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Eur J Cardiothorac Surg 2006;30:759-761
© 2006 Elsevier Science NL
Division of Cardiothoracic Surgery, Los Angeles UCLA School of Medicine, Los Angeles, CA 90095-1741, USA
* Tel.: +1 310 2061027; fax: +1 310 8255895. (Email: gbuckberg{at}mednet.ucla.edu).
Left ventricular reconstruction or restoration shall become the emerging field of treating dilated cardiomyopathy from either ischemic causes, as in this report from the Cleveland Clinic, or subsequently from valvular and nonischemic cardiomyopathy [1], because surgical rebuilding geometrically changes the diseased spherical chamber into a more natural elliptical form. Registry data confirms collaborative information from the RESTORE multicenter cohort [2], and Dor [3] who launched this surgical evolution. Furthermore, these functional and mortality late findings are unachievable by CABG with or without mitral valve procedures [4–6].
Randomized testing is underway in the STICH trial, and the Cleveland Clinic re-establishes its vital importance by mirroring their 1978 report regarding the VA Hospital CABG trial [7]. The prior question investigated if a closed artery should be opened, whereas this article tests a comparable biologic principle by surveying mechanical changing of a diseased sphere into conical form with restoration. The original answer was to open the vessel, but revascularization results became distorted by inexperience at the VA centers (2–13% mortality with higher death rate in centers with uncommon cases) [8] compared with 1% CCF mortality in >1000 patients. Now, the 1% hospital mortality during LV reconstruction at CCF coupled with 5.3% RESTORE series mortality establishes entry criteria that the STICH trial must match to insure that inexperience (110 centers doing 600 procedures) does not compromise outcomes. Failure to achieve these landmarks will impair randomized trial credibility, rather than allow evaluation of the importance of surgical rebuilding.
Approaching the ‘triple V’ concept, or ‘vessel valve and ventricle’ is appropriately emphasized, and 2 other V's (volume and ventricular arrhythmias) are also explored while posing questions about this important report. Ejection fraction is a poor surrogate of survival, as emphasized by White et al. [9], and rose only from 21.5% to 24.7%, compared with the robust parameter of end systolic volume index that rose from 120 ± 46 m–2 to 77 ± 26 m–2. Emphasis upon volume is central during evaluation and follow-up, as this measurement defines recovery during late follow-up [10,11].
Volume measurement influences ventricular arrhythmia development, rather than ejection fraction that conveys a crude parameter of size. DiDonato et al. [12] recently reported 382 restoration patients requiring only one AICD, and this experience is supported by the current reports reference to Sartipy et al. [13] who avoided arrhythmias by restoration. The extensive work of Lab defines volume as the centerpiece of arrhythmia formation [14]. Ventricular restoration diminishes volume thereby underscoring why DiDonato et al. [12] found amiodorone effective after surgical ventricular reconstruction. These positive ventricle findings mirror the excellent capacity of amiodorone to reduce atrial fibrillation in postoperative coronary patients whose atrial size is normal [15]. Perhaps excluding this vital drug treatment was a reason for extensive AICD utilization in the recent CCF report following reconstruction [16]. Recommendation for AICD implantation if postoperative EF is <30% presumably recognizes this volume factor, but measuring ventricular size is a better guideline.
Mitral valve procedures were done in almost half of the patients, thereby emphasizing that secondary mitral regurgitation from annular stretch and tethering of valve apparatus from dilation are commonplace architectural factors. Addressing the valve and vessel without the ventricle places Gillinov et al.'s [17] prior late results of 55% survival at 5 years in concert with similar yardsticks of other institutions [18–20] that did not approach the ventricle. Failure to change ventricular geometry also explains recurrence of CHF and regurgitation [21,22], thereby making current efforts to separate this series from Gillinov's earlier report more likely related to indecisions about directly addressing ventricular disease, rather than differences in prior patient selection.
The current CCF report is selective because 69% of the patients have aneurysms, whereas dyskinesia is now rare following use of thrombolysis and PTCA. Revascularization after infarction preserves epicardial muscle and converts the bulging dyskinetic noncontractile chamber into a segment with akinesia; the commonplace ventricular morphology. It is now clear that no regional recovery can be expected following revascularization if MRI gadolinium scan shows >50% of ventricular mass retains late hyper enhancement [23]. This is a critical finding, since the akinetic heart is the centerpiece of ischemic cardiomyopathy, and ventricular restoration is the surgical solution for this process. Technical considerations come into play during ventricular reconstruction of segments with akinesia in order to avoid muscle tearing during rebuilding of friable nontransmurally scarred ventricular wall, but this goal is accomplished readily [24,25].
Most current patients shall undergo restoration for akinetic anterior walls and similar mortality and functional results are expected if ventricular size is not enormous (>150 ml m–2) [10]. The included report of survival at 54% in 5 years following CABG alone is an incomplete follow-up [26], as Yamaguchi et al. [27] now records 90% 5-year survival if reconstruction is added to CABG in failing dilated hearts.
This Cleveland Clinic report showing that ventricular reconstruction provides excellent early and late findings helps set the stage for geometric cardiac rebuilding as the major change in operative objectives. The surgical community must again congratulate this hallmark center for its superb communication, since this report ranks with the earlier Loop report regarding CABG implementation [7], and simultaneously accomplishes two other things. First, setting guidelines for excellence in surgical methodology, and second introducing the vital role of experience in determining surgical outcome. Statisticians deal with numbers, but surgeons provide these figures. Our capacity to adequately protect the heart and demonstrate technical excellence tells the tale. This vital role can become confused by statistical analysis if STICH trial randomization fails to recognize the importance of surgical credibility in data collection. Biology advises opening the closed vessel and rebuilding the normal cone from the abnormal sphere. These goals are achievable by safe procedures.
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