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Eur J Cardiothorac Surg 2000;18:458-465
© 2000 Elsevier Science NL

Left ventricular regional wall motion, ejection fraction, and geometry after partial left ventriculectomy. Influence of associated mitral valve repair

Heart Institute-Incor, University of São Paulo Medical School, São Paulo, Brazil

Received 2 February 2000; received in revised form 19 May 2000; accepted 23 May 2000.

Corresponding author. Rua Oscar Freire 2077 apto 161, São Paulo, CEP 06509-011, Brazil. Tel.: +55-11-3064-6446; fax +55-11-3069-5502
e-mail: dcledimar{at}incor.usp.br

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion and future... References

 
Objective: Left partial ventriculectomy has been proposed for treatment of heart failure. We investigated the effects of isolated left partial ventriculectomy and left partial ventriculectomy associated with mitral annuloplasty on refractory heart failure due to idiopathic dilated cardiomyopathy. Methods: Nineteen patients underwent partial left partial ventriculectomy associated with mitral annuloplasty and six patients isolated left partial ventriculectomy. In two patients the left partial ventriculectomy associated with mitral annuloplasty was combined with tricuspid annuloplasty. We evaluated before and after the surgery (24±14 days): the functional class, left ventricular ejection fraction (LVEF), right ventricular ejection fraction (EF), regional wall motion, hemodynamics, mitral regurgitation, left ventricular geometry and coronary angiography. Results: For the overall group LVEF improved from 14.5±8.0 to 30.3±12.2% (P<0.0002) and right ventricular EF from 21.2±7.1 to 28.4±8.3% (P<0.002). In patients who underwent left partial ventriculectomy associated with mitral annuloplasty LVEF increased from 14.5±8.6 to 29.5±12.2% (P<0.002). Isolated left partial ventriculectomy increased LVEF from 13.5±7.5 to 31.5±11.1% (P<0.04). Distal segments of marginal branches of the circumflex artery were not visualized by coronary angiography. Left partial ventriculectomy associated with mitral annuloplasty reduced the wedge pressure from 25.0±12.1 to 18.0±7.0 mmHg (P<0.03) and increased cardiac output from 3.8±0.8 to 4.6±1.1 l/min (P<0.004), while isolated left partial ventriculectomy increased cardiac output from 3.7±1.0 to 4.8±1.3 l/min (P<0.03). Regional wall motion increment was more evident in anterolateral region from 4.2±6.8 to 14±8.3% (P<0.002) except in two patients. Left ventricular geometry changed in most patients, but a homogeneous pattern was not identified. Seven patients died during a mean follow-up of 546±276 days. Survivors had improvement in functional class. Augmentation of LVEF >5% was associated with a favorable clinical outcome with improvement in clinical status without death. Conclusions: Effects of left partial ventriculectomy are not necessarily dependent upon reduction of mitral regurgitation or changes in left ventricular geometry. However, risk of death after the surgery must be reduced for a clinical application.

Key Words: Congestive heart failure • Surgery • Cardiomyopathy • Transplantation • Remodeling • Partial left ventriculectomy • Batista’s procedure

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion and future... References

 
The cardiac remodeling process, also, has become a target in the surgical treatment of congestive heart failure (CHF). Cardiomyoplasty may partially reverse the remodeling process [1], thereby improving heart failure. However, selection criteria for cardiomyoplasty in association with concerns about long-term muscle flap characteristics and sudden death, have limited its application [2]. Partial left ventricular ventriculectomy (Batista's procedure) has been proposed for treatment of refractory heart failure to reverse some aspects of cardiac remodeling [3]. Recently, improvement in left and right ventricular function, functional class, cardiac index, and neurohormonal activation reduction were demonstrated after partial left ventriculectomy [4,5].

The purpose of this study was to investigate prospectively, by contrast left ventriculography, the effects of partial left ventriculectomy on global and regional function, and geometry of left ventricle. In addition, we studied the effects of isolated partial left ventriculectomy, partial left ventriculectomy combined with mitral annuloplasty, and partial left ventriculectomy combined with mitral and tricuspid annuloplasty.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion and future... References

 
2.1. Study population
From April 1995 to September 1997, 35 patients underwent isolated partial left ventriculectomy or partial left ventriculectomy combined with mitral annuloplasty, or partial left ventriculectomy combined with mitral and tricuspid annuloplasty for treatment of chronic refractory CHF in the Heart Institute (INCOR), Medical School of São Paulo University (Brazil). All patients were referred for surgical treatment of CHF according to reported criteria [4]. Ten patients were not included in this study because of chronic atrial fibrillation (two patients), or death in immediate postoperative period (eight patients). The causes of death were sepsis (two patients), sustained ventricular tachycardia (two patients), bleeding (one patient), progressive congestive heart failure (one patient) and post operative acute congestive heart failure (two patients).

The study group consisted of 20 male and five female patients, with idiopathic dilated cardiomyopathy, age 48±9 years with a symptom duration of 4.4±2.2 years, with previous history of cardiogenic shock (six patients), intermittent New York Heart Association functional class IV (19 patients) with several hospital admissions a for heart failure treatment, and syncope (three patients). Immediately before admission for surgery, patients were in New York Heart Association functional class IV (15 patients), cardiogenic shock (one patient) or class III (six patients) in spite of maximum tolerated medical therapy. Patients were receiving digitalis (24 patients), furosemide (25 patients) (mean dosage of 58±23 mg/day), furosemide combined with thiazide, or amiloride or spironolactone (seven patients), ACE inhibitors (25 patients) (mean captopril dose 70±44 mg/day, enalapril 15 mg), nitrates (one patient), amiodarone (eight patients), and ibopamine (one patient). Six patients refused heart transplantation, and 19 patients presented limitations for heart transplantation, such as social condition (ten patients), psychological instability (three patients), overweight (one patient), pulmonary disease (two patients), cerebral vascular disease (one patient), age (one patient), and delay in heart transplantation because of overweight and blood type (one patient).

All patients underwent endomyocardial biopsy, and coronary angiography to exclude myocarditis and ischemic cardiomyopathy. The patients were selected according exclusion criteria [4]. Preoperative laboratory data are summarized in Table 1. This study was approved by the Heart Institute Review Committee and all subjects gave informed consent.

2.3. Left ventricular function, geometry, and coronary angiography
We determined the ejection fraction and the left ventricular (LV) geometry (according published methods) [1,6]. Regional motion method is demonstrated in Fig. 1 . The severity of mitral regurgitation assessed by left ventriculography was graded using a scale of mild (+), moderate (++), moderately severe (+++), and severe regurgitation (++++) [7]. Since October 1996 patients have undergone routine postoperative coronary angiography because of early incidence of acute myocardial infarction diagnosed in patients who died in the immediate post-operative period.

View larger version (26K): [in this window] [in a new window]   Fig. 1. Analysis of left ventricular (LV) regional motion. Panel a and b (left): LV end-diastolic (ED) and LV end-systolic (ES) endocardial contours at 30-degree right anterior oblique. The mathematical center of gravity is determined for the ED and ES contours. Right mitral-valve point is determined, and the wall between the left-aortic valve and the right-mitral points is then divided into five anatomical wall segments. Segments are shown for the ED contour only. Panel a and b (right): graph of radial shortening plotted against location. The vertical axis represents the percentage displacement of corresponding ED and ES wall locations with reference to center of gravity. The difference in length between the ED and ES radius is divided by the length of the ED radius. The average shortening percentages for each of the five anatomical segments are determined. AB, anterobasal; AL, anterolateral; AP, apical; DPH, diaphragmatic; PB, posterobasal. (a) Preoperative. (b) Postoperative.

2.5. Statistical analysis
The Student's paired t-test was used for normally distributed data. Wilcoxon's signed rank test was performed for non normally distributed paired data. The relationship between variables were examined by linear regression analysis. For analysis of the improvement of NYHA functional class, statistical categorical models were used. A value of P<0.05 was considered statistically significant. Data are presented as mean±1 SD.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion and future... References

 
3.1. Global left ventricular function, mitral regurgitation, and coronary angiography
Left ventricular ejection fraction before the surgery was 14.5±8.0%, whereas postoperative left ventricular ejection fraction was 30.3±12.2% (P<0.0002) (Fig. 2) for the whole group. Left ventricular ejection fraction did not improve in six patients and it became worse in two. Preoperative and postoperative mean left ventricular ejection fraction was 14.5±8.6 and 29.5±12.2% (P<0.002), respectively, in the subgroup including patients who underwent partial left ventriculectomy combined with isolated mitral valvuloplasty or ventriculectomy with mitral valvuloplasty associated with tricuspid valvuloplasty. In this subgroup, five patients (26%) did not show improvement in left ventricular ejection fraction. Left ventricular ejection fraction improved from 13.5±7.5 to 31.5±11.1% (P<0.035) in patients who underwent isolated partial left ventriculectomy.

View larger version (28K): [in this window] [in a new window]   Fig. 2. Line graph showing effects of isolated partial left ventriculectomy or partial left ventriculectomy combined with mitral annulosplaty on left ventricular ejection fraction (LVEF) by contrast angiography. Pre, preoperative; post, postoperative.

View larger version (101K): [in this window] [in a new window]   Fig. 3. Angiography views of left coronary artery on right anterior oblique position. Panel a: preoperative left coronary angiography. Panel b: postoperative left coronary angiography. Distal segments of two obtuse marginal branches of circunflex artery are not visualized in the postoperative angiography (arrows).

View larger version (17K): [in this window] [in a new window]   Fig. 4. Bar graphy showing effects of isolated partial left ventriculectomy and partial left ventriculectomy combined with mitral annuloplasty on left ventricular regional wall motion (in percentage). AB, anterobasal region; AL, anterolateral; AP, apical; DPH, diaphragmatic; PB, posterobasal. Patients after the surgery (POST) had improvement of all studied regions compared with preoperative determinations (PRE) (P<0.048).

In patients who underwent isolated partial left ventriculectomy regional wall motion improved in anterobasal region from 5.9±4.7% (P<0.02), anterolateral region from -0.7±8.5 to 7.3±10% (P<0.03). The tendency toward improvement was observed in the apical region from -0.8±9.3 to 6.8±2.0% (P<0.07). Preoperative and postoperative values of diaphragmatic and posterobasal regions were 7.3±10 and 14±9.1% (P=not significant (NS)), and 7.9±5.6 and 12.7±4.9% (P=NS), respectively.

3.3. Left ventricular geometry
In the whole group changes in left ventricular geometry were observed in most patients without a homogeneous pattern. The preoperative minor-to-major axis ratio was 0.71±0.07 and the postoperative ratio was 0.68±0.09 (P=NS) in the whole group. Also, The preoperative and postoperative sphericity indexes were 0.70±0.07 and 0.69±0.08, respectively, (P=NS).

The preoperative and postoperative minor-to-major axis ratios were 0.72±0.75 and 0.69±0.09, respectively, (P=NS) in patients who underwent combined procedures (ventriculectomy with mitral annuloplasty and ventriculectomy with mitral and tricuspid annuloplasty). In this group preoperative and postoperative sphericity indexes were 0.71±0.07 and 0.69±0.09, respectively, (P=NS). Changes were not observed for minor-to-major axis ratio (0.68±0.06 and 0.66±0.1) or sphericity index (0.67±0.06 and 0.69±0.8) in the subgroup that underwent isolated partial left ventriculectomy.

3.4. New York Heart Association functional class and follow-up
In the whole group the mean studied follow-up was 546±276 days (from 920 to 74 days). Most surviving patients presented improvement in functional class (Table 2). Seven patients of the whole study group died during a follow-up from 107 to 50 days being two patients of the isolated left ventriculectomy subgroup and five patients of the mitral plasty left ventriculectomy subgroup. During the follow-up one patient who developed atrial fibrillation received carvedilol for control of high ventricular rate, and one patient underwent heart transplantation because of persistent decompensated heart failure.

3.5. Correlation between left ventricular function by contrast angiography and clinical outcome
In the whole group left ventricular ejection fraction did not improve in six patients. Three of these patients died, two from progressive heart failure, one from heart failure and infection, and one underwent heart transplantation. One patient showed late improvement in left ventricular ejection fraction.

Augmentation of left ventricular ejection fraction >5% before discharging patients from hospital was associated with a favorable clinical outcome in most patients with improvement in NYHA functional class (Table 2). Four of these patients died (21%). The cause of death was infected pulmonary embolism in one patient, suspected progressive heart failure in one patient, and two patients had sudden death.

3.6. Relationship between changes in left ventricular ejection fraction and studied variables
No relationship was observed by linear regression between changes in left ventricular ejection fraction from preoperative to postoperative evaluation and: preoperative (R²=0.07) and postoperative (R²=0.09) left ventricular end-diastolic diameter; changes in left ventricular end-diastolic diameter (R²=0.12); preoperative (R²=0.0003) and postoperative (R²=0.07) ratio of the minor-to-major axis; changes in ratio of the minor-to-major axis (R²=0.05); preoperative (R²=0.002) and postoperative (R²=0.05) diastolic sphericity index; changes in sphericity index (R²=0.03); changes in right ventricular ejection fraction (R²=0.04); and time of history (R²=0.06). There was a weak correlation between changes in left ventricular ejection fraction and preoperative left ventricular ejection fraction (R²=0.32) (Fig. 5) .

View larger version (12K): [in this window] [in a new window]   Fig. 5. Plot of linear regression analysis between changes in left ventricular ejection (LVEF, difference between postoperative and preoperative values) and preoperative left ventricular ejection fraction.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion and future... References

The association between relatively modest augmentation in left ventricular ejection fraction observed after the ventriculectomy and more evident improvement in functional class may be explained by the exponential relationship between one-year mortality as the left ventricular ejection fraction decreased to less than 0.35 [9]. The mechanism proposed that might explain the improvement in left ventricular function include: (1) reduction of diameters reducing ventricular wall stress and consequently unloading the left ventricle that could lead to an improvement in muscle shortening. This hypothesis is supported by demonstrated reduction of ventricular stress after heart reduction surgery [10], by the relative decrease in the ratio between left ventricular diameter and wall thickness, and by the well-known inverse correlation between ventricular stress and fiber shortening [11]. (2) Reduction of oxygen consumption resulting from the decrease in stress could improve the cellular metabolism. However, cardiac oxygen consumption is influenced by other factors, such as muscle hypertrophy, contractility, pressure work, heart rate, the Fenn effect, and volume work [10,12]. (3) Reduction of mitral regurgitation could result in improvement in symptoms, left ventricular performance, and decrease in left ventricular end-diastolic volume [13]. In our results the isolated procedure may improve clinical status, left ventricular function and hemodynamics; however, the combination of ventriculectomy with mitral valvuloplasty was more effective for reducing pulmonary artery wedge pressure. (4) Reduction of sphericity associated with improvement in cardiac function reported by an echocardiographic study [10], was not found in our study. However, in this echocardiographic study the relationship between improvement in left ventricular function and changes of geometry was not specifically studied. Also, it was postulated that a more spherical cardiac configuration in heart failure may reduce elevated left ventricular wall stress [14]. (5) Stress reduction leading to a decrease in sarcomere overstretching and mechanogenic transduction that could reverse the gene reprogramming of remodeling in heart failure, and fiber-based slippage. Left ventricular unloading of sufficient magnitude and duration can result in reduction of myocyte damage, contraction band necrosis, myocytolysis, and increase in fibrosis [15–17]. (6) Reduction of the overstretch after heart muscle surgery could acutely change the response of sarcomeres in the Starling's curve. It could improve the reduced myocardial wall shortening at a time when the sarcomere length of the ventricle has become maximal, perhaps in a descending limb of curves [18]. Starling's mechanism seems to be present in myocardium of patients with heart failure with end-diastolic left ventricular diameters of 6.8±0.9 cm [19]; however, investigators reported that this mechanism is exhausted in severe functional class IV heart failure [20]. Recently, it was demonstrated that calcium uptake and calcium-binding rates may be improved by unloading the left ventricle.

Our results are in concordance with heterogeneous abnormal regional left ventricular function observed in nonischemic dilated cardiomyopathy. This heterogeneous abnormal regional left ventricular function is probably influenced by local factors in a spatially heterogeneous fashion rather than systemic factors [21]. Mechanisms proposed to explain this include bundle branch block [22], and heterogeneity in regional wall stress [23,24], impaired regional oxidative metabolism [21], the myopathic process, the remodeling process [25], regional geometry, and neurohormonal activity [26]. Higher regional stress in anterolateral and diaphragmatic areas with an inverse relationship between fiber shortening and stress was reported by a contrast angiography study [23]. It is likely that the more evident augmentation in anterolateral and diaphragmatic regions is a result of more intense selective action of surgery in some heterogeneous local factors.

4.1. Study limitations
This was a prospective nonrandomized study without a control group including patients who did not die during the surgical procedure; however, considerable data were obtained and the spontaneous improvement in 21 of 35 patients is unlikely based on natural history of the disease without expressive changes in medication. The study of region wall motion did not include a left anterior oblique analysis; however, this analysis excluded the influence of postoperative reported acute lateral myocardium infarction on lateral regional wall motion [4]. Despite the fact that the regional method is not suited for analyzing cardiomyopathy, it is commonly used in clinical practice. The small number of patients of the isolated ventriculectomy subgroup is a limitation for comparison between subgroups, however, the results in this subgroup was expressive.

	5. Conclusion and future approaches

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion and future... References

 
Isolated partial left ventriculectomy alone or in combination with mitral annulosplasty may improve heterogeneous regional wall motion and consequently have clinical benefits for global cardiac function in the immediate post-operative period. However, risks of acute myocardial infarction and death due to surgery as observed in this study must be reduced for these procedures to have wide clinical application. The influence of left coronary artery dominance should be investigated. Appropriated selection of patients, though, could be mainly centered on identifying cellular mechanisms rather than approaches that analyze the geometric design of the heart. In our institution the surgery has been indicated in very selected patients without chances of heart transplantation. Future investigation is needed to clarify myocardial cellular mechanism by which partial left ventriculectomy may improve cardiac function.

	Acknowledgments

 
The authors would like to thank Professor Liberato John Alphonse DiDio and Ann Morcos, MA, ELS for editorial assistance.

	Footnotes

 
Presented at the 70th Scientific Sessions of the American Heart Association, Convention Center, Orlando, FL, USA, 1997.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusion and future... References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Edimar Alcides Bocchi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bocchi, E. A. Articles by Ramires, J. F. Search for Related Content PubMed PubMed Citation Articles by Bocchi, E. A. Articles by Ramires, J. F.