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Ann Thorac Surg 1999;67:1703-1707
© 1999 The Society of Thoracic Surgeons

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Original Articles

Early experience with partial left ventriculectomy in the Asia-Pacific region

^a Prince of Wales Hospital, Hong Kong
^b Shonan Kamakura General Hospital, Kamakura, Japan
^c Madras Medical Mission, Chennai, India
^d P. D. Hinduja National Hospital, Bombay, India
^e Sapporo Medical University, Sapporo, Japan

Accepted for publication December 23, 1998.

Address reprint requests to Dr Izzat, PO Box 33831, Damascus, Syria
e-mail: izzat{at}cyberia.net.lb

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. We report our early experience with partial left ventriculectomy done by a group of cardiac surgeons in the Asia-Pacific region.

Methods. Partial left ventriculectomy was done in 48 patients (mean age, 43 years) with advanced symptomatic cardiomyopathy. The origin of cardiomyopathy was idiopathic in 30 patients, valvular in 10, ischemic in 3, peripartum in 3, sarcoidosis in 1, and viral myocarditis in 1. Procedures performed on the mitral valve were repair with Alfieri method in 8 patients, ring annuloplasty in 2, and replacement in 25.

Results. Seventy-seven percent of patients required myocardial support for weaning from cardiopulmonary bypass, and the overall in-hospital mortality rate was 27%. Mean follow up was 6.5 months (range, 1 to 18 months), and patient survival at 1, 3, and 6 months after discharge was 91%, 88%, and 84%, respectively. Sixty-five percent of survivors with idiopathic and valvular disease achieved significant and sustained improvement in ventricular contractility and symptoms, but there were no clear symptomatic benefits from partial left ventriculectomy in patients with cardiomyopathy from other causes. Most cases of late recurrence of heart failure symptoms (90%) appeared to be related to the development of progressive mitral incompetence.

Conclusions. After partial left ventriculectomy left ventricular function improved in patients with idiopathic and valve related cardiomyopathies. Late deterioration was related to the development of significant mitral valve incompetence postoperatively, hence definitive mitral valve repair or replacement at the time of the partial left ventriculectomy procedure is advised.

	Introduction

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In the past 2 years there has been more interest in partial left ventriculectomy (PLV) as a treatment modality for end-stage heart failure [1]. Several centers with access to mechanical assistance and heart transplantation facilities are already exploring the advantages and outcome of PLV, predominantly in patients with idiopathic dilated cardiomyopathy [2–4]. Notwithstanding, the most significant impact of the development of PLV procedures is likely to be in regions such as the Asia-Pacific, where the incidence of heart failure is rapidly increasing and heart transplantation is largely unavailable [5, 6]. It is unlikely, however, that the early outcome of PLV in the Asia-Pacific region will relate to the reports currently at hand from other regions because a spectrum of causes of heart failure other than idiopathic cardiomyopathy are prevalent [7], and bail-out procedures with left ventricular assist devices or heart transplantation are not readily accessible.

The Surgical Reduction of Ventricular Volume Trial (SURVIVAL) group is an international working group recently formed in the Asia-Pacific region to share experiences with PLV operations and to improve the understanding of indications, techniques, and outcome of this procedure [5, 8]. This report describes the clinical experience of members of the SURVIVAL group with PLV operations.

	Material and methods

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Study population
Six regional and academic centers contributed their experience to the SURVIVAL group database. A specially designed form was used for data collection, which was completed in full and returned for all PLV procedures done by end of July 1998.

Between November 1996 and July 1998, 48 patients (mean age, 43 years; range 3 to 67 years; 81% male) had PLV surgery. Preoperatively, all patients had advanced symptomatic congestive heart failure (New York Heart Association [NYHA] functional class III [n = 20] or IV [n = 28]) despite maximal tolerated medical therapy consisting of angiotensin-converting enzyme inhibitors, diuretics, digitalis, and, in 13 cases, dobutamine infusion or intraaortic balloon pump support.

The cause of cardiomyopathy was idiopathic in 30 patients, valvular in 10, ischemic in 3, peripartum in 3, sarcoidosis in 1, and viral myocarditis in 1. The left ventricle was assessed preoperatively by echocardiography. Left ventricular ejection fraction (EF), measured through the parasternal cross-sectional plane, was 23% ± 1% (mean ± standard error of the mean) and end-diastolic diameter (EDD) was 7.6 ± 0.2 cm. Ethics committee approval was obtained in all centers, and each patient gave informed consent for the operation.

Surgical technique
Standard cardiac anesthesia was used, with hemodynamic monitoring using Swan-Ganz catheters intraoperatively and postoperatively. Normothermic cardiopulmonary bypass and cardioplegic arrest with intermittent antegrade warm blood cardioplegia was used in 32 patients, and the procedure was done on a beating heart in 16 patients, as described by Batista and associates [1].

Our PLV technique is similar to that described previously [1, 2]. Briefly, the ventricular incision was started at the apex, 2 cm lateral to the left anterior descending coronary artery, and extended towards the mitral valve annulus. In the early cases (n = 23), attempts were made to preserve the papillary muscles of the mitral valve, so only the interpapillary myocardium was excised. In 8 of these patients, the midpoints of the free edges of the two mitral leaflets were approximated with a single suture (Alfieri repair) [2]. In later patients (n = 25), a larger segment of the ventricular wall was excised, and the mitral valve was replaced with a valve prosthesis. The free wall of the left ventricle (LV) was reconstituted in a linear fashion with pericardium or Teflon strips for added reinforcement. Other associated procedures were then done (eg, coronary artery bypass grafting or aortic valve replacement) before removal of the aortic cross-clamp.

Most patients were weaned from cardiopulmonary bypass with inotropic support with dobutamine or dopamine in combination with afterload reduction with nitrates infusion; however, additional intraaortic balloon pump support was necessary in 19% of patients. Once hemodynamic stability had been established, patients were extubated as soon as possible, and myocardial support was weaned as appropriate. During the following 7 to 10 days, aggressive antifailure pharmacologic therapy was reintroduced gradually using a combination of angiotensin-converting enzyme inhibitors, nitrates, and diuretics.

Procedures performed
Myocardial resection was directed purposely to the lateral wall of the LV, except in 1 patient who had a dense scar in the anterior LV wall from previous myocardial infarction; hence the resection was limited to this region. The average width of the resected area was 6.3 cm (range, 3 to 10 cm).

Procedures done on the mitral valve included repair with Alfieri method in 8 patients, annuloplasty with ring in 2, and replacement with a valve prosthesis in 25, and the mitral valve was left intact in 13 patients. Associated procedures were aortic valve replacement in 9 patients, coronary artery bypass grafting in 3, tricuspid valve repair in 17, right ventricular plication in 1, and the Maze procedure in 1.

	Results

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In-hospital and follow-up data were complete for all patients except for one who was lost to follow up after discharge from hospital. The overall in-hospital mortality rate was 27%. Mean follow-up period was 6.5 months, and patient survival at 1, 3, and 6 months after discharge was 91%, 88%, and 84%, respectively.

Because the origin of cardiomyopathy might influence the outcome of PLV procedures, results are classified according to cardiomyopathic origin.

Idiopathic cardiomyopathy
Thirty patients with idiopathic dilated cardiomyopathy (LVEDD 7.3 ± 0.1 cm and EF 19 ± 1%) had PLV procedures. Preoperatively, 10 patients were in NYHA functional class III and 20 in functional class IV, with 9 patients dependent on inotropic agents or intraaortic balloon pump support. Twenty-five patients (83%) required the aid of inotropic drugs to be weaned from cardiopulmonary bypass, and 6 (20%) required additional intraaortic balloon pump support. One patient had cardiac arrest immediately preoperatively and failed to recover postoperatively. There were seven more in-hospital deaths resulting from low cardiac output and multiorgan failure, and 1 patient died of acute bacterial mediastinitis. Therefore, there were 21 hospital survivors (70%), and predischarge echocardiography showed a decrease in LVEDD to 5.7 ± 0.2 cm and an increase in EF to 32% ± 2% (both p < 0.01, paired Student t-test).

One patient was lost to follow-up after discharge; otherwise follow-up was complete for 20 patients, and ranged from 1 to 14 months (mean, 6 months). Seven patients had progressive heart failure after discharge, of whom 6 showed evidence of worsening mitral incompetence (3 had had Alfieri repair and 3 had no mitral valve repaired). Redo mitral valve replacement was done in 1 patient 6 weeks later, and another patient had heart transplantation at 6 months postoperatively. Of the 5 medically treated patients, 3 died at 1, 2, and 7 months postoperatively, and the other 2 remain in NYHA class III. The remaining 13 patients are in NYHA classes I (n = 5) and II (n = 8). Repeated echocardiography showed that LVEDD was maintained at 5.8 ± 0.2 cm and EF at 3% ± 2%.

Valvular cardiomyopathy
Nine patients with long-standing aortic valve incompetence and 1 patient with chronic mitral incompetence (LVEDD 8.6 ± 0.4 cm and EF 31% ± 4%) had PLV surgery. Preoperatively, 6 patients were in NYHA functional class III and 4 in functional class IV, with 2 patients dependent on inotropic agents.

All patients but one were weaned from cardiopulmonary bypass with the aid of inotropic drugs, and two required additional intraaortic balloon pump support. One patient died in-hospital of low cardiac output, and 9 survived and were discharged from hospital. Predischarge echocardiography showed a decrease in LVEDD to 7.9 ± 0.6 cm and an increase in EF to 42% ± 3% (both p < 0.01).

Follow-up was complete in all patients and ranged from 1 to 18 months (mean, 7 months). After discharge, 1 patient died of prosthetic valve thrombosis 3 months postoperatively. In 3 patients, one with Alfieri repair and two with un-repaired mitral valves, progressive mitral incompetence developed. Two of these patients died of intractable heart failure 1 and 13 months postoperatively, and the third remains in NYHA class III. The remaining 5 patients improved to NYHA class I (n = 3) and II (n = 2) at a mean follow-up period of 8 months (range, 2 to 18 months), and repeated echocardiography showed persistent LVEDD of 8.0 ± 1 cm and EF of 40% ± 4%.

Ischemic cardiomyopathy
Three patients with ischemic cardiomyopathy (all NYHA class III, LVEDD 7.1 ± 0.2 cm and EF 24% ± 3%) had PLV procedures. The lateral wall of the LV was resected in 2 patients, whereas the densely scarred anterior wall was resected in the third. All three patients had an uneventful postoperative course and were discharged from hospital within 2 weeks postoperatively. Predischarge echocardiography showed a LVEDD of 6.8 ± 0.2 cm and EF of 34% ± 2% (p < 0.01). There was no symptomatic benefit from the procedure in 2 patients, and only mild improvement in the third. Severe mitral incompetence developed in 1 patient (Alfieri repair), and redo mitral valve replacement was done 3 months later. This patient died 7 months after the second procedure of intractable heart failure. Another patient died suddenly 15 months after PLV, and the third patient remains in NYHA class II. Repeated echocardiography in this patient showed a persistent ejection fraction of 37%.

Other causes
Five other patients had PLV procedures, and the origin of heart failure was peripartum cardiomyopathy in 3, viral myocarditis in 1, and sarcoidosis in 1. All patients were in NYHA class IV preoperatively, with 2 patients dependent on inotropic support. The LVEDD was 7.4 ± 1 cm and EF was 22% ± 2%. All 3 patients with peripartum cardiomyopathy died postoperatively of low cardiac output. The remaining 2 patients were discharged from the hospital but did not seem to derive notable symptomatic benefit from the procedure. Echocardiography 6 months postoperatively did not show any increase in LV ejection fraction compared with preoperative values.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The most significant impact of new developments in the treatment of end-stage heart failure is likely to be in regions such as Asia-Pacific where heart transplantation is not a viable option [5, 6]. Partial left ventriculectomy resulted in a significant improvement in left ventricular contractility and functional class in many patients [1–4, 9]; nevertheless the high rate of early procedural failure continues to cause considerable concern. Recent reports indicated an immediate failure rate of 17%, and a 1-year actuarial freedom from procedure failure (death or relisting for transplantation) of only 52%–58% [1–4, 10, 11]; yet this outcome was achieved by the aggressive use of bail-out LVADs and heart transplantation whenever necessary. It is unlikely, therefore, that the outcomes of PLV procedures in the Asia-Pacific region are comparable to those, because LVADs or heart transplantation are largely unattainable. The 27% in-hospital mortality rate in our series is higher than that in other reports. Nevertheless, one must consider that the present study represents the early learning curve in six different centers and is unlikely to represent the eventual potential of this operation. Moreover, the group of patients included several who were critically ill and dependent on inotropic support. The general lack of alternative therapy in our settings meant that a short life expectancy and minimal chance of hospital discharge were hallmarks in many patients. However, the present 6-month survival rate is similar to that in some recent series of PLV operations [4, 10], and the improvement in LV function and functional class concurs with other reports as well.

Experience with PLV procedures has been predominantly in patients with idiopathic dilated cardiomyopathy, and data concerning the efficacy of the procedure in cardiomyopathy from other causes has been lacking. Although the number of patients is small, our data suggest that the PLV procedure might not be beneficial where there has been advanced structural damage to the cardiomyocytes and myocardial fibrosis (eg, in ischemic, viral, and peripartum cardiomyopathy), which agrees with a recent proposal [9]. Conversely, patients with cardiomyopathy related to valvular disease appear to benefit from PLV procedures, which is likely to be related, at least in part, to the natural tendency of the left ventricle to recover and to remodel after successful valve repair or replacement [12].

The influence of mitral valve competence on patient outcome merits particular attention. The isolated correction of severe mitral incompetence can improve LV function in dilated cardiomyopathy [12], and the beneficial effects of PLV and mitral valve repair are believed to be complimentary [11]. In the present series, most patients in whom heart failure symptoms recurred after PLV also had significant mitral incompetence. It is conceivable, therefore, that the development of progressive postoperative mitral incompetence had substantially increased LV overload and wall stress and was responsible for compromizing the remodeling process of PLV. Although this hypothesis is yet to be substantiated in a larger series, it is evident that maintenance of mitral valve competence is of paramount importance after PLV procedures.

Several factors might be involved in the development of mitral incompetence after the PLV procedure. The change in orientation of the papillary muscles could create redundant length to the chordae and leaflet prolapse [2]. Also, resection of left ventricular wall is associated with acute myocardial infarction surrounding the incision, and often involving one or both papillary muscles [4], with the attendant risk of papillary muscle fibrosis or dysfunction. It is not surprising, therefore, that when the mitral valve was unrepaired or the simple Alfieri suture was used, patients had a 55% to 60% risk of developing progressive mitral valve incompetence postoperatively. We now believe that definitive mitral valve repair [2, 10] or its replacement at the time of the PLV procedure is necessary to ensure long-term valve competence. Future experience will indicate whether this will translate into improved midterm outcome after PLV procedures, and larger series are also required before other factors responsible for late procedural failure are recognized.

Increased experience with PLV and future advances in postoperative treatment methods are likely to improve the outcome from PLV surgery [5]. In this regard, we recently reported a perioperative management strategy through which we have achieved hemodynamic stability and improved early patient outcome [13]. We believe that future development of more successful, but still widely attainable, methods for myocardial protection and pharmacological support of the chronically failed myocardium will lead to wider adoption of the PLV procedure [5]. This study has several limitations. Patients were not randomized, and there is no control group. Our group included patients with heterogeneous clinical diagnoses treated in six different medical centers, with inherent differences in care methods. The lack of back up with left ventricular assist devices or heart transplantation in our practice means that this experience does not reflect the expected outcome from the PLV procedures in centers where such facilities are available. Nevertheless, our settings are representative of a significant number of cardiac surgical centers worldwide which are currently treating many patients with advanced heart failure without access to such facilities.

In our experience, PLV improves left ventricular function in patients with idiopathic and valve related cardiomyopathies. Late postoperative deterioration appears related to the development of progressive mitral valve incompetence. Therefore, we believe that definitive mitral valve repair or replacement is necessary at the time of the PLV procedure to ensure maintenance of the critical mitral valve competence (Appendix 1).

	Appendix

 
Members of the SURVIVAL Asia-Pacific group

Name Institution City Country Brian Buxton Victorian Heart Center Richmond Australia John L. Knight Flinders Medical Center South Australia Australia Julian A. Smith Alfred Hospital Victoria Australia James Tatoulis Royal Melbourne Hospital Victoria Australia Peter Tesar Prince Charles Hospital Chermside Australia Xu Ping Qingdao University Qingdao China Bao-Ren Zhang Changhai Hospital Shanghai China Chen Zhong Yuan Shanghai Second Medical University Shanghai China Song Wan The Chinese University of Hong Kong Hong Kong Hong Kong Anthony P.C. Yim The Chinese University of Hong Kong Hong Kong Hong Kong K. K. Cherian Institute of Cardiovascular Diseases Chennai India K. M. Cherian Institute of Cardiovascular Diseases Chennai India Himansu K. Dasmahapatra Peerless Hospital Calcutta India Anil Jain Rajasthan Hospital Ahmedabad India A. G. Jayakrishnan Srge Uthradom Thirunal Hospital Trivandrum India Pavan Kumar P.D. Hinduja National Hospital Mumbai India Arkalgud S. Kumar All India Institute of Medical Sciences New Delhi India Nitu V. Mandke Lilavati Hospital & Research Center Mumbai India S. Muralidharan G. Kuppuswami Naidu Memorial Hospital Coinbatore India Kaushal Pandey P.D. Hinduja National Hospital & Medical Bombay India Dharma Rakshak Nizams Institute of Medical Sciences Hyderabad India D. Prasada Rao Care Hospital Hyderabad India Edwin Ravikumar Christian Medical College Hospital Vellore India Devendra S. Saksena Bombay Hospital & Medical Research Center Bombay India Kole Shrikant Bombay Hospital Mumbai India Solomon Victor The Heart Institute Chennai Chennai India Maizul Anwar National Cardiac Center Jakartra Barat Indonesia Adhiwidjdja Budhi Rajawali Hospital Bandung Indonesia Ito Puruhito Airlangga University Medical School Surabaya Indonesia T. Isomura Shounann Kamakura General Hospital Kamakura Japan Takashi Kunihara Hokkaido University Sapporo Japan Yasushi Kawaue Hiroshima General Hospital Hiroshima Japan Hikaru Matsuda Osaka University Medical School Osaka Japan Kiyofumi Morishita Sapporo Medical University Sapporo Japan Katsushi Oda Kochi Medical School Kochi Japan Shinji Sano Okayama University Medical School Okayama Japan Akira Seki Okazaki Municipal Hospital Aichi Japan Hisayoshi Suma Shounann Kamakura General Hospital Kamakura Japan Juro Wada Yudou Clinic Medical Center Tokyo Japan Hyuk Ahn Seoul National University Hospital Seoul Korea Byung-Chul Chang Yonsei University Seoul Korea Bong Hyun Chang Kyungpook National University Hospital Taegu Korea Kwang-Hyun Cho Inje University Pusan Paik Hospital Pusan Korea Dong-Hyup Lee Yeungnam University Hospital Taegu Korea Weonyong Lee Kangdong Sacred Heart Hospital Seoul Korea Sang Joon Oh Inje University Seoul Paik Hospital Seoul Korea Sin Keat Khoo National Heart Institute Kuala Lumpur Malaysia Poo Sing Wong Sultanah Aminah Hospital Johor Bahru Malaysia N. Baasanjav National Institute of Health Ulaanbaatar Mongolia David Haydock Green Lane Hospital Auckland New Zealand Peter Raudkivi Green Lane Hospital Auckland New Zealand Masud ur-Rehman Kiani Armed Forces Institute of Cardiology Rawalpindi Pakistan Parvez Mannan Postgraduate Medical Institute Hayatabad Pakistan J. Garcia Makati Medical Center Makati Philippines Adrian E. Manapat Makati Medical Center Makati Philippines Eugene Sim National University Hospital Singapore Singapore Ming Chuan Tong Singapore National Heart Center Singapore Singapore Tan Yong Seng Singapore General Hospital Singapore Singapore Saw Huat Seong Gleneagles Medical Center Singapore Singapore Mohammad Bashar Izzat Damascus University Cardiovascular Center Damascus Syria Sami S. Kabbani Damascus University Cardiovascular Center Damascus Syria Chung-I Chang National Taiwan University Hospital Taipei Taiwan Yu-Sheng Chang Chang Gung Memorial Hospital Taipei Taiwan Hou Shou Hsien Mackay Memorial Hospital Taipei Taiwan Tarng-Jenn Yu Veterans General Hospital—Taipei Taipei Taiwan Chalit Cheanvechai Chulalongkorn Hospital Bangkok Thailand Weerachai Nawarawong Chiangmai University Chiangmai Thailand Pinya Sakiyalak Siriraj Hospital Bangkok Thailand Yoosuph Abdul-Nazer Al-Mafraq Hospital Abu-Dhabi U.A.E.

	References

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1. Batista R.J.V., Santos J.L.V., Takeshita N., Bocchino L., Lima P.N., Cunha M.A. Partial left ventriculectomy to improve left ventricular function in end-stage heart disease. J Cardiac Surg 1996;11:96-97.[Medline]
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6. Takagi H. Organ transplants still too few in Japan and Asian countries. Transplant Proc 1997;29:1580-1583.[Medline]
7. Sanderson J., Chan S.K.W., Chan W.W.M., Hung Y.T., Woo K.S. The aetiology of heart failure in the Chinese population of Hong Kong—a prospective study of 730 consecutive patients. Int J Cardiol 1995;51:29-35.[Medline]
8. Regional news. Asian Cardiovasc Thorac Ann 1998;6:31A.
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10. Moreira L.F.P., Stolf N.A.G., Bocchi E.A., et al. Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy. J Thorac Cardiovasc Surg 1998;115:800-807.[Abstract/Free Full Text]
11. McCarthy J.F., McCarthy P.M., Starling R.C., et al. Partial left ventriculectomy and mitral valve repair for end-stage congestive heart failure. Eur J Cardiothorac Surg 1998;13:337-343.[Abstract/Free Full Text]
12. Izzat MB, Yim APC, Buckley T, Khaw KS, Sanderson JE, Angelini GD. Perioperative care in left ventricular volume reduction. J Cardiac Surg [in press].
13. Bolling S.F., Pagani F.D., Deeb G.M., Bach D.S. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg 1998;115:381-388.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohammad Bashar Izzat Sami S. Kabbani Hisayoshi Suma Kaushal Pandey Kiyofumi Morishita Anthony P.C. Yim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Izzat, M. B. Articles by Yim, A. P.C. Search for Related Content PubMed PubMed Citation Articles by Izzat, M. B. Articles by Yim, A. P.C.