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  • Review Article
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Surgical ventricular restoration for the treatment of heart failure

Nature Reviews Cardiology volume 9, pages 703–716 (2012)Cite this article

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Abstract

Heart failure (HF) is an emerging epidemic affecting 15 million people in the USA and Europe. HF-related mortality was unchanged between 1995 and 2009, despite a decrease in the incidence of cardiovascular disease. Conventional explanations include an aging population and improved treatment of acute myocardial infarction and HF. An adverse relationship between structure and function is the central theme in patients with systolic dysfunction. The normal elliptical ventricular shape becomes spherical in ischemic, valvular, and nonischemic dilated cardiomyopathy. Therapeutic decisions should be made on the basis of ventricular volume rather than ejection fraction. When left ventricular end-systolic volume index exceeds 60 ml/m2, medical therapy, CABG surgery, and mitral repair have limited benefit. This form–function relationship can be corrected by surgical ventricular restoration (SVR), which returns the ventricle to a normal volume and shape. Consistent early and late benefits in the treatment of ischemic dilated cardiomyopathy with SVR have been reported in >5,000 patients from various international centers. The prospective, randomized STICH trial did not confirm these findings and the reasons for this discrepancy are examined in detail. Future surgical options for SVR in nonischemic and valvular dilated cardiomyopathy, and its integration with left ventricular assist devices and cell therapy, are described.

Key Points

  • Heart failure with systolic dysfunction is caused by ventricular dilatation, in which the natural elliptical shape of the heart becomes spherical

  • Ventricular dilatation alters the relationship between structure and function by compromising helical fiber orientation, whereby the oblique fibers become more-transversely orientated leading to reduced myocyte function

  • Management decisions should be made on the basis of ventricular volume rather than ejection fraction, although the value of volume measurement has not been universally accepted in ischemic cardiomyopathy

  • In ischemic disease, surgical therapy addresses the 'triple V' of vessel, valve, and ventricle in concert, rather than separately

  • Effectiveness of surgical ventricular restoration was demonstrated in >5,000 patients and is recommended in European guidelines, thereby contradicting the STICH trial conclusions; the reasons for this discrepancy are fully discussed

  • Future indications for surgical ventricular restoration might include nonischemic cardiomyopathy, valvular heart disease, and in conjunction with ventricular assist devices or cell therapy

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Figure 1: Causes of DCM with a unified spherical cardiac form.
Figure 2: Effects of left ventricular dilatation on heart failure and death.
Figure 3: Myocardial ventricular fiber orientation.
Figure 4: Ventricular remodeling after myocardial infarction.
Figure 5: Mitral valve and ventricle connections.
Figure 6: Surgical ventricular restoration.
Figure 7: Steps in the surgical ventricular restoration procedure.
Figure 8: Changes in left ventricular architecture after SVR.
Figure 9: Percentage left ventricular volume reduction with surgical ventricular reconstruction.

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Authors and Affiliations

  1. Department of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 62-258 CHS, Los Angeles, 90095, CA, USA

    Gerald Buckberg

  2. Division of Cardiothoracic Surgery, University of Alabama at Birmingham, THT-720 1530, 3rd Avenue South, Birmingham, 35234, AL, USA

    Constantine Athanasuleas

  3. Division of Cardiac Surgery, Johns Hopkins Hospital, Blalock 618 600 North Wolf Street, Baltimore, 21287, MD, USA

    John Conte

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  1. Gerald Buckberg
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  2. Constantine Athanasuleas
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  3. John Conte
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All the authors contributed substantially to researching data for the article, discussion of content, writing the article, and review/editing before submission.

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Correspondence to Gerald Buckberg.

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Buckberg, G., Athanasuleas, C. & Conte, J. Surgical ventricular restoration for the treatment of heart failure. Nat Rev Cardiol 9, 703–716 (2012). https://doi.org/10.1038/nrcardio.2012.143

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