Eur J Cardiothorac Surg 2007;32:52-57. doi:10.1016/j.ejcts.2007.02.030
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Mid-term changes of left ventricular geometry and function after Dor, SAVE, and Overlapping procedures
Tetsuya Ueno*,
Ryuzo Sakata,
Yoshifumi Iguro,
Hiroyuki Yamamoto,
Masahiro Ueno,
Takayuki Ueno,
Kazuhisa Matsumoto
Department of Thoracic and Cardiovascular Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8520, Japan
Received 18 December 2006;
received in revised form 5 February 2007;
accepted 28 February 2007.
* Corresponding author. Tel.: +81 99 275 5368; fax: +81 99 265 8177. (Email: tueno{at}m.kufm.kagoshima-u.ac.jp).
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Abstract
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Background: The aim of this study was to investigate the mid-term changes of left ventricular (LV) geometry and function after Dor, septal anterior ventricular exclusion (SAVE), and Overlapping ventricular remodeling procedures. Methods: Forty-three patients who underwent LV reconstruction for end-stage ischemic heart disease, were divided into three groups, undergoing Dor (n
= 15), SAVE (n
= 12), and Overlapping procedures (n
= 16). Coronary artery bypass grafting and mitral annuloplasty were performed concomitantly when indicated. Left ventricular diastolic and systolic dimensions (LVDd and LVDs), LV end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI), LV ejection fraction (LVEF), deceleration time (DcT), sphericity index (SI), and grade of mitral regurgitation were measured on preoperative and postoperative (immediately and at intermediate-term) echocardiography. Results: In the Dor group, the LVEDVI and LVESVI were significantly reduced immediately after the operation, and increased again at intermediate follow-up. The SI was significantly increased immediately after the operation and increased thereafter in a linear fashion. In the SAVE group, the DcT was significantly reduced immediately after the operation and was not improved in the later stage. In the Overlapping group, the LVEDVI and LVESVI were significantly reduced, and remained as such at intermediate follow-up. The SI was not increased and remained almost unchanged after the operation. Conclusion: Progression in LV sphericity after the Dor procedure and persistent reduction of the DcT after the SAVE procedure seem to be procedure-related problems. The Overlapping procedure provided significant LV volume reduction, maintaining the most elliptical LV shape with acceptable early and late mortality.
Key Words: Ischemic heart disease • Cardiac function
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1. Introduction
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Vincent Dor introduced in 1985 the concept of aggressive surgical therapy for patients with end-stage heart failure due to postinfarction left ventricular (LV) remodeling and dilatation [1]. Since then, a growing body of clinical experience with the Dor procedure has shed light not only on its efficacy [2,3] but also on the limitations to its widespread use [4,5]. Over the last decade, minor modifications have been made to the Dor procedure [6] and different types of LV reconstruction such as the septal anterior ventricular exclusion (SAVE) [7] and Overlapping [8] procedures have been developed. In our study, we examined the mid-term changes of the LV geometry and function after three different types of LV reconstruction – the Dor, SAVE, and Overlapping procedures – and reviewed their characteristics and potential problems.
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2. Patients and methods
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Between January 2000 and October 2005, 50 patients underwent LV reconstruction for end-stage ischemic heart disease with antero-septal infarction with or without postero-inferior or lateral infarction. After exclusion of 7 patients due to incomplete echocardiographic data, 43 patients were divided into three groups depending on the type of LV reconstruction: the Dor group (n
= 15), SAVE group (n
= 12), and Overlapping group (n
= 16).
All patients were admitted to the Department of Cardiology to treat congestive heart failure when present before they were referred to the Cardiac Surgery service. Although standard preoperative regime was consisted of diuretics, ß-blockers, and angiotensin-converting enzyme inhibitors, selection and dose of medication depended on cardiologists’ preference. Hyperthermia therapy, infusion of catecholamines, and insertion of intra-aortic balloon pumping (IABP) were performed if required.
They underwent transthoracic echocardiography within a week before the operation, 1–2 weeks after the operation (immediate postoperative stage), and at least 6 months after the operation (intermediate postoperative stage). The LV diastolic and systolic dimensions (LVDd and LVDs) were measured through a long-axis view. The LV end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI), and LV ejection fraction (LVEF) were calculated by the modified biplane Simpson's method. The deceleration time (DcT) was calculated as a parameter of diastolic function. The sphericity index (SI) was calculated at the mid-systolic phase as the long-axis diameter divided by the short-axis diameter. Mitral regurgitation was classified as none (grade 0), mild (1), moderate (2), moderately severe (3), and severe (4). The changes of these parameters were statistically analyzed in each group.
All operations were performed by a single surgeon (R.S.). Coronary artery bypass grafting (CABG) was performed using as many arterial grafts as possible, aiming at complete revascularization. Mitral annuloplasty (MAP) was performed for associated ischemic mitral regurgitation (IMR). It is our basic policy to use complete rigid rings through left atriotomy when preoperative MR is more than moderate, and to use partial flexiable rings through left ventriculotomy when MR is mild. The Dor procedure performed in our series was what we call an ‘original’ procedure, in which a purse-string suture was placed around the circumferential scar tissue at the transition zone and a circular Dacron patch (about 2.5 cm in diameter) was secured over the opening after a purse-string suture was tied. The Dor procedure was performed during the initial 2 years of this study period and was later replaced by the SAVE or the Overlapping procedure, because of the non-negligible incidence of postoperative heart failure reported in the literature. The technical detail of SAVE procedure has been shown elsewhere [7]. In brief, after a long left ventriculotomy was made along the left anterior descending artery, an elliptical-shaped Dacron patch (about 3.0 cm x 7.0 cm) was sutured to the transition zone to exclude the akinetic region after broad antero-septal infarction [7]. The Overlapping procedure is a relatively new LV reconstructive procedure and its technique has been described in details [8]. Briefly, after the left ventriculotomy which was similar to that in the SAVE procedure, but not so extended upward towards the base, the left marginal incision was sutured to the septum and then the right marginal incision was sutured to the epicardium to cover LV free wall [8]. The selection between SAVE or Overlapping procedure depends on the expected residual LV volume after exclusion of the non-viable infarcted myocardium during the operation. In those cases in which residual LV volume (measured by inserting a balloon) was so small that postoperative diastolic dysfunction was highly likely, the SAVE rather than the Overlapping procedure was selected.
2.1 Statistical analysis
Data are presented as mean ± standard deviation of the mean. The Kruskal–Wallis test and Mann–Whitney U-test were used to compare the values among three groups and between two groups. The 
2-test was used to compare the frequency of each parameter among three groups. The repeated measure of analysis of variance (ANOVA) with Fisher's LSD test was used to analyze the data between three stages in each group. Stepwise multiple regression analysis was used to determine the preoperative contributing factors, including the parameters on echocardiography and types of LVR procedure, to the parameters on the intermediate postoperative echocardiography with significant difference detected by above-mentioned analyses. A p-value of less than 0.05 was considered statistically significant.
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3. Results
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The characteristics of all patients in the three groups are summarized in Table 1
. The patients in the SAVE group had higher values of the systolic and diastolic pulmonary artery pressures, pulmonary artery wedge pressure, and LV end-diastolic pressure, with a significant difference in central venous pressure (p
= 0.028).
The grade of MR was none in six, mild in seven, moderate in one, and moderately severe in one patient in the Dor group (mean 0.8); none in four, mild in six, and moderate in two patients in the SAVE group (mean 0.83); and none in three, mild in seven, moderate in five, and severe in one patient in the Overlapping group (mean 1.31).
The primary and common indication for LV reconstruction in three groups was antero-septal infarction. On echocardiography and LV graphy, limited apical dyskinesis or aneurysm was detected in three patients in the Dor group, six in the SAVE group, and three in the Overlapping group. The wall motion of other infarcted areas was severe hypokinesis or akinesis. The period from the onset of acute myocardial infarction to the date of operation was 63.6 ± 54.4 (3–132) months in the Dor group, 76.9 ± 63.1 (2–156) in the SAVE group, and 33.6 ± 58.4 (2–204) in the Overlapping group.
The details of the operation are shown in Table 2
. The number of CABG procedures was not significantly different among the three groups (p
= 0.928). In the Overlapping group, the MAP and subvalvular procedures were most frequently performed for associated IMR. Papillary muscle elevation is the procedure for selective relocation of posterior papillary muscle, accomplished by localized plication of the LV underlying the papillary muscle. Insertion of IABP at weaning from the cardiopulmonary bypass (CPB) was required in five patients in the Overlapping group and one patient each in the Dor and SAVE groups. The CPB time and aortic cross-clamp time in the SAVE and Overlapping groups were longer (although not significantly) than those in the Dor group.
Data concerning LVDd and LVDs are presented in Fig. 1
. There was no significant difference in both parameters among three stages in each group. The LVEDVI and LVESVI data are presented in Fig. 2
. In the Dor group, the LVEDVI (p
= 0.008) and LVESVI (p
= 0.011) were significantly reduced immediately after the operation and increased again in the intermediate postoperative stage. In the SAVE group, there was no significant difference among three stages with regard to LVEDVI (p
= 0.133) and LVESVI (p
= 0.146). In the Overlapping group, the LVEDVI (p
= 0.020) and LVESVI (p
= 0.030) were significantly reduced immediately after the operation and remained almost unchanged at the intermediate postoperative follow-up.
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Fig. 1. LVDd and LVDs. There was no significant difference at the three follow-up intervals in LVDd and LVDs in any of the procedure groups. The postoperative reduction of LVDd and LVDs in the Dor group was nevertheless much less than those in the SAVE or Overlapping groups (LVDd, left ventricular diastolic dimension; LVDs, left ventricular systolic dimension).
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Fig. 2. LVEDVI and LVESVI. The LVEDVI and LVESVI were significantly reduced immediately after the operation in the Dor and Overlapping groups. However, they increased again in the Dor group, but remained almost unchanged in the Overlapping group at intermediate postoperative follow-up (LVEDVI, left ventricular end-diastolic volume index; LVESVI, left ventricular end-systolic volume index; (*) p
< 0.05, (**) p
< 0.01).
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Results for LVEF and DcT are presented in Fig. 3
. The LVEF was increased slightly after the operation in all three groups. In the Dor group, the DcT in the intermediate postoperative phase was significantly increased in comparison to that in the immediate postoperative follow-up (p
< 0.0001). In the SAVE group, the DcT was significantly reduced immediately after the operation (p
= 0.007) and remained low at the intermediate postoperative follow-up. In the Overlapping group, there was no significant difference in the DcT among three stages (p
= 0.257). Stepwise regression analysis showed only a type of procedure-Dor versus SAVE and Overlapping, as a significant contributing factor (p
= 0.023) to increase in DcT in the intermediate postoperative stage.
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Fig. 3. LVEF and DcT. In the SAVE group, the DcT was significantly reduced immediately after the operation and, in contrast to that in the Dor or Overlapping groups, remained low at intermediate postoperative follow-up (LVEF, left ventricular ejection fraction; DcT, deceleration time; (**) p
< 0.01).
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The SI and MR grade data are presented in Fig. 4
. The SI in the Dor group was significantly increased immediately after the operation (p
= 0.022) and continued increasing thereafter almost in a linear fashion. In the SAVE group, the SI was increased linearly after the operation. In contrast to the Dor and SAVE groups, the SI in the Overlapping group, which was highest among the three groups preoperatively, was reduced in the immediate postoperative stage and remained low even at the intermediate postoperative follow-up. Stepwise regression analysis showed preoperative SI (p
= 0.004), EF (p
= 0.04), and types of procedures-Dor versus SAVE and Overlapping (p
< 0.0001) or SAVE versus Overlapping (p
= 0.014), as significant contributing factors to increase in the SI in the intermediate postoperative stage. The severity of preoperative MR in the Overlapping group was highest among the three groups, and became the lowest after the operation. Although the MR grade in the intermediate postoperative stage was increased again in the Dor and SAVE groups, it showed a minimal increase in the Overlapping group.
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Fig. 4. SI and MR grade. The SI in the Dor and SAVE groups was increased in a linear fashion, with a significant difference in the Dor group. However, the SI in the Overlapping group was mildly decreased and remained low. The preoperative grade of MR in the Overlapping group was highest. However, it became lowest after the operation. (SI, sphericity index; MR, mitral regurgitation; (*) p
< 0.05).
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There were two in-hospital deaths due to congestive heart failure in the Dor and SAVE groups. Despite the higher incidence of intraoperative use of the IABP and concomitant procedures, one patient died of congestive heart failure and another of sepsis in the Overlapping group. During the follow-up period, one patient in the Dor group died suddenly of an unknown cause. One patient in the SAVE group and one patient in the Overlapping group died of congestive heart failure. Postoperative survival was presented in Fig. 5
. All the death occurred within 1 year after the operation. No patient was deceased after initial first postoperative year. The NYHA functional status of survivors was 1.2 ± 0.4 in three groups.
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Fig. 5. Postoperative survival. It is noteworthy that postoperative death occurred within 1 year after the operation in three groups, providing no further death after this stage.
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4. Comment
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The increased sphericity of the LV has been known as one of the non-negligible limitations of the Dor procedure [4]. In our study, the LVDd and LVDs were least reduced. However, the LVEDVI and LVESVI were reduced immediately after the Dor procedure, which can indicate that the long-axis length of the LV must have been further decreased, leading to development of a more spherical LV. These results were compatible with a significant increase in the sphericity index in the Dor group immediately after the operation.
More importantly, the SI in the Dor group increased linearly after the operation, potentially causing a progressive increase in LV wall tension and energy consumption. The improvement in LVEDVI and LVESVI in the intermediate postoperative stage may originate from a compensatory mechanism for increasing LV wall tension. Although the follow-up period was not long enough to make any conclusions, we speculate that progressive LV sphericity after the Dor procedure could predispose to an increased incidence of refractory heart failure with increased wall tension and reduced compliance of the LV at late follow-up.
Another possible limitation of the Dor procedure was a high mortality rate when applied for broad antero-septal infarction or large preoperative LVESVI [9]. To exclude broad septal involvement of infarction sufficiently and, simultaneously, to reconstruct more elliptical LV shape, Suma developed the SAVE procedure [7] and reported its favorable late outcome [10]. Placement of a long, elliptical patch along the watershed zone between viable and non-viable regions was supposed to help solve the aforementioned problems observed after the Dor procedure.
However, one of the potential problems of the SAVE procedure is thought to be the postoperative reduction in overall LV compliance as a consequence of placing a non-compliant patch instead of excluding non-viable, but still more compliant myocardium. In our study, the DcT in the SAVE group was significantly reduced immediately after the operation, while in the other groups it was only mildly reduced. Because both deceased patients after the SAVE procedure had quite low DcTs, some relationship between the postoperative values or changes of DcT and in-hospital mortality rate can be inferred. To our knowledge, no study has objectively demonstrated whether the placement of a patch as part of the SAVE procedure has contributed to postoperative reduction of DcT, and to what degree. Raman and co-workers listed a large, stiff patch as one of the contributors to non-fatal failure modes after Dor procedure [11]. In addition, refractory CHF with reduced values of DcT may occur not only after the SAVE procedure but also after any other cardiac procedures performed in patients with considerably impaired pump function preoperatively.
It is also noteworthy that the DcT in the SAVE group remained almost unchanged while that of the other two groups increased considerably in the intermediate postoperative stage. In addition, SI in the SAVE procedure had a linear increase following operation. It is also difficult to draw conclusions from our present study regarding the actual impact of the postoperative changes of the DcT and SI on the late survival, because of the limited number of patients and extent of follow-up. With respect to the late outcome after the SAVE procedures, Isomura and co-workers showed an excellent 5-year survival rate of 80.3%, with 75% of the patients classified as NYHA classes I and II at late follow-up [10].
Matsui and co-workers developed a particular technique for LV reconstruction (the Overlapping procedure) which excludes the infarcted wall in the antero-septal region by placing sutures so as to overlap the medial side of the LV wall on the lateral side of the LV wall after a longitudinal left ventriculotomy between the left anterior descending artery and its diagonal branch, restoring the elliptical shape of the LV [8]. The Overlapping procedure is now our preferred method of LV reconstruction for cases with antero-septal infarction not only because of its morphologic effect in re-creating a more elliptical LV but also because of its simultaneous effect of tethering reduction. With this procedure, the distance between the anterior and posterior papillary muscles is shortened and, consequently, the tethering force on the mitral leaflets is reduced, leading to improvement in co-existent mitral regurgitation.
To amplify this tethering-reduction effect, we tend to more widely overlap the LV wall underlying the papillary muscles. We believe that it is quite important to perform such LV reconstruction with tethering-reduction effect, combining subvalvular repair procedures that include chordal cutting, papillary muscle realignment, and papillary muscle elevation. Our current strategy is based on the relatively high observed incidence of IMR in ischemic heart disease [12], its known negative impact on long-term patient survival [13], and the possible limitations of mitral annuloplasty alone for such advanced cases of IMR [14]. A high ratio of concomitant mitral annuloplasty and subvalvular procedures in the Overlapping group may reflect the aggressive approach we have taken for associated IMR.
Although longer CPB and aortic cross-clamping time, and more frequent use of IABP might have been required, prevention of postoperative recurrence of IMR with acceptably low early and intermediate postoperative mortality may support our surgical strategy for these high-risk patients. A longer follow-up study may be necessary to determine the actual impact of our surgical strategy on the vicious cycle of end-stage ischemic heart disease and IMR.
There are several limitations to our study, including the size of the patient cohort and the length of follow-up, and the fact that preoperative myocardial viability was not precisely evaluated by MRI and no other hemodynamic studies besides echocardiography were performed postoperatively. Three procedures of LVR were not performed during the same time span: the Dor procedure was limited during the initial 2 years and Overlapping procedure during the last 3 years in our study. Furthermore, MR was not quantitatively evaluated. We nevertheless believe that our study will shed some new light on characteristics after the Dor, SAVE, and Overlapping procedures.
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References
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- Dor V, Kreitmann P, Jourdan J. Interest of "physiological" closure (circumferential plasty on contractive areas) of left ventricle after resection and endocardectomy for aneurysm or akinetic zone comparison with classical technique about a series of 209 left ventricular resections. J Cardiovasc Surg 1985;26:73.
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Top
Abstract
1. Introduction
