Surgical treatment of ischemic heart failure: the Dor procedure.

Despite the improvements in the treatment of myocardial infarction that have translated into a decline in mortality rates, the incidence of heart failure has increased and, because of the limited number of cardiac donors, non-transplant heart surgery has developed in the past 10 years. Surgical ventricular reconstruction was launched by Dor and defined as endoventricular circular patch plasty repair. It represents a relatively novel surgical approach aiming to restore (bring back to normal) the dilated, distorted left ventricular (LV) cavity in order to improve function. The term ;surgical ventricular reconstruction/restoration' includes operative methods that reduce LV volume and restore its shape. The concept of reducing wall stress through surgical restoration of chamber size and geometry remains the guiding principle behind this innovative technique. Results from different Institutions are uniform and show an improvement in cardiac and clinical status and in survival. The present review will approach the rationale to re-shape the heart on the basis of pathophysiology and cardiac architecture, and will describe the efficacy of the Dor procedure in ischemic dilated cardiomyopathy, as well as some technical aspects and patient selection pathway.

Left ventricular restoration: how important is the surgical treatment of ischemic heart failure trial?

If the Surgical Treatment of Ischemic Heart Failure (STICH) trial demonstrates that surgical therapy is superior to medical therapy, early aggressive evaluation of coronary artery disease as a potentially correctable cause of new-onset heart failure would be the preferred strategy. This strategy could tremendously change the treatment of ischemic heart disease. Confirming the STICH revascularization hypothesis will dramatically increase the use of coronary artery bypass grafting among the millions of patients now being medically treated without evaluation for an ischemic cause.

Left ventricular geometry in normal and post-anterior myocardial infarction patients: sphericity index and 'new' conicity index comparisons.

BACKGROUND: Anterior myocardial infarction leads a sequence of structural changes that alter the size and the shape of the left ventricle. Efforts to assess shape have been made by global left ventricular (LV) chamber analysis (sphericity index, SI) but this analysis does not detect regional shape abnormalities like those at the apical level, which precede global ventricular dilatation. OBJECTIVE: The present study will introduce a new analysis of regional apical changes in 52 normal subjects and in 92 patients with previous anterior myocardial infarction. METHODS: All patients had transthoracic echocardiogram and multiple views were obtained (long axis, 4CH, 2CH and short axis view). From the 4CH view the long and the short axes were measured and their ratio was calculated (sphericity index). In the same view, the apical axis length was also measured and the ratio between apical and short axis length was calculated (apical conicity index, ACI). RESULTS: Patients had all the measured parameters significantly worse than normal, except the sphericity index which remained unchanged. Ventricular length and width increased following anterior MI but the ratio between the two measurements did not change. Conversely, apical conicity index is significantly different following anterior MI, thereby indicating anterior infarction produces a less conical shape. SI and ACI differed when correlations were made in the relationship of mitral valve function; SI correlates with the degree of mitral regurgitation (MR) and with the distance of papillary muscles, conversely ACI shows an inverse correlation with the determinants of mitral regurgitation. These observations reflect differences between apical versus global dilatation in ischemic cardiomyopathy, so that mitral function is better (lower tenting area and lower coaptation height) when the apex is markedly dilated in respect to the short axis (high conicity index). In contrast, mitral function is impaired (bigger distance between papillary muscles and higher degree of mitral regurgitation), when sphericity index is high. CONCLUSIONS: Sphericity index fails to detect regional apical shape abnormalities. To address this focal change, we introduce a simple new measure termed apical conicity index, which is abnormal in patients with myocardial infarction, and can be useful to evaluate changes induced by the subsequent surgical approach of ventricular re-shaping.

Right ventricular restoration during pulmonary valve implantation in adults with congenital heart disease.

OBJECTIVE: Pulmonary regurgitation may cause progressive right ventricular dilatation and dysfunction in adult patients previously repaired for right ventricular outflow tract obstruction (RVOTO), and who require subsequent valve implantation for relief of these symptoms. Right ventricular recovery after pulmonary valve implantation (PVI) may be closely linked to the functional importance of the structural presence of an aneurysm or akinetic segment in the RVOT area. To test this concept, the impact of the right ventricular restoration with a new surgical ventriculoplasty technique is evaluated following pulmonary valve implantation in patients with severe pulmonary regurgitation and right ventricular dilatation. METHODS: Sixteen patients with severe pulmonary valve regurgitation (PVR) and right ventricular dilatation with RVOT aneurysm underwent right ventricular remodelling since January 2002. Each underwent preoperative evaluation by Doppler echocardiography, magnetic resonance imaging (MRI), and right ventricular myocardial acceleration during isovolumic contraction (IVC). The surgical procedure included pulmonary valve implantation and RVOT restoration achieved by removal of the aneurysm tissue, coupled with a ventriculoplasty to reduce volume, accomplished by creating a satisfactory RVOT dimension by placing with 2-0 Gortex suture to allow acceptance of a 26 Hegar dilator to avoid restriction. Thirteen associate surgical procedures were added in nine patients. RESULTS: All patients survived the operative procedure and underwent a 16-month follow-up interval. A reduction of cardio thoracic index and a clinical improvement occurred in each patient. Significant reduction of RVEDV and RVESV and increased right ventricular ejection fraction was observed, and IVC changed from 0.7+/-0.5 m/s2 to 1.3+/-0.6 m/s2 in the 13 patients that underwent MRI and IVC during the preoperative control interval and 6 months after the procedure. CONCLUSIONS: This preliminary database implies that the right ventricular restoration is a simple and effective procedure, and introduces a structural component that should be added during pulmonary valve implantation in patients with severe right ventricular dilatation and underlying aneurysm or akinesia of the right ventricular outflow tract.

Safety and efficacy of surgical ventricular restoration in unstable patients with recent anterior myocardial infarction.

BACKGROUND: The effects and efficacy of surgical ventricular restoration (SVR) in ischemic cardiomiopathy caused by chronic anterior myocardial infarction (MI) are well established. Normally, SVR is delayed at least 3 months after MI to allow the healing of infarcted tissue. Some patients have instability <30 days after anterior MI, with increased risk for morbidity and mortality.Objectives- This study tests the safety and efficacy of SVR in the setting of subacute complicated anterior MI, in terms of early and late outcome. METHODS AND RESULTS: 74 patients (62+/-10 years) were submitted to SVR at < or =30 days after anterior MI for clinical instability and were retrospectively selected from a series of 430 patients undergoing SVR at our center, between 1998 and 2001. The surgical indications included: angina (60%); New York Heart Association class 4 (62%); clinical signs of heart failure (18%); life-threatening arrhythmias (12%); and cardiogenic shock in 4% (or 3) patients. Follow-up is available for 93% of patients. All patients had coronary artery bypass grafting (CABG) (3.1+/-1.2) with internal mammary artery (IMA) utilization. An endoventricular patch was used in 17 patients (23%); direct ventriculotomy closure was used in the remaining patients. Operative mortality was 5.4% (4/74). Hemodynamic parameters improved significantly in patients with dilated hearts and reduced ejection fraction. Mitral regurgitation that resulted was significantly reduced. Survival at 3 years was 87% in the overall population and 85% in patients 70 years or older. CONCLUSIONS: This study reports the largest series of patients with complicated, recent anterior MI treated with SVR. The results show that SVR is feasible, has acceptable in-hospital mortality, and has good early and late outcome. Further experience is needed to establish whether SVR, which excludes the infarcted region, can prevent the long-term adverse remodeling of LV dilated hearts after anterior infarction.

Surgical ventricular restoration improves mechanical intraventricular dyssynchrony in ischemic cardiomyopathy.

BACKGROUND: In ischemic cardiomyopathy, dyssynchrony of left ventricular (LV) mechanical contraction produces adverse hemodynamic consequences. This study tests the capacity of geometric rebuilding by surgical ventricular restoration (SVR) to restore a more synchronous contractile pattern after a mechanical, rather than electrical, intervention. METHODS AND RESULTS: A prospective study of the global and regional components of dyssynchrony was conducted in 30 patients (58+/-8 years of age) undergoing SVR at the Cardiothoracic Center of Monaco. The protocol used simultaneous measurements of ventricular volumes and pressure to construct pressure/volume (P/V) and pressure/length (P/L) loops. Angiograms were done before and after SVR to study a 600-ms cycle during atrial pacing at 100 bpm. Mean QRS duration was similar, at 100+/-17 ms preoperatively and 114+/-28 ms postoperatively (NS). Preoperative LV contraction was highly asynchronous, because P/V loops showed abnormal isometric phases with a right shifting. Endocardial time motion was either early or delayed at the end-systolic phase so that P/L loops were markedly abnormal in size, shape, and orientation. Postoperatively, SVR resulted in leftward shifting of P/V loops and increased area; endocardial time motion and P/L loops almost normalized to allow a better contribution of single regions to global ejection. The hemodynamic consequences of SVR were improved ejection fraction (30+/-13% to 45+/-12%; P=0.001); reduced end-diastolic and end-systolic volume index (202+/-76 to 122+/-48 and 144+/-69 to 69+/-40 mL/m(2); P=0.001); more rapid peak filling rate (1.75+/-0.7 to 2.32+/-0.7 EDV/s; P=0.0001); peak ejection rate (1.7+/-0.7 to 2.6+/-0.9 Sv/s; P=0.0002), and mechanical efficiency (0.56+/-0.15 to 0.65+/-0.18; P=0.04). CONCLUSIONS: SVR produces a mechanical intraventricular resynchronization that improves LV performance.

Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation.

OBJECTIVES: The purpose of this study was to test how surgical ventricular restoration (SVR) affects early and late survival in a registry of 1,198 post-anterior infarction congestive heart failure (CHF) patients treated by the international Reconstructive Endoventricular Surgery returning Torsion Original Radius Elliptical shape to the left ventricle (RESTORE)team. BACKGROUND: Congestive heart failure may be caused by late left ventricular (LV) dilation after anterior infarction. The infarcted segment is often akinetic rather than dyskinetic because early reperfusion prevents transmural necrosis. Previously, only dyskinetic areas were treated by operation. Surgical ventricular restoration reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. METHODS: The RESTORE group applied SVR to 1,198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined, and risk factors were identified. RESULTS: Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair; p < 0.001). Perioperative mechanical support was uncommon (<9%). Global systolic function improved postoperatively. Ejection fraction (EF) increased from 29.6 +/- 11.0% preoperatively to 39.5 +/- 12.3% postoperatively (p < 0.001). The left ventricular end-systolic volume index (LVESVI) decreased from 80.4 +/- 51.4 ml/m(2) preoperatively to 56.6 +/- 34.3 ml/m(2) postoperatively (p < 0.001). Overall five-year survival was 68.6 +/- 2.8%. Logistic regression analysis identified EF or=80 ml/m(2), advanced New York Heart Association (NYHA) functional class, and age >or=75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were NYHA functional class III or IV and postoperatively, 85% were class I or II. CONCLUSIONS: Surgical ventricular restoration improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent five-year outcome.

Moderate ischemic mitral regurgitation and coronary artery bypass surgery: effect of mitral repair on clinical outcome.

BACKGROUND AND AIM OF THE STUDY: The optimal management of moderate (grade 2-3+) ischemic mitral regurgitation (MR) at the time of coronary artery bypass grafting (CABG) remains the subject of controversy. The study aim was to determine whether mitral repair associated with CABG is preferable to CABG alone in patients with moderate ischemic MR, in terms of intermediate outcome. METHODS: Among 60 patients with moderate ischemic MR, 30 who underwent CABG plus mitral repair were compared with 30 others who underwent CABG alone. All patients underwent follow up echocardiographic and clinical examinations between 12 and 36 months after surgery. The decision to repair the valve during surgery was totally at the surgeons' discretion. RESULTS: Preoperatively, both groups were substantially homogeneous. Patients who had CABG plus mitral repair had a lower NYHA functional class at intermediate follow up, and fewer signs and symptoms of heart failure. On multivariate analysis, mitral repair proved to be a protective factor for the development of heart failure. The preoperative size of the mitral annulus was seen to be a risk factor for subsequent heart failure events. At intermediate follow up, echocardiographic parameters were significantly better in the mitral repair group (left ventricular volume smaller, ejection fraction and pulmonary artery pressure improved). CONCLUSION: The results of this case-control study showed that, in a homogeneous series of patients with moderate ischemic MR, repair of the mitral valve at the time of CABG leads to a better clinical status due to an improved hemodynamic profile.

Surgical left ventricle reconstruction, pathophysiologic insights, results and expectation from the STICH trial.

Post-infarction ischemic cardiomyopathy is the most frequent cause of clinical heart failure in the western society. Despite aggressive early revascularization, myocardial infarction leaves shape and function abnormalities in a consistent number of patients with increased risk of death and ischemic events. Alternative treatment strategies are therefore advisable in these high-risk patients. Surgical ventricular restoration (SVR) is a safe and effective surgical option for post-infarction ischemic cardiomyopathy resulting in improvement of pump function, functional class and survival. Observational data now need to be confirmed by randomized data and the multicenter international randomized surgical treatment of ischemic heart failure (STICH) trial will definitely assess if SVR adds benefit to coronary bypass alone in patients with left ventricular dysfunction and dilated ventricle.

Infective endocarditis due to Capnocytophaga canimorsus.

We report the case of a 41-year-old woman with severe mitral regurgitation due to infective endocarditis caused by a rare zoonotic microorganism (Capnocytophaga canimorsus). She had had a rheumatic mitral endocarditis successfully treated with antibiotics when she was 13 years old. She arrived to our attention for a fever of unknown origin. She had been bitten by her dog and medicated the wound herself. About 2 weeks later she developed a fever with values up to 39.5 degrees C. Blood cultures were initially negative but in view of her particular history (dog bite), the samples were sent to a specialized center where a Capnocytophaga canimorsus (a commensal bacterium contained in the saliva of dogs and cats) infection sensitive to ceftriaxone was detected. The antibiotic therapy was consequently modified and the patient's fever resolved. At echocardiography a mild mitral stenosis with severe regurgitation (3-4+/4+) was detected. We planned surgical mitral repair but the operative findings clearly showed the need for mitral replacement and a 29 mm size bileaflet mechanical prosthesis was implanted. The postoperative course was regular and the patient was discharged on the fifth day. We highlight the importance of a careful history and correct work-up for the diagnosis and treatment of false negative blood culture endocarditis.

Continuous recording of dicrotic and pulse pressures during head-up tilting test: the vasodepressive profile. Preliminary data.

BACKGROUND: The aim of this study was to assess whether a non-invasive automatic evaluation of the pulse wave characteristics could provide clinical clues when monitoring the hemodynamic adjustments to head-up tilting. METHODS: A continuous assessment of the peripheral pulse wave characteristics (systolic, diastolic, dicrotic and pulse pressures) in 8 control subjects with a negative response to head-up tilting (60 degrees for 45 min) compared to 13 syncopal patients with a vasodepressive one was performed. RESULTS: Controls exhibited, when up-tilted, an increase in blood pressure as well as in the dicrotic and pulse pressures and no changes in heart rate. On the contrary, syncopal patients showed a progressive increase in heart rate associated with a progressive decrease in dicrotic pressure and a trend towards lower values of pulse pressure, but no changes in systolic pressure. Thereafter and until the pre-syncopal symptoms supervened, the systolic, diastolic and dicrotic pressures progressively declined. A decrease in dicrotic pressure mainly characterized the early vasodepressive response while its increase identified the negative one. CONCLUSIONS: Our data, even though preliminary, strongly suggest that automatic hemodynamic evaluation is to be used in the clinical setting as a monitor of the sudden changes in blood pressure induced by head-up tilting. Furthermore, the dicrotic and pulse pressures, even those measured during the early phases of the test, should be considered as non-invasive parameters characterizing the vasodepressive response to head-up tilting.

Insights from the STICH trial: change in left ventricular size after coronary artery bypass grafting with and without surgical ventricular reconstruction.

OBJECTIVE: The present analysis of the Surgical Treatment for Ischemic Heart Failure randomized trial data examined the left ventricular volumes at baseline and 4 months after surgery to determine whether any magnitude of postoperative reduction in end-systolic volume affected survival after coronary artery bypass grafting alone compared with bypass grafting plus surgical ventricular reconstruction. METHODS: Of the 1000 patients randomized, 555 underwent an operation and had a paired imaging assessment with the same modality at baseline and 4 months postoperatively. Of the remaining 455 patients, 424 either died before the 4-month study or did not have paired imaging tests and were excluded, and 21 were not considered because they had died before surgery or did not receive surgery. RESULTS: Surgical ventricular reconstruction resulted in improved survival compared with coronary artery bypass grafting alone when the postoperative end-systolic volume index was 70 mL/m(2) or less. However, the opposite was true for patients achieving a postoperative volume index greater than 70 mL/m(2). A reduction in the end-systolic volume index of 30% or more compared with baseline was an infrequent event in both treatment groups and did not produce a statistically significant survival benefit with ventricular reconstruction. CONCLUSIONS: In patients undergoing coronary artery bypass grafting plus surgical ventricular reconstruction, a survival benefit was realized compared with bypass alone, with the achievement of a postoperative end-systolic volume index of 70 mL/m(2) or less. Extensive ventricular remodeling at baseline might limit the ability of ventricular reconstruction to achieve a sufficient reduction in volume and clinical benefit.

MicroRNA dysregulation in diabetic ischemic heart failure patients.

Increased morbidity and mortality associated with ischemic heart failure (HF) in type 2 diabetic patients requires a deeper understanding of the underpinning pathogenetic mechanisms. Given the implication of microRNAs (miRNAs) in HF, we investigated their regulation and potential role. miRNA expression profiles were measured in left ventricle biopsies from 10 diabetic HF (D-HF) and 19 nondiabetic HF (ND-HF) patients affected by non-end stage dilated ischemic cardiomyopathy. The HF groups were compared with each other and with 16 matched nondiabetic, non-HF control subjects. A total of 17 miRNAs were modulated in D-HF and/or ND-HF patients when compared with control subjects. miR-216a, strongly increased in both D-HF and ND-HF patients, negatively correlated with left ventricular ejection fraction. Six miRNAs were differently expressed when comparing D-HF and ND-HF patients: miR-34b, miR-34c, miR-199b, miR-210, miR-650, and miR-223. Bioinformatic analysis of their modulated targets showed the enrichment of cardiac dysfunctions and HF categories. Moreover, the hypoxia-inducible factor pathway was activated in the noninfarcted, vital myocardium of D-HF compared with ND-HF patients, indicating a dysregulation of the hypoxia response mechanisms. Accordingly, miR-199a, miR-199b, and miR-210 were modulated by hypoxia and high glucose in cardiomyocytes and endothelial cells cultured in vitro. In conclusion, these findings show a dysregulation of miRNAs in HF, shedding light on the specific disease mechanisms differentiating diabetic patients.

Baseline left ventricular volume and shape as determinants of reverse remodeling induced by surgical ventricular reconstruction.

BACKGROUND: Early postoperative data show that surgical ventricular reconstruction (SVR) induces reverse remodelling (RR) in dilated ischemic cardiomyopathy. The stability of these results at follow-up is debated. This retrospective study determined whether RR was stable at follow-up and the role, if any, of preoperative left ventricle volume and shape on SVR-induced changes. METHODS: The study group comprised 220 patients (age, 64 ± 9 years) with an echocardiography study at baseline, discharge, and at follow-up. RR was defined as a reduction of left ventricular end-systolic volume index (ESVI) at follow-up exceeding 15% vs baseline. RESULTS: Reverse remodelling occurred in 162 patients (74%); the ESVI at follow-up in the remaining 58 (26%) was equal to or greater than at baseline (no-RR). At baseline, the no-RR patients had lower volumes and higher ejection fraction; at the 1-week post-SVR evaluation, all patients reached significant ESV reduction, but at follow-up, the no-RR patients had dilated and showed significantly higher volumes and lower ejection fraction vs patients with RR. New York Heart Association class improved in both groups (2.6 ± 0.6 to 1.6 ± 0.5 and 2.5 ± 0.8 to 1.8 ± 0.7, respectively, p = 0.0001). Baseline ESVI less than 73 mL/m(2), apical axis less than 4.35 cm, and conicity index less than 0.759 were predictors of no-RR. CONCLUSIONS: A relatively small ESVI and a more physiologic apical shape (conical) are predictors of no-RR after SVR. Despite lack of RR, the ESV at follow-up is not severely enlarged, which explains the good survival rate in these patients.

Optimizing dose and administration regimen of a high-relaxivity contrast agent for myocardial MRI late gadolinium enhancement.

OBJECTIVES: To investigate the time-course of late gadolinium enhancement of infarcted myocardium using gadobenate dimeglumine at different dosages and administration regimens. MATERIALS AND METHODS: After institutional review board approval and informed consent, we studied 13 patients (aged 63±11 years) with chronic myocardial infarction. They underwent two gadobenate dimeglumine-enhanced MR examinations (interval 24-48 h) using short-axis inversion-recovery gradient-echo sequences, with the following two different protocols, in randomized order: 0.05 mmol/kg and imaging at the 2.5th, 5th, 7.5th and 10th minute plus 0.05 mmol/kg and imaging at the 12.5th, 15th, 17.5th and 20th minute; the same as before but using 0.1 mmol/kg for both contrast injections. Contrast-to-noise ratios (CNRs) between infarcted myocardium, non-infarcted myocardium and left ventricle cavity were calculated for each time-point (2.5-min steps). Friedman ANOVA was used for comparing the CNR time-course; Wilcoxon test for comparing CNR at the 10th and the 20th minute. RESULTS: The CNR between infarcted and non-infarcted myocardium obtained at the 20th minute with 0.05 plus 0.05 mmol/kg resulted significantly higher than that obtained at the 10th minute with 0.05 mmol/kg (P=0.033) while not significantly different from that obtained at the 10th (0.1mm/kg) or at the 20th minute with 0.1 plus 0.1 mmol/kg. The CNR between infarcted myocardium and the left ventricle cavity obtained at the 20th minute with 0.05 plus 0.05 mmol/kg resulted significantly higher than all other measured values (P≤0.017). CONCLUSION: Using gadobenate dimeglumine, 0.05 plus 0.05 mmol/kg allows for a higher CNR between infarcted myocardium and the left ventricle cavity allowing for reliable assessment of the sub-endocardial infarctions.

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

AIMS: 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. METHODS AND RESULTS: 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]. CONCLUSION: 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%).

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

OBJECTIVE: 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. METHODS: 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). RESULTS: 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). CONCLUSIONS: 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.

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

OBJECTIVE: 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. METHODS: 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). RESULTS: 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). CONCLUSIONS: Mild preoperative diastolic dysfunction (pseudonormalized pattern) and increased septolateral dimensions are independent predictors of diastolic restriction after surgical ventricular reconstruction.