HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Sérgio A. Oliveira Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Benício, A. Articles by Oliveira, S. A. Search for Related Content PubMed PubMed Citation Articles by Benício, A. Articles by Oliveira, S. A. Related Collections Mechanical Circulatory Assistance

Ann Thorac Surg 2003;76:821-827
© 2003 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Reevaluation of long-term outcomes of dynamic cardiomyoplasty

^a Heart Institute (Incor), São Paulo University Medical School, São Paulo, Brazil

Accepted for publication March 13, 2003.

^* Address reprint requests to Dr Moreira, Heart Institute (Incor), University of São Paulo Medical School, Av. Dr. Enéas Carvalho Aguiar, 44-2° Level, Block 2, Room 13, São Paulo SP, Brazil 05403-000
e-mail: dcimoreira{at}incor.usp.br

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
BACKGROUND: Palliative procedures have been proposed for treatment of dilated cardiomyopathies. This study analyzes long-term outcomes of 43 patients who underwent dynamic cardiomyoplasty.

METHODS: Patients were in New York Heart Association class III (n = 35) or IV (n = 8) before the procedure. Hospital mortality was 2.2%, and patients were followed for 44 ± 33 months. Thirty-nine patients completed the skeletal muscle adaptation period, and the muscle flaps were stimulated to contract in concert with every cardiac beat (n = 27) or with every other beat (n = 12).

RESULTS: One-year event-free survival was 81.3% ± 5.9%; 2-year, 65.1% ± 7.2%; 5-year, 34.7% ± 7.2%; and 9-year, 10.8% ± 5.3%. Causes of late deaths were equally divided between progressive heart failure and arrhythmia-related events. Multivariable Cox proportional hazard regression identified that functional class IV, high pulmonary vascular resistance, and muscle flap stimulation synchronized to every cardiac beat were independent predictors of poor event-free survival. The same factors were associated with the occurrence of progressive heart failure, but none was a predictor of arrhythmia-related deaths. Five-year survival of patients maintained with the muscle flap stimulated at every other cardiac beat was 58.3% ± 14.2%. Skeletal muscle stimulation protocols also influenced the long-term behavior of left ventricular ejection fraction.

CONCLUSIONS: Long-term results of dynamic cardiomyoplasty are limited by the patient’s preoperative condition and by a high incidence of sudden cardiac death. These results may be improved using modified skeletal muscle stimulation protocols and cardioverter-defibrillator implantation, while maintaining dynamic cardiomyoplasty as an option for selected patients.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
In the last decade, dynamic cardiomyoplasty was cautiously investigated by several authors as an alternative treatment for patients with advanced cardiomyopathies [1–4]. This procedure improves left ventricular function and ameliorates congestive heart failure. Nevertheless, its clinical application is limited for patients operated on in New York Heart Association functional class III, and comparative studies failed to demonstrate survival improvement against medical therapy [1, 5, 6]. Furthermore, long-term results of this procedure may be limited by high incidences of sudden cardiac death and by the decrease of the power production of the skeletal muscle graft with time [4]. On the other hand, it does not seem yet to be the time to have dynamic cardiomyoplasty relegated only to an interesting idea, rather than a legitimate alternative treatment for patients with dilated cardiomyopathies. Technological advances incorporated in the myostimulators and a better knowledge about the mechanisms of action of the procedure or regarding the late response of the skeletal muscle to electrical stimulation should potentially improve early and long-term performances of dynamic cardiomyoplasty.

In this study, we investigated the influence of preoperative variables and technical aspects of dynamic cardiomyoplasty, including the stimulation regimen applied to the skeletal muscle flap, on 10-year outcomes of 43 patients operated on for treatment of idiopathic or ischemic dilated cardiomyopathies. Predictors of progressive heart failure and sudden cardiac death were also identified.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patient population
Dynamic cardiomyoplasty was indicated by the Heart Failure Program of the Heart Institute (InCor), São Paulo University Medical School, for patients with severe dilated cardiomyopathies and significant functional limitation despite attempts to optimize medical therapy. They also had reduced left ventricular function characterized by radioisotopic ejection fraction of less than 0.26 and persistently high filling pressures. Patients using intravenous inotropic drugs were contraindicated for cardiomyoplasty, as well as those with complex or intractable arrhythmias, left ventricular chamber greater than 50 mm/m², pulmonary vital capacity less than 55%, and any life-threatening noncardiac disease. Medical or psychosocial contraindications to heart transplantation were present or this procedure was refused by the patients. Informed consent according to our ethical and scientific review board was obtained after discussion of risks, alternatives, and perceived benefits of the operation.

Accordingly, 43 patients (79% men, 44 ± 9 years; range, 18 to 63 years) underwent dynamic cardiomyoplasty between May 1988 and September 1997. Patients were in New York Heart Association functional class III (n = 35) or IV (n = 8) owing to idiopathic (n = 39) or ischemic (n = 4) dilated cardiomyopathies. They also had heart failure of at least 1 year’s duration and had being hospitalized at least once in the last 6 months for heart failure treatment. Preoperative left ventricular ejection fractions, documented by radioisotopic angiography, ranged from 0.13 to 0.25 (mean, 0.193). Patients also presented with a mean pulmonary wedge pressure of 23 ± 6 mm Hg and mean cardiac index of 1.98 ± 0.75 L · min^-1 · m^-2 at heart catheterization. Eight patients had atrial fibrillation, and 26 had nonsustained ventricular tachycardia episodes on Holter monitoring. One patient had moderate and 17 had mild mitral insufficiency on two-dimensional echocardiography. Significant one-vessel coronary artery compromise was shown in 2 patients.

Surgical procedure
Dynamic cardiomyoplasty was performed by means of separate incisions: a lateral approach for muscle flap dissection and a median sternotomy for cardiac access. Dissection and transposition of left latissimus dorsi muscle followed the technique described by Carpentier and colleagues [7]. The muscle flap was wrapped around the ventricular surfaces, providing a left posterior cardiocostal wrapping. Two intramuscular pacing electrodes were implanted in the skeletal muscle graft, and an epimyocardial sensing lead was placed in either the right or the left ventricle. Implantation of the Medtronic SP1005 and Medtronic Transform 4710 cardiomyostimulators (Medtronic Inc, Minneapolis, MN) finalized the surgical procedure. Associated techniques were necessary in 3 patients. One patient with moderate mitral regurgitation underwent mitral valve annuloplasty under normothermic extracorporeal circulation without cardiac arrest. Coronary artery bypass grafting with a saphenous vein was performed without extracorporeal circulation to the left anterior descending artery or to the right coronary artery in the other 2 patients. These patients presented stenosis of 80% and 90% of these coronary arteries, respectively, without other important associated lesions.

Electrical stimulation of the skeletal muscle flap followed the protocol proposed by Chachques and associates [7]. After the muscle-conditioning period, the first 27 patients who completed that period had the muscle flap predominantly maintained with 1:1 stimulation in relation to the heart rate. The other 12 patients who concluded the muscle-conditioning period had the left latissimus dorsi muscle constantly stimulated in concert with every other cardiac beat (1:2 mode). The delay between the ventricular sensed event and the muscle burst was adjusted to provide an exact synchronization between the muscle flap and ventricular systole.

Clinical follow-up outcomes
None of the patients were lost to follow-up, which was performed at the Heart Failure Clinic of the Heart Institute. Mean follow-up was 44.3 ± 33.1 months and encompassed 158.7 patient-years. The longest follow-up extended to 10 years.

Patients were studied every 3 months during the first year of follow-up and every 6 months thereafter. They continued to use digoxin, diuretics, vasodilators, and angiotensin-converting enzyme inhibitors. More recently, ß-adrenergic blockers were introduced in 7 patients. Three of these patients had the muscle flap stimulated at every cardiac beat, whereas the muscle flap was stimulated at every other cardiac beat in 4 patients.

The end points considered in this study were mortality owing to all causes and heart transplantation. The earliest of these end points accounted for the event-free survival. Cumulative mortality and event rates with time were determined by the nonparametric Kaplan-Meier method.

Predictors of follow-up outcomes
Exploratory analysis of preoperative and procedure-related variables, including correlation analysis, preceded the multivariable analyses of outcomes. Potential preoperative risk factors were screened among clinical data, echocardiographic and radioisotopic assessment of left ventricular function, hemodynamic measures, and cardiac rhythm disturbances. The variables related to dynamic cardiomyoplasty procedure were the percentage of the external ventricular wall wrapped by the skeletal muscle graft and the occurrence of muscle flap ischemia at the immediate postoperative period, which was evidenced in 6 patients by elevated creatine kinase enzyme serum levels (equal or greater than 1,500 IU), associated with the absence of muscle graft contraction at radioscopic examination. The synchronization ratio predominantly used for long-term stimulation of the skeletal muscle flap was also included as a procedure-related variable.

Multivariable analyses were performed sequentially, first considering baseline preoperative data and procedure-related variables thereafter. The multivariable models were calculated by stepwise Cox proportional hazard regression. The p value criterion for retention of variables in the final models was 0.1. The differences between the event rates with time according to the independent predictors of event-free survival were assessed by the log-rank test. Logistic regression was used to calculate the relationship between continuous variables and 5-year mortality or necessity of heart transplantation.

Left ventricular function noninvasive evaluation
Left ventricular ejection fraction was routinely investigated until the fifth postoperative year by means of radioisotopic angiography. This evaluation was obtained after in vivo labeling of red blood cells by technetium 99m. Gated blood pool imaging was acquired in the left oblique view with a Siemens model LEM+ camera (Siemens Corp, Union, NJ). The images were analyzed in a Microvax model 3300 computer (Siemens).

Repeated left ventricular ejection fraction measures for at least 3 years of follow-up were obtained from 12 patients who had the muscle graft predominantly stimulated in 1:1 mode with the heart rate and in 10 patients whose skeletal muscle flap was synchronized to contract in concert with every other cardiac beat (1:2 mode). One-way and two-way analyses of variance, complemented by Bonferroni tests, were used to compare data obtained before and after the procedure in each group and between them, respectively. Values of p less than 0.05 were considered significant.

Statistical data presentation
Mean values are presented ± 1 standard deviation, whereas confidence levels for proportions are 68%, corresponding to 1 standard error. All data were analyzed by Statistical Package for Social Sciences (SPSS) software (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Clinical outcomes
There was 1 hospital death (2.3%) as a result of pulmonary infection and acute ventricular failure after dynamic cardiomyoplasty. Urgent heart transplantation was successfully performed in 1 patient with acute ventricular failure. During the muscle-conditioning period, 2 other patients died as a result of multiorgan failure or pulmonary thromboembolism, associated with decompensation of heart failure.

During the late follow-up, 30 patients died, and the survival rates were 83%, 69%, 38%, and 12% at 1, 2, 5, and 9 years, respectively. Two additional patients underwent heart transplantation long-term after the operation; thus the event-free survival was 81%, 65%, 35%, and 11% at the same periods, as shown in Figure 1. The causes of death were related to progressive heart failure in 14 patients, and 16 patients died suddenly or because of incessant ventricular tachycardia. The hazard function for death or heart transplantation because of progressive heart failure was 1%/mo during the first 3 years of follow-up and declined to 0.3%/mo thereafter. On the other hand, a constant hazard rate of 0.7%/mo was observed in relation to sudden cardiac death.

View larger version (17K): [in this window] [in a new window]   Fig 1. Kaplan-Meier estimates of the probability of event-free survival after dynamic cardiomyoplasty. Numbers indicate patients at risk at each time.

View larger version (17K): [in this window] [in a new window]   Fig 2. Kaplan-Meier estimates of the probability of event-free survival after dynamic cardiomyoplasty according to preoperative New York Heart Association functional class (F.C.). (Circles = F.C. IV; squares = F.C. III.)

View larger version (17K): [in this window] [in a new window]   Fig 3. Kaplan-Meier estimates of the probability of event-free survival after dynamic cardiomyoplasty according to preoperative pulmonary vascular resistance (PVR) values measured as dyne · s · cm-5. (Circles = PVR is greater than 266; squares = PVR is less than or equal to 266.)

View larger version (16K): [in this window] [in a new window]   Fig 4. Estimates of the probability of 5-year event-free survival after dynamic cardiomyoplasty according to preoperative pulmonary vascular resistance (PVR) values measured as dyne · s · cm-5.

View larger version (17K): [in this window] [in a new window]   Fig 5. Kaplan-Meier estimates of the probability of event-free survival after dynamic cardiomyoplasty according to skeletal muscle flap stimulation mode. (Circles = 1:1 mode; squares = 1:2 mode.)

Long-term durability of left ventricular function improvement
Table 2 shows the long-term behavior of left ventricular ejection fraction after dynamic cardiomyoplasty. In patients maintained with skeletal muscle flap stimulation at 1:1 mode, this variable increased significantly in relation to preoperative data at 6 months of follow-up. Nevertheless, left ventricular ejection fraction tended to decrease after the first year and returned to preoperative levels at 5 years. Otherwise, the improvement of this variable became significant only at 1 year of follow-up in patients with the muscle flaps stimulated to contract in concert with every other cardiac beat. In addition, left ventricular ejection fraction values were superior to their preoperative levels in those patients at all periods. Despite these contrasts, the difference of the long-term behavior of this variable between the two groups was not statistically significant (p = 0.236).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Dynamic cardiomyoplasty improves left ventricular function by the direct action of synchronized skeletal muscle flap contraction and from a girdling effect that helps to reverse chamber remodeling and to decrease ventricular wall stress [4]. This improvement is responsible for left ventricular ejection fraction increases from 0.15 to 0.40 in relation to preoperative data. Besides these effects, another mechanism of action of this procedure is the possibility of cross-revascularization between the skeletal muscle flap and the ventricular epicardium in patients with ischemic cardiomyopathy [2, 4]. These influences on left ventricular function justify the clinical improvement consistently reported in dynamic cardiomyoplasty follow-up. This positive impact on the clinical status may be evaluated by the significant modifications on quality-of-life measures documented in multicenter studies [3, 8] and by the important decrease in patients’ hospitalizations caused by progressive heart failure [2, 4]. Furthermore, quality-of-life modifications were significantly better in patients who underwent dynamic cardiomyoplasty than in those maintained on medical therapy in the US Food and Drug Administration arm of the Medtronic Phase 2 trial [8] or in the C-Smart study [6].

On the other hand, dynamic cardiomyoplasty is not definitely accepted as an alternative treatment for dilated cardiomyopathies to date. This fact is related to the lack of a clear survival advantage against medical therapy [5, 6], to the limitations of its application in patients with critical left ventricular function compromise, and to the possibility of skeletal muscle flap long-term deterioration [4, 10, 11].

Regarding the long-term modifications of the skeletal muscle flap, the present investigation indicates that better preservation of the functional performance of the muscle graft may be chronically obtained with low stimulation rates, leading to a consequent stability of left ventricular function benefits. This fact was demonstrated by maintenance of left ventricular ejection fraction values for up to 5 years of follow-up in patients with the muscle flap stimulated in concert with every other cardiac beat. Furthermore, skeletal muscle stimulation at lower rates was also responsible for a significant improvement of long-term survival with dynamic cardiomyoplasty, which achieved values of approximately 58% at 5 years and 43% at 8 years of follow-up. The influence of skeletal muscle-stimulation protocol on the outcomes of this procedure was previously suggested by comparison of the long-term results of patients who chronically underwent skeletal muscle flap stimulation in concert with every cardiac beat in our early experience [11] and those of other series that used the muscle flap stimulation synchronized with every other cardiac beat [2, 4]. Several studies suggested that impairment of muscle flap blood flow is the principal cause for deterioration of skeletal muscle integrity after dynamic cardiomyoplasty [12, 13]. The structural compromise of the skeletal muscle flap subjected to excessive stimulation includes decrease of muscle flap thickness and a major amount of fat tissue infiltration, which are significantly related to the follow-up time [10]. This fact was identified in autopsy studies [4, 10] and by in vivo evaluation of skeletal muscle flap integrity using computed tomographic scanning [4]. Among several ideas proposed to improve the performance of the skeletal muscle flap long term, positive results have also been documented with the use of adaptive pulse train durations [12] and activity-rest stimulation protocols [14, 15].

Besides the influence of skeletal muscle stimulation on patients’ long-term survival after dynamic cardiomyoplasty, this study also identified preoperative functional class IV and elevated pulmonary vascular resistance as independent predictors of higher mortality and necessity of heart transplantation. The same factors were previously recognized by other studies with shorter follow-up [2, 16, 17]. Additional factors that also seem to have a significant impact on 5-year mortality after this procedure are Chagas disease cardiomyopathy [17], presence of atrial fibrillation [16], and peak oxygen consumption at treadmill test of less than 10 mL · kg^-1 · min^-1 [16].

Causes of long-term mortality after dynamic cardiomyoplasty have been equally divided between progressive heart failure and arrhythmia-related events [4]. Regarding the predictors of progressive heart failure, occurrence of deaths or necessity of heart transplantation caused by this complication were also related to the skeletal muscle-stimulation protocol and to the preoperative clinical compromise in this study. Otherwise, no predictor was identified for sudden cardiac death. The role of preexisting atrial fibrillation and nonsustained ventricular tachycardia on the occurrence of this event remains controversial in patients with dilated cardiomyopathies, and the absence of significant influence of these factors on the current dynamic cardiomyoplasty outcomes could be explained by the limited number of patients involved in the study. On the other hand, sudden cardiac death was similarly observed in patients with or without significant improvement of left ventricular function after dynamic cardiomyoplasty, whose occurrence was not influenced by any cardiac rhythm disturbance in our experience [4]. Furthermore, comparable incidences of sudden cardiac death have also been reported in the long-term follow-up of other palliative interventions, such as isolated correction of mitral valve insufficiency [18] and partial left ventriculectomy [19]. Despite these findings, this important limitation for any palliative procedure in the treatment of dilated cardiomyopathies should be dramatically reduced with the implantation of automatic cardioverter-defibrillators, as recommended by several authors [19–21].

Dynamic cardiomyoplasty may also be associated with other surgical approaches to improve the outcomes of palliative interventions in patients with dilated cardiomyopathies. This improvement could be obtained on the basis of association of different mechanisms of action, as the correction of atrioventricular valve insufficiency, ventricular volume reduction, active support for myocardial contraction, and ventricular containment. In this regard, successful associations of dynamic cardiomyoplasty with mitral insufficiency correction or left ventricular volume reduction operations were described [4]. Furthermore, the importance of ventricular containment to halt the progressive remodeling process has also been evaluated with the use of a passive cardiac constraint device in association with mitral insufficiency correction [22].

Regarding dynamic cardiomyoplasty perspectives, it is also important to emphasize that this procedure associates the ventricular containment effect with an active action of synchronized skeletal muscle flap contraction on left ventricular systolic function. The diastolic girdling effect of dynamic cardiomyoplasty, which helps to reverse chamber remodeling, was clearly demonstrated by Kass and associates [23]. Similar changes have also been consistently reported by Konertz and coworkers [22], using the Acorn cardiac support device, whose clinical experience has shown statistically significant improvements of left ventricular ejection fraction, associated with a reduction in heart size. On the other hand, the relevance of active contraction of the skeletal muscle flap was clearly demonstrated by several authors. Studies performed long term after dynamic cardiomyoplasty documented significant changes in left ventricular ejection fraction, shape, and pressure-volume relationships comparing results obtained under stimulated and nonstimulated beats [24], or with the myostimulator turned on and off [4, 25].

In conclusion, based on the marked improvement of the long-term performance of the skeletal muscle graft obtained with better stimulation protocols, the use of dynamic cardiomyoplasty continues to be justified as an alternative treatment for patients with dilated cardiomyopathies. Although many functional class III patients can be managed effectively with medical therapy alone, there are clearly several of them whose quality of life and exercise capacity have worsened, justifying the indication of a safe surgical procedure. Furthermore, dynamic cardiomyoplasty may be associated with other procedures, and its benefits may represent only a single aspect of a more aggressive palliative approach for the treatment of refractory heart failure. This approach may include sustained improvement of left ventricular function, interruption of the progressive remodeling process, and prevention of sudden cardiac death. Nevertheless, whether we will see a renewed interest of the industry in further developments of dynamic cardiomyoplasty is uncertain, but the focus on this procedure continues to be strongly justified by its mechanisms of action.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Acker M.A. Dynamic cardiomyoplasty: at the crossroads. Ann Thorac Surg 1999;68:750-755.[Abstract/Free Full Text]
2. Chachques J.C., Marino J.P., Lajos P., et al. Dynamic cardiomyoplasty: clinical follow-up at 12 years. Eur J Cardiothorac Surg 1997;12:560-567.[Abstract]
3. Jessup M. Dynamic cardiomyoplasty: expectations and results. J Heart Lung Transplant 2000;19(Suppl):S68-S72.[Medline]
4. Moreira L.F.P., Stolf N.A.G. Dynamic cardiomyoplasty as a therapeutic alternative: current status. Heart Fail Rev 2001;6:201-212.[Medline]
5. Furnary A.P., Jessup M., Moreira L.F.P. Multicenter trial of dynamic cardiomyoplasty for chronic heart failure. The American Cardiomyoplasty Group. J Am Coll Cardiol 1996;28:1175-1180.[Abstract]
6. Young JB, Kirklin JK. Cardiomyoplasty-skeletal muscle assist randomized trial (C-SMART): 6 month results (abstract). Circulation 1999;100(Suppl 1):I-514.
7. In: Carpentier A., Chachques J.C., Grandjean P.A., eds. Cardiomyoplasty. Mount Kisco, NY: Futura Publishing, 1991.
8. Furnary A.P., Swanson J.S., Grunkemeier G., Starr A. Lessons learned before and after cardiomyoplasty: risk sensitive patient selection and post procedure quality of life. J Card Surg 1996;11:200-206.[Medline]
9. Chachques J.C., Argyriadis P.G., Latremouille C., et al. Cardiomyoplasty. Ventricular reconstruction after tumor resection. J Thorac Cardiovasc Surg 2002;123:889-894.[Abstract/Free Full Text]
10. Gutierrez P.S., Pires W.O., Jr, Marie S.K., et al. Histopathological findings in skeletal muscle used in human dynamic cardiomyoplasty. J Pathol 2001;194:116-121.[Medline]
11. Moreira L.F.P., Stolf N.A.G., Bocchi E.A., et al. Clinical and left ventricular function outcomes up to five years after dynamic cardiomyoplasty. J Thorac Cardiovasc Surg 1995;109:353-362.[Abstract/Free Full Text]
12. Gealow K., Solien E., Bianco R., Grandjean P. Effect of adaptive pulse train duration on latissimus dorsi blood flow. Artif Organs 1997;21:243-246.[Medline]
13. Van Doorn C.A., Bhabra M.S., Hopkinson D.N., Barman D., Cranley J.J., Hooper T.L. Latissimus dorsi muscle blood flow during synchronized contraction: implications for cardiomyoplasty. Ann Thorac Surg 1996;61:603-609.[Abstract/Free Full Text]
14. Kashem A., Santamore W.P., Chiang B., Unger L., Ali A.T., Slater A.D. Vascular delay and intermittent stimulation: keys to successful latissimus dorsi muscle stimulation. Ann Thorac Surg 2001;71:1866-1873.[Abstract/Free Full Text]
15. Rigatelli G., Carraro U., Barbiero M., et al. Activity-rest stimulation protocol improves cardiac assistance in dynamic cardiomyoplasty. Eur J Cardiothorac Surg 2002;21:478-482.[Abstract/Free Full Text]
16. Furnary A.P., Chachques J.C., Moreira L.F.P., et al. Long-term outcome, survival analysis, and risk stratification of dynamic cardiomyoplasty. J Thorac Cardiovasc Surg 1996;112:1640-1649.[Abstract/Free Full Text]
17. Moreira L.F.P., Stolf N.A.G., Braile D.M., Jatene A.D. Dynamic cardiomyoplasty in South America. Ann Thorac Surg 1996;61:408-412.[Abstract/Free Full Text]
18. Badhwar V., Bolling S.F. Mitral valve surgery: when is it appropriate?. Congest Heart Fail 2002;8:210-213.[Medline]
19. Moreira L.F.P., Stolf N.A.G., Higuchi M.L., Bacal F., Bocchi E.A., Oliveira S.A. Current perspectives of partial left ventriculec-tomy in the treatment of dilated cardiomyopathy. Eur J Cardiothorac Surg 2001;19:54-60.[Abstract/Free Full Text]
20. Chekanov V.S., Deshpande S. Cardioverter-defibrillator implantation to safeguard against fatal arrhythmias in cardiomyoplasty patients. Basic Appl Myol 1999;9:187-194.
21. Lorusso R., Marchini A., Bianchetti F., Curnis A., Visioli O., Zogno M. Cardiomyoplasty and implantable cardioverter defibrillator: efficacy and safety of concomitant device implantation: sudden death and cardiomyoplasty. J Card Surg 1998;13:150-155.[Medline]
22. Konertz W.F., Shapland J.E., Hotz H., et al. Passive containment and reverse remodeling by a novel textile cardiac support device. Circulation 2001;104(Suppl):I-270-I-275.
23. Kass D.A., Baughman K.L., Pak P.H., et al. Reverse remodeling from cardiomyoplasty in human heart failure. External constraint versus active assist. Circulation 1995;91:2314-2318.[Abstract/Free Full Text]
24. Schreuder J.J., van der Veen F.H., van der Velde E.T., et al. Beat-to-beat analysis of left ventricular pressure-volume relation and stroke volume by conductance catheter and aortic model flow in cardiomyoplasty patients. Circulation 1995;91:2010-2017.[Abstract/Free Full Text]
25. Tasdemir O., Vural K.M., Kucukaksu S.D., et al. Comparative study on cardiomyoplasty patients with the cardiomyostimulator on versus off. Ann Thorac Surg 1996;62:1708-1713.[Abstract/Free Full Text]

This article has been cited by other articles:

				J. C. Chachques Cardiomyoplasty: is it still a viable option in patients with end-stage heart failure? Eur. J. Cardiothorac. Surg., February 1, 2009; 35(2): 201 - 203. [Full Text] [PDF]

				J. C. Chachques, O. J. Jegaden, V. Bors, T. Mesana, C. Latremouille, P. A. Grandjean, J. N. Fabiani, and A. Carpentier Heart transplantation following cardiomyoplasty: a biological bridge Eur. J. Cardiothorac. Surg., April 1, 2008; 33(4): 685 - 690. [Abstract] [Full Text] [PDF]

				R. F. Padera Jr. and F. J. Schoen Pathology of Cardiac Surgery Card. Surg. Adult, January 1, 2008; 3(2008): 111 - 178. [Full Text]

				J. C Chachques, C. Salanson-Lajos, P. Lajos, A. Shafy, A. Alshamry, and A. Carpentier Cellular Cardiomyoplasty for Myocardial Regeneration Asian Cardiovasc Thorac Ann, September 1, 2005; 13(3): 287 - 296. [Abstract] [Full Text] [PDF]

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): Sérgio A. Oliveira Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Benício, A. Articles by Oliveira, S. A. Search for Related Content PubMed PubMed Citation Articles by Benício, A. Articles by Oliveira, S. A. Related Collections Mechanical Circulatory Assistance