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Ann Thorac Surg 2001;71:2046-2049
© 2001 The Society of Thoracic Surgeons

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How to do it

Left ventricular volume reduction without ventriculectomy

^a Institute for Cardiac Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom
^b Cardiovascular Research, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom

Accepted for publication January 13, 2001.

Address reprint requests to Dr Nair, Department of Cardiothoracic Surgery, D Floor, Jubilee Wing, Yorkshire Heart Centre, Leeds General Infirmary, Great George St, Leeds LS1 3EX, United Kingdom
e-mail: unair{at}ulth.northy.nhs.uk

	Abstract

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Partial left ventriculectomy (the Batista procedure) to achieve left ventricular volume reduction (LVVR) has been advocated as an alternative to cardiac transplantation in patients with end-stage dilated left ventricles. Here, we describe a new technique of LVVR that uses realignment of the papillary muscles, thus avoiding ventriculectomy, and report preliminary results. Eight patients (all male, mean age 49.3 [range 38 to 70] years) underwent LVVR between October 1998 and March 2000 as an adjunct to surgical coronary revascularization. Five were assessed with echocardiography and cardiopulmonary exercise testing before and after (mean follow-up time 267 [range 94 to 416] days) the operation. LVVR significantly improved left ventricular end-diastolic volume (254 ± 32 to 218 ± 36 mL, p = 0.03), left ventricular ejection fraction (20.14% ± 1.36% to 31.28% ± 2.32%, p = 0.007), and exercise duration (from 394 ± 88 to 611 ± 79 seconds, p = 0.03). A nonsignificant improvement in maximal oxygen consumption was also observed. This technique of LVVR is relatively simple to perform and is accomplished through a small apical cardiotomy. Preliminary results show an encouraging functional improvement following surgery. Future controlled studies are required to assess this novel technique further.

	Introduction

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Cardiac transplantation, an accepted treatment option for patients with end-stage cardiac failure, is limited by severe shortages of donor hearts. Other surgical options are critically needed. Batista and coworkers [1] first described left ventricular volume reduction (LVVR) for the treatment of dilated failing left ventricles in 1996. The Batista procedure involves resecting myocardium from left ventricular free wall to reduce wall tension according to the law of LaPlace. However, despite initial encouraging results, the process of partial ventriculectomy was not consistently associated with symptomatic benefit [2] and was not entirely free of technical problems [3]. Recently, questions have been raised regarding the resection of areas with viable myocardium during the procedure [4].

As an alternative to the resection of potentially viable myocardium, we have recently developed a new technique for LVVR without ventriculectomy. The technique involves graded plication of the papillary muscles through a small apical incision, thus avoiding ventriculectomy. The realignment of papillary muscles and the resultant volume reduction may lead to reversed remodeling of the left ventricle which, in theory, would enhance ventricular dynamics and exercise performance.

	Technique

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Patients
Eight patients (all male) with a mean age of 49.3 years (range 38 to 70) underwent LVVR without ventriculectomy, in addition to coronary artery bypass grafting (CABG), between October 1998 and March 2000. Mean follow-up time was 368 days (range 171 to 750). A subgroup of 5 patients underwent functional assessment. This consisted of measurements of left ventricular volumes (left ventricular end diastolic volume [LVEDD]) and left ventricular ejection fraction (LVEF) by two-dimensional echocardiography, and assessment of exercise capacity using treadmill exercise testing with measurement of gas exchange before and after their procedure (mean follow-up time 267 days, range 94 to 416). Medication did not change in the period of assessment.

Surgical technique
The patient is anesthetized in the supine position. Cardiopulmonary bypass is instituted with aortic and right atrial cannulation through a median sternotomy with systemic cooling to reach a nasopharyngeal temperature of 30°C. Coronary revascularization and valve repair or replacement is completed under cold blood cardioplegia arrest by the standard approach.

A 2.0 to 2.5 cm long incision is made in the anterolateral wall of the left ventricle near the apex, 2 cm away from the left anterior descending artery (Fig 1). The papillary muscles are identified and three Ethibond (0) sutures (Ethicon, Somerville, NJ) placed through the trabeculae around the bases of the anterior and posterior muscles (Fig 2), the deepest being just below the attachment of the chordae tendineae. These sutures are tied over a small piece of autologous pericardium achieving approximation without tension. The ventriculotomy incision is repaired with 3-0 Prolene (Ethicon, Somerville, NJ) sutures. Rewarming takes place on completion of surgical repair and bypass discontinued in the usual manner. In 1 patient who had a mitral valve replacement, the papillary muscles were approximated through the mitral orifice, thus avoiding ventriculotomy.

View larger version (126K): [in this window] [in a new window]   Fig 1. Photograph showing the small apical incision that is required for the surgery.

View larger version (64K): [in this window] [in a new window]   Fig 2. Schematic representation of graded plication of papillary muscles, resulting in left ventricular volume reduction.

During the exercise test, electrocardiogram, heart rate (HR), and blood pressure (BP) were monitored throughout. Rates of oxygen consumption (VO₂), carbon dioxide production (VCO₂) and other standard respiratory variables were recorded breath by breath using the Medgraphics CardiO₂ analytic system (Medgraphics, St. Paul, MN). Patients were encouraged to exercise to exhaustion, and their limiting symptom (eg, breathlessness, fatigue, or chest pain) was recorded.

Echocardiography
Two-dimensional images were obtained in standard views using an Accuson Sequoia system (Accuson, Mountain View, CA). Left ventricular volumes were calculated using standard techniques and LVEF was calculated by the area-length method.

Statistical analysis
Group data for continuous variables (exercise duration, maximal oxygen consumption [VO_2max], LVEF, LVEDD) are expressed as mean ± SEM. Differences between preoperative and postoperative values were compared using Student’s t test for paired samples. A value p less than 0.05 was considered statistically significant.

	Results

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All 8 patients had severe coronary artery disease causing their heart failure and 1 had mitral and tricuspid lesions. Five of them had previously sustained an anterior myocardial infarction. All patients underwent coronary revascularization with mammary artery and saphenous vein grafts (mean 2.3 grafts, range 1 to 4 grafts) in addition to their LVVR surgery, and 1 patient received mitral valve replacement and tricuspid repair. The mean aortic cross- clamp time was 43 minutes (range 36 to 87 minutes) and mean bypass time 158 minutes (range 107 to 300 minutes). Four patients with hemodynamic instability required intraaortic balloon pump support ([IABP] 2 requiring intraaortic balloon soon after anesthetic induction and 2 during the course of the operation) around the perioperative period. One patient died 13 days postoperatively with systemic infection and renal failure. For the other 7 patients, the mean intensive care stay was 1.6 days (range 1 to 4 days) and overall mean hospital stay was 9.3 days (range 7 to 14 days). One patient in atrial fibrillation for more than 14 months before surgery recovered sinus rhythm 7 months later.

Functional assessment
In the subgroup of 5 patients undergoing functional assessment, the mean (± SEM) LVEDD was significantly reduced from 254 ± 32 mL preoperatively to 218 ± 36 mL postoperatively (p = 0.03). This was accompanied by a significant improvement in mean LVEF (20.14% ± 1.36% to 31.28% ± 2.32%, p = 0.007). Mean exercise duration increased significantly by 55% (394 ± 88 seconds preoperatively to 611 ± 79 seconds postoperatively, p = 0.03), although a 13% increase in mean VO_2max did not achieve statistical significance (18.7 ± 1.6 mL · kg^-1 · min^-1 increasing to 21.1 ± 1.8 mL · kg^-1 · min^-1, p = 0.16). Figure 3 displays bar chart images in these categories for each individual patient. New York Heart Association (NYHA) functional classification was observed to improve from an average of class III preoperatively to an average of class I postoperatively.

View larger version (43K): [in this window] [in a new window]   Fig 3. (A) Changes in left ventricular ejection fraction in patients before and after left ventricular volume reduction (LVVR) surgery without ventriculectomy. (B) Changes in exercise duration in patients before and after LVVR surgery without ventriculectomy. (C) Changes in left ventricular end diastolic volume in patients before and after LVVR surgery without ventriculectomy. (D) Changes in maximal oxygen consumption (VO2) in patients before and after LVVR surgery without ventriculectomy. (LVEDV = left ventricular end diastolic volume; LVEF = left ventricular ejection fraction.)

	Comment

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Increasing distance between papillary muscles is a feature of dilated left ventricles. The surgical technique described above is based on the premise that papillary muscles could be used as a dynamic anchor to counter and prevent excessive dilatation of the left ventricle and to minimize functional mitral regurgitation. The resultant approximation of the papillary muscles would also reduce left ventricular circumferential diameter. This operation can be accomplished either through a small incision near the apex or through the mitral annulus in cases of mitral valve surgery, thereby avoiding trauma to the ventricular muscles.

The patient who died in this series had previously been turned down for cardiac transplantation. He came off bypass with intraaortic balloon support and was extubated 44 hours later. On the fourth postoperative day he developed systemic infection and died of septicemia and renal failure 9 days later.

Our preliminary results are promising although they need to be interpreted with caution owing to the small number of patients assessed. The most significant finding was the more than 50% increase in exercise duration. It is also difficult to separate out the effects of myocardial revascularization from the benefits of volume reduction and how much the observed improvements were due to myocardial revascularization alone.

This method of left ventricular volume reduction is relatively simple to perform with low mortality and has been observed to result in clinical, echocardiographic, and functional improvements. It can be accomplished through a limited incision without sacrificing viable myocardium. It may, in theory, decrease wall tension (according to LaPlace’s law) thereby enhancing myocardial contractile function and ventricular pumping capability. Further studies are required to investigate whether this operation is a surgical option for selected patients with dilated failing left ventricles, who would otherwise be considered inoperable. A controlled study needs to be performed comparing this technique with that of sole coronary bypass surgery, to assess the effect of the volume reduction surgery alone.

	References

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1. Batista R.J.V., Santos J.L.V., Takeshita N., et al. Partial left ventriculectomy to improve left ventricular function in end-stage heart disease. J Cardiovasc Surg 1996;11:96-107.
2. Izzat M.B., Kabbani S.S., Suma H., Pandey K., Morishita K., Yim A.P. Early experience with partial left ventriculectomy in the Asia-Pacific region. Ann Thorac Surg 1999;67:1703-1707.[Abstract/Free Full Text]
3. Cury P.M., Higuchi M.L., Gutierrez P.S., et al. Autopsy findings in early and late postoperative death after partial left ventriculectomy. Ann Thorac Surg 2000;69:769-773.[Abstract/Free Full Text]
4. Moreira L.F., Stolf N.A., 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]
5. Cooke G.A., Marshall P., Al-Timman J.K., Wright D.J., Riley R., Tan L.B. Physiological cardiac reserve; development of a non-invasive method and first estimates in man. Heart 1998;79:289-294.[Abstract/Free Full Text]
6. McDonagh T.A., Morrison C.E., Lawrence A., et al. Symptomatic and asymptomatic left ventricular systolic dysfunction in an urban population. Lancet 1997;350:829-833.[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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nair, R. U. Articles by Tan, L.-B. Search for Related Content PubMed PubMed Citation Articles by Nair, R. U. Articles by Tan, L.-B. Related Collections Cardiac - other Congestive Heart Failure