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Eur J Cardiothorac Surg 2006;29:S231-S237
© 2006 Elsevier Science NL

Myocardial protection during surgical ventricular restoration

^a Norwood Clinic, 1528 Carraway Boulevard, Birmingham, AL, USA
^b Kemp-Carraway Heart Institute, 1528 Carraway Boulevard, Birmingham, AL, USA
^c Option on Bioengineering, California Institute of Technology, 1200 E. California Blvd., Pasadena, CA 91125, USA
^d David Geffen School of Medicine at UCLA, Box 951741, 62-258 CHS, Los Angeles, CA 90095-1741 USA

Received 2 February 2006; received in revised form 27 February 2006; accepted 1 March 2006.

^_* Corresponding author. Address: Division of Cardiothoracic Surgery, 62-258 Center for the Health Sciences, Los Angeles, CA 90095-1701, USA. Tel.: +1 310 206 1027; fax: +1 310 825 5895. (Email: gbuckberg{at}mednet.ucla.edu).

Objective: Ventricular restoration is a novel procedure for treating congestive heart failure (CHF). The two important features include a technically correct procedure and adequate myocardial protection. The two protective techniques include conventional cardioplegia and the beating heart. Methods: This report reviews a RESTORE clinical registry and summarizes background experimental work related to myocardial protection in failing dilated hearts. Results: The RESTORE registry is reported, where protection is 55% with cardioplegia and 45% with beating heart. The beating method was used more frequently in patients with ejection fraction <30%, end systolic volume 80 ml/m², NYHA class >III/IV. Overall survival results favored cardioplegia except for the first 30 days, but after matching patients on age, ejection fraction (EF) and NYHA the beating results and cardioplegic results were comparable. Experimental work evaluated the safety of the beating method in failing dilated ventricles under acute conditions. Supplemental coronary perfusion studies in chronically dilated hearts after tachycardia induced cardiomyopathy were analyzed to show that (a) there was vascular remodeling (less flow at the same pressure in failing hearts with cardioplegic, but not beating delivery; (b) in the open state (used during restoration) subendocardial flow increased in the beating heart, and fell after cardioplegia. These studies were done without ischemia. Conclusions: Cardioplegic delivery for protection is ‘time dependent’ (needing ischemic intervals) while beating nourishment is ‘procedure dependent,’ as continuous perfusion is provided throughout the procedure is suggested. The importance of maintaining high perfusion pressure is emphasized.

Key Words: Ventricular restoration • Beating heart • Cardioplegic delivery • Vascular remodeling • Subendocardial underperfusion • Open ventricle • Myocardial protection