Left Ventricular Reconstruction Research Articles

Left ventricle reconstruction and heartmate3 implantation. The "double patch technique".

HeartMate 3 is a left ventricular assist device, composed of a centrifugal pump. It can be applied as a myocardial recovery, a bridge to transplant, or a destination therapy, in the treatment of patients with left ventricular heart failure. Herein we describe a technique applied against a giant aneurysmal dilatation, which combines a surgical device implantation and a left ventricular reconstruction using a double patch. The patch minimizes thrombotic risk thanks to its internal bovine pericardium layer, which is in contact with blood. The outlined technique is relatively reproducible and safe in a selected group of patients, as it employs a high-quality device and enables the restoration of an appropriate ventricular geometry.

Preoperative contrast-enhanced magnetic resonance imaging in ischemic cardiomyopathy patients undergoing surgical left ventricular reconstruction

Purpose. The aim of this study was to identify the signifi cance of myocardial viability indicators calculated based on cardiac magnetic resonance imaging (MRI) with delayed contrast, as predictors of the adverse course of postoperative period in the surgical treatment of patients with ischemic cardiomyopathy.Material and Methods. A total of 178 patients underwent surgical treatment for ischemic cardiomyopathy from March, 2013 to December, 2017. All patients underwent preoperative cardiac MRI scan with paramagnetic contrast.Results. The logistic regression analysis showed that the left ventricular volumetric indicators and the amount of residual viable myocardium, calculated using delayed contrast-enhanced MRI, were the essential predictors of favorable and complicated course of postoperative period in ischemic cardiomyopathy patients. In patients with a residual viable left ventricular myocardium amount over 64.5%, surgical ventricular reconstruction procedure may be performed with a low risk of early postoperative complications (OR 8.25, 95% CI 1.45-46.8, p = 0.017).Conclusion. Cardiac MRI with delayed paramagnetic contrasting is a valuable method contributing to the preoperative identifi cation of a cohort of ischemic cardiomyopathy patients who can benefi t the most from surgical left ventricular reconstruction.

Clinical analysis of surgical treatment of post-infarction left ventricular aneurysm: a series of 254 patients

Objective: To examine the efficacy of two surgical procedures on post-infarction left ventricular aneurysm. Methods: The clinic data of 254 patients with post-infarction left ventricular aneurysm, who underwent surgical ventricular reconstruction between January 1997 and December 2019 in Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University was analyzed retrospectively. There were 183 males and 71 females aged from 31 to 81 years, with a median age of 64.6 years. Based on the size of the ventricular aneurysm, there were 73 patient received linear reconstruction (linear group) and 181 patients received endoventricular patch plasty technique (patch plasty group). Ejection fraction, left ventricular systolic and end diastolic volume and left ventricular systolic and end diastolic volume index were recorded preoperatively, 2-week, 3-month, 1-year and 5-year after operation. The survival curves were plotted with Kaplan-Meier method and the survival rates were compared by Log-rank test. Results: All patients underwent surgery with a mean cardiopulmonay bypass duration of (92±32) minutes (44 to 196 minutes) and aortic cross clamp duration of (67±22) minutes (33 to 152 minutes).There were 9 perioperative deaths with a mortality rate of 3.5%. Angina pectoris of other cases are relief and heart function improved greatly. Five years after operation, the percentage of cardiac function (New Yord Heart Association) class Ⅲ to Ⅳ patients decreased from 96.1%(244/254) to 9.9%(16/161). There was no significant difference in survival rate between linear group and patch plasty group at 1-, 3-, 5-years postoperatively (96%, 91%, 77% vs. 96%, 90%, 79%, P=0.562). Ejection fraction increased from (39±10)% (range: 22% to 50%) preoperatively to (46±6)% (range: 39% to 54%) 1-year postoperatively in the linear group, while increased from (38±13)% (range: 26% to 51%) preoperatively to (50±6)% (range: 39% to 55%) in the patch plasty group. Conclusions: Left ventricular reconstruction is quite effective for patients with post-infarction left ventricular aneurysm. The choice of operative approaches is determined by the size and range of ventricular aneurysm. Both linear reconstruction and endoventricular patch plasty technique can got similarly surgical outcomes with near and late curative effect.

557 Streptococcus Pneumoniae: A Rare Case of Fulminant Multivalvular Infective Endocarditis Presenting With Septic Arthritis

Streptococcus pneumoniae is an uncommon cause of native valve infective endocarditis in the post-antibiotic era. We present a rare case of disseminated s.pneumoniae infection presenting with septic arthritis, complicated by life-threatening Infective Endocarditis (IE). A 52 year old female presented to the emergency department (ED) with a painful swollen right knee two weeks after a fall. Fracture was excluded and a provisional diagnosis of ruptured Baker’s cyst was made. She re-presented by ambulance to ED two weeks later with fever, confusion and worsening knee swelling. Blood cultures and joint aspirate were positive for S. pneumoniae and joint washout was performed. On day 3 of admission, she deteriorated with hypotension, hypoxia and bilateral chest x-ray infiltrates requiring intubation and noradrenaline infusion. Bedside transthoracic echocardiogram on day 5 demonstrated a 1.5cm aortic valve vegetation with severe aortic regurgitation, aortic root abscess and mitral regurgitation. Transoesophageal echocardiogram confirmed severe endocarditis with aortic, mitral and tricuspid involvement, aortic root abscess and perforation of the interventricular septum and aorto-mitral curtain. She underwent emergency surgery with extensive debridement, ventricular septal defect closure, left ventricular outflow tract reconstruction, mitral and tricuspid valve repair, and mechanical aortic valve replacement. She required a pacemaker for postoperative atrioventricular block and has recovered completely. This report describes an unusual presentation of endocarditis caused by an uncommon and destructive pathogen, S. pneumoniae. It highlights the importance of early investigation for infective endocarditis in cases of bacteraemia with haemodynamic or respiratory compromise, even in pathogens uncommonly causing endocarditis.

Left ventricle reconstruction in patients with ejection fraction less than 30% and left ventricle aneurysm of the 2 and 3 type according to L. Menicanti classification improves the quality of life

Aim. To assess the quality of life (QOL) in patients with left ventricular reconstructions with an ejection fraction of less than 30%and left ventricle (LV) aneurysm of type 2 and 3 according to L. Menicanti. Materials and methods. The retrospective one-center study included 72 patients with left and right ventricular aneurysms of the second and third types according to the classification of L. Menicanti and an extremely reduced ejection fraction (less than 30%). The observation period was up to 33 months. The study included 61 (84%) men and 11 (16%) women, whose average age at the time of surgery was 58.2±9.2 years. All patients underwent LV reconstruction under CPB. Patients independently filled in the questionnaire before surgery. Repeated questionnaires were conducted no earlier than a year after the operation, in order to exc-lude the influence of possible complications associated with surgical access on the physical and mental health components. QOL was assessed using a standard SF-36 questionnaire. Results. According to the analysis, it was found that during the observation period of up to 33 months in patients, the "physical functioning" parameter is significantly lower than the initial value ( p =0.001). Also at a fairly high level the value of the indicator "body pain" is maintained, which is higher than the initial value ( p =0.001). According to other indicators, in patients with a low ejection fraction after reconstruction of the LV, an improvement in the QOL parameters was revealed. The mental and physical health of patients after reconstruction of the LV is significantly higher than the values before surgery. Results. Reconstruction of the LV in patients with LV aneurysm of type 2 and 3 according to L. Menicanti significantly improves the QOL of patients in such parameters as role-playing activity, general health, vitality, social functioning, emotional condition and mental health. A decrease in the indexed value of stroke volume of less than 23% is a predictor of a decrease in both physical and mental components of health.

Fractal Analysis of Cardiac Fibrosis Patterns Derived From Magnetization Transfer Contrast MRI in Patients With End-Stage Renal Disease.

OBJECTIVE. The purpose of this study is to use fractal analysis to characterize diffusely fibrotic, focally fibrotic, and healthy myocardium in patients with end-stage renal disease (ESRD) on the basis of previously published magnetization transfer (MT) contrast images. MATERIALS AND METHODS. The MT ratio values of patients with ESRD (n = 34) and healthy control subjects (n = 19) were used to construct anatomically faithful 3D left ventricular reconstructions. Established MT ratio threshold values were used to define healthy, diffusely enhanced, focally enhanced, and total enhanced tissue domains. The fractal dimension (FD) for reach domain was calculated using a 3D box-counting algorithm. RESULTS. Patients with ESRD showed a higher FD across all fibrotic domains compared with control subjects, in whom diffusely and focally enhanced myocardium showed largely planar distributions (mean [± SD] FD, 2.12 ± 0.02 and 1.92 ± 0.09, respectively), whereas the combined domain was fractal in 3D (mean FD, 2.41 ± 0.04). The FD and volume of fibrotic tissue were logarithmically correlated in the population with ESRD. Fractal analysis of MT-weighted cardiac MRI data revealed that the geometric characteristics of cardiac scar in patients with ESRD transition from fractal in 2D to planar in 2D to fractal in 3D as scar volume increases. CONCLUSION. Fatal arrhythmias in individuals with ESRD are increasingly attributed to cardiac fibrosis. Histologic analysis reveals that fibrosis progresses via a fractal expansion pattern. The method presented in this study can be applied to characterize the irregular space-filling morphometry of any pathologic substrate identified by contrast enhancement across noninvasive imaging modalities.

Outcomes After Left Ventricular Outflow Tract Reconstruction With a Tube Graft for Annular Erosion

Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement. This study examined the outcomes of a technique for left ventricular outflow tract reconstruction using a polyester tube graft, followed by translocation of the aortic valve and coronary arteries. A total of 23 patients with extensive annular erosion resulting from endocarditis or previous aortic valve replacement with or without pseudoaneurysm formation, or occurring after excision of the native valve, underwent suture of a polyester tube graft in the left ventricular outflow tract below the annulus, replacement of the aortic valve and proximal ascending aorta with a composite graft, and reimplantation of the coronary arteries with the use of interposition polyester grafts. The mean age of the patients was 50 years, and 57% were men. There were no hospital deaths. The mean duration of follow-up was 6.5 years and extended to 16 years. Actuarial survival at 1, 5, and 10 years was 86.7%, 82.2%, and 62.6%, respectively. Two patients required reoperation for a graft-graft pseudoaneurysm and for degeneration of a porcine bioprosthesis. Echocardiograms obtained at a mean of 75 months postoperatively in 15 of the 23 patients demonstrated normal left ventricular outflow tract dimensions and velocities and a mean effective valve orifice area of 1.07 cm2/m2. All coronary artery grafts were patent on angiography a mean of 40 months postoperatively in 13 patients. Extended experience with this technique confirms its safety and effectiveness for patients withextensive destruction of the aortic annulus. It represents a suitable alternative to other currently used techniques.

Risk factors for the return of mitral insufficiency after coronary artery bypass graft and reconstruction of the mitral valve in patients with ischemic cardiomyopathy

Aim. This study aimed to compare the surgical correction results for isolated coronary artery bypass graft (CABG) and CABG in combination with mitral valve (MV) repair for moderate ischemic mitral insufficiency (IMI) in patients with ischemic cardiomyopathy and to identify the risk factors for MI return.Methods. This single-centre prospective study enrolled 76 patients with ischemic cardiomyopathy and moderate MI with a left ventricular ejection fraction < 35% who did not undergo left ventricular reconstruction. The patients were treated with isolated CABG or CABG in combination with MV repair. The mean age of the patients was 57.5 ± 8.6 years (range, 30–75 years), and 90% were men. Isolated annuloplasty was used with a rigid support ring brand with a ring size of 26–30 mm to correct mitral insufficiency in the CABG + MV repair group.Results. We found that isolated CABG or CABG + MV repair in patients with ischemic heart disease and severe systolic left ventricular dysfunction does not result in significant decrease in the MI in the long term compared with that at baseline. However, the degree of MI after CABG + MV repair is lower than the initial values, unlike that after isolated CABG 12 months postoperatively. In the observation period, of up to 36 months, the MI degree after isolated CABG corresponds to the initial values. The determination of the predictors of IMI progression in ischemic cardiomyopathy enabled us to determine the threshold values of the performance indicators of MV repair, and the evaluation of Echo predictors for annuloplasty preoperatively help select the surgical treatment strategies for patients with ischemic cardiomyopathy and moderate MI.Conclusion. Correction of IMI in patients with ischemic cardiomyopathy does not increase the number of complications in the early postoperative period compared to isolated CABG (p = 0.015). After isolated CABG in patients with ischemic cardiomyopathy and moderate MI, progression of mitral regurgitation (grade 3 mitral regurgitation, initially 0%; after 12 months, 31%; after 36 months, 71%; p < 0.001) is observed even with initially moderate changes in the geometry of the mitral valve.Received 6 December 2018. Revised 25 March 2019. Accepted 28 March 2019.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

The infective endocarditis of synthetic patch after left ventricle reconstruction (Dor procedure)

Infective endocarditis (IE) has become an increasingly significant problem in cardiology and cardiac surgery over the past 30 years. Despite the noticeable progress made in the diagnosis and treatment of IE, the prognosis for this condition is still poor and the mortality rate reaches 15-30% [1, 2]. The risk of developing IE is especially high in patients with «intracardiac» artificial materials (artificial valves, prostheses of any type, implantable antiarrhythmic devices). This article presents a rare clinical case of IE of synthetic patch after left ventricle reconstruction (Dor procedure).

Role of type IV collagen and matrix metalloproteinase-9 in remodeling of the left ventricular in coronary artery disease

Currently, the analysis of the fibrosis severity during the restructuring of the surrounding extracellular matrix (ECM) is studied in most of the research works devoted to “cardiac remodeling”. At the same time, the role of the basal membrane of cardiomyocytes in heart diseases was not studied. The basal membrane of cardiomyocytes is a highly organized layer of the ECM which is located on the outer side of the sarcolemma. Degradation of ECM components is carried out by different types of matrix metalloproteinases (MMP), which have proteolytic activity and are actively involved in the process of ECM remodeling, destroying its components such as collagen, elastin, fibronectin, glycosaminoglycans and other structural components.Aim. To evaluate the ECM status in patients with coronary artery disease and its effect on left ventricular myocardial remodeling.Material and methods. Morphological and immunohistochemical (IHC) examination of left ventricular myocardial biopsies was performed in 16 patients undergoing left ventricular reconstruction in combination with coronary artery bypass grafting.Results. The IHC study revealed the accumulation of matrix metalloproteinase-9 in the cytoplasm of cardiomyocytes. This accumulation was combined with partial or complete destruction of the basal membranes (BM) of cardiomyocytes formed by type IV collagen.Conclusion. Type IV collagen destruction in basal membranes of left ventricular cardiomyocyteswasrevealed. It iscausedbytheactionofmatrixmetalloproteinase-9, which accumulates in the cell cytoplasm.

Results of Left Ventricular Reconstruction With and Without Mitral Valve Surgery

This study aims to compare the midterm outcomes of left ventricular reconstruction with those of left ventricular reconstruction plus mitral valve surgery in patients with left ventricular aneurysm due to anterior myocardial infarction and moderate mitral regurgitation. A total of 523 patients (75 who underwent left ventricular reconstruction plus mitral valve surgery and 448 who underwent left ventricular reconstruction) with concomitant moderate mitral regurgitation were included in the study population. All-cause mortality was considered the primary endpoint. Major adverse cardiovascular and cerebrovascular events, including death, myocardial infarction, stroke, and subsequent mitral valve surgery, were considered secondary endpoints. Multivariable proportional hazards Cox regression models were used to assess the associations between groups and outcomes. In the sensitivity analysis we excluded patients who did not undergo coronary artery bypass graft and repeated the statistical analysis above. The median follow-up time among all patients was 41 months. There was no significant difference between the left ventricular reconstruction plus mitral valve surgery and the left ventricular reconstruction groups with regard to all-cause mortality (P= .208) and major adverse cardiovascular and cerebrovascular events (P= .817) after adjustment for covariates. In the sensitivity analysis there was no significant difference between the left ventricular reconstruction plus mitral valve surgery and left ventricular reconstruction groups with regard to all-cause mortality (P= .158) and major adverse cardiovascular and cerebrovascular events (P= .651) after adjustment for covariates. The clinical outcomes of left ventricular reconstruction are comparable with those of left ventricular reconstruction plus mitral valve surgery in patients with left aneurysm and moderate mitral regurgitation.

Experience of post-infarction left ventricular aneurysm reconstruction with on-pump beating heart technique

Aim. To evaluate the results of surgical treatment of post-infarction left ventricular aneurysms with on-pump beating heart technique. 
 Methods. In our center from April, 2009 to January, 2014 169 patients had reconstruction of the left ventricle with on-pump beating heart technique. Among the patients 159 were males (94.1%) and 10 of them were females (5.9%), average age 53.8±8.9 years (39 to 72 years). Angina pectoris class I (according to the classification of Canadian Heart Association) was established in 7 (4.1%) patients, class II - in 49 (29.0%), class III - in 107 (63.3%), class IV - in 4 (2.4%), unstable angina in 2 (1.2%) patients. Chronic heart failure class I (according to New York Heart association functional classification) was diagnosed in 5 (3.0%) patients, class II in 37 (21.9%), class III in 124 (73.4%), class IV in 3 (1.8%) patients. Average ejection fraction of the left ventricle was 38.6±7.9% (25 to 67%). Mitral valve insufficiency stage 2-3 was revealed in 23 (13.6%) patients. 
 Results. Endoventriculoplasty of the left ventricle by Dor's technique was performed in 49 (29.0%) patients, auto-septoplasty of the left ventricle - 59 (34.9%) patients, linear repair in 40 (23.7%) patients. Combined surgical interventions were performed in 21 (12.4%) patients. In-hospital lethality was 2.4% (n=4). 
 Conclusion. Left ventricular reconstruction with on-pump beating heart technique without cardioplegic arest is effective and safe; the method allows performing remodelling of the left ventricle and reaching the target volume parameters.

Invited Commentary

Invited Commentary

10-Year Outcomes After Left Ventricular Reconstruction: Rethinking the Impact of Mitral Regurgitation

Heart failure with reduced ejection fraction due to a post-infarction anteroseptal aneurysm carries a poor prognosis. Patients with refractory heart failure may be considered for advanced surgery, including left ventricular assist device implantation, heart transplantation and left ventricular reconstruction. The aim of this study was to evaluate outcomes after anintegrated approach of left ventricular reconstruction with concomitant procedures (mitral/tricuspid valve repair, coronary revascularization), and assess risk factors for event-free survival, focusing on left ventricular geometry/function and presence of functional mitral regurgitation (MR). A total of 159 consecutive heart failure patients who underwent left ventricular reconstruction between 2002 and 2011 were included. Mid-term echocardiographic and long-term clinical outcomes were evaluated. Preoperative risk factors were correlated to event-free survival (freedom from mortality, left ventricular assist device implantation, and heart transplantation). Mid-term echocardiography demonstrated decreased indexed left ventricular end-systolic volumes (89 ± 42 mL/m2 preoperatively; 51 ± 18 at mid-term, p < 0.001), and absence of MR ≥ grade 2. Event-free survival was 83% ± 3% at 1-year, 68% ± 4% at 5-year, and 46% ± 4% at 10-year follow-up. Preoperative wall motion score index (WMSI; hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.7-5.8, p < 0.001) and presence of MR ≥ grade 2 (HR 1.9, 95% CI 1.1-3.1, p= 0.014) were independently associated with adverse event-free survival. Event-free survival is favorable in patients with WMSI < 2.5 and significantly worse when WMSI is ≥ 2.5. In both groups, the presence of preoperative MR ≥ grade 2 negatively affects event-free survival, despite successful correction of MR. Risk stratification by preoperative WMSI and MR grade supports the Heart team in choosing the optimal surgical strategy for patients with refractory heart failure.

Left Ventricular Reconstruction Surgery in Candidates for Heart Transplantation.

ObjectiveTo report our center’s experience in the surgical treatment of ventricular reconstruction, an effective and efficient technique that allows patients with end-stage heart failure of ischemic etiology to have clinical improvement and increased survival.MethodsObservational, clinical-surgical, sequential, retrospective study. Patients with ischemic cardiomyopathy and left ventricular aneurysm were attended at the Heart Failure, Ventricular Dysfunction and Cardiac Transplant outpatient clinic of the Dante Pazzanese Cardiology Institute, from January 2010 to December 2016. Data from 34 patients were collected, including systemic arterial hypertension, ejection fraction, New York Heart Association (NYHA) functional classification (FC), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II value, Society of Thoracic Surgeons (STS) score, ventricular reconstruction technique, and survival.ResultsOverall mortality of 14.7%, with hospital admission being 8.82% and late death being 5.88%. Total survival rate at five years of 85.3%. In the preoperative phase, NYHA FC was Class I in five patients, II in 18, III in eight, and IV in three vs. NYHA FC Class I in 17 patients, II in eight, III in six, and IV in three, in the postoperative period. EuroSCORE II mean value was 6.29, P≤0.01; hazard ratio (HR) 1.16 (95% confidence interval [CI] 1.02-1.31). STS mortality/morbidity score mean value was 18.14, P≤0.004; HR 1.19 (95% CI 1.05-1.33). Surgical techniques showed no difference in survival among Dor 81% vs. Jatene 91.7%.ConclusionSurgical treatment of left ventricular reconstruction in candidates for heart transplantation is effective, efficient, and safe, providing adequate survival.

Surgical ventricular reconstruction for ischemic left ventricular aneurysm. Early and medium-term outcomes for two surgical techniques

Left ventricular aneurysm is a severe complication of acute myocardial infarction, which contributes significantly to mortality and morbidity associated with this pathology. Despite the progress of correction techniques, there are still controversies about the optimal approach addressing this pathology. The aim of this study was to analyse short and medium term outcomes of left ventricular reconstruction for ischemic left ventricular aneurysm using two surgical techniques (endoventricular patch plasty and liniar suture) in order to determine if one of these techniques has supperior results. 117 patients were included in the study, 48 patients (41%) underwent left ventricular reconstruction with endoventricular patch (Group 1), 69 patients (59%; Group 2) had linear reconstruction. 113 patients (96.5%) required associated procedures: 108 surgical myocardial revascularization, 18 mitral valvuloplasty and 8 ventricular septal defect closure. Short and medium term morbidity, mortality, alteration of ejection fraction and NYHA class were analysed. Perioperative mortality was 11.11%, 4.2% in the endoventricular patch group, and 15.9% in the linear suture group (p = 0.03). The overall 5-year survival was 78.5% (88.7% in Group 1 and 71.2% in Group 2). The left ventricular ejection fraction and NYHA functional class improved in both groups, with greater improvement in the endoventricular patch group. Surgical ventricular reconstruction is a procedure performed for the correction of ischemic left ventricular aneurysm with good early and medium-term results, but with better results with the endoventricular patch technique regarding early and medium-term mortality, ejection fraction and NYHA functional class improvement. Orv Hetil. 2018; 159(51): 2167-2174.

Left ventricular reconstruction surgery in ischemic heart disease: a systematic review of the past two decades.

The aim of this paper is to systematically review the existing literature reporting on patients recruited during the past twenty years regarding the role of left ventricular (LV) reconstruction in ischemic cardiomyopathy in terms of efficacy and mortality and provide an updated overview of the current evidence. The PubMed and Cochrane bibliographical databases were thoroughly searched for the following MeSH terms: "ventricular reconstruction" OR ventriculoplasty OR "ventricular aneurysm" OR "ventricular restoration." Original studies -recruiting patients during the past twenty years- on LV reconstruction surgery in more than five cases and reporting on the associated peri- or postoperative mortality were deemed eligible. Twenty-seven studies were included and provided data for 3220 patients with a mean age of 61 years. Angina was present in 66.6% (510/766) of the patients, while nine out of ten (635/699) had a history of myocardial infarction. Average preoperative ejection fraction was 29.9% and end-systolic volume index was 93.6 mL/m2. With respect to complications, low cardiac output syndrome and the need for intra-aortic balloon pump were prevalent in 9.3% (79/850) and 18.8% (334/1773), respectively. Thirty-day mortality was 7.1% (230/3220) and late-mortality (mean follow-up of 36.9 months) was 19.6% (548/2791), while the rate of MACCE was 40.1% (367/915). Five-year mortality was 29% (340/1171). Our findings provide a current perspective of the role of LV reconstruction in the treatment of ischemic cardiomyopathy suggesting its benefit in survival. Taking into consideration the existing debate, further studies are required so that a solid conclusion to be made.

LEFT VENTRICULAR EJECTION FRACTION: COMPARISON BETWEEN TRUE VOLUME-BASED MEASUREMENTS AND AREA-BASED ESTIMATES.

Left ventricular ejection fraction (LVEF) is a critical measure of cardiac health commonly acquired in clinical practice, which serves as the basis for cardiovascular therapeutic treatment. Ultrasound (US) imaging of the heart is the most common, least expensive, reliable and non-invasive modality to assess LVEF. Cardiologists, in practice, persistently use 2D US images to provide visual estimates of LVEF, which are based on 2D information embedded in the US images by examining the area changes in LV blood pool between diastole and systole. There has been some anecdotal evidence that visual estimation of the LVEF based on the area changes of the LV blood pool significantly underestimate true LVEF. True LVEF should be calculated based on changes in LV volumes between diastole and systole. In this project, we utilized both idealized models of the LV geometry - a truncated prolate spheroid (TPS) and a paraboloid model - to represent the LV anatomy. Cross-sectional areas and volumes of simulated LV shapes using both models were calculated to compare the LVEF. Further, a LV reconstruction algorithm was employed to build the LV blood pool volume in both systole and diastole from multi-plane 2D US imaging data. Our mathematical models yielded an area-based LVEF of 41 4.7% and a volume-based LVEF of 55 ±5.7%, while the 3D recon-struction model showed an area-based LVEF of 35 11.9% and a volume-based LVEF of 48.0 ± 14.0%. In summary, the area-based LVEF using all three models ±underestimate the volume-based LVEF using corresponding models by 13% to 14%. This preliminary study confirms both mathematically and empirically that area-based LVEF estimates indeed underestimate the true volume-based LVEF measurements and suggests that true volumetric measurements of the LV blood pool must be computed to correctly assess cardiac LVEF.

Transcatheter and minimally invasive surgical left ventricular reconstruction for the treatment of ischaemic cardiomyopathy: preliminary results†.

Adverse remodelling of the left ventricle (LV) after myocardial infarction (MI) results in a pathological increase in LV volume and reduction in LV ejection fraction (EF). We describe the preliminary results of a novel, multicentre, combined transcatheter and minimally invasive technique to reconstruct the remodelled LV by plication and exclusion of the scar, and to reduce the excess volume, resulting in decreased wall stress and increased EF. A novel hybrid transcatheter technique that relies on microanchoring technology (Revivent TC™ System, BioVentrix Inc., San Ramon, CA, USA) was used. The LV is reconstructed without the use of extracorporeal circulation by plication of the fibrous scar. This is achieved by implantation of a series of internal and external microanchors brought together over a PEEK (poly-ether-ether-ketone) tether to form a longitudinal line of apposition between the LV free wall and the anterior septum. Internal anchors are deployed by a transcatheter technique on the right side of the ventricular septum through the right internal jugular vein. Paired external anchors are advanced through a left-sided minithoracotomy and deployed on the LV epicardium. A specialized force gauge is used to bring these 'right ventricle (RV)-LV' anchors together under measured compression forces. LV-LV' anchor pairs through the LV apex beyond the distal tip of the RV complete the reconstruction. Patients who were considered eligible for the procedure presented with symptomatic heart failure (New York Heart Association class ≥II) and ischaemic cardiomyopathy (EF <40%) after anteroseptal MI. All patients had a dilated LV with either an a- or dys-kinetic scar in the anteroseptal wall and apex of ≥50% transmurality. Between October 2016 and April 2017, 9 patients (8 men, 1 woman; mean age 60 ± 8 years) were operated on in 2 Dutch centres. Procedural success was 100%. On average, 2.6 anchor pairs were used to reconstruct the LV. Comparing echocardiographic data preoperatively and directly postoperatively, LV ejection fraction increased from 28 ± 8% to 40 ± 10% (change +43%, P < 0.001) and LV volumes decreased LV end-systolic volume index 53 ± 8 ml/m2 to 30 ± 11 ml/m2 (change -43%, P < 0.001) and LVEDVI 75 ± 23 ml/m2 to 45 ± 6 ml/m2 (change -40%, P = 0.001). In 1 patient, an RV perforation occurred which necessitated conversion to full sternotomy. One patient underwent a postoperative revision because of RV restriction. After the removal of 1 'RV-LV' anchor pair, the patient recovered completely. Hospital mortality was 0%. The median duration of intensive care unit stay was 2 days [interquartile range (IQR) 1-46 days], and the median length of hospital stay was 9 days (IQR 3-57 days). Hybrid transcatheter LV reconstruction is a promising novel treatment option for patients with symptomatic heart failure and ischaemic cardiomyopathy after anteroseptal MI. The early results demonstrate that the procedure is safe and results in a significant improvement in EF and reduction in LV volumes in the early postoperative period.

PECULIARITIES AND SURGICAL TREATMENT TACTICS OF POSTERO-BASAL LEFT VENTRICULAR ANEURYSMS

The literary review reflects the main current data on the problem of surgical treatment of postero-basal left ventricular aneurysms. It is shown that, despite the small percentage of these aneurysms in patients with coronary heart disease (CHD), their importance for surgical treatment is significant, since the effective correction of detected disorders of cardiac structures, myocardium and coronary arteries has not been sufficiently developed to date, and many issues of surgical tactics are contradictory. This applies both to the type of geometric reconstruction of the left ventricle, and the feasibility of mitral regurgitation correction, which due to dysfunction of the papillary muscles is observed in almost all patients with postero-basal aneurysms of the heart. The question of the combined correction of the interventricular septum rupture in patients with postero-basal aneurysms remains complex and unresolved until now. The relevant problem is the choice of surgical tactics of left ventricular reconstruction using two patches in the presence of anteroposterior aneurysms. All of the above reflects the need for further research on the problem of surgical treatment of postero-basal aneurysms of the heart.