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Ann Thorac Surg 2001;72:1446-1447
© 2001 The Society of Thoracic Surgeons
a Siyami Ersek Thoracic and Cardiovascular Surgery Center, Department of Cardiovascular Surgery, 
stanbul, Turkey
b Siyami Ersek Thoracic and Cardiovascular Surgery Center, Department of Anesthesiology, stanbul, Turkey
e-mail: ckonuralp{at}usa.net
To the Editor
We read the recent article by Raman and coworkers [1] with great interest. We have some questions and some comments.
The authors produced cardiac remodeling by using synthetic material in patients who were candidates for revascularization and surgical ventricular remodeling. After standard coronary artery bypass grafting and a geometric endoventricular repair, a synthetic graft was placed around both ventricles to prevent ventricular dilatation. Five patients underwent ventricular containment in this manner. There was no control group. Without such a comparison, it is very hard to analyze the effectiveness of the technique. Would the result have been the same if the patients had undergone only the standard procedure?
In 4 of the 5 patients, left ventricular diameter and wall tension were reduced using a technique similar to the Batista procedure. It is possible that the early recovery of these patients is solely due to the reduced diameter of the ventricle. This idea is supported by the postoperative data, which are very similar to those after the Batista procedure as reported by Moreira and colleagues [2].
According to the results obtained by Raman and colleagues [1], treadmill test and ejection fraction improved slightly but not significantly so by the sixth postoperative month. How do the authors explain the observed improvement from New York Heart Association class III to class I?
Raman and associates did not mention whether or not complete revascularization was achieved in patients with coronary artery disease. Could undetected incomplete revascularization be a contributing factor to ventricular dilatation after 3 months?
One of the main purposes of cardiac binding is to limit progression of dilatation [3]. However, it is not clear how much pressure was produced by wrapping the ventricles with synthetic material. Takagi and coauthors [4] showed that wrapping is not effective if the pressure exerted on the ventricle is too high or too low; low pressure does not prevent dilatation and high pressure decreases stroke volume and intraventricular pressure. This group suggested that an intrapericardial pressure (ie, in the space between the synthetic material and the epicardium) of 10 mm Hg is ideal. Did Dr Raman and colleagues measure wrapping tension? Would it be better to wrap the ventricles more tightly than they did?
In the study of Dr Raman and associates, left ventricular end-diastolic diameter decreased significantly in the first postoperative month, but at 3 months postoperatively, it had increased. Thus, this variable approaches preoperative values in patients after 3 months. How do the authors explain this progression?
We share the optimism of Dr Raman and his coauthors about ventricular containment. However, we believe that more organized, prospective studies are needed to test the effectiveness of the procedure.
References
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  A. Lembcke, S. Dushe, S. Sonntag, C. Kloeters, C. N. H. Enzweiler, T. H. Wiese, B. Hamm, F.-X. Kleber, and W. F. Konertz Changes in right ventricular dimensions and performance after passive cardiac containment Ann. Thorac. Surg., September 1, 2004; 78(3): 900 - 905. [Abstract] [Full Text] [PDF]
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