Eur J Cardiothorac Surg 1999;15:26-30
© 1999 Elsevier Science NL
Early and intermediate results of left ventricular reduction surgery 1
Wolfgang Konertza,*,
A Khoynezhada,
A Sidiropoulosa,
V Borakb,
G Baumannc
a Department of Cardiovascular Surgery, Universitatsklinikum Charite, Schumannstralie 20–21, 10117 Berlin, Germany
b Department of Anesthesiology, Universitatsklinikum Charite, Berlin, Germany
c Department of Cardiology, Universitatsklinikum Charite, Berlin, Germany
* Corresponding author. Tel.: +49-30-2802-8280; fax: +49-30-2802-5426; e-mail: cardiac@rz.charite.hu-berlin.de
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Abstract
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Objective: Left ventricular reduction surgery is a new surgical option for treatment of end-stage cardiac dysfunction, and little is known about hemodynamics and outcome in the European heart failure population. We present our early results with this operation. Methods: From January 1995 to September 1997, 30 patients (25 men, 5 women; mean age 61.2 years) underwent partial left ventriculectomy. The underlying disease was ischemic in 18 patients and idiopathic dilated cardiomyopathy in 12 patients. Preoperatively 23 patients were in New York Heart Association functional class IV and 7 were in class III. Mean cardiac index, stroke index and ejection fraction were 1.8±0.3 1/m2 per min, 23.5±5.1 ml/m2 and 19.3%±6.8%, respectively. Associated procedures were coronary bypass in 18 patients, mitral valvuloplasty in one, aortic or mitral valve replacement in three, dynamic cardiomyoplasty in two, and left ventricular assist device implantation in 1. Results: There were two early deaths: one from bleeding and one from anticoagulant-related cerebral hemorrhage. Regarding late deaths, one patient died from pneumonia 3 months after the operation and two died from dysrhythmia 4 and 17 months postoperatively. The estimated 1-year survival rate calculated by the Kaplan–Meier log-rank method was 85%. Mean cardiac index, stroke index, and ejection fraction rose significantly (P=0.0001) to 2.9±0.51/m2 per min, 36.9±6.2 ml/m2 and 37.8%±9.2%. Currently 26 patients are in New York Heart Association functional class I or II. Conclusions: Left ventricular reduction surgery improves objective and subjective parameters of cardiac performance significantly in early and intermediate follow-up. Randomized studies and carefully documented long-term results seem to be necessary to define the role of left ventricular reduction surgery.
Key Words: Partial left ventriculectomy • Mitral repair • Alternatives to transplantation • Heart failure
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1. Introduction
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Death due to cardiac failure is increasing, and most patients are unsuitable for cardiac transplantation because they are too old or have pathologic conditions that prevent transplantation or make it extremely risky. Therefore left ventricular (LV) reduction [1]may be an alternative treatment [2]. This operation reduces left ventricular cavity diameter and mass by means of resection of viable myocardium, that is, excision of the lateral portion, and in our experience, also the posterior or the anterior portion of the ventricle. Exactly 3.14 cm of the circumference must be excised to effect 1 cm of diameter reduction. Partial left ventriculectomy is a novel approach and patient selection criteria are not yet established [3–5]. It seems especially important in ischemic patients to differentiate between aneurysmectomy, a well-established procedure [6], and ventriculectomy, which may, if performed inappropriately, further deteriorate an impaired left ventricle.
Fig. 1
is a left ventriculogram in a patient who would not be a candidate for partial ventriculectomy. This patient was listed for transplantation in another hospital and came to us for a second opinion. We performed an aneurysmectomy, which resulted in good contraction at the base of the heart and moderate contraction in the lateral portion, and the patient was discharged home after 20 days. Fig. 2
is a left ventriculogram in a patient with a globally dysfunctional heart who would be a candidate for LV reduction.
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Fig. 1. Left ventriculogram in a patient who would not be a candidate for partial left ventriculectomy.
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2. Materials and methods
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Between January 15, 1995 and September 15, 1997 we performed LV reduction in 30 patients, 18 with ischemic dilated myopathy and 12 with idiopathic dilated myopathy. Cardiac comorbidities included previous myocardial infarctions in 21 patients and valvular heart disease in 20, most often mitral valve regurgitation grade 2 or greater. Two patients had mixed aortic valve lesions, and 7 had previous cardiac operations or interventions. Non-cardiac comorbidties included diabetes in ten patients, renal failure in eight, hypertension in four, and chronic obstructive lung disease in two. The 12 patients with idiopathic dilated myopathy had a mean age of 62.8±11.3 years (range 44–85 years); 11 were male and one was female, and seven were transplantation candidates. The 18 patients with ischemic dilated myopathy had a mean age of 60.2±8.8 years (range 39–71 years); 14 were male and four were female, and five were candidates for cardiac transplantation. All patients were evaluated with left and right heart catheterization, coronary angiography, transthoracic and transesophageal echocardiography, and more recently electron beam tomography. Spiroergometry, resting and exercise radionuclide ventriculography, and Holter electrocardiography were performed when appropriate. The last seven patients underwent preoperative sodium nitroprusside and dobutamine testing.
Table 1
Table 2
show the preoperative findings in our patients. In the 12 patients with idiopathic dilated myopathy, the mean LV ejection fraction was 17%, the mean LV end-diastolic diameter was 71 mm, the mean cardiac index was 1.7 l/min per m2, and the mean stroke volume index was 22 ml/m2. Nearly the same findings were observed in the 18 patients with ischemic dilated myopathy (Table 2).
Cardiopulmonary bypass consisted of a centrifugal pump with a membrane oxygenator, a 1200-ml crystalloid prime, high flow (2.8–3 l/min per m2), and 1 l of Bretschneider's cardioplegic solution. After cardioplegic arrest, we performed coronary artery bypass grafting or aortic or mitral valve replacement if required, the ventriculotomy, the partial ventriculectomy, and mitral valve repair with the Alfieri technique [7]. Left ventricular chamber reconstruction was performed either on the arrested or the beating heart depending on the total cross-clamp time and how much time the repairs consumed. Ventriculectomy sites were anterior in nine patients, lateral in six, posterior in 12, and anterior plus posterior in three. Fig. 3
shows a typical site after the operation; we reinforce the suture line with either a piece of pericardium or a very small Teflon strip. Weaning from cardiopulmonary bypass was performed slowly and gradually with a medical regimen of maximal afterload reduction. Postoperatively a protocol with early extubation and maximal afterload reduction was followed.
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3. Results
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No intraoperative deaths occurred. There were two early deaths, one of whom was our second patient, who died from rupture of the suture line in the intensive care unit when his blood pressure rose above 150 mmHg. This had two consequences: first. we controlled blood pressure more strictly in the intensive care unit, maintaining it at less than 120 mmHg for the first 48 h, and second, we reinforced the suture line with pericardium or Teflon felt in subsequent patients. The second early death occurred in a patient we were unable to wean from bypass; a Novacar heart assist device (Baxter Healthcare Corporation, Oakland, CA) was implanted and she was extubated and well, but she died from intracranial bleeding a few days later. Three late deaths consisted of two arrhythmic deaths 4 and 17 months postoperatively and one very sick patient who was discharged but returned and died of pneumonia 3 months after the operation. Overall 1-year survival was 85% (Fig. 4
). Survival is better in patients with ischemic dilated myopathy (Fig. 5
) and in patients with an anterior resection site (Fig. 6
). However, the total number of patients is quite small at this time, and conclusions should be drawn cautiously.
Concomitant surgery was extensive: 18 patients received one to five coronary artery bypass grafts, 14 patients had mitral valve repair, two patients had dynamic cardiomyoplasties, two patients had aortic valve replacement, one patient had mitral valve replacement, and one patient had an aneurysmectomy. Fig. 7
shows the figure-of-eight appearance of the mitral valve after the Alfieri repair.
Hemodynamic changes were quite impressive (Table 3
). We saw a 100% increase in LV ejection fraction, a 61% increase in cardiac index, and a 61% increase in stroke volume index. Arrhythmias occurred very frequently both preoperatively and postoperatively. In a current prospective trial, we support every patient with an implantable cardioverter–defibrillator in order to study the arrhythmic events that occur during late follow-up.
New York Heart Association class improvement was very significant (85% of the patients are currently in class I or II). Fig. 8
shows preoperative (top) and 6-month postoperative (bottom) electron beam computed tomography in a 70-year-old patient demonstrating the difference in contraction and heart size before and after the operation. Preoperative cardiac index was 1.79 l/min m2, left ventricular end-diastolic volume was 181 ml/m2, left ventricular ejection fraction was 16%, stroke index was 19 ml/m2, and heart rate was 95 beats/min; postoperative cardiac index was 2.62 l/min per m2, left ventricular end-diastolic volume was 104 ml/m2, left ventricular ejection fraction was 42%, stroke index was 32 ml/m2, and heart rate was 82 beats/min.
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Fig. 8. Preoperative (top) and 6-month postoperative (bottom) electron beam computed tomography in a 70-year-old patient.
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Postoperative evaluation at this point is very thorough and comparable with that in transplantation patients because the operation is still in its early stages. We perform echocardiography, Holter electrocardiography, spiroergometry, and electron beam tomography and administer a quality-of-life questionnaire 3, 6 and 12 months after the operation and then yearly thereafter. Postoperative medications include an angiotensin converting enzyme inhibitor (quinapril), a diuretic (torasemid), a beta blocker (carvedilol). digitalis (digitoxin), and an antiplatelet drug (acetylsalicylate).
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4. Summary
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In summary, we treated 30 patients ranging in age from 39 to 85 years (12 idiopathic and 18 ischemic) with partial left ventriculectomy between January 15, 1995 and September 15, 1997. Concomitant surgeries included coronary artery bypass grafting, mitral valve replacement, aortic valve replacement, mitral valve reconstruction, and dynamic myoplasty. There were two early and three late deaths; median hospital stay was 18 days. Actuarial 1-year survival was 85%. Left ventricular diameter decreased by 22% and cardiac index, LV ejection fraction, and stroke volume index increased by 61%, 100% and 61%, respectively. We maintain close follow-up and currently implant every patient with an implantable cardioverter defibrillator. We conclude from this early short-term experience that partial ventriculectomy increases cardiac function significantly, and short-term results are comparable to or better than those of cardiac transplantation. Idiopathic and ischemic patients tolerate the procedure well, and all cardiac comorbidities should be treated simultaneously.
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Conference discussion
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Mr S. Westaby
(Oxford, UK): What was the indication for and the value of the cardiomyoplasty?
Dr. W. Konertz
: The indication was earlier in the series, when we had two ischemic patients in whom the ventricle was thin and fibrotic. Currently, I do not see any indication for dynamic cardiomyoplasty. We have performed a total of only 11 in our hospital over the last few years, and it has not fulfilled our expectations. The patients are either too well or too sick for myoplasty, so we do not perform this procedure any more.
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Footnotes
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1 Presented at the Sulzer Carbomedics Sixth International Clinical Symposium, Copenhagen, Denmark, 2 September 1997. 
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References
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Abstract
1. Introduction
