Endoventricular Circular Patch Plasty Research Articles

Outcomes of continuous flow left ventricular assist device after surgical left ventricular restoration

ObjectivesThis study aimed to report the clinical outcomes of continuous flow left ventricular assist device implantation in end-stage chronic heart failure patients with a history of surgical left ventricular restoration.MethodsWe retrospectively identified 190 patients undergoing continuous flow left ventricular assist device implantation at our center from November 2007 to April 2020. In total, six patients underwent continuous flow left ventricular assist device implantation after various types of surgical left ventricular restoration procedures, including endoventricular circular patch plasty (n = 3), posterior restoration procedure (n = 2), and septal anterior ventricular exclusion (n = 1).ResultsContinuous flow left ventricular assist device (Jarvik 2000, n = 2; EVAHEART, n = 1; HeartMate II, n = 1; DuraHeart, n = 1; HVAD, n = 1) was successfully implanted in all patients. During a median follow-up of 48 months (interquartile range, 39–60 months; censoring heart transplantation), no death was documented, which means that overall survival after left ventricular assist device implantation was 100% at any time point. Finally, three patients received heart transplantation (waiting time: 39, 56, and 61 months, respectively) and the other three patients are still awaiting heart transplantation (waiting time: 12, 41, and 76 months, respectively).ConclusionsIn our series, continuous flow left ventricular assist device implantation after surgical left ventricular restoration was safe and feasible, even if an endoventricular patch was used, and effective for bridge to transplant strategy.

Surgical Decision Making for Left Ventricular Aneurysmectomy

Left ventricular aneurysms may be repaired by the linear technique or endoventricular circular patch plasty technique. Choice of technique should be based on the individual patient, including cavity and aneurysm geometry. In this article, we describe the principles underlying decision making with 2 illustrative cases.

Application of Circular Patch Plasty (Dor Procedure) or Linear Repair Techniques in the Treatment of Left Ventricular Aneurysms

ObjectiveThe aim of this study was to evaluate early clinical outcomes and echocardiographic measurements of the left ventricle in patients who underwent left ventricular aneurysm repair using two different techniques associated to myocardial revascularization.MethodsEighty-nine patients (74 males, 15 females; mean age 58±8.4 years; range: 41 to 80 years) underwent post-infarction left ventricular aneurysm repair and myocardial revascularization performed between 1996 and 2016. Ventricular reconstruction was performed using endoventricular circular patch plasty (Dor procedure) (n=48; group A) or linear repair technique (n=41; group B).ResultsMulti-vessel disease in 55 (61.7%) and isolated left anterior descending (LAD) disease in 34 (38.2%) patients were identified. Five (5.6%) patients underwent aneurysmectomy alone, while the remaining 84 (94.3%) patients had aneurysmectomy with bypass. The mean number of grafts per patient was 2.1±1.2 with the Dor procedure and 2.9±1.3 with the linear repair technique. In-hospital mortality occurred in 4.1% and 7.3% in group A and group B, respectively (P>0.05).ConclusionThe results of our study demonstrate that post-infarction left ventricular aneurysm repair can be performed with both techniques with acceptable surgical risk and with satisfactory hemodynamic improvement.

Post infarction left ventricular aneurysm—our experience

Left ventricular aneurysms (LVAs) stand as one of the serious complications of myocardial infarction and are associated with increased mortality. Considerable differences exist regarding the optimal surgical management of LVAs. In this study, we report our single center/single surgeon experience with post infarction LVAs. This is a retrospective analysis of 25 patients, who underwent endoventricular circular patch plasty (Dor procedure) for LVAs of ischemic origin from 2009 to 2013. The demographic data was collected in addition to patients mode of presentation, New York Heart Association (NYHA) class, past medical history particularly ischemic heart disease, preoperative electrocardiography, chest X-ray, echocardiography, and coronary angiography. The postoperative functional class and the echocardiography data were also collected and analysed. All patients underwent follow-up cardiac computerized tomogram (CT) scan to calculate the sphericity index (SI). The mean age of presentation was 60.76 ± 9.57 years. Seventeen were males and eight were females. The associated comorbidities were, diabetes and hypertension. The most common presentations were, the angina and the left ventricular failure. Among the study group, two (8%) patients presented within 72 h of myocardial infarction (MI) owing to the hemodynamic instability due to ventricular septal rupture (VSR) and severe mitral regurgitation (MR), and required moderate doses of inotropes and intra-aortic balloon pump. The time of presentation in the remaining 23 (92%) patients ranged from 14 to 38 days following the MI (mean −21.36 ± 0.38 days). The preoperative mean NYHA functional class was 2.44 ± 0.71. Posterior aneurysms were predominated in our study. The mean left ventricular internal diameter in diastole (LVIDd), the left ventricular internal diameter in systole (LVIDs) and the ejection fraction (EF) were; 6.52 ± 0.40 cm, 5.24 ± 0.37 cm, and 37.44 ± 3.92% respectively. The mean end-diastolic volume (EDV) was 167 ± 28.38 ml and the mean end-systolic volume (ESV) was 87.84 ± 12.90 ml. The mean pulmonary artery systolic pressure (PASP) was 51.48 ± 5.72 mmHg. The mean tricuspid annular plane systolic excursion (TAPSE) was 11.52 ± 0.71 mm. Six cases showed mural thrombus, four had MR, and one had an associated ventricular septal defect (VSD). The coronary angiogram showed multivessel coronary artery disease in majority of patients. The hospital mortality was 8% (two cases). The mean follow-up period was 2.4 ± 0.91 years. The postoperative mean NYHA class was 1.76 ± 0.43. There was a significant improvement in the left ventricular function. There was a significant improvement in MR following concomitant Dor procedure and mitral valve interventions. Patients with mitral interventions had trivial to mild MR and were asymptomatic. The mean SI was 0.5 ± 0.11. Dor procedure is reproducible and simple to perform, restores the natural left ventricular geometry and is associated with significant improvement in the left ventricular performance and hemodynamics, which translates into improved functional class of the patient.

Transcatheter Structural Heart Interventions for the Treatment of Chronic Heart Failure.

Heart failure (HF) is a major cause of mortality and morbidity in developed countries.1 In the past 2 decades, improvements in drug therapy and the widespread use of implantable cardioverter-defibrillators and cardiac resynchronization therapy devices has improved the prognosis of HF patients.2 However, morbidity and mortality rates remain high, with an estimated 5-year mortality rate exceeding 50% coupled with significant rehospitalization rates. Several transcatheter implantable devices have recently emerged in an attempt to improve the prognosis and quality of life of such patients. We reviewed the current literature on interventional chronic HF. The review focus on the description of the devices and main procedural characteristics, patient eligibility, procedural results, and clinical outcomes associated with such devices. This article will focus only on mechanical transcatheter structural heart interventions for treating chronic HF. Devices used for percutaneously delivering biological therapies and interventions for acute HF fall beyond the scope of this article. Several surgical and device-based therapies have emerged in an attempt to reverse LV remodeling by restoring normal LV architecture and reducing LV volumes and wall stress. Among these surgical therapies, the most commonly used is the endoventricular circular patch plasty or Dor procedure, which consists of excluding the akinetic septal and apical ventricular regions by performing aneurysm resection with the insertion of a circular pericardial patch. Although this procedure showed promising results in multicenter registries,3 the only randomized trial—Surgical Treatment for Ischemic Heart Failure (STICH)—failed to demonstrate differences in the composite end point of death and rehospitalization for cardiac causes between surgical ventricular restoration+coronary artery bypass graft versus coronary artery bypass graft alone.4 However, some subgroups, experienced significant benefits with surgical ventricular restoration.5,6 In this regard, the parachute device (Cardiokinetix, Inc, Menlo Park, CA) emerged as a percutaneous device with the purpose of …

Sublocalization of Cardiac Involvement in Sarcoidosis and Surgical Exclusion in Patients With Congestive Heart Failure

In sarcoidosis, cardiac involvement can cause fatal conditions such as left ventricular (LV) dysfunction and rhythm disturbance. We surgically treated critical patients with congestive heart failure due to cardiac sarcoidosis. During 14 years, 384 patients with nonischemic dilated cardiomyopathy were operated. Among them, 14 patients (3.6%) with New York Heart Association (NYHA) class IV (male/female, 3/11; 57 ± 11 years) caused by sarcoidosis underwent surgery (elective/emergent, 12/2). The akinetic lesion, as identified by speckle-tracking echocardiography, was excluded. Localization of akinetic lesions was achieved in 13 patients (93%). In the short axis, lesional distribution was higher in the anterior (62%) and septal segments (54%) when compared with the posterior (31%) and lateral segments (23%). Along the long axis, regional distribution was higher in the mid (85%) and apical segments (69%) when compared with the basal segment (31%). The main lesions were excluded by septal anterior ventricular exclusion (n = 5), posterior restoration procedure (n = 3), endoventricular circular patch plasty (n = 3), and linear resection (n = 2). Mitral valve surgery included mitral valve plasty (n = 7) and replacement (n = 7). In patients undergoing elective surgery, early results showed that 10 patients survived (83%) and NYHA class improved (6 patients in class II and 4 in class III). Patients who underwent emergent surgery did not survive. The observation period was 55 ± 59 months in survivors. During follow-up, 4 patients died after 42 ± 48 months. The other 5 patients have survived for 71 ± 61 months. The 3- and 5-year survival rates were 65% and 52%, respectively. Sarcoidosis can result in sublocalized LV involvement, which can be surgically excluded.

Evidence of myocardial regeneration after endoventricular circular patch plasty with CorMatrix ECM

was repaired with a pericardial patch and the posterior leaflet reattached to the neo-annulus (made of pericardium and left atrium). The remaining leaflet tissue was augmented with pericardium and a 32 mm Physio II (CarpentierEdwards) annuloplasty ring was employed. Discussion: It has been shown that the well understood morbidity and mortality benefit conveyed by mitral valve repair compared to replacement in the setting of degenerative mitral valve disease is also relevant in the presence of mitral disease caused by infective endocarditis. Several studies have now established feasibility of mitral valve repair in the setting of annulus calcification. Timing and staged order of the surgical procedures is an important point of consideration. The clinical severity and immediate sequelae of an untreated leaking AAA dictates urgent repair of this issue in the first instance. It is important to note that elimination of non-cardiac infective sources prior to valve surgery is an important principle which reduces the risk of recurrent endocarditis and is particularly important if valve replacement is required. It was important this patient was treated in a specialist centre (tertiary facility) by a multidisciplinary team from surgical, intensive care, anaesthetic, cardiology and allied health departments; and we advocate a tailored approach to complex cases of mitral valve endocarditis.

Optimization of surgical ventricular restoration by in-silico simulations

A hypothesis on left ventricular aneurysms states that there is better preservation of contractile myocardium when the aneurysm geometry is rectangular as opposed to circular. Pre-surgical planning of surgical ventricular restoration was performed on the basis of this hypothesis. The intraventricular patch used to exclude scarred or aneurysmal myocardium remains akinetic, hence it was used to define aneurysm geometry as circular or rectangular. Hausdorff distance analysis was carried out by mathematical computational methods on the baseline cardiac magnetic resonance images of 5 patients. The mean Hausdorff distance for the full range of frequencies was significantly greater after endoventricular linear patch plasty (0.474 ± 0.190 vs. 0.722 ± 0.221 mm, p = 0.047), whereas after endoventricular circular patch plasty, the difference was not significant (0.474 ± 0.190 vs. 0.594 ± 0.193, p = 0.175). The mean Hausdorff distance <0.5 mm was also significantly greater after endoventricular linear patch plasty than after endoventricular circular patch plasty: 0.258 ± 0.03 mm at baseline vs. 0.40 ± 0.16 mm after linear patch plasty (p = 0.039) and 0.258 ± 0.03 vs. 0.32 ± 0.10 mm (p = 0.130) after circular patch plasty. In-silico technology using the Hausdorff distance enables pre-surgical planning and optimization of the technique for surgical ventricular restoration.

Analysis of patient-specific surgical ventricular restoration: importance of an ellipsoidal left ventricular geometry for diastolic and systolic function

Surgical ventricular restoration (SVR) is a procedure designed to treat heart failure by surgically excluding infarcted tissues from the dilated failing left ventricle. To elucidate and predict the effects of geometrical changes from SVR on cardiac function, we created patient-specific mathematical (finite-element) left ventricular models before and after surgery using untagged magnetic resonance images. Our results predict that the postsurgical improvement in systolic function was compromised by a decrease in diastolic distensibility in patients. These two conflicting effects typically manifested as a more depressed Starling relationship (stroke volume vs. end-diastolic pressure) after surgery. By simulating a restoration of the left ventricle back to its measured baseline sphericity, we show that both diastolic and systolic function improved. This result confirms that the increase in left ventricular sphericity commonly observed after SVR (endoventricular circular patch plasty) has a negative impact and contributes partly to the depressed Starling relationship. On the other hand, peak myofiber stress was reduced substantially (by 50%) after SVR, and the resultant left ventricular myofiber stress distribution became more uniform. This significant reduction in myofiber stress after SVR may help reduce adverse remodeling of the left ventricle. These results are consistent with the speculation proposed in the Surgical Treatment for Ischemic Heart Failure trial (20) for the neutral outcome, that "the lack of benefit seen with surgical ventricular reconstruction is that benefits anticipated from surgical reduction of left ventricular volume (reduced wall stress and improvement in systolic function) are counter-balanced by a reduction in diastolic distensibility."

Early results after surgical treatment of left Ventricular Aneurysm

BackgroundLeft ventricular aneurysm (LVA) is a serious complication of myocardial infarction and reduces the chances of survival. Controversy still exists regarding the optimal surgical technique for LVA repair. We analyze the efficacy of two techniques, linear vs. endoventricular circular patch plasty, for repair of LVA and the efficacy of surgical ventricular restoration (SVR) on beating heart.MethodsThis study included 62 patients who underwent SVR from 1086 consecutive patients were subjected to coronary artery bypass grafting (CABG) between 2000 and 2009. All selected patients were divided either into group liner or patch according to the choice of the repair technique depended on factors such as localization, size and dimension of the scar. The patients also were divided either into group beating heart or cardioplegia. The pre-, intra- and postoperative relevant data of all selected patients were analyzed.ResultsThe mortality was not significantly different between linear and patch repair groups, also the actuarial survival rates within 24 months (p= 0.529). Postoperative echocardiographic findings showed significant improvements in left ventricular function in both groups. The beating heart technique reduced postoperative peak release by 27% for Cardiac troponin I (cTnI) compared with the cardioplegia group (0.46 ± 0.06 ng/mL versus 0.63 ± 0.09 ng/mL, p= 0.004), and increased the perioperative survival by 9% (97.2% versus 88.5%), but the actuarial survival rates were not significantly different between the groups from 2 to 24 months (p= 0.151).ConclusionsBoth techniques (linear and patch) achieved good results with respect to mortality, functional status and survival. The choice of surgical technique should be adapted in each patient. The beating heart technique may to some extent relieve myocardial injury in patients undergoing SVR.

Lessons from a mathematical hypothesis: modification of the endoventricular circular patch plasty

Lessons from a mathematical hypothesis: modification of the endoventricular circular patch plasty

Reply to Poullis

We read Dr Poullis’s letter addressing our article with great interest [1]. Firstly, we would like to clarify that our article was not meant to be a head-to-head comparison with the patients in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Our patients were significantly younger than the Western population comprising the STICH trial. This is due to the incidence of coronary artery disease at a younger age in the Indian population, due to various ethnic predisposing factors. Our patients mostly had single-vessel disease involving the Left Anterior Descending Coronary Artery (LAD), although some had two- and three-vessel disease. Those patients with multivessel disease received multiple grafts. The pathophysiology of left ventricular aneurysm has been seen in predominantly single coronary artery territory involvement [2], which may often be recanalized and therefore not requiring revascularization, with only resection of scar tissue and reshaping of the contractile myocardium providing adequate clinical benefit. The immediate and 30-day postoperative functional class has been mentioned in the table. The re-hospitalization for heart failure occurred at 9.2 1.2 months following surgery. The reasons for this were multi-factorial and related to associated pulmonary hypertension and renal dysfunction, and not to the surgical technique per se. Postoperatively, all patients were on maximally tolerated doses of beta-blockers, ace inhibitors, statins, aspirin, and diuretics. The dosages of diuretics and ace inhibitors, however, decreased significantly following surgery. We had centerline analysis of contrast ventriculography of all our patients before and after surgery. All our patients had discrete areas of dyskinesis/akinesis at baseline conforming to the definition of left ventricular aneurysm. Following surgery, there was a significant decrease in hypokinetic chords from 61.1 12.8 to 36.5 14.8 ( p < 0.001) [3]. This was in the anterior and anterolateral segments in anterior aneurysms and in the inferior and inferbasal segments of the inferior aneurysms. There was also a significant decrease in akinetic/dyskinetic chords from 32.5 11 at baseline to 25 8.1 following surgery ( p < 0.001). Here, the akinetic/ dyskinetic chords in the postoperative ventricle conformed to the intracavitary patch which remained akinetic. We agree with Dr Poullis that the success of surgical ventricular restoration (SVR) depends on the presence of discrete areas of akinesis/dyskinesis, conforming to scar tissue and definite areas of contractile myocardium. For patients with diffusely hypokinetic ventricles, the only option would be cardiac transplantation, if eligible. This has been adequately described in our article [4]. Our study follows Pocar et al. [5] in validating the surgical techniques resulting in a more ellipsoid ventricular geometry. Our left ventricular shape analysis also proved significantly better alignment of the contractile myocardial fibers in the anterior wall, which was not seen with endoventricular circular patch plasty [6]. In our patients, despite a postoperative decrease in left ventricular stroke volume, there was a significant clinical improvement as assessed by functional class, which cannot be attributed to decreased contractility. This has also been proved by our centerline analysis and shape analysis. The heart rate did not change significantly following surgery (baseline heart rate (HR): 84 3 beats per minute (BPM) to postoperative HR: 81 4 BPM). The phenomenon of decreasing stroke volume following SVR will be the subject of future study.

Volume reduction rate by surgical ventricular restoration determines late outcome in ischaemic cardiomyopathy

Surgical ventricular restoration (SVR) effectively reduces left ventricular (LV) volume in ischaemic cardiomyopathy (ICM), but the recent Surgical Treatment of Ischemic Heart Failure (STICH) Trial questions its importance. We report 8-year SVR experience in patients with ICM. Between 2000 and 2008, 135 patients underwent SVR for ICM. This report analyses data from 90 patients who underwent accurate pre- and post-operative assessment of LV volumes by left ventriculogram or scintigram. All patients also had echocardiograms. Pre-operative LV end-systolic volume index (ESVI) was 123.5 ± 53.2 mL/m(2) (range 92-310). Overall, 63 patients were in NHYA class III and 27 were in class IV. The SVR procedure was endoventricular circular patch plasty in 33 patients, septal-anterior ventricular exclusion in 43, and 14 patients had posterior exclusion. Coronary artery bypass grafting was performed in 78 patients (87%) and 50 underwent mitral procedures. Eighteen follow-up late deaths occurred owing to chronic heart failure (n = 12) and sudden death (n = 6). Post-operative ESVI was < 90 mL/m(2) (Group-S) in 54 patients, 90-120 mL/m(2) (Group-M) in 16, and >120 mL/m(2) (Group-L) in 20 patients. The 8-year survival rate was 82.4% in group-S following a > 33% LV volume reduction. In contrast, in Group-M and Group-L, the volume reduction was ∼ 15%, and 100% of patients died within 7 years following the SVR procedure (or 0% 8-year survival). SVR is most effective when a >33% volume reduction rate achieves an ESVI of < 90 mL/m(2). No long-term benefits occur when SVR induces an LV volume reduction of < 15% leaving a residual ESVI >90 mL/m(2). This database contradicts the STICH trial findings.

Lessons from a mathematical hypothesis — modification of the endoventricular circular patch plasty

Surgical ventricular restoration has been the bailout therapy for end-stage heart failure due to ischemic cardiomyopathy in patients not suitable for cardiac transplantation. The recently concluded STICH trial has stated that surgical restoration of the left ventricle does not benefit this subgroup of patients clinically as compared with revascularization alone. The reasons for failure of this trial are multifactorial. The technique of surgical ventricular restoration employed in the STICH trial was circular endoventricular patch plasty. The various drawbacks related to this technique can be offset by a modification based on a mathematical hypothesis, which should result in a more physiological ventricular geometry, with consequent late reverse remodeling and improved left-ventricular performance. A total of 54 consecutive patients out of 102 patients with post-infarction left-ventricular aneurysms were studied before and 2 years after surgical ventricular restoration by linear endoventricular patch plasty using two-dimensional (2D) echocardiography and contrast ventriculography. Linear endoventricular patch plasty resulted in a decrease in end-diastolic volume (EDV) of 40.2 ml (95% confidence interval (CI): 33.6, 46.7) and stroke volume (SV) of 10.0 ml (95% CI: 6.6, 13.5) and increase in ejection fraction (EF) of 6.7% (95% CI: 5.5, 7.9). There was a further 14% decrease in EDV and SV (30%) at 2 years with increase in EF (20%). There was a persistent significant improvement in sphericity index. The changes in EDV and SV were linearly related (r=0.72, p<0.001) and persisted at 2 years following surgery. The change in EDV was linearly related to the EF (r=0.35, p=0.02). The left-ventricular shape analysis showed improvements in the anterior and anterolateral segments (effect size=1.1, p<0.001) with nonsignificant changes in the inferior segments, conforming to an ellipsoid geometry. Linear endoventricular patch plasty restored a physiological elliptical ventricular geometry with persistent late reverse remodeling. The decreases in EDVs following surgery were significantly linearly proportional to the decreases in SVs at rest, which conforms to the normal left-ventricular geometry.

Left Ventricular Aneurysm Using the Dor Technique: Mid-term Results

We have retrospectively analyzed the early and the mid-term results of the operations for modified endoventricular circular patch plasty for left ventricular aneurysm (LVA) repair in our clinic. Sixty-seven cases with anterior LVA were included in the study. Mean age of the patients were 64.8 +/- 8.9 (ranged from 51 to 74) years. Fifty-three patients were male and 14 female (M:F = 3.8). Preoperative left ventricular ejection fraction (LVEF) was 30.8% +/- 4.5%, LV end-diastolic diameter (LVEDD) 6.0 +/- 1.9 cm, and end-systolic diameter (LVESD) was 4.6 +/- 0.8 cm in average. Coronary revascularization was performed in 61 patients and mitral ring annuloplasty in five patients. Thirty-day mortality was 5.9%. The surviving 63 patients were followed up for 4.3 +/- 2.3 years on average (ranged from 0.2 to 8.5 years), adding up to 267.8 patient/years. In the immediate postoperative and long-term follow-up, there was a significant improvement in LVEF, LVESD, LVEDD, and mitral valvular function. Four patients died in the follow-up with only a single patient due to cardiac causes. The five years survival was 87.7% +/- 4.1% and the freedom from cardiac death was 98.2% +/- 1.7%. LVA repair with Dor procedure can be performed with low mortality. With appropriate repair of LVA and coronary revascularization, patients may have benefit both for survival and also for clinical status.

Resizable Ventricular Patch Plasty in the Porcine Left Ventricle a Pilot Study

: Endoventricular circular patch plasty is a method used to reconstruct the ventricular cavity in patients with (post) ischemic left ventricular aneurysm or global dilatation. However, late redilatation with mitral regurgitation has been reported, in which postoperative apex shape seems to play an important role. We studied the feasibility of ventricular volume downsizing with a variably shaped patch in porcine hearts. : In five in vitro and two acute animal experiments, a dyskinetic aneurysm was simulated with a pericardial insert. Reducing patch surface by changing patch shape diminished end-diastolic volume. In vitro, static end-diastolic volume was determined for each patch shape using volumetry and echocardiography. In the acute animal experiments, preliminary observations of patch behavior in live material were made, and pressure/time relationship, dPdTmax, was registered. : In vitro, bringing the convex patch into a flat plane reduced LV volume from 66 ± 7 mL (aneurysm) to 49 ± 5 mL. Four of 5 patch shapes further reduced volume to a mean of 38 ± 7 mL (P = 0.03). The in vitro echocardiographic measurements correlated with volumetry findings (r = 0.81). In the acute animal experiments, dPdTmax varied with patch shape, independent of volume changes. : In this pilot study, in vitro shape configuration of the resizable ventricular patch resulted in a calibrated end-diastolic volume reduction. The data of the two in vivo pilot experiments clearly indicate that change in patch configuration in the situation of more or less unchanged end-diastolic volume had impact on cardiac performance. Future studies must substantiate the results of this observation.

Left Ventricular Aneurysm in a Child With Severe Combined Immunodeficiency Syndrome

We describe the case of a 23-month-old girl with combined immunodeficiency syndrome and a left ventricular aneurysm. Due to the size of the aneurysm and development of an intramural thrombus, repair was performed after confirmation of bone marrow transplant engraftment. Endoventricular circular patch plasty (Dor procedure) was performed, with excellent outcome and normalization of ventricular geometry and function.

Balloon sizing in surgical ventricular restoration: What volume are we targeting?

Surgical ventricular restoration (SVR) by endoventricular circular patch plasty was described by Dor and colleagues as a new approach to treat patients with left ventricular (LV) aneurysm. Over time, this technique was optimized, and most centers currently use an intraventricular balloon to standardize volume and shape of the residual cavity. During SVR, the left ventricle is opened through the infarct, and an endocardial encircling suture (Fontan stitch) is placed at the transitional zone between scarred and normal tissue. Next, the balloon is introduced into the left ventricle and filled with 50 to 60 mL saline per square meter of body-surface area. The Fontan stitch is tightened to approximate the ventricular wall to the balloon, and the residual orifice is closed with a patch. Subsequently, the excluded scar tissue is closed over the patch to ensure hemostasis. The guiding principle behind this operation is the concept that SVR reduces wall stress (according to Laplace’s law) leading to reduced oxygen demand and improved function of the healthy remote myocardium. The balloon technique is generally considered to produce more consistent and more predictable results with improved clinical outcome. One of the first papers to describe balloon sizing mentioned that the balloon was inflated to check that the new LV diastolic volume was between 50 and 70 mL/m. Recently, Dor and associates reported a tighter range of 50 to 60 mL/m and explained that the balloon should help to avoid excessive volume reduction, which might cause impaired diastolic function and restrictive cardiomyopathy. The technique is referred to as ‘‘diastolic volume balloon sizing,’’ but the basis for selecting this specific target volume range was not explicitly mentioned. To put the values in perspective, recent magnetic resonance imaging studies indicate a normal end-diastolic volume index (EDVI) of 74 15 mL/m in men and 65 11 mL/m in women with, respectively, 25 9 mL/m and 18 5 mL/m for indexed end-systolic volume (ESVI). Furthermore, a 20% increase in EDVI after myocardial infarction is considered to indicate remodeling, and an ESVI>60 mL/m is associated with advanced

Surgical Treatment of Ischemic Heart Failure

Despite the improvements in the treatment of myocardial infarction that have translated into a decline in mortality rates, the incidence of heart failure has increased and, because of the limited number of cardiac donors, non-transplant heart surgery has developed in the past 10 years. Surgical ventricular reconstruction was launched by Dor and defined as endoventricular circular patch plasty repair. It represents a relatively novel surgical approach aiming to restore (bring back to normal) the dilated, distorted left ventricular (LV) cavity in order to improve function. The term ;surgical ventricular reconstruction/restoration' includes operative methods that reduce LV volume and restore its shape. The concept of reducing wall stress through surgical restoration of chamber size and geometry remains the guiding principle behind this innovative technique. Results from different Institutions are uniform and show an improvement in cardiac and clinical status and in survival. The present review will approach the rationale to re-shape the heart on the basis of pathophysiology and cardiac architecture, and will describe the efficacy of the Dor procedure in ischemic dilated cardiomyopathy, as well as some technical aspects and patient selection pathway.

Patch size, shape and orientation affect geometrical outcomes of surgical anterior ventricular restoration

To verify whether the use of a small, oval-shaped patch limits the trend toward re-dilatation compared to endoventricular circular patch plasty and leads to different geometrical and functional results in surgical anterior restoration. Thirty-seven patients with ischemic cardiomyopathy after anterior myocardial infarction end-systolic volume index of > or =45 ml/m2, ejection fraction of < or =35%, and no combined mitral procedures, underwent surgical anterior ventricular restoration between January 2000 and April 2003: 18 patients (group 1) were operated on using the endoventricular circular patch plasty technique (mean patch area 9.6 cm2) and 19 patients (group 2) received a small, obliquely oriented, oval-shaped patch (mean patch area 6.2 cm2). Ten geometrical parameters were studied preoperatively and at least 6 and 12 months after surgery. Data were analyzed using repeated-measures ANOVA, chi2, paired and unpaired Student's t-test, and binary logistic regression. Group 1 showed a worsening over time in systolic and diastolic longitudinal length, end-diastolic volume (P < 0.001), end-diastolic volume index (P = 0.006), end-systolic volume (P = 0.005), and end-systolic volume index (P = 0.03). Group 2 showed an improvement in percentage of akinesia and wall motion score index (P < 0.001) and a worsening only in end-systolic diameter (P = 0.03) and end-diastolic volume (P = 0.04). At 12-month follow-up, ANOVA revealed that the oval patch positively influenced end-diastolic volume (P = 0.03), end-systolic volume (P = 0.03), and end-systolic volume index (P = 0.05), and group 2 had a significantly higher number of patients with an end-systolic volume index of <45 ml/m2 (P = 0.01). The use of a small, narrow, obliquely oriented, oval patch may help to prevent adverse ventricular remodeling over time.