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Initial results with Combined
Surgical Reconstruction in Patients
with Ischemic Dilatative Cardiomyopathy

Mitrev, Zan; Angusheva, Tanja; Joshevska, Sladana;
Vasileva, Anica; Petrovski, Vlado

Cardiosurgery, CVZU Skopje, Republic of Macedonia

SUMMARY
Introduction: End stage of heart failure as a result of severe coronary disease is a syndrome with high mortality rate and poor quality of life. Increasing of the cardiac transplantation incidence and the small number of organ donors has favored searching for new surgical methods. The current results of promoting of partial cuneate resection (Batista) are encouraging, but because of the considerable mortality raqte and common rhythm disturbances, are set forth as questionable.
Objectives: The aim of this presentation is to evaluate early clinical results from application of combined partial cuneate resection and circular aneurysmectomy following total myocardial revascularisation.
Material and Methods: On three patients with end stage of ischemic dilatative cardiomyiopathy, with big aneurysm of apicoposterior left ventricle wall, next to the total revascularisation with mandatory artery grafting of left internal mamarian artery to left arterial descendents, a partial cuneate resection of the posterior wall aneurysmatical dilatation and circular aneurysmectomy of the anterior aneurysmatic wall were performed.
Results: All patients were extubated in 8-10 h, treated with moderate doses of cathecholamines, with obvious hemodynamic improvement of heart function such was improving of the ejection fraction from 20% vs. 35% postoperatively, decreasing of the endiastolic volumen 202+/- 5,6ml v.s.139+/- 4,6ml postoperatively, reduction of the mitral valve regurgitation from +3 on +1. The average number of vein grafts was 2,3 per pts. The mean NYHA classify improved from IV on II class (6 months follow up).
Conclusion: This surgical technique has shown improvement of the hemodynamic status in patients with end stage of the ischemic dilatative cardiomyopathy. These initial results have encouraging us to implement this technique in patients who are potential candidates for heart transplantation.

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BACKGROUND
   Functional and morphological waste of the left ventricular myocardial mass in patients with severe coronary artery disease develops dilative cardiomyopathy with significant left ventricular failure (EF<20%), with poor quality of life and high mortality rate. The current results of promoting the posterior cuneate resection (Batista) are not satisfactory for patients with ischemic dilative cardiomyopathy, due to considerable mortality rate and common rhythm disturbances.
The aim of this presentation was to evaluate early clinical results from application of combined posterior cuneate and direct circular resection in selected patients with enormous left ventricular aneurysm of the antero-apico-posterior wall, followed by total myocardial revascularisation.

   Direct circular repair (DCR) is a technique indigenous for our clinic, developed by utilizing the good sides such as direct closure of the ventricular defect and geometric reconstruction of the left ventricle with eliminating the adverse effects such as: the application of a non-contractile foreign body or geometrical disproportion of the other techniques.

MATERIAL AND METHODS
   Three patients with end-stage of ischemic dilative cardiomyopathy with enormous aneurysm of the apico-posterior and anterior left ventricular wall, were treated with combination of Batista and DCR procedure.

Including criteria:
· Data for previous myocardial infarction;
· Frequent decompensations (more 3/year);
· NYHA classif. IV;
· coronarographic findings for multivessel disease;
· lack of medicamentous effects.

   Radionuclid left ventricle myocardial viability assessment and transoesophageal exploring were performed on each patient preoperatively.

   Standard cardiac anestesiologic procedures with haemodynamic monitoring were performed intraoperatively and postoperatively.

   After a medial sternotomy and cardiac arrest with warm blood cardioplegy an incision was made on the apex of the left ventricle, which was extended toward the ring of the mitrale valve, between the papillary muscles of the posterior wall (Figure 1). Fibrotically changed posterior wall was resected triangularly, and posterior wall was reconstructed with direct 1-0 prolen suture in continued fashion.

Figure 1

   The apex and the anterior wall were circularly resected. For geometric reconstruction of the ventricle a prolene purse 1 string suture was placed within the fibrous sewing ring leaving approximately 1cm of fibrous border (Figure 2).

Figure 2

   Because of the myocardial incision of the anterior and posterior wall, with placement of a profound circular suture the dyskinetic septum was completely excluded from the newly formed ventricular chamber. The ventricular suture was pulled to reduce the ventricular orifice to a diameter approximately 1cm.

   Next a prolene-1.0 suture was used over two autologe pericardial strips to bring the circular cuff together. The suture used to close the fibrous cuff was placed in such a fashion, that the suture lines retain the circular aspect (Figure 3).

Figure 3

    The excluded external tissue was folded to reinforce the suture line with the other side of the prolene 1-0 suture, which was placed over the reconstruction, so even epicardial surface results after the reconstruction (Figure 4).

Figure 4

RESULTS
   All pts were extubated within 8-10h, and treated with moderate doses of norepinephrin (0,3-0,5µg/kg/min), low doses of epinephrine (0,1µg/kg/min), dopamine in diuretic dosage, according to hemodynamic parameters (Table 1).

    Early postoperatively the second patient had rhythm disturbances with frequent VES and transitory episodes of tachyarrhythmia absolute, so amiodarone was included within first three months.

    Three pts were treated with digitalis, diltiasem, spironolacton, ACE inhibitors and diuretics (Figure 5).

Figure 5

   Follow up period is three to six months, so we intend to perform a control radionuclid examination after the first year.

DISCUSSION
   Current experience from PCR operation shows some positive results for pts with idiopathic dilative cardiomyopathy, but it is not satisfactory for ischemic dilative cardiomyopathy. The positive result in these pts depends from mitral valve competition. Mitral valve reconstruction significantly improves the left ventricle function (in our presentation-one pts).

   This study shows the initial experiences from this kind of combined operation for pts with extremely dilated left ventricle and who are potential candidates for transplantation. The six months survival period with haemodynamic improvement encourage us for further application of this operation.

CONCLUSION
   Combined surgical technique with posterior cuneate resection (Batista) and direct circular repair (DCR) for patients with enormous aneurysm of the anteroapicoposterior left ventricular wall has shown improvement of the hemodynamic status, decreasing of the volumes and increasing the ejection fraction.

   These initial results have encouraged us to further implement this technique in patients who are potential candidates for heart transplantation.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
rbretal@netverk.com.ar
apacher@fac.org.ar
apacher@satlink.com

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