Surgical Left Ventricular Restoration 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.

Long-Term Outcomes of Left Ventricular Restoration in Patients Ineligible for Concomitant Coronary Artery Bypass Grafting.

The prognosis of severe coronary artery disease (CAD) patients undergoing left ventricular restoration (LVR) and ineligible for concomitant coronary artery bypass grafting (CABG) is unclear. This study illustrates the clinical characteristics and the long-term survival of these patients in a retrospective cohort. From January 1999 to March 2021, a total of 78 patients underwent surgical left ventricular restoration without concomitant CABG at our center. The primary endpoint was the major adverse cardiovascular and cerebrovascular events (MACCE). Kaplan-Meier analysis was performed to calculate survival, and compared by log-rank test, followed by multiple adjustments using Cox regression. The mean age was 55.3 ± 11.4 years. There were 76 (97.4%) true and 2 (2.6%) pseudo-aneurysms. Forty-six (59.0%) patients presented NYHA functional class III or IV. The mean EuroSCORE was 10.6 ± 3.2. Concomitant surgeries included mitral valve repair (N = 3), mitral valve replacement (N = 2), tricuspid valve repair (N = 2), ventricular septal defect closure (N = 18), maze procedure (N = 1), and appendage ligation (N = 1). Reoperation for bleeding was performed in one patient (1.3%). Prolonged ventilation was observed in 21 (26.9%) patients. Fourteen (17.9%) patients presented with low cardiac output and were supported with IABP. Operative death occurred in one (1.3%) patient. The median duration of echocardiographic follow-up was 53 months (interquartile range, 81.5) and was obtained in 46 (59.0%) patients. Left ventricular ejection fraction (LVEF) improved from 41.1% ± 10.5% to 45.6% ± 7.9% (P < 0.001), and the left ventricular end-diastolic dimension (LVEDD) fell from 57.8 ± 6.6 mm to 52.0 ± 6.2 mm (P < 0.001). The median patient follow-up time was 79.5 months (interquartile range, 53.5). Overall, 1-, 5-, and 10-year survival rates were 98.7%, 95.5% and 82.3%, respectively. Patients with severe CAD and ineligible for concomitant CABG are in critical condition, and LVR could be a reliable approach to improving cardiac function with satisfactory early and long-term outcomes.

Outcomes after surgical ventricular restoration for ischemic cardiomyopathy

ObjectiveThe study objective was to evaluate the short- and long-term outcomes of patients with ischemic cardiomyopathy after surgical ventricular restoration and to identify risk factors related to poor results. MethodsBetween August 2002 and April 2016, 62 patients affected by ischemic cardiomyopathy underwent surgical left ventricular restoration at our unit. Patients' mean age at operation was 63 years (39-79 years). Mean ejection fraction was 29.6%. The Surgical Treatment for Ischemic Heart Failure trial criteria have been used as indications for surgery. Fifty-seven patients (91%) received surgical myocardial revascularization. Mitral valve repair was performed in 39 patients (63%). The surgical technique consisted of the classic Dor operation or a different approach reducing the equatorial diameter of the left ventricle and avoiding the use of a patch. The data were analyzed retrospectively for perioperative results and short- and long-term clinical outcomes. ResultsOne patient died of noncardiac causes within 30 days (1.6%). All-cause death occurred in 36 patients (58%) during follow-up (0.6-14.7 years; median follow-up time, 7.02 years), of whom 15 died of cardiac causes. Age, need for preoperative intra-aortic balloon pump, reduction less than 35% of postoperative left ventricular end-diastolic and end-systolic volumes, type of surgical technique, and ejection fraction less than 25% were identified as risk factors for late cardiac mortality. Perioperative levosimendan administration and presence of preoperative moderate to severe mitral regurgitation influenced early and intermediate-term outcomes, but no statistical relevance on long-term results was demonstrated. ConclusionsPatients with ischemic dilative cardiomyopathy have favorable short- and long-term outcomes after ventricular restoration. Age, preoperative ejection fraction less than 25%, inadequate left ventricular surgical reverse remodeling, and type of surgical technique negatively affect long-term survival.

Cell therapy and left ventricular restoration for ischemic cardiomyopathy: long-term results of a perspective, randomized study.

Aim of this study is to verify the potential advantages and benefits of bone-marrow derived autologous stem cells implantation associated to surgical left ventricular restoration (SVR), to report a new modality of cell delivery to myocardium, and to identify possible side effects of this procedure. Between March 2007 and March 2013, 30 patients affected by ischemic dilative cardiomyopathy who received a SVR operation were enrolled in the study. The population was divided in two groups:16 patients were randomly assigned to receive stem cells therapy in addition to SVR (groupA), 14 patients received a placebo (group B). The two groups were homogeneous in respect of age, gender, preoperative NYHA class, mitral incompetence and left ventricular sizes and volumes. The patients were evaluated by echo and pet-scan before surgery and at 6 months follow-up, and by echo at subsequent follow-up. Overall 30 days-in hospital mortality was 0 for the entire cohort. At last follow-up ejection fraction increased from 25.3% before surgery to 36.3% in group A, and from 31.8% to 45.6% in group B. Reduction of LVEDD was 6% in group A, 9% in group B. ESLVV and EDLVD decreased more significantly in patients receiving stem cells (55% vs. 35%). Late cardiac mortality at 9 years follow-up was similar in the two groups of patients. No early or late adverse reaction nor cases of infections were observed. Patients affected by ischemic cardiomyopathy have a favourable outcome after SVR. A higher reduction of LVEDV and LVESV assessed by CT-Scan evaluation in patients receiving cell therapy, when compared to control group, encourages the evolution and refinement of myocardial regenerative therapy added to SVR.

Vasoplegia After Surgical Left Ventricular Restoration: 2-Year Follow-Up

Vasoplegia is a severe complication that can develop after surgical procedures for heart failure. The current study evaluated the effect of vasoplegia on survival, cardiac function, and renal function 2 years after surgical left ventricular restoration (SVR). Heart failure patients with a left ventricular ejection fraction (LVEF) of 0.35 or less who underwent SVR in 2006 to 2014 were included. Vasoplegia was defined as the continuous need of vasopressors (norepinephrine ≥0.2 μg · kg-1 · min-1 or terlipressin [any dose], or both) combined with a cardiac index of 2.2 L · min-1 · m-2 or higher for at least 12 consecutive hours, starting within the first 3 days postoperatively. The effect of vasoplegia on mortality, New York Heart Association Functional Classification, LVEF, and creatinine clearance was assessed up to 2 years of follow-up. SVR was performed in 113 patients (80% men), aged 62 ± 10 years, and with an LVEF of 0.25 ± 0.06. Postoperative vasoplegia developed in 23%. Survival was lower in patients with vasoplegia compared with patients without vasoplegia at 6 months (62% vs 90%, p= 0.001) and at 2 years (50% versus 84%, p < 0.001). At the 2-year follow-up, New York Heart Association class and LVEF had improved and were similar in both groups (respectively, p= 0.319 and p= 0.444). Creatinine clearance was lower in patients with vasoplegia compared with patients without vasoplegia 2 years postoperatively (p < 0.001), even after correcting for baseline creatinine clearance (p= 0.009). Vasoplegia after SVR is associated with decreased survival. Despite an improved and similar cardiac function, renal function was compromised in vasoplegic patients at the 2-year follow-up.

Right ventricular dysfunction after surgical left ventricular restoration: prevalence, risk factors and clinical implications.

Surgical left ventricular (LV) restoration (SVR) induces changes in LV systolic and diastolic function that may affect postoperative right ventricular (RV) function. This study aimed to evaluate the long-term effect of SVR on RV function, with specific focus on determinants and prognostic implications of RV dysfunction. Eighty-six patients (age 60 ± 10 years, 73% male) with clinical and echocardiographic follow-up 2 years after SVR were included. RV dysfunction was defined as RV fractional area change <35%. The association between RV dysfunction at follow-up and clinical and echocardiographic characteristics and outcome was investigated. RV dysfunction at follow-up was present in 40% of patients and was associated with worse preoperative RV fractional area change (39 ± 9 vs 46 ± 7%, P < 0.01), pulmonary hypertension (18 vs 4%, P = 0.03) and higher follow-up LV filling pressures (E/E' ratio 23 ± 8 vs 15 ± 8, P = 0.02). At follow-up, patients with RV dysfunction were more frequently in New York Heart Association Class III or IV (30 vs 12%, P = 0.04) and 5-year mortality, heart transplantation and LV assist device implantation rate was increased (49 vs 17%, P < 0.01) as compared to patients with normal RV function. RV dysfunction after SVR was observed in 40% of patients and was associated with preoperative RV dysfunction, presence of pulmonary hypertension and an increase in LV filling pressures at follow-up. Patients with RV dysfunction after SVR had worse clinical functioning and outcome as compared to patients with normal RV function.

Concomitant CABG, Left Ventricular Restoration and Mitral Valve Repair for Ischemic Heart Disease.

To evaluate the effects of combined coronary artery bypass grafting (CABG), surgical left ventricular restoration (LVR), and mitral valve repair (MVP) in treating ischemic heart disease combined with mitral regurgitation; and to evaluate the different strategies of LVR and MVP. From January 2001 to December 2015, 61 consecutive patients with left ventricular aneurysm and ischemic mitral regurgitation underwent concomitant CABG, LVR and MVP. We evaluated the clinical and echocardiographic outcomes of the patients. The mean follow-up was 5.8 ± 3.3 years. The operative mortality was 4.9%. One-, five-, and ten-year survival rates were 95.1%, 86.9%, and 80.3%, respectively. Mitral regurgitation, left ventricular ejection fraction (LVEF), and left ventricular end diastolic diameter (LVEDD) improved significantly after surgery (P < .001). During follow-up, 3 patients (5.2%) had moderate mitral regurgitation and 1 patient (1.9%) had severe mitral regurgitation. The clinical outcomes were not influenced by the LVR technique and MVP approach. Combined CABG, LVR, and MVP was effective for ischemic left ventricular aneurysm with mitral regurgitation. The procedure was associated with acceptable operative risk and clinical outcomes.

Incidence and predictors of vasoplegia after heart failure surgery.

Vasoplegia has been described as a complication after cardiac surgery, particularly in patients with a poor left ventricular ejection fraction. The aim of this study was to assess the incidence, survival and predictors of vasoplegia in patients undergoing heart failure surgery and to propose a risk model. A retrospective study including heart failure patients who underwent surgical left ventricular restoration, CorCap implantation or left ventricular assist device implantation between 2006 and 2015. Patients were classified by the presence or absence of vasoplegia. Two hundred and twenty-five patients were included. The incidence of vasoplegia was 29%. The 90-day survival rate in vasoplegic patients was lower compared with non-vasoplegic patients (71% vs 91%, P < 0.001). After adjusting for age, sex and surgical procedure, anaemia (OR 2.195; 95% CI 1.146, 4.204; P = 0.018) and a higher thyroxine level (OR 1.140; 95% CI 1.033, 1.259; P = 0.009) increased the risk of vasoplegia; a higher creatinine clearance (OR 0.980; 95% CI 0.965, 0.994; P = 0.006) and beta-blocker use (OR 0.257; 95% CI 0.112, 0.589; P = 0.001) decreased the risk. The risk model consisted of the same variables and could adequately identify patients at risk for vasoplegia. Vasoplegia after heart failure surgery is common and results in a lower survival rate. Anaemia and a higher thyroxine level are associated with an increased risk on vasoplegia. In contrast, a higher creatinine clearance and beta-blocker use decrease the risk on vasoplegia. These factors are used in the risk model that may guide treatment strategy.

Right ventricular dysfunction affects survival after surgical left ventricular restoration

ObjectiveSeveral clinical and left ventricular parameters have been associated with prognosis after surgical left ventricular restoration in patients with ischemic heart failure. The aim of this study was to determine the prognostic value of right ventricular function. MethodsA total of 139 patients with ischemic heart failure (62 ± 10 years; 79% were male; left ventricular ejection fraction 27% ± 7%) underwent surgical left ventricular restoration. Biventricular function was assessed with echocardiography before surgery. The independent association between all-cause mortality and right ventricular fractional area change, tricuspid annular plane systolic excursion, and right ventricular longitudinal peak systolic strain was assessed. The additive effect of multiple impaired right ventricular parameters on mortality also was assessed. ResultsBaseline right ventricular fractional area change was 42% ± 9%, tricuspid annular plane systolic excursion was 18 ± 3 mm, and right ventricular longitudinal peak systolic strain was −24% ± 7%. Within 30 days after surgery, 15 patients died. Right ventricular fractional area change (hazard ratio, 0.93; 95% confidence interval, 0.88-0.98; P < .01), tricuspid annular plane systolic excursion (hazard ratio, 0.80; 95% confidence interval, 0.66-0.96; P = .02), and right ventricular longitudinal peak systolic strain (hazard ratio, 1.15; 95% confidence interval, 1.05-1.26; P < .01) were independently associated with 30-day mortality, after adjusting for left ventricular ejection fraction and aortic crossclamping time. Right ventricular function was impaired in 21%, 20%, and 27% of patients on the basis of right ventricular fractional area change, tricuspid annular plane systolic excursion, and right ventricular longitudinal peak systolic strain, respectively. Any echocardiographic parameter of right ventricular dysfunction was present in 39% of patients. The coexistence of several impaired right ventricular parameters per patient was independently associated with increased 30-day mortality (hazard ratio, 2.83; 95% confidence interval, 1.64-4.87, P < .01 per additional impaired parameter). ConclusionsBaseline right ventricular systolic dysfunction is independently associated with increased mortality in patients with ischemic heart failure undergoing surgical left ventricular restoration.

Giant true inferoposterior left ventricular aneurysm presenting with heart failure: insights from multimodality imaging

A 58-year old male patient who had undergone post-infarction ventricular septal defect closure and venous coronary bypass grafting to the obtuse marginal artery 2 years previously, presented with congestive heart failure. Echocardiography, computed tomography and ventriculography revealed a giant inferoposterior left ventricular aneurysm (Fig. 1A–D, Supplementary Video 1). Surgical left ventricular restoration was performed by a direct linear suture (Fig. 1E and F).

Left ventricular surgical restoration: is it a matter of shape or volume?

Left ventricular surgical restoration: is it a matter of shape or volume?

Alternatives to heart transplantation integration of biology with surgery

Chronic heart failure is one of the major health care issues in terms of increasing number of patients, rate of hospitalizations and costs. Heart transplantation is the best established therapy for patients with severe heart failure. However, the number of donors limits the activity to 5000 heart transplants performed annually worldwide. This limitation has generated alternative treatments. The increase of the interest in the reversibility of the heart failure and the application of new biological alternatives has generated therapeutic strategies designed to integrate biology and medical technologies in order to act to the biomechanical, the molecular and the neurohormonal mechanisms of heart failure. These treatments include cellular cardiomyoplasty, tissue engineering, surgical left ventricular restoration as well as passive and active mechanical ventricular assistance as destination therapy, bridge to recovery or bridge to transplantation. The integrated development of these approaches could offer hopeful treatments, although there is still much to be learned regarding the optimal use of these strategies.

Left ventricular surgical restoration for anteroseptal scars: Volume versus shape

We report the long-term results of left ventricular surgical restoration in which 2 different strategies were used, which had restoration of ventricular volume or ventricular shape as their target. From 1988 to 2008, 308 patients with anterior scars underwent elective left ventricular surgical restoration. Before 2002, a Dor procedure was performed in 107 cases to reduce left ventricular volume (group V); from 1998 to 2001, a Guilmet procedure was performed in 32 patients to rebuild a left ventricular conical shape (group S). From 2002, 169 patients (group S) underwent left ventricular surgical restoration to reshape a conical left ventricle by means of the Dor procedure (n = 29, septoapical scars) or septal reshaping (n = 140, when the septum was more involved than the anterior wall). The 2 groups were similar for all features but age, mitral regurgitation grade, mitral valve surgery rate (higher in group S), and ejection fraction (higher in group V). Early mortality was 7.8% (11.2% in group V vs 6.0% in group S, P = .102). Logistic regression showed that volume reduction was significantly related to higher early mortality. Five-year cardiac survival, cardiac event-free survival, and event-free survival were higher in group S. Cox analysis showed that the choice of volume reduction provided lower survival (hazard ratio, 2.1), cardiac survival (hazard ratio, 3.0), cardiac event-free survival (hazard ratio, 2.7), and event-free survival (hazard ratio, 2.2). When 30-day events were excluded, volume reduction was still a risk factor for cardiac event-free survival (hazard ratio, 2.2). When the main target of left ventricular surgical restoration is left ventricular reshaping rather than left ventricular volume reduction, early and late outcomes seem to improve.

347: Surgical Left Ventricular Restoration Improves Systolic Function by Optimizing Mechanical Intraventricular Synchrony and Synergy in Ischemic Cardiomyopathy

347: Surgical Left Ventricular Restoration Improves Systolic Function by Optimizing Mechanical Intraventricular Synchrony and Synergy in Ischemic Cardiomyopathy

Surgical left ventricular restoration improves systolic function by optimizing mechanical intraventricular synchrony and synergy in ischemic cardiomyopathy

Objective: Surgical left ventricular restoration (SVR) by endoventricular patch aneurysmectomy should result in improved left ventricular (LV) performance.

Acute decrease of left ventricular mechanical dyssynchrony and improvement of contractile state after left ventricular restoration

Objective: Surgical left ventricular restoration (SVR) by means of endoventricular patch aneurysmectomy in patients with post infarction aneurysm should result in acutely improved left ventricular performance. This study tests the capacity of geometric rebuilding by SVR to reconstitute a more synchronous and synergic contractile pattern.

Helical myofiber orientation after myocardial infarction and left ventricular surgical restoration in sheep

It has been proposed that successful left ventricular surgical restoration should restore normal helical myofiber orientation. A magnetic resonance imaging technique, magnetic resonance diffusion tensor imaging, has been developed to measure myocyte orientation. By using magnetic resonance diffusion tensor imaging, this study tested the hypothesis that (1) myocyte orientation is altered after anteroapical myocardial infarction and (2) left ventricular surgical restoration restores normal helix angles. Thirteen sheep underwent anteroapical myocardial infarction (25% of left ventricular mass). Ten weeks later, animals underwent either aneurysm plication (n = 8) or sham operations (n = 5). Six weeks after this operation, hearts were excised, perfusion fixed in diastole, and underwent magnetic resonance diffusion tensor imaging. Hearts from normal sheep (n = 5) were also harvested and imaged. Primary eigenvectors of the diffusion tensors from magnetic resonance diffusion tensor imaging were resolved into helix angles relative to a local wall coordinate system. Transmural samples of the helix angles were compared at the border zone of the aneurysm or repair (or a comparable distance from the base in normal sheep), 1 cm below the valves, and halfway between. The helical myofiber orientation did not change after myocardial infarction. However, aneurysm plication caused myofibers in the anterior border zone to rotate counterclockwise (-35.6 +/- 10.5 degrees , P = .028) and those in the lateral border zone to rotate clockwise (34.4 +/- 8.1 degrees , P = .031). Surgical restoration alters myocyte orientation adjacent to the surgical repair. However, myofiber orientation is not abnormal after myocardial infarction, and thus surgical restoration techniques intent on restoring normal helix angles might not be warranted.

Acute decrease of left ventricular mechanical dyssynchrony and improvement of contractile state and energy efficiency after left ventricular restoration

Objective Surgical left ventricular restoration by means of endoventricular patch aneurysmectomy in patients with postinfarction aneurysm should result in acute improved left ventricular performance by decreasing mechanical dyssynchrony and increasing energy efficiency. Methods Nine patients with left ventricular postinfarction aneurysm were studied intraoperatively before and after ventricular restoration with a conductance volume catheter to analyze pressure-volume relationships, energy efficiency, and mechanical dyssynchrony. The end-systolic elastance was used as a load-independent index of contractile state. Left ventricular energy efficiency was calculated from stroke work and total pressure-volume area. Segmental volume changes perpendicular to the long axis were used to calculate mechanical dyssynchrony. Statistical analysis was performed with the paired t test and least-squares linear regression. Results Endoventricular patch aneurysmectomy reduced end-diastolic volume by 37% ( P < .001), with unchanged stroke volume. Systolic function improved, as derived from increased +dP/dt max, by 42% ( P < .03), peak ejection rate by 28% ( P < .02), and ejection fraction by 16% ( P < .0002). Early diastolic function improved, as shown by reduction of −dP/dt max by 34% ( P < .006) and shortened τ by 30% ( P < .001). Left ventricular end-systolic elastance increased from 1.2 ± 0.6 to 2.2 ± 1 mm Hg/mL ( P < .001). Left ventricular energy efficiency increased by 36% ( P < .002). Left ventricular mechanical dyssynchrony decreased during systole by 33% ( P < .001) and during diastole by 20% ( P < .005). Conclusions Left ventricular restoration induced acute improvements in contractile state, energy efficiency, and relaxation, together with a decrease in left ventricular mechanical dyssynchrony.