Surgical Ventricular Reconstruction Research Articles

Second successful surgical ventricular reconstruction: a cardiac magnetic resonance imaging illustration

This case reports a magnetic resonance imaging (MRI) illustration of a successful ventricular reconstruction of a left ventricle pseudoaneurysm that developed four months after postmyocardial infarction ventricular repair. Thus, preoperative non-invasive MRI techniques are valuable diagnostic tools in this setting. Indeed, the present case shows that MRI greatly helped in the management and surgical decision-making.

The STICH trial: evidence‐based conclusions

The process begins with infarct expansion nearlyimmediatelypost-MIandisfollowedbyprogressiveeccentrichyper-trophy, cardiac fibrosis, and reduced contractility of the remainingcardiomyocytes and can result in significant LV distortion, impairedventricular filling, reduced ventricular function, and mitral regurgita-tion.

The STICH trial unravelled

The STICH trial unravelled

Low-Risk Profile for Malignant Ventricular Arrhythmias and Sudden Cardiac Death after Surgical Ventricular Reconstruction

Although it has been recently demonstrated that there was no significant difference in total survival and clinical outcomes between patients who underwent coronary artery bypass grafting (CABG) with or without surgical ventricular reconstruction (SVR), the question of whether or not SVR decreases the arrhythmic risk profile in this population has not been clarified yet. To determine the real incidence of sudden cardiac death (SCD) and sustained ventricular tachycardia/ventricular fibrillation (sustained VT/VF) in patients following CABG added to SVR and to define their clinical and echocardiographic parameters predicting in-hospital and long-term arrhythmic events (SCD + sustained VT/VF). Pre- and postoperative clinical and echocardiographic values as well as postoperative electrocardiogram Holter data of 65 patients (21 female, 63 ± 11 years) who underwent SVR + CABG were retrospectively evaluated. Mean follow-up was 1,105 ± 940 days. At 3 years, the SCD-free rate was 98% and the rate free from arrhythmic events was 88%. Multivariate logistic analysis identified a preoperative left ventricular end-systolic volume index (LVESVI) > 102 mL/m(2) (odds ratio [OR] 1.4, confidence interval [CI] 1.073-1.864, P = 0.02; sensitivity 100%, specificity 94%) and a postoperative pulmonary artery systolic pressure (PASP) > 27 mmHg (OR 2.3, CI 1.887-4.487, P = 0.01; sensitivity 100%, specificity 71%) as independent predictors of arrhythmic events. Our and previous studies report a low incidence of arrhythmic events in patients following SVR added to CABG, considering the high-risk profile of the study population. A preoperative LVESVI > 102 mL/m(2) and a postoperative PASP > 27 mmHg had a good sensitivity and specificity in predicting arrhythmic events.

Impact of surgical ventricular reconstruction for ischemic dilated cardiomyopathy on restrictive filling pattern

Little information related to the effects of surgical ventricular reconstruction on left ventricular diastolic function is available. The aims of this study were to examine the effects of surgical ventricular reconstruction on left ventricular diastolic function and assess the predictive significance of that function on clinical outcome in patients with ischemic cardiomyopathy due to broad anteroseptal myocardial infarction undergoing surgical ventricular reconstruction. We studied 21 patients undergoing surgical ventricular reconstruction and combined surgery for ischemic cardiomyopathy with a low ejection fraction (mean ejection fraction 23% +/- 6%). Doppler echocardiography was performed before and 6 +/- 4 months after the operation. There were no deaths within 30 days. Of the 21 patients, 6 reached the clinical endpoint (cardiac death or hospitalization due to congestive heart failure). The Doppler-derived restrictive filling pattern--defined as the deceleration time (DcT) <140 ms and the mitral peak early/mitral late diastolic filling velocity (E/A) ratio >1.5--was significantly related to reaching the clinical endpoint (P < 0.01). Furthermore, stepwise multivariate analysis showed that a preoperative restrictive filling pattern was the only independent predictor of reaching the clinical endpoint (P < 0.005, F = 11.2). In patients with ischemic cardiomyopathy undergoing surgical ventricular reconstruction and combined surgery, surgical ventricular reconstruction did not change the restrictive filling pattern, and the preoperative restrictive filling pattern was an important marker of postoperative clinical outcome.

Left ventricular aneurysm that grew to rupture☆

We present the case of a 47-year-old man who presented with asymptomatic ischemic cardiomyopathy. His left ventricular end-diastolic volume (EDV) measured 302 ml, ejection fraction (EF) was 30%, and a large akinetic area with no typical aneurysm was present. He was managed medically but within three years his ventricle remodeled, developed an aneurysm and ruptured. He was operated on using our own modification of the Dor/Menicanti method and autoseptoplasty with no patch. The operation decreased EDV from 950 ml to 205 ml and improved EF from 5% to 55%. In addition, the ventricle became conical with no akinetic segments. This case shows that in some patients surgical ventricular reconstruction may be unavoidable. Good quality of proximal segments ensures a favorable outcome of surgery even in extremely enlarged ventricles with very low EF. The surgical technique presented may be used in cases of grossly enlarged ventricles.

Clinical Characteristics of Patients Undergoing Surgical Ventricular Reconstruction by Choice and by Randomization

The aim of this study was to confirm the generalizability of the conclusions of the STICH (Surgical Treatment for Ischemic Heart Failure) trial. Surgical ventricular reconstruction (SVR) added to coronary artery bypass grafting (CABG) did not decrease death or cardiac hospitalization in STICH patients randomized to CABG with (n = 501) or without (n = 499) SVR. Baseline clinical characteristics of 1,000 STICH SVR hypothesis patients and 1,036 STICH-eligible Society of Thoracic Surgeons (STS) National Cardiac Database patients undergoing CABG plus SVR were entered into a multivariate model equation to predict a mortality that placed these 2,036 patients in 1 of 32 risk at randomization (RAR) groups. The number of patients in each RAR group profiled the risk of STICH treatment arms and of STICH and STS STICH-eligible patients. That 85% of the 1,000 STICH patients known to have no significant differences in baseline characteristics between the 2 treatment arms shared the same RAR group suggests that the RAR methodology has sufficient accuracy to compare RAR profiles of STICH and STS patients. RAR group was shared by 1,522 of 2,036 STICH and STS STICH-eligible patients (75%) who underwent CABG plus SVR. Differences in baseline characteristics responsible for more low-risk STICH patients and more high-risk STS patients were modest. Cox proportional hazard ratios of 1,000 STICH patients in 3 RAR groups suggested by STICH and STS RAR differences showed no differential treatment effect on survival across the low-, intermediate-, and high-risk groups. The STICH conclusion of no benefit from adding SVR to CABG applies to a broad spectrum of CABG-eligible patients with ischemic cardiomyopathy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease; NCT00023595).

Clinical trials update from the American College of Cardiology meeting 2010: DOSE, ASPIRE, CONNECT, STICH, STOP‐AF, CABANA, RACE II, EVEREST II, ACCORD, and NAVIGATOR

This article provides information and a commentary on trials relevant to the pathophysiology, prevention and treatment of heart failure presented at the annual meeting of the American College of Cardiology held in March 2010. Unpublished reports should be considered as preliminary, since analyses may change in the final publication. Results from DOSE suggest that giving diuretics using a high-dose, bolus strategy may be better than using lower doses or a continuous infusion for patients with acute decompensated heart failure. In the ASPIRE study, addition of aliskiren to standard therapy failed to attenuate left ventricular remodelling in post-MI patients and was associated with more adverse events. In CONNECT, remote monitoring reduced the time from CRT-D- or ICD-detected events to clinical decision and this was associated with fewer clinic visits and shorter hospitalizations. An analysis from STICH testing the effects of surgical ventricular reconstruction showed no benefit in the sub-group of patients who achieved a greater reduction in LV volume. STOP-AF and CABANA did not provide convincing evidence of the effectiveness or safety of catheter ablation for the treatment of AF. RACE II suggests that lenient heart rate control might be as effective as strict rate control in patients with permanent atrial fibrillation. In EVEREST II, a catheter-based mitral valve repair procedure using the MitraClip system had similar efficacy to traditional surgery but with fewer short-term adverse effects. Valsartan reduced progression to diabetes in patients with impaired glucose tolerance but had no effect on cardiovascular events in NAVIGATOR. In ACCORD, strict blood pressure control failed to reduce the risk of overall cardiovascular events in high-risk diabetic patients.

Impact of surgical ventricular reconstruction on stroke volume in patients with ischemic cardiomyopathy

Left ventricular end-diastolic volume is decreased and ejection fraction is increased after surgical ventricular reconstruction; however, the impact on left ventricular stroke volume is not well established. We analyzed 248 consecutive patients who underwent surgical ventricular reconstruction at a single center. There were 14 perioperative deaths (5.6%). The 234 surviving patients had pre- and postsurgical ventricular reconstruction echocardiographic measurement of end-diastolic volume, end-systolic volume, and stroke volume, each indexed to body size and ejection fraction. A total of 120 patients had echocardiography data at follow-up (median 8 months). Overall, surgical ventricular reconstruction resulted in reductions in end-diastolic volume index (-30% ± 18%) and end-systolic volume index (-37% ± 20%), and increases in ejection fraction (21% ± 18% relative increase). However, stroke volume index decreased from 35 ± 8 mL/m(2) preoperatively to 28 ± 7 mL/m(2) early postoperatively (a 17% ± 24% relative reduction, P < .0001); 165 patients (71%) exhibited a decrease and 69 patients (29%) exhibited an increase or no change in stroke volume index after surgical ventricular reconstruction. Stroke volume index reduction was strictly related to end-diastolic volume reduction. Patients who initially had a stroke volume index decrease showed recovery, so that at the time of chronic follow-up there was no significant difference between the groups. Notably, 4-year survival was approximately 85% and did not differ between patients with an increase or decrease in stroke volume index (P = .383). Although surgical ventricular reconstruction uniformly results in an impressive decrease in end-diastolic volume index and increase in ejection fraction, seemingly indicating beneficial remodeling and improved pump function, systolic volume index, which more directly indexes cardiac pump function, frequently decreases after surgical ventricular reconstruction. Further study is needed to identify baseline characteristics that predict those patients in whom cardiac performance is enhanced by surgical ventricular reconstruction and to clarify whether there is a beneficial impact on exercise tolerance and cardiac output at peak exercise.

Surgical ventricular reconstruction with different myocardial protection strategies. A propensity matched analysis☆

The aim of this study is to compare outcomes of patients undergoing surgical ventricular reconstruction (SVR) with normothermic cardiopulmonary bypass (CPB) and beating heart or hypothermic CPB and cardioplegic arrest. Between 2001 and 2008, 588 patients underwent SVR. A propensity score matching was performed and 91 matched pairs were created: group 1 (G1) operated with normothermic CPB and beating-heart technique, and group 2 (G2) operated with hypothermic CPB and cardioplegic arrest. Mean age was 62+/-9 years in G1 and 63+/-10 years in G2 [not significant (NS)]. Average follow-up was 42.7+/-26 months (range 1-72). Major cardiac and cerebro-vascular events (MACCE) were assessed. Thirty-day mortality was 4% in G1 and 5% in G2 (NS). Kaplan-Meier survival at six years was 79+/-4% and 72+/-9% (NS) and freedom from MACCE was 82+/-4% and 83+/-7% in G1 and G2, respectively (NS). Left ventricular volume reduction, ejection fraction and New York Heart Association (NYHA) class improvement were significant in the overall population; no significant differences were found between groups. The following independent risk factors for cardiac death were identified: mitral valve regurgitation, surgery <3 months from myocardial infarction, NYHA class III-IV. This study showed that outcomes following SVR are not affected by myocardial protection strategies neither in cardiac function and clinical status nor in survival.

End‐systolic volume following surgical ventricular reconstruction impacts survival in patients with ischaemic dilated cardiomyopathy

A left ventricular end-systolic volume (LVESV) > or =60 mL/m(2) has been shown to be associated with increased cardiac mortality after a reperfused myocardial infarction (MI). The reduction in LVESV following surgical ventricular reconstruction (SVR) is reported to be between 19% and 50% but its impact on prognosis is not well-established. The aim of this study was therefore to assess the impact on survival of a residual LVESV index (LVESVI) of > or = or <60 mL/m(2) following SVR. All patients undergoing SVR at our Centre between July 2001 and March 2009 were eligible to be included in this study if they had a preoperative LVESVI of > or =60 mL/m(2) and an LVESVI measurement performed at discharge (7-10 days after surgery). Two hundred and sixteen patients (aged 64 +/- 9 years, 33 women) satisfied these criteria. Coronary artery bypass graft was performed in 197 patients (91.2%) and mitral repair in 63 patients (29%). Left ventricular ESVI had decreased by 41% at discharge in the overall population. Patients were grouped according to the residual LVESVI at discharge as follows: Group 1, LVESVI > or = 60 mL/m(2) (n = 71), and Group 2, LVESVI < 60 mL/m(2) (n = 145). In both groups, LVESVI decreased significantly with respect to baseline, by 29% in Group 1 and by 47% in Group 2. At multivariate analysis, the presence of a non-Q-wave MI and a preoperative internal diastolic diameter of 65 mm were the strongest predictors of a residual post-operative LVESVI of > or =60 mL/m(2). Risk of all-cause death was significantly higher in Group 1. Post-operative LVESVI of > or =60 mL/m(2) was an independent predictor of mortality at follow-up [Exp(B) = 10.7, CI: 2.67-42.9, P = 0.001]. Our findings confirm the role of LVESVI in predicting survival following SVR; the lack of additional improvement in survival with SVR observed in the STICH trial might be due to the inadequate volume reduction (-19%).

CMR-based quantification of basal myocardial scar as predictor of functional improvement after left ventricular surgical ventricular reconstruction

Background: Surgical ventricular reconstruction (SVR) is a treatment option for patients with apical a- or dyskinesia. The STICH trial (Jones et al. NEJM 2009) demonstrated its safety but no added benefit to bypass surgery. However, the trial's inclusion criteria for SVR were not specific and did not contain shape or viability parameters.

Global and regional function quantified on MRI before and after surgical ventricular reconstruction

Methods Cardiac MRI was performed before (n = 14) and 1.4 ± 1.1 months after (n = 11) SVR (64 ± 9 years, 10 male). Global function and ventricular volumes were assessed by cine MRI. Cardiac output was calculated by MR flow measurement of the aorta. Strain (change in myocardial length divided by original length) was used as a parameter of regional function and measured by phase velocity encoded MRI of the myocardium. Strain measurements could be adequately obtained in 7 patients before and 7 patients after surgery where 5 were imaged both before and after.

Coronary Bypass Surgery with or without Surgical Ventricular Reconstruction

Coronary Bypass Surgery with or without Surgical Ventricular Reconstruction

Coronary Bypass Surgery with or without Surgical Ventricular Reconstruction

Coronary Bypass Surgery with or without Surgical Ventricular Reconstruction

Effects of surgical ventricular reconstruction on diastolic function at midterm follow-up

Limited data are available on the effects of surgical ventricular reconstruction on diastolic function. The aim of the present study was to evaluate changes in diastolic function induced by surgical ventricular reconstruction at 2 time intervals after surgery (discharge and follow-up) and to assess the impact of diastolic changes on clinical outcome. A total of 129 patients (65 +/- 9 years, 14 women) underwent echocardiographic Doppler evaluation before surgical ventricular reconstruction, at discharge, and at follow-up (median 7 months). Patients with mitral regurgitation were excluded. Diastolic pattern was graded as follows: 0 (normal), 1 (abnormal relaxation), 2 (pseudo normalization), 3 (restrictive, reversible), and 4 (restrictive, irreversible). At follow-up, 28 (21.7%) of 129 patients showed a restrictive diastolic pattern (grade 3-4; group 1) and 101 did not (diastolic pattern grade 0-2; group 2). Preoperative and postoperative factors strongly associated with late diastolic restriction included sphericity index (higher in group 1), ventricular shape (nonaneurysmal shape more frequent in group 1), internal dimensions (greater in group 1), diastolic pattern (higher in group 1), ejection fraction (lower in group 1); left atrial dimensions (greater in group 1); mitral regurgitation rate (higher in group 1). At multivariate analysis the most powerful predictors of restriction were preoperative pseudonormalization of diastolic pattern (diastolic pattern 2) and septolateral dimensions (short axis). Overall, ejection fraction improved from 33% +/- 9% to 40% +/- 9% to 40% +/- 9%; P = .001; end-diastolic and end-systolic volumes decreased (112 +/- 41 to 73 +/- 21 to 88 +/- 28 mL/m(2), respectively; P = .001; and 77 +/- 38 to 44 +/- 17 to 52 +/- 24 mL/m(2), respectively; P = .001); New York Heart Association class improved (2.4 +/- 0.8 to 1.6 +/- 0.6; P = .001). Mild preoperative diastolic dysfunction (pseudonormalized pattern) and increased septolateral dimensions are independent predictors of diastolic restriction after surgical ventricular reconstruction.

Quality of life and economic outcomes with surgical ventricular reconstruction in ischemic heart failure: Results from the Surgical Treatment for Ischemic Heart Failure trial

Surgical ventricular reconstruction (SVR) is used in conjunction with coronary artery bypass graft surgery (CABG) to improve left ventricular function and clinical outcomes in selected patients with ischemic heart failure. The impact of SVR on quality of life (QOL) and medical costs is unknown. We compared CABG plus SVR with CABG alone in 1,000 patients with ischemic heart failure, an anterior wall scar, and a left ventricular ejection fraction <or=0.35. In 991 (99% of eligible), we collected a battery of QOL instruments. The principal, prespecified QOL measure was the Kansas City Cardiomyopathy Questionnaire, which evaluates the effects of heart failure symptoms on QOL using a scale from 0 to 100 with higher scores indicating better QOL. Structured QOL interviews were conducted at baseline, 4, 12, 24, and 36 months post randomization and were >or=92% complete. Cost data were collected on 196 (98%) of 200 patients enrolled in the United States. Heart-failure-related QOL outcomes did not differ between the 2 treatment strategies out to 3 years (median Kansas City Cardiomyopathy Questionnaire scores for CABG alone and CABG plus SVR, respectively: baseline 53 versus 54, P = .53; 3 years 85 versus 84, P = .89). There were no treatment-related differences in other QOL measures. In the US patients, total index hospitalization costs averaged over $14,500 higher for CABG plus SVR (P = .004) due primarily to 4.2 extra postoperative, high-intensity care days in the hospital. Addition of SVR to CABG in patients with ischemic heart failure did not improve QOL but significantly increased health care costs.

Coronary Bypass Surgery with or without Surgical Ventricular Reconstruction

Surgical ventricular reconstruction is a specific procedure designed to reduce left ventricular volume in patients with heart failure caused by coronary artery disease. We conducted a trial to address the question of whether surgical ventricular reconstruction added to coronary-artery bypass grafting (CABG) would decrease the rate of death or hospitalization for cardiac causes, as compared with CABG alone. Between September 2002 and January 2006, a total of 1000 patients with an ejection fraction of 35% or less, coronary artery disease that was amenable to CABG, and dominant anterior left ventricular dysfunction that was amenable to surgical ventricular reconstruction were randomly assigned to undergo either CABG alone (499 patients) or CABG with surgical ventricular reconstruction (501 patients). The primary outcome was a composite of death from any cause and hospitalization for cardiac causes. The median follow-up was 48 months. Surgical ventricular reconstruction reduced the end-systolic volume index by 19%, as compared with a reduction of 6% with CABG alone. Cardiac symptoms and exercise tolerance improved from baseline to a similar degree in the two study groups. However, no significant difference was observed in the primary outcome, which occurred in 292 patients (59%) who were assigned to undergo CABG alone and in 289 patients (58%) who were assigned to undergo CABG with surgical ventricular reconstruction (hazard ratio for the combined approach, 0.99; 95% confidence interval, 0.84 to 1.17; P=0.90). Adding surgical ventricular reconstruction to CABG reduced the left ventricular volume, as compared with CABG alone. However, this anatomical change was not associated with a greater improvement in symptoms or exercise tolerance or with a reduction in the rate of death or hospitalization for cardiac causes. (ClinicalTrials.gov number, NCT00023595.)

Surgical Ventricular Reconstruction: Function Fails to Follow Form

Can surgical reconstruction of the left ventricle at the time of coronary artery bypass grafting improve outcomes in patients with depressed LV

Fluid-Dynamic Modeling of the Human Left Ventricle: Methodology and Application to Surgical Ventricular Reconstruction

The efficacy of surgical ventricular reconstruction (SVR) for ischemic cardiomyopathy has never been truly quantified. Methods to assess ventricular flow have not been applied to these patients. The objective is to develop a volume-independent technique for assessing the effects of ischemic remodeling and SVR on left ventricular blood flow dynamics. Cardiac magnetic resonance images from a healthy volunteer and from a patient before and after SVR were segmented and transformed to generate a grid model of the heart by generating numeric grids and running third-order approximations to achieve 850 grid images per cardiac cycle. These grids formed the skeletal structure of our patient-specific time-dependent ventricular geometry model, the Karlsruhe Heart Model, used for modeling fluid dynamics. We modeled flow, ejection fraction, and blood washout from the ventricle. The model was validated using a silicone ventricle and mock circulation. In the healthy heart and before SVR, ejection fractions were 0.61 and 0.15 and left ventricular volumes were 166 mL and 175 mL, respectively. Surgical ventricular reconstruction decreased left ventricular volume by one fourth. Postoperative ejection fraction was 0.18 in the patient. Post-SVR shape was more spherical than preoperatively and also more spherical than the healthy heart. Ventricular flow patterns in the patient were significantly altered by SVR. However, fluid washout from the ventricle was similar before and after SVR but worse than in the healthy heart. Fluid dynamic modeling of the heart is possible based on cardiac magnetic resonance imaging data and enables volume-independent quantitative assessment of the surgical procedure. In the future, preoperative modeling for patients with remodeled ventricles may help to achieve optimized post-SVR flow characteristics and potentially outcomes.