Left Ventricular Reconstruction Research Articles

Genetic Variants Are Not Associated with Outcome in Patients with Coronary Artery Disease and Left Ventricular Dysfunction: Results of the Genetic Substudy of the Surgical Treatment for Ischemic Heart Failure (STICH) Trials

Objectives and Background: We evaluated the ability of 23 genetic variants to provide prognostic information in patients enrolled in the Genetic Substudy of the Surgical Treatment for Ischemic Heart Failure (STICH) trials. Methods: Patients assigned to STICH Hypothesis 1 were randomized to medical therapy with or without coronary artery bypass grafting (CABG). Those assigned to STICH Hypothesis 2 were randomized to CABG or CABG with left ventricular reconstruction. Results: In patients assigned to STICH Hypothesis 2 (n = 714), no genetic variant met the prespecified Bonferroni-adjusted threshold for statistical significance (p < 0.002); however, several variants met nominal prognostic significance: variants in the β₂-adrenergic receptor gene (β₂-AR Gln27Glu) and in the A₁-adenosine receptor gene (A₁-717 T/G) were associated with an increased risk of a subject dying or being hospitalized for a cardiac problem (p = 0.027 and 0.031, respectively). These relationships remained nominally significant even after multivariable adjustment for prognostic clinical variables. However, none of the 23 genetic variants influenced all-cause mortality or the combination of death or cardiovascular hospitalization in the STICH Hypothesis 1 population (n = 532) by either univariate or multivariable analysis. Conclusion: We were unable to identify the predictive genotypes in optimally treated patients in these two ischemic heart failure populations.

0141: Value of cardiac magnetic resonance imaging to predict the occurrence of ventricular tachycardia in post-infarct patients

The use of implantable cardioverter-defibrillators (ICD) is recommended to prevent sudden cardiac death (SCD) in patients with a reduced (≤30-35%) left ventricular ejection fraction (LVEF) due to previous myocardial infarction (MI). Some patients, however, never receive adequate ICD intervention. We studied whether the characteristics of MI scar, as assessed by magnetic resonance imaging (MRI), could predict the occurrence of ventricular tachycardia (VT). Fifty-one patients (41 men, mean age=59±11 years) with a remote (>6 months) MI and a class I primary prevention indication for ICD implantation underwent a cardiac MRI study before implantation. Delayed contrast enhancement (DCE) was used to delineate post-MI scars.On the basis of manually outlined contours of left ventricular epicardial, endocardial and scar borders, the location and transmural extent of the scar were calculated. VT occurred in 15 patients (29%) after a follow-up of 43±24 months. There were no statistical differences between patients who experienced VT and those who did not for demographic data, LVEF, total myocardial and MI surface. At infarct borders, MRI showed areas with intramural and/or epicardial scar in all but one patients. Epicardial scar surface (3.6±0.5 vs. 1.4±0.3 cm2; p=0.0005) and intramural scar surface (4.0±0.6 vs. 1.8±0.4 cm2; p=0.002) were greater in patients with VT. In multivariate analysis, intramural and sub-epicardial scar surface remained significantly associated with the occurrence of VT (respectively: HR, 1.28/1cm2; CI, 1.10 to 1.51; p=0.003 and HR, 1.23/1cm2; CI, 1.01 to 1.51; p=0.04). Patients with intramural scar surface>1.65 cm2 had lower 5 years VT free survival (33.8% vs. 100%; p<0.0001). The presence of a critical surface of both intramural and epicardial scars at an infarct border may be key factors for the occurrence of VT after MI. Abstract 0141 - Figure: 3D left ventricular reconstruction

Impact of Surgical Ventricular Restoration on Cardiac Function, Ischaemic Mitral Regurgitation and Long-term Survival

Objectives: Adverse cardiac remodelling is a major cause of morbidity and mortality post myocardial infarction. The role of surgical ventricular restoration compared to medical and electrophysiological treatments has recently come under intense scrutiny. We aimed to evaluate 10-year clinical outcomes of surgical ventricular restoration in our institution. Methods: From January 2001 to 2011, surgical ventricular restoration was performed in 126 consecutive patients (M2.3: 1F), mean age 65.5 (44-86) years. All patients presented with angina, heart failure and/or ventricular tachycardia. Post-infarction left ventricular aneurysm was present in all patients and ischemic dilated cardiomyopathy with a large akinetic left ventricle in 11.6%. The preoperative left ventricular ejection fraction was 33.1 ± 8.9%. Multi-vessel disease was present in 117/126(93%) patients. Mitral regurgitation more than grade+2 was found in 39/126(31%). The mean Logistic EuroSCORE was 13.8 ± 5.9%. A minimum of two-year post-operative follow-up was obtained on all patients. Results: Most patients underwent endoventricular or elliptical patch repair; 94% had concomitant coronary revascularisation with a median of 2 grafts and 5% had mitral valve repair. Intra-aortic balloon pump was placed preoperatively in 24/126 (19%) patients while 21/126 (17%) needed inotropic support for more than 24 h. Postoperative stroke occurred in 2 patients. In-hospital mortality was 7/126 (5.5%). All cause cardiovascular mortality at ten years was 12/126 (9.5%). Mean follow-up in operative survivors was 8.2 ± 1.2 years. Actuarial survival was 95.3%, 90.6%, 86.3% and 79.1% at 1-month, 1, 5 and 10-years. Echocardiographic follow-up demonstrated a reduction in the mean left ventricular end-diastolic volume and left atrial diameter. Ejection fraction improved over first year from 33.1 ± 8.9 to 45 ± 8.6% (P<0.006). Conclusions: Left ventricular reconstruction surgery is a good surgical option for treatment of post-infarction left ventricular aneurysm.

0300: Relationship between spatial scar characteristics assessed by cardiac magnetic resonance imaging and cycle length of monomorphic ventricular tachycardia in post-infarct patients

We have previously demonstrated that the spatial characteristics (intramural and epicardial components) of MI scar predicts the occurence of monomorphic ventricular tachycardia (MVT) after a myocardial infarction (MI). We studied whether MI scar characteristics, as assessed by magnetic resonance imaging (MRI), was related to the minimum cycle lenght(mCL) of MVT. We studied 50 patients (43 men, mean age 60±13 years) with previous MI, cardiac MRI study, primary (n=12) or secondary prevention indication of implantable cardiac defibrillator (ICD) and who experienced MVT. Delayed contrast enhancement (DCE) was used to delineate post-MI scars. MVT occurred 15±9 years after MI and the mCL was 303±49ms. MRI showed areas with intramural and/or epicardial scar (adjacent to areas showing endocardial or transmural scar) in all patient. Patients were classified depending on the median of the mCL (300ms). There were no statistical differences between the 2 groups for: gender, medication, indication of ICD, history of coronary artery revascularization, infarct location and for the following MRI parameters: left ventricular (LV) ejection fraction, LV end-diastolic volume, LV mass, total myocardial surface, total MI scar surface, transmural, endocardial or epicardial MI scar surface. In patients with a mCL>300ms, there was a trend for older age at first MVT episode (64±2 vs. 57±3 year; p=0.06) and a greater intramural scar surface (5.8±3.7 vs. 2.9±1.6cm 2 ;p=0.002). Age (r=0.32; p=0.02) and intramural scar surface (r=0.47; p<0.001)were associated with the mCL. After multiple linear regression, age and intramural scar surface remained significantly associated with the mCL (respectively: P=1.3±0.6; p=0.03 and P=6.5±2; p=0.003). Our study suggests that the mCL of MVT may be related to age and to the intramural MI scar surface at the infarct border (figure next page). Abstract 0300 – Figure: 3D left ventricular reconstructions

Devices in heart failure--the new revolution.

Heart failure is a growing epidemic, with more patients living longer and suffering from this disease. There is a growing segment of patients who have persistent symptoms despite pharmacologic therapy. In an era when transplants are rare, the need for devices and interventions that can assist ventricular function is paramount. This review goes through the devices used in heart failure, including left ventricular reconstruction, aortic counterpulsation, short-term mechanical circulatory support, long-term mechanical circulatory support, and right heart interventions.

Cellular automata-based left ventricle reconstruction from magnetic resonance images

Despite advanced medical imaging technologies being available, image segmentation still continues to represent a major bottleneck in practical applications due to high noise level and lack of contrast. This paper presents a semi-automatic algorithm that uses stochastic resonance as a pre-processing step for enhancing the contrast of input magnetic resonance (MR) images followed by a cellular automata (CA)-based mechanism for surface reconstruction of the left ventricle (LV) from a few selected MR slices. The main contribution, in this work, is a new formulation for preventing the CA method to leak into surrounding areas of similar intensity. Another contribution is the use of level sets for segmenting the rest of the slices of a subject automatically between the selected slices segmented by the CA to build the LV surface. Both qualitative and quantitative evaluations performed on York and MICCAI Grand Challenge workshop database of MR images show promising segmentation accuracy when compared with the ground truth, reflecting the potential of the proposed method.

Left Ventricle Postinfarction Pseudoaneurysm: Anatomical Forms and Surgical Management

Introduction: Left Ventricle Postinfarction Pseudoaneurysm (LVPS)—false aneurysm occurs after a free-wall rupture contained by the adjacent pericardium. LVPS lacks the normal structure of the ventricular wall and disrupts the normal chamber anatomy. However, the natural history, clinical presentation and surgical outcome are still unclear. For that reason, it is necessary to describe the most relevant anatomical characteristics of LVPS and the appropriate surgical strategies currently applied. Methods: We reviewed the anatomical characteristics of several patients diagnosed of LVPS and the surgical technique performed. In this work two different anatomical types of LVPS are described in detail, with the surgical and structural implications for left ventricle reconstruction. Results: There are two different anatomical forms of LVPS: 1) Typical pseudoaneurysm, with a small gateway neck between the Left Ventricle and the false aneurysm chamber (Figure 1(A)); 2) Atypical pseudoaneurysm, in which the anatomical defect is bigger, without well-defined edges, extends over a large segment of infarcted and thinned myocardial tissue. In both cases, the therapeutics targets and the surgical techniques used were directed to restore the normal geometry of Left Ventricle, keeping the optimal mitral valve function. Conclusions: The surgical key-step is to preserve or to remodel the ventricular chamber anatomy. This fact restores the ventricular geometry, not only removing the wall discontinuity that generated the pseudoaneurysm. Nevertheless, final prognosis depends on the underlying ischemic cardiomyopathy and mechanical complications, such us mitral regurgitation or ventricular septal defect.

Geometric adaption of biodegradable magnesium alloy scaffolds to stabilise biological myocardial grafts. Part I

Synthetic patch materials currently in use have major limitations, such as high susceptibility to infections and lack of contractility. Biological grafts are a novel approach to overcome these limitations, but do not always offer sufficient mechanical durability in early stages after implantation. Therefore, a stabilising structure based on resorbable magnesium alloys could support the biological graft until its physiologic remodelling. To prevent early breakage in vivo due to stress of non-determined forming, these scaffolds should be preformed according to the geometry of the targeted myocardial region. Thus, the left ventricular geometry of 28 patients was assessed via standard cardiac magnetic resonance imaging (MRI). The resulting data served as a basis for a finite element simulation (FEM). Calculated stresses and strains of flat and preformed scaffolds were evaluated. Afterwards, the structures were manufactured by abrasive waterjet cutting and preformed according to the MRI data. Finally, the mechanical durability of the preformed and flat structures was compared in an in vitro test rig. The FEM predicted higher durability of the preformed scaffolds, which was proven in the in vitro test. In conclusion, preformed scaffolds provide extended durability and will facilitate more widespread use of regenerative biological grafts for surgical left ventricular reconstruction.

A historical overview of the left ventricular reconstruction

Over the past 3 decades, several observational studies established a role for the left ventricular reconstruction procedure (LVR) in the treatment of ischemic cardiomyopathy. In 2009, the Surgical Treatment for Ischemic Heart Failure (STICH) trial reported their findings and found no benefit of adding LVR to coronary artery bypass surgery in ischemic dilated cardiomyopathy. The STICH findings precipitated a decline in interest in LVR. In the presentation, I review the historical background and observational data that established a role for LVR. The STICH trial should be contended that the limitations are such that the study cannot provide any reliable conclusion on the role of SVR because of suboptimal patient selection and inadequacy of volume reduction (only19% mean reduction in volume). Several post-STICH publications continue to demonstrate that LVR is effective in dilated ventricles, provided the procedure achieves >30% volume reduction. It is critical that surgeons continue their work in LVR, and continue to analyze their data, to enable better clarification of the indications and future role for this procedure.

GW24-e3975 Plasma brain natriuretic peptide lever between dynamic blood pressure and left ventricular hypertrophy in elderly hyperension

ObjectivesTo study the relationship between parameters of 24 hour dynamic blood pressure (BP) and plasma brain natriuretic peptide and left ventricular hypertrophy in elderly Hyperension patients.MethodsAmbulatory BP monitoring (ABPM) for...

An unusual complication of infective endocarditis: left ventricular outflow tract perforation

A 24-year-old female was admitted to our hospital complaining of fever, chest pain, cough and dyspnoea. Physical examination revealed tachycardia with heart rate 115 bpm, dull and decreased respiratory sounds in the lower left lung field, systolodiastolic murmur at the aortic and mesocardiac area. Chest X-ray showed an increased cardiothoracic ratio and left-sided pleural effusion. The erythrocyte sedimentation rate was found to be 64 mm/h. Echocardiography revealed moderate aortic insufficiency. Pathological flow was detected at left ventricular outflow tract (LVOT) by Doppler imaging. LV free wall was seen to be compressed partially by the haematoma surrounding the heart. Chest computed tomography (CT) showed the perforation at LVOT, partial compression of LV lateral wall, main pulmonary artery, superior vena cava, and nearly complete obstruction of left pulmonary veins (Figs. 1–3). The patient underwent emergent cardiac surgery. A pseudoaneurysm sac was detected starting from the lateral side of the aorta extending through transverse sinus and including the left anterior descending coronary artery region. Aortotomy was performed. The aortic valve was detected to be bicuspid. A perforation with a diameter of 10 × 15 mm was seen just below the aortic valve (Fig. 4). The perforation was repaired with a dacron graft, and aortic valve replacement was performed. The pathological examination revealed inflammation and vegetation at the sample taken from the perforation region, which demonstrated that the aetiology of perforation was mural infective endocarditis. Mural endocarditis is an inflammation and disruption of the nonvalvular endocardial surface of the cardiac chambers. Mural endocarditis may develop on LVOT secondary to chronic aortic regurgitation due to chronic endocardial trauma. Traumatised endocardium provides a nidus for the development of bacterial vegetation. It is well known that inflammation and vegetation may cause destructive lesions and perforation usually affecting valves, and result in acute valvular regurgitation, or may result in fistula formation. But myocardial perforation and pseudoaneurysm formation has rarely been reported. Excision of the pseudoaneurysm with LV reconstruction should be the treatment of choice in patients presenting with myocardial perforation and pseudoaneurysm formation.

Prognostic Significance of Biomarkers in Predicting Outcome in Patients With Coronary Artery Disease and Left Ventricular Dysfunction

Background— Patients with heart failure and coronary artery disease often undergo coronary artery bypass grafting, but assessment of the risk of an adverse outcome in these patients is difficult. To evaluate the ability of biomarkers to contribute independent prognostic information in these patients, we measured levels in patients enrolled in the biomarker substudies of the Surgical Treatment for Ischemic Heart Failure (STICH) trials. Patients in STICH Hypothesis 1 were randomized to medical therapy or coronary artery bypass grafting, whereas those in STICH Hypothesis 2 were randomized to coronary artery bypass grafting or coronary artery bypass grafting with left ventricular reconstruction. Methods and Results— In substudy patients assigned to STICH Hypothesis 1 (n=606), plasma levels of soluble tumor necrosis factor-α receptor-1 (sTNFR-1) and brain natriuretic peptide (BNP) were highly predictive of the primary outcome variable of mortality by univariate analysis (BNP: χ 2 =40.6; P &lt;0.0001 and sTNFR-1: χ 2 =38.9; P &lt;0.0001). When considered in the context of multivariable analysis, both BNP and sTNFR-1 contributed independent prognostic information beyond the information provided by a large array of clinical factors independent of treatment assignment. Consistent results were seen when assessing the predictive value of BNP and sTNFR-1 in patients assigned to STICH Hypothesis 2 (n=626). Both plasma levels of BNP (χ 2 =30.3) and sTNFR-1 (χ 2 =45.5) were highly predictive in univariate analysis ( P &lt;0.0001) and in multivariable analysis for the primary end point of death or cardiac hospitalization. In multivariable analysis, the prognostic information contributed by BNP (χ 2 =6.0; P =0.049) and sTNFR-1 (χ 2 =8.8; P =0.003) remained statistically significant even after accounting for other clinical information. Although the biomarkers added little discriminatory improvement to the clinical factors (increase in c -index ≤0.1), net reclassification improvement for the primary end points was 0.29 for BNP and 0.21 for sTNFR-1 in the Hypothesis 1 cohort, and 0.15 for BNP and 0.30 for sTNFR-1 in the Hypothesis 2 cohort, reflecting important predictive improvement. Conclusions— Elevated levels of sTNFR-1 and BNP are strongly associated with outcomes, independent of therapy, in 2 large and independent studies, thus providing important cross-validation for the prognostic importance of these 2 biomarkers.

Post myocardial infarction left ventricular dysfunction – Assessment and follow up of patients undergoing surgical ventricular restoration by the endoventricular patchplasty

Authors of this important article by D'Mello et al, have nicely presented a prospective study of clinical and echocardiographic follow up of Left Ventricular (LV) geometry of 59 consecutive patients with previous transmural anterior myocardial infarction, who underwent LV restoration, analyzed between June 2007 and May 2008.1 The authors are to be complemented for this important series which showed excellent immediate and short-term results following LV restoration surgery. The results show a progressive remodeling after ventricular reconstruction mainly by excluding the scar area. Volume reduction is more important than the post surgical shape of the ventricle. The study was done before the MRI era; and hence the images of the scar are not demonstrated in the study.2,3 Analysis of the precise mechanism of remodeling is perhaps not possible without MRI. Distinction between dyskinetic and akinetic forms of the scar are not clearly brought out; it is usually transmural with dyskinesia and subendocardial with akinesia. The size of a synergy and its extension determine the extent of remodeling.4,5 It is surprising that these 59 patients were not severe cases of ischemic failing ventricle, as the mean ejection fraction was 33.5 ± 5%, preoperative end diastolic volume index 89.7 ± 6 and end systolic volume index 48.8 ± 11.3 which are below the threshold of very severe cardiac failure. White et al have given a figure of >60 ml of end systolic volume index as the major determinant of survival after recovery from myocardial infarction.6 This work is indeed of great interest and I hope the authors with their experience will present more severe cases showing a positive interest in LV reconstruction and thereby demonstrating that the S.T.I.C.H trial was a miss organized trial.7 The global approach of heart failure by Buckberg cannot be accepted; it is apparent that Buckberg is a prisoner of his “flying fancies” trying to establish something without any serious base.7 The myocardial systolic contraction is a “twist up” like a “snake” ascension. The crux of the problem of systolic heart failure is the ventricular spherical dilatation whatever be the anatomic substrate. The surgical ventricular restoration (S.V.R) or surgical anterior ventricular restoration (S.A.V.R) are acronyms in place of left ventricular reconstruction (L.V.R.) because this technique is applied most of time only for anterior LV wall, with the objective of “volume reduction” and to get an elliptical shape of LV. Finally, I would like to emphasize the following points: Ventricular wall has a systolic concentric (centripetal contraction) confirmed by MRI video examination of left ventricular wall in 4 projections.8 Heart failure is not an entity but a syndrome with various causes; in post myocardial infarction failure, the cause is an extension of the necrotic, then fibrous and finally calcified transmural or subendocardial scar, when it reaches = or <30% of LV perimeter. The dilatation is not the cause, but the consequence; dilatation is more ovoid than spherical. LVR as proposed by as in 1984, have these main goals: to suppress or exclude the scarred asynergic wall, to abolish the mechanism of progressive dilatation i.e. the eccentric systolic motion, restoring the curvature of non-infarcted myocardium and maintain the physiological diastolic volume of the rebuilt cavity by balloon sizing before “clothing” of the cavity by a patch anchored on contractile edge of normal myocardium.9 In conclusion, this article by D'Mello et al demonstrates and emphasizes the modern approach toward post myocardial infarction heart failure which is a very prevalent disease encountered in day to day clinical practice.

Left ventricular reconstruction: update to left ventricular aneurysm/reshaping techniques

The increase in left ventricular (LV) volume after a myocardial infarction (MI) is a component of the remodelling process and is associated with a poor clinical outcome. Hence, the current management strategy for ischaemic LV dysfunction has been aimed at reversing the remodelling process. Surgical LV reconstruction (LVR) has been introduced as an optional therapeutic strategy aimed at reducing LV volumes through the exclusion of the scar tissue, thereby restoring the physiological volume and shape and improving LV function and clinical status. Until recently, several studies have shown that surgical LVR is effective and relatively safe, with a favourable 5-year outcome. However, in spite of the large amount of reports drawn on various data sets, the additional benefit of LVR to CABG remains debated. We briefly discuss the rationale for surgically reversing LV remodelling through LVR, and, more extensively, the technique and the indications to the best of our knowledge.

Postmyocardial infarction left ventricular dysfunction – Assessment and follow up of patients undergoing surgical ventricular restoration by the endoventricular patchplasty

Surgical ventricular restoration with endoventricular patchplasty improves left ventricular function and restores left ventricular shape. The study included patients who presented with transmural anterior myocardial infarctions between June 2007 and May 2008. Briefly the technique included - coronary revascularization, resection of the endocardial scar, left ventricular reconstruction using an endoventricular synthetic patch. Left ventricular geometric parameters were studied preoperatively, early postoperatively, at 3 and 6 months and statistically analyzed by SPSS 14 software package. The ejection fraction increased from 33.5 ± 5.02 to 37.77 ± 7.17 immediate postoperatively. The preoperative left ventricular ejection fraction - a mean of 33.25% (±5.02%), increased by 10.3%-11% at the third and fourth follow up respectively after surgical ventricular restoration (p ≤ 0.001). The left ventricular end systolic volume index improved from a mean of 48.84 ± 11.37 preoperatively to 24.66 ± 5.92 postoperatively (p ≤ 0.001). Surgical ventricular restoration in our study has clearly demonstrated a positive effect on LV geometry.

Long-term results and mid-term features of left ventricular reconstruction procedures on left ventricular volume, geometry, function and mitral regurgitation

We retrospectively analysed the long-term results and mid-term features of the surgical procedures on left ventricular (LV) volume, geometry, function and mitral regurgitation (MR) in patients with ischaemic cardiomyopathy (antero-septal dominant) who underwent LV reconstruction (LVR). The LVR was mainly accomplished by the Dor procedure, modified by the Fontan stitch maintained by the base of the LV septum prior to the flattened-out elliptical patch closure. Other techniques such as the linear closure or septal anterior ventricular exclusion (SAVE) were used when indicated. Sixty patients were divided into three groups, undergoing LVR with the Dor procedure (n = 40), linear closure (n = 12) or SAVE (n = 8). The LV function, volume and sphericity (eccentricity index) were logged before the operation and 1 year after. Survivors (79% at 7 years) showed a significant improvement in the LV ejection fraction from 35.1 ± 8.1 to 43.5 ± 11.5% and NYHA status from 2.9 ± 0.7 to 1.3 ± 0.6. The LV end-systolic volume index was significantly reduced from 110.3 ± 35.9 to 57.8 ± 20.7 ml/m(2) in the Dor, from 71.9 ± 10.3 to 52.9 ± 19.4 ml/m(2) in the linear closure and from 93.1 ± 14.5 to 47.9 ± 15.7 ml/m(2) in the SAVE group. The postoperative changes in the Dor group are characterized by the reduction in the significantly larger LV volume and a more spherical chamber (systolic eccentricity index from 0.82 ± 0.10 to 0.80 ± 0.09), although not significantly so compared with other techniques. The MR grade measured on echocardiography was reduced (from 1.9 ± 0.8 to 1.7 ± 0.8), with postoperative moderate MR in four Dor patients. Despite the more spherical LV change, LVR led to a significant volume reduction (45%), still maintaining its physiological shape that confirmed an improved LV function and better long-term results. The Dor procedure could significantly reduce the larger LV volume without losing the end-systolic elliptical shape and mitral valvular competence like other techniques without the Fontan stitch.

Outcomes of left ventricular reconstruction when established parameters are followed, and subsequent questions

The 2010 Task Force guidelines from the European Society of Cardiology/European Association of Cardiothoracic Surgery (ESC/EACTS) recommend ‘consideration of surgical ventricular restoration (SVR) to treat ischemic dilated cardiomyopathy, following measurement of ventricular volume and assessment of myocardial scar in centers with high experience’ [1]. This issue contains a report by Cho et al. [2] concerning ‘Long-term results and mid-term features of left ventricular reconstruction procedures on left ventricular volume, geometry, function and mitral regurgitation’ that amplifies the importance of surgical ventricular restoration (SVR) to architecturally remedy the failing hearts of patients with ischaemic dilated cardiomyopathy. Their superb results confirm how this procedure carries a very low perioperative mortality (1.6%), dramatically diminishes rehospitalization for cardiac causes over a 7-year interval and allows 79% long-term survival. These beneficial results are in concert with the broad number of world-wide SVR reports [3] and thus provide yet another contradiction to the flawed Surgical Treatment for Ischemic Heart Failure (STICH) study [4], whose misguided results have caused global curtailment of properly treating ischaemic dilated cardiomyopathy. Cho et al. precisely followed the benchmark SVR entry criteria of >60 ml/m left ventricular end-systolic volume index (LVESVI), >35% scarring of the left ventricle (LV) perimeter and achieved the requisite 40% reduction of ventricular volume to reduce the LVESVI of <60 ml/m. These SVR-induced changes show why LVESVI <60 ml/m is an independent predictor of prognosis [5], as the very low 7-year mortality ‘resulted from the natural events of neoplasm and infection’ rather than from pump failure or sudden death. These splendid results were similarly achieved by the Dor, linear closure and septal anterior ventricular exclusion (SAVE) procedures, yet each outcome was accompanied by creating a more spherical ventricle instead of the intended elliptical form. Confirmation of improved systolic performance was garnered from the increased systolic eccentricity index that indicated the smaller remote muscle contracted more efficiently as it became more helical during ejection. Moreover, late findings in patients with larger pre-SVR ventricular volumes showed the development of a 22% incidence of mitral regurgitation (MR), which parallels Di Donato’s report of 38% later mitral insufficiency in patients with even larger preoperative ventricular volumes [6]. These shape and MR change direct attention towards how the procedure execution influenced these findings, since Pocar recently pointed out the disadvantage of a more spherical chamber and functional MR [7].

Left ventricular pseudoaneurysm following aortic valve prosthesis endocarditis

A 63-year-old man underwent aortic valve replacement and an early reoperation for recurrent endocarditis. Sixteen months later he presented with persistent fever and a 64-slice computed tomography (CT) scan revealed a subannular left ventricular pseudoaneurysm. He underwent successful left ventricular outflow tract reconstruction and aortic valve prosthesis, partial root and ascending aorta replacement.

Surgical left ventricular radius enlargement by patch insertion on the beating heart: a new experimental aneurysm model

We presented a novel experimental aneurysm model for studies in left ventricular (LV) reconstruction techniques and assessed LV function. In eight pigs, the LV radius and geometry were enlarged surgically on the beating heart by inserting an aortic allograft construct. Haemodynamics and LV dimensions were assessed by echocardiography at baseline and under dobutamine stress. Surgery was successfully performed without lethal blood loss or arrhythmias. LV end-diastolic and end-systolic short-axis areas increased from 13.0 ± 1.7 to 17.0 ± 4.3 cm(2) (P = 0.001) and from 4.0 ± 0.9 to 13.0 ± 2.6 cm(2) (P = 0.001), respectively. Stroke volume decreased from 56 ± 11 to 33 ± 16 ml (P = 0.001). Incremental dobutamine infusion concurred with a biphasic response on fractional area shortening. Mitral valve insufficiency ranging from grades 2 to 4 was observed. In the pig, a novel, reproducible aneurysm model for acute cardiac dysfunction was created on the beating heart. Innovative (surgical) strategies for (staged) reconfiguration of the ventricle, e.g. adjustable Dor procedures and stepwise volume restraining cardiac support devices, can be tested for efficacy using this acute model.

Surgical approaches to left ventricular reconstruction: a matter of perspective

Surgical reconstruction of physiological shape and size of a postischemically remodeled left ventricle has been advocated to improve ventricular function and improve patient long-term outcome. What initially started as linear aneurysm resection surgery developed over the years into the endoventricular repair techniques (surgical ventricular reconstruction, SVR) that have also been applied in patients with postischemically dilated ventricles and mainly anterior akinesia. SVR improved function as measured by the ejection fraction. Whether it affects survival was finally tested in the largest surgical trial ever conducted, the STICH trial (Surgical Treatment for IsChemic Heart failure). The trial, however, presented rather sobering information with its Hypothesis 2 outcome by demonstrating identical 5-year survival rates between SVR plus bypass grafting (CABG) and CABG alone. SVR also did not improve quality of life. This neutral finding spawned a series of critical responses with respect to trial design and conduct accompanied by appropriate responses by the trial's leadership. At the end of this dispute, it appears that SVR has been accepted as not very useful for most patients and is less and less performed in daily practice. What remains is a series of different perspectives that will be discussed in this review. The conclusion will be that SVR may be of low value for the patient with dilated and massively remodeled ventricles, but the technique bears therapeutic potential for some patients for different reasons so that the surgeon's ability to perform this operation should not get lost.