Impact of Surgical Ventricular Restoration on Diastolic Function: Implications of Shape and Residual Ventricular Size

doi:10.1016/j.athoracsur.2008.08.010

The Annals of Thoracic Surgery

Volume 86, Issue 6, December 2008, Pages 1849-1854

https://doi.org/10.1016/j.athoracsur.2008.08.010 Get rights and content

Background

Limited data are available on left ventricle (LV) diastolic function in patients with ischemic dilated cardiomyopathy submitted to surgical ventricular restoration (SVR). The purpose of this study was to assess postoperative diastolic function changes and identify potential predictors of its worsening.

Methods

One hundred and forty-six patients (65 ± 9 years) with previous anterior myocardial infarction were evaluated before and after SVR. Hemodynamic and geometric parameters including the sphericity index and conicity index were measured. Diastolic function was explored using the transmitral flow velocity pattern, and four classes were defined: normal, abnormal relaxation, pseudonormal, and restrictive pattern. Diastolic function was defined as unchanged (no difference in diastolic pattern), improved (at least one class less), or worsened (at least one class more or, in the case of preoperative restrictive pattern, an early transmitral flow velocity to atrial flow velocity [E/A] ratio increase of at least 20%).

Results

The filling pattern before SVR was normal in 7 patients (4.8%), abnormal relaxation in 99 (68%), pseudonormal in 28 (19%), and restrictive in 12 (8.2%). After SVR, the filling pattern was unchanged in 105 patients (72%), improved in 14 (9.6%), and worsened in 27 (18.4%). Based on the univariate analysis, the preoperative conicity index and the end-diastolic volume difference (the result of surgical volume reduction) were associated with a diastolic pattern worsening.

Conclusions

Diastolic function did not change or improve in the majority of patients. In the minority of patients who experienced worsening, this was associated with the preoperative LV shape and residual volume.

Section snippets

Study Design

This was a retrospective study based on the institutional database of the Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato for patients undergoing SVR. The study design was submitted to the Local Ethics Committee, which waived the need for approval in consideration of the retrospective nature of the study. All the patients admitted to the study gave their informed consent for the scientific analysis of their clinical data in an anonymous form.

Patient

One hundred and forty-six

Results

The preoperative diastolic profile is reported in Table 1. Seven (7) patients (4.8%) showed a normal pattern, 99 patients (68%) an abnormal relaxation pattern, 28 patients (19%) a pattern of pseudonormalization, and 12 patients (8.2%) a restrictive pattern. Factors associated with the degree of diastolic dysfunction were age (abnormal relaxation vs pseudonormalization, p = 0.004), EF (pseudonormalization vs restrictive pattern, p = 0.015), left atrium dimension (abnormal relaxation vs

Comment

The major findings of this study include the following; (1) Diastolic dysfunction occurs in the majority of patients affected by ischemic dilated cardiomyopathy and heart failure suitable for SVR; (2) after surgery, the average DF is impaired even if a worsening of the diastolic pattern occurs in a minority of the patients; (3) the preoperative shape, irrespective of the volumes, is a predictor of DF worsening; and (4) a limited surgical volume reduction associated with a relatively small

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Cited by (46)

Long-term results of surgical ventricular reconstruction and comparison with the Surgical Treatment for Ischemic Heart Failure trial
2024, Journal of Thoracic and Cardiovascular Surgery
The role of surgical ventricular reconstruction (SVR) in patients with ischemic cardiomyopathy is controversial. Observational series and the Surgical Treatment of IsChemic Heart failure (STICH) trial reported contradictory results. SVR is highly dependent on operator experience. The aim of this study is to compare the long-term results of SVR between a high-volume SVR institution and the STICH trial using individual patient data.
Patients undergoing SVR at San Donato Hospital (Milan) were compared with patients undergoing SVR in STICH (as-treated principle) by inverse probability treatment-weighted Cox regression. The primary outcome was all-cause mortality.
The San Donato cohort included 725 patients, whereas the STICH cohort included 501. Compared with the STICH-SVR cohort, San Donato patients were older (66.0, lower quartile, upper quartile [Q1, Q3: 58.0, 72.0] vs 61.9 [Q1, Q3: 55.1, 68.8], P < .001) and with lower left ventricular end-systolic volume index at baseline (LVESVI: 77.0 [Q1, Q3: 59.0, 97.0] vs 80.8 [Q1, Q3: 58.5, 106.8], P = .02). Propensity score weighting yielded 2 similar cohorts. At 4-year follow-up, mortality was significantly lower in the San Donato cohort compared with the STICH-SVR cohort (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .001). Greater postoperative LVESVI was independently associated with mortality (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03). At 4 to 6 months of follow-up, the mean reduction of LVESVI in the San Donato cohort was 39.6%, versus 10.7% in the STICH-SVR cohort (P < .001).
Patients with postinfarction LV remodeling undergoing SVR at a high-volume SVR institution had better long-term results than those reported in the STICH trial, suggesting that a new trial testing the SVR hypothesis may be warranted.
Restrictive filling pattern in ischemic cardiomyopathy: Insights after surgical ventricular restoration
2021, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Once established, RFP appears to be refractory to pharmacologic intervention, device implantation, and surgery.7,9-13 In many cases, even when EDVI is reduced by SVR, there are no significant changes in this specific LV filling pattern.9,25 The findings of the present study, based strictly on patients with severe ICM and RFP, show primarily a surprising “all-or-nothing” response to SVR in terms of LV filling pattern.
To examine factors possibly involved in the resolution or persistence of restrictive filling pattern (RFP) after surgical ventricular restoration (SVR) in a series of patients with ischemic cardiomyopathy (ICM) and RFP.
Echocardiography was performed at baseline (pre-SVR), discharge, and follow-up in 43 patients with ICM and RFP (E/A ratio ≥2). Patients were divided into 2 groups based on E/A ratio at discharge: improved (E/A ratio <2; 22 patients) and unchanged (E/A ratio ≥2; 21 patients).
The improved group had a significantly increased mean deceleration time (from 137 ± 22 ms to 194 ± 68 ms; P = .002) and mean A wave velocity (from 43 ± 10 cm/s to 92 ± 37 cm/s; P = .001), and decreased E/e′ ratio (from 27.7 ± 9.5 to 19.2 ± 7.8; P = .01) after SVR. The unchanged group did not show any significant variations in diastolic parameters. The only significant differences at baseline between the two groups were thinner left ventricle posterior wall and lower relative wall thickness (RWT) in the unchanged group. RWT was the sole baseline parameter independently associated with persistent RFP.
RFP was reversed after SVR in 22 of our 43 patients with ICM with a response that remained stable over time, associated with improved New York Heart Association class. RWT was the sole baseline echocardiographic parameter significantly associated with the evolution of RFP after SVR.
Morphologic Analysis of the Normal Right Ventricle Using Three-Dimensional Echocardiography–Derived Curvature Indices
2018, Journal of the American Society of Echocardiography
Right ventricular (RV) remodeling involves changes in size, wall thickness, function, and shape. Previous studies have suggested that regional curvature indices (rCI) may be useful for RV shape analysis. The aim of this study was to establish normal three-dimensional echocardiographic values of rCI in a large group of healthy subjects to facilitate future three-dimensional echocardiographic study of adverse RV remodeling.
RV endocardial surfaces were reconstructed at end-diastole and end-systole in 245 healthy subjects (mean age, 42 ± 12 years) and analyzed using custom software to calculate mean curvature in six regions: RV inflow tract (RVIT) and RV outflow tract, apex, and body (both divided into free wall and septal regions). Associations with age and gender were studied.
The apical free wall was convex, while the septum (apex and body) was more concave than the body free wall. Septal curvature did not change significantly from end-diastole to end-systole. The RV outflow tract and RVIT became flatter from end-diastole to end-systole. In keeping with the “bellows-like” action of RV contraction, the body free wall became flatter, while the apex free wall changed to a more convex surface. There were no intergender differences in rCI. In older subjects (≥55 years of age), the RV free wall and RV outflow tract were flatter, and from end-diastole to end-systole, the RVIT became less flattened and the apex less pointed. These changes suggest that the right ventricle is stiffer in older subjects, with less dynamic contraction of the RVIT and less bellows-like movement.
This study established normal three-dimensional echocardiographic values for RV rCI, which are needed to further study RV diastolic dysfunction and remodeling with disease.
Improvements in Left Ventricular Diastolic Mechanics After Parachute Device Implantation in Patients With Ischemia Heart Failure: A Cardiac Computerized Tomographic Study
2017, Journal of Cardiac Failure
Percutaneous ventricular restoration therapy with the use of a left ventricle (LV)–partitioning Parachute device has emerged as a clinical treatment option for LV apical aneurysm after extensive anterior myocardial infarction (AMI). We assessed changes of diastolic mechanics and functional improvements following LV Parachute device implantation by means of cardiac computerized tomography (CCT).
CCT data were obtained from 28 patients before and after LV Parachute device implantation. Diastolic functional indices were determined by means of quantitative CCT assessment: 1) transmitral velocities in early (E) and late (A) diastole and ratio (E/A); 2) early diastolic mitral septal tissue velocity (Ea) and E/Ea; and 3) vortex formation time (VFT). Functional improvements were assessed with the use of New York Heart Association (NYHA) functional classification. Among the study patients, there were no significant differences in all transmitral velocities and E/A, though there was significantly increased Ea, reduced E/Ea, and greater VFT 6 months after LV Parachute device implantation. Finally, the improvement of diastolic functional indices after Parachute treatment correlated with observed clinical functional alterations (Δ E/Ea and Δ NYHA functional class:, r = 0.563; P = .002; Δ VFT and Δ NYHA functional class: r = −0.507; P = .006).
LV Parachute device implantation therapy in heart failure caused by AMI and LV apical aneurysm formation showed improvements in several diastolic functional mechanics according to CCT-based measures.
The additional prognostic value of left atrial volume on the outcome of patients after surgical ventricular reconstruction
2013, Annals of Thoracic Surgery
Citation Excerpt :
Our group has already shown that diastolic dysfunction occurs in the majority of patients who are suitable for SVR, remaining stable or worsening infrequently after operation, and therefore contrasting with the proposed hypothesis [13]. In our previous studies, we assessed diastolic function only by Doppler measurements, which are load dependent and do not give information about long-term dysfunction [13, 14]. In the present study, we specifically analyzed the LAV as an index of the severity of the underlying chronic disease.
Left atrial volume (LAV) is a powerful predictor of outcome in patients with chronic heart failure (HF). It is unknown whether LAV provides additional prognostic information in patients undergoing surgical ventricular reconstruction (SVR). Our objective was to assess the prognostic power of LAV on survival in patients with HF after undergoing SVR.
One hundred twenty-eight patients (109 men aged 64 ± 9 years) referred to our center for surgical ventricular reconstruction had an echocardiographic assessment of LAV at admission.
Overall, 18 patients experienced operative mortality. The median follow-up time for the 110 survivors was 32 months. At Cox regression analysis, left atrial volume index (LAVI) (LAV/body surface area – mL/m²) was inversely associated with survival rate (hazard ratio [HR], 1.033 for every 1 mL/m² of LAVI; 95% confidence interval [CI], 1.015–1.051; p = 0.001). The predictive value of LAVI was independent of age and the more powerful preoperative diastolic restrictive pattern (RP) (HR, 1.56; 95% CI, 1.06–2.31; p = 0.024 for LAVI quartile; HR, 1.09; 95% CI, 1.05–1.14; p = 0.001 for age; and HR, 7.31; 95% CI, 3.1–17.4; p = 0.001 for diastolic RP). A receiver operating characteristic (ROC) curve analysis for separate models was applied to determine the discriminatory power of each determinant of survival. The best accuracy was achieved by including the LAVI quartile, which increased the accuracy of survival prediction up to 0.87 (95% CI, 0.81–0.93).
Preoperative LAV is a powerful indicator of poor outcome after SVR and improves the accuracy of survival prediction when added to other independent determinants.
Atypical myocardial delayed enhancement after surgical ventricle restoration
2012, European Journal of Radiology
To retrospectively evaluate delayed enhancement after surgical ventricle restoration (SVR).
Thirty patients with post-ischemic akinetic dilatation underwent cine and gadobenate dimeglumine-enhanced MRI before and 2–6 months after SVR. End-diastolic volume (EDV) normalized to body surface area (EDV index, EDVI), end-systolic volume index (ESVI), and ejection fraction (EF) of the left ventricle were obtained. Delayed enhancement involving subendocardial myocardium was considered typical (TDE) while enhancement apparently not involving subendocardium in its typical location was considered atypical (ADE). Wilcoxon signed-rank, Mann–Whitney U, and χ² tests were used.
All 30 patients showed TDE prior to surgery but 16 of them (53%) showed ADE after SVR. Before SVR, EDVI (ml/m²) was 171 ± 101 in patients with ADE and 127 ± 41 in patients with TDE, ESVI (ml/m²) was 130 ± 105 and 94 ± 36, EF was 25 ± 6% and 24 ± 9%, respectively, without significant differences (P > 0.347). After SVR, EDVI (ml/m²) was 99 ± 24 and 89 ± 28 (P = 0.275), ESVI (ml/m²) 66 ± 24 and 65 ± 30, respectively, without significant differences (P > 0.275) while EF was 37 ± 12% and 29 ± 13%, respectively, with a near-significant difference (P = 0.077). The increase in EF before/after SVR was significant only for patients with ADE (P = 0.006). Of 20 patients in whom a patch had been used for SVR, 14 showed ADE and 6 TDE; of 10 patients without patch, 2 and 8, respectively (P = 0.010).
ADE was found in about half of SVR patients and was associated with the use of patch and EF improvement.

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Original articleAdult cardiacImpact of Surgical Ventricular Restoration on Diastolic Function: Implications of Shape and Residual Ventricular Size

Background

Methods

Results

Conclusions

Section snippets

Study Design

Patient

Results

Comment

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Semin Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Original article
Adult cardiac
Impact of Surgical Ventricular Restoration on Diastolic Function: Implications of Shape and Residual Ventricular Size