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Ann Thorac Surg 1997;64:634-638
© 1997 The Society of Thoracic Surgeons
Hospital Angelina Caron, Campina Grande, Brazil; and the State University of New York at Buffalo and the Buffalo General Hospital, Buffalo, New York
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods. Partial left ventriculectomy was performed in 120 patients with end-stage dilated cardiomyopathies of varying causes. Most patients were in New York Heart Association functional class IV. The procedure consisted of removal of a wedge of left ventricular muscle from the apex to the base of the heart. Depending on the distance between the two papillary muscles, the mitral valve apparatus was either preserved, repaired, or replaced with a tissue prosthesis.
Results. The 30-day mortality was 22% and the 2-year survival was 55%. Although 10% of surviving patients showed no improvement in New York Heart Association functional class, most of the surviving patients were in either class I (57%) or II (33.3%), and the others were in class III and IV.
Conclusions. Partial left ventriculectomy can be used to treat end-stage dilated cardiomyopathy. Further studies and a longer follow-up period are needed to fully assess the effects of this procedure.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Partial left ventriculectomy (PLV) was recently used to treat patients with end-stage dilated cardiomyopathies of varying causes in Brazil [1, 2]. Performance of this operation at the Buffalo General Hospital began in July 1995. We report a combined experience of 120 patients with dilated cardiomyopathy who were treated by PLV at the Hospital Angelina Caron, Campina Grande, Brazil, and at the Buffalo General Hospital, Buffalo, NY.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Institutional Review Board approval was obtained at the Buffalo General Hospital, and all patients gave informed consent for the operation. It was stipulated that the Cardiac Transplantation Committee would determine the suitability of patients for PLV. Patients in Buffalo were receiving maximum medical therapy, consisting of vasodilator therapy, digitalis, and, in a few cases, dobutamine infusion and intraaortic balloon pump support. Initial Institutional Review Board approval precluded patients who were on the cardiac transplantation list from undergoing this procedure, unless there were contraindications to transplantation or if requested by the patient. Therefore, the initial experience in Buffalo included elderly patients or patients who were not transplant candidates due to socioeconomic, psychological, and other reasons. All patients underwent cardiac catheterization and echocardiographic assessment before the operation. All patients received modern cardiac anesthesia, hemodynamic monitoring (Swan-Ganz catheter) and transesophageal echocardiographic assessment during the operation. Cardiac support in the form of intraaortic balloon pumping or an LV assist device (Heartmate) was available. Follow-up of all patients in Buffalo is complete.
Once the team from Buffalo learned the procedure by a visit to Brazil, it was thought that it was justified to initiate our program under Institutional Review Board approval and informed consent. One of the most difficult tasks was the selection of patients in Buffalo, as the best candidates (cardiac transplant patients) were excluded due to the Institutional Review Board determination. Whereas in Brazil all patients presenting with dilated cardiomyopathy, regardless of the cause, underwent PLV, in Buffalo only elderly patients with viral and idiopathic dilated cardiomyopathy with or without associated valvular diseases were initially offered the operation. Most of the mortality and complications in the Buffalo experience occurred during the initial experience, due to poor case selection, the learning curve on the technical aspects of the procedure, emergency operations in patients who should have received assist devices, and inadequate resection of LV muscle to preserve the mitral valve apparatus.
Surgical Technique
Standard cardiac anesthesia and monitoring were used. Cardiopulmonary bypass was instituted at normothermia. In most cases, double caval cannulation with snaring was used. A DeVega's tricuspid repair was performed in cases of tricuspid insufficiency. A two-stage venous cannula was used in patients in whom tricuspid repair was not anticipated. The patient was placed in the Tredenlenberg position and the mean systemic arterial pressure was maintained at greater than 65 mm Hg. The procedure was performed in a beating heart except in 2 patients with aortic insufficiency who received cardioplegic arrest.
An incision was made at the apex of the left ventricle and was extended toward the base. The interior cavity of the left ventricle was inspected, and the distance between the anterior and posterior papillary muscles was determined. Early in our experience, an attempt was made to preserve the papillary muscles, and mitral valve repair was performed by approximating the center of the free wedges of the mitral leaflets by a single suture of 4-0 Prolene (Ethicon, Somerville, NJ) [3]. This is still the case in Brazil due to socioeconomic factors. In Buffalo, most of the patients had mitral valve replacement with a tissue prosthesis. The left ventriculotomy was closed with a single layer of 1-0 Vicryl (Ethicon) suture, followed by a second hemostatic suture of 1-0 Vicryl suture. Although Prolene suture closure of the ventriculotomy was initially used, bleeding occurred frequently due to stretch of the suture, with catastrophic (exsanguination) results in some patients. In Buffalo, a strip of bovine pericardium was used to cover the ventriculotomy incision, because resorcine glue is not available. Air was carefully removed from the left ventricle.
Before weaning from cardiopulmonary bypass, nitroprusside was infused to decrease afterload. In some cases, milrinone was infused to decrease pulmonary vascular resistance and to improve hemodynamics. Most patients were weaned from cardiopulmonary bypass without the use of intraaortic balloon pumping. During the postoperative period particular attention was paid to blood pressure control. Early extubation was emphasized. Due to the large pericardial cavity in relation to the new heart size, the chest tube drains were left in place until the return from the chest tubes was serous.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The procedures performed were as follows:
Ischemic patients received coronary artery bypass grafting when appropriate. A few patients also underwent autotransplantation, used in selected patients to treat atrial fibrillation by reduction of the left atrial size. Seven patients in Buffalo underwent autotransplantation, but the inferior vena cava was not divided, as this was the site that caused most bleeding problems in the experience in Brazil.
The combined 30-day operative mortality in the two institutions was 22%. The rates of complications were as follows:
As can be seen, congestive heart failure, bleeding, arrhythmias, and renal failure were the most common complications. Most patients are in NYHA functional class I (57%) or II (33%), and the remainder are in classes III and IV (10%). As mentioned earlier, complete follow-up is not available for the patients in Brazil. For this reason, life-table analyses of the patients in Buffalo are presented in Figures 1 through 3
. Figure 1 shows the life-table analysis of the total experience. This represents patients with a variety of complex cardiac diseases superimposed on a substrate of dilated cardiomyopathy, including our learning curve. Figure 2 depicts the midterm experience and Figure 3 the recent experience with PLV. It is apparent that patient selection, standardization of the operative techniques, and overall care of the patients allow for reasonable results.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Transcribing the clinical experience from Brazil to Buffalo was disappointing initially (see Fig 1
), but improved with time (see Figs 2, 3). Institutional Review Board approval in Buffalo only allowed patients who were not transplant candidates, elderly patients, and patients with multiorgan diseases. Two patients underwent PLV on a humanitarian basis, by special dispensation, as they were thought to be near the end of their lives, unresponsive to medical therapy. Both did extremely well. As with any new operation, there was a learning curve in case selection, in the technical aspects of the operation, and in the overall care of these patients perioperatively. Whereas in Brazil all patients presenting with dilated cardiomyopathy, regardless of the cause, were operated on, in Buffalo only patients with viral and idiopathic cardiomyopathy with or without valvular involvement were offered the operation. There were two ischemic patients in Buffalo who were offered this procedure. Furthermore, most of the mortality in Buffalo occurred during the initial experience (see Fig 1), for a variety of reasons, including poor case selection, emergency cases, and inadequate resection of LV muscle to preserve the mitral valve apparatus. We now recommend that only patients with dilated cardiomyopathy of a viral/idiopathic cause with or without valvular involvement be offered this operation. Patients with multiorgan failure or emergency operation are at increased risk and are not offered this operation in Buffalo and are treated by other means, such as mechanical assistance. Patients with ischemic dilated cardiomyopathy are not being considered at this time. Pulmonary hypertension is not a contraindication for the operation.
There may be regional differences in patients in the two countries. In Brazil Chagas's disease is endemic. Destruction of the myocardium by Trypanosoma cruzi leads to diffuse fibrosis and thinned out myocardium, explaining why patients with Chagas' disease do not do well after PLV. Could it be that ischemic patients are similar, as they have diffuse fibrosis? The best candidates in both countries appear to be patients with dilated heart due to valvular diseases (aortic, mitral, or both) with a thick LV wall. Finally, patients in Brazil may not be receiving adequate vasodilator and antifailure therapies compared with their counterparts in the United States. All of these factors potentially could affect the outcome of the procedure. There are also important differences in the perioperative care and follow-up of these patients in the two countries.
At present, it is uncertain whether LV redilatation may occur after PLV. In the Buffalo General Hospital experience, redilatation developed in 1 patient, who subsequently underwent cardiac transplantation. Examination of the explanted heart at the time of transplantation revealed diffuse fibrosis and dilated LV chamber with thinned out wall. Potential causes for redilatation include progression of the cardiac disease and inadequate removal of LV muscle at time of PLV.
Sudden death has been observed in patients after PLV, suggesting that this operation does not appear to change the natural history of dilated cardiomyopathy in terms of cardiac arrhythmias. As a result, all patients in Buffalo undergo physiologic studies after PLV before discharge from hospital. An implantable cardioverter-defibrillator is implanted in those patients with inducible tachycardia.
Although surgical bleeding during and early (24 to 48 hours) after the operation was a problem, this has been minimized by the use of Vicryl suture as well as by glue, pledgeted sutures, and bovine pericardial closure of the ventriculotomy. The effect of the ventriculotomy scar in terms of development of a new focus of arrhythmias remains to be defined.
The final and key question about PLV is the intermediate and long-term results. It is most unfortunate that not all patients who underwent this procedure in Brazil were followed up, as a great insight into the different aspects of PLV could have been obtained. In this current article, we can only report in-hospital mortality and a rough estimate of patients who are alive in Brazil. On the other hand, in Buffalo, all patients have been followed up and some inferences can be made, considering the differences between the two patient populations. The first patient operated on in Buffalo in July 1995 was severely incapacitated (NYHA functional class IV) and today he leads a normal life (NYHA functional class I). In some cases the degree of improvement in ejection fraction is small and yet the patients are clinically improved. It is difficult to predict outcome beyond 2 years, although surviving patients are doing reasonably well. A longer follow-up period is needed to determine whether these improvements are long-lasting.
In conclusion, a combined experience with PLV is presented, reflecting two different populations of patients in two countries. As mentioned, it is difficult to obtain information in patients from Brazil other than the cause of the disease, procedures performed, and crude operative mortality. Follow-up of patients in Brazil is incomplete and it is not possible to make conclusions regarding long-term outcome. The experience in Buffalo, however, suggests that the procedure has merits for selected patients, such as those with dilated cardiomyopathy of a viral or idiopathic cause with or without valvular involvement. Life-table analyses indicate that results improve with experience, with acceptable mortality in the last 10 patients. A large proportion of these patients are in NYHA functional class I or II. Left ventricular redilatation has developed in 1 patient, who has undergone cardiac transplantation. We continue to be optimistic about the role that PLV will play in the treatment of these difficult patients. Recently The Society of Thoracic Surgeons published a position paper dealing with PLV [4]. We encourage those surgeons interested in this procedure to read this document and adhere to these guidelines.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Address reprint requests to Dr Batista, Hospital Angelina Caron, Rua Alcidez Munhoz, 566, Merces, Curitiba PR, 80.810-040, Brazil.
This article has been selected for the open discussion forum on the STS web site: http://www.sts.org/annals
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