Left Ventricular Reduction Surgery Research Articles

Should Jehovah’s Witness patients be listed for heart transplantation?

This best evidence topic in Cardiac Surgery was written according to a structured protocol. The question addressed was: for [Jehovah’s Witness patients with end-stage heart failure] can these patients undergo a [heart transplantation] without an increased rate of mortality. Altogether, 133 papers were found using the reported search strategy. Of those, 29 papers represented the best evidence to answer the clinical question. Five papers focusing on patients of the Jehovah’s Witness (JW) faith who had end-stage heart failure were published. Successful heart transplantation was performed in a total of seven patients without mortality, re-exploration or blood transfusion. One patient had left ventricular reduction surgery twice and another patient had bypass surgery several years after transplantation. Other successful organ transplantations were also reported, including lung, liver, kidney and pancreas in both adult and paediatric patients of the JW faith, with comparable mortality and morbidity to non-JW patients. A publication bias is likely; nevertheless, we conclude that although there are no large studies directly focused on heart transplantation in JW patients, a multidisciplinary team approach to such surgery can make it technically feasible and without an increased mortality risk in suitable candidates. Therefore, such patients may be considered for heart transplantation under selected and favourable circumstances.

Should Jehovah's Witness patients be listed for heart transplantation?

This best evidence topic in Cardiac Surgery was written according to a structured protocol. The question addressed was: for [Jehovah's Witness patients with end-stage heart failure] can these patients undergo a [heart transplantation] without an increased rate of mortality. Altogether, 133 papers were found using the reported search strategy. Of those, 29 papers represented the best evidence to answer the clinical question. Five papers focusing on patients of the Jehovah's Witness (JW) faith who had end-stage heart failure were published. Successful heart transplantation was performed in a total of seven patients without mortality, re-exploration or blood transfusion. One patient had left ventricular reduction surgery twice and another patient had bypass surgery several years after transplantation. Other successful organ transplantations were also reported, including lung, liver, kidney and pancreas in both adult and paediatric patients of the JW faith, with comparable mortality and morbidity to non-JW patients. A publication bias is likely; nevertheless, we conclude that although there are no large studies directly focused on heart transplantation in JW patients, a multidisciplinary team approach to such surgery can make it technically feasible and without an increased mortality risk in suitable candidates. Therefore, such patients may be considered for heart transplantation under selected and favourable circumstances.

Beating Heart Surgery for Patients with Poor LV Function

Beating heart surgery expand the surgical indications to the old patient and serious case. We present a favorable outcome of beating heart surgery for the valvular disease and the aortic aneurysm patient with low cardiac function. In every cases, we use antegrade worm blood perfusion to coronary artery. First case of a 56-year-old man with a preoperative diagnosis of severe aortic stenoinsufficiency, Fractional shortening (FS=10%) is reduced, the left ventricle is dilated (LVDd=66mm), and severe tricuspid regurgitation was detected by echocardiogram. Aortic valve replacement and tricuspid annuloplasty was performed on baeating heart. At postoperative day 1, maximal CK-MB activity was 32(10.9%)IU/I. At postoperative day 7, Fractional shortening (FS=18%) was recovered. Second case of a 77-year-old man with thoracic aorta aneurysm, At preoperative echocardiogram, poor LV function (FS=27%, E/A=0.54, LV tei index=0.81) was pointed out. Total arch replacement with elephant trunk procedure was performed on beating heart. At postoperative day 1, maximal CK-MB activity was 23(7.0%)IU/I. Postoperative LV function was almost the same (FS=21%, E/A=0.88, LV tei index=0.86). Third case of a 71-year-old man with non-ischemic dilated cardiomyopathy, severe heart failure (FS=7%) and left ventricular dilatation (LVDd=90mm), and severe mitral regurgitation was detected by echocardiogram. Left ventricular reduction surgery (Batista procedure) and mitral valve plasty was performed on beating heart. We got an early postoperative recovery of LV function in every cases.

Down-regulation of Endothelin-1 and Alteration of Apoptosis Signaling Following Left Ventricular Volume Reduction Surgery in Heart Failure of Adult Rats

While left ventricular (LV) reduction surgery (LVR) is a novel treatment for severe heart failure, alteration of signal transduction pathways by this surgery is unknown. LV endothelin-1 plays a critical role in LV remodeling following myocardial infarction (MI). Another possible mechanism of remodeling is myocardial cell loss due to apoptosis. The purpose of the present study was to determine whether the LV endothelin-1 level and apoptosis signaling change after LVR. Adult rats were divided into two groups: non-MI group and MI group, and the MI group was subjected to permanent ligation of the left anterior descending artery. Four weeks later, rats in the MI group were subjected to LVR (LVR group) or a sham operation (OMI group). Two weeks after the second operation, echocardiography revealed that LVR improved LV systolic function and remodeling. Upregulation of LV endothein-1 was detected only in the OMI group but not in the non-MI group nor in the LVR group. The percentage of terminal deoxynucleotidyl transfer-mediated end-labeling of fragmented nuclei (TUNEL)-positive cardiac myocytes was significantly higher in the OMI group than in the LVR group or the non-MI group. Western blotting of extracts from the left ventricle showed that bcl-2 and bcl-xL levels were restored and caspase-3 activation was repressed after LVR. Thus, LVR modulates the expression of endothelin-1 and apoptosis signaling in failing hearts. These alterations of signal transduction pathways might contribute to the beneficial effects of LVR on systolic function in heart failure.

Herztransplantation in Münster - Entwicklungen der letzten 10 Jahre

The evolution of the heart transplant program at the Dept. of Cardiothoracic Surgery, University Hospital Munster, is reported, including the foundation of the regional collaboration UNI NRW, which was very successful in optimizing donor resources and patient care until the implementation of the German transplant law. The ongoing shortage of donor organs has led to the increasing usage of alternative surgical treatment modalities, mainly conventional high-risk surgery, Norwood palliation, biventricular pacemaker stimulation and left ventricular reduction surgery. Moreover, long-term mechanical support has gained special attention and is meanwhile a special focus of the research program.

Effect of partial left ventriculectomy on left and right ventricular volumes and function as assessed with electron beam tomography: preliminary results.

Our objective was to determine if left ventricular reduction surgery affects left and right ventricular volumes and function. Twenty-three patients with end-stage heart failure underwent contrast-enhanced electron beam tomographic function studies before and twice after partial left ventriculectomy (PLV). The PLV was combined with other cardiosurgical procedures in 20 of 23 patients. Left and right ventricular enddiastolic volume (LVEDV, RVEDV), stroke volume (LVSV, RVSV), ejection fraction (LVEF, RVEF), and enddiastolic diameter (LVEDD, RVEDD) were determined by manual tracing of endo- and epicardial borders at enddiastole and endsystole. Patients were scanned 31 days (+/-34) before and 18 days (+/-13) and 8 months (+/-4) after PLV. Mean pre- and early and late postoperative values for LVEDV, LVSV, LVEF, and LVEDD were 387.9 ml (+/-125.5 ml), 255.6 ml (+/-79.3 ml; p<0.01), and 253.7 ml (+/-97.8 ml; p<0.05), 79.7 ml (+/-25.2 ml), 74.8 ml (+/-17.9; n.s.), and 79.1 ml (+/-26.5 ml; n.s.), 21.6% (+/-7.3%), 31.9% (+/-13.4%; p<0.05), and 34.1% (+/-14.1%; p<0.05), and 72.0 mm (+/-10.6 mm), 64.3 mm (+/-8.5 mm; p<0.05), and 63.5 mm (+/-9.4 mm; p<0.05), respectively. Mean pre- and postoperative values for RVEDV, RVSV, RVEF, and RVEDD were 177.7 ml (+/-72.8 ml), 172.4 ml (+/-59.2 ml; n.s.), and 178.9 ml (+/-60.8 ml; n.s.), 60.3 ml (+/-21.6 ml), 68.8 ml (+/-19.9 ml; n.s.), and 78.3 ml (+/-25.3 ml; n.s.), 38.1% (+/-15.4%), 43.7% (+/-16.3%; p<0.05), and 45.1% (+/-11.2%; n.s.), and 50.4 mm (+/-10.9 mm), 48.1 mm (+/-8.7 mm; n.s.), and 48.5 mm (+/-9.8 mm; n.s.), respectively. The PLV may induce a significant early reduction of left ventricular volumes and improvement of biventricular function; however, our results must be judged carefully as the majority of patients in this study underwent additional cardiosurgical procedures, the contributory effect of which on the overall outcome remains unclear.

OPTIMIZATION OF LV GEOMETRIC MODIFICATIONS

Devices that modify left ventricular geometry by creating a bi-lobed ventricle to reduce wall stress are being developed as a treatment for dilated cardiomyopathy. Similar to these devices, left ventricular reduction surgery (LVRS) modifies ventricular geometry and consequently wall stress, but has had mixed clinical results. To evaluate the maximum functional benefit of geometrical modification devices (GMD) a simple analytical model of ventricular geometry modification was developed and coupled to numerical optimization techniques. The wall tension-length relations were determined from the pressure-volume characteristics of the dilated ventricle and these myocardial properties were then used to predict cardiac function following application of a GMD or LVRS. The model predicts both types of modifications cause increased end-systolic elastance and decreased diastolic compliance, consistent with reported animal experiments. Analysis of a dilated ventricle with an initial ejection fraction (EF) of 10% predicted a maximum stroke volume increase of 47% and 14% for a GMD and LVRS respectively. A ventricle with a 17% EF, under identical loading conditions, with the corresponding optimized GMD showed a 6% increase in stroke volume, however any extent of LVRS decreased the stroke volume. The results show optimum GMD application and LVRS are dependent on the systolic and diastolic properties of the dilated ventricle. Matching the extent of modification to the specific LV is needed if acute function is not to be degraded.

Reverse remodeling by surgery - fact or fiction?

Mortality of chronic heart failure in industrial countries remains unacceptably high despite advances in medical therapy. Heart transplantation, the gold standart in the treatment of end-stage heart failure is reserved for only a few patients because of the shortage of donor hearts. Surgical alternatives to transplantation include dynamic cardiomyoplasty (CMP), mitral valve reconstruction, left ventricular reduction surgery (PLVR) and ventricular assist devices (VAD). Improved survival and objective physiologic improvement have not been documented for CMP in the treatment of dilative cardiomyopathy. Mitral valve reconstruction of the other hand shows promising results. PLVR is an innovative procedure in which the heart is surgically reduced in size and cardiac function is dramatically improved immediately after surgery. The presence of long-term effects is still unknown. VAD have been shown to be extremely effective as a short- and long-term "bridge" to heart transplantation. They are not approved for permanent support. A randomized trial in the U. S. is underway to compare the efficacy of these devices with the efficacy of medical therapy in NYHA functional class IV patients in quality of life, survival and costs.

Left ventricular reduction in a Jehovah’s Witness

For Jehovah’s Witnesses with severe heart failure, left ventricular reduction surgery may be a satisfactory alternative to cardiac transplantation. Compared with transplantation, left ventricular reduction surgery can involve less blood loss thus decreasing the need for blood-volume replacement. More importantly, left ventricular reduction surgery obviates the need for a donor organ.

Mechanical circulatory support devices in the treatment of heart failure.

With an increasingly aging population, heart failure is a major health issue, affecting more than 10% of the population over 65 years of age, and costing hundreds of millions of dollars per year for ongoing care. Even with maximal medical therapy, annual mortality rates of in excess of 25% are commonly reported. Over the last three decades, various surgical approaches have been examined in the hope of improving the outcome of congestive cardiac failure. These procedures range from simple coronary revascularisation to left ventricular reduction surgery and cardiac transplantation. Although of value in selected situations, no surgical approach, beyond transplantation, has had significant impact on the outcome of heart failure. In the last decade, development in the area of mechanical support for the failing heart has continued to expand at a rapid rate. Strong evidence now exists to show that in many patients with advanced heart failure, prolonged mechanical support results in significant myocardial recovery. There are currently several mechanical support devices available for clinical use, although most are considered experimental in this country. These devices are expensive and are not without significant complications, but early results of their use as either a bridge to transplantation or as a stand alone treatment, have been very encouraging. Currently available mechanical assist devices are described, with discussion of indications for implantation, complications and results of their use.

Early and intermediate results of left ventricular reduction surgery1

Left ventricular reduction surgery is a new surgical option for treatment of end-stage cardiac dysfunction, and little is known about hemodynamics and outcome in the European heart failure population. We present our early results with this operation. From January 1995 to September 1997, 30 patients (25 men, 5 women; mean age 61.2 years) underwent partial left ventriculectomy. The underlying disease was ischemic in 18 patients and idiopathic dilated cardiomyopathy in 12 patients. Preoperatively 23 patients were in New York Heart Association functional class IV and 7 were in class III. Mean cardiac index, stroke index and ejection fraction were 1.8 +/- 0.3 l/m2 per min, 23.5 +/- 5.1 ml/m2 and 19.3% +/- 6.8%, respectively. Associated procedures were coronary bypass in 18 patients, mitral valvuloplasty in one, aortic or mitral valve replacement in three, dynamic cardiomyoplasty in two, and left ventricular assist device implantation in 1. There were two early deaths: one from bleeding and one from anticoagulant-related cerebral hemorrhage. Regarding late deaths, one patient died from pneumonia 3 months after the operation and two died from dysrhythmia 4 and 17 months postoperatively. The estimated 1-year survival rate calculated by the Kaplan-Meier log-rank method was 85%. Mean cardiac index, stroke index, and ejection fraction rose significantly (P = 0.0001) to 2.9 +/- 0.51/m2 per min, 36.9 +/- 6.2 ml/m2 and 37.8% +/- 9.2%, respectively. Currently 26 patients are in New York Heart Association functional class I or II. Left ventricular reduction surgery improves objective and subjective parameters of cardiac performance significantly in early and intermediate follow-up. Randomized studies and carefully documented long-term results seem to be necessary to define the role of left ventricular reduction surgery.

Left Ventricular Reduction Surgery

Left Ventricular Reduction Surgery