Left Ventricular Restoration (Dor procedure).
Experience of the Hospital Universitario Juan Canalejo
(La Coruņa, Spain)

Francisco Estévez Cid *
Alberto Juffé Stein *
Cardiac Surgery Service, Heart Area, Juan Canalejo University Hospital Complex, La Coruña, Spain

 

Introduction
Physiopathological Concepts

The morphology and spatial arrangement of myocardial fibres enhances the effectiveness of the cardiac contractile function. Their oblique orientation, from the mid-part of the ventricle to the apex, enables a 15% shortening of myocardial fibre to produce an ejection of 60% of ventricular volume Figures 1a and 1b. As shown diagrammatically, the movement of the ventricle base throughout systole produces a twist [1,2]. This geometrical configuration not only affects cardiac ejection, but the untwisting of the ventricle contributes greatly to the filling of the ventricle during protodiastole [3]. During this stage articular blood is aspired into the ventricle, accounting for about 50-60 % of rapid ventricular filling.

Figures. 1a and 1b.: Diagrammatic representation of the oblique arrangement (Fig. 1a) of the myocardial fibres (spiral) and the twisting mechanism (Fig. 1b) that make greater ventricular ejection (60%) possible. Taken from Buckberg GD et al, Semin in Torca Cardiovasc Surg 2001; 13: 258.

Any cardiac disease that affects the structure and morphology of the heart will also affect its functioning. It is well known that the appearance of physiopathological "compensation” mechanisms Figure 2, whether at cardiac level (ventricular remodelling: concentric/eccentric hypertrophy, fibrosis, etc.) or systemic level (neurohormonal activation) has a detrimental effect in the medium to long term. A large proportion of pharmacological therapies (betablockers, ACEI, etc.) are based on attempting to counteract these compensation mechanisms at different levels.

Figure 2: Neurohormonal adaptation mechanisms after cardiac failure (Modified  from www.portalesmedicos/portalcardio).


Left ventricular aneurysm is a saccular dilatation that extends to all the layers of the free wall, and is frequently located in the antero-lateral and apical areas. Its origin is generally closely related to a physiological process of adaptation (ventricular remodelling) in the presence of a transmural myocardial necrotic scar after an acute myocardial infarction (AMI), which includes the thinning and progressive dilatation of this tissue. This transmural affectation should be differentiated from non-transmural scars or zones corresponding to diffuse myocardial fibrosis, which produce akinetic or dyskinetic zones but which do not correspond to a clearly defined ectasia of the ventricular wall. The incidence of transmural necrosis has now decreased due to thrombolytic treatment and above all to post-AMI primary angioplasty. Studies by Bogaert et al. [3] using MRI show that after recanalisation of the affected artery necrosis occurs in the inner 2/3 of the ventricular wall, an area of the epicardial myocardium remaining viable. This area prevents an extensive remodelling of the zone and the subsequent formation of an aneurysm (dyskinetic zone), behaving angiographically like an akinetic zone.

Because of their physiopathological similarity, the concept of Asynergy Area (non-contractile) now includes all those myocardial segments whose contractability is below two standard deviations from the mean, regardless of whether they happen to be akinetic or dyskinetic. Therefore, the remodelling process of the ventricular wall at both scar and healthy myocardium level is responsible for a change in the morphology of the heart from elliptical to more spherical, which as we have seen reduces the effectiveness of the cardiac function. Furthermore, the secondary dilatation of the ventricular cavity produces an increase in non-aneurysmatic parietal stress (Laplace’s Law), which leads to greater systolic effort and oxygen consumption, as a result of which contractile capacity may be lost and dilation ensue, thus further deteriorating cardiac function.
A modification of this kind in ventricular morphology causes an imbalance between the traction and coaptation forces in the subvalvular mitral apparatus, leading to functional mitral insufficiency (FMI), which may or may not be associated with dilatation of the valve annulus [5] Figure 3. This is a third physiopathological mechanism that contributes to an overload of the ventricular volume, exacerbating ventricular remodelling. The development of even moderate FMI means a clinical deterioration in the natural history of the patient and a reduction in survival [6].


Figure 3: Taken from Comin et al. [5] Ao (aorta), VI (left ventricle), MP (papillary muscle), VM (mitral valve), AI (left auricle), FC (coaptation forces), FT (traction forces) and IMF (functional mitral insufficiency).

In contrast to the concept of ventricular remodelling, we have that of ventricular restoration. This is an attempt to normalise the myocardium from an anatomical and morphological point of view. In addition to sufficient myocardial revascularisation to recover viable zones, it is also necessary to act on the mechanisms that lead to a distended ventricle [7,8]. Several studies have related a high left ventricle end-systolic volume index (LVESVI calculated with MRI or ventriculography) to congestive heart failure (CHF). White et al. [9] show that mortality in post-AMI patients with LVESVI>60 ml/m2 is five times greater than in those with normal volumes (<25 ml/m2). Similarly, the GUSTO I study [10] shows the importance of ventricular volume: 17% of post-AMI patients with successful thrombolysis had progressive ventricular dilatation (>40 ml/m2). One-year mortality was 16% when the LVESVI was between 40-50 ml/m2, 21% when the LVESVI was between 50-60 ml/m2 and as high as 33% when the LVESVI was 60 ml/m2 [11].

In this regard it has been observed that after myocardial revascularisation mortality and rehospitalisation for CHF is higher when the LVESVI is greater than 100 ml/m2. This pre-operative parameter is the only predictor of improvement of the ejection fraction after revascularisation [7,8]. In the series described by Bolling et al. [12,13], after mitral valve repair in patients with dilated cardiomyopathy, late mortality of up to 50% was observed in the follow-up if there was no significant reduction in the end-systolic index.

Bypass revascularisation does not change the left ventricular volume in dilated ventricles (LVESVI >75 ml/m2), in spite of the prior evidence of viability in the akinetic zone (hibernated myocardium), and therefore has no effect on the progression of the patient towards CHF [14].

We should therefore see the concept of ventricular remodelling as a trilogy [15] Figure 4. Thus, from a surgical standpoint we do not only have to act to re-establish coronary flow, but also have to correct the existence of moderate or large mitral insufficiency (MI) that contributes to volumetric overload and ventricular distension. Good results are now being obtained from implanting a full flexible overcorrecting annuloplasty ring [16] (1 measure smaller than the native annulus, defined by the intertrigonal distance), which favours the coaptive forces of the mitral leaflets.

Figure 4: Ventricular remodelling trilogy.

 

Finally, surgery can act on ventricular morphology through the use of different techniques.

Classically speaking, the treatment of choice for ventricular aneurysms has been pharmacological, and surgical treatment, consisting of an aneurysmectomy and closure with linear suture, has been reserved for patients with a poor clinical situation and/or associated cardiopathies (with poor results), cardiac transplant being really the only effective alternative that modified the prognosis of these patients. However, the limited number of donors, the presence of comorbidities or advanced age mean that only a minimum number of these patients can really benefit from this alternative: this has lead to new lines of research aimed at determining which patients would benefit from surgical treatment of their cardiopathy, and which is the most appropriate technique in each case. In that of ventricular aneurysms, the most commonly used technique for acting on the cardiac muscle and reducing the ventricular cavity is Endoventricular Circular Plasty (ECP) [17,18,19], described by Vincent Dor et al. in 1985, which basically consists of the exclusion of the non-contractile aneurysmatic portion and the reconstruction of the apex in order to regenerate the elliptical morphology. This technique has recently been modified to allow treatment of those areas with non-transmural infarction (akinetic). There are other techniques, such as partial left lateral ventriculectomy (Batista technique [20]), which are generally used in dilated cardiomyopathies of idiomatic or valvular origin, i.e. in the absence of necrosis.

Finally, with regard to the clinical manifestation of post-AMI patients with dyskinetic or akinetic zones, the most typical symptoms run from episodes of CHF or angina pectoris that are hard to treat medically to the appearance of malign ventricular arrhythmias originating in the perianeurysmatic zone.

 

AIM
To evaluate our experience by means of the Dor procedure, which has as its goal, through the use of an endoventricular circular suture, the anatomical and geometrical recovery of the left ventricle, evaluating the results obtained from the standpoint of early mortality, improved quality of life and early evaluation with MRI.

 

Patients and Method
Patients
Between June 1994 and April 2004 interventions were performed on 60 patients with left ventricle aneurysms, 37 (84.09%) male and 7 (15.9%) female, with a mean age of 64.51± 9.43 years old (range 46 – 77). The majority (55.91%) presented cardiovascular risk factors, 45% being smokers, 20% diabetics, 51% suffering from dyslipaemia, 65% from arterial hypertension and 15% from light or greater chronic renal insufficiency (creatinine > 1.5 mg /dl). Additionally, 2 patients (3.3%) had been fitted with IDCs and a further 2 (3.3%) with pacemakers. A large group of patients (55, 91%) presented antecedents of myocardial infarction, 8% of which had not been transmural, the location of the remainder being anteroseptoapical (70%), inferobasal (20%) and anteroinferior (2%). The pre-operative clinical situation included 12 (20%) patients with dysneaa after a slight effort (NYHA III-IV), the mean NYHA value being 1.95±0.90; a further 46 (76%) presented angina pectoris after effort (mean CCS scale value 1.86± 1.28) and 17 (26.6%) had had at least one documented episode of malign ventricular arrhythmias. The pre-operative study, in addition to biochemistry, haemogram and coagulation, also included a transthoracic echocardiogram (68.18%) and an invasive haemodynamic study (95.45%), whilst an electrophysiological study was performed on 8 patients with ventricular arrhythmias with a view to their ablation, without success. Mean preoperative ejection fraction measured by transthoracic echocardiogram was 38.06%± 11.27% (range 20% – 70%) and by left ventriculography 35.8%±10.45% (range 15% - 65%). The haemodynamic study revealed severe coronary disease in at least 1 major vessel in all patients, the mean being 2.19±0.83 diseased major vessels per patient; additionally, 2 (3.3%) presented double aortic valve lesion and a further 2 (3.3%) severe mitral insufficiency.

The indication for surgery was the presence of sustained untreatable ventricular tachycardia in 17 patients (28%), unstable angina pectoris and CHF in 33 (55%) and CHF in another 10 (16%).

 

Method
The study consisted of 60 consecutive patients undergoing surgery in our hospital for left ventricular aneurysm and manifesting any of the symptoms described above. The study is based on a descriptive analysis of the sample population and a comparison of the mean pre-and postoperative functional classes and ejection fractions (transthoracic echocardiogram), applying Student’s t-test for related samples with a 95% confidence interval. When analysing patients who had been given an MRI, comparison was made using Student’s t-test for paired samples after checking the normal distribution in the sample of quantitative variables with the Kolmogorov-Smirnov test. Given sample size (n=10), a further analysis was performed using a non-parametric test (Wilcoxon’s test), the same variables being found to be significant (p<0,05). The analysis was done with the Statistical Package for the Social Sciences (SPSS 12.0, SPSS Inc, Chicago, IL).

Surgical Technique
All the interventions were performed with extracorporeal circulation, mean total ECC time being 115.37±48.99 minutes (range 54-300), and mean aortic clamp time 88.98± 34.49 minutes (range 20-200). The myocardial protection method used in our centre is intermittent antegrade/retrograde cold-blood cardioplegia, since in our opinion avoiding ischemic damage is of the utmost importance in patients with a low ejection fraction. The two patients presenting aortic valve pathology underwent valve replacement surgery during the intervention, and the two patients presenting mitral insufficiency underwent successful valve repair. Additionally, 52 patients (86%) underwent associated coronary revascularisation surgery, a total of 2.05±1.48 bypasses per patient. The conduit of choice in all patients was the skeletonized bilateral internal mammary artery, using the Tector technique (Y or T-grafts) [21].

Description of the Surgical Technique
After commencing extracorporeal circulation and inserting the left ventricular vent, it is a simple matter to delimit the left ventricular aneurysmal zone through palpation and direct sight, since it collapses, being the thinnest zone of the scar. This manoeuvre is becoming increasingly important, since the decrease in the number of transmural infarctions means that it is difficult to clearly delimit the dyskinetic/akinetic zone by means of a visual inspection alone. Once the zone has been located, a 3-4 cm incision is made along the same parallel as the anterior descending artery Figure 5a, opening up the ventricle where a large amount of thrombotic material is commonly found. From the interior the extension of the endocardial scar is determined and its point of union with the normal myocardium is identified along the full circumference of the aneurysm Figure 5b. If there is no calcification, the septal scar is dissected up to the point of union with the healthy myocardium and is then resected, being used as a patch to close the ventricular cavity Figure 6. In cases of septal calcification or an inferior aneurysm with a small endocardial scar, a Dacron patch is used for this purpose. Elliptical remodelling of the ventricle is then performed, creating a new apex by means of a tobacco-pouch suture with either 2-0 or 3-0 gauge monofilament suture, as described by Fontan and collaborators [22], along the full circumference of the aneurysm at the point of union between the healthy myocardium and the endocardial scar Figure 5c.

 

Figure 5a
Figure 5b
Figure 5c
Figure 5d
Figure 5e
Figure 5f

Figures. 5a-f: Dor surgical sequence described in the text (taken from Gardner T. et al, Operative Cardiac Surgery. 2004, 5th Edition) ISBN: 9780340759745).



Figure 6: Left ventriculotomy on a previous transmural infarction. The boundary between the healthy myocardium and fibrous scar tissue can be clearly seen.


This suture should be done at sufficient depth to prevent it from tearing when tied, maintaining sufficient tension to reduce the neck of the aneurysm and shape it into an oval with greater and lesser diameters of approximately 3 and 2 cm, respectively. The patch, whether of endocardial scar tissue or prosthetic material, will be cut to the same morphology and dimensions and sutured continuously with monofilament suture at the same point of union between the healthy myocardium and the endocardial scar Figure 5d, thus excluding the non-contractile anterior or inferior portion of septal myocardium from the ventricular cavity. Finally, the tissues of the excluded myocardial wall are lineally sutured over each other and reinforced with strips of Teflon to increase haemostasis (Figs. 5d and 5f). This technique is generally accompanied by extensive myocardial revascularisation that should include the anterior descending artery even when it is completely chronically occluded or of poor quality, in order to recover the hibernated myocardium of the basal portions of the septum and by a mitral plasty if the patient presents moderate or greater mitral insufficiency.

 

Results
A total of 4 (6.6%) patients died, all during the immediate post-operative period and in situations of refractory cardiac failure. It should be noted that of the 56 patients (93%) who underwent elective surgery only 3 (5.3%) died, as opposed to the 1 (25%) patient who died of the 4 (6%) who underwent emergency surgery.

Mean mechanical ventilation time was 36.2±77.34 hours (range 3 – 384) per patient. If we exclude from the group a single patient with an intubation time of 384 hours, who later died, the mean time is 21.71±27.63 hours (range 3 – 120). A large majority (80%) of the patients required inotropic support, although its mean duration (in the case of survivors) was only 2.39±4.17 days. 5 patients (8.3%) required intraaortic balloon counterpulsation (4 [80%] of them elective and 1 [20%] emergency), the mean duration of this assistance being 1.75±0.957 days. Of these 5 patients 1 died (20% of those requiring balloon counterpulsation). Cardiogenic shock occurring in 2 patients (3.3%) resulted in emergency cardiac transplants, with good post-operative evolution. The mean stay in intensive care was 2.98±3.69 days (range 1 – 20), the mean total post-operative stay being 7.55±10.14 days (range 3 – 64).

With regard to the postoperative clinical situation, patients were classified according to the NYHA scale 6 months after surgery, with only 2 (3.3%) of the 56 survivors (93%) still experiencing dyspnea after slight efforts (NYHA III), and the remainder (54; 90%) with no dyspnea or dyspnea only after major effort (Fig. 7). The mean value of this NYHA classification was 1.44±0.583, this being statistically significant (p=0.002) when compared with the preoperative classification on the same scale Figure 8.

Of the 46 patients who experienced effort angina pectoris during the preoperative period, only 8 (13%) continued to experience it for major effort after 6 months Figure 7, with none of them presenting angina pectoris after moderate or minor effort or resting, the mean value on the CCS scale at 6 months being 0.24±0.52 Figure 8, with statistically significant differences being observed (p<0.05). With regard to malign ventricular arrhythmias (17; 28%), relapse occurred in only 1 patient (5.8%) with inferior aneurysm Figure 7: although a new electrophysiological study was not performed, Holter tests were administered on several occasions. The two patients fitted with defibrillation systems showed no evidence of ventricular tachycardias when readings were taken from the devices.

Figure 7: Clinical situation 6 months after surgery (p<0,05).




Figure 8: Decrease in mean functional NYHA and CCS class before and after surgery (p<0,05).



The tests performed during the follow-up period included a transthoracic echocardiogram one and six months after surgery, the mean ejection fraction at one month being 41.14%±10.72% and at 6 months 48.5%±11.15%. When the preoperative ejection fraction is compared with the ejection fractions at 1 and 6 months, the differences were not statistically significant (p=0.245 at 1 month, p=0.106 at 6 months). Figure 9. In the ten patients evaluated by postoperative MRI, there was a reduction in the LVESVI (left ventricular end-systolic ventricular index) (76.64±19.72 vs. 47.39±11.87, p<0.001) and left ventricular mass (169.28±39.29 vs. 147.72±43.46, p=0.025), and an increase in the left ventricular ejection fraction (31.09±9.04 vs. 38.76±9.92, p=0.006) (Table 1).

Figure 9: Ejection fraction before surgery, one month after surgery and six months after surgery (p>0.05).



Table 1: Pre- and post-surgical evaluation with MRI.

 

Discussion
As has already been mentioned, the basic principle in ventricular restoration surgery is the functional reconstruction of the ventricular cavity, with maximum exclusion of akinetic zones and elimination of paradoxical movement, and including myocardial revascularisation and mitral repair (MI > 2) surgery whenever possible. According to previously published results, the majority of patients experience a high degree of clinical and functional improvement, although in the case of some patients no correlation could be established between this improvement and an increase in ventricular function. Furthermore, the published survival curves are significantly superior to those of patients who have not undergone surgery, particularly for patients with three-vessel coronary disease.

A fundamental reference in this regard are the results of a multi-centre study performed in 13 European and US centres, called "RESTORE" [23] (Reconstructive Endoventricular Surgery, returning Torsion Original Radius Elliptical shape to left ventricle), which covered 1,198 patients between 1998 and 2003, evaluating early results and results after 5 years’ follow-up. Mean patient age was 63±10 years, all had antecedents of a previous infarction and 67% presented dyspnea in NYHA functional classes III-IV. The mean preoperative ejection fraction was 29.6±10% and the LVESVI 80.4±51.4 ml/m2. 95% received associated myocardial revascularisation, 22% mitral repair and 1% replacement mitral valves. Hospital mortality was 5.3% (8.7% in patients with additional mitral repair/replacement and 4% in patients in which this was not performed, the difference being statistically significant). A counterpulsation balloon was needed by 8.2%; left-ventricular assistance by 0.7% and ECMO (extracorporeal membrane oxygenation) by 0.3%.

Postoperatively, the mean ejection fraction rose to 39±12% (p<0.01 in comparison with the preoperative situation), this representing a 10% increase. The postoperative LVESVI was 56.6±34.3 ml/m2, representing a decrease of 23.8 ml/m2 (p<0,01). At 5 years survival was 68.6%±2.8%, with 78% of patients not returning to hospital as a result of cardiac failure. Similarly, 85% of patients remained in NYHA functional classes I-II after five years of follow-up. Logistic regression analysis was used to determine the risk factors for early or late mortality after surgery, these being: age of 75 or older, advanced NYHA functional class (III-IV), ejection fraction lower than 30% and LVESVI 80 ml/m2 or higher Figure 10a-d. A relevant aspect in this regard is early surgical indication. If there is extensive myocardial damage, all revascularisation techniques are doomed to failure. In Dor’s experience, if the LVESVI is greater than 120 ml/m2 survival at 6 years is approximately 50%, as opposed to almost 90% if the LVESVI is lower than 90 ml/m2. Similarly, Cwajg et al. [24] show poor surgical results if the left ventricular wall is less than 0,6 cm thick.

Figure 10a: Survival [23] and preoperative LVESVI


Figure 10b: Overall survival [23] at 5 years


Figure 10c: Survival [23] and ejection fraction.



Figure 10d: Survival [23] and NYHA functional class.

 

Early and short term results of the major series, i.e. the RESTORE group (fundamentally in terms of mortality and improved quality of life, as measured by NYHA functional class), are in general fairly similar with those obtained for our group, with the exception of the significant improvement of the postoperative ejection fraction evaluated by echocardiography, perhaps due to the small number of patients in our sample, and to the shorter follow-up period of only 6 months. Nevertheless, MRI has revealed morphological and functional changes in the left ventricle, a reduction in the LVESVI similar to that of the RESTORE group (29.24±15.25, p<0.05) being worthy of note. There are also major population differences with regard to the advanced NYHA functional class (III-IV): 20% in our series as opposed to 67% in the RESTORE group. Another major difference between the two studies is the percentage of surgical interventions on the mitral valve (22% in the RESTORE group vs. 3.3% in our series). This may partly be explained by the intense activity of the cardiac transplant programme at our centre in the late 1990s, when many patients with reduced EF, dilated ventricle (very often associated with moderate/severe mitral insufficiency) and advanced functional class were candidates for a heart transplant.

Finally, we conclude that the Dor procedure is a valid surgical alternative for patients in NYHA functional classes III-IV who are not candidates for a heart transplant, since:

- Mortality is low in patients undergoing elective surgery (6.6%), emergency surgery or the need for intraaortic balloon assistance being the variables that cause mortality to rise.
- Significant differences are obtained in left-ventricular morphofunctional indicators (ejection fraction and LVESVI), functional class improvement and reduced angina pectoris, resulting in a better quality of life for these patients.
- The fact that the endoventricular plasty not only acts on the aneurysm but also on the perianeurysmatic tissue contributes to the disappearance of ventricular arrhythmias.
- Finally, we consider that this ventricular restoration technique is a safe and effective treatment for patients with left-ventricular aneurysms following a myocardial infarction fundamentally located in the anterior region.

It should also be mentioned, due to its expected repercussion, that we are awaiting the outcome of the STICH (Surgical Treatment for IsChemic Heart Failure) trial [25], which randomly assigns patients with ischemic cardiopathy to three treatment groups: medical therapy, coronary artery bypass surgery and coronary artery bypass surgery with surgical ventricular restoration. This study will reveal whether coronary artery bypass surgery increases survival rates in patients with coronaropathy and cardiac failure and whether or not a clear benefit can be obtained from myocardial restoration therapies.

LIST OF ABBREVIATIONS:
ECC = Extracorporeal Circulation.
ICD = Implantable Cardioverter Defibrillator.
ECMO = Extra Corporeal Membrane Oxygenation.
EF = Ejection Fraction.
CHF = Congestive heart failure.
ACEI = Angiotensin Converting Enzyme Inhibitors.
FMI = Functional Mitral Insufficiency.
LVESVI = Left Ventricular End-Systolic Volume Index.
ECP = Endoventricular Circular Plasty.
MRI = Magnetic Resonance Imaging.
CT = Cardiac Transplant.

Bibliography

  1. Torrent-Guasp F. Mecánica de los segmentos descendente y ascendente de la banda miocárdica ventricular. Rev Esp Cardiol 2001;54:1091- 1102.
  2. Shapiro EP, Rademakers FE. Importance of oblique fiber orientation for left ventricular wall deformation. Technol Health Care 1997;5:21-28.
  3. Bogaert J, Maes A, Van der Werf F, Bosmans H, Herregods MC, Nuyts J, et al. Functional recovery of subepicardial myocardial tissue in transmural myocardial infarction after successful reperfusion: an important contribution to the improvement of regional and global left ventricular function. Circulation 1999;99:36-43.
  4. Lorenz CH, Pastorek JS, Bundy JM. Delineation of normal human left ventricular twist throughout systole by tagged cine magnetic resonance imaging. Journal of Cardiovascular Magnetic Resonance 2000;2(2):97-108.
  5. Comin J, Manito N, Roca J, Castells E, Esplugas E. Insuficiencia mitral functional. Fisiopatología e impacto del tratamiento médico y de las técnicas quirúrgicas de reducción ventricular izquierda. Rev Esp Cardiol 1999;52:512-520.
  6. Konno T, Sabbah HN, Rosman HJ, Alam M, Jafris S, Stein PD et al. Left ventricular shape is the primary determinant of functional mitral regurgitation in heart failure. Am Coll Cardiol 1992;20:1594-1598.
  7. Yamaguchi A, Ino T, Adachi H, et al. Left ventricular end-systolic volume index in patients with ischemic cardiomyopathy predicts postoperative ventricular function. Ann thorac Surg 1995;60:1059-62.
  8. Yamaguchi A, Ino T, Adachi H, et al. Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy. Ann thorac Surg 1998;65:434-438.
  9. White HD, Norris RM, Brown MA, Brandt PW, Whitlock RM, Wild CJ. Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction. Circulation 1987;76:44-51.
  10. Migrino RQ, Young JB, Ellis SG, White HD, Lundergan CF, Miller DP, et al. End-systolic volume index at 90 to 180 minutes into reperfusion therapy for acute myocardial infarction is a strong predictor of early and late mortality. The Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-I Angiographic Investigators. Circulation 1997;96:116-21.
  11. Gaudron P, Eilles C, Kugler I, Ertl G. Progressive left ventricular dysfunction and remodelling after myocardial infarction: potential mechanism and early predictors. Circulation 1993;87:755-63.
  12. Bolling SF, Pagani FD, Deeb GM, et al. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg 1998;115:381-386.
  13. Bolling SF. Mitral reconstruction in cardiomyopathy. J Heart Valve Disease 2002;11(suppl1):S26-S32.
  14. Vanoverschelde JL, Depre C, Gerber BL, Bogers M, Wijns W, Robert A, et al. Time course of functional recovery after coronary artery bypass graft surgery in patients with chronic left ventricular ischemic dysfunction. Am J Cardiol 2000;85:1432-9.
  15. Buckberg G. Congestive heart failure: treat the disease, not the symptom – return to normalcy. J Thorac Cardiovasc Surg 2001;121:628-37.
  16. Romano MA, Bolling SF. Update on mitral repair in dilated cardiomyopathy. J Card Surg. 2004 Sep-Oct;19(5):396-400.
  17. Dor V. Surgery for left ventricular aneurysm. Curr Opin Cardiol. 1990;5:773-80.
  18. Athanasuelas CL, Stanley AWH, Buckberg GD, Dor V, Di Donato M, Blackstone EH, and the RESTORE Group. Surgical anterior ventricular endocardial restoration (SAVER) in the dilated remodeled ventricle following anterior myocardial infarction. J Am Coll Cardiol 2001; 37:1210-1213.
  19. Beyersdorf F, Doenst T, Athanasuelas C, Suma H, Buckberg G. The beating open heart rebuilding ventricular geometry during surgical anterior restoration. Semin Thorac Cardiovasc Surg 2001;13:42-51.
  20. Batista RJV, Verde J, Nery P, et al. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg 1997;64:634-638.
  21. Tector AJ, Amundsen F, Schmahl TM, Kress DC, Downey FX. Total revascularisation with T-graft. Ann Thorac Surg. 1994: 57: 53-59.
  22. Fontan F. Transplantation of knowledge. J Thorac Cardiovasc Surg 1990;99:387-395.
  23. Athanasuleas C. et al The RESTORE GROUP. Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation. J Am Coll Cardiol 2004; 44 (7), 1439-45.
  24. Cwajg JM, Cwajg E, Nagueh SF, et al. End-diastolic wall thickness as a predictor of recovery of function in myocardial hybernation. Relation to rest-redistribution Tl-201 tomography and dobutamine stress echocardiography. J Am Coll Cardiol 2000;35:1152-1161.
  25. Torsten Doenst et al. To STICH or not to STICH: We know the answer, but do we understand the question? J Thorac Cardiovasc Surg 2005; 129: 246-9.


 

Abstract
Introduction: The concept of ventricular restoration (Dor procedure, coronary revascularisation and mitral repair) has been presented in recent years as a new diagnostic and therapeutic approach to patients with congestive heart failure (CHF).
Objective: To evaluate our experience with this surgical technique and its results with regard to early mortality, improved quality of life and early evaluation with MRI.
Patients and Method: Between June 1994 and April 2004 operations were performed by our Service on 60 patients using endoventricular circular patch plasty (EVCPP or the Dor procedure) through the scar tissue left by the previous infarction, in some cases associated with coronary revascularisation and/or valve replacement or repair. Ten of the latest patients were evaluated with MRI before and after surgery (11±10 months post-surgery).
The mean preoperational ejection fraction as measured by a transthoracic ECG was 38.06%±11.27%, and 35.80%±10.45% by left ventriculography. Surgical indication was the presence of sustained and untreatable ventricular tachycardia (17 patients, 28%), CHF (10 patients, 16 %) and CHF with angina pectoris (33 patients, 55%).
Results: Hospital mortality was 4 patients (6.6%) and 2 patients (3.3%) were given an emergency heart transplant. Clinically speaking, in contrast with the 12 patients (20%) with initial functional class III-IV, after 6 months, only two (3.3%) continued to suffer dyspnea after slight effort or when resting, 77.5% of patients continued to be free of angina pectoris after 6 months and relapse only occurred in the case of one patient with inferior aneurysm out of the 17 with malign ventricular arrhythmias. Post-surgical MRI showed a reduction in the LVESVI (left ventricular end-systolic ventricular index) (76.64±19.72 vs. 47.39±11.87, p<0.001) and left ventricular mass (169.28±39.29 vs. 147.72±43.46, p=0.025), and an increase in the left ventricular ejection fraction (31.09±9.04 vs. 38.76±9.92, p=0.006)
Conclusions: Ventricular restoration is an effective surgical technique for treating post-infarction ventricular aneurysms. Our results after surgery, and in the short term, are similar to those of the reference series (RESTORE group).


CV of the author
Francisco Estévez Cid
- Licenciatura en Medicina y Cirugía, Universidad de Santiago de Compostela (España) (1996-2002)
- Examen MIR de acceso a formación médica especializada. (Feb 2003)
- Inicio de formación especializada en Cirugía Cardiaca en el Hospital Juan Canalejo, La Coruña, España. (Jun 2003)
- En la actualidad, médico residente de cuarto año de Cirugía Cardiaca en el Complejo Hospitalario Juan Canalejo, La Coruña, España.

Alberto Juffé Stein
- Licenciatura de Medicina, en la Facultad de Medicina de la Universidad de Buenos Aires, Argentina, 1963 a 1969.
- Tesis Doctoral: Variaciones metabólicas y de la conducción AV durante la hipotermia. Calificada "CUM LAUDE".
- Academico Correspondiente de la Real Academia de Medicina y Cirugía de Galicia, 31.1.92.
- Grandfhater Clause de la European Board of Thoracic and Cardiovascular Surgeons (EBTCS). Noviembre 2000.
- Jefe Adjunto de Cirugía Torácica y Cardiovascular de la Clínica Puerta de Hierro, Madrid. 1.975 - 1.985.
- Fellow del Servicio de Cirugía Cardiaca. Children’s Hospital Medical Center. Harvard Universiy. 1979.
- Special Cardiovascular Fellow. Servicio de Cirugía Cardiovascular. University of Alabama . Birmingham. Alabama. USA 1.980
- Jefe del Servicio del Instituto de Enfermedades Torácicas y Cardiovasculares. Buenos Aires. Argentina. 1986-1988.
- Director de la Unidad Torácica y Cardiovascular. Clínica Privada Nueva Córdoba. Córdoba. Argentina. 1988- 1990.
- Jefe de Servicio de Cirugía Cardíaca. Director del Programa de Trasplantes de órganos torácicos. Complejo Hospitalario Juan Canalejo. A Coruña. España. Desde 1990
- Educational Council for Foreign Medical Graduates (154.010.3), obteniéndolo mediante examen, para convalidación del título de Licenciado en Medicina, en Estados Unidos.
- Profesor no Numerario, de la Primera Cátedra de Anatomía Patológica de la Universidad de Buenos Aires. Argentina. 1967 - 1972.
- Profesor Adjunto "Ad Honorem" de la Cátedra de Cirugía de la Facultad de Medicina de la Universidad Autónoma de Madrid, desde 1975 a 1985.
- Director de Cursos del Doctorado .Universidad de la Coruña.
- Programa de Residente de la Especialidad, Cirugía Cardiovascular. Complejo Hospital "Juan Canalejo". A Coruña.
- Director del Programa de Trasplantes del Sanatorio Modelo Quilmes. Buenos Aires. Argentina. 1985-1989.
- Director del Programa de Trasplante de Organos Torácicos del Hospital Juan Canalejo. La Coruña. España. Febrero de 1991.
- El Dr. Alberto Juffé ha sido habilitado como cirujano cardiovascular, para la ablación e implante de riñón y uréteres. 1989. Ministerio de Sanidad. Buenos Aires. Argentina.
- Director del Programa de Cardiomioplastia. Bakken Research Center. Maastricht. The Netherlands. Septiembre de 1991.
- Director del Programa de Asistencia Circulatoria en el Hospital Juan Canalejo. La Coruña. España.1994

 

 

Publication: September 2007

FORM DEACTIVATED SINCE
November 30th., 2007

Your questions, contributions and commentaries will be answered
by the lecturer or experts on the subject in the Cardiovascular Surgery list.
Please fill in de form and Press the "Send" button.

E-Mail address:
Re-type Email address:
    

 

Actualización: 30-Nov-2007