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Ann Thorac Surg 2008;86:1849-1854. doi:10.1016/j.athoracsur.2008.08.010
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Impact of Surgical Ventricular Restoration on Diastolic Function: Implications of Shape and Residual Ventricular Size

Serenella Castelvecchio, MDa,*, Lorenzo Menicanti, MDa, Marco Ranucci, MDb, Marisa Di Donato, MDc

a Department of Cardiac Surgery, IRCCS, San Donato Hospital, Milan, Italy
b Department of Cardiothoracic and Vascular Anesthesia, IRCCS, San Donato Hospital, Milan, Italy
c Department of Critical Care Medicine, University of Florence, Florence, Italy

Accepted for publication August 4, 2008.

* Address correspondence to Dr Castelvecchio, Department of Cardiac Surgery, IRCCS, San Donato Hospital, Via Morandi 30, San Donato, Milanese, Milan, 20097, Italy (Email: castelvecchio.serenella{at}gmail.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Limited data are available on left ventricle (LV) diastolic function in patients with ischemic dilated cardiomyopathy submitted to surgical ventricular restoration (SVR). The purpose of this study was to assess postoperative diastolic function changes and identify potential predictors of its worsening.

Methods: One hundred and forty-six patients (65 ± 9 years) with previous anterior myocardial infarction were evaluated before and after SVR. Hemodynamic and geometric parameters including the sphericity index and conicity index were measured. Diastolic function was explored using the transmitral flow velocity pattern, and four classes were defined: normal, abnormal relaxation, pseudonormal, and restrictive pattern. Diastolic function was defined as unchanged (no difference in diastolic pattern), improved (at least one class less), or worsened (at least one class more or, in the case of preoperative restrictive pattern, an early transmitral flow velocity to atrial flow velocity [E/A] ratio increase of at least 20%).

Results: The filling pattern before SVR was normal in 7 patients (4.8%), abnormal relaxation in 99 (68%), pseudonormal in 28 (19%), and restrictive in 12 (8.2%). After SVR, the filling pattern was unchanged in 105 patients (72%), improved in 14 (9.6%), and worsened in 27 (18.4%). Based on the univariate analysis, the preoperative conicity index and the end-diastolic volume difference (the result of surgical volume reduction) were associated with a diastolic pattern worsening.

Conclusions: Diastolic function did not change or improve in the majority of patients. In the minority of patients who experienced worsening, this was associated with the preoperative LV shape and residual volume.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Surgical ventricular restoration (SVR) is a relatively new and continuously improving technique for restoring left ventricle (LV) shape, size, and function in patients with ischemic, dilated cardiomyopathy and heart failure. The technique, initially introduced by Dor and colleagues [1] and Jatene [2], has been refined over the last ten years in an effort to standardize the procedure and to optimize the results. So far, it has been well-established that SVR improves LV systolic function by reducing ventricular volumes and increasing the ejection fraction (EF) [3–6]. Moreover, the beneficial effects of SVR include an improvement in LV mechanical synchrony, resulting in a more efficient myocardial pump function [7].

To date, however, few data are available on LV diastolic function (DF) in patients submitted to SVR. It is well-known that ventricular remodeling after an acute myocardial infarction is accompanied by changes in the diastolic properties of the LV due to scar formation, which in turn increases chamber stiffness and compensatory hypertrophy of the remote zone, which is responsible for delayed relaxation [8]. The resulting increase in filling pressure within the ventricle may be responsible, in turn, for LV dilatation. Recently, our group demonstrated that severe diastolic dysfunction, when associated with mitral regurgitation and a high New York Heart Association functional class, is a risk factor for SVR outcome [6]. Experimental studies suggested an adverse effect on DF induced by surgical volume reduction [9, 10]. Tulner and colleagues [11] reported data obtained from pressure-volume loops analysis before and after SVR showing a leftward shift of the end-systolic and end-diastolic pressure-volume relationship with an increased slope of both, suggesting an improvement in systolic function and counteracting changes in diastolic properties as evidenced by an increased stiffness constant. However, the study was conducted under cardioplegia, which could be partially responsible for interstitial edema and increased diastolic chamber stiffness, as also suggested by Ratcliffe and Guy in their editorial [12]. Moreover, Gibson and Francis [13] had already pointed out as "the stiffness constant," derived by applying an exponential equation to a curvilinear relationship (as the relationship between pressure and volume is in fact) is not actually measuring stiffness but rather the extent by which stiffness varies with volume changes.

The SVR aims to resize and reshape the LV, raising the question of what is the ideal volume reduction and what are the geometric implications that may affect the prognosis of patients submitted to SVR. Standard Doppler echocardiography indices derived from mitral inflow have been widely used to assess diastolic dysfunction in the clinical setting, offering the opportunity to interpret different diastolic abnormalities in conjunction with information from M-mode and two-dimensional echocardiography such as LV size and shape.

The aim of the present study was to assess whether LV volumes and shape changes may induce changes in DF. Additional endpoint was to investigate the potential role of echocardiographic parameters in predicting a DF that has worsened after SVR.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Study Design
This was a retrospective study based on the institutional database of the Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato for patients undergoing SVR. The study design was submitted to the Local Ethics Committee, which waived the need for approval in consideration of the retrospective nature of the study. All the patients admitted to the study gave their informed consent for the scientific analysis of their clinical data in an anonymous form.

Patient
One hundred and forty-six patients (119 men, mean age 65 ± 9) with previous anterior myocardial infarction and secondary LV dilatation referred to our institution for SVR between July 2001 and October 2005 received a complete echocardiographic examination. Exclusion criteria were a posterior LV dilatation and the need for mitral valve repair or replacement. All but 6 patients received coronary artery bypass plus SVR. Indications for surgery were heart failure, angina, or a combination of the two.

Echocardiography
Complete M-mode, two-dimensional, and Doppler echocardiography were performed using a commercially available imaging system (Vivid 7; GE Medical System, Fairfield, CT) before SVR and at the time of hospital discharge. Hemodynamic and geometric parameters, including the long axis length (from the apex to the midpoint of the mitral valve plane in the 4-chamber view), the short axis length (as the axis that perpendicularly intersects the midpoint of the long axis in the same view), and the apical axis length (measured as the diameter of the sphere that best fits the apex in the 4-chamber view), were collected in all patients,. Diastolic and systolic measurements were obtained, and the sphericity index (SI, short to long axis ratio) and the conicity index (CI, apical to short axis ratio) were calculated.

The DF was explored using the transmitral flow velocity curve obtained by pulsed-Doppler imaging, positioning the sample volume between the tips of the mitral leaflets. According to the LV filling pattern, four progressive classes have been described: normal, abnormal relaxation, pseudonormal, and restrictive patterns [14]. After surgery, DF was defined as unchanged (no difference in diastolic pattern), improved (at least one class less), or worsened (at least one class more or, in case of a preoperative restrictive pattern, an early transmitral flow velocity to atrial flow velocity [E/A] ratio increase of at least 20%).

Surgical Technique
Details of the surgical technique have been previously reported [5, 6, 15]. Briefly, the procedure was conducted on an arrested heart with anterograde crystalloid or cold blood cardioplegia. Patients received crystalloid cardioplegia if the preoperative EF was 0.40 or greater (n = 36, 24%). Therefore, the great majority of the patients received cold blood cardioplegia. Complete coronary revascularization was first performed, almost always with the left internal mammary artery on the left anterior descending coronary artery and sequential venous grafts on the right and circumflex arteries, when needed. Since July 2001, we systematically introduced the use of a preshaped mannequin (TRISVR; Chase Medical, Richardson, TX) filled at 50 to 60 mL/m2 to optimize the size and shape of the new ventricle. The technique is a refinement of the Dor technique and allows for standardization of the procedure.

Statistical Analysis
Statistical analysis included the analysis of variance with the Bonferroni correction for comparisons within group, or an independent variables Student t test for comparisons between the two groups. The association between DF worsening and the preoperative and operation-related changes were explored with a logistic regression analysis. For all the statistical tests, a p value less than 0.05 was considered to be significant. Data in the tables and in the text are reported as number (percentage) or mean (standard deviation of the mean). Statistical analyses were performed using a computerized statistical package (SPSS 11.0; SPSS, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
The preoperative diastolic profile is reported in Table 1. Seven (7) patients (4.8%) showed a normal pattern, 99 patients (68%) an abnormal relaxation pattern, 28 patients (19%) a pattern of pseudonormalization, and 12 patients (8.2%) a restrictive pattern. Factors associated with the degree of diastolic dysfunction were age (abnormal relaxation vs pseudonormalization, p = 0.004), EF (pseudonormalization vs restrictive pattern, p = 0.015), left atrium dimension (abnormal relaxation vs pseudonormalization, p = 0.005), and systolic sphericity index (normal vs abnormal relaxation, p = 0.023).


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  		Table 1 Echocardiographic Preoperative Data Within Groups
 
On average, the diastolic filling pattern showed a significant increase after the operation (from 1.27 ± 0.65 to 1.45 ± 0.7, p = 0.031) (Table 2). Within the groups, 105 patients (72%) did not change their diastolic pattern, 14 patients (9.6%) improved, and 27 patients (18.4%) worsened (Table 2). Postoperatively, the hemodynamic echo-derived profile as a function of diastolic pattern (Table 3) was significantly different for end diastolic volume (EDV) (abnormal relaxation vs restrictive pattern, p = 0.016), stroke volume (restrictive pattern vs the other groups, p = 0.008), left atrium diameter (abnormal relaxation vs restrictive pattern, p = 0.012), and systolic and diastolic sphericity index (normal vs restrictive pattern, p = 0.027 and p = 0.035, respectively).


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  		Table 2 Diastolic Pattern Changes After the Operation
 

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  		Table 3 Echocardiographic Postoperative Data Within Groups
 
Determinants of postoperative DF worsening were explored by comparing the worsened group (n = 27) to the unchanged or improved group (n = 119) (Table 4). In this analysis, we considered the preoperative diastolic pattern and the operation-induced changes as potential predictors. Only the preoperative systolic conicity index was associated with a diastolic pattern worsening; the only operation-related change associated with a diastolic pattern worsening was the EDV difference.


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  		Table 4 Preoperative and Operative Factors Associated With Diastolic Function Worsening
 
A univariate association between the above indices and the diastolic pattern worsening likelihood was explored with a logistic regression analysis. The CI and EDV differences (preoperative-postoperative) were independently and inversely associated with the likelihood of DF worsening (p values 0.038 and 0.036, respectively).

The risk of diastolic pattern worsening as a function of the preoperative systolic conicity index is reported in Figure 1. Patients with a low conicity index (greater conical apex) are more prone to DF worsening with respect to patients with a high conicity index (lesser conical apex). Figure 2 shows two different examples. To investigate the role of preoperative volumes associated with different shapes, the preoperative EDVs in the quintiles of distribution of the CI were calculated and reported (Fig 1). No differences in the preoperative EDV were observed for each CI quintile. Therefore, this shape-related predictor of DF worsening is independent of the preoperative EDV.


Figure 1
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  		Fig 1. Diastolic function worsening likelihood as a function of preoperative systolic index – CI (S). Preoperative EDVs in each quintile of distribution of sCI are indicated (right axis) as diamonds (mean values and standard deviation). There is no significant difference between quintiles of volumes. (CI = conicity index; EDV = end diastolic volume.)

 

Figure 2
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  		Fig 2. On the left is reported an example of classical aneurism showing an apical axis bigger than the short axis (systolic conicity index = 1.15); on the right is reported an example of ischemic dilated cardiomyopathy showing an apical axis smaller than the short axis (systolic conicity index = 0.72). (EDV = end diastolic volume; EF = ejection fraction; ESV = end systolic volume.)

 
The risk of diastolic pattern worsening as a function of the EDV difference induced by SVR is reported in Figure 3; preoperative EDVs were calculated for the quintiles of distribution of the EDV difference. In this case, there is a significant difference in the volumes; patients with a large preoperative EDV receiving a wide LV size reduction have a minimal risk for DF worsening, whereas patients with a relatively small preoperative LV (receiving a limited LV size reduction) are more prone to DF worsening.


Figure 3
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  		Fig 3. Diastolic function worsening likelihood as a function of operative changes in end diastolic volume (EDV). Preoperative EDVs in each quintile of distribution of EDV difference are indicated (right axis) as diamonds (mean values and standard deviation). There is a significant difference between quintiles in volumes.

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The major findings of this study include the following; (1) Diastolic dysfunction occurs in the majority of patients affected by ischemic dilated cardiomyopathy and heart failure suitable for SVR; (2) after surgery, the average DF is impaired even if a worsening of the diastolic pattern occurs in a minority of the patients; (3) the preoperative shape, irrespective of the volumes, is a predictor of DF worsening; and (4) a limited surgical volume reduction associated with a relatively small preoperative EDV is a predictor of DF worsening.

Diastolic dysfunction occurs in 95% of the population in this study before the operation, and this confirms that diastolic dysfunction is an integral part of systolic heart failure [16]. After the operation, only 27 patients (18%) showed a worsening of the DF, defined as at least one grade more or, in the case of preoperative restrictive pattern, an E/A ratio increased by at least 20% with respect to the preoperative value.

Diastolic Function and LV Volumes
Although SVR is increasingly performed and large series of data are now available in the literature [3, 6, 17, 18], results are sometimes difficult to interpret either because the surgical technique is not standardized yet or because of the lack of clear indications for which ventricles should be treated. In particular, this applies to the problem of the preoperative volumes and shapes and to the concept of the "ideal residual volume" that should be associated with the greater improvement of the overall cardiac function. It is well known that SVR induces a significant reduction in LV end-diastolic and end-systolic volumes and a significant improvement in the EF, indicating an improvement in systolic function [3, 6]. However, the observation coming from this study that DF is impaired after SVR, even if in a minority of patients (18%), raises the question on the possible role of the preoperative EDV and the related changes induced by resizing the LV cavity. To verify this hypothesis, we analyzed the risk for diastolic pattern worsening as a function of the EDV difference induced by SVR, with respect to the preoperative EDV (Fig 3). We showed that the likelihood for DF worsening is higher when the surgical volume reduction, in terms of the EDV difference, is lower, which in turn is directly related to the preoperative EDV. It is reasonable to suspect that a relatively small ventricle (EDV < 160 mL), which necessarily will have a smaller surgical reduction, should not be treated with SVR to avoid a deterioration in DF.

Diastolic Function and LV Shape
The remodeling process after an anterior myocardial infarction includes a sequence of structural changes, which alter the size and the shape of the LV. Previous efforts to assess LV shape have been making use the sphericity index (SI) as a short to long axis ratio [19, 20]. More recently, our group [21] demonstrated that a new parameter named the conicity index (CI), which is calculated as the apical to short axis ratio, is more accurate in detecting regional shape abnormalities originating from the apex, which is primarily involved in anterior myocardial infarction. The results obtained in the present study confirm the superiority of the CI with respect to the SI in predicting the likelihood of DF worsening after SVR. This indicates that, irrespective of the preoperative EDV, globally dilated LV cavities (CI < 1) are more likely to worsen the DF compared with LV cavities equally dilated but mainly at the apical level (CI > 1) for the presence of a dyskinetic scar. A CI greater than 1 can reflect a relatively more compliant tissue, and its resection or exclusion does not affect a DF that eventually may improve, in agreement with the theoretic considerations expressed by Artrip and colleagues [22].

Study Limitations
This study has a few potential limitations. First, the number of patients with a worsening of the DF is small. However, this is the first time, to the best of our knowledge, that detailed changes in diastolic filling pattern are reported in patients who underwent SVR. Second, we utilized echo-Doppler measurements of the mitral inflow to assess DF and tissue Doppler imaging might have been more indicative; however, Tissue Doppler imaging is still not routinely available in the clinical setting. Third, DF assessment through either Doppler flow or tissue Doppler does not allow examination of passive ventricular properties. Fourth, we recognize that early changes in diastolic function may not be completely conclusive; we are currently assessing late postoperative data that will be the subject of a future paper.

Conclusions
Before surgery, diastolic dysfunction is often detectable in patients affected by postanterior myocardial infarction dilated cardiomyopathy and depressed systolic function. After surgery, DF remains unchanged or improved in the great majority of patients while it worsens in a minority of cases.

Our study suggests that Doppler echocardiographic assessment, in conjunction with a careful evaluation of geometric and hemodynamic parameters, may provide additional prognostic information and may be used to select patients who will benefit from SVR the most. Moreover, the data reported in this study were collected during a period in which we believed the surgical procedure had been sufficiently standardized, as previously mentioned, leaving the patient selection as a matter of debate. The role of the preoperative shape and of the surgical residual LV volume in predicting DF outcome after SVR is a major finding that has never been reported in the clinical setting.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F. Left ventricular aneurysm: a new surgical approach Thorac Cardiovasc Surg 1989;37:11-19.[Medline]
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