Review article
Surgical remodeling of left ventricle

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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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