvan Moghissi (Fig. 2), who helped write most of the original constitution, and who carefully preserved the balance between cardiac and thoracic surgery in the offices and governing bodies of the Association. First congress was organised in Vienna in 1987 by Ernst Wolner and was opened by the first president of the Association, Francis Fontan, on September 14th, 1987. The first meeting of the EACTS was an unequivocal success, and led in 1988 to the second meeting in Bordeaux, and continued with a series of annual meetings leading to this 16th congress in 2002. Why did we decide to start another cardio-thoracic association? First, many of us were frustrated and unhappy with the state of surgical meetings in Europe. In those earlier conferences, there was often an obvious geographical bias in the selection of papers, with several countries having to be represented in the program, without consideration for the scientific quality of the material. Anonymous selection of papers was not applied, many speakers announced in the program did not bother to appear, and papers were rarely published. Even worse, those meetings often addressed only a narrow choice of topics, with soporific consequence of sessions consisting of 6, 7 or 8 almost identical papers about the same subject. Meetings did not keep to the announced schedule, afternoon sessions were sometimes delayed for hours due to substantial lunch breaks. In summary, it was a far cry from truly professional meetings of the American Association of Thoracic Surgery (AATS) and Society of Thoracic Surgeons (STS), where European surgeons went to present their best material, and to learn about advances in our profession. But the founders of the EACTS were also aware of the important tradition of the European cardio-thoracic surgery, and we felt that it deserved a proper scientific forum. First documented suture of the heart was performed by Ludwig Rehn in Frankfurt in 1896 (Fig. 3). Application of pneumothorax for treatment of pulmonary tuberculosis – the European Journal of Cardio-thoracic Surgery 22 (2002) 857–863

Peer review versus public review ? new possibilities of on-line publishing!

The traditional paper based journals, like the European Journal of Cardio-thoracic Surgery, have developed a sophisticated manuscript selection system in order to improve the quality of the papers accepted for publication. This so-called peer review system includes in addition to the usual verification of formal requirements and language editing, the systematic assessment of submitted manuscripts by experts in the field and statistical work-up, prior to the evaluation by the section editor and final decision by the editor-inchief. The multiplication of these parallel and serial filters of such a peer review system certainly guarantees a minimal level of quality and is the basis of the high reputation the leading journals have developed. The Impact Factor, which is based on the number of citations per article published, is the yardstick by which the Journals, the papers published, and their authors are measured. As a result, the equation {publication in a journal with high impact factor 1⁄4 good science 1⁄4 excellent author} is readily made, but not always justified. Although, the peer review system for manuscript selection has reached a high rate of acceptance by academic standards there are also a number of limitations. These include the fact that the peer review process happens behind the scenes, that the peers are by definition experts in a specific field and therefore part of the establishment, that there is a certain lack of transparency how the final decisions are reached (even if the opinions expressed are forwarded to the authors and the reviewers on a routine base), that the manuscripts are amended during iterative revisions, and that the original message may be diluted or even entirely lost. As a matter of fact, the editor-in-chief faces at the end of the traditional peer review evaluation chain three typical scenarios.

Giant pulmonary hamartoma

A 30-year-old man was admitted to our hospital because he wished us to remove the pulmonary mass that was incidentally detected on healthy examination. The patient was free of symptoms and in good general condition. Radiologic findings showed a giant intrapulmonary mass lesion in the lower lobe of the right lung (Fig. 1). Open thoracotomy and wedge resection including mass were performed. The gross appearance of the resected specimen showed a 16 £ 9-cm yellow-gray encapsulated, ovoid mass with homogeneous cartilage containing multiple crypts (Fig. 2). Histopathologic pathological findings were consistent with a diagnosis of hamartoma, and no sign of malignancy was observed. The patient recovered well and was discharged on the tenth postoperative day. At 8-month follow-up, He was in a healthy state with no signs of recurrence. European Journal of Cardio-thoracic Surgery 22 (2002) 1006

Discussion: Session 3—Dissection

Discussion: Session 3—Dissection

Reply to Alverez

Dr Alverez claims that our own results show that the left internal mammary artery (LIMA) used as a composite graft to the left anterior descending (LAD) territory arteries has a higher failure rate than non composite IMA [1]. He does not appear to understand that composite IMA was grafted to the LAD territory arteries of mild or moderate stenosis more frequently than non-composite IMA. Since the degree of coronary stenosis was the most powerful predictor of patency, these two groups are therefore not directly comparable. Though long term studies are required, our short-term study strongly suggests that Dr Alverez may be in error. Arterial conduit was anastomosed to the LAD territory 174 times, Table 1. Of 89 anastomoses from composite IMA there were ten string signs in eight patients, and from non-composite IMA there were 80 anastomoses with no string signs. Indication for grafting was, moderate left main coronary stenosis with normal LAD; moderate LAD stenosis in the setting of triple vessel coronary disease; and `crossing' a distal LAD stenosis with the anastomosis resulting in minimal residual LAD stenosis. All but one of these string sign conduits were grafted to LAD stenoses #60%. Patency was 100% where coronary stenosis was $80% and all radial artery (RA) grafts were patent, irrespective of composite origin or coronary stenosis. These data compare favourably with historical studies where grafting would generally have been restricted to coronary arteries of stenosis $80%. This supports the ®ndings of the original paper that the most important in uence on patency was the degree of coronary stenosis to which a graft is competing. These eight patients were followed up for the purposes of this reply at 43:6 ^ 11:6 months postoperative. Four had further angiograms subsequent to the original paper so that angiographic follow up for all eight patients is 24:3 ^ 7:9 months. There were no new ®ndings. Seven patients European Journal of Cardio-thoracic Surgery 19 (2001) 543±544

Reply to Nagy and Péterffy

We would like to thank Drs Nagy and PeÂterffy for their considerations on mitral reconstruction without the use of annuloplasty ring, and thank them for their interest in our work. While it is generally accepted that Carpentier's philosophy of implanting a rigid ring has resulted in good long-term stabilization of mitral ring size, its rigidity also impairs physiologic motion of the mitral ring during the cardiac cycle. In addition, its cost in European countries is approximately US$ 600 and thus not insigni®cant. Suture annuloplasty achieves a similar goal, i.e. reduction of the mitral ori®ce and improved lea et cooperation without the physiologic disadvantages of a rigid structure and at a much lower price. In addition, it requires less ischemic time compared to implantation of an annuloplasty ring. Drs Nagy and PeÂterffy very correctly point out two technical aspects of suture annuloplasty that need to be taken into consideration. The individual bites of the continuous suture have to be placed deep enough into the ®brous tissue of the mitral ring to prevent it from tearing out; we can only reiterate this point. The second aspect concerns the choice of suture material. Prolene sutures are now standard in most cardiac and cardiovascular procedures due to the stability of the material and the minimal degree of tissue drag. Minimal tissue drag appears advantageous during implantation since only small changes in suture tension will easily alter the size of the mitral ori®ce. Since prolene leads to minimal ®brosis, however, breakage in a chronic stage or knot disruption may lead to recurrence of ring dilatation. Different suture material, such as polytetra uoroethylene is more dif®cult to place and adjust the ori®ce due to its increased tissue drag. It usually results in a stronger ®brous tissue reaction and possible ingrowth of connective tissue into the suture material itself. These connective tissue reactions can be expected to improve long-term stability of mitral repair even in the face of suture breakage, as can be concluded from the experience of Drs Nagy and PeÂterffy. Also we have not yet seen recurrent ring dilatation after suture annuloplasty using Gore-Tex material. We agree with Drs Nagy and PeÂterffy that suture annuloplasty is a very effective means of reducing and stabilizing ring size in mitral reconstruction. We would like to encourage the authors to follow their patients further and produce 10-year follow-up results to provide true long-term data for comparison with ring annuloplasty. European Journal of Cardio-thoracic Surgery 18 (2000) 741

Reply to Rogers

Thank you for your comments regarding the article on `Early and long term complaints following video-assisted thoracoscopic surgery: evaluation in 173 patients'. The purpose of our article was the assessment of early and long term pain after video-assisted thoracoscopic surgery (VATS), time of incapacity for work and patient satisfaction with scar cosmetics. We found an impressively high number of patients with a very early recovery and rapid reintegration into the working process after VATS. However, as you pointed out there is a signi®cant number of patients with long term complaints after VATS. Approximately 10% had moderate to severe pain at 3 months and 5% at 1 year. We considered this information as interesting for physicians and especially important for counselling patients before a VATS procedure. In our article we did not state that chronic postthoracoscopy pain is signi®cantly lower compared to open thoracotomy. This could only be assessed in a prospective randomized study. In this regard we fully agree. European Journal of Cardio-thoracic Surgery 18 (2000) 738

The language of science.

I am honored by President Joachim Hasse and the European Association for Cardio-thoracic Surgery (EACTS) to have been invited to speak to you today. It is a special pleasure because to celebrate the millennium the Society of Thoracic Surgeons (STS) and EACTS are honoring one another, and the seeds for this coming together began on both sides of the Atlantic during the year I had the privilege of presiding at the STS. Why did I hope the language of science might be of interest to you? The EACTS, with English as its of®cial language, is one of the great international melting-pots of thoracic surgery. For many of you English is a second language, and I supposed that this might present you with more challenge in presenting your work than it would be to do so in your own languages. Why is this topic of interest to me? I was stimulated to think about differences between the research environment in the US and elsewhere when David Nahrworld sounded an alarm in 1995 with the observation that the number of publications from US authors in peer-reviewed surgical journals had been decreasing [1]. He said `The most striking ®nding was the dramatic, signi®cant fall in the number of1⁄4research pages from the US and the increase in1⁄4pages from countries other than the US1⁄4' Most of the American Surgical Association audience believed this re ected a decrease in time and funds allotted to research in the US. It took a French colleague, during the discussion period, to reassure us Americans and to make us chuckle. Professor Henri Bismuth of Villejuif, France responded by saying that this `1⁄4may re ect the increased ability of non-American surgeons to write English1⁄4It is like the French complaining of more Americans in French restaurants. It does not mean that French taste is losing.' John Waldhausen, editor emeritus of our sister journal, added perspective by saying, `1⁄4we should be thankful that these manuscripts are1⁄4in English rather than in Mandarin Chinese, the language spoken by more people than any other in the world.' Shortly after the Nahrwold±Bismuth±Waldhausen exchange that called attention to language, my interest was further stimulated when I lectured in Vienna. My offer to speak in Viennese German, my ®rst language, was politely declined in favor of English ± their of®cial language. I then realized how much more work it would have been for me to speak in my mother tongue than in my daily language. During the discussion period, which was in German, my audience understood better, and expressed itself more clearly and succinctly, in its own language than in English. This was true despite their sophistication and good knowledge of English. Subsequent visiting professorships in the Netherlands, France and Japan enhanced my awareness of the language burden faced by English second language scientists. My personal editorial experience for the Annals of Thoracic Surgery (ATS), the European Journal of Cardiothoracic Surgery, and a number of other journals has made me sensitive to today's topic. In addition, friends in Europe and Asia, who have impeccable skill in their own languages, have repeatedly asked me to review or edit manuscripts from the language viewpoint. Ladies and gentlemen, with native tongues other than English, my hat is off to you. You have accepted and coped admirably with an English language burden, and my hope is that you will see my remarks as constructive. I began my audacious venture into language studies by consulting the late Professor Victoria Fromkin, former chairperson of our UCLA Department of Linguistics. She reminded me that mathematics is the most durable language of science and she stressed a commonalty among written European Journal of Cardio-thoracic Surgery 18 (2000) 642±648

Less invasive surgery

As has been mentioned, we must reinvent ourselves every so often if we are to stay alive. Mr Westaby introduced the first session by pointing out that there was a condition for which there was no known successful alternative treatment. We will now discuss minimally invasive surgical therapy. Some of you have questioned the definitions of ‘minimal’ and ‘invasive,’ and I hope by the end of today we will know a little more about both. European Journal of Cardio-thoracic Surgery 15 (Suppl. 1) (1999) S31

Welcome from the European Association for Cardio-Thoracic Surgery

At the five previous international symposia sponsored by Sulzer Carbomedics, I had the pleasure and privilege of chairing a session, making a presentation, or serving as a panelist. This year, everything has changed, including the topic of the symposium. Everyone knows that the CarboMedics Prosthetic Heart Valve is a good valve, so it is not necessary to discuss it again; therefore, the company has selected an interesting program that will be attractive to many. I wish the symposium much success. As president of the European Association for CardioThoracic Surgery, I am very pleased that so many satellite symposia, including this one, are organized around our annual meeting, and as a consequence, attendance this year will be the highest ever. Attendance was approximately 1700 at our very successful meeting last year in Prague, and this year we expect over 2000 attendees, making the annual meeting of the European Association, along with the annual meetings of The American Association for Thoracic Surgery and The Society of Thoracic Surgeons, one of the three major meetings worldwide. European Journal of Cardio-thoracic Surgery 15 (Suppl. 1) (1999) S2

Partial left ventriculectomy – the Batista procedure1

Heart transplantation is a good option for heart failure, but there are not many organ donors; even in the most developed countries of the world, only 1% of those who need heart transplantation will receive it. The situation is even worse in Brazil. So I would like to discuss a procedure I developed for the 99% of patients who do not have access to heart transplantation, which is the partial left ventriculectomy (PLV). Its concept is that rather than operating on the heart, I am operating on its diameter. If you look at the heart as a bad muscle, it does not make any sense to excise a piece of it in order to make it better because the heart needs more muscle. Why then does the patient improve? It has to do with the diameter. Nature has been shaping the heart for 100 million years, which is a great deal of experience bringing it to where it is today. The snake heart is very tiny, and if it is placed beside a human heart and a buffalo heart, it is immediately recognized as a snake heart (Fig. 1). But if a computer image of the snake heart is enlarged to the size of the buffalo heart, you can no longer determine which is which. The ratio of mass to diameter is the same in both hearts. In fact, all hearts have the same ratio of mass to diameter, from the snake to the buffalo to the whale. Everything in nature, from strawberries to oranges to hearts, has the same ratio, regardless of its size. Thus there is a single formula common to all hearts in nature, which is that muscle mass is four times the radius cubed (M = 4 × R). A small snake heart is 1 cm and 5 g (Fig. 2). A human heart is five times larger and has 100 times more muscle mass; an ox heart is ten times larger and has 1000 times more muscle mass. Any heart that is not within this formula simply needs to be returned to it. Fig. 3 shows a transplanted heart that looks like a normal ox heart from the outside, but cross-sections reveal that it is not (Fig. 4). For this heart to be normal, either the cavity must be filled with muscle or the diameter must be decreased. Fig. 5 shows what the heart looks like if its diameter is decreased. Removing a piece of the heart and decreasing its diameter returns it to its natural state, where the diameter is appropriate for the amount of muscle. We performed experiments in sheep to determine the importance of the heart’s diameter. In a normal heart we split the ventricle in two and added a patch to increase the diameter of the heart (Fig. 6). What happened? The heart simply stopped and would no longer beat. To cause it to beat again, we excised the patch. So if I were to increase the diameter of a heart by 20%, heart function (ejection fraction) would decrease by 30%. If I were to decrease the heart by 1 cm, the effect would be the same as if I added 1 kg of muscle. That is the importance of the diameter. Fig. 7 is magnetic resonance imaging showing how thick the muscle is in one area and how thin in another. If we bring one edge to the other, decreasing the diameter of the heart, it will beat much better. A dilated heart contracts isometrically, that is, it expends a lot of energy without doing much work. If I reduce it to a size that I can hold in only one hand, the resulting curvature will strengthen the heart’s ability to contract. Two groups from Japan and the Netherlands measured pressure/volume loops both before and after PLV in approximately 120 of my patients by putting pressure and conductance catheters through the apex of the heart or the European Journal of Cardio-thoracic Surgery 15 (Suppl. 1) (1999) S12–S19