Ann Thorac Surg 2008;86:1854-1855. doi:10.1016/j.athoracsur.2008.09.038
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
L. Michael Graver, MD
Department of Cardiothoracic Surgery, Long Island Jewish Medical Center, Room 2123 270-05, 76th Ave, New Hyde Park, NY 11040
(Email: lmgraver{at}ix.netcom.com).
To achieve symptomatic and survival benefit in the surgical management of heart failure in appropriate patients, each of the three "Vs" must be addressed: (1) vascularization, (2) valvular competence, and (3) volume restoration of the left ventricle. Standardized management strategies and selection criteria exist for coronary and valvular reconstructions, but there remains quite significant surgeon and institutional variability with regard to selection and technique of surgical ventricular restoration (SVR). In past publications, Menicanti and colleagues [1] have provided us with techniques to help standardize the technique of the procedure, but the Achilles' heel of SVR has been patient selection. Here Castelvecchio and colleagues [2] have provided us with a preliminary, but insightful and objective technique to consider in case selection.
Abnormal diastolic function (DF) is the component of heart failure, which produces symptoms and as such relates directly to functional class and quality of life after surgical correction. The goal of surgery is to improve DF. Using objective echocardiographic measurements (sphericity and conicity indices) Castelvecchio and colleagues [2] have suggested to us which types of adversely remodeled left ventricles are most likely and which are least likely to demonstrate improvement in postoperative DF. These data, although admittedly limited in numbers and not prospectively generated, help to focus our attention on geometric features of the left ventricle, which should be considered in preoperative selection and planning. It seems clear from these data that not all patients with high end-diastolic volumes after anterior infarction are the same. Some have more generalized dilatation as indicated by a conicity index less than 1 and these patients will have potential worsening of DF after surgery. We hope that these investigators will ultimately relate these and other preoperative echocardiographic criteria, such as tissue Doppler to postoperative functional class improvement and survival. This, as well as the surgical treatment of the ischemic heart failure (STICH) trial patients, whose results are expected in the coming year, may help us to further refine selection criteria for these complex patients.
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References
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- Menicanti L, Di Donato M. The Dor procedure: what has changed after fifteen years of clinical practice? J Thorac Cardiovasc Surg 2002;124:886-890.[Free Full Text]
- Castelvecchio S, Menicanti L, Ranucci M, Di Donato M. Impact of surgical ventricular restoration on diastolic function: implications of shape and residual ventricular size Ann Thorac Surg 2008;86:1849-1855.[Abstract/Free Full Text]
Related Article
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Impact of Surgical Ventricular Restoration on Diastolic Function: Implications of Shape and Residual Ventricular Size
- Serenella Castelvecchio, Lorenzo Menicanti, Marco Ranucci, and Marisa Di Donato
Ann. Thorac. Surg. 2008 86: 1849-1854.
[Abstract]
[Full Text]
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