Ann Thorac Surg 2005;80:315-316
© 2005 The Society of Thoracic Surgeons
Case report
Reversal of Ventricular Dilatation in Aortic Regurgitation After Valve Replacement and Cardiac Support Implant Surgery Using the CorCap Cardiac Support Device
Anders Franco-Cereceda, MD PhDa,*,
Ulf Lockowandt, MD PhDa,
Jan Liska, MD PhDa,
Arne Olsson, MDb
a Department of Cardiothoracic Surgery, Karolinska Hospital, Stockholm, Sweden
b Department of Clinical Physiology, Karolinska Hospital, Stockholm, Sweden
Accepted for publication December 29, 2003.
* Address reprint requests to Dr Franco-Cereceda, Department of Cardiothoracic Surgery, Karolinska Hospital, Stockholm S-171 76, Sweden (Email: andfra{at}mbox.ki.se).
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Abstract
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The effects of combined aortic valve replacement, coronary bypass surgery, and passive containment surgery in a patient with long-standing aortic regurgitation and marked ventricular dilatation are described. After surgery there was a rapid decrease in left ventricular size and maintained ventricular function.
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Introduction
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It is well known that in patients with aortic regurgitation (AR) and moderate to severe reduction of left ventricular (LV) function, the left ventricle diameter is a predictor of long-term survival [1]. After valve replacement in patients with AR, short-term and long-term improvement of LV systolic function is related to early reduction of LV dilatation [2]. However, predictive factors for persistent LV dilatation after aortic valve replacement for chronic AR include a preoperative left ventricular end-diastolic diameter (left ventricular end-diastolic diameter) of more than 80 mm, left ventricular end-systolic diameter of more than 55 mm, and an LV ejection fraction of less than 50% [3]. Therefore it seems important to obtain an early reduction in LV diameter in patients with AR and LV dilatation to optimize cardiac function and long-term survival. Herein we report on what we believe is the first case of passive containment surgery for reduction of LV dilatation in connection with aortic valve replacement.
A 75-year-old man was admitted to surgery for AR, which was ongoing for at least 15 years. He had dyspnea and angina pectoris at exercise. His daily medications included furosemide (40 mg), spironolactone (25 mg), and aspirin (75 mg). An echocardiogram revealed an enlarged heart with a left ventricular end-diastolic diameter of 75 mm, an left ventricular end-systolic diameter of 60 mm, and a ejection fraction of 40%. His aortic valve was tricuspid with a regurgitation grade III/IV. The aortic root was normal in size, and the ascending aorta had a maximal diameter of 42 mm. Apart from a small regurgitation in his mitral valve (I/IV), no other lesions were observed. A coronary angiogram revealed an occluded right coronary artery.
After discussing surgical options with the patient, including possible benefits with passive containment surgery using the CorCap Cardiac Support Device (Acorn Cardiovascular Inc, St Paul, MN) in combination with valve surgery and coronary bypass surgery, ethical permission was obtained from the Ethics Committee of the Karolinska Hospital. Written consent was obtained from the patient. The CorCap Cardiac Support Device is a device made of mesh and polyester fabric with bidirectional compliance. It is placed around the heart in order to reduce wall stress and reshape the dilated heart from a spherical to a more ellipsoidal shape. The device is positioned over the ventricles and is stabilized at the atrioventricular grove by interrupted 3-0 Prolene sutures (Ethicon, Somerville, NJ). Theoretically, the device reduces the outward forces on the ventricle according to La Place’s law, thereby decreasing ventricular wall stress without any influence on chamber stiffness or diastolic filling pressures [4].
The patient was operated on using cardiopulmonary bypass (125 minutes), aortic cross clamp (75 minutes), and antegrade and retrograde blood cardioplegia with a core temperature of 34°C. The surgical procedure was uneventful with application of the CorCap Cardiac Support Device combined with implantation of a 25-mm Mosaic tissue valve (Medtronic, Santa Barbara, CA), and a saphenous vein graft, anastomosed through a small incision in the cardiac device to the right posterior descending coronary artery. The cardiac device was implanted with echocardiographic monitoring to ensure a snug fit that did not reduce the left ventricular end-diastolic diameter by more than 10% compared with baseline. The postoperative course was uneventful.
At the patient’s 3-month and 6-month postoperative evaluations, he was doing well with no angina or signs of heart failure. Echocardiography showed that his left ventricular end-diastolic diameter had decreased to 58 mm and 59 mm at 3 and 6 months, respectively, and the left ventricular end-systolic diameter decreased to 54 mm and 48 mm at 3 and 6 months, respectively (Fig 1). The ejection fraction was estimated to be 25% at 3 months postoperatively and 35% at 6 months postoperatively. Although there was no accurate estimate of effective stroke volume that could be made by echocardiography, the total cardiac output was reduced from 12 L per minute to 3.8 L per minute at 3 months postoperatively and 4.6 L per minute at 6 months postoperatively. No mitral regurgitation was present. After 2 months of postoperative warfarin treatment the patient was back on the same medications as he was preoperatively with his daily aspirin dosage increased to 160 mg.
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Comment
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Improvement of LV function in patients with AR undergoing AVR is related to early reduction (ie, within 6 to 8 months) of LV dilatation arising from correction of LV volume overload. Less reversed myocardial remodeling after aortic valve replacement occurs with advanced dilatation [3] and impaired LV function [5]. It should be emphasized that the present patient had undergone multiple surgical procedures (ie, valve replacement, coronary bypass surgery, and passive containment surgery), and their relative contributions to the reduced LV dilatation cannot be established. However, aortic valve replacement alone has minor impact on severe LV dilatation in patients with AR [3], and the spontaneous regression of LV dilatation after coronary artery bypass grafting is primarily seen in patients with three-vessel disease [6].
Because reversal of LV dilatation is associated with better functional recovery and long-term survival, it seems likely that passive containment surgery using the CorCap Cardiac Support Device (Acorn Cardiovascular Inc) in patients with AR and marked LV dilatation will prove beneficial. Randomized trials will eventually determine whether or not this will prove to be valid.
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Acknowledgments
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Supported by the Mats Kleberg Foundation and the Janne Elgqvist Foundation. None of the authors have any financial interest or any other association with Acorn Cardiovascular, Inc.
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References
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- Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Sewart JB, Tajik J. Mortality and morbidity of aortic regurgitation in clinical practice Circulation 1999;99:1851-1857.[Abstract/Free Full Text]
- Bonow RO, Dodd JT, Maron BJ, et al. Long-term serial changes in left ventricular function, and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation Circulation 1988;78:1108-1120.[Abstract/Free Full Text]
- Khatouri A, Fall PD, Mouyopa C, et al. Predictive indices of the persistence of left ventricular dilatation after valve replacement for chronic aortic insufficiency Ann Cardiol Angeiol 1998;47:716-721.
- Konertz WF, Shapland JE, Hotz H, et al. Passive containment and reverse remodelling by a novel textile cardiac support device Circulation 2001;104:I270-I275.
- Xu X-F, Kumpati G, McCarthy PM, Qin JX, Thomas J. Positive myocardial remodeling after surgical correction for isolated advanced aortic regurgitation complicated by severe left ventricular dysfunction Circulation 2001;104(Suppl II):494.
- Elefeteriades J, Edwards R. Coronary bypass in left heart failure Semin Thorac Cardiovasc Surg 2002;14:125-132.[Medline]
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F. Bredin, A. Olsson, and A. Franco-Cereceda
No Additive Effect of Passive Containment Surgery in Patients With Aortic Regurgitation and Left Ventricular Dilation
Ann. Thorac. Surg.,
August 1, 2007;
84(2):
510 - 513.
[Abstract]
[Full Text]
[PDF]
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Top
Abstract
Introduction
), changes in millimeters of left ventricular end-diastolic diameter (LVEDD) (
), and changes in millimeters of left ventricular end-systolic diameter (LVESD) (
) in a patient with long-standing aortic regurgitation operated on with valve replacement and passive containment surgery. (Pre = preoperative.)