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Ann Thorac Surg 2000;69:1257-1259
© 2000 The Society of Thoracic Surgeons

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CASE REPORTS

Late ventricular structure after partial left ventriculectomy

^a University Hospital, Münster, Germany
^b Institute of Numerical Mathematics, Münster, Germany
^c National Heart and Lung Institute, Imperial College School of Medicine, London, England, United Kingdom
^d Fundação do Coração Vilela Batista, Curitiba, Brazil

Address reprint requests to Dr Lunkenheimer, Klinik und Poliklinik für Thorax-, Herz- und Gefäßchirurgie, Experimentelle Thorax-, Herz- und Gefäßchirurgie, Domagkstr 11, D-48129 Münster, Germany
e-mail: redmann{at}uni-muenster.de

	Abstract

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Nine months after partial ventriculectomy, a 53-year-old man died of progressive heart failure. His heart was examined to determine the alignment of the muscle fibers around the ventricular scar, which was 11 cm long, 1.3 cm thick and 4 cm wide. The scar reached 2 to 12 mm beyond the surgical suture line. The fibers in the middle and subendocardial layers were malaligned, resulting in convergence, compression and regional necrosis.

	Introduction

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Recently, the technique of partial left ventriculectomy has been suggested as a surgical treatment for patients in severe cardiac failure due to dilated cardiomyopathy [1, 2]. It consists of surgical resection of an extended, essentially asymmetrical wedge of muscle from the left ventricular wall. The intervention is designed to reduce ventricular diameter, with the aim of ameliorating wall stress [3, 4].

This operation is a new procedure with little scientific basis, thus far. We have now had the opportunity to study a single postoperative specimen, and have used this material to reconstruct the consequences of the procedure in terms of myocardial structure.

We examined the heart of a 53-year-old man who survived for 9 months after partial ventriculectomy in the Hospital Angelina Caron in Curitiba, Brazil. The patient ultimately died of refractory heart failure. Attempts to reanimate him using external massage were unsuccessful. Before intervention, it was known that the patient had consumed excessive amounts of alcohol over several years, and alcoholic cardiomyopathy was deemed the reason for his cardiac failure, New York Heart Association stage IV. After intervention, the patient improved to grade II. Unfortunately, he was unable to abstain from alcohol, and eventually died of grade IV heart failure. The heart, weighing 430 g, was fixed in formaldehyde (10%) for 30 days. After fixation, it measured 12 cm from base to apex, was 12 cm wide at the base, and 9 cm in diameter at the equatorial plane.

Dissection was achieved by peeling off strands, in a layered sequence, using watchmaker’s tweezers [5]. Special care was devoted to the area around the ventricular scar.

Quantitation was achieved by digitizing the alignment of fibers using an electromagnetic system (3 Draw Digitizer, Polhemus, Cochester, VT). A stylus was employed to follow, by hand, the exposed surfaces of the fibers [6] after peeling off layers of strands.

A protruding scar (11-cm long) was found taking a slightly curvilinear course from the left ventricular apex to two-thirds of the ventricular height (Fig 1). The scar was directly adjacent to the left anterior descending artery. Its distal end crossed to the inferior aspect of the apex. Its central portion was 1.3 cm thick. The exposed central part was only 2 cm wide. After progressive removal of the myocardium, the scar was seen to reach its full width of 4 cm near the endocardium. Here, the scar stretched from 2 to 12 mm beyond the transmural surgical suture. The scar was at its largest width in the inferior lip of the incision, near to the base. In the superior lip, close to the apex, the scar was continuous with an area of septal infarction.

View larger version (80K): [in this window] [in a new window]   Fig 1. (Left) The surgical scar on the sternocostal surface of the left ventricle is shown from the left anterior side. The superficial contractile pathways are peeled off. The originally circular pathways are displaced, ascending here from the lateral apex to the septal base. Note the marked widening of the scar into the basal inferior lip of the wound. (Right) Alignment of the contractile pathways in three layers of the normal (upper) and the volume reduced left ventricle (lower); the scar is encircled.

View larger version (64K): [in this window] [in a new window]   Fig 2. The oyster-shaped excision from the free wall of the left ventricle (left) before adaptation of the two lips of the wound and (right) after the surgical suture is adapted. The basal and apical edges are indicated which delineate the two lips. Note the ascending and converging alignment of the contractile pathways in the inferior lip of the wound.

	Comment

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Partial left ventriculectomy remodels ventricular size and shape, irrespective of the fine structure of the ventricular wall [1]. In consequence of the surgical adaptation of the two unevenly spaced lips of the incision, the fibers in the inferior lip of the wound are kept in a state of oblique ascending displacement. Furthermore, using the oyster technique of resection, the longer inferior lip of the wound is adapted to the shorter anterosuperior lip, by necessity compressing the inferior margin. The extension of the scar beyond the suture line is presumably caused by the convergence of fibers. Indeed, we found that the scar extended to the greatest extent in that area where the convergence of fibers was most obvious. After 9 months of survival, however, there was no discernable evidence of realignment of fibers to the normal pattern.

We recognize that this study is no more than an introductory investigation, based on a single case. The acquisition of hearts from those patients who die after partial ventriculectomy, however, is becoming more and more difficult for ethical reasons. Because of this, it is important to document all morphologic evidence pertaining to this newly emerging technique.

	Acknowledgments

 
Supported by Deutsche Forschungsgemeinschaft, Bundesministerium für Bildung und Forschung und Ernst und Berta Grimmke Stiftung. Robert H. Anderson and Siew Yen Ho are supported by the British Heart Foundation, together with the Joseph Levy Foundation.

	References

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1. Batista R.J.V., Verde J., Nery P., et al. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg 1997;63:634-638.[Abstract/Free Full Text]
2. McCarthy P.M., Starling R.C., Wong J., Scalia G.M., Buda T., Vargo R.L. Early results with partial left ventriculectomy. J Thorac Cardiovasc Surg 1997;114:755-765.[Abstract/Free Full Text]
3. Dickstein M.L., Spotnitz H.M., Rose E.A., Burckhoff D. Heart reduction surgery. An analysis of the impact on cardiac function. J Thorac Cardiovasc Surg 1997;113:1032-1040.[Abstract/Free Full Text]
4. Ratcliffe M.B., Hong J., Salahieh A., Ruch S., Wallace A.W. The effect of ventricular volume reduction surgery in the dilated poorly contractile left ventricle. J Thorac Cardiovasc Surg 1998;116:566-577.[Abstract/Free Full Text]
5. Anderson RH, Becker AE. The orientation of fibres within the ventricular mass. In: Anderson RH, Becker AE, eds. Cardiac anatomy. London: Churchill Livingstone, 1980:5.14–26.
6. Sanchez-Quintana D., Garcia-Martinez V., Hurle J.M. Myocardial fibre architecture in the human heart. Acta Anatomica 1990;138:352-358.[Medline]
7. Lunkenheimer P.P., Redmann K., Dietl K.H., et al. The heart’s fibre alignment assessed by comparing two digitizing systems. Methodological investigation into the inclination angle towards wall thickness. Technol Health Care 1997;5:65-78.[Medline]

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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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert H. Anderson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lunkenheimer, P. P. Articles by Batista, R. V. Search for Related Content PubMed Articles by Lunkenheimer, P. P. Articles by Batista, R. V.