Review articleSurgical remodeling of left ventricle
Section snippets
Classical concept
For many years it has been well known that the evolution of the ventricular wall after infarct is different in the diseased and the nondamaged areas.
In the diseased area, after transmural or nontransmural infarct, healing follows three steps: (1) necrosis, followed by (2) fibrotic evolution, and finally, (3) scarred tissue evolving progressively toward calcification and rigidification with, very often, mural thrombi.
The myocardium of nondamaged areas is first normal, then hypertrophied to
Clinical assessment
The definition of an “asymptomatic patient after infarct” is not the same according to the cardiologist, the patient, and the family. Very often the patient is categorized as asymptomatic at rest and under such complete heavy medical therapy as diuretic, ACE inhibitors, vasodilators, beta blockers, and so on. To more objectively assess such a patient, the New York Heart Association (NYHA) classification remains the rule, with congestive heart failure (CHF) for Grades II+, III, or IV; and the
Complete revascularization is mandatory
In the remote myocardial areas distally from the scarred part, other narrowed arteries have to be revascularized; this is obvious, and must be done completely.
In the ischemic area, even on the territory of the main thrombosed vessel, it is possible to revascularize distal runoff of the left anterior descending artery (LAD) of some diagonal branches, to increase septal perfusion. In our experience, this revascularization of the thrombosed LAD yields a patency rate above 80% at 1 year, which has
Standard technique
The mitral valve is checked by transoesophageal echography. Surgery is conducted with a totally arrested heart. Coronary revascularization is accomplished first, then the LV wall is opened in the center of the depressed area, the clots are removed, and the endocardial scar is dissected and resected if the scar is calcified or if spontaneous or inducible ventricular tachycardia (VT) exists. In such circumstances, cryotherapy is applied in addition on the edge of the resection. In case of mitral
The whys and wherefores of endoventricular circular patch plasty
Enhancing the partial effects of the coronary revascularization and of mitral repair (if necessary), left ventricular reconstruction improves the LV performances for several reasons:
Septal scar exclusion
Reorganization of the LV wall: this suppress the wall tension of myocardial remote areas and improves contraction of these areas, and this is clearly shown by the analysis of pressure volume curves [21].
The patch avoids a too-large reduction of volume and maintains a reasonable physiological
What surgery can do for ischemic cardiomyopathy
Even in end-stage ischemic cardiomyopathy with CHF grade 3 to 4, end systolic volume index above 60 mL, global ejection fraction below 30%, and often after failure of complete medical therapy, LVR by EVCPP is useful, with acceptable risk (below 8%), to slow down the remodeling, to avoid or delay heart transplantation or the need of mechanical assist device, and long term results in such category of patient is positive (life expectancy above 50% at 10 years) [30].
Summary
In the future, we can certainly expect better assessment of myocardial wall, LV morphology, and performance, with careful approach and analysis of CMR allowing us to check exactly the morphology and volume performances of the LV, and chiefly the wall itself (Fig. 6).
Perhaps it will be possible to have a hope of recovery for dilated but nonscarred myocardium, through a combination of currently existing surgical treatment (LVR + myocardial revascularization + mitral repair) and new techniques such as
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Long-Term Survival and Echocardiographic Findings After Surgical Ventricular Restoration
2019, Annals of Thoracic SurgeryCitation Excerpt :As expected, many patients in our group had previous documented myocardial infarction as well as coronary interventions. The operative mortality of 4.6% in the current series compares favorably to the 4.8% to 6.6% operative mortality reported by others in contemporary reports [2, 14]. Importantly, we also noted a steady decline in RV function where the incidence of moderate to severe RV dysfunction increased from 12% at the time of surgery to 38% on follow-up.
Surgical Treatments for Advanced Heart Failure
2009, Surgical Clinics of North AmericaCitation Excerpt :Although mild mitral insufficiency may resolve with SVR, moderate and severe mitral insufficiency is also typically addressed surgically.37–39 Usually, mitral valve replacement is not necessary and ischemic mitral regurgitation can be addressed with complete ring annuloplasty.29,40 Therefore, the SVR procedure is typically performed with concomitant coronary artery bypass graft (CABG) revascularization in patients with ischemic cardiomyopathy.
Left ventricular torsional mechanics after left ventricular reconstruction surgery for ischemic cardiomyopathy
2007, Journal of Thoracic and Cardiovascular SurgeryCitation Excerpt :In addition, to define normal LV torsional mechanics, 7 healthy volunteers (5 male/2 female, mean age 34 ± 7 years) were recruited as part of an institutional review board–approved study for evaluation of normal cardiovascular function by MRI. LVR was performed in each patient by a modification of the Dor technique.19 As described previously,9 this involves exclusion of the scarred anteroapical postinfarction regions of the LV using circumferential endocardial sutures, and a patch if necessary, to restore elliptical LV configuration.
Surgery for Heart Failure: Now Something for Everyone?
2007, Heart Failure ClinicsCitation Excerpt :In the event of spontaneous or inducible ventricular tachycardia, cryotherapy was also applied to the edges of the resection (50% of cases). Between development of the surgical principles in 1984 and 2002, the Dor group operated on 1050 patients who were predominantly NYHA III or IV with LVEF less than 35%, LVESVI greater than 50 mL/m2, LVEDVI greater than 100 mL/m2, and mean pulmonary arterial pressure greater than 25 mm Hg [53]. One third of the cases had mitral regurgitation requiring repair.
Optimal Pharmacologic and Non-pharmacologic Management of Cardiac Transplant Candidates: Approaches to Be Considered Prior to Transplant Evaluation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006
2006, Journal of Heart and Lung TransplantationHeart failure in 2004
2005, Revista Espanola de Cardiologia Suplementos