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Eur J Cardiothorac Surg 2001;19:684-689
© 2001 Elsevier Science NL

Left ventricle restoration in patients with non-ischemic dilated cardiomyopathy: risk factors and predictors of outcome and change of mid-term ventricular function

^a Hayama Heart Center, 1898 Shimoyamaguchi, Hayama, Kanagawa 240-0116, Japan
^b Shonan Kamakura General Hospital, 1202-1, Yamazaki, Kamakura, Kanagawa 247-8533, Japan

Received 9 October 2000; received in revised form 26 February 2001; accepted 8 March 2001.

Corresponding author. Tel.: +468-75-1717; fax: +468-75-3636
e-mail: mail{at}hayamaheart.gr.jp

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objective: The partial left ventriculectomy (PLV) for end-stage dilated cardiomyopathy (DCM) which worked in some patients has been reported, although the hospital mortality is high. To reduce hospital mortality, we selected operative procedures of left ventricular (LV) restoration to improve the operative results. We analyzed the risk factors and predictors of outcome, and the mid-term changes of the LV function were determined. Patients and methods: Between December 1996 and September 2000, 74 patients with non-ischemic DCM received LV restoration. The age ranged from 14 to 76 years (mean, 49.0±14.0 years), and there were 63 men and 11 women. The etiology of the DCM was idiopathic DCM in 49 patients, and dilated hypertrophic cardiomyopathy in seven patients and others in 18. The preoperative New York Heart Association (NYHA) functional class was 29 in class III and 45 in class IV, in which 32 patients depended on inotropic support. PLV or septal anterior ventricular exclusion (SAVE) was selected depending on the akinetic lesion of the LV based on the intraoperative echo-test. Fifty-six patients received elective operations, and emergency operations were performed in 18 patients. The risk factors and predictors of outcome were analyzed in 74 patients, and in 35 patients who survived more than 1 year after receiving LV restoration, the mid-term cardiac function was examined by cardiac echogram and catheterization. Results: PLV was performed in 62 patients and SAVE in 12 patients. Concomitant mitral surgery was performed in 66 patients (89%) and tricuspid annuloplasty in 42 patients (57%). There were 15 hospital deaths and 13 patients died after discharge from the hospital (cardiac deaths in nine and non-cardiac deaths in four). In the 46 late survivors, the NYHA class was I or II in 42 patients and III in four patients. Selection of the procedure of LV restoration (P<0.01), elective operation (P<0.05), and the preoperative volume of LV (endodiastolic volume index of <180 ml/m²; P<0.05) were risk factors and predictors influencing hospital and late death. After the operation, the LV function improved significantly and the improvement was maintained at the mid-term period; the LV ejection fraction was 31.8±7.9% (P<0.01) at 1 year from 23.0±7.3% preoperatively, left ventricular diastolic diameter was 62.8±10.9 (P<0.01) from 81.7±8.2 mm and the LV endosystolic volume index was 88.5±45.8 (P<0.05) from 162.6±41.6 ml/m². Conclusions: The operative results improved with the selection of the procedures, with elective operation, and mitral plasty for less cardiac dilatation. The mid-term results of clinical status and LV function showed the effectiveness of the operation.

Key Words: Non-ischemic dilated cardiomyopathy • Partial left ventriculectomy • Septal anterior ventricular exclusion • Left ventricular function • Risk factors

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion Appendix A. Conference... References

 
For various types of dilated cardiomyopathy (DCM), partial left ventriculectomy (PLV) [1] has been performed to improve cardiac function by reducing the diameter of the left ventricle. However, the early postoperative results have been reported to be widely variable, as inconstant as those after heart transplantation. There have been few reports regarding the mid-term results after PLV [2]. Since December in 1996, we have been performing various operations for end-stage DCM by reconstruction of the patient's own heart [3]. We have previously reported that the PLV was not always effective in all types of DCM, but the operative procedure should be selected based on an intraoperative echo-test to improve the early operative results [4]. In this paper, the risk factors and predictors of outcome were analyzed and the improvement of clinical symptoms. The left ventricular (LV) function after LV restoration was also studied in the mid-term follow-up to evaluate LV restoration surgery for non-ischemic DCM.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Between December 1996 and August in 2000, 96 patients with non-ischemic DCM received various types of non-transplant cardiac operations. Among them, 74 patients underwent restoration of the LV and 22 patients received solo-valvular operations. Seventy-four patients with LV restoration were studied. All 59 hospital survivors were followed up and LV function was studied in 35 patients 1 year after the operation.

There were 63 men and 11 women, and the age ranged from 14 to 76 years (mean, 49.5±14.0 years).

The etiology of the DCM was idiopathic dilated in 49 patients, and dilated hypertrophic cardiomyopathy in seven, valvular in ten, and sarcoidosis in four, myocarditis in two, arrythmogenic right ventricular dysplasia in one and Chagas’ disease in one.

The preoperative New York Heart Association (NYHA) functional class comprised 29 in class III and 45 in class IV, in which 32 patients were supported by inotropic infusion. All patients had a history of beta-blocker treatment and were failed.

Preoperative examinations consisted of cardiac echograms with color kinesis, catheterization, cine magnetic resonance images (MRI), and angiograms. The initial 24 patients received PLV according to Batista's procedures. For the recent 50 patients after March in 1998, the operative procedures were selected based on the findings of LV wall motion and viability of the myocardium as reported previously [4]. The wall motion and the thickness of the LV muscle changed after the reduction of LV volume during extracorporeal circulation (ECC). The changes in the LV wall motion were observed by echogram with color kinesis during the operation (intraoperative echo-test). After the reduction of LV volume by ECC, both the kinetic and akinetic areas were detected by the thickness of the color echo. When akinesis was present in the postero-lateral wall, PLV of postero-lateral wall was indicated, while antero-septal wall exclusion with a patch was indicated when the postero-lateral wall was more kinetic compared with the antero-septal wall. According to the findings, PLV was carried out in 38 patients and the septal anterior ventricular exclusion (SAVE) operation in 12 patients. There were 56 patients with elective operations and 18 patients with emergency operations. There was mitral regurgitation in 66 patients, no regurgitation in three, and previous mitral valve replacement in five patients. Mitral plasty was simultaneously performed in 20 patients and valve replacement in 46 patients. There was tricuspid regurgitation in 42 patients and tricuspid annuloplasty was performed simultaneously with the LV restoration surgery.

2.1. Surgical technique
The operative procedures were described in the previous report [4]; in brief, after the institution of cardiopulmonary bypass, the LV surgery was performed under on-pump beating heart without aortic cross-clamping, while cardioplegic arrest with antegrade intermittent warm blood cardioplegia was used for mitral annuloplasty. For PLV, the incision was placed close to the second diagonal branch first and then it proceeded down to the apex of the left ventricle along the left anterior descending artery (LAD). The LV muscle of the postero-lateral wall between the bilateral papillary muscles was then excised. The left ventricle was closed in two layers with large monofilament sutures. For the left ventriculoplasty with SAVE, the incision was made along the left side of the left anterior descending artery from the apex to the base of the left ventricle. After the incision, an oval shaped Dacron (Haemashield^®) patch was sutured with a monofilament suture to exclude the antero-septal akinetic lesion of the left ventricle. After exclusion of the lesion, the ventricular wall was closed in two layers. Mitral valve reconstruction was performed with an undersized prosthetic ring with or without additional repairs such as Alfieri's suture. A bioprosthesis was preferably used for mitral valve replacement because of the low incidence of thromboembolism. Tricuspid regurgitation was repaired with Devega's annuloplasty or ring annuloplasty.

Before operation, the intracardiac pressure and cardiac index were measured by either cardiac catheterization or the Swan–Ganz catheter. The volume and diameter of the left ventricle were measured by cardiac echogram. After the operation, early cardiac catheterization was performed before discharge and cardiac echogram was performed on all patients.

After the patients were discharged from the hospital, medical treatment was continued by a cardiologist and all patients were followed-up and received re-examinations every 6 months after the operation.

2.2. Statistical analysis
Continuous variables are presented as means±SD. Cumulative survival rates were calculated by Kaplan–Meier estimation using the date of operation and the date of the last follow-up. A multivariate analysis of independent factors was performed with Cox's proportional hazards model analysis. A probability value of less than 0.05 was considered significant.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion Appendix A. Conference... References

 
After the operation, there were eight hospital deaths of the initial 24 patients with PLV. Among 50 patients who had selection of operative procedures based on the findings of an intraoperative echo-test, PLV was performed in 38 patients and SAVE was chosen in 12 patients. There were seven hospital deaths of the 38 PLV operations and no deaths in the 12 SAVE operations. For mitral regurgitation, mitral valve replacement was undergone in 46 patients and mitral valve plasty in 20 patients. Tricuspid annuloplasty was performed in 42 patients. Aortic cross-clamps were placed in 39 patients, with a mean cross clamp time of 67.0±30.7 min, while the whole procedure was carried out in on-pump beating hearts in the other 35 patients. Cardiopulmonary bypass was weaned in all patients; without mechanical support in 62 patients and with intra-aortic balloon pumping in ten patients or LV assist devices in two patients. The mean CPB time was 131.5±44.6 min.

In the late follow-up periods, there were nine cardiac deaths and four non-cardiac deaths. Congestive heart failure (CHF) recurred in 16 survivors after discharge from the hospital. Among them, CHF recurred in 13 patients within 1 year and six of them died. The factors influencing the operative outcome were statistically analyzed (Table 1). Late cardiac death analysis, including hospital deaths, was significantly low in patients with selection of the operative procedure using the intraoperative color test, in patients with elective operations, and in patients with less dilated LVs (left ventricular endodiastolic volume index (LVEDVI) of <180 ml/m²). In patients with mitral surgery, mitral valve plasty tended to have better results than mitral valve replacement (P=0.057). Three patients required re-LV restoration surgery because of the LV remaining too large at 26, 19 and 12 months after the initial operation, respectively. Three patients died at later than 1 year after the initial operation; two of them had re-LV restoration and died in hospital after the second operation. One patient died 13 months after the PLV because of re-dilatation of the LV due to failure of the mitral annuloplasty.

View larger version (76K): [in this window] [in a new window]   Fig. 1. Findings of left ventriclulogram before operation and follow-up examination after partial ventriculectomy (PLV) and mitral valve replacement (MVR). The dilated spherical left ventricle became small and ellipsoid after the operation. The left ventricular function improved more and the volume became smaller at 2 years after the operation.

View larger version (13K): [in this window] [in a new window]   Fig. 2. The Kaplan–Meier survival rate after LV restoration for DCM. The 1-year survival rate after operation, including both emergency cases and hospital deaths, was 71.0% and the 2-year survival rate was 60.6%.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion Appendix A. Conference... References

The major reason for the high operative mortality was considered to be postoperative prolonged CHF, or the deterioration of diastolic function which was caused by too small a heart after the PLV. In our early experience, we tried to make the diameter of the LV as small as the normal size and it easily caused diastolic dysfunction [3]. From the pathological examination of resected cardiac muscle, we found that the myocardium was not damaged homogeneously, but focally diseased in many patients with non-ischemic DCM. After those initial experiences, we started to use the intraoperative echo-test to detect the weakest akinetic lesion [4]. When akinesis was present in the postero-lateral wall, PLV was effective in improving the cardiac function. In contrast, if the postero-lateral wall was kinetic, PLV should be a contraindication because of the removal of good muscle, and exclusion of the antero-septal wall similar to the procedures introduced by Dor et al. [9] was performed. After the use of the intraoperative echo-test and selection of operative procedures, the hospital mortality decreased as shown in the previous report [4].

Most of the LV restoration procedures were performed with mitral surgery. In patients with DCM and severe mitral regurgitation, mitral repair without LV surgery might work as the surgical procedure, as Bolling et al. reported [10,11]. We have not examined a randomized study, however, we have considered that LV restoration seemed to work better than solo-mitral surgery when the LV dilated strikingly. In fact, ten out of 22 patients with solo-valvular surgery died within 1 year after the operation, including four hospital deaths due to CHF.

We analyzed the risks and predictors influencing the late outcome, including hospital death. Selection of the operative procedures, elective operation and the avoidance of operation for over-dilated LV showed a better outcome, and mitral valve plasty seemed to be better than replacement. For those reasons, the dilated heart is not equally diseased and the selection of operative procedures seems to be important. Too much dilatation of the LV is considered to have more involved lesions and less healthy muscle is preserved to function after the LV restoration.

Our mid-term results showed that the improvement of LV function was prolonged after the surgery and dilatation was rarely seen in patients who survived more than 1 year after the operation. In our experience of 74 LV restoration operations, the 1-year survival rate, including hospital death and emergency patients, was 70.6%, while the 2-year survival rate was 60.6%. Therefore, both medical and surgical treatment during and after the operation within 1 year seemed to be most important for a good clinical outcome for LV restoration. After 1 year of survival with proper medical treatment, the improvement of cardiac function was maintained, and further improvement of cardiac function in the mid-term was also expected. If the late follow-up after the operation is examined and the results are comparable with those after heart transplantation, the LV restoration might be indicated for patients who are end-staged non-ischemic DCM and waiting for heart transplantation.

Conclusively, PLV did not seem to work out in all patients with non-ischemic DCM, but antero-septal exclusion as left ventriculoplasty seemed to be effective in cases with severe antero-septal akinesis. The mid-term results encourage performing LV restoration surgery with selected surgical procedures in elective situations for the improvement of cardiac function.

	Footnotes

 
Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr E. Wolner (Vienna, Austria): Have you proved or have you done any studies to treat this group of patients also medically with this more intensive medical treatment, which we use usually as a bridge to transplantation? In other words, can you be sure that in these patients, you have only 70% survival after the first year. In our transplant cohort, including the mortality of the waiting list, we have better results. Can you be sure that these patients can also be treated medically to achieve the same results?

Dr Isomura: We did not compare the randomized study, but all the patients whom we treated surgically were referred from the cardiologists, who already had fully medicated, and the cardiologists gave up their medical treatment. Actually, this procedure was not indicated for several patients, but all those patients died within 3 months. I think the patients whom we treated are more severe than the patients who are candidates for heart transplantation.

Dr C. Torrealba (Caracas, Venezuela): How many of your patients needed an ICD in the postoperative period?

Dr Isomura: Two patients had an ICD after the operation. We had ventricular arrhythmia for three patients. Unfortunately, one patient died in the hospital.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion Appendix A. Conference... References

 

1. Batista R.J.V., Santos J.L.V., Takeshita N. Partial left ventriculectomy to improve left ventricular function in end-stage heart disease. J Card Surg 1996;1:96-97.
2. Franco-Cereceda A, McCarthy PM, Blackstone EH, Hoercher KJ, White JA, Youbg JB, Starling R. The Batista procedure is not an alternative to cardiac transplantation. Abstract. 80th Annual Meeting of the American Association for Thoracic Surgery, 2000;44.
3. Suma H., Isomura T., Horii T., Sato T., Kikuchi N., Iwahashi K., Hosokawa J. Two-year experience of the Batista operation for non-ischemic cardiomyopathy. J Cardiol 1998;32:269-276.[Medline]
4. Isomura T., Suma H., Horii T., Sato T., Kikuchi N. Partial left ventriculectomy, ventriculoplasty or valve surgery for idiopathic dilated cardiomyopathy – the role of intra-operative echography. Eur J Cardio-thorac Surg 2000;17:239-245.[Abstract/Free Full Text]
5. McCarthy P.M., Starling R.C., Wong J., Sclis G.M., Guda T., Vargo R.L., Goormastic M., Thomas J.D., Smedira N.G., Young J.B. Early results with partial left ventriculectomy. J Thorac Cardiovasc Surg 1997;114:755-763.[Abstract/Free Full Text]
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7. Moreia L.F.P., Stolf N.A.G., Bocchi E.A., Bacal F., Giorgi M.C.P., Parga J.R., Jatene A.D. Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy. J Thorac Cardiovasc Surg 1998;115:800-807.[Abstract/Free Full Text]
8. Gradinac S., Miric M., Popovic Z. Partial left ventriculectomy for idiopathic dilated cardiomyopathy: early results and six-month follow-up. Ann Thorac Surg 1998;66:1963-1968.[Abstract/Free Full Text]
9. Dor V., Sabatier M., DiDonato M., Montiglio F., Toso A., Maioli M. Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars. J Thorac Cardiovasc Surg 1998;116:50-59.[Abstract/Free Full Text]
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