Surgical Ventricular Restoration Research Articles

Growth and remodeling of the left ventricle: A case study of myocardial infarction and surgical ventricular restoration

Cardiac growth and remodeling in the form of chamber dilation and wall thinning are typical hallmarks of infarct-induced heart failure. Over time, the infarct region stiffens, the remaining muscle takes over function, and the chamber weakens and dilates. Current therapies seek to attenuate these effects by removing the infarct region or by providing structural support to the ventricular wall. However, the underlying mechanisms of these therapies are unclear, and the results remain suboptimal. Here we show that myocardial infarction induces pronounced regional and transmural variations in cardiac form. We introduce a mechanistic growth model capable of predicting structural alterations in response to mechanical overload. Under a uniform loading, this model predicts non-uniform growth. Using this model, we simulate growth in a patient-specific left ventricle. We compare two cases, growth in an infarcted heart, pre-operative, and growth in the same heart, after the infarct was surgically excluded, post-operative. Our results suggest that removing the infarct and creating a left ventricle with homogeneous mechanical properties does not necessarily reduce the driving forces for growth and remodeling. These preliminary findings agree conceptually with clinical observations.

Transventricular Edge-to-Edge Repair of the Mitral Valve During Surgical Ventricular Restoration: Review of the Literature

Mitral valve surgery for functional ischemic mitral regurgitation (MR) in high-risk patients, including those requiring multiple concomitant cardiac operations, carries a significant risk of morbidity and mortality. In patients undergoing surgical ventricular restoration, transventricular edge-to-edge repair provides an effective alternative to conventional mitral valve surgery. We report such a case. A 67-year-old male with ischemic cardiomyopathy and severe left ventricular dysfunction presented to our institution with a 3-month history of dyspnea on exertion, angina, and leg edema. He was found to have triple-vessel coronary artery disease, a severely dilated left ventricle with an apical aneurysm, and moderate-to-severe MR (3+). In addition to coronary artery bypass graft surgery, an edge-to-edge mitral valve repair was undertaken via a longitudinal ventriculotomy performed for concomitant surgical ventricular restoration. Total cardiopulmonary bypass and aortic cross-clamp times were 101 minutes and 86 minutes, respectively. Postoperative transesophageal echocardiography revealed no MR, and the patient was discharged home on postoperative day 9. A follow-up transthoracic echocardiogram revealed trace MR on postoperative day 15. At 11 months postoperative, the patient remains in New York Heart Association functional class I. Transventricular edge-to-edge repair of the mitral valve in patients with ischemic cardiomyopathy and functional MR undergoing SVR is a safe and effective alternative to conventional valve surgery, and should be considered in this high-risk population.

A Mid-Term Follow-Up of Surgical Ventricular Restoration Patients From the STICH Era

A Mid-Term Follow-Up of Surgical Ventricular Restoration Patients From the STICH Era

Myocardial collagen turnover after surgical ventricular restoration in heart failure patients

Surgical ventricular restoration (SVR) aims to normalize left ventricular (LV) volume and shape in patients with ischaemic cardiomyopathy and anterior wall scar. The chronic effects on LV function may depend on alterations in myocardial collagen metabolism. The present study evaluated myocardial collagen synthesis and degradation rates at baseline and at 6 months follow-up after SVR. We hypothesize that the chronic effects of SVR on LV function and clinical outcome depend on alterations in myocardial collagen metabolism. Serum levels of aminoterminal propeptides of type I and III collagen (PINP, PIIINP), carboxyterminal telopeptide of type I collagen (ICTP), and tenascin-C (TNC) were measured at baseline and 6 months after SVR in 24 patients. In addition, New York Heart Association (NYHA) functional class, LV volumes and function were evaluated. At follow-up, a significant improvement in NYHA class (from 3.2 ± 0.8 to 1.4 ± 0.6, P< 0.001) and LV ejection fraction (from 28 ± 9 to 35 ± 7%, P< 0.001) was found, whereas E/A ratio tended to increase (from 1.4 ± 1.1 to 1.9 ± 1.1, P= 0.064). Serum levels of PINP, PIIINP, ICTP, and TNC increased significantly (PINP: from 37 ± 15 to 67 ± 26 μg/L, P< 0.001; PIIINP: from 4.9 ± 1.7 to 7.9 ± 4.0 μg/L, P< 0.001; ICTP: from 5.9 ± 3.7 to 10.0 ± 5.3 μg/L, P< 0.001; TNC: from 30 ± 20 to 44 ± 23 μg/L, P= 0.020). At follow-up, an LV ejection fraction <34% and E/A ratio ≥ 2.0 were significantly associated with increased serum levels of PIIINP and ICTP. In patients who underwent SVR, myocardial collagen metabolism was significantly enhanced 6 months after surgery. Serum levels of myocardial collagen turnover biomarkers were related to post-surgical LV systolic and diastolic function.

Implantation of a Jarvik 2000 left ventricular assist device as a bridge to eligibility for refractory heart failure with renal dysfunction

A 55-year-old man, who previously underwent surgical ventricular restoration and mitral valve surgery, was referred to our department for management of refractory heart and multiple organ failure. At the time of admission to our hospital, he could not be registered as a candidate for heart transplantation because of severe renal failure with a serum creatinine level of 4.6 mg/dl. We considered that he was a marginal candidate for heart transplantation; thus, it was essential to understand the etiology of renal failure and estimate whether it was reversible. Cardiac catheterization revealed poor hemodynamic function with a systemic pressure of 107/60 mmHg, cardiac index of 2.5 l/min/m(2), and pulmonary artery pressure of 63/27 mmHg, despite intense medical treatment. Contrary to biochemical examination findings of blood, renal biopsy findings showed no significant glomerular abnormality. Furthermore, the severity of tubular atrophy and interstitial fibrosis in the cortex was mild. These pathological findings suggested that the renal dysfunction in this case was possibly attributable to a hemodynamic factor. His symptoms gradually deteriorated despite an increasing dose of inotropic support; thus, we planned implantation of a Jarvik 2000 axial-flow pump (Jarvik Heart Inc., New York, NY, USA) as a bridge to eligibility, and informed consent was obtained. Because of a tight adhesion on the anterior wall, we placed the device on the lateral wall of the left ventricle, making sure not to direct the pump at the septum. Postoperatively, the implantable left ventricular assist device provided relief from heart failure symptoms as well as recovery of renal function, with serum the creatinine level at 1.2 mg/dl, which allowed the patient to become an appropriate candidate for heart transplantation. At an 18-month follow-up examination, his status was uneventful, and he is now at home awaiting heart transplantation.

Restrictive Mitral Annuloplasty With or Without Surgical Ventricular Restoration in Ischemic Dilated Cardiomyopathy With Severe Mitral Regurgitation

We assessed changes in left ventricular (LV) volume and function and in regional myocardial wall stress in noninfarcted segments after restrictive mitral annuloplasty (RMA) with or without surgical ventricular restoration (SVR). Thirty-nine patients with ischemic cardiomyopathy (ejection fraction ≤ 0.35) and severe mitral regurgitation (≥ 3) were studied before and 2.8 months after surgery with cine-angiographic multidetector computed tomography (cine-MDCT). Eighteen underwent RMA alone (RMA group) and 21 underwent RMA and SVR (RMA+SVR group). In addition to measuring conventional parameters (LV end-diastolic volume index [LVEDVI], LV end-systolic volume index [LVESVI], and LV ejection fraction), we evaluated the regional circumferential end-systolic wall stress and mean circumferential fiber shortening in both the basal and mid-LV regions using 3-dimensional cine-MDCT images. LV end-diastolic and end-systolic volume indexes were significantly greater in the RMA+SVR group than in the RMA group preoperatively, but these values did not differ significantly postoperatively. LV end-diastolic and end-systolic volume indexes decreased significantly, by 21% and 27% after RMA and by 35% and 42% after RMA and SVR, and the percent reductions in LV end-diastolic and end-systolic volume indexes were significantly larger in the RMA+SVR group. Regional end-systolic wall stress decreased and circumferential fiber shortening increased significantly in the noninfarcted regions after RMA with or without SVR. RMA plus SVR showed a potentially greater reduction of LV end-diastolic and end-systolic volume indexes than RMA alone. In selected patients with more advanced LV remodeling, concomitant SVR may favorably affect the LV reverse-remodeling process induced by RMA.

Catheter ablation of ventricular tachycardia after left ventricular reconstructive surgery for ischemic cardiomyopathy

After surgical ventricular restoration (SVR) for ischemic cardiomyopathy, ventricular tachycardias (VTs) are an important reason for postoperative morbidity and mortality. The purpose of this study was to elucidate the VT substrate, VT characteristics, and outcome of radiofrequency catheter ablation (RFCA) in patients with VT after SVR. Twelve (3%) of 416 patients referred for RFCA for VT after myocardial infarction in three centers had undergone SVR. After induction of VT, left ventricular (LV) electroanatomical mapping was performed. Ablation target sites were identified by entrainment, substrate, and/or pace mapping. Four (33%) patients presented within the perioperative period with incessant VT, and eight (67%) presented with incessant or recurrent VT late after SVR (VT cycle length 453 ± 102 ms). The region of surgical scar was identified by electroanatomical mapping in 11 patients. Twenty-eight VTs (cycle length 384 ± 95 ms) were induced. The VT exit was bordering the surgical scar in 20 (71%) VTs, of which 15 were at the septal side. All VTs were abolished in five patients: in four only the clinical VTs were abolished, and in one reinducibility was not tested. In two patients, ablation failed after which surgical ablation was performed successfully. During follow-up, three (25%) patients died (nonarrhythmic deaths); all had presented early after SVR. Two (17%) experienced recurrent VT. VT after LV SVR seems to have a bimodal presentation; one-third presented with incessant VT in the acute postoperative phase and had a high mortality. Two-thirds presented late after SVR; in these patients RFCA is usually effective. Successful ablation sites are frequently located at the border of surgical scars and patch material.

Reply to Poullis

We read Dr Poullis’s letter addressing our article with great interest [1]. Firstly, we would like to clarify that our article was not meant to be a head-to-head comparison with the patients in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Our patients were significantly younger than the Western population comprising the STICH trial. This is due to the incidence of coronary artery disease at a younger age in the Indian population, due to various ethnic predisposing factors. Our patients mostly had single-vessel disease involving the Left Anterior Descending Coronary Artery (LAD), although some had two- and three-vessel disease. Those patients with multivessel disease received multiple grafts. The pathophysiology of left ventricular aneurysm has been seen in predominantly single coronary artery territory involvement [2], which may often be recanalized and therefore not requiring revascularization, with only resection of scar tissue and reshaping of the contractile myocardium providing adequate clinical benefit. The immediate and 30-day postoperative functional class has been mentioned in the table. The re-hospitalization for heart failure occurred at 9.2 1.2 months following surgery. The reasons for this were multi-factorial and related to associated pulmonary hypertension and renal dysfunction, and not to the surgical technique per se. Postoperatively, all patients were on maximally tolerated doses of beta-blockers, ace inhibitors, statins, aspirin, and diuretics. The dosages of diuretics and ace inhibitors, however, decreased significantly following surgery. We had centerline analysis of contrast ventriculography of all our patients before and after surgery. All our patients had discrete areas of dyskinesis/akinesis at baseline conforming to the definition of left ventricular aneurysm. Following surgery, there was a significant decrease in hypokinetic chords from 61.1 12.8 to 36.5 14.8 ( p < 0.001) [3]. This was in the anterior and anterolateral segments in anterior aneurysms and in the inferior and inferbasal segments of the inferior aneurysms. There was also a significant decrease in akinetic/dyskinetic chords from 32.5 11 at baseline to 25 8.1 following surgery ( p < 0.001). Here, the akinetic/ dyskinetic chords in the postoperative ventricle conformed to the intracavitary patch which remained akinetic. We agree with Dr Poullis that the success of surgical ventricular restoration (SVR) depends on the presence of discrete areas of akinesis/dyskinesis, conforming to scar tissue and definite areas of contractile myocardium. For patients with diffusely hypokinetic ventricles, the only option would be cardiac transplantation, if eligible. This has been adequately described in our article [4]. Our study follows Pocar et al. [5] in validating the surgical techniques resulting in a more ellipsoid ventricular geometry. Our left ventricular shape analysis also proved significantly better alignment of the contractile myocardial fibers in the anterior wall, which was not seen with endoventricular circular patch plasty [6]. In our patients, despite a postoperative decrease in left ventricular stroke volume, there was a significant clinical improvement as assessed by functional class, which cannot be attributed to decreased contractility. This has also been proved by our centerline analysis and shape analysis. The heart rate did not change significantly following surgery (baseline heart rate (HR): 84 3 beats per minute (BPM) to postoperative HR: 81 4 BPM). The phenomenon of decreasing stroke volume following SVR will be the subject of future study.

Improved aorto-ventricular matching in ischemic dilated cardiomyopathy patients after surgical ventricular restoration

Scope This paper contains (i) derivation of the aorto-ventricular matching (AVM) index in terms of the ratio of aortic elastance and LV end-systolic elastance, E aorta / E es ; (ii) procedure for determination of this index, by means of non-invasive measurements of auscultatory pressures, time-variation of blood volume ejected into the aorta, stroke volume and ejection fraction; (iii) results of improved AVM index evaluation in ischemic dilated cardiomyopathy (IDCM) patients following surgical ventricular restoration (SVR), as a result of reduced end-diastolic and end-systolic LV volumes and increased LV E es . Methodology Among the ten recruited IDCM patients, four of them underwent surgical ventricular restoration (SVR) and coronary artery bypass graft (CABG), while six of them underwent CABG alone. All patients were studied by echocardiography pre- and 4 months post-operatively; LV volumes were determined by echo Doppler. LV end-systolic elastance E es was determined from a derived expression, by employing blood pressure, stroke volume, ejection fraction, pre-ejection and systolic periods, and estimated normalized ventricular elastance at end-diastole, based on single-beat measurements. Aortic elastance E aorta was determined by means of our modified single-beat method for determining aortic pressure profile. Results In the CABG plus SVR group, the AVM index E aorta / E es was reduced by 35% from 0.93 ± 0.32 to 0.60 ± 0.33, consistent with improved aorto-ventricular matching. However, in the CABG alone group, the AVM index E aorta / E es decreased only 11% from 1.02 ± 0.24 to 0.91 ± 0.29. Conclusion There is shown to be increased value of LV E es and a more favorable decreased value of AVM index in those IDCM patients who underwent SVR.

The Impact of Surgical Ventricular Restoration on Ischemic Mitral Regurgitation

The aim of current study was to evaluate and compare the changes in clinical status and mitral regurgitation (MR) grade and long-term postoperative survival after left ventricle surgical restoration (SVR) operations. We retrospectively analyzed the data of 139 patients suffering from ischemic heart disease and left ventricular aneurysms or large akinesia, who underwent SVR and coronary artery bypass grafting without MR surgical correction between 1999 and 2006. The mean long-term postoperative follow-up was 3.6 years (SD, 3.0). Nine patients (6.5%) died during the first 30 postoperative days. The mean MR grade during the long-term period increased significantly. The univariate logistic regression analysis showed that factors for the long-term mortality were age (P=0.002), decompensation signs before SVR (P=0.03), treatment with diuretics (P=0.01), NYHA functional class IV (P=0.008), and moderate and severe MR (P=0.04); however, multivariate logistic regression analysis demonstrated that only patient's age was an independent predictive factor (P=0.004). MR correction was found to be a significant prognostic factor of borderline significance for perioperative mortality (P=0.05). The analysis of MR grade (mild versus moderate versus severe) impact on long-term survival failed to demonstrate any association (P=0.22). Remodeling continued during the long-term period after SVR and CABG: there was an increase in the mean MR degree. Left ventricular remodeling with moderate and severe MR decreased survival rates during long-term period after surgical ventricular restoration; however, mitral regurgitation was not found to be an independent predictor of poor outcome.

Volume reduction rate by surgical ventricular restoration determines late outcome in ischaemic cardiomyopathy

Surgical ventricular restoration (SVR) effectively reduces left ventricular (LV) volume in ischaemic cardiomyopathy (ICM), but the recent Surgical Treatment of Ischemic Heart Failure (STICH) Trial questions its importance. We report 8-year SVR experience in patients with ICM. Between 2000 and 2008, 135 patients underwent SVR for ICM. This report analyses data from 90 patients who underwent accurate pre- and post-operative assessment of LV volumes by left ventriculogram or scintigram. All patients also had echocardiograms. Pre-operative LV end-systolic volume index (ESVI) was 123.5 ± 53.2 mL/m(2) (range 92-310). Overall, 63 patients were in NHYA class III and 27 were in class IV. The SVR procedure was endoventricular circular patch plasty in 33 patients, septal-anterior ventricular exclusion in 43, and 14 patients had posterior exclusion. Coronary artery bypass grafting was performed in 78 patients (87%) and 50 underwent mitral procedures. Eighteen follow-up late deaths occurred owing to chronic heart failure (n = 12) and sudden death (n = 6). Post-operative ESVI was < 90 mL/m(2) (Group-S) in 54 patients, 90-120 mL/m(2) (Group-M) in 16, and >120 mL/m(2) (Group-L) in 20 patients. The 8-year survival rate was 82.4% in group-S following a > 33% LV volume reduction. In contrast, in Group-M and Group-L, the volume reduction was ∼ 15%, and 100% of patients died within 7 years following the SVR procedure (or 0% 8-year survival). SVR is most effective when a >33% volume reduction rate achieves an ESVI of < 90 mL/m(2). No long-term benefits occur when SVR induces an LV volume reduction of < 15% leaving a residual ESVI >90 mL/m(2). This database contradicts the STICH trial findings.

Surgical Ventricular Restoration for Ischaemic Heart Failure: Experience of the Royal Prince Alfred Hospital Cardiothoracic Surgical Unit

Surgical Ventricular Restoration for Ischaemic Heart Failure: Experience of the Royal Prince Alfred Hospital Cardiothoracic Surgical Unit

A Modified Technique of Left Ventricular Restoration:

We describe a modified technique of left ventricular restoration after anterior myocardial infarction, referred to as endoventricular spiral plication (ESP). This technique was designed for surgical ventricular restoration with a modified spiral stitch and no patch plasty. A continuous spiral stitch can reconstruct the left ventricular shape both at the short and long axis, and appropriate restoration can be achieved by adjusting the tension of the string and the degree of spiral rotation.

Impact of surgical ventricular restoration on ventricular shape, wall stress, and function in heart failure patients

Surgical ventricular restoration (SVR) was designed to treat patients with aneurysms or large akinetic walls and dilated ventricles. Yet, crucial aspects essential to the efficacy of this procedure like optimal shape and size of the left ventricle (LV) are still debatable. The objective of this study is to quantify the efficacy of SVR based on LV regional shape in terms of curvedness, wall stress, and ventricular systolic function. A total of 40 patients underwent magnetic resonance imaging (MRI) before and after SVR. Both short-axis and long-axis MRI were used to reconstruct end-diastolic and end-systolic three-dimensional LV geometry. The regional shape in terms of surface curvedness, wall thickness, and wall stress indexes were determined for the entire LV. The infarct, border, and remote zones were defined in terms of end-diastolic wall thickness. The LV global systolic function in terms of global ejection fraction, the ratio between stroke work (SW) and end-diastolic volume (SW/EDV), the maximal rate of change of pressure-normalized stress (dσ*/dt(max)), and the regional function in terms of surface area change were examined. The LV end-diastolic and end-systolic volumes were significantly reduced, and global systolic function was improved in ejection fraction, SW/EDV, and dσ*/dt(max). In addition, the end-diastolic and end-systolic stresses in all zones were reduced. Although there was a slight increase in regional curvedness and surface area change in each zone, the change was not significant. Also, while SVR reduced LV wall stress with increased global LV systolic function, regional LV shape and function did not significantly improve.

Surgical approach to end-stage heart failure

End-stage heart failure is a challenging disease with growing incidence. With decreasing heart transplant rates worldwide organ preserving therapies become, again, of interest. The purpose of the present review is to examine the potential challenges of surgical therapies in patients with end-stage heart failure. The gold-standard for end-stage heart failure is and will be cardiac transplantation. However, due to organ shortage this therapy is limited to a few patients. Therefore implantation of ventricular assist devices (VADs) or long-term minimal-invasive partial support devices will increase. Improvements in device design with smaller devices, easier implantation techniques, and modified anticoagulation outcome and long-term success will likely improve. In addition, good quality of life as destination therapy is almost available. Organ conservation surgery (coronary artery bypass grafting and surgical ventricular restoration or surgical repair of mitral valve regurgitation) in end-stage heart failure patients could not prove the expected results. Transcatheter or minimal-invasive approaches of these therapies might become routine in the near future. Due to the overwhelming outcome rates, cardiac transplantation is the most established surgical therapy for end-stage heart failure. VAD therapy is increasing and minimized VADs might further open the market for destination therapy/permanent support.

Surgical Ventricular Restoration for Patients With Ischemic Heart Failure: Determinants of Two-Year Survival

Surgical ventricular restoration (SVR) improves left ventricular (LV) systolic function by partially restoring the normal geometry of the left ventricle. However, the beneficial effects of this surgical procedure on long-term clinical outcome remain controversial. The present study aimed to evaluate the independent determinants of 2-year morbidity and mortality rates after SVR. Seventy-nine patients with ischemic heart disease and LV ejection fraction of 0.35 or less were included. All patients underwent SVR and additionally coronary artery bypass grafting or mitral valve surgery if clinically indicated. Clinical and echocardiographic examination was performed before SVR and at 6 months' follow-up. The primary end point was a composite of all-cause mortality and hospitalizations for heart failure. At 6 months' follow-up a significant improvement in heart failure symptoms was noted. In addition, LV ejection fraction increased from 0.27 ± 0.07 to 0.36 ± 0.10 (p < 0.001). During a median follow-up of 2.7 years, the primary end point was recorded in 22% of the patients. Baseline New York Heart Association functional class IV and a 6-month follow-up LV end-systolic volume index of at least 60 mL/m(2) were independently associated with worse outcome (hazard ratio, 5.4; 95% confidence interval, 1.9 to 15.2; p < 0.001; hazard ratio, 2.7; 95% confidence interval, 1.3 to 5.6; p < 0.001, respectively). Advanced heart failure status at baseline and large residual postsurgery LV end-systolic volume index were independently associated with increased mortality and heart failure hospitalization rates at 2 years' follow-up after SVR.

Surgical Ventricular Restoration Improves the Left Ventricle Basal Wall Function Using Quantitative Gated Spect

It is not clear whether surgical ventricular restoration (SVR) or procedures approaching mitral complex for controlling functional mitral regurgitation (MR) affect the regional left ventricular wall function. The purpose of the present study was to evaluate the regional LV function after SVR using overlapping left ventriculoplasty (OLVP) using quantitative gated myocardial perfusion SPECT (QGS). Forty-one heart failure patients, including those with ischemic cardiomyopathy (ICM) (n = 25) and non-ICM (NICM) (n = 16), underwent SVR and/or papillary muscle approximation (PMA). The rest myocardial perfusion SPECT were performed before and early after operation (mean 25.8 ± 10.6 days). These patients were divided into 4 groups based on the surgical procedures (SVR and/or PMA) and etiology of patients (ICM or NICM) as follows: SVR (with or without PMA) of ICM, SVR of NICM, PMA of ICM and PMA of NICM groups. The regional wall thickening was compared before and after the operation between the four groups. NYHA functional classes were improved after the operation in all four groups. MR grade was also improved in three groups other than SVR of the ICM group. The left ventricular basal wall thickening was improved postoperatively in following three groups (SVR of ICM: 12.7 ± 3.8% to 16.5 ± 4.6% p <0.05, PMA of ICM: 11.1 ± 4.3% to 14.9 ± 4.8% p <0.05, SVR of NICM: 5.8 ± 6.6% to 12.3 ± 6.4% p <0.05), whereas PMA of the NICM group did not show an improvement. Wall thickening in the middle and distal levels was not improved in all groups. OLVP improved NYHA functional classes, and also improved the regional wall function at the basal level of the left ventricle. In contrast, lone PMA did not improve or impair the regional wall function at any of the levels.

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.

The Impact of Volume Reduction on Early and Long-Term Outcomes in Surgical Ventricular Restoration for Severe Heart Failure

Recent published results suggest no additive benefit to surgical ventricular restoration (SVR) when combined with coronary artery bypass grafting. However, there may still be a subgroup of patients with severe heart failure who can benefit from this procedure. We reviewed our institutional experience with SVR to determine early and late outcomes based on volume reduction. We retrospectively reviewed our SVR patients (January 2002 to April 2008) with follow-up to March 2009. Baseline comorbidities, operative data, and postoperative outcomes were assessed by chart review, phone calls, and mailings. Survival was modeled using the Kaplan-Meier method. Cardiac magnetic resonance imaging, myocardial perfusion scans, and echocardiography assessed cardiac function, candidacy for SVR, and volume reduction. We reviewed 87 consecutive SVR patients (69 men). Mean age at operation was 61.1 years. Preoperatively, all patients had congestive heart failure, with 80 (92%) at New York Heart Association III/IV. All patients underwent preoperative viability studies. Three-vessel occlusion exceeding 50% was present in 69 (79%). After SVR, ejection fraction improved from 0.236 to 0.332 (p<0.001). Preoperative and postoperative magnetic resonance imaging in 26 patients (30.0%) showed a 30.8% reduction in left ventricular end systolic volume index. At follow-up, 51 of 66 (77%) improved to New York Heart Association I/II. One intraoperative death occurred. Preoperative left ventricular end systolic volume index of 80 to 120 was associated with improved survival (73% at 3 years). SVR is a surgical option for appropriately selected patients with severe congestive heart failure. In these high-risk patients, SVR successfully increased ejection fraction and decreased symptoms. A left ventricular end systolic volume index of 80 to 120 may be the ideal range for SVR procedures.

Lessons from a mathematical hypothesis — modification of the endoventricular circular patch plasty

Surgical ventricular restoration has been the bailout therapy for end-stage heart failure due to ischemic cardiomyopathy in patients not suitable for cardiac transplantation. The recently concluded STICH trial has stated that surgical restoration of the left ventricle does not benefit this subgroup of patients clinically as compared with revascularization alone. The reasons for failure of this trial are multifactorial. The technique of surgical ventricular restoration employed in the STICH trial was circular endoventricular patch plasty. The various drawbacks related to this technique can be offset by a modification based on a mathematical hypothesis, which should result in a more physiological ventricular geometry, with consequent late reverse remodeling and improved left-ventricular performance. A total of 54 consecutive patients out of 102 patients with post-infarction left-ventricular aneurysms were studied before and 2 years after surgical ventricular restoration by linear endoventricular patch plasty using two-dimensional (2D) echocardiography and contrast ventriculography. Linear endoventricular patch plasty resulted in a decrease in end-diastolic volume (EDV) of 40.2 ml (95% confidence interval (CI): 33.6, 46.7) and stroke volume (SV) of 10.0 ml (95% CI: 6.6, 13.5) and increase in ejection fraction (EF) of 6.7% (95% CI: 5.5, 7.9). There was a further 14% decrease in EDV and SV (30%) at 2 years with increase in EF (20%). There was a persistent significant improvement in sphericity index. The changes in EDV and SV were linearly related (r=0.72, p<0.001) and persisted at 2 years following surgery. The change in EDV was linearly related to the EF (r=0.35, p=0.02). The left-ventricular shape analysis showed improvements in the anterior and anterolateral segments (effect size=1.1, p<0.001) with nonsignificant changes in the inferior segments, conforming to an ellipsoid geometry. Linear endoventricular patch plasty restored a physiological elliptical ventricular geometry with persistent late reverse remodeling. The decreases in EDVs following surgery were significantly linearly proportional to the decreases in SVs at rest, which conforms to the normal left-ventricular geometry.