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Eur J Cardiothorac Surg 2001;20:319-323
© 2001 Elsevier Science NL

Left ventriculoplasty for ischemic cardiomyopathy

Hisayoshi Suma, Tadashi Isomura, Taiko Horii, Kouichi Hisatomi

Department of Cardiovascular Surgery, Hayama Heart Center, 1898 Shimoyamaguchi, Hayama, Kanagawa 240-0116, Japan

Received 15 January 2001; received in revised form 17 April 2001; accepted 27 April 2001.

Corresponding author. Tel.: +81-468-75-1717; fax: +81-468-75-3636
e-mail: mail{at}hayamaheart.gr.jp


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: In order to treat ischemic cardiomyopathy, which is defined as non-aneurysmal diffuse akinetic left ventricle with chronic heart failure following myocardial infarction, the mid-term effect of the endoventricular circular patch plasty (EVCPP) was studied. Materials and methods: EVCPP has been performed on 54 patients (46 men and eight women with a mean age of 61 years) during 4 years from March 1997 to December 2000. Thirty-two patients (59%) were NYHA class III and 22 patients (41%) were class IV. Nine patients (17%) had mild angina pectoris before the operation but others had no chest pain. Single, double, triple, and left main disease were noted in six, 13, 32, and three patients, respectively. Mean left ventricular ejection fraction was 23.3±6.3% (6–30%). Coronary artery bypass grafting was concomitantly undergone by 51 patients (94%) and mitral valve reconstruction was done on 19 patients (35%). Results: Two patients (3.7%) needed an intra-aortic balloon pump to wean from cardiopulmonary bypass. Seven patients (12.9%) died in the hospital. Among them, two patients (4.4%) out of 45 patients who underwent elective operation died of stroke and heart failure. Five patients (55.5%) out of nine patients who required emergency operation died of heart failure and multiorgan failure. Late death occurred in six patients (11.1%) due to arrhythmia and heart failure in each of three patients. Out of 41 survivors, 38 patients returned to NYHA class I or II and three patients to class III. Out of 50 patients who underwent left ventricular study before and after operation, ejection fraction increased from 22.8±6.6 to 36.2±8.0% and mean left ventricular end-diastolic volume and left ventricular end-systolic volume indices reduced from 152.8±24.6 to 105.0±36.5 and from 113.6±45.7 to 66.4±28.4 ml/m2, respectively. Mean pulmonary wedge pressure decreased from 19.1±8.8 to 14.9±6.8 mmHg. One-, 2-, and 3-year actuarial survival rates were 87.9, 82.7 and 77.2%, respectively. Conclusion: Left ventriculoplasty using EVCPP is effective to exclude the akinetic LV segment, and left ventricular function and clinical status improve in patients with ischemic cardiomyopathy.

Key Words: Heart failure • Myocardial infarction • Ischemic cardiomyopathy • Ventriculoplasty


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Endoventricular circular patch plasty (EVCPP) was introduced by Vincent Dor [1,2] in 1984 as an effective reconstructive procedure for postinfarction ventricular aneurysm. Having achieved successful results, Dor et al. [3,4] started to apply this surgical technique to treat end-stage ischemic cardiomyopathy, which is defined as non-aneurysmal diffuse akinetic left ventricle with chronic heart failure following myocardial infarction. Over the years, those groups of patients with dilated left ventricle, chronic heart failure, and minimal or no angina pectoris have been known to be unfavorable candidates for coronary artery bypass grafting (CABG) and cardiac transplantation is considered to be a possible surgical treatment when medical treatment has failed. We report the 4-year results of left ventriculoplasty with EVCPP for patients with ischemic cardiomyopathy.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
From January 1997 to December 2000, 54 patients with ischemic cardiomyopathy underwent the left ventriculoplasty using EVCPP at Shonan Kamakura General Hospital and Hayama Heart Center. This was 47% of the 115 patients who underwent ventricular reconstruction for ischemic heart disease in the same period. There were 46 men and eight women with a mean age of 61 years, ranging from 40 to 74 years old. All patients had anteroseptal myocardial infarction with or without postero-lateral or inferior infarction. A coronary arteriogram showed single-vessel disease (anterior descending artery) in six patients, double-vessel disease in 13 patients, triple-vessel disease in 32 patients, and left main trunk disease with distal coronary artery lesion in three patients. Three patients had previous CABG. All patients had signs of congestive heart failure with NYHA class III in 32 patients (59%) and class IV in 22 patients (41%), including 13 patients (17%) who were supported with inotropes. Nine patients (17%) had mild angina pectoris prior to the operation but the others did not complain of any chest pain. Mitral regurgitation was associated with 19 patients (35%) and tricuspid regurgitation was noted in five patients (Table 1). The mean left ventricular ejection fraction was 23.3±6.3% (6–30%). The mean preoperative left ventricular end-diastolic and end-systolic volume (LVEDV and LVESV) indices were 154.3±23.3 and 115.8±46.9 ml/m2, respectively. The mean pulmonary capillary wedge pressure was 19.1±8.8 mmHg.


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  		Table 1. Left ventriculoplasty for ischemic cardiomyopathy

 
The surgical technique was basically the same as that described by Dor [5]. We used normothermic cardiopulmonary bypass and intermittent antegrade warm blood cardioplegia. CABG was always done first, and then the left ventricle was opened. By observing the left ventricular endocardium thoroughly, a purse-string suture [6] was made along the border between the akinetic and kinetic area from the free wall to the septum with 2-0 prolene. The akinetic ventricular septum was fully excluded by placing the purse-string suture properly. The border between the akinetic and kinetic areas was always difficult to define because there are no clear scars in the left ventricle in ischemic cardiomyopathy, which is quite different from ventricular aneurysm. Therefore, preoperative evaluation of the left ventricular wall motion by using a ventricular echogram including dobutamine echo, cine angiographic ventriculogram with biplane method, ultrafast emission-beam computed tomography (CT) scan and cine MRI is important to properly design the ventriculoplasty. During operation when there is no clear scar, the akinetic area can be detected by palpation under the open beating heart by declamping the ascending aorta.

When the valve reconstruction was necessary: (1) Devega's tricuspid annuloplasty was performed through the right atriotomy under the on-pump beating heart; (2) mitral annuloplasty was performed through the left atrial incision before the left ventricle was opened to assess the completeness of mitral repair; and (3) mitral valve replacement, if indicated, was performed through the left ventriculotomy before the ventricular purse-string suture was placed.

Out of 54 patients, CABG was combined in 51 patients (94%) with a mean of 3.2 distal anastomoses. The anterior descending artery was grafted whenever possible.

The left internal thoracic artery graft was used in all cases to bypass the anterior descending, large diagonal, or circumflex arteries depending on their importance. Mitral valve reconstruction was concomitantly performed on 19 patients (35%) with valve replacement in six patients and mitral plasty in 13 patients. Tricuspid annuloplasty was done on five patients. The mean durations of aortic cross-clamp and cardiopulmonary bypass were 78±30 and 144±51 min, respectively.

Left ventricular volume measurements were made by angiographic ventriculography in most patients, but echographic study was used in some patients who were intolerant of catheter study.

Follow-up studies were performed in all patients. For statistical analysis, continuous variables are expressed as mean±SD and the P-value was calculated using the chi-square test. Cumulative survival was calculated by the Kaplan–Meier estimation.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Two patients (3.7%) needed an intra-aortic balloon pump to wean from cardiopulmonary bypass. Seven patients (12.9%) died in the hospital. Among them, two patients (4.4%) out of the 45 patients who underwent elective operation died of heart failure and stroke during hospitalization, respectively. Five patients (55.5%) out of nine patients who required emergency operation due to ongoing shock died of heart failure and multiorgan failure. Late death occurred in six patients (11.1%) due to arrhythmia in three and heart failure in the other three (Table 2). Out of 41 survivors, 38 patients returned to NYHA class I or II and three patients to class III. Out of 50 patients who underwent left ventricular study both pre- and post- (3–4 weeks) operative period, ejection fraction increased from 22.8±6.6 to 36.2±8.0% and mean LVEDV and LVESV indices reduced from 152.8±24.6 to 105.0±36.5 and from 113.6±45.7 to 66.4±28.4 ml/m2, respectively (Figs. 1 and 2 ). Mean pulmonary wedge pressure decreased from 19.1±8.8 to 14.9±6.8 mmHg. At one postoperative year, wedge pressure stayed as low as 15.8±9.2 mmHg in 12 patients who had repeat catheterization. All variables improved significantly after the operation (P<0.05). One-, 2- and 3-year actuarial survival rates estimated by the Kaplan–Meier method were 87.9, 82.7 and 77.2%, respectively.


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  		Table 2. Left ventriculoplasty for ischemic cardiomyopathy

 


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  		Fig. 1. Emission-beam CT (top) and MRI (bottom) ventriculogram before (left) and after (right) EVCPP in a 42-year-old woman. Left ventricular end-diastolic and end-systolic volume indices decreased from 208 to 97 and from 183 to 63 ml/m2. Left ventricular ejection fraction increased from 26 to 47% and left ventricular end-diastolic pressure decreased from 26 to 14 mmHg.

 


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  		Fig. 2. Pre- and postoperative left ventriculogram in left anterior oblique view in a 65-year-old man. Improvement of septal motion is remarkable.

 
In elective and emergency groups, the 1-, 2- and 3-year survival rates were 91.1, 85.6 and 85.6 and 29.6, 14.8 and 14.8%, respectively (Fig. 3 ).



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  		Fig. 3. Three-year survival rate after ventriculoplasty for ischemic cardiomyopathy. One-, 2- and 3-year actuarial survival rates estimated by the Kaplan–Meier method were 87.9, 82.7 and 77.2%, respectively. The 3-year survival rate was 85.6% in 45 elective operations and 14.8% in nine emergency operations.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
The term ‘ischemic cardiomyopathy’ was introduced by Burch [7] in 1972 to express a poorly functioning left ventricle due to diffuse patchy fibrosis caused by chronic myocardial ischemia. Dilatation of the left ventricle occurs in a chronic process of ventricular remodeling after myocardial infarction [8]. Those having a non-aneurysmal diffuse akinetic left ventricle with chronic heart failure have been known to be less favorable candidates for CABG and cardiac transplantation is a possible option when medical treatment has failed. To overcome a high mortality with medical treatment in these groups of patients, several attempts have been made to improve longevity by CABG since the 1970s [9–11]. While CABG alone has shown some benefit in selected groups of patients [12], the results were generally poor in those patients with a dilated left ventricle associated with congestive heart failure. The left ventricular volume is an important predictor of outcome after myocardial infarction. The larger the volume, the higher the mortality. White et al. [13] have shown that LVESV is a more powerful predictor of outcome than LVEDV, ejection fraction, or other variables. In their 605 patients, 5-year survival was 94% in patients whose LVESV was below 95 ml at 4–8 weeks after myocardial infarction, 78% in patients with LVESV between 95 and 130 ml, and 52% in patients with LVESV greater than 130 ml. Yamaguchi et al. [14] also have demonstrated that the larger the LVESV, the poorer the later outcome following CABG. Five-year survival rates in their patients with end-systolic volume index less than 100 ml/m2 (n=18) and larger than that (n=23) were 85.0 and 53.5%, and their heart failure free rates were 85.0 and 31.4%, respectively, by CABG alone.

Dor et al. [1–3] have proposed EVCPP to achieve better geometrical reconstruction for left ventricular aneurysm. Since the effectiveness of this technique has been proven in over 700 patients [2], they extended this procedure to treat ischemic cardiomyopathy [3,4]. In their series with 49 patients [4], hospital mortality was 10% and ejection fraction increased from 23 to 38%. Pulmonary capillary wedge pressure decreased from 19 to 13 mmHg. Late death was noted in 13 patients including five cardiac deaths, four non-cardiac deaths and three unknown causes and one sudden death during 8 years of follow-up.

The left ventricular volume reduction procedure proposed by Batista et al. [15] has been attempted to treat ischemic and non-ischemic dilated cardiomyopathy. We also have experiences of Batista operation for non-ischemic dilated cardiomyopathy and have found some beneficial effects [16]. For ischemic cardiomyopathy, however, we believe that EVCPP is the procedure of choice because infarcted akinetic septum, which frequently exists in ischemic cardiomyopathy, is easily excluded by this technique and a striking improvement of septal motion can be obtained (Fig. 2). To detect the border between the kinetic and akinetic area during the operation, palpation of the left ventricular wall with on-pump open beating heart was useful particularly when there was no clear endocardial scar.

While it is hard to differentiate the isolated effect of CABG and ventriculoplasty on the left ventricular function in such combined procedures, we believe that this procedure can be performed with low risk on the elective basis and exclusion of akinetic area and geometrical correction could have an important role in improving ventricular function and slowing the process of ventricular remodeling.


   Footnotes
 
This study was carried out as a part of the RESTORE group project.


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

  1. Dor V., Kreitmann P., Jourdan J. Interest of ‘physiological’ closure (circumferential plasty on contractile areas) of left ventricle after resection and endocardectomy for aneurysm or akinetic zone: comparison with classical technique about 209 left ventricular resections. J Cardiovasc Surg 1985;26:73.
  2. Dor V. Left ventricular aneurysm: the endoventricular circular patch plasty. Semin Thorac Cardiovasc Surg 1997;9:123-130.[Medline]
  3. Dor V. Reconstructive left ventricular surgery for postischemic akinetic dilatation. Semin Thorac Cardiovasc Surg 1997;9:139-145.[Medline]
  4. Dor V., Sabatier M., Di Donato M., Montiglio F., Toso A., Maioli M. Efficacy of endoventricular patch plasty repair in large post infarction akinetic scar and severe LV dysfunction. Comparison with a series of large dyskinetic scar. J Thorac Cardiovasc Surg 1998;116:50-59.[Abstract/Free Full Text]
  5. Dor V. Surgical management of left ventricular aneurysms by the endoventricular circular patch plasty technique. Operat Tech Cardiac Thorac Surg 1997;2:139-150.
  6. Fontan F. Transplantation of knowledge. J Thorac Cardiovasc Surg 1990;99:387-395.[Medline]
  7. Burch G.E., Tsui C.Y., Harb J.M. Ischemic cardiomyopathy. Am Heart J 1972;83:340-350.[Medline]
  8. Gaudron P., Eilles C., Kugler I., Ertl G. Progressive left ventricular dysfunction and remodeling after myocardial infarction. Potential mechanisms and early predictors. Circulation 1993;87:755-763.[Abstract/Free Full Text]
  9. Yatteau R.F., Peter R.H., Behar V.S., Bartle A.G., Rosati R.A., Kong Y. Ischemic cardiomyopathy; the myopathy of coronary artery disease. Am J Cardiol 1974;34:520-525.[Medline]
  10. Faulkner S.L., Stoney W.S., Alford W.C., Thomas C.S., Burrus G.R., Frist R.A., Page H.L. Ischemic cardiomyopathy; medical versus surgical treatment. J Thorac Cardiovasc Surg 1977;74:77-88.[Abstract]
  11. Manley J.C., King J.F., Zeft H.J., Johnson W.D. The ‘Bad’ ventricle: results of coronary surgery and effect on late survival. J Thorac Cardiovasc Surg 1976;72:841-848.[Abstract]
  12. Dreyfus G.D., Duboc D., Blasco A., Vigoni F., Dubois C., Brodaty D., de Lentdecker P., Bachet J., Goudot B., Guilmet D. Myocardial viability assessment in ischemic cardiomyopathy: benefits of coronary revascularization. Ann Thorac Surg 1994;57:1402-1407.[Abstract]
  13. White H.D., Norris R.M., Brown M.A., Brandt P.W.T., Whitlock R.M.L., Wild C.J. Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction. Circulation 1987;76:44-51.[Abstract/Free Full Text]
  14. Yamaguchi A., Ino T., Adachi H., Murata S., Kamio H., Okada M., Tsuboi J. Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy. Ann Thorac Surg 1998;65:434-438.[Abstract/Free Full Text]
  15. Batista R.J.V., Verde J., Nery P., Bocchino L., Takeshita N., Bhayana J.N., Bergslad J., Graham S., Houck J.P., Salerno T.A. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg 1997;64:634-638.[Abstract/Free Full Text]
  16. Suma H., Isomura T., Horii T., Sato T., Kikuchi N., Iwahashi K., Hosokawa J. Nontransplant cardiac surgery for end-stage cardiomyopathy. J Thorac Cardiovasc Surg 2000;119:1233-1245.[Abstract/Free Full Text]



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